Grasset was also tough. During the drive back to our respective homes following an evening meeting with Diesh, I asked why she had been so subdued and seemed to hold back in promoting an idea she was developing. She responded that she was passing a kidney stone and was experiencing renal colic. This involves one of the most severe pains known and regularly incapacitates people, but it didn’t stop her. Neither did her dedication to work keep her from appreciating the beauty around her. One time when we were waiting for a meeting to begin, she called my attention to the scene outside the seventh-floor hotel conference room in Lucknow. Outside, a light fog had covered the city, and streetlights shone like jewels through the fog. She said, “That is the way expatriate children see India, as a land of diamonds without the illness and pain and poverty.”
At the conclusion of the smallpox eradication effort, she drove from New Delhi back to Paris, through Pakistan, Afghanistan, and Iran. This was not an uncommon trip for two or more people to make; rarely did a single individual do it alone.
Dr. Zdeno Jezek, a physician originally from Czechoslovakia, was accustomed to working under difficult conditions and had spent some years in Mongolia. While smallpox eradication attracted many type-A personalities, Jezek was the type-A gold standard. He seemed to have a well-thought-out speech always formulated in his head, ready for any occasion. Once when a speaker merely mentioned his name, Jezek jumped to his feet and began a rapid-fire delivery of a speech. Full of enthusiasm for the work at hand, he led others to do things by example. If he was ever discouraged, we did not see it. Even before we finally had smallpox on the run, he continued day after day as if each day would be the turning point.
Dr. Larry Brilliant, an American physician, had come to the Indian subcontinent to find truth, not smallpox. He learned the language, studied the country, and studied himself. When his guru told him it was now time to share his gifts by working to eradicate smallpox, he went to SEARO looking for a job, and Grasset was clever enough to provide one. Brilliant brought to the work a sincere interest in India as well as the desire to make his life count and to use his training to promote health. He could inspire local workers to see that it was not just a job, but a way to do good that would ripple through the coming generations. That is what karma is about.1
AN ALLIANCE AT THE CORE
It was more than good people that made the program succeed. An alliance formed between the Central Government and WHO that transcended all expectations. The reason for this alliance is complex. It may have formed because we traveled together, spending time with one another on trains and in jeeps, sharing lodgings, meals, and conversation. The rapport that develops through such experiences cannot be replicated by meetings in an office. We shared the moments of discouragement and the moments when things went right. The alliance formed not only because we developed respect for each other, but because we ended up trusting each other.
The shared travel was not a calculated choice. It happened almost by accident. In the beginning of the program, the WHO staff would travel between New Delhi and the state capitals by plane. One day Nicole Grasset and I were sitting at a table in the Patna airport, waiting for the daily flight from Patna to New Delhi. I said, “Nicole, does anything at the next table strike you as odd?” She looked at the two men, obviously pilots, seated at that table and answered, “No.” I responded, “We know there is only one flight to New Delhi. Therefore the pilot and copilot at the next table must be for our flight. And they are drinking beer!”
I resolved to stop flying. It was easier, more dependable, and apparently safer to take overnight trains between New Delhi and either Lucknow or Patna for monthly meetings. In addition, I could use the time on the train both before and after the meetings to analyze data. As it turned out, the real value was that the Indian smallpox leadership—Drs. Diesh, Sharma, and Dutta—also traveled on these trains, which provided the opportunity to talk in a casual setting. Soon we could predict each others’ responses, and we found that we were thinking alike. As the insider-outsider barriers evaporated, an openness developed that helped to buffer both sides from problems within their own administrative structures. These train discussions, sometimes continuing in the sleeping compartments before we drifted off to sleep, helped us to work out the most difficult situations. When the Indian government could not provide an adequate per diem for the necessary field visits of Indian workers in the states, we faced that problem together and found a way for WHO to provide the funds. When all of the WHO resources had to go into surveillance and containment and WHO/Geneva could not provide additional money for evaluation, we were able to develop an approach with the Government of India.
The alliance formed to the point where it was unnecessary to develop guidelines on how we would operate. We reached decisions together. Our allegiance put us in a position of facing the world of problems united, rather than wasting effort in competing with each other. If anything, our competitive impulses were directed to competition with the virus. One of the lessons learned about collaboration is that the best ones begin with a clear vision of the last mile, rather than developing around a common interest and then laboring to define desired outcomes and identify a strategy. Smallpox eradication in India exemplified this. It also demonstrated a second important law for successful collaborations: the need to suppress egos and seek satisfaction in a shared outcome rather than holding individual power or protecting turf.
One distinction between the majority of collaborations and the ones that turn out to be especially productive is that the effective groups literally form a new substance. In chemistry, a mixture retains all the characteristics of the ingredients. A compound, on the other hand, forms a new substance with new characteristics, for example, when oxygen and hydrogen become water. The best alliances cannot be described simply by identifying the members. The sum is something different; it is a new compound. The objective becomes a shared objective that supersedes competition for turf. The talents coalesce into something more powerful than simply the addition of talents.
