In fact, the manual included a warning to not let outbreak containment divert efforts from the mass campaign during the three years. “The need may occasionally arise for a rapid vaccination effort in an area to control an outbreak. In pre-planning, provision should be made for handling these situations. For completion of the attack phase on schedule, the time table drawn up for area coverage should be reasonably strictly followed. If vaccination teams are frequently forced to disrupt their activities to perform mopping up or ‘fire fighting’ operations, great damage will be done to the orderly progress of the campaign.”6
Surveillance/containment approaches were not new to the CDC team. Vaccinating those at highest risk of exposure makes logical sense and had been used frequently. Indeed, it was endorsed by a royal commission in England as early as the 1890s. Surveillance/containment was also written into plans for the containment of a possible smallpox importation in various cities (such as New York) and had been used for outbreak control in many countries, especially importations of smallpox into Europe in the twentieth century. As already mentioned, it was also the follow-on plan in the WHO program after mass vaccination had reduced the intensity of transmission. This was the reason for developing the surveillance system for identifying all cases of smallpox. While surveillance/containment was the logical follow-on to mass vaccination, it was always seen in a secondary role, never as the primary strategy and certainly not as a substitute for mass vaccination.
After the positive results in Ogoja province (and later in the entire Eastern Region of Nigeria), however, surveillance and containment began to be seen as the primary strategy for smallpox eradication. This had not been presented as an option in our training before we left for Africa. The lessons learned in the outbreak in Ogoja province led eventually to the abandonment of mass vaccination as the primary strategy in other countries and finally in all countries as eradication activities rapidly accelerated. When surveillance and containment are made the primary strategy, mass vaccination can be dropped totally. In fact, it becomes a wasted effort.
In retrospect, it is easy to see why surveillance and containment worked so well for this particular disease. The presence of the virus was easy to detect, since almost everyone infected developed lesions, mostly on the face and extremities, where they were easily seen. Moreover, most people who acquired the virus became so severely ill that it stopped their movement. Family, friends, and community members were likely to be aware of cases. Even if a patient remained undetected from the first day of the rash, the chain of transmission didn’t remain hidden for long. Even if only a single person was infected during each incubation period, which is two or three weeks, only twenty persons were needed to keep a single chain of transmission intact for a year. If any one of those twenty people failed to pass the virus on, the chain was broken. In fact, in most cases, an annual chain involved hundreds of people, making the virus easy to find.
Not only did the virus have difficulty remaining incognito during the illness, it also left a trail after the fact. Pockmarks, especially on the face, told the story of the virus’s visit. Surveys of a village quickly revealed the last time the virus was active in the community, based on the age of the youngest people showing scars. The bottom line is that unlike many other viruses, smallpox virus simply could not hide. It left too many clues.
The ease of identifying the smallpox virus is highlighted by an incident in November 1971. Smallpox workers at the CDC in Atlanta watching the nightly news happened to see a report about refugees leaving Bangladesh, bound for India. One of the refugees in the film clip appeared to have smallpox. The Atlanta observers called the report in to WHO in Geneva. The WHO alerted officials in India, who alerted local workers, and the following day the outbreak was found and contained.
Surveillance and containment also works particularly well for smallpox because the virus is so specialized. It can only commandeer human cells. Over the centuries it must have tried repeatedly to adapt to other species, but without success. The smallpox virus must find a new, susceptible host within weeks of initiating disease in a person or it will die. The virus also dies quickly outside the human body unless it is kept in freezing conditions. It turned out that a perimeter containing no susceptible people needed to extend for only a half-dozen feet from the person with smallpox to be effective. Therefore, once the virus was located, vaccinators could concentrate their efforts on vaccinating anyone who might have come within that perimeter. It was necessary, of course, to prevent the virus from traveling out of that protective bubble on contaminated clothes—just as firefighters must prevent a fire from crossing a fire line.
Although the surveillance/containment method worked exceedingly well for smallpox, this does not mean it would work as effectively for other diseases. The smallpox eradication story contains many lessons, but giving up mass vaccination as a methodology for other diseases is not one of them. Rather, the lesson is that every problem has to be considered individually.
Our experience in Eastern Nigeria and then in West and Central Africa was compelling. Surveillance/containment was eventually used as the primary strategy in all areas of the world in the smallpox eradication effort. It would be refined and tested to the utmost and would provide its most dramatic results seven years in the future, in the state of Bihar, India. But it started that night in Ogoja province during a problemsolving discussion about inadequate supplies.
PART TWO India
MEETING THE CHALLENGE OF ERADICATION
SIX Under the Rule of Variola
As the new decade began, the win column in the global effort to eradicate smallpox started to lengthen. In January 1971, nine months after the last smallpox case in West and Central Africa, Brazil reported its final case. Three months later, Indonesia became free of smallpox. By the end of the year, only nine countries still had continuous smallpox transmission. In July 1972, Afghanistan became smallpox free.
