Navigating resistance in global health governance: Certification of smallpox eradication in China

ABSTRACT

Certification is an essential stage in disease eradication efforts, encompassing epidemiological, managerial, and political complexities. The certification of smallpox eradication in the People’s Republic of China (PRC, or China) exemplifies the multifaceted nature of the certification. Despite eradicating smallpox in the early 1960s, before the Global Smallpox Eradication Programme (SEP) intensified in 1967, China was one of the last countries certified as smallpox-free by the World Health Organization (WHO) in 1979. The WHO encountered notable resistance during the certification of smallpox eradication in China. This article examines the underlying motivations propelling China’s resistance, the factors that contributed to the shifts in its stance, the challenges navigated by the WHO, and the ultimate achievement of certification despite controversies surrounding its transparency and credibility. Through the case of the certification of smallpox eradication, the article provides a historical context of China’s selective engagement in global health governance, emphasising the critical importance of building a trusting relationship between the WHO and its member states. It offers insights for fostering effective collaboration among diverse stakeholders driven by varied political agendas in addressing shared global health challenges such as the coronavirus disease (COVID-19) pandemic.

KEYWORDS:

• Smallpox eradication
• certification
• China
• World Health Organization
• global health politics

Introduction

Certification is a crucial phase in disease eradication programmes, serving as a rigorous and systematic evaluation process to officially confirm the absence of the targeted disease in a specific geographic region. It not only validates the effectiveness of disease eradication interventions but also instils confidence in public health efforts, facilitating global cooperation and resource allocation for ongoing and future eradication initiatives. While scientific criteria primarily form the foundational basis of certification, the successful attainment of certification of disease eradication is contingent on the imperative of international cooperation, epitomised by social, political, and managerial complexities. This article directs its focus towards the certification of smallpox eradication in China to underscore the intricate dynamics of international cooperation in disease eradication programmes.

The Smallpox Eradication Programme (SEP), aiming for zero incidence of the disease worldwide, was an ambitious and complex campaign launched by the World Health Organization (WHO) in 1958 and intensified in 1967. Spanning various continents and nations for two decades, the global eradication of smallpox was officially declared by Halfdan T. Mahler, the Director General (DG) of the WHO, on 8 May 1980, making it the only human infectious disease to achieve such a status so far. The prevailing literature on the SEP predominantly concentrates on its operational aspects, such as funding dynamics, rollout strategies, and programme intensification, while a notable gap exists in scholarly investigations concerning the certification process. Extant studies tend to focus on the intensified phase of the programme between 1967 and 1977, particularly in regions where the WHO and the major powers, including the United States (US) and the Union of Soviet Socialist Republics (USSR), were actively involved (Arita, 2010; Birn, 2011; Foege, 2011; Greenough, 1995, 2011; Henderson, 2009; Manela, 2010; Ogden, 1987). Noteworthy critical assessments have brought to light the involvement of a more expansive array of actors in the SEP, challenging the historiography of smallpox eradication that primarily focuses on its intensified phase (Bhattacharya, 2006, 2013; Bhattacharya & Campani, 2020; Chen, 2021; Hochman, 2009). Despite these contributions, scholars have yet to undertake a critical examination of the certification, which is often seen as a technical exercise with insufficient attention to its inherently political underpinnings (Breman & Arita, 2011; Brilliant & Khodakevich, 1978; Fenner et al., 1988).

This article endeavours to provide a nuanced inquiry into the political intricacies inherent in disease eradication, specifically focusing on the certification of smallpox eradication in China. Given the nation’s substantial size and population, China was indispensable to the global efforts against smallpox. However, the independent verification of the country’s smallpox-free status was contingent upon establishing a trusting relationship between Geneva and Beijing. This article discerns critical challenges in the certification of smallpox eradication in China, critically examines the underlying political complexities propelling the country’s resistance, and subsequently elucidates the geopolitical shift and diplomatic efforts that facilitated the resolution despite the controversies surrounding its transparency and credibility. This article provides a historical context of the country’s selective engagement in global health governance by analysing the key challenges in China’s resistance to the certification of smallpox eradication and how the WHO navigated them. It emphasises the critical role of building a trusting relationship between the WHO and its member states in navigating such complexities. The experiences surrounding the certification of smallpox eradication in China offer insights applicable to contemporary global health crises, such as the ongoing coronavirus disease (COVID-19) pandemic. It serves as a backdrop for understanding the intricacies of engaging diverse stakeholders with disparate political interests in global health governance.

The global smallpox eradication programme

The consideration of smallpox as a feasible candidate for eradication was grounded in its substantial disease burden, the identification of humans as the sole reservoir, easily recognisable clinical manifestations, and the ability to mass produce an effective vaccine. Smallpox was an acute infectious disease caused by the variola virus, a DNA virus classified within the orthopoxvirus genus. The virus existed in two forms: variola major and variola minor. Variola major caused more severe clinical symptoms, leading to a fatality rate of approximately 20% in unvaccinated individuals, while variola minor exhibited a lower lethality of less than 1% (Fenner, 1982, p. 916). The transmission of smallpox primarily occurred through person-to-person contact, with natural infection commonly arising from inhaling respiratory droplets and direct contact with mucous membranes or contaminated objects (Belongia & Naleway, 2003). The clinical manifestations of smallpox included fever, head and body aches, severe fatigue, and characteristic skin lesions that typically progressed from the face and extremities. There was no effective curative treatment for the disease, and it left the majority of survivors disfigured by pox scars, with some also suffering from blindness (Henderson, 2011).

Nevertheless, smallpox was preventable through vaccination. The earliest documentation of smallpox prevention practices can be traced back to the tenth century. The ancient Chinese employed a variolation method to confer immunity by insufflating powdered material from smallpox lesions into the nostrils. This technique was later adopted in India, Central Asia, and Africa before it was introduced to Western Europe in the eighteenth century (Belongia & Naleway, 2003). However, improper handling and storage of variolation material could cause infection and subsequent disease transmission. In 1796, a safer and more effective method of inducing immunity against smallpox through cowpox was discovered by Edward Jenner. This breakthrough enabled industrial nations to curtail smallpox transmission during the nineteenth and twentieth centuries. Yet, the disease continued to exact a devastating toll, resulting in an estimated 300 million deaths in the twentieth century, primarily among populations in the developing world where vaccination coverage was limited (Henderson, 2011). The eradication of smallpox only became feasible in the 1950s, following the refinement of heat-stable vaccine techniques, a critical development for the effective deployment of smallpox vaccines in tropical regions (Henderson, 2011).

