INTERVIEW—Toynbee Coronavirus Series: Erez Manela on the WHO, smallpox eradication, and the need for renewed internationalism

Living through historically unprecedented times has strengthened the Toynbee Prize Foundation's commitment to thinking globally about history and to representing that perspective in the public sphere. In this multimedia series on the covid-19 pandemic, we will be bringing global history to bear in thinking through the raging coronavirus and the range of social, intellectual, economic, political, and scientific crises triggered and aggravated by it.

Toynbee Coronavirus Series—A global historical view of the coronavirus pandemic

Interview with Erez Manela

May 20, 2020

Erez Manela researches international society and the modern international order. Recently he has written about smallpox and the globalization of development, illuminating the power structures and international infrastructure that underwrote the World Health Organization’s (WHO) smallpox eradication program from 1965 to 1980. Professor of History at Harvard University, Prof. Manela teaches the history of the United States in the world and modern international history, and is the Director of Graduate Programs at the Weatherhead Center for International Affairs at Harvard and co-chair of the Harvard International and Global History seminar. He co-edits the Cambridge University book series ‘Global and International History.’

NICOLE CUUNJIENG ABOITIZ: With regard to the WHO Smallpox Eradication Program (SEP), you have written that in choosing smallpox as the disease to be eradicated through global solutions, there was a suggestion that it was the low hanging fruit and was the disease that would have been eradicated anyway, but that:

…this is not the whole story of smallpox eradication. The vaccine, after all, had been available for a long time, and its existence in itself is an insufficient explanation for the undertaking, much less for the success, of global eradication. It also required the ability and inclination to conceive of health as a global problem and, furthermore, as a problem amenable to a global solution. It is here the WHO, as a premise and an institution, was crucial to the Smallpox Eradication Program. The very existence of the WHO both reflected and shaped the notion of disease as a global problem that called for a global solution through the exercise of “international authority”…[1]

Following from here, you then discuss the program as a neutral space for collaboration across Cold War divides.

But there is also running through the piece and in the public sphere a perception, whether or not it is true, that from the 1960s onwards the WHO is powered by the developed world and faces the Global South—that it has a directionality to it, rather than being a flat, shared world health organization. If that’s the case, what implications does that have for how we understand global health as a concept and discourse, as you discuss it? And how does that differ from the role we see the WHO play in the current pandemic?

EREZ MANELA: Actually, Sunil Amrith has written very interestingly about this in his first book where he makes the point that the WHO and international global health in the postwar period had a lot of continuities with colonial health projects in the pre-World War Two era, and I think that’s right. On the other hand, I think it’s fair to say that, though it’s not a smooth process, over the course of the postwar decades the WHO becomes less of a Global North-run organization facing the Global South—reflecting the Global North doing something to the Global South—and becomes somewhat flatter and more universal in its aspirations, decision-making processes, and staffing. The SEP global campaign happens primarily between the mid-1960s to 1970s, and by the mid-1960s the Global South had gained much more clout in the WHO—not least because there are many more Global South nations that are now independent and members of the United Nations (UN) and, as a result, are also members of the World Health Assembly. This is the governing body that just met in Geneva in May, as they annually do, to which Xi Jinping sent a video and Trump his angry letter.

By the mid-1960s, the so-called Third World nations had a majority voting bloc and, I worked out that actually the SEP campaign happens on the strength of votes from Global South countries and to significant extent against the wishes of Global North countries. This is because Global North countries, particularly the US, said: yes, I support this; we need to do this, but I am not happy with the WHO demands for significant additional budget. The real background story to this is that the WHO, as an institution and particularly the director general at the time, were quite skeptical about smallpox eradication for a number of practical and ideological reasons. They weren’t eager to do it and they try to derail through the usual bureaucratic maneuver of saying we need much more money to do it, on the idea that the budget will make big donor countries, i.e. the US, less willing. And this is precisely what happens, but at that point it was already on the agenda, and it due to the votes of Global South countries that stood to benefit from it.

Moreover, significant numbers of top-level leaders in the SEP came from the Global North, but there were also quite a number of high-level experts from the Global South. The program in Afghanistan was run by an Indian physician, to name just one among many examples. Additionally, the Global North, here, is a complicated concept because a lot of the people involved came from the Eastern Bloc. One of the most important epidemiologists who worked on the program was Czechoslovakian. So, it’s not as simple—there is still the element you described before, but it’s more complicated.

NCA: When you think of global health as a concept and discourse, do you think that it is a flat global concept, or is it lumpy, uneven—does it have directionality and those kinds of contours?

EM: Oh yes, to me it’s not an either/or question; it’s one of degree. One could actually argue that the 1960s and 1970s were the highpoint of relative flatness—not complete flatness, to use your term, which I like.