Yet even as the number of countries with smallpox was declining, progress was disappointing in the four smallpox-endemic countries of South Asia: Bangladesh, India, Nepal, and Pakistan. In India, a new mass vaccination campaign, the fourth within ten years, was having little impact. There was strong feeling both inside and outside the country that smallpox in India was different, that success in other places simply underscored the problem. Even experienced public health workers, including some with extensive experience in the Africa smallpox program, came away frustrated, concluding that the problems of smallpox in India could not be approached in the same way as elsewhere. In India, it seemed, smallpox was inevitable.
By this time I was back in Atlanta, working at the CDC as director of the smallpox program. Dr. David J. Sencer, then director of CDC, had a passion for getting smallpox eradicated. He was a bright, dedicated physician who took delight in solving problems.
The CDC had remained involved in the WHO global program even after eradication was accomplished in West and Central Africa. At the beginning of the program, Leo Morris was assigned to work in Brazil, and then a flood of CDC people were assigned around the world. Most were assigned through WHO, but a few were assigned directly on a bilateral basis. CDC staff traveled frequently in response to WHO requests, evaluating programs and attending WHO-sponsored meetings. The working relationship between CDC and WHO was so close that any jurisdictional issues or turf problems could be negotiated. The combined heft of the two agencies was often important, since public health officials looked to the CDC on questions of science but expected consultants to come with a WHO stamp of approval.
I found that the ideal position was to be seconded, that is, loaned, by CDC to WHO for work in the field. I used my WHO position when working with administrative or political staff and my CDC position when working with scientific staff. Most work straddled both areas. Because of my experience with the surveillance/containment methodology, I was often asked to present at WHO meetings in various parts of the world.
The surveillance and containment method had been promoted at
every global smallpox meeting since the regional meeting in Accra in July 1967. The idea was strongly pushed in letters from WHO/Geneva to the WHO regional office in New Delhi. However, surveillance and containment as the primary strategy was simply not imagined in India. Many seriously doubted that smallpox transmission could be interrupted in high population density areas where smallpox was endemic. Henry Gelfand, for instance, a longtime CDC public health worker, had been part of an evaluation of smallpox in India that recommended virtually 100 percent vaccination coverage as the only way to interrupt smallpox transmission in that country.
In a May 2, 1969, letter to Don Millar, then chief of the smallpox program at CDC, Gelfand voiced his doubts that the method that had been so successful in Africa would be applicable in South Asia:
It is a remarkable document, and its exposition and description of “Eradication Escalation” will make it a landmark in the history of disease eradication. . . .
In a luscious bowl of honey, however, one must look out for the rare fly that may be trapped and spoil the dish. I do have a tiny complaint, because I well know how some people in this world can quote out of context to select a point which will serve their own self interest or justify their own complacency. In about the middle of page 6 this sentence appears, “This approach (referring to search/investigation/control) is now considered of equal and, under certain circumstances, of even greater importance than systematic mass campaign activities.” I should rather see the underlining applied to a different phrase as follows, “This approach is now considered of equal and, under certain circumstances, of even greater importance than systematic mass campaign activities.”
I am sure that you had in mind the unusual nature of the circumstances pertaining in the West African program in the fall of last year: the unusually high ratio of epidemiologists to population, the caliber of the epidemiologists, the availability of special surveillance/control teams, the non-interruption of intensive and concurrent mass vaccination activities. Deliberately or stupidly misinterpreted, the emphasis given in the original sentence could be used to justify fruitless and inefficient epidemic chasing in India and Pakistan. Please don’t give them the chance.1
The power of surveillance/containment to stop transmission had been demonstrated in 1968 and 1969 in the South Indian state of Tamil Nadu in a program directed by Dr. A. R. Rao, following the reports from West Africa in 1967. However, Rao introduced surveillance/containment after mass vaccination had already reduced smallpox to a few hundred cases. In essence, he had simply confirmed the WHO’s original recommendation of using mass vaccination first, followed by surveillance and containment as a secondary strategy. It was a success for Tamil Nadu but did not actually test surveillance/containment as a primary strategy in an area of high population density.2
In the spring of 1973, a breakthrough in thinking occurred in India. During the seasonal high-transmission period, which runs from January through May or June, major outbreaks were discovered in a district in South India believed to be free of smallpox. The health staff mobilized to do a house-to-house search to determine the extent of the epidemic. Two weeks of preparation led to a ten-day search, which a later assessment found to be surprisingly complete. The searchers discovered numerous unreported outbreaks, which were rapidly contained. The district became free of smallpox in a matter of weeks.
This experience demonstrated that India’s large health staff could readily be mobilized for search and containment activities. More importantly, it showed that the smallpox virus in India played by international rules.
Soon after this, Dave Sencer told me that D. A. Henderson at WHO Geneva wanted to assign me to India as a consultant to the WHO regional office in New Delhi to help them apply the surveillance/containment strategy to smallpox-endemic South Asia. The first step was to visit India and meet with the Indian and WHO staff to determine their interest in having me join their program.
My coworkers at the CDC advised me not to go unless I had a solid contract with WHO and India that spelled out what would be provided and what my authority would be. Since I had no idea what the job would require, I found it impossible to specify details. In the end, there was no contract. As the eradication effort progressed, I was very happy that I had gone without preconditions. No one could have predicted the scope of the challenges and how job descriptions would morph dramatically to meet the needs of the moment. Almost any prior agreement would have hampered the effort.