The initiative to embark on a global eradication campaign against smallpox was a subject of contention. Upon the establishment of the WHO, a strategic competition emerged between vertical mass campaigns targeting specific diseases and social medicine advocating for strengthening essential healthcare services (Medcalf & Nunes, 2018). The ascendancy of the vertical approach gained momentum due to the prevailing confidence in the magic bullet of biomedical technologies and pharmaceutical innovations to address health-related challenges, buoyed by the emergence of medical advancements during World War II, such as DDT and penicillin (Litsios, 1997). Consequently, the Global Malaria Eradication Programme (MEP) was launched in 1955, representing the WHO’s largest single initiative. However, despite the significant financial and human resources allocated to the programme, the attainment of malaria eradication appeared increasingly elusive by the end of the 1960s, resulting in a swift decline in interest and funding for disease eradication programmes (Cueto et al., 2019). In contrast, smallpox eradication faced initial resistance from the WHO and its member states. In 1953, when Brock Chisholm, the first DG of the WHO, advocated for the global eradication of smallpox, it was opposed by El Salvador, India, Pakistan, the United Kingdom (UK), the US, and Venezuela, with the argument that the smallpox issue was fundamentally regional or even localised in nature (Fenner et al., 1988, p. 392). The détente of the Cold War presented an auspicious opportunity for the pursuit of global smallpox eradication (Manela, 2010). The proposition for the worldwide eradication of smallpox was rekindled by Viktor Zhdanov, the Deputy Minister of Health of the Union of Soviet Socialist Republics (USSR), at the 11th World Health Assembly (WHA) in 1958. Notwithstanding its approval, the allocated budget was relatively modest, resulting in limited staff recruitment and sluggish progress of the SEP (Henderson, 2011).

Despite widespread scepticism regarding the feasibility of smallpox eradication, the global programme ultimately succeeded in 1977. At the onset of the SEP, disbelief in achieving smallpox eradication was pervasive. Even the DG of the WHO, Marcolino Candau himself, feared the possible failure of the programme, given the concurrent difficulties faced by a much larger MEP that had been underway for a decade and was facing setbacks. Nevertheless, in 1966, a resolute decision was taken to embark on a more earnest endeavour to eradicate smallpox within ten years (Henderson, 2011). Following the decision, the intensified form of the SEP was launched in 1967, and a Smallpox Eradication Unit (SEU) was established in the WHO Headquarters (HQ) in Geneva to oversee this global campaign. Donald A. Henderson, an American physician and epidemiologist, served as the unit’s director from 1967 to 1977, and he was succeeded by Isao Arita, a Japanese physician, virologist, and vaccination specialist. At the time when the intensified SEP was initiated in 1967, smallpox was considered endemic in 30 nations in most countries in the African Region, Brazil in the Pan-American Region, Afghanistan and Pakistan in the Eastern Mediterranean Region, as well as India, Indonesia, and Nepal in the South-East Asia Region. In 1977, the SEP advanced to its concluding phase through effective coordination between the WHO HQ and its six regional offices, support from both sides of the Iron Curtain, and the unprecedented active participation of more than 50 member states over a decade. The imperative of certifying global smallpox eradication became paramount when the last naturally occurring case was identified in Somalia on 26 October 1977 (Cueto et al., 2019).

Criteria for smallpox eradication

The definition and criteria for smallpox eradication were initially formulated in 1971. The first success of the SEP was achieved in 1970 when smallpox transmission was halted in 20 countries in West and Central Africa. By the end of 1971, the persistence of smallpox was predominantly restricted to four countries: Ethiopia, India, Pakistan, and Sudan (WHO Expert Committee on Smallpox Eradication [WHOECSE] & WHO, 1972, p. 6). In November 1971, the second WHO Expert Committee on Smallpox Eradication (ECSE) was convened to review the progress of the first five years of the SEP, evaluate the epidemic worldwide, and plan the strategies for the further implementation of the programme. The committee defined the eradication of smallpox as ‘the elimination of clinical illness caused by variola virus’ (WHOECSE & WHO, 1972, p. 5). Drawing upon the disease’s epidemiological features and observations during the SEP, the commission suggested that in a nation equipped with an effective disease surveillance system, the interruption of smallpox transmission could be considered achieved if no cases were reported over two years, except clearly identified and effectively controlled imported cases (WHOECSE & WHO, 1972, p. 5).

The procedures for the certification of smallpox eradication were initially piloted in South America in 1973 and were subsequently refined through the applications in the nations that participated in the SEP. Following the development of the definition and criteria for smallpox eradication, a series of independent international assessments, known as the certification of smallpox eradication, were carried out by eight International Commissions for the Certification of Smallpox Eradication (ICCSE). The ICCSEs, composed of independent consultants operating under the auspices of the WHO, were established to validate the efficacy of the SEP and surveillance systems of member states, with a particular focus on those countries where smallpox had remained endemic at the commencement of the programme. In 1973, the first certification of smallpox eradication was carried out in Brazil, two years after its last case was reported. The procedures and criteria were further refined in subsequent certification efforts in Indonesia (1974), West Africa (1976), Pakistan and Afghanistan (1976), India/Nepal/Bhutan (1977), Central Africa (1977), Burma (1977), and Bangladesh (1977) (Brilliant & Khodakevich, 1978).

The certification process typically commenced with member states preparing a country report evaluated by the relevant ICCSE. Various methods were employed to confirm the success of smallpox eradication, including assessment of active search for unreported cases, pockmark surveys, rumour registers, chickenpox surveillance, specimens for laboratory diagnosis, and public campaigns aimed at encouraging the reporting of suspected cases (Fenner et al., 1988, pp. 1114–1123). The approaches to the certification of individual states varied based on the time of eradication and their involvement with the SEP. In countries that participated in the SEP, the WHO-affiliated experts either worked directly alongside national staff in the certification, including assessing the active search for unreported cases of smallpox, conducting pockmark surveys, and monitoring chickenpox cases, or provided consultancy when required. In contrast, the certifications of nations that achieved smallpox eradication before the SEP without the involvement of the WHO encountered heightened challenges, often requiring procedure adjustments and careful negotiations with national health authorities (Fenner et al., 1988, pp. 1115–1116).

