Writing the history about the eradication of smallpox from India, it is seductively easy to get caught in triumphalist rhetoric. It is therefore all the more important to retain a critical distance to this process, however remarkable it might be. In Expunging Variola Sanjoy Bhattacharya makes it clear that the heroic accounts of smallpox eradication have already been written by the agencies involved in it,Footnote ¹ and he emphasises his intentions to offer a broader and more nuanced perspective on a sometimes surprisingly heterogeneous process (pp. 7–9). Basically, the author seeks to question the notion that smallpox eradication was achieved as the culmination of a continuous and uniform enterprise carried out in harmonious collaboration between Indian authorities and international organisations, most notably the World Health Organisation (WHO). In what turns out to be a fascinating and truly pioneering book, Bhattacharya convincingly demonstrates that this was not the case. Despite this critical approach, the author does, of course, have ‘heroes’. These heroes are not, however, the highly placed officials in the headquarters in Geneva and New Delhi, but the workers in the field. Towards the end of the book he writes about the experiences of field workers of all ranks, that it was ‘generally bittersweet—sometimes frustrating, but greatly satisfying at times, especially when India was certified free of variola in the face of overwhelming odds’ (pp. 247–8).

Despite Bhattacharya's intention to distance himself from the heroic accounts of smallpox eradication, it is nevertheless a story which possesses great dramatic potential. In the first decade after independence smallpox control in India was patchy and unsystematic. Local administrations often panicked when an epidemic threatened, but did little as soon as the crisis was over (pp. 49–50). Although South Asia was seen as the major reservoir of smallpox virus in the world, the disease was responsible for far less deaths than malaria and tuberculosis, and received less attention from the government. The attempt to control smallpox did, however, intensify around 1960. In 1958 WHO called for global smallpox eradication and soon after India inaugurated its National Smallpox Eradication Programme (NSEP). But any hopes for speedy progress were soon curbed as it was realised that three basic fundamentals for a successful eradication programme were missing: 1) a steady supply of potent vaccine; 2) devoted public health personnel; and 3) the co-operation of the population. According to Bhattacharya, this situation was yet another illustration of the fact that ‘policy-making proved far easer than implementation’ (pp. 125–6). In the 1970s—as we get into the ‘final phase’—the programme began to show signs of improvement. A new strategy based on ‘surveillance and containment’ replaced (though not without dissonance) the established belief that a very high overall vaccination level was necessary to eradicate smallpox. In 1973, the Indian national smallpox eradication programme (NSEP) was ‘officially’ intensified and became ‘INSEP’. It is in this context that the reader gets some of the dramatic highlights in the book. One example is an unofficial, personal and passionate appeal from WHO official Nicole Grasset to Indira Gandhi to support the campaign (p. 170). This letter also serves as an example of the fascinating primary material that Bhattacharya has dug out from the WHO archives. In 1975, the so-called ‘smallpox-zero’ status was reached, when the last case of smallpox in India was reported in May from Bihar. After two tense years searching for more cases (and warning the administration not to loosen its surveillance activities) smallpox eradication was certified in India on 23 April, 1977. Bhattacharya's achievement is to show in great detail how this triumph was reached despite clashes between WHO officials in Geneva and in New Delhi, despite widespread aversion against foreign experts among many Indian bureaucrats, and despite the belief of many that smallpox eradication was impossible. Thus, this ‘deconstruction’ of the heroic campaign against smallpox does not make the eradication any less an accomplishment. As the author himself remarks: ‘rather, it makes it all the more remarkable’ (p. 287).

Expunging Variola is closely following the publication of Fractured States (2005), also written by Bhattacharya, together with Mark Harrison and Michael Worboys, and dealing with smallpox control in colonial India. In this sense it is a ‘volume II’ in the history of smallpox control in India, and there are obvious similarities between the perspective taken and the main arguments employed in these two books. In Fractured States it is argued that the colonial state was fractured and heterogeneous, and this argument is now extended to independent India. While Fractured States emphasized the gap between schemes designed by central government agencies and their implementation at the district level in colonial India, the same conditions seem to have applied to newly independent India: ‘within a few years of independence, it was clear that the gap between the rhetoric and the reality of health policy in India was quite considerable’ (p. 19). In a similar vein, Bhattacharya argues that WHO's technical recommendations often faltered before national and state-level priorities and the organisation thus ‘comes through as a far less influential entity than is commonly assumed’ (p. 103). Disagreements, competition and strife between different departments of the state was the order of the day during colonial rule. In this respect, 1947 did not change much, and in independent India anti-smallpox programmes would have to compete for scarce funding with anti-malaria activities, anti-tuberculosis vaccination and later on the controversial family-planning programmes. That neither states nor international organisations are monolithic structures pursuing clearly defined goals is consistently and almost stubbornly argued throughout the two books.

Another similarity is that there is relatively little emphasis on popular, ‘culturally’ informed reactions to vaccination. In Fractured States this was explained as an attempt to avoid describing the Indian population as an irrational mass, which stubbornly refused vaccination on ‘cultural’ or ‘religious’ grounds. Expunging Variola contains no such discussion of the significance of studying popular reactions, but it does have a section on ‘civilian responses’. Here, interesting findings from a 1964-report are reproduced. According to this report the vast majority of non-vaccinated Indians explained that they had not taken the vaccination because they were old or because the anti-smallpox campaign never reached them. The idea that ‘traditional beliefs’ explained why people were not vaccinated seems to have existed mainly among vaccination staff (and perhaps in the minds of some sociologists and anthropologists) (pp. 230–4). At the same time, however, it is clear—not least through Paul Greenough's work—that compulsory and forced vaccination was not uncommon. In the future, we should clearly learn more about the reasons why some Indians were not vaccinated and why some were vaccinated with the use of force.

Reading through the pages of Expunging Variola one is struck by the fact that very little secondary literature is discussed and utilized. The obvious reason for this is that almost nothing has been written on the subject, and the book is instead based on a wealth of sources, which are often used for the first time. Still, one would have wished that more had been done to place Expunging Variola in a broader historiographical setting. In the epilogue, Bhattacharya makes an attempt to discuss his findings in such a context. Among other things, he takes issue with John Farley's critique of WHO as an organization serving the interests of the old imperial powers. According to Bhattacharya, Farley's critical assessment of WHO is flawed, not because WHO was a benign ally of the developing countries, but because WHO was too weak and divided to act as a tool for any kind of neo-imperialism. This is a highly interesting discussion, which also has links to the role of other organisations like the Rockefeller Foundation. It is commendable that Bhattacharya raises these broader issues, but it is a pity that they have been relegated to the epilogue.

Medical history in developing countries is booming and more books on smallpox control will, no doubt, follow Expunging Variola. Some will deal with comparable efforts in other parts of the world, others with more detailed studies of specific regions within India, and others again will deal with certain aspects of smallpox control. Some of the views expressed by Bhattacharya will be disputed or modified, but Expunging Variola is bound to be mandatory reading for anyone dealing with smallpox control or other major health programmes not only in independent India, but anywhere in the developing world.