At times the ministry’s knowledge of its own country saved us from error. I argued early on for a reward system to help us find new cases of smallpox—an approach that had worked exceedingly well during the final phases of eradication in West and Central Africa. I thought we should implement such a system as soon as possible in India. The ministry people wanted to wait until we knew how much smallpox actually existed—we might not be able to afford rewards. They saved the program from disaster. With thousands of new cases found in the early searches, rewards at that time would have broken the bank.
As time went on, the alliance just grew stronger, which in turn attracted others to participate. Notable was the Swedish International Development Authority (SIDA), which provided resources at a critical time. SIDA’s approach to assistance is one of the most enlightened among development agencies. Before committing SIDA to the smallpox effort, J. E. Tranneus, director of the New Delhi SIDA office, was careful to evaluate the program, the strategy, and the probability of success. Following his review, SIDA made a grant with no strings attached. We were free to use the money in any way we felt advisable. The only stipulation was that we had to provide adequate accounting for how it was used.
MANAGERS FROM THE CDC
From the very first days of the eradication program in Africa, it was obvious that fighting smallpox was not just a medical or scientific endeavor but was very much a matter of management. We did need science; we needed to make scientific observations to understand the epidemiology of smallpox, the role of population density, the impact of cultural practices, the influence of climate, the vulnerabilities of the virus, and the impact of public health tools and experiences. And, of course, we needed to document our clinical observations. However, the real problems were in implementing the strategy: developing routines, documenting the implementation of those routines, hiring the right people, supervising, motivating, and evaluating. We needed managers, administrators, and logistics experts—people who
knew how to solve problems and how to get things done. The program would not fail for lack of scientists, but it could fail—even with the best strategy—if we didn’t attract the very best managers.
When commodities or people were needed, my first thought was to ask David Sencer, the director of CDC. He always found creative ways to provide the needed people, equipment, and support. Over the smallpox years, he developed a reputation for delivering on every request made of him. CDC smallpox workers soon realized that if you asked him for something, you had better be able to use it, because you would be stuck with whatever you had requested.
It has been said that genius is seeing one’s field as a whole. Sencer saw the public health world as a whole. He understood that a healthy United States required a healthy world and that involving domestic public health workers in the global smallpox eradication program directly benefited the health of Americans. Addressing smallpox internationally obviously reduced the risk of smallpox importations to the United States, reduced risks for Americans traveling, and reduced the costs incurred by vaccinating the entire U.S. population. But there were other benefits. Don Millar, by this time in charge of the domestic program for immunization, was instrumental in sending many CDC staff members to the Indian program. He once wrote me that if his three-month loan of people for the program in India did nothing to improve smallpox eradication, he still wanted me to request them because they returned to the United States as different people. Once they had faced the problems of a developing country, they were unwilling to put up with the simpler barriers they encountered in domestic program implementation. The investment of domestic resources therefore seemed absolutely logical, and Sencer was willing to send CDC workers to help in the global effort.
In November 1973, shortly after the first search, I sent a telegram to Sencer stating that we needed a capable manager to help us develop administrative systems to handle the overwhelming situation we were facing in India. It was indicative of Sencer’s interest that I received a phone call within a few days from his deputy at the CDC, William Watson, who asked if he would be acceptable as that manager. Watson had served in the U.S. Army during World War II and then earned a degree in political science, after which he worked under Johannes Stuart, whose combined interests in political science and public health translated into his effort to stem the postwar rise in sexually transmitted diseases. Stuart recruited college graduates to trace the partners of people discovered to have a sexually transmissible disease and get them to treatment before they in turn could become transmitters. It was, of course, a form of surveillance and containment, and it required combining the attributes of a detective with the sensitivity of a psychiatrist and the insights of a political scientist, a person who could see connections. Stuart’s cadre of highly educated activist public health workers eventually became the managerial backbone of CDC, and Bill Watson became a father figure for this group.
Upon his arrival in India, Watson went to work on setting up a management system, addressing matters such as adequate training programs, sufficient transportation for field-workers (including a way to have vehicles repaired out in the field), and distribution of funds to those who would need them—the practical issues big and small that can become serious obstacles if not thought through. He was succeeded by an equally outstanding manager, Stuart Kingma, who was the kind of person who not only built his own telescope but also ground the lens himself. Kingma was a superb and creative craftsman whose talents transferred easily to administration. A compulsive manager, Kingma left no possibility unstudied. Watson and Kingma were followed by a continuous flow of top-notch CDC managers assigned to the SEARO in New Delhi on three-month assignments.
