S2E6 / Bodies Remember What Was Done to Them

In the early 1970s, all around the world, worries about overpopulation were mounting. Politicians warned about the dangers.

Our cities are going to be choked with people.

They're going to be choked with traffic. They're going to be choked with crime, and they will be impossible places in which to live.

Popular books like The Population Bomb suggested an impending apocalyptic future. Pulpy paperbacks were passed around capturing people's imagination and stoking fears. 2 million copies of The Population Bomb were sold, and the author landed on late-night television, his dire predictions becoming entertainment for Americans sitting at home on their couches. Meanwhile, on the other side of the globe, India, with its growing population, was in the crosshairs of the world's anxieties. In the early '50s, India had launched a family planning program.

There are 5 million more mouths to feed every year. If our population continues to grow unchecked at the present alarming rate, We cannot solve our problems of food and shelter.

And that state-sponsored campaign got political and financial backing from international organizations like the World Bank and American foundations like Ford and Rockefeller. Health workers were dispatched across India to get people to have fewer children. Sometimes voluntarily. Sometimes for a monetary reward. Sometimes using force. Violence and coercion created distrust. In this episode, we'll explore how that distrust affected the public health campaign to stop smallpox and ask, what is the path to restoring trust? I'm Dr. Celine Gounder, and this is Epidemic.

Ready? Good afternoon. My name is Dr. Chandrakant Pandav. This is a recording in my office at New Delhi.

Chandrakant Pandav's office is decorated with his academic degrees, lantern lights, and floral wallpaper. There are photos of Mahatma Gandhi, Mother Teresa, and various Hindu deities framed in gold. And on his desk is a small saffron white and green flag.

Most important, I have India's flag always in front of me.

And what's the reason for that?

Patriotism. "Mera Desh Mahan." "Mera Desh Mahan"—

"My great nation," he says in Hindi. Chandrakant was so eager to share his pride that at one point he picked up the flag and waved it around a bit. He could barely contain his love for his country and its culture. He even got up out of his chair, turned on a song, and started dancing. A twist of the hand here, a little shimmy there. He did a few hand mudras with a look of delight on his face. I couldn't help but smile along with him. But even with all that joy, when the music stopped and he shuffled back to his chair, you're reminded that Chandrakant is in his 70s with more than 50 years of experience in public health. He was one of thousands of people asked to take part in the smallpox eradication program in the early and mid-'70s. He didn't hesitate when he got the call.

I said, this is the time to serve my India because India has spent so much of money on my education and making me a doctor. So I came from this culture, strong, strong ethical background. That your life is not for yourself, money doesn't matter, serve the society.

Chandrakant led a team of smallpox eradication workers. He says nearly every person he talked to about the smallpox vaccine seemed to have the same worry, the same questions.

What is this vaccine? What is it you're doing to us? Maybe it's a population control measure. So the strongest question they had This is the government of India's new policy for sterilization.

Sterilization, the government's decades-long family planning campaign, was very much top of mind. Decades later, when Chandrakant thinks about the program and the unethical tactics India used, the pride melts off his face.

It was a very aggressive strategy. Unfortunately, I don't want to go into that period. It was very aggressive.

Chandrakant didn't want to talk about it, but you can't tell the story of smallpox eradication's success without talking about the family planning policies that came first. Without talking about the state-sponsored coercive tactics that were commonplace and accepted by many. Without acknowledging the violence of forced sterilizations. Public health doesn't happen in a vacuum. And India's approach to family planning eroded trust in public health workers for years. So in this season all about smallpox, we're going to spend some time this episode diving into the details of the family planning program.

My name is Gyan Prakash, and I'm a professor of history at Princeton University.

Gyan has spent years studying India's family planning campaign and the various tactics the government used to sterilize millions of people. The government would pay people to get sterilized, and after natural disasters like a drought, when many were desperate, any amount of money could be a powerful motivator. Patients might receive fewer than 100 rupees as compensation, which translates to only a few days' wages, according to a 1986 article published in the journal Studies in Family Planning.

It was a very small amount, but it mattered. It mattered to the poor. It was coercive because it was between going hungry and not going hungry.

And if you chose not to get sterilized, Guion says, the government found other ways to twist the screw. Families would receive food rations for up to only 3 children. Any child beyond that would not be allotted food.

Which punishes families which have more than 3 children.

