S2E1 / The Goddess of Smallpox

It's a hot, humid day in New Delhi. Little shops line the street. Food stalls, a kite store, and a small neighborhood temple nestled among them. And just outside the Orange Temple gate, a pile of flip-flops and sandals. The temple bells are calling, so I take off my shoes and head inside. The walls are covered in floral tiles, and all around me, people pray barefoot in the glow of the fluorescent lights. There are offerings of flowers and sweets in front of the statue of the elephant-headed Hindu god Ganesh. And nearby, a less familiar figure, the goddess Sitala Mata. She's riding a donkey with a pitcher of water in one hand and a broom in the other. She wears a fan on her head like a crown. There's a garland of marigolds strung around her neck. Sitala Mata, the goddess of smallpox. I'm Dr. Celine Gounder. I'm an epidemiologist and infectious disease specialist. My dad grew up in a rural part of southern India, and his childhood there was shaped by relative poverty. Dad was the first person in his village to make it past the 5th grade, smart and fortunate enough to make it to a prestigious university. He came to the United States for grad school and became an engineer, but he told us stories of the big divides back home in India in health and education and opportunity. Those stories shaped me. Those inequities are a big part of why I chose a career in public health. I became a physician and over the years worked on infectious disease outbreaks all over the world—tuberculosis, HIV, Ebola, and of course, most recently, COVID. Watching the United States respond to the pandemic got me thinking back to another disease that gripped the world: smallpox. In the 20th century alone, smallpox killed over 300 million people. But in one of the greatest success stories in science, medicine, and public health history, we conquered smallpox. Gone everywhere. In the summer of 2022, I traveled to India and Bangladesh to seek out that history. This podcast is the story of the final days of smallpox eradication in South Asia. But before we get to that, I want to share what I'm beginning to understand about the role smallpox played in people's lives. That's why I'm here at this temple. Smallpox was seen as part of nature, elemental. Something so old, so ingrained in daily life, that it had a place among the gods.

I am Rajendra Prasad Dhyani. I serve at the Sitala Mata Temple, Madangir C, 1st Block. You want to know about Sitala Mata, don't you?

There are lots of origin stories for Sitala Mata. The story the temple priest Rajendra told me starts like this: One day in a village, people were washing clothes. A goddess was wandering the town disguised as an old woman when someone threw scalding water on her.

She got blisters all over her body. She got on a donkey and started roaming around the village, screaming in pain.

One of the villagers poured cold water on the old woman. She was magically healed and revealed her true form as the goddess Sitala Mata.

She said, "Anyone who suffers from a blistering disease, be it chickenpox or smallpox, if you give them food cooked a night before as my blessing, they will be cured." Shitala Mata both gives smallpox and cures it.

Her disease can be seen as a curse, a terrible illness, or as a blessing. —an opportunity to rest and reflect.

She blesses people with peace of mind and calm. Sital means cool, so she soothes the mind and bestows devotees with peace of mind. She is the goddess of tranquility.

What Sitala Mata represents in Indian culture is complex. And defeating smallpox required appreciating and respecting that complexity. It also took medical advances, fresh ideas about epidemiology, unlikely partnerships, and the unwavering dedication of hundreds of thousands of healthcare workers. We have firsthand accounts from health leaders who were there, some who have never been heard outside of India and Bangladesh. I'm Dr. Celine Gounder. And this is Epidemic. Today, it's hard to even imagine what it was like to live in a world with smallpox. Where in the course of your daily life—riding a train, sitting in a classroom, going to work—you could catch a virus so deadly that it killed about 1 in 3 people. That was the death toll before smallpox vaccination became widespread. 1 in 3. And if you did survive, the scars left behind might haunt you for the rest of your life. I met up with someone who lived in those before times, when eradication was still a far-off dream.

My name is Dinesh Kumar Bhadani. I'm a retired station manager in Indian Railways. Now my age is 68 years.

I met up with Dinesh Bhadani and his daughter Priyanka at their apartment in New Delhi. As we drank sweet pomegranate juice, Dinesh told me about growing up in the 1960s in Gaya, a small holy city in the eastern state of Bihar. Pilgrims from around the world traveled there to visit the temples. And in the Bihar of Dinesh's youth, his hometown was one of the last hotspots for smallpox. Dinesh says diseases like smallpox, measles, mumps—they weren't just a matter of bad luck. To many, they were the will of the gods.

People used to call all of these as some type of wrath from God. People did not consider them illness. People used to say they were divine rots.

Dinesh's family home was enormous. It was hundreds of years old. Sometimes more than 50 people cooked together, ate together, and with little ability to isolate, they got sick together. Especially during a smallpox outbreak.

There was an atmosphere of fear because the number of deaths had increased.

Especially teenagers.

At that time, many people died, especially teenagers. A lot of young people died.