When the prospect of the final achievement of the SEP became evident, a Consultation on Worldwide Certification of Smallpox Eradication (CWCSE) was convened by the DG in Geneva on 11–13 October 1977. Seventeen experts in virology, epidemiology, and public health provided advice on the certification (Consultation on Worldwide Certification of Smallpox Eradication [CWCSE] & WHO, 1977). As a result, the Global Commission for the Certification of Smallpox Eradication (GCCSE) was established to continue the international commissions’ task of providing consultation and verification for the official endorsement of smallpox eradication worldwide. Frank Fenner, an Australian microbiologist and virologist, was elected chair of the committee (World Health Organization Global Commission for the Certification of Smallpox Eradication [WHOGCCSE], 1978). Fenner noted that ‘certification of smallpox eradication was not solely a technical matter but also involved many managerial and political questions’ (Fenner et al., 1988, p. 1114).

In the late 1970s, the WHO encountered a constellation of formidable challenges, underscoring the compelling need for the certification and official announcement of smallpox eradication to bolster the organisation’s leadership and instil confidence. The progress of decolonisation in the 1960s led to the inclusion of newly independent states in the General Assembly of the UN. The growing influence of the countries from the global south, collectively known as the Group of 77 (G-77), brought forth the demand for a New International Economic Order (NIEO) to rectify the historical inequalities in economic power and resource distribution between developed and developing nations. This transformation in global dynamics led to a recalibration of power relations within the UN and its specialised agencies, including the WHO (Chorev, 2012, p. 288). Meanwhile, the MEP, characterised by a heightened operational intricacy, including the absence of a viable vaccine, symptoms not easy to diagnose, and the vector-borne nature of malaria that required mosquito control, encountered an imminent failure notwithstanding the substantial financial and personnel investments. Despite the achievement in smallpox eradication, a growing discourse concerned the cost-effectiveness of the vertical approach – a strategy hitherto endorsed by the WHO, which presented a formidable challenge to the organisation’s leadership (Litsios, 2002). Consequently, the WHO shifted its focus to primary health care, an approach addressing a wider array of socioeconomic determinants of health and promoting inter-sectoral coordination and universal access to essential health services (Brown et al., 2006, pp. 66–67). In this context, the successful eradication of smallpox assumed heightened significance, symbolising a milestone in the organisational history of the WHO and reasserting its leadership in international health cooperation.

Certification of smallpox eradication in China: A challenging mission

The certification of China presented a formidable challenge to the global commission, entailing intricate political complexities arising from the country’s distinctive relationship with the WHO, accentuated by the unfolding Cold War and China’s position within it. When the Chinese Communist Party (CCP) won the civil war, and the Nationalist Party (Kuomintang, KMT) retreated to Taiwan in 1949, the WHO was forced to navigate a strategy to address the dilemma that both regimes across the Taiwan Strait asserted themselves as the sole legal representative of China (Kaufman, 2000). Given that the Republic of China (ROC) was one of the WHO’s founding members, there was a predisposition within the organisation to maintain the existing membership arrangement while acknowledging the PRC’s entry. Nonetheless, the communist leadership in Beijing renounced its involvement with the WHO and vehemently pressed for its acknowledgement as the sole legitimate representative of China in the global arena.

Citing UN Resolution 396 (V), the WHO proposed that disputes related to membership should be initially resolved in New York (General Assembly, 1950). In accordance with the provisions of the UN constitution, the legal representation of a nation was contingent upon approval from both the General Assembly and the Security Council, which was fundamentally hinged on international recognition (Foreign Office, 1949). With the escalation of the Cold War, the representation of China in the international arena became the forefront of the competition for power in East Asia between the two blocks. To curb the expansion of communist influence in Asia, the US and its allies backed the ROC in its persistent pursuit of legal representation of China within the UN and its specialised agencies until 1971. Following the evolving relationship between Beijing and Washington, D.C., the General Assembly passed a resolution on 25 October 1971, recognising the PRC as the only lawful representative of China at the UN and one of the five permanent members of the Security Council (United Nations General Assembly, 1971). Consequently, the PRC was admitted as a member of the WHO at the 25th WHA in May 1972 (WHA, 1972). Throughout these two decades, China denied diplomatic relations with the WHO, declined technical collaborations with the organisation, and imposed restrictions on sharing information with it.

In this context, the PRC embarked on its own initiative to fight against smallpox without relying on external financial, material, and personnel assistance. The smallpox eradication campaign in mainland China was launched in October 1950, following instructions from the state council of the central government. This campaign encompassed a nationwide mass vaccination programme, accompanied by mass production of smallpox vaccines, public education initiatives, and training programmes for the vaccinators (Xu & Jiang, 1981). By 1953, more than 560,000 million doses of smallpox vaccines were administered nationwide. The incidence rate of smallpox cases dropped from 11.22/100,000 in 1950–0.59/100,000 in 1953 (Chen, 2021). Apart from the mass vaccination campaign, routine smallpox vaccination was included in the national immunisation programme and provided to newborns, with revaccinations scheduled at 6, 12, and 18 years old (Chen, 2021). China’s capacity to independently develop, manufacture, and distribute vaccines, along with its ability to ensure nationwide compliance with smallpox vaccination and to implement other public health interventions on a mass scale, played crucial roles in strengthening population immunity and reducing the risk of a smallpox epidemic.

In addition to vaccination, the successful eradication of smallpox in China was facilitated by a range of public health measures, encompassing the strengthening of community health infrastructure, rigorous epidemic surveillance, proactive case identification, meticulous contact tracing upon reporting of suspected cases, effective isolation of confirmed cases, and prudent quarantine of potential contacts. Major metropolitan areas such as Beijing, Tianjin, and Shanghai achieved initial success in smallpox eradication as early as 1951, followed by provinces along the eastern coast, including Jiangsu, Zhejiang, and Shandong (Chen, 2021). After 1953, smallpox cases were no longer reported in the middle and southern regions of China, including Hebei, Jiangxi, Hubei, Hunan, and Guangxi. In contrast, the eradication took an extended period in border areas such as Inner Mongolia, Xinjiang, and Xizang (Tibet) Autonomous Regions, as well as Yunnan Province. Although it was believed that the last smallpox case in China occurred around 1960, this information was not officially validated (Chen, 2021).