In the summer of 1973, I visited New Delhi—my first time back in India since serving with the Peace Corps in 1963. I found that my interest in the country had not diminished. I met Dr. Nicole Grasset, director of smallpox eradication in WHO’s Southeast Asia Regional Office (SEARO), and was immediately impressed by her enthusiasm and desire for success. I also met with the staff at the Government of India’s Ministry of Health at Nirman Bhavan and at the National Institute of Communicable Diseases. At their request, I addressed a meeting of state smallpox leaders gathered in New Delhi to plan a national strategy. I was asked to share the West African experience and to inspire the group to embrace the strategy that had worked so well in that setting. I was wearing, under my dress shirt, a T-shirt that said, in large letters, “Smallpox Zero.” At the high point of my talk I said that we would gird for this historic battle and settle for nothing less than . . . I undid my necktie and unbuttoned and pulled my shirt open so the audience could read “Smallpox Zero.” There was no reaction!
There was nothing to do but bring my talk to an anticlimactic close as I rebuttoned my shirt. It was not a great start. A year later, the same closing would have elicited applause and cheering. Timing is everything, and I was a year off.
In consultation with my family, I made the decision to go to India to work under Dr. Grasset as a CDC consultant. I arranged to spend an additional week in New Delhi, preparing for our move. However, I became so involved in smallpox discussions that in the end I had only the last day of my visit to make personal arrangements. With a great deal of help, a week’s worth of activity was accomplished in that whirlwind day—a harbinger of what was possible in India.
I rented a ground-floor flat in Maharani Bagh, New Delhi, that came without furniture but would be fixed up, painted, and ready for our arrival in August. I arranged for air-conditioning units to be installed in the bedrooms. I went to two different specialty offices, where I rented furniture and a refrigerator. After reviewing recommendations by former WHO workers, I secured the services of a cook, N. Joseph, who in turn agreed to arrange for a gardener and a night watchman. I then opened a bank account, registered the children for school, and signed an agreement for an Indian-made car and a driver. I interviewed several drivers, as I wanted someone who was slow and careful so I could feel secure about our children. In Jit Singh I found the perfect person. I ended the day exhausted but energized, able to depart happily for the airport that night to return to Atlanta.
Even living in Africa did not adequately prepare us for the adventure of life in India. During the twenty months we were there, the children never lost their fascination with it. The day after we arrived, Paula, myself, and our three boys, David, Michael, and three-year-old Robert, explored New Delhi in the rented car with Jit Singh as driver. Cows, camels, and bullocks walked in the streets alongside motor scooters, three-wheeler taxis, buses, and foot traffic. Affluent shaded residential areas stood in stark contrast to slum areas with houses made of discarded materials. We saw brightly colored flowers, saris in every color, and even colorful old buildings, such as the Red Fort. Stores of all kinds bore witness to the spirit of entrepreneurship and the thriving marketplace. Michael, now age seven, had his nose pressed to the window. Suddenly he turned and said, “This is the second best day in my whole life.” Surprised, I asked him, “What was the first best day?” He said, “Yesterday.”
SMALLPOX IN INDIA’S HISTORY
An outsider should approach everything about India, including its history, ready to put preconceptions aside. India is o
verwhelming in its scope and confusing in its detail, as well as in the lessons it provides. Its history abounds with items never taught in U.S. schools, such as the efficiency of Chandragupta, who recaptured India from the Macedonian authority left by Alexander the Great to form the most powerful government in the world at that time. His organizational skills were impressive: he ordered his day into sixteen 90-minute periods. We hear little about the ruler Ashoka, who, after developing a reputation for cruelty, abruptly changed and based his government on the golden rule. We generally are not exposed to the decency of Krishna Raya, a contemporary of Henry VIII; the wisdom of Akbar, who created the most powerful empire of the time; or the paradox of Shah Jehan, who left a trail of ruthlessness and artistic beauty.
The religious, political, and artistic histories of India are matched by its scientific contributions. Astronomy and mathematics come immediately to mind. India is credited with inventing the zero. Indian medical sciences were describing the circulation of the blood before the time of Harvey, and offered a medical creed before Hippocrates. Nalanda, a redbricked university whose ruins are in Bihar state, flourished for more than a millennium before Cambridge was even founded.
The history of smallpox in India is intertwined in the subcontinent’s history and is no less ancient and complex. Smallpox was very likely present in India for a very long time, although evidence dating before the sixteenth century is circumstantial and mainly found in Hindu myths and Brahmin traditions. J.Z. Holwell, in his eighteenth-century Account of the Manner of Inoculating for the Smallpox in the East Indies, comments that the Brahmin caste maintained traditions concerning smallpox from time immemorial.3 Smallpox was probably known in India at the time of Ramses V.4 The Atharva Veda, an ancient Hindu scripture dated to the twelfth to tenth century B.C.E., describes the worship of a deity whose protection was invoked on the outbreak of this disease. It also describes rituals and prayers to be done by Brahmins at the time of inoculation, or variolation, with smallpox.5
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