The compromise, unfortunately, was to do both, that is, to do an inadequate job at every outbreak visited and not reach some outbreaks at all. The smallpox team’s “unwarranted optimism” allowed us to hope that vaccinating even a small number of people who were at highest risk would impact disease transmission, just as small increases in humidity and reductions in wind velocity can dramatically improve the efficiency of firefighting efforts. On this point, our optimism was trumped by reality.
One of the first changes introduced after the initial search was to shift the focus of attention from smallpox cases to smallpox outbreaks. This shift was made in Uttar Pradesh more quickly than in Bihar. The practical implications for control were the same whether a village had one, two, or twenty cases of smallpox. Both the number of cases and the number of outbreaks continued to be collected and reported, because WHO was using number of cases as the global metric. However, the number of outbreaks was the real indicator of the containment work required in each state, district, PHC, village, and municipality. It remained one of the program’s most meaningful metrics.
At the end of the second search, using the new reporting system, Uttar Pradesh recorded 514 outbreaks that were pending, that is, requiring all of the attention and work of containment. The third search, held December 10–15, revealed 1,148 new cases and a total of 306 new outbreaks in Uttar Pradesh. New cases and new outbreaks do not correlate directly; for instance, the 1,148 cases were among the new outbreaks but also included cases reported from previous outbreaks that week in various stages of containment. In general, the median per outbreak was 5 cases.
The monthly improvements in searches were making it clear that Bihar had by far the biggest problem with smallpox in India, even though its population was only one-third that of neighboring Uttar Pradesh. During the third search, Bihar workers found 406 new outbreaks, with 2,619 new cases. Furthermore, whereas the first search had revealed smallpox in sixteen of Bihar’s seventeen districts, it was now clear that all seventeen districts were infected. The first search had missed smallpox in an entire district, with a population numbering in the millions. As of the third search, over 25 percent of all PHCs in the state had cases of smallpox, and in the district of Bhagalpur, 80 percent of the PHCs were infected. It was almost impossible to travel anyplace in Bhagalpur without encountering smallpox.
REFLECTIONS AFTER THE THIRD SEARCH
In the final three months of 1973, the team learned a lot about what needed to be done to scale up the surveillance/containment strategy so that it would be adequate to confront the reality of smallpox in India. Each month saw changes in how the searches were conducted, the addition of new and complementary search techniques, and better approaches to record keeping and containment. The year ended with a system of smallpox detection that seemed to work. Certainly it far surpassed the effectiveness of the old passive system.
By the end of the year, most outbreaks were being visited by a containment team, even if the visit was weeks after the report and inadequate in actual containment. The containment team visits also supported the surveillance effort, since people are more likely to provide information when they have seen that it brings a response.
The light being shed on India’s smallpox situation was gradually increasing in intensity. We were coming to know what was true, and this was inspiring everyone at all levels, from the central team to the PHCs. Knowing the truth has a way of inspiring belief and optimism that the job can be done, even when the job is overwhelming. The continuing optimism helped us to maintain the level of work.
In effect, the surveillance/containment strategy was a learning program, and experiences were regularly analyzed so we could figure out what would actually work in India. For example, it took time to find the most efficient ways of eliciting information. The fact that the residents had seen someone with smallpox did not necessarily mean they would pass on that information. They could be reluctant to share what they knew for many reasons. The solution was to have searchers, if they saw cases of smallpox, record on the reporting form for the village where the person lived and how he or she could be found.
Some experiments showed us what didn’t work. For example, hoping for a shortcut, the central government/WHO team tried using presearch reports to indicate where searchers would most likely find new cases, but they proved useless. Districts that reported more than 20 cases of smallpox in the five weeks before the search averaged 133 new cases during the search. In districts averaging fewer than 10 cases during those five weeks, 139 new cases were found during the search. Even districts that reported no cases for the preceding five weeks averaged 67 new cases. The search itself, then, was the first reliable indicator of where smallpox would be found. This meant that searches had to be extended to every district in the state. There weren’t many shortcuts.
By the end of the year it was also abundantly clear that even with barely trained search teams, the new system was more efficient than India’s old passive reporting system. It doesn’t take a great smallpox tracker to find more cases than someone who is not out looking. The weak link in the program was the inadequately trained and insufficient number of containment teams; it would take them months to dig their way out of the morass of outbreaks discovered by the search teams, and this hurt morale. Again, we were saved by an unexpected finding: even poor containment teams were able to slow smallpox transmission.
Perhaps most significant, the smallpox workers were learning and improving every month, while the smallpox virus, for all of its evolutionary success, could not respond with the same agility. It continued in the way of its ancestors, unaware that its strategy for survival, adequate for millennia, would soon no longer suffice.