At one point, the government began to prioritize men for sterilization. Vasectomies were sometimes pushed on men, according to a 1972 report from the Associated Press. Ghyan says India's family planning campaign created an atmosphere of intimidation and harassment that was nearly impossible to escape.

You know, sending district authorities backed by police to the countryside and hold sterilization camps. So, I mean, the entire state machinery was mobilized to get people to the sterilization table.

Some of the harshest treatment during the sterilization campaign was aimed at Muslims and indigenous populations like Adivasi tribes living in remote and rural parts of the country. I spoke to Sanjoy Bhattacharya about this.

I'm a historian of medicine with a deep interest in health policy, national, international, and global. And I'm the head of the School of History at the University of Leeds, United Kingdom.

Sanjoy says marginalized communities were often scapegoated.

That global narrative of overpopulation took the shape of, oh, Muslims have more children than Hindus. Therefore, Muslims are the problem behind Indian overpopulation, so we need to control the Muslim birth rate. What sterilization did was to violently sterilize men from a certain community who were blamed for a population problem that was a general population problem.

Sanjoy says many Adivasi and Muslim communities in particular lost trust in the government. This distrust lingered and simmered for years. Imagine for a moment that for decades, government trucks have descended on your village unannounced. Tents were set up. Equipment was unloaded. Workers fanned out to talk to village leaders. This is what it looked like when Indian health workers showed up to sterilize you and your people. And then in the early 1970s, more government trucks arrived, maybe with familiar faces at the wheel. Maybe it's some of the same public health workers. They unload similar sharp-edged tools and set up their tents. But this time, they promise it's not for sterilization. It's for a smallpox eradication program. You'd have a hard time trusting them.

And there are tales of how villages would empty when rumors would spread that these teams were coming ostensibly to vaccinate, but maybe really to sterilize. I mean, People's bodies still remember what was done to them. They were treated like animals. Cohesion, coercion, coercion.

That's community medicine physician and longtime public health leader Chandrakant Pandav again. He says when he arrived in the northern region of the state of Bihar, he knew these communities had every reason to doubt his team. So first, he worked to earn people's trust.

So when you sit with the leader of the village along with the batch of people there, you talk to them, you explain to them.

And Chandrakant says it's helpful to think of yourself more as a guest than a guest of honor.

You don't sit on a chair. I didn't sit on a chair. I sat next to them to make them feel that I'm part of that community.

It sounds like convincing the village leader was enough to convince the villagers.

It is the first step.

Another important step, he says, was to learn the local traditions around smallpox. Locals in Bihar faced the disease for many years, and they'd developed their own ways of dealing with it. They would tie the leaves of a neem tree outside the homes of infected people. The neem tree is said to have medicinal properties. Displaying its leaves outside homes where an active infection was present alerted others to stay away. A strategy designed to slow disease spread. It didn't stop the virus. It wasn't effective in the same way as vials of vaccine or the bifurcated needle. But the traditions needed to be honored. So Chandrakant and the other public health workers adopted some of the local strategies.

So it was a very good combination of ancient medicine, ancient practice with modern approach. Very good combination.

Another tradition his team tapped into was folk songs. They frequently used drums, songs, and the public address systems to communicate with people about smallpox. Music was an especially good match for Chandrakant's lively personality. Remember all that joy for India I witnessed in his office in New Delhi? The flag? The dancing? Imagine that harnessed on behalf of his mission to wipe out smallpox. In fact, he still remembers some of those folk songs nearly half a century later.

Because it's part of me. Every atom, every molecule breathes Ayurveda. Raini ratvara, jaage ke ka bhatwara, manika mushari, jaage ke ki kachari. So it became an important method of communication. I come back again and again, Selin, to the same point: establish a rapport and instill a sense of faith. Anything is possible.

Chandrakant was able to pave the way for acceptance of the smallpox vaccine and rebuild trust in public health. But he was one charismatic man. His approach, his compassion were admirable, and it worked where he was with the people in front of him. But the Indian government broke trust with tens of millions of its citizens during the family planning campaign. It makes me wonder about what it might look like to repair trust at that level across the public health system, across an entire country. Maybe that would mean an apology. Maybe that would be some kind of reparation to victims for the damage done to their bodies. My friend and colleague Tom Boyke says there's no single silver bullet for rebuilding trust.

That is too big of a mission for public health. We have enough challenges as it is. Instead of planning for how do we rebuild trust, we should be planning for dysfunction.