If that argument’s right, it’s because after the 1970s with the rise of neoliberalism, Reagan, and Thatcher, and even more so after the end of the Cold War, the Global North and particularly the US become less interested in the WHO. That’s one of the reasons that China was able to gain influence in the WHO in the last nearly two decades—the US just didn’t care. Out of inertia, the US remained the biggest contributor, but diplomatically and politically it didn’t care. What replaced it are organizations like the Gates Foundation, which in some ways, though not all ways, represents a return to the inter-war period, when the leading spender on global health was the Rockefeller Foundation. You can say all sorts of bad things about the WHO, but the one thing the WHO does is it gives some sort of voice to small nations and was designed to do precisely that. So, if you go to the World Health Assembly you have to listen to what various small nations have to say, which is not necessarily true if you run the Gates Foundation.

Out of inertia, the US remains the biggest contributor, but diplomatically and politically it doesn’t care. What replaces it are organizations like the Gates Foundation, which in some ways, though not all ways, represents a return to the inter-war period, when the leading spender on global health was the Rockefeller Foundation. You can say all sorts of bad things about the WHO, but the one thing the WHO does is it gives some sort of voice to small nations and was designed to do precisely that.

NCA: What close reading analyses can be made of the smallpox eradication campaign’s portrayal of the crisis that are particular to that history? For example, Sheila Jasanoff has commented on the visual language globally employed around the coronavirus, e.g. "flattening the curve," and how it is distinct from that used during the AIDS epidemic.

EM: There has been some discussion of the metaphor of war in the context of disease control and pandemics, and that certainly was present in the smallpox eradication campaign—just calling it a campaign is a martial metaphor. But, there were also other martial metaphors that were used, and the international group involved actually called themselves ‘smallpox warriors.’ They still do call themselves this; they still meet and keep in touch.

The other kind of metaphorical language we could read into, and which a lot of  people involved credit the program’s success to, was that of a technique called ‘surveillance containment.’ This was similar to the idea of contract tracing with an additional step. ‘Surveillance’ means you pay attention to where flare ups occur and ‘containment’ means you contain those flare ups through radial vaccination: you vaccinate within a certain circle around each flare up. ‘Containment,’ especially then, had a strong Cold War flavor to it.

There was all sorts of evocative language, not least the language of tradition versus modernity. One of the challenges in many places in the Global South, including South Asia and sub-Saharan Africa, that the program had to contend with were “traditinal” methods for fighting smallpox, which often were contradictory to “modern” vaccination. So they had to figure out all sorts of ways to either circumvent tradition, as they saw it, or to take tradition and yoke it to the program. So, for example, many places in India where smallpox was endemic had various popular deities associated with smallpox. They had  power to make you survive or to make you sick with the disease. A common smallpox deity in India was Shitala Mata, and the SEP made posters with this deity recast as a vaccinator: she was holding a vaccination needle, and there was a message that if you really were serious about worshipping her, you should vaccinate yourself.

A common smallpox deity in India was Shitala Mata, and the SEP made posters with this deity recast as a vaccinator: she was holding a vaccination needle, and there was a message that if you really were serious about worshipping her, you should vaccinate yourself.

NCA: Smallpox has such a vintage—it has a long historical memory; whereas with the coronavirus, we are told that though we may have encountered coronaviruses before, this is something different, this is something new, and there’s a primacy placed on novelty. I am wondering if you still see in the current crisis that tradition and modernity binary at work or as something to be overcome? There seems to be something always to do with tradition versus modernity, ast least in the twentieth to twenty-first centuries, when we talk about the discourse of global health.

EM: That’s a really good question. Obviously if you look at the 1960s and 1970s, the framework of modernity versus tradition encodes assumptions about certain cultures being traditional by defintion and others being modern by definition. So the question of tradition always comes up, in my recollection, in the context of the Global South—whether in sub-Saharan Africa, Muslim countries, or South Asia, where “tradition” was sometimes said to be inimical to vaccination. The same thing happened in more recent decades with regard to polio.

The term tradition is rarely applied, in these contexts, to the Global North. We might perhaps talk about ideals or political culture when we try to explain things like the armed protests in Michigan against lockdown, but we don’t talk of these as representing American tradition.

NCA: Nor anti-vaxxers. Anti-vaxxers in the Global North are ‘new age.’

EM: Right—even though anti-vax thought is as old as the vaccine itself. The last time there was some signifcant outbreak of smallpox in Boston was 1900-1901 and in the Harvard library there is an anti-vax pamphlet from that era, because one of the ways the city and state responded was to try to make vaccination compulsory, and they had this big debate about whether they could or could not make vaccination compulsory. There is a Supreme Court case in the early twentieth century that says the state does have the right to do so or to prevent unvaccinated people from sending their children to schools.

NCA: What comments do you have on the use of data in the smallpox campaign as it relates to the history of global governance, globalization, or biopolitics?