Smallpox could spread quickly, traveling from person to person from a cough or a sneeze, through everyday family contact with contaminated bedsheets or towels. The first signs of infection were usually a high fever, headache, and sometimes vomiting and diarrhea. Then pustules filled with fluid appeared on the body, both inside and out. It was searingly painful. People often died within 2 weeks, many of them young children. Those who survived could be left severely severely scarred, infertile, or blind. A smallpox vaccine has been around since the 18th century, but that protection didn't reach enough people, so smallpox thrived and continued to kill millions around the world. Dinesh says he remembers that in Bihar, people had real misgivings about getting the vaccine. Some didn't want to interfere with the will of the goddess Sitala Mata. Other people hesitated because of the vaccine itself, and the procedure could hurt.

They were afraid that it was painful.

That's why people would run away, like, "We will not take it." Smallpox vaccinations in the 1960s really did hurt more than the quick shots we get today. Health workers dipped a rotating barbed disk into the vaccine solution and then twirled it into a patient's skin. The vaccine entered the body through these open wounds. It was a brutal procedure.

It used to be very painful. It took more than one week to heal.

But as more and more people fell ill, the calculus of fear began to change. For Dinesh, it happened when he was 10. A classmate died of smallpox. It was the mid-1960s.

He was a very handsome boy. He was the most good-looking boy in our group.

Dinesh was curious about what happened to his friend, so he went to see the body.

The skin was not visible at all. It looked like a person who got burned, whose entire skin had been burnt. There were blisters all over his body, and a foul smell was coming from his body.

Dinesh was so terrified that he couldn't sleep for 3 days.

The fear that it created after seeing him, after witnessing his death, fear spread among people like, let's take the vaccine so that we don't have to face these kind of deaths.

There was a vaccine camp at his school, and Dinesh lined up for his dose. Then health workers went house to house, knocking on doors to find any children they'd missed. In the end, Dinesh says every student at his school was vaccinated. And that feeling of fear that gripped the community began to fade. School by school and town by town, health workers repeated this painstaking work across the state of Bihar. Decades after smallpox was eradicated, it was hard for people who had survived the disease to really leave it behind. Dinesh's daughter Priyanka Bhadani says that when she was maybe 10 or 12 years old, she started noticing how the adults around her reacted to lingering smallpox scars. It was the 1990s by then.

I realized that a lot of people were not welcome in the house, a lot of people with those marks that smallpox left on their bodies. So there's this one uncle who couldn't get married till the time he was 45, 46, because he had these Scars.

Survivors like her uncle were isolated, sometimes cut off from society. Priyanka remembers a local businessman who experienced the stigma that often followed someone who'd had smallpox.

He loved one girl in the community. He wanted to get married to that girl. The girl was also in love with him, but then he got smallpox and the family refused. And his entire life was spent in proving himself to be worthy of the girl. So he established a business which was huge for people to take notice of him.

Traveling around New Delhi and Pune, I met several older people with pockmarks on their faces. But this is the last generation with those scars. In 1980, the World Health Organization declared that smallpox was eradicated, wiped from the planet. It's one of the greatest triumphs of science, medicine, and public health. But today, roughly 40 years after the disease was defeated, hardly any of my colleagues in public health have any living memory of smallpox or the Herculean effort it took to eradicate it. We're going back in time to consider that history. If we're to overcome current-day crises, from COVID to climate change, perhaps there's something we can learn from those bold leaders of the past. Generations before us imagined a world without smallpox when that goal must have felt like science fiction.

In science fiction, there's questions that generally guide how we create. So it's, what if? Like, what if cars could fly? What if everyone had healthcare? What if? And if this goes on where it's like, if this goes on the way it is, if nothing was to change, can we live with this?

Can we live with this? What would it take to imagine a world with fewer COVID deaths When we come back, we'll speak with social justice organizer and author Adrienne Maree Brown. She'll tell us what science fiction can teach us about dreaming up the next great public health triumph. Our reporting on what it took to eradicate smallpox has me wishing that our country had a bit more moral imagination as it faces COVID and braces for the next public health crisis. Moral imagination is the idea that to solve big problems, you have to think big, dream big. Then you have to fuel those dreams with down-to-earth creativity, empathy, and commitment. Joining us is social justice organizer and science fiction author Adrienne Maree Brown.

It's really nice to be here, and I'm grateful you're approaching this topic. So let's see what we can do.

Adrienne, whether you're writing science fiction or organizing for social change, a lot of your work is about imagination. Over the course of my career, and I'm sure you've run into this too, of people saying some version of, "This is the way the real world is," or, "This is just the way it is." Mm-hmm. And they tell you that some changes aren't possible, that some ways of doing things just don't make sense. Where do you find the inspiration to think up, to dream up the worlds that are so wildly different different from our present reality.