That's after the break. Distrust and mistrust in the government became something of a defining feature of the response to the COVID pandemic here in the United States. And while that might have taken many Americans by surprise, it was totally predictable to Tom Boykie. He's the director of the Global Health Program at the Council on Foreign Relations. Boikie says trust in the US has been deteriorating since Watergate, and that decline accelerated around the 2008 financial crisis. Mistrust here divides along racial lines. It's lower among African Americans, for example. And most notably, mistrust tends to be partisan, but it didn't start that way during the COVID pandemic.

I think we all forget that there was, for a period of time, a surprising level of political consensus. Almost all states imposed protective policy mandates, and most states imposed them at the same time. But as the fall stretched out, you saw some of those mandates and responses become more politicized. And the moment I regret is I think there was a moment when the Biden administration came in and there was an attempt to reset. And I myself and many others really, again, focused on this message of following the science. But I do feel like perhaps we missed an opportunity to try to pull in some people across partisan lines at that moment.

So as I'm hearing you describe this, restoring trust seems like a really massive undertaking. I wonder whether you think that's even the right framework that we should be using to think about this challenge?

Such a great question. No, I think it isn't. I think if we set an agenda for public health to rebuild the cohesiveness of our societies, to make us have a better relationship with our government, with each other, we will fail. That is too big of a mission for public health. We have enough challenges as it is. Instead of planning for how do we rebuild trust, we should be planning for dysfunction. That's really what preparedness is about.

So what are some of the ways that public health officials can reach skeptical communities?

Through kinship networks and local leaders has been important. In some other public health crises like HIV, people have used soap operas.

I remember being in South Africa in the early 2000s. There was a soap opera called Soul City. We pulled a clip of it, and there's this one scene where a husband comes home to find his wife has placed a romantic gift by their bedside. He opens it up and sees condoms.

So that we can have safe sex.

Safe sex?

I can't have sex with you while I'm anxious about getting sick.

Or would you prefer I use condoms?

Maybe we don't need condoms. I do.

I was in South Africa, and the country was riveted. People really talked about it. It took hold. They did a nice job of making it interesting, like weaving in the themes you wanted to weave in about HIV. About people getting tested and talking to their partners and loved ones about their circumstances. I know, Celine, you were very involved in the Ebola response in 2013 through 2016. You know, there is high levels of mistrust in government in those post-conflict settings that were most affected in that epidemic.

People there don't trust government. They think that people who serve in government do so to enrich themselves and their family and friends. When I was in Guinea during the Ebola epidemic, they said Ebola was a hoax, that it was just a way for government officials and international organizations to enrich themselves. And yet we were able to make some inroads convincing people to comply with Ebola control measures, so handwashing, testing, safe burials. Much of that was done through imams and other religious and community leaders.

Those are the types of strategies we should be deploying when the next health crisis emerges, but not simply waiting until that happens. We need to start to build the infrastructure, the relationships. Again, even if it isn't around fundamentally transforming, you know, communities' relationships with the government or even how community members feel about one another, because interpersonal trust, social trust is a big part of this too. It's about building about building the connections, the networks, about starting to engage individuals in these programs or through those institutions so that when the crisis emerges, you're not building that from scratch.

Well, and to your point, as we prepare for the next pandemic, do you think we've learned those lessons about trust or are there things we're still getting wrong?

I think there is a greater appreciation for trust as an important issue. You hear that messaging. What I worry about is we're not seeing it reflected yet in where the money is going. Where the money is going by and large is to developing vaccines faster, better vaccines in the future. But if really the lessons we're drawing from this crisis are that developing a vaccine instead of in 326 days in 250 days. If we really think that would have made a difference in this pandemic, we haven't been paying attention.

Next time on Epidemic.

They did not consider smallpox as the major issues among the many issues they were confronting. Number one priority is food and food and food. And the second priority is It's food and food and food.

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 Taylor Cook, Zack Dyer, Bram Sable-Smith, and me. Syed Tijan Thomas Jr. was scriptwriter for the episode. Swagata Yadavar was our translator and local reporting partner in India. Our managing editor is Tanya English. Una Tempest is our graphics and photo editor. The show is engineered by Justin Garrish. We had extra editing help from Simone Poprel. Music in this episode is from The Blue Dot Sessions and Soundstripe. This episode featured clips from National Education and Information Films Limited. 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 more people find the show. Follow KFF Health News on X, formerly known as Twitter, Instagram, and TikTok. And find me on X @CelineGounder. On our socials, there's more about the ideas we're exploring on our 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.

Mm-hmm.