When the global SEP intensified in 1967, both the SEU and the WHO Western Pacific Regional Office (WPRO) sought information on the status of smallpox transmission in mainland China. However, access to such information was limited, primarily relying on observations from WHO-affiliated personnel who had either visited China or had personal connections in the country. For example, Karel Raška, the director of Prague’s Institute of Epidemiology and Microbiology, visited China in the 1950s before he was appointed director of the Division of Communicable Diseases of the WHO in 1963 (Cueto, 2019, p. 120). He confirmed the implementation of a mass vaccination programme and supported the claim that smallpox had already been eradicated in China (World Health Organization Western Pacific Regional Office [WPRO], 1967). Furthermore, David McKenzie, a former health officer in Hong Kong, informed WPRO staff that smallpox was eradicated in the PRC in the early 1960s based on his observation of the vaccination records of immigrants from mainland China to Hong Kong (WPRO, 1967).

Throughout the decade of the intensified SEP, WHO officials in Geneva and Manila continued to collect evidence of smallpox eradication in China through unofficial channels, such as pockmark surveys of mainland Chinese travellers to Hong Kong (Thomson, 1968). Following China’s accession to the WHO, Chang Wei-hsun, a Chinese representative in Geneva who served as Assistant DG, confirmed the assertion that the last case of smallpox in China was reported around 1960 (Fenner et al., 1988, pp. 1248–1250). Additional insights into the eradication of smallpox in China were presented by a Chinese delegation led by Huang Shu-tse during the 26th WHA in May 1973. It was elucidated that smallpox transmission had ceased in China in 1959 following a nationwide mass vaccination programme. After the mass campaign concluded, smallpox vaccination was integrated into the national immunisation programme, with all citizens mandated to be vaccinated at six-year intervals (WHA, 1973). However, despite the prevailing belief among WHO officials that smallpox was eradicated in China in the late 1950s and early 1960s, the available evidence was not sufficient to officially verify such a claim (CWCSE & WHO, 1977).

Political intricacies in certifying China

Given the political intricacies, China’s circumstances warranted special consideration in the certification of smallpox eradication. Due to the strained diplomatic relations between Beijing and Geneva, China developed a profound and enduring mistrust of the WHO. The country maintained a persistent belief that the WHO was controlled by the imperialist powers, grounded in the observation that a substantial proportion of the organisation’s employees, especially those occupying senior positions, originated from Western nations, primarily the US and the UK, while individuals from the socialist countries were largely marginalised. This perception was further reinforced by the withdrawal from the WHO of the USSR and other socialist countries, including Albania, Bulgaria, Belarus, Czechoslovakia, Romania, and Ukraine in the late 1940s and early 1950s. The Chinese authorities perceived the WHO’s endeavours aimed at improving health as a façade and an excuse for imperialist powers to interfere in another nation’s domestic affairs. From their perspectives, participation in the WHO entailed inherent risks that would enable the imperialist powers to collect intelligence information and exert control over Chinese people’s minds (Ministry of Foreign Affairs, 1949). The mistrust of the WHO persisted even after China joined the organisation in 1972. When Halfdan T. Mahler, who succeeded Marcolino Candau as the DG of the WHO, visited China in 1973, the Chinese authorities still held the view that the WHO mainly served Western countries for collecting intelligence information and infiltrating Asian and African countries (External Liaison Group of the Revolutionary Committee of Shanghai Municipal Health Bureau [ELGRCSMHB], 1973a).

Additionally, China celebrated its accomplishments in public health as national pride and exercised caution regarding the potential use of information shared with external entities to its detriment. In the 1950s, the nascent communist government in Beijing severed ties with the Western world and leaned heavily on assistance from the USSR and Eastern European countries. However, escalating tension between China and the USSR in the late 1950s and early 1960s resulted in an abrupt cessation of foreign aid (Shen, 2003). China subsequently embraced an ethos of self-reliance, taking pride in independently achieving substantial advancements in public health despite challenges such as extensive territorial expanse, a sizable population, sluggish economic growth, and limited medical personnel and resources. Therefore, information shared with WHO visitors in the 1970s was often expected to serve propaganda purposes, promoting the nation’s accomplishments, showcasing the leadership of the CCP, and substantiating the political ideology behind its public health policies and strategies (ELGRCSMHB, 1973a). China exercised caution in disseminating health statistics, harboured scepticism and apprehension towards evaluations by international organisations, and expressed concerns about potential hidden agendas, such as gathering intelligence and collecting evidence against the nation. Consequently, despite specific vital statistics becoming permissible for disclosure after 1972, epidemiological data continued to be regarded as sensitive information, and its sharing with WHO officials and external entities remained prohibited (ELGRCSMHB, 1973a).

The certification of smallpox eradication in China encountered additional challenges due to the country’s political landscape, which created a perception that the engagement with the WHO was highly political, restraining the direct communication between Geneva and Beijing. When the PRC joined the WHO in 1972, the country was still deeply entrenched in the Cultural Revolution. Spanning from 1966 to 1976, the Cultural Revolution ushered in a governance system characterised by the predominance of authoritarian political directives, leading to frequent public mobilisations to participate in political campaigns and movements aiming to eradicate remnants of capitalist and traditional elements from Chinese society. During this period, technical collaborations with external entities were construed as political activities and subjected to stringent control. During visits by WHO officials to China, explicit instructions were frequently issued to host organisations on how to address the guests’ inquiries, especially those related to political matters. Additionally, all instances of technical collaboration were mandated to adhere to the principles of foreign affairs (ELGRCSMHB, 1973a). Upon witnessing the discernible tendency of WHO officials to exhibit restrained engagement in commenting on political affairs, directing their attention predominantly towards technical matters, the Chinese experts and authorities expressed their surprise and perplexity (ELGRCSMHB, 1973b). Despite any interaction with the WHO, even on technical matters, being perceived as political, the Chinese authorities sought to address political and technical concerns as distinct and separate issues in their negotiations. They expressed a preference for maintaining a direct communication channel with the WHO HQ in Geneva, specifically for matters related to the organisation’s overall policy, while addressing all other issues, including joint activities, collaborative programmes, and technical visits, through the WPRO in Manila (Mahler, 1977). Regarding the certification of smallpox eradication as a technical issue, the Chinese authorities asserted their stance for negotiating via Manila and sought to emphasise the regional office’s involvement in addressing the technical aspects associated with the certification.