Saying that stuff is just the way it is, that's one of the greatest ways that those who currently benefit from the way things are keep us from even imagining that things could be different. For centuries in this country, we were told that slavery was just the way things are and that it could never be any different. And yet there are people in those systems who said, this isn't right, this isn't fair, something else is actually possible. So a lot of The work of radical imagination for me is the work of saying, can we imagine a world in which our lives actually matter and we structure our society around the care that we can give to each other, the care that we need?

And as part of this idea of radical imagination, I know that you really draw on science fiction as a way of helping us test out solutions to real problems. Is there an example from your fiction, maybe your new book Grievers, of fiction helping provide solutions to real problems?

Grievers is the first in a trilogy of books, and in the beginning, the first novella, we have a plague that rolls out through the city of Detroit and stops people from being able to function in any way. And they're really overcome with what appears to be debilitating grief. And when COVID happened, I felt what I had been writing about in the book was in practice. And so what is emerging in these books is how do we actually come up with plans for surviving changing conditions together?

Well, one of the frustrations I've had as a doctor and epidemiologist working in the pandemic is that our leaders seem to think that our current COVID death rates are acceptable, even though at the current levels we'd be looking at about 100,000 deaths per year. How can we influence change when many people in power aren't willing to spend more money to save more lives, especially when it comes to marginalized communities that have been hit hardest by COVID?

Hmm. I think what's very difficult, and I think what you've been pointing to, is we're in a situation right now where our economic structure works directly against every other aspect of our survival. I lost people to COVID. I'm not okay with it. I don't accept it. And it's so heartbreaking because it's like, your government could have protected you from this. Your job could have protected you from this. Like, there's so many front lines that could be held that would protect our people. And I keep coming back to disability justice and disabled communities because that's where I see some of the most interesting hard work happening around this now. 'Cause they're like, it's great that y'all are all trying to rush back into acting all normal. We literally can't do that. We're not willing to pay the cost. And so watching communities start to figure out how to navigate that with each other, how are disabled communities getting together? Why are we so willing to let so many people die unnecessarily rather than making the necessary pivots inside of our economic models and inside of our approach to community with each other?

Early in the pandemic, it did feel like people were reimagining things to some degree, like remote learning, you know, or how do you expand access to broadband or access to healthcare coverage or paid sick and family medical leave for everybody. But now we're seeing fewer and fewer resources being allocated towards saving lives. People are feeling really beaten down in public health right now. We're really at an all-time low in terms of morale. Where do you turn to for reminders that another world is possible, that there is hope?

What I have learned is that people cannot jump straight from crisis and despair to like, "A whole new world," right? You just— that's not a leap you make. Each of us is carrying the small piece of this collective grief. These are not numbers. They're people. They're mothers and fathers, grandparents, children. They're people that we loved. And we want to live a life and structure a world that honors what we've lost, as well as what we're dreaming of. What does that grief make us want to fight for? What does it make us want to dream up? What does it make us want to open room for?

Adrienne, it's interesting. We're addressing some of the same issues, but with very different tools. And I'm curious, do you have any final questions for me?

I think my question for you would be, What do you feel like are the most exciting innovations that you wish people understood and knew were in development around this? Oh, interesting.

I think it's not necessarily new innovation. Mm-hmm. Sometimes it's stuff that we already have and we just haven't scaled up and used. It's not enough to invent something new. You have to take it to scale. Yes. And so whether that is cleaning the air or paid sick and family medical leave. You know, as many as 15, 20 million people might be losing their Medicaid. Could we imagine everyone having healthcare or access to healthcare? What would it take to get there? Um, I think that's where I'd like to see innovation is actually in our ability to imagine that.

I love that these are things that we actually know work and it's how do we get people to be in the practice of implementation. So thank you for sharing on that.

Thank you, Adrienne. I've really enjoyed our conversation.

I'm really glad we got to speak. Thank you, Céline.

That was Adrienne Marie Brown, author of the Grievers novels, a speculative fiction series about survival and hope in a pandemic-stricken Detroit. Eradicating Smallpox, our latest season of Epidemic, is a co-production of KFF Health News and Just Human Productions. Additional support provided by the Sloan Foundation.

This episode was produced by Zach Dyer, Jenny Gold, Taylor Cook, and me. Tonya English is our managing editor. Una Tempest is our graphics and photo editor. The show was engineered by Justin Garrish. Voice acting by Ashish Mukherjee. Guruguruji, and Jatinder Singh Taneja. Music in this episode is from the Blue Dot Sessions and Soundstripe. We're powered and distributed by Simplecast. If you enjoyed the show, please tell a friend and leave us a review on Apple Podcasts. It helps more people find the show. Follow KFF Health News on Twitter, Instagram, and TikTok, and find me on Twitter @CelineGounder. On our socials, there's more about the ideas we're exploring on the podcasts and subscribe to our newsletters at kffhealthnews.org so you'll never miss what's new and important in American healthcare, health policy, and public health news. I'm Dr. Celine Gounder. Thanks for listening to Epidemic.