In the other two states where smallpox was endemic, West Bengal and Madhya Pradesh, monthly searches were also conducted through the fall of 1973. In West Bengal, all sixteen districts reported smallpox. Importations were frequent from neighboring Bihar and Bangladesh, but surprisingly, only 74 new cases were detected during the first search, for a total of 143 outbreaks listed at the end of the search. At the end of December 1973, the state listed 124 active outbreaks. While most countries of the world would have declared an emergency with a single outbreak of smallpox, much less 124, West Bengal was nevertheless a manageable problem compared to Uttar Pradesh and Bihar.
During the first search in Madhya Pradesh, 192 new outbreaks were detected, 53 during the second search, and 49 in the third search. These outbreaks were reported so early in their development that two-thirds of them had three cases or fewer, and 40 percent consisted of a single case. Madhya Pradesh’s outbreaks were also limited geographically: only three districts had more than five new outbreaks. This was another manageable problem compared to Uttar Pradesh and Bihar.
Ten other states reported smallpox during these early months of the campaign, but all of them combined reported fewer than two hundred cases each week. Therefore, in most of India, while the problem had to be taken seriously, the containment of outbreaks was well within the state health systems’ capacity and required little in the way of resources from the Central Government or other countries.
By the end of the third month, then, the smallpox program in India had developed its main themes. First, to eliminate smallpox it is necessary to know the truth; therefore, surveillance was the highest priority, followed by containment. Second, both surveillance and containment needed constant improvement. Third, we were all in this together. A unique group of Indian and international workers was clearly functioning as a team.
EIGHT A Gorgeous Coalition
Mahatma Gandhi once said: “Interdependence is and ought to be as much the ideal of man as self-sufficiency. Man is a social being.” Whatever people set out to accomplish requires teamwork. Every team does not work together efficiently or effectively. The vast team that came together to eradicate smallpox in India achieved both.
KEY MEMBERS OF INDIA’S TEAM
By 1973, smallpox eradication had become such a priority in
India that the best possible people in India’s Ministry of Health were assigned to it. Such a statement may be fashionable, even diplomatic; in this case, it was also true. In addition, over six hundred high-level supervisory personnel were eventually deployed from the central and state governments as well as from medical colleges, hospitals, and even private industry. These were in addition to the tens of thousands involved at the state, district, and PHC levels actually doing the searches, vaccinations, and outbreak control. Some states, such as Andhra Pradesh, contributed over fifty supervisors to the task. The Maulana Azad Medical College in Delhi provided ninety staff members. At a crucial point, Tata Industries, in an incredible contribution from the private sector, provided over a hundred high-level supervisors and actually managed smallpox eradication in a large geographic area of Bihar. With time, I came to realize that it would have been impossible to find a better team, even with a global search.
India’s top health official, Dr. Karan Singh, took an active interest in the program. His background was impressive. He was regent of Jammu and Kashmir at the age of eighteen and later governor of that state, and was India’s tourism minister before becoming minister of health and family planning in 1973. He set up periodic briefings with the smallpox team, asking useful questions and displaying both a quick mind and great managerial abilities. He especially liked the idea of setting monthly objectives for every state as well as conducting the monthly meetings in smallpox-endemic states, which provided a rapid exchange of information and obligated program directors at central and state levels to be involved in the field.
Dr. M. I. D. Sharma, head of the National Institute of Communicable Diseases (NICD), became in time the wise person to whom everyone turned. He had worked for many years in India’s malaria program, had a comprehensive understanding of the Indian medical services, and was highly respected in the Indian states. He had participated in many international meetings. He never had to raise his voice to command people’s attention. A large man, he might have been intimidating, but he was so kind and gentle that some likened him to a large teddy bear. He was known for his integrity, and when he requested people to do things, they complied without hesitation—not out of fear, but because they trusted him.
Although Dr. Sharma exuded calmness in the most difficult situations, there were telltale signs when his patience was reaching its limit. One such sign was that he began to rub his head. This would soon be followed by a very deliberate statement to end whatever argument was disturbing him. He would then, with good manners, move the meeting to a conclusion. On one occasion at a meeting of both Indian and foreign workers, an epidemiologist from outside of India was forcefully condemning the work of some of the medical workers. He became more animated as he continued, and Dr. Sharma began to rub his head. He did not interrupt the speaker but waited until he had finished and then said quietly, “Let me remind you that this is our country.” The meeting continued on a very different tone.
Dr. Sharma enjoyed laughing, even at himself. Once as he and I waited to cross the street at an intersection in Patna, Bihar, he said, “Let me tell you what happened to me once at this very intersection.” While he was waiting to cross the street, he told me, a rickshaw approached carrying a woman of such beauty that he could not stop staring at her. He was shaken from his spell when the woman greeted him by name. Seeing his confusion, she identified herself as a classmate from medical school. Flattered, he asked how she had recognized him after so many years. She replied, “I recognized your nose.”
Dr. Sharma received bad news with equanimity and immediately set to solving the problem, and he received good news with the phrase, “God is good!” In one person was combined scientific acumen, managerial savvy, and a rare sensitivity.