Apart from the political complexities, the certification also encountered substantial technical challenges. The deficiency in data science arising from China’s isolation from the international community and a malfunctioning reporting system during the Cultural Revolution resulted in the absence of accurate and consistent record-keeping of data and documentation at various administrative levels. The dearth of meticulous data at county, municipal, provincial, and state health departments presented significant obstacles to the certification of smallpox eradication in China (Wei, 2006). Moreover, the limited experience collaborating with the WHO posed additional challenges for the Chinese authorities and experts to understand the specific criteria and documentation standards required for certification (Wei, 2006). In addition, the Chinese authorities displaced limited interest in the certification of smallpox eradication because the disease had not been reported for more than a decade, and the primary concerns of public health in the country had shifted from infectious diseases to non-communicable diseases, particularly cardiovascular disease and cancer, in the late 1970s (WHO, 1978). It aligned with the WHO officials’ observation that the interest and motivation for certification often declined in countries where smallpox had been eradicated many years before the certification (Breman & Arita, 2011).

Following the heightened prospect of global smallpox eradication in 1977, with the remaining cases confined to Somalia and Ethiopia, there was a notable increase in communication between the WHO and China concerning the certification. In April 1977, F. J. Dy, the Director of the WPRO, extended an invitation to China, urging them to nominate candidates as members of the ICCSE to oversee the certification of smallpox eradication in Bangladesh and Burma. However, the Chinese authorities declined the invitation, citing their inability to participate in the commission due to ‘heavy working arrangements’ in the Ministry of Health (MoH) (Hsueh, 1977). In September, the SEU at the WHO HQ officially requested a summary of China’s smallpox eradication programme through the WPRO. Approximately one month later, they received a half-page introduction in response, stating the commencement and conclusion years of the country’s eradication effort. It also briefly touched upon the nation’s mass vaccination campaign and surveillance system without providing specific details (Huang, 1977). Meanwhile, China declined to send delegates to the CWCSE in October to provide consultation for the global certification (Arita, 1977). Arita expressed concerns regarding the limited progress made in the certification of China and emphasised the importance of including the country in the narrative of global eradication. He told Dy, ‘I believe you well understand the position … for the global certification, information is missing from that vast country with a population of 800 million’ (Arita, 1977).

Consequently, China was identified as the ‘key country in the context of global certification’ (Arita, 1978a). At the onset of 1978, Dy conveyed the CWCSE’s decision to the MoH in Beijing. He underscored the importance of the certification of smallpox eradication, emphasising that its success would facilitate the discontinuation of vaccination worldwide and represent an unprecedented milestone in history. He communicated the certification criteria and proposed a visit to China by three experts in July or August 1978. The primary objective of the proposed visit was to collect and review data on historical smallpox eradication efforts, assess the ongoing vaccination programme, evaluate the disease surveillance system, and discuss the safety of laboratory retention of the variola virus (Dy, 1978a). However, a letter from Huang Shu-tse, the Vice Minister of Health of the PRC, declined the visit. The letter displayed a discernible sense of dissatisfaction, seemingly rooted in perceived mistrust arising from the recurrent requests by the WHO for the certification of smallpox eradication. Huang unequivocally reiterated that smallpox had been eradicated in China in 1959 and emphasised the unassailable efficiency of the disease surveillance system in his country (Huang, 1978). The letter reflected the misunderstanding of the purpose of the certification, which was exacerbated by the ineffective communication between Geneva and Beijing.

In response to the prevailing mistrust and the lack of direct communication between the WHO HQ and China, Arita proposed the inclusion of a Chinese member in the GCCSE (Arita, 1978b), despite it conflicting with the established rule against selecting members of international and global commissions with potential conflicts of interest. Again, the Chinese authorities declined the invitation (Huang, 1978). During the 31st WHA held in Geneva in May 1978, a meeting was arranged with Hsueh Kung-Cho, the director of the Bureau of Foreign Affairs of the MoH. Arita and Dy attended this diplomatic encounter at the Palais des Nations. Hsueh reiterated his assertion regarding the timeline of smallpox eradication in his country. Arita, in turn, emphasised his personal conviction of Hsueh’s statement while underscoring the compelling necessity for international recognition of China’s achievement through certification by the WHO. He also indicated that if China was willing to be certified, certain concessions could be contemplated to expedite the procedure. Arita suggested that some nations, such as Burma, that considered the certification a politically sensitive matter were granted autonomy to collect data on smallpox eradication through their own nationals without the direct engagement of GCCSE members. He articulated that the certification of China could embrace such an approach to address the concerns of their Chinese counterparts. Hsueh eventually agreed to provide a country report elucidating the process of smallpox eradication and disease surveillance in China but declined the visit by the GCCSE members (Arita, 1978c). In light of the notable progress made through direct communication with the Chinese authorities, Arita identified the imperative need for more frequent direct intercommunication with Beijing. Therefore, he proposed that China nominate a technical officer to join the SEU in Geneva (Arita, 1978c). However, the authorities in Beijing adhered to their positions of negotiating technical activities, specifically the certification of smallpox eradication, through Manila (Dy, 1978b).

A favourable turn

The political transformations within China presented an opportune juncture for the certification. The demise of Mao Tse-tung in September 1976 marked the conclusion of the tumultuous Cultural Revolution. Deng Xiaoping, who assumed leadership of the CCP, launched economic reforms that introduced market-oriented policies, fostered private entrepreneurship, and opened the Chinese market to foreign investment. Deng’s reformation facilitated collaboration between China and various UN agencies, including the United Nations Development Programme (UNDP), the United Nations International Children’s Emergency Fund (UNICEF), and the WHO. In June 1978, William Foege, the Director of the US Centers for Disease Control and Prevention (CDC), visited China. At the behest of Arita, Foege engaged in a conversation with the Chinese Medical Association, elucidating the importance of collaborating with the WHO on the certification of smallpox eradication. Forge clarified that certification was not intended to question China’s accountability and capability in smallpox eradication but to persuade the broader international community that smallpox transmission had been halted worldwide, justifying the discontinuation of vaccination against the disease (Foege, 1978). Drawing from his empirical observations and interactions with the local population, Foege estimated that China’s most recent smallpox outbreak occurred around 1958. Additionally, he expressed confidence in the effectiveness of the country’s disease surveillance system to detect any potential cases promptly. Foege also noted an increasing level of openness and heightened responsiveness among the Chinese when one was physically present, as opposed to attempting to gather information through remote correspondence (Foege, 1978).

