Big story of small pox in Nepal

When we think of Nepal's history, mostly political events jump to mind: the expansion of the Gorkhali state, Jang Bahadur's takeover, or the 'People's War’. We rarely think about disease. But diseases have shaped the course of history in the Himalaya in many unexpected and important ways. 

Perhaps no disease did so more than malaria, which plagued low hill valleys and especially Tarai forests for centuries. Its near complete eradication in the 1960s has altered the lives of almost every Nepali in one way or another. 

Viruses somewhat similar to the coronavirus have also touched the lives of countless Nepalis, and shaped larger events. Measles, influenza, hepatitis, polio, and rabies have killed or maimed thousands. In 1918, the Spanish Influenza cut down 12-18 million Indians, and probably tens of thousands of Nepalis. 

In some districts in north India, 1 in 10 died. Near Agra, 1 in 7 died. More recently, 50,000 Nepalis now live with HIV, many others have been lost to this virus which first appeared three decades ago.

Part II: The smallpox virus in British India

Part III: Smallpox, politics and power in Kathmandu

Part IV: How Nepal eradicated the smallpox virus

Part V: Viruses past, present and future

Before COVID-19, perhaps the most feared virus in Nepali history was smallpox. Until its eradication in the mid 1970s, smallpox (biphar in Nepali, chechak in Hindi) regularly terrorised Nepali towns and villages. It struck mostly children, causing excruciating pain, killing many, and leaving survivors permanently disfigured. 

Every year saw new cases, but every five or ten years, a broader epidemic would tear through communities, particularly dense settlements such as Kathmandu and avenues of trade and communication, such as Nepal's postal routes. 

A large outbreak hit Kathmandu in 1958, and a pockmark survey in 1965 showed that 16% of the Valley's population had contracted smallpox at some time in their lives. And they were the survivors -- the virus killed roughly one of every three it afflicted.

Unlike diseases like cholera that hit the poor in greater numbers, smallpox was an equal opportunity killer. It struck down both raja and raiti. Several times it invaded Nepal's royal palace.

The last case of smallpox in Nepal appeared in 1975. The disease, historian Elizabeth Fenn has written, is ‘a misery commonplace in years gone by but unfamiliar to the world today'.

Kathmandu in the time of Cholera, Tom Robertson

Viruses like smallpox and COVID-19 originate in animals before spreading to humans. Coronavirus developed in bats, but no one knows where smallpox came from. Today, experts believe that as many as 100 million types of viruses exist in animals worldwide, waiting to jump to humans under the right conditions. 

Once in the human body, viruses become tiny engines of infection of simple but deadly design, little bits of genetic coding packaged in a protein that hijack the body's cells, transforming them into ‘virus producing factories', as historian of medicine Frank Swowden has put it. The virus then reproduces exponentially, killing its host cells and, unless checked, overwhelming the body's defenses.  

All diseases have different characteristics and personalities. Their origins, methods of transmission, symptoms, and social impact vary widely. 

Smallpox spread easily. It moved not by bite of flea or mosquito but from human to human contact, normally through droplets coughed or sneezed into the air. Because the disease caused open sores in a patient's mouth and throat, a single sneeze or cough could launch thousands of infected particles into the air. 

The virus could also spread through beds and items of clothing. If you lived in a house with a relative suffering from smallpox, and if you had never had the disease before, you had a 50-50 chance of getting it. There was no cure.

The insect that changed Nepal's history, Tom Robertson

Smallpox was horrific. Perhaps only bubonic plague and cholera sparked more terror. It left survivors badly pockmarked and often blind. Historically, smallpox caused three-quarters of all blindness in India. 

Smallpox, an Indian observer noted in 1879, ‘touches the keenest of human susceptibilities; for there are thousands in this country who, though spared by it from death, still have traces of its violence in the deep marks on the face or the loss of an eye’.

Around the world, the smallpox virus wrought havoc and dramatic social change. In Europe, it ripped through the dense, disorganised cities and towns of the 17th and 18th  centuries. Half of Europe's population carried scars from the disease. Smallpox afflicted rich and poor alike. It killed England's Queen Mary and Prince William, ending the house of Stuart.

In the Americas, smallpox spurred even more devastation and turmoil. Because indigenous groups had no previous exposure and therefore no immunity, they died in much higher rates than Europeans. Whole communities were wiped out. 

“Nepal is a microcosm of all of the changes in world health”, Nepali Times 

The massive waves of death cleared the way for European settlement and spurred the import of slaves from Africa, many of whom had immunities from childhood. Smallpox acted as an ‘unwitting instrument of empire,’ according to Fenn.

In its tragic wake, smallpox also prompted important public health innovations. In many parts of Asia, including India and Nepal, people for centuries used variolation -- inoculation using live virus -- to block the disease. A string infected from a mild case of the disease would be rubbed under the skin, thus actually giving the person the disease. Some would perish, but most survived, thereby gaining immunity from future outbreaks.

A less risky and more broadly effective vaccine was developed in Britain in the 1790s. A country doctor named Edward Jenner, noticing that milkmaids never contracted smallpox, discovered that intentionally giving humans cowpox -- a virus related to smallpox -- could create immunity to the disease without inoculation's painful symptoms and risk of death. 

Jenner predicted that vaccines like his could one day eradicate smallpox from the planet. ‘The annihilation of the smallpox, the most dreadful scourge of the human species,' he wrote in 1801, 'must be the final result of this practice.’

That prophecy became reality in the 1970s -- but only after a century of misguided British efforts in colonial India, and only after a complicated and controversial global eradication campaign in the 1960s and 1970s that only succeeded, as one historian of medicine put it, ‘by the thinnest of margins’. 

Coronavirus differs from smallpox in important ways. Nonetheless, revisiting smallpox's history in the Himalaya can help us better understand the interconnected social, medical, and political landscapes in which we live. 

This is the first in a series of articles about the history of disease in Nepal. Forthcoming columns will explore British attempts to spread vaccination in India and the role of smallpox in Kathmandu’s power struggles in the 19th century, and its eradication campaign in the 1960s. Tom Robertson, PhD, is researching the environmental history of Kathmandu Valley.