Worldwide eradication of the devastating viral disease of smallpox was devised as a distant global policy, but success depended on implementing a global vaccination programme within nation states. How this was achieved remains relevant and topical for responding to today’s global communicable disease challenges. The small and poor Himalayan kingdom of Nepal faced enormous geographical and infrastructure challenges if it was going to succeed in a nationwide vaccination programme. This book acknowledges the key role of the WHO but disrupts the top—down, centre—led standard narrative. Against a background of widespread internal political and social change, Nepal’s programme was expanded, effectively decentralised and a vaccination strategy introduced that aligned with people’s beliefs. Few foreign personnel were involved.