Due to the limited opportunities for direct communication with the Chinese authorities, SEU officials in Geneva sought assistance from individuals visiting China to facilitate the certification process. When the DG visited China from 28 September to 7 October 1978, Arita requested him to stress the importance of the certification to the Chinese authorities. He expected that the DG’s involvement would exert additional pressure, ultimately leading to their agreement for his visit to China to assist in preparing its country report and assess its disease surveillance system (Arita, 1978a). The WHO-affiliated officials visiting China for various technical collaborations were also tasked with gathering pertinent information in their personal capacity to amass comprehensive insights into the status of smallpox eradication in China. For example, Paul Lawton, the senior representative of the Pan American Health Organization (PAHO), was requested by John Wickett, an administrative officer of SEU, to privately collect information related to smallpox eradication during his visit to China with the DG. Lawton was expected to collect information on the mass vaccination campaigns, vaccine technology and production, vaccination policy, the epidemic prevention system, and the laboratory retention of variola virus in China. Wickett told Lawton that the SEU ‘would be eternally grateful’ if Lawton ‘could somehow manage to get someone’s signature and some answers … Negative answers, information not available, as long as it is a reply of some kind’ (Wickett, 1978).

During the DG’s visit, the Chinese authorities displayed a strong interest in strengthening connections with the WHO and expanding their collaboration on health-related issues (WHO, 1978). Approximately three weeks following the visit, a ‘General Introduction on the Eradication of Smallpox in the People’s Republic of China’ was received from the Minister of Health, Chiang Yi-chen (Chiang, 1978). While this two-page report did contain specific numerical figures and new details requested by Geneva, it lacked substantiating data or comprehensive accounts, falling considerably short of meeting the prerequisites for the certification. By the end of 1978, the SEU had not yet reached an agreement with its Chinese counterparts on the visit by WHO officials and GCCSE members, and a satisfactory country report was still absent. In response to the conundrum surrounding the certification of China, a special meeting with a sub-group of the GCCSE was convened by Arita on 4 December 1978. The subcommittee decided that ‘the certification of freedom from smallpox (in China) was deferred pending receipt of additional information’ (WHO GCCSE, 1978). The prerequisites for the certification of China entailed the submission of a comprehensive country report on a province-by-province basis encompassing detailed documentation of the last recorded smallpox cases, a historical overview of past smallpox control endeavours in each province, and a comprehensive assessment of the current epidemiological surveillance system (WHO GCCSE, 1978). Meanwhile, an agenda was set for the Executive Board (EB) and the WHA to review the evidence of the global certification and announce the achievement of smallpox eradication worldwide in 1980 (Arita, 1979a). However, the little progress made in China put the agenda at stake.

In April 1979, a meeting was held in Geneva to discuss the laboratory retention of the variola virus, and a Chinese delegation attended the meeting. Arita was ‘extremely glad’ with their participation, perceiving it as the initial stride towards certification of smallpox eradication in China (Arita, 1979b). Therefore, he rekindled the proposal for a visit by Frank Fenner, the Chairman of the GCCSE, accompanied by a WHO staff (Arita, 1979c). Drawing upon lessons learned from previous unsuccessful negotiation attempts, the request was initially conveyed through informal in-person communication rather than formal written correspondence. In April 1979, Sir Gustav Nossal, representing the WPRO, embarked on a technical visit to China. He served as the director of the Walter and Elizabeth Hall Institute for Medical Research in Australia and the chairman of the Western Pacific Advisory Committee for Medical Research (Arita, 1979b). Dy requested Nossal to present the proposition of Fenner’s visit to high-level Chinese authorities and convey the specified conditions from Beijing. Dy emphasised the political sensitivity underlying the certification of smallpox eradication and advised Nossal to exercise discretion in gauging the most opportune timing for such a diplomatic overture (Dy, 1979a).

Subsequently, Nossal introduced the proposal of Fenner’s visit informally to several Chinese authorities, including Vice-Minister Tan Yen-He, the Director of the Foreign Affairs Bureau of the MoH Hsueh Kung-Cho, and the Deputy Chief of the Division of International Organisation under the Foreign Affairs Bureau of the MoH Wang Lien-Sheng. They consented to the proposal unofficially and warmly welcomed Fenner’s visit. Nossal discerned a ‘positive and flexible attitude’ in Beijing, fostering his conviction that the certification would progress smoothly (Nossal, 1979). Despite the verbal agreement, no formal confirmation or official invitation regarding the visit was issued from Beijing. The absence of pertinent evidence of smallpox eradication in China left Arita apprehensive, characterising the situation as potentially ‘embarrassing’ (Arita, 1979d). Recognising the urgent need to expedite the certification of China, Arita urged Dy to request official endorsement from Beijing for Fenner’s visit and the submission of the country report (Arita, 1979e). However, instead of responding directly to the official request from Geneva and Manila, the authorities in Beijing confirmed Lawton, who had previously accompanied the DG on his visit to China, that Fenner’s visit could be arranged in July (Arita, 1979f).

A controversial result

After nearly two years of delicate negotiations, the visit for the certification of smallpox eradication in China by Frank Fenner, the chair of the GCCSE, accompanied by Joel Breman, a WHO staff, finally took place from 14 to 30 July 1979. Upon their arrival in Beijing, Fenner and Breman received a country report prepared by the Chinese experts and a comprehensive itinerary meticulously crafted for them. Their itinerary included Beijing, Shanghai, and Kunming, the capital city of Yunnan Province, where it was believed to be the last smallpox case was reported. The key focuses of their investigation encompassed a comprehensive examination of China’s public health infrastructure, as well as its infectious disease control and surveillance systems operating at the national, provincial, municipal, and district levels. In Beijing, they visited the National Institute for Biological Station, where the variola virus was retained; the National Serum and Vaccine Institute; Fangshan County; and Doudian, a rural commune of the county. In Shanghai, they visited the First Medical College, the city’s Serum and Vaccine Institute, the municipal hygiene and epidemic station, and two local districts. In Kunming, they visited the Yunnan Province Bureau of Health, the Institute of Medical Biology, and the epidemic prevention stations at the provincial and municipal levels. They also carried out pockmark surveys in several schools and kindergartens in the capital city of Yunnan province (Fenner & Breman, 1979).