EM: Certainly, people thought data were very important; it is embedded in the word surveillance, which is a collection of data. We know that at the SEP headquarters they had massive maps with pins tracking where every outbreak occurred and massive tables with pieces of data. Further, even in the original conception of the WHO, and before that still in the League of Nations, were the aims of data collection and data standardization. Even if the League of Nations did not directly collect data, its most important role was to standardize ways to collect data, so that the data coming in from regional or national bodies would be collatable. That was seen as crucial. The smallpox eradication campaign fit squarely within that tradition. In fact, one of the problems we have now, given the tremendous weakness of the WHO, with so little influence and so few people listening to it, is that many countries are just doing their own thing and collecting and publishing data in incompatible formats and with incompatible definitions. So, the data are not comparable and don’t aggregate. I think one of the results of the neglect of the WHO in the last thirty or forty years is that it is not able to do even that very basic task for which it was designed.

NCA: Do you have any comments on the comparison to today to the way you see data being discussed or used? Do you think the situation is continuous, that the discussion at the level of the international or the global has been about standardization and legibility?

EM: I haven’t heard much. My sense of it is that the recent discussion in the era of COVID-19 has been very broken up into national conversations, and data have been broken up into national bits. To the extent that we get data across national borders, it seems to be primarily designed to compare one nation to the other. We see all these tables and it’s almost like the Olympics: which nation is leading in this measure or that, and that bothers me for a number of different reasons. First is this assumption that national units are by definition comparable, which is deeply embedded in the idea of what a nation is and what international society is, but for this purpose it is ridiculous; it’s completely false, because each of these equivalent nations is so different along so many axes. The second is that there is almost no conversation about a global response to COVID-19 or how this data may help mount something that looks like a global response or at least a coordinated response. I would expect this of people who already have an ideological tendency to operate nationally, but what strikes me is that even those who are of the opposite camps, who I would consider to be internationalists in their outlook, such as certain news sources, are making little effort to propose, suggest, or even highlight the absence of coordinated international response to this crisis.

NCA: That is something I was thinking about. What normative or practical weaknesses in our political thought and structures do you believe have been exposed by this crisis? If we have a pandemic that is truly global—and we discuss its globality all the time—what are the normative and practical corrections needed to meet such globality?

EM: To me it seems obvious, and is already present if we go back to the beginning of international organizations in the nineteenth century.

I see internationalism not as synonymous with globalization but as a response to it. So, globalization is set of processes that heighten and quicken the connections—economic, cultural, biological, demographic—between different parts of the world, and internationalism is an attempt to respond to globalization by setting up mechanisms of governance or coordination. By the nineteenth century, it was clear that so many of the problems humanity faced had global aspects, the responses to which must be coordinated, or maybe even governed, internationally. That was the premise of setting up the institutions we have today, including the WHO. Health and disease are things in which the globality of the problem is so obvious it doesn’t even need to be argued. And yet despite the obviousness of the problem, we’ve really neglected and let atrophy these institutions. ‘We’ being the west, the international community, whomever, the people who are interested in this, you and me—these institutions have been allowed to atrophy as if they are not needed, and what this crisis shows so clearly, though I’m surprised few people seem to be saying it, is that they are needed.

For example: travel restrictions. Although there is a sovereign right to decide the travel parameters for each nation, it doesn’t make sense to me that there is no mechanism to coordinate them even on the informational level—not a world government with coercive powers to restrict travel, but a coordinating mechanism. The effectiveness of travel restrictions in one place depend at least partly upon the effectiveness or nature of travel restrictions in other places. We discovered this when Trump put his much-vaunted stop on travel from China. It was only a stop on direct travel from China, so it turned out a lot of people were still coming through Europe or other places. It just seems so obvious that strong functioning institutions on the international level are necessary that I am continuously puzzled that even outlets that would be sympathetic to that idea ideologically don’t seem to be talking about it.

NCA: To close on that note, how would you see today’s moment within the history and heuristic of ‘international society as a historical subject,’ as you defined it in your Diplomatic History article?

EM: I think when the history of COVID-19 and the pandemic is written, international society will be a crucial framework. These are early days yet and I want to use the Zhou Enlai—Mao Zedong’s longtime premier—escape hatch. When asked in the 1970s of the impact of the French Revolution, he reportedly said: it’s too early to tell.

I think it’s too early to tell what the history of our current moment will look like, but I have no doubt that a crucial, compelling component of that story would be international, and would have to use international society as a lens to think through the response to COVID-19, to unearth the interconnections that seem buried in the current discourse, and to explain why the international response has been so weak, so lacking, in the context of the history of the international society.

[1] Erez Manela, “A Pox on Your Narrative: Writing Disease Control into Cold War History” Diplomatic History 34, no. 2 (April 2010), p. 318.