Once Bill Watson had set up the basic management structure, it was a matter of adjusting as needed. We had a framework, and succeeding CDC managers were expert at maintaining the right balance between attending to the never-ending daily needs of the program and keeping their eye on the big picture. The smallpox eradication effort in India would not have worked without these individuals: they got funds to the teams in the field, secured supplies to print and distribute thousands of forms, developed joint approaches between WHO and the Indian government, assured oversight, moved workers in and out of the field (and the country), and responded to thousand of requests from field-workers needing more vaccine, more bifurcated needles, or approval to purchase supplies. It was never ending.
THE CAVALRY: THE SPECIAL EPIDEMIOLOGISTS
To deal with the overwhelming numbers of cases unearthed through surveillance, the program in India needed, alongside managerial expertise at the central level, additional public health professionals in the field. India’s fourth five-year plan for eradicating smallpox, initiated in 1969, included a category of workers called “special epidemiologists.” Some were trained epidemiologists who had worked on smallpox or other diseases. Others were medical specialists in internal medicine or infectious diseases. Some were public health managers, and some were simply people who had worked in public health programs in India or around the world and developed a reputation for solving problems; these were taught smallpox epidemiology as part of their orientation. As with the workers in the Africa program, many found their life’s calling by working for a period of three months to several years as special smallpox epidemiologists.
They were the smallpox program cavalry—highly mobile, able to inspire, and in charge of particularly difficult geographic areas with high smallpox rates. Each special epidemiologist was provided with a vehicle, a driver, and a health worker—a paramedical assistant (PMA) who if necessary also acted as an interpreter—as well as funds to use for expenses, including hiring day laborers. Each three-person team was assigned to assist in a state, a collection of districts, or even a single district where smallpox transmission was especially high.
Initially these consultants were mainly Indians and included just a few outsiders. Some of the most knowledgeable and capable smallpox workers in the world were in India. A. R. Rao, who had published a textbook on smallpox, was without peer in the world.2 But just as a prophet often lacks credibility in his or her own community, it proved difficult to make full use of India’s own expertise, including that of Rao. In any case, even India did not have enough experts for the scale of the problem that we on the smallpox team now knew we were facing. Epidemiologists from other countries could augment India’s resources, and the SEARO team had already requested WHO/Geneva to send sixty more. However, bringing more foreign experts to help with what India saw as its own smallpox problem was a sensitive matter for this newly independent country. My several attempts to discuss this delicate matter with Dr. Diesh were unsuccessful. He could easily see where the conversation was going and expertly changed the subject.
On one of those overnight train trips back to New Delhi, in late 1973 or the first weeks of 1974, the topic of bringing more epidemiologists from other countries came up again. In the hour just before we arrived back in New Delhi, we found agreement on the point that India clearly had the ability to eradicate smallpox without additional outside workers. However, if we were interested in speed—in India not being the last country to stop smallpox—then the credibility and energy of outside workers were assets not to be overlooked. This view of the situation so excited Diesh that he decided to go directly from the train station to see the minister of health, Karan Singh, to make the case.
Later in the day, I encountered a very subdued Dr. Diesh, the only time in two years that I saw him discouraged. Even before Diesh stated the reason for his visit, the minister asked why foreigners were working on smallpox in India when India itself had so many experts. Taken aback, Diesh said nothing about bringing in more outside people and simply reported on the monthly meeting we had just attended.
By now, however, Diesh and I were both convinced that bringing in more foreign expertise was the right thing to do, and we discussed ways of making the case. Within the week, Diesh had regained his footing and he revisited the minister to make his
case. Yes, India could do this without any outside people or resources, but acquiring experts from around the world would increase the chance of an early success—perhaps even during the minister’s time in office. And, drawing on the help of the international community would demonstrate the Indian government’s commitment to eradicating this disease. Diesh succeeded in convincing the minister that making this a global effort rather than an Indian effort alone would greatly accelerate eradication. The minister agreed, but asked that a balanced approach be used, one that would increase the numbers of foreigners and Indians simultaneously.
Following the first search, SEARO had asked WHO/Geneva for sixty more special epidemiologists (this included both medical officers and managers doing fieldwork). Now that the Government of India had approved that estimate and requested the additional expertise, consultants joined the team through arrangements made by Geneva, as well as from various parts of India itself.
During the ensuing months, thirty countries provided 235 consultants, with the United States providing 100 of them. With its experience managing the first successful regional smallpox eradication effort in West and Central Africa, the CDC now became a source of both long-term and temporary personnel for the eradication effort in India. People with experience in the Africa program were eager to see the same techniques applied in a more difficult situation, and we in India needed them.
The new recruits, who were usually seconded for three months or more, came first to New Delhi for a three-day training course. For eighteen months, I had the privilege of being involved in the training of all international as well as Indian special epidemiologists. The training course included a review of smallpox, the technical aspects of search and containment (even as we were learning them), a case study, information on the procedures they were expected to follow, and details on forms, reporting, and the role of monthly meetings.
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