Epidemic: What good is a vaccine when there is no rice? – News-Medical.Net

The 1970s was the deadliest decade in the "entire history of Bangladesh," said environmental historian Iftekhar Iqbal. A deadly cyclone, a bloody liberation war, and famine triggered waves of migration. As people moved throughout the country, smallpox spread with them.

In Episode 7 of "Eradicating Smallpox," Shohrab, a man who was displaced by the 1970 Bhola cyclone, shares his story. After fleeing the storm, he and his family settled in a makeshift community in Dhaka known as the Bhola basti. Smallpox was circulating there, but the deadly virus was not top of mind for Shohrab. "I wasn't thinking about that. I was more focused on issues like where would I work, what would I eat," he said in Bengali.

When people's basic needs like food and housing aren't met, it's harder to reach public health goals, said Bangladeshi smallpox eradication worker Shahidul Haq Khan.

He encountered that obstacle frequently as he traveled from community to community in southern Bangladesh.

He said people asked him: "Theres no rice in peoples stomachs, so what is a vaccine going to do?"

To conclude this episode, host Cline Gounder speaks with Sam Tsemberis, president and CEO of Pathways Housing First Institute.

He said when public health meets people's basic needsfirst, it gives them the best shot at health.

Senior Fellow & Editor-at-Large for Public Health, KFF Health News @celinegounder

Cline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board.

Sam Tsemberis Founder, president, and CEO of Pathways Housing First Institute @SamTsemberis

Shohrab Resident of the Bhola basti in Dhaka Iftekhar Iqbal Associate professor of history at the Universiti Brunei Darussalam Shahidul Haq Khan Former World Health Organization smallpox eradication program worker in Bangladesh

Podcast Transcript

Epidemic: "Eradicating Smallpox"

Season 2, Episode 7: What Good Is a Vaccine When There Is No Rice?

Air date: Oct 24, 2023

Editor's note: If you are able, we encourage you to listen to the audio of "Epidemic," which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

[Ambient sounds from a ferry play softly.]

Cline Gounder: Im on a boat in southern Bangladesh, headed toward Bhola, the countrys largest island.

We're traveling by ferry on calm waters. But my head spins and my stomach roils just a bit as I imagine how these same waters nearly destroyed Bhola Island.

[Tense instrumental music begins playing.]

It was 1970.

In November, under an almost-full moon and unusually high tides.

The island was hit by one of the most destructive tropical storms in modern history: the Bhola cyclone.

[Shohrab speaking in Bengali fades under English translation.]

Shohrab: There were floods. Back then there werent any embankments to stop the water from rising.

Cline Gounder: Counterclockwise winds, torrential rains, and treacherous waves swept entire villages into the sea. People held onto whatever they could to keep their heads above water.

[Shohrab speaking in Bengali fades under English translation.]

Shohrab: I remember at that time the water level rose so high that people ended up on top of trees. The water had so much force. Many people died.

Cline Gounder: The Bhola cyclone killed some 300,000 people. And for those who survived, there wasnt much left to return to. Hundreds of thousands of people lost their homes, their farms, and their access to food.

The man whose voice youve been hearing was one of the survivors.

[Shohrab speaking in Bengali fades under English translation.]

Shohrab: My name is Shohrab. I am 70 years old.

Cline Gounder: Shohrab was a teenager when the cyclone hit. And in the days and weeks after the storm, he and his family joined a mass migration of people who fled southern Bangladesh.

They traveled about a hundred miles north from Bhola Island to the streets of Dhaka, the busy capital of Bangladesh.

There, they settled in a makeshift community, a kind of unsanctioned encampment dubbed the Bhola basti.

In Bengali that word,"basti," means settlement or "slum," in some translations.

The residents forged a community, but soon, the poor people there and what they built would be seen as a threat to the effort to keep smallpox in check.

Not just in South Asia but around the world.

Im Dr. Cline Gounder. This is "Epidemic."

["Epidemic" theme music plays.]

[Ambient sounds from the Bhola basti, including voices of people speaking Bengali, play softly.]

Cline Gounder: More than 50 years after the cyclone, Shohrab lives in the same area in Dhaka.

I interviewed him at a tea stall near his home. It's the kind of place where men gather to gossip and share stories over hot drinks.

Inside there's a colorful display of snacks and sweets hanging from the ceiling. Just outside we sat on well-worn wooden benches.

And as we sip our tea, he tells me about life in the encampment in the 1970s

[Sparse music plays softly.]

[Shohrab speaking in Bengali fades under English translation.]

Shohrab: I used to rent a place there. Five or six of us used to live in one room. Sometimes it was eight people in a room.

Cline Gounder: To cover his portion of the rent he worked as a day laborer, doing odd jobs here and there. Over time the basti became home.

But Shohrabs new home was likely seen as an eyesore by outsiders and by the Bangladeshi government.

Such settlements often lack running water, or electricity, or access to proper sanitation. Those conditions spotlight suffering and for local leaders that spotlight can be uncomfortable.