Dr. P. Diesh, India’s additional director-general of health services, was at first an enigma to me. On our initial meeting, I was disturbed by the way he treated a female colleague and his subordinates in the Ministry of Health. I was sure I would never warm up to him, only to find him a close friend within the year. It took me months to realize that his gruffness was his way of communicating his authority, which he exercised not to aggrandize himself, but to make the system work. He became a powerful force in guiding the Indian bureaucracy to embrace smallpox eradication. People would fall over themselves to comply when he barked out his orders. It was a surprise, then, to hear him express his fears and doubts as well as his concern for those carrying out the orders he gave. He wanted to be sure they had good working conditions and the support of their supervisors.
Diesh was dependable, had high standards, and could get things done. He also had the courage to take truth to power, including correcting the minister of health when he thought the minister was wrong. He knew everyone in government, enjoyed impressing an outsider with that network, and could make a call to solve almost any problem. Given his position, he did not have to get involved personally in the smallpox eradication effort, but he took a personal interest in the program anyway, attending state meetings and making field visits—indications of both his managerial style and the importance the government was giving to the program.
His pleasure on receiving a good cigar was so great that I would at times offer him a cigar while saying, “I have a great idea.” We soon were joking that the idea did not even need to be a good one for him to agree; all I needed was a good cigar. Twenty years later, as we reminisced over lunch in New Delhi, he said that he had given up tobacco and alcohol and returned to being a vegetarian. He told me that he could never believe how shameless I had been in plying him with cigars. I told him that I could never believe how easy it had been. We reminisced about the smallpox program and our many discussions on field trips. Diesh said it was such a high point in his life that if I returned to India, he would come out of retirement and we could tackle another health problem.
Another key member of the Indian smallpox team was Dr. Mahendra Dutta, one of the most valued assistants to Dr. Sharma at NICD. His work in public health was part of a family legacy. His father had received a Rockefeller Foundation grant to study public health in the 1930s and later became the health commissioner for New Delhi. After the completion of the smallpox eradication effort, Mahendra Dutta in turn became the health commissioner for New Delhi. Mahendra’s son, Dr. Umesh Parasher, followed the family tradition and became a brilliant public health worker at the CDC in Atlanta.
Dutta was the epitome of deliberateness and common sense in both speech and action, and was totally unafraid of fieldwork and all of its discomforts. He was given the job of providing central government supervision for the smallpox program in Bihar state. During the intensified smallpox campaign, he traveled almost continuously, attending meetings, making field visits, analyzing data, and solving problems. Early in the program, he discovered that a leader of Bihar’s state staff was diverting smallpox resources for his personal use. This man was listing vaccinators who did not actually appear at work. For the use of their names on the employment rolls, they would receive their pay, despite no work, and split the money with him. Once this issue came to Dutta’s attention, he was relentless in seeing to it that the man was replaced, despite the difficulties of removing an entrenched government leader.
Dr. Mahendra Singh was in a class by himself. As deputy assistant director-general of health services (smallpox), he had the longest institutional memory regarding smallpox of anyone in the ministry. He was the sole medical officer in smallpox at the central level from 1966 until 1972, with an impossible job: trying to hold back the relentless tide of smallpox virtually single-handedly. Before the government got serious about smallpox, Singh was working tirelessly to both fight smallpox and convince everyone from the central government level to the field that more resources were needed to do the job. Report after report showed his tenacity in promoting smallpox eradication before others accepted it as possible. For years he continued his uphill battle to tame smallpox; the obstacles were many, but he was never discouraged. He was the gold standard for
a dedicated field-worker.
Two of the youngest members of India’s central-level smallpox team were Drs. C. K. Rao and R. N. Basu. Rao, from NICD, was assigned to Uttar Pradesh as a central government supervisor because of his solid dependability and competence, and after his smallpox career he continued to be highly productive in the Indian medical service. Basu, who as assistant director-general of health services (smallpox) answered directly to Diesh, traveled widely to inspect field operations and continued to work in India and for WHO for three decades after the last smallpox case, using his experience and expertise for immunizations in general. Dr. R. R. Arora, a top epidemiologist at NICD, became a dependable and tenacious member of the team.
THE SEARO TEAM
I was fortunate to work alongside some exceptional people in SEARO. Dr. Nicole Grasset’s dedication was unsurpassed. The distinction between days, nights, and weekends seemed to be irrelevant to her as she charged ahead with flair and courage. If Indian government officials at one level did not provide a positive response, she would go to the next higher level, and if that didn’t work, she would go to the prime minister. Comfortable in any situation, and as charming as she was beautiful, she could endure the most difficult field conditions and also make sophisticated presentations at a conference or to the minister of health. Outcomes were her measure of a person, and she would give anyone a chance to contribute. She never lost her focus.
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