Based on their on-site assessment, Fenner was unequivocally convinced by the statements of the Chinese authorities and expressed a high level of confidence in the effectiveness of disease surveillance measures in China. In conjunction with the country report prepared by the Chinese experts, the team submitted a report of their visit and recommended certifying China as smallpox-free despite the absence of data from Tibet. Fenner proposed the consideration of the certification of China based on existing data, rationalising that the last case in the country occurred in Yunnan, and it was not feasible to arrange another visit to Tibet before the scheduled deadline of the global certification (Fenner, 1979). In his letter to Arita, he underscored the DG’s intention to declare Africa free of smallpox in Nairobi on 26 October, and ‘it would be highly anomalous if China’, Fenner wrote, ‘where smallpox was eradicated years before the Smallpox Eradication Programme began, remained the only country in the world not certified by the Global Commission’ (Fenner, 1979).

Following Fenner’s suggestions, Arita initiated contact with the members of the GCCSE to evaluate the evidence for the certification of smallpox eradication in China, including a country report prepared by the MoH of the PRC, a report of Yunnan Province, a comprehensive account of the visit to China by Fenner and Breman, and a report of Taiwan (Arita, 1979g). He consulted the GCCSE members’ opinions on the certification of China based on the principles outlined in the commission’s first meeting in December 1978 (Arita, 1979g). By the end of November 1979, eight out of nineteen members of the GCCSE recommended immediate certification, five recommended against it, and six did not respond (Responses of Members of the Global Commission, 1979). In recognition of the formidable challenges associated with obtaining information from China, Henderson, the former director of the SEU, was impressed by the extensive and detailed content within the country report, and he strongly recommended certifying China as smallpox-free (Henderson, 1979).

Conversely, Holger Lundbeck from the National Bacteriological Laboratory of Sweden voiced concerns. He noted that Fenner’s report appeared to be influenced by strong preconceived opinions and personal judgements. Given the lack of transparency in the data collection procedures, he also expressed scepticism regarding the credibility of the reports prepared by the Chinese counterparts. Lundbeck pointed out that in other countries facing analogous scenarios to China, where the certifications were carried out years after the eradication, country reports were usually prepared by the members of the GCCSE and/or the WHO staff after careful investigation, while China was allowed to collect data by its own nationals (Lundbeck, 1979). Despite his reservations concerning both the reports and the certification procedures, Lundbeck agreed to certify China because ‘refusal to accept the statement of the Chinese government would place China in another category than these countries and would mainly be based on lack of trust in the credibility or the ability of the Chinese authorities’ (Lundbeck, 1979). He also underscored that there was no substantial basis for such mistrust. Moreover, considering the vast size of China’s population and territory, it was deemed unfeasible for the WHO or any other organisation to validate the existing evidence satisfactorily. Consequently, he suggested the GCCSE had no other option but to rely upon the official statements of the Chinese authorities (Lundbeck, 1979).

In November 1979, after submitting a pockmark survey and a supplementary report on Tibet, China was officially certified as smallpox-free by the WHO. Subsequently, the GCCSE declared that smallpox had been eradicated worldwide in December (WHO GCCSE, 1979), and the DG announced this achievement during the 33rd WHA on 8 May 1980 (WHA, 1980). However, continuous retrospective studies on smallpox eradication carried out by Chinese experts revealed inaccuracies within the country report but did not raise concerns in Geneva (Fenner, 1980). In 1984, when Fenner requested information for the official history of smallpox eradication from Jiang Yu-tu, who participated in preparing the country report, the new evidence that emerged from China caught Fenner’s attention and heightened his alertness. Contradicting the Chinese official statement endorsed by the WHO, which claimed that the last smallpox case in China occurred in Cangyuan of Yunnan Province in 1961, the new data provided by Jiang indicated two extra smallpox outbreaks: one in Tibet in 1964 resulting in 3 deaths, and another in Shanxi and Inner Mongolia in 1963–1965 (Jiang, 1984). Jiang explained that the initial claim that the last smallpox case in China occurred in Cangyuan was based on an oral report rather than a thorough investigation, and the relevant data from the local government was not provided until the end of 1984 (Jiang, 1985a).

The revelation of the outbreak in Shanxi and Inner Mongolia ignited extended controversy, which not only cast doubts about the credibility of the certification of China but also challenged the criteria adopted in the certification of smallpox eradication worldwide. The outbreak comprised 28 cases in Shanxi and 73 cases in Inner Mongolia in 1963, 26 cases in Inner Mongolia in 1964, and 3 in Shanxi in 1965 (Jiang, 1984). Before this outbreak, Inner Mongolia’s last documented smallpox cases occurred in 1956 and Shanxi in 1952. Evidence from the SEP in Afghanistan and Ethiopia suggested the viability of the variola virus was improbable beyond two years. This particular scientific finding formed the basis for one of the certification criteria, requiring a cessation of smallpox transmission for a minimum of two years in a designated area (Henderson, 1984). However, in the instances of Shanxi and Inner Mongolia, the virus retained its pathogenicity for extended durations, persisting for 7 and 11 years, respectively. Therefore, Fenner, Henderson, and Arita expressed shared concerns that the certification could not exclude the risks of the reintroduction of smallpox. In response to their concerns, Jiang explained that the recently uncovered outbreaks were caused by mishandling and improper storage of variolation materials while adopting traditional Chinese variolation methods (Jiang, 1985b). He further clarified that the smallpox vaccination programme in China was interrupted during the great famine from 1959 to 1962 due to a shortage of vaccine supplies. In remote areas, a number of residents adopted traditional variolation methods to prevent smallpox, offered by non-registered traditional medicine practitioners known as herb doctors. These practitioners often stored variolation materials in poorly secured containers and intentionally inoculated local populations to sustain the viability of vaccinia. The unsafe storage and handling of the vaccinia resulted in infections in a village in Shanxi, and the outbreak soon spread to Inner Mongolia (Jiang, 1985b).

Instead of being officially rectified by the WHO, the findings from the investigation of outbreaks in 1962–1965 in Shanxi and Inner Mongolia were published as a journal article in the American Journal of Epidemiology in 1988 (Jiang et al., 1988). Despite reasonable explanations being provided for the misreports in the country report, lingering doubts persisted regarding the credibility of the certification of smallpox eradication in China. Arita posed a crucial question: ‘How can China assure the WHO that the variolators completely stopped their practice and that the material no longer exists?’ (Arita, 1985). The scientifically and politically controversial result of the certification of China diminished the reliability of the WHO’s assertions of the global eradication of smallpox. Nonetheless, WHO officials contended that the credibility of the certification hinged on the rigour of the process, as well as the expertise and independence of the commissions (Breman & Arita, 2011).