But, public health experts had a different concern: that the settlement of Bhola migrants in Dhaka would become a deadly stronghold for smallopox. Cramped and unsanitary living conditions put the residents at high risk.

I ask Shohrab if he remembers seeing or hearing about people with smallpox when he first arrived.

[Shohrab speaking in Bengali fades under English translation.]

Shohrab: I wasnt thinking about that. I was more focused on issues like where would I work, what would I eat, etc.

Cline Gounder: As he tried to rebuild his life, other things like food and shelter were more urgent.

[Music fades to silence.]

Widening beyond that one migrant encampment in Dhaka, researchers say the picture was similar in cities and villages all across the country.

Bangladesh was hit with a series of crises. Environmental historian Iftekhar Iqbal says each brought human suffering and that each was a blow to the smallpox eradication effort.

Iftekhar Iqbal: Seventies was really a time when, the coming of the smallpox couldnt come at a, at a more unfortunate time.

Cline Gounder: In 1970 the Bhola cyclone hit. In 1971, just four months later, the country fought a bloody liberation war. Then, in 1974, heavy rain and flooding triggered a famine. And in 1975 there was a military coup.

Iftekhar Iqbal: The 1970s was the deadliest decade in the history of Bangladesh.

Cline Gounder: This period is when the country became Bangladesh winning its independence from Pakistan in the liberation war. But residents of the young nation faced cascading upheaval and turmoil. And too much death.

[Instrumental music plays softly.]

On the global stage stopping smallpox was important, but many in Bangladesh were just trying to make it to the next day.

Daniel Tarantola: No. 1 priority is food and food and food. And the second priority is food and food and food.

This was an area where survival was always in question.

Cline Gounder: That's Daniel Tarantola.

He's from France and arrived in the region with the mission of helping to eradicate smallpox, but he says the people in front of him needed help with many other things.

Besides hunger, some of the villages he visited were dealing with two epidemics: smallpox and cholera.

Daniel Tarantola: And we were not equipped to do anything but smallpox containment and smallpox eradication. By design or by necessity, we didnt have the means to do anything much more than that.

Cline Gounder: Over the course of this season weve talked about big, complicated issues like stigma and bias, distrust, or First World arrogance that threatened to derail the smallpox eradication campaign. We've documented the public health workers who found a way around those roadblocks.

But sometimes the need is so big, so entrenched, that your inability to meet it can be demoralizing. I sometimes felt that during my own fieldwork: battling HIV and tuberculosis in Brazil and southern Africa, and during an Ebola outbreak in Guinea, West Africa.

Daniel Tarantola says in South Asia the best he could do was focus on the task at hand.

Daniel Tarantola: Meaning that you had to set up a program to eradicate smallpox or at least eliminate it from Bangladesh and at the same time not get if I can use the word distracted, um, by other issues that prevailed in Bangladesh.

[Music fades out.]

Cline Gounder: Those were tough emotional realities for health workers and the people they wanted to care for.

But

Daniel Tarantola: The level of resilience of this population is absolutely incredible given the number of challenges that they have had to survive.

Cline Gounder: One of the main ways people survived the upheaval in Bangladesh was by picking up and moving away from the things trying to kill them.

Remember how Shohrab fled to Dhaka after the cyclone?

Well, mass migration is a survival strategy but one that can worsen disease.

When the cyclone refugees from Bhola landed in that under-resourced basti in Dhaka, all smallpox needed was an opportunity to spread.

[Solemn music begins playing.]

That opportunity came in 1975 when the Bangladeshi government decided to bulldoze the Bhola basti.

Daniel Tarantola says it was a bad idea.

Daniel Tarantola: We knew there was smallpox transmission in this particular area and therefore they should wait until the outbreak subsides before dismantling the shanties.

Cline Gounder: Government officials did not wait for the outbreak to subside. They bulldozed the basti anyway.

Daniel Tarantola: That resulted in a wide spread of smallpox.

Cline Gounder: Here's environmental historian Iftekhar Iqbal again.

Iftekhar Iqbal: This eviction is considered one of the policy errors that led to the second wave of postwar smallpox.

Cline Gounder: In the wake of that eviction in 1975, thousands of people scattered. Some surely returned back home to Bhola.

[Music fades out.]

Cline Gounder: Public health's failure the government's failure to meet the basic need for safety, for food and housing, delayed the goal to stop the virus.

Shahidul Haq Khan, the Bangladeshi public health worker and granddad we met in Episode 4, says he learned that lesson over and over as he urged people to accept the smallpox vaccination.

Their frustration with him and by extension public health was clear.

[Shahidul speaking in Bengali fades under English translation.]

Shahidul Haq Khan: There was no rice in peoples stomachs, so what is a vaccine going to do? "You couldn't bring rice? Why did you bring all this stuff?" That was the type of situation we had to deal with.

[Atmospheric music begins playing.]

Cline Gounder: What good is a vaccine when there is no rice?

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Epidemic: What good is a vaccine when there is no rice? - News-Medical.Net