Final remarks

In global health governance, international organisations such as the WHO consistently encounter challenges securing compliance from member states. The motivations driving states to comply with prescribed protocols and adhere to the commitments aimed at enhancing global health and well-being are diverse, such as preserving reputations, seeking reciprocal benefits, avoiding retaliatory consequences, maintaining the legitimacy of legal agreements, and responding to domestic pressures (Kavanagh et al., 2023). Conversely, various factors contribute to their resistance to international and global health collaborations. These impediments may include concerns related to geopolitics, state sovereignty, national interests, constraints in resource availability, domestic policies, questions about the alignment of proposed international measures with immediate state priorities, and scepticism regarding the efficacy or jurisdiction of international entities like the WHO. In the case of the certification of smallpox eradication, China’s resistance was influenced by various factors, including the geopolitics of the Cold War, the country’s evolving political landscape, strained diplomatic relations between Geneva and Beijing, profound mistrust stemming from these tensions, a sense of national pride in its public health achievements, scepticism regarding external evaluation, as well as technical challenges such as the absence of data and a limited understanding of the WHO’s protocols and requirements.

Examining China’s historical resistance to the certification of smallpox eradication provides insights into its selective engagement in contemporary global health governance. Despite its growing influence, China’s involvement in global health governance has been characterised by a cautious approach to multilateral collaborations, a preference for bilateral engagements, a disinclination to transparently share information with external entities, and a resistance to aligning its policies and practices with established international norms (Youde, 2018). The country’s resistance to comprehensive engagement in global health governance has been evident during the ongoing COVID-19 pandemic. Since the onset of the pandemic, the country has faced criticism for its reluctance to share crucial data and a notable lack of transparency in its pandemic response. Allegations also indicated that Chinese officials might have withheld or manipulated data in the WHO’s investigation into the origins of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This led to the dismissal of specific hypotheses related to the origins of SARS-CoV-2, raising concerns about the impartiality of the investigation and adding complexity to the understanding of the origins of the virus (Dyer, 2021). The parallels between China’s resistance to the certification of smallpox eradication and its response to the COVID-19 pandemic underscores the trust issues that persisted in the country’s engagement with the WHO and other global health governance institutions. The analysis of the challenges encountered by the WHO in the certification of smallpox eradication in the 1970s provides a context to understand how geopolitical positioning, foreign policies, and sovereignty concerns have contributed to a complex dynamic where China balances its national interests with global health governance.

The WHO’s response to China’s resistance to the certification of smallpox eradication emphasises the critical importance of establishing a trusting relationship in addressing shared global health challenges. Trust between the WHO and its member states is essential for facilitating the exchange of information, knowledge, technologies, and resources, enabling more coordinated and effective responses to health emergencies. The consistent efforts of the SEU in seeking direct communication to dispel misunderstanding and mistrust with their Chinese counterparts during the certification of smallpox eradication exemplify the necessity of open and transparent dialogue from both the WHO and its member states to foster mutual understanding, cooperation, and effective collaboration in global health. Additionally, given China’s significant advancements in science, technology, and medicine, as well as its increasing political and economic influence, the country’s proactive engagement in global health governance holds promise for strengthening global health security, fostering scientific research and innovation, and enhancing public health outcomes worldwide. Building a trusting relationship with the WHO and other global health governance institutions also demonstrates China’s commitment to transparency, accountability, and responsible leadership in global health. It requires the country to recognise the WHO’s role as a neutral and evidence-driven entity, notwithstanding the inevitable political entanglement in international collaborations.

The complexities of the negotiations between the WHO and China regarding the certification of smallpox eradication also underscore the multifaceted nature of the organisation’s responsibilities, where its scientific, technical, and humanitarian pursuits intersect with complex political considerations that await international coalitions. Throughout the COVID-19 pandemic, the WHO has encountered a plethora of obstacles in securing cooperation and compliance from member states, spanning from the sharing of critical data to the equitable distribution of vaccines. Apart from China’s lack of transparency in the early stages of the pandemic and withholding of data in the investigation into the origins of the virus (Kupferschmidt, 2021), the US also intended to withdraw from the WHO, citing perceived deficiencies in the organisation’s response to the pandemic (Gostin et al., 2020). Amid these challenges, Tedros Adhanom Ghebreyesus, the DG of the WHO, emphasised the persistent threat posed by the politicisation of the pandemic. He advocated for the quarantine of ‘COVID politics’ and called for a collaborative approach grounded in science, solutions, and solidarity (Ghebreyesus, 2020). However, the certification of smallpox eradication in China highlights the persistent reality that navigating political challenges is an integral part of global health governance. It exemplifies the WHO’s essential role as a global health authority, inevitably intertwined with complex political challenges that demand nuanced analysis and sophisticated diplomatic efforts. Therefore, carefully examining the political, economic, historical, and emotional factors interwoven within the resistance exhibited by individual states can provide valuable insights into navigating the intricate landscape of global health governance. It fosters more effective collaboration for evidence-based decision-making in engaging with a diverse array of actors in global health, each driven by varying political agendas.

Acknowledgement

The article originated from chapters in my PhD thesis, ‘China in the Worldwide Eradication of Smallpox, 1900-1985: Recovering and Democratizing Histories of International Health’, supported by the Wellcome Trust (Grant number 208142/Z/17/Z). It was rewritten and revised under the Wellcome Trust-funded project ‘Connecting Three Worlds: Socialism, Medicine and Global Health after WWII’ (Grant number 221321/Z/20/Z). I thank the editor, anonymous reviewers, Sanjoy Bhattacharya, Dóra Vargha, Sarah Howard and the colleagues of Connecting Three Worlds for their comments. Previous versions of this paper were presented at the ‘Global Interference? Science and Foreign Policy Interactions in China’ workshop supported by the Lise Meitner Research Group at the Max Plank Institute for the History of Science, and ‘Afterlives of Epidemics: Ends, Legacies and Hauntings’ supported by the Department of Culture Studies and Oriental Languages at the University of Oslo, I thank the organisers for their sponsorship and the participants for their comments.

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Additional information

Funding

This work was supported by Wellcome Trust: [Grant Number: 208142/Z/17/Z]. It was rewritten and revised under the Wellcome Trust-funded project ‘Connecting Three Worlds: Socialism, Medicine and Global Health after WWII’ [Grant number: 221321/Z/20/Z].