House on Fire

by William H. Foege

  The three-day briefing also included practical things learned by other special epidemiologists. For example, drivers or other people could remove petrol from vehicles during the night, sometimes even during daytime stops, and sell it for extra revenue. Many workers had tried to solve this problem by having a lock made for the petrol tank. But a clever driver could have a key made, even if the epidemiologist retained the original key. And four or five liters of fuel could easily be removed without detection, especially since the driver had to travel an unknown distance, after dropping off the epidemiologist, to find his own quarters for the night. The solution was to provide accommodations for the driver wherever the epidemiologist spent the night, and to fill the tank at the end of the day and again first thing in the morning, with the driver paying for any petrol added in the morning that exceeded one liter. The driver himself thus had to secure the tank in a way that prevented others from removing fuel.

  The teams of short-term epidemiologists brought a continuing supply of fresh energy and new eyes to the operations. The special epidemiologists turned out to be invaluable in providing the flexibility the program needed in responding to shifting conditions and the changes in tactics that followed each monthly meeting. It took good planning to be able to use three-month assignees effectively, especially when most of the foreign recruits were experiencing India for the first time. It required adaptation on their part, but the training program was of sufficient quality that the results were far better than many predicted.

  Problems occasionally arose, especially involving the diplomacy of non-American foreigners being supervised by Americans, who in turn were working under the direction of the host country, India. Given the Cold War politics of the day, the situation was especially sensitive if the Indian officials were displeased by a Soviet worker. It was much easier, and less political, for an American to send another American home. Yet the problems were generally worked through to a successful conclusion.

  In an attempt to get to know the trainees, I invited many of them to spend an evening at our home. As the program progressed, I sometimes invited foreign workers who had stopped in New Delhi on their way home after their time in the field. On average, Paula and I had guests two to four nights per week. Joseph, our cook, provided home-cooked meals of great variety and was remarkably flexible about adding more places for visitors at a moment’s notice. We were generously rewarded by witnessing the breadth of experience and high motivation of people from around the world who had come to India to make a contribution. Our children loved the opportunity to engage with a kaleidoscope of new people, especially those from other countries.

  Unexpectedly, these evenings also provided opportunities to assess the relative strengths of and make assignments for these temporary workers. On occasion, a new worker’s affinity for alcohol would raise a red flag in my mind. Others expressed false bravado regarding their ability to solve any problem in the field. A few complained about their hotel room in New Delhi, raising immediate suspicion that they would not fare well in the field. Over the ensuing year, many short-term volunteers arrived, were trained, worked for three months, were observed over two or three monthly progress meetings, and were then debriefed. A few workers were unable to adapt and were retired early. Eventually, it became clear that certain qualities were indicators of how they would do. These observations improved the chances of placing the most likely to succeed workers in the most difficult situations. The experience also provided me with a lifelong approach to evaluating candidates for positions.

  The first quality was absolute integrity. These short-term epidemiologists would be handling large sums of money to pay daily workers, hire vehicles, provide fuel, and the like. There was no efficient way to verify how many day laborers they had hired or how many vehicles they had rented, and resources were simply inadequate for inspecting travel vouchers and weekly expenditure forms in real time. In any case, a worker would likely be gone before any discrepancy was spotted, so it was important to start with people who did not require that type of supervision.

  A second quality was cultural sensitivity. The workers would be operating in someone else’s culture. How they treated coworkers, patients, village leaders, school teachers—in short, everybody—was crucial to their access to people, the type of information they collected, and the work climate they would leave behind.

  A third quality was optimism. The assignees were about to enter a world of work that was stressful and a climate that could be debilitating, with few amenities to soften the day. They were about to experience poverty and, in a small way, share the pessimism that is daily reality for so many. A pessimist transplanted into such a situation was not likely to thrive and be productive. Even an optimist would feel despair at times. Many workers later described their three months in the Indian smallpox program as the most difficult work they had ever done and yet, to their own surprise, the most satisfying.

  Fortunately, all three qualities are easily researched, even though they are not found in the usual résumé or recommendations by supervisors. It is not that hard for people to assemble an impressive résumé and list references who will give them a positive review. Coworkers and subordinates are rarely listed by an applicant, yet they are the ones who can say immediately whether the person under consideration is trustworthy, sensitive to others in the work environment, or optimistic.

  One of the early special epidemiologists, Dr. Don Francis, became for me the prototype of the person needed to defeat smallpox. He later had a distinguished career in infectious diseases, designing and supervising the first human trials testing an AIDS vaccine in the United States and Thailand. Francis began his India work in Bareilly, Uttar Pradesh.

  This was an area of many smallpox outbreaks. Don resided initially in living quarters belonging to the Clara Swain Hospital, which was a place of historical significance because it had been built by the first woman medical missionary to India. Clara Swain left the United States in 1869, arriving in Bareilly on a January morning in 1870 after an all-night trip in a horse-drawn wagon. She began seeing patients that same day. By the end of the year, she had established her credentials as a doctor and was also training local students. By 1874, she had established the Women’s Hospital and Medical School, the first in Asia. She went to see the Nawab of Rampore, who had publicly said he would not allow a Christian missionary in his city. He was so charmed by this determined young woman that he gave her forty-two acres for the hospital and school. Now Don Francis was building on that legacy by using the medical complex as the base for his smallpox activities.

  Because of his success at motivating large numbers of local health workers, he was eventually transferred to Lucknow to oversee, under the state medical officials, the smallpox operation for the entire state. Don, in turn, had the utmost praise for Rajendra Singh, the PMA who worked with him throughout his two years as a special epidemiologist:

  When we first started together, [Rajendra Singh] was helpful, but rather quiet and respectful. He watched as I met with high-level officials to explain the new search and containment strategy. He watched as I went to the field to do my own search for cases of smallpox. And he watched as I went to villages with outbreaks to evaluate the vaccination or, if there wasn’t any, to vaccinate myself.

  Soon, whether it was controlling an outbreak in a village or meeting with a high-level official in the state capital in Lucknow, Singh knew what to do.

  In the villages I learned to turn to Singh to ask him how to proceed, especially in villages where there was some resistance to vaccination or ill-founded concerns. Standing as straight as an arrow, he would gently raise his hand before a protesting villager and say, “Gul suno” (Listen to what I am saying). Then, with personal force and gentle words, he would convince even the most resistant person of the good of what we were doing.

  He had equal insight into the complexities of higher levels of the Indian government. He would rapidly assess what was behind the problems we confronted. Then, quietly an
d in private, would let me know exactly what was standing in my way and whether or not there was a way to address it.

  Especially during the first year, when the program was failing and smallpox was everywhere, I don’t ever remember him getting impatient or complaining of the long hours or the days-on-end away from home. Indeed, he was always there to help. When the weather got unbearably hot or when the road was so dusty that we couldn’t see where we were going, he would urge us onward.

  After smallpox, Singh returned to Pilibhit and headed up the District’s immunization program. In 2008, while working on polio eradication, I visited Pilibhit and was fortunate to find him. He retired from government service to run his farm and a private pharmaceutical supply business.3

  THE MONTHLY MEETINGS

  The foundation of quality improvement for the smallpox campaign was the monthly meeting held in every smallpox-endemic state. The monthly meetings brought workers from every district to the state capital—Patna for Bihar, and Lucknow for Uttar Pradesh. Attendees included between two and six people from SEARO and the Central Government, the state smallpox officer, state health and political leaders, district medical officers, special epidemiologists, urban health officers for the largest cities, and several people from blocks that were of special concern. There might be fifty to one hundred attendees, and while the meeting could be completed in a day, many workers came a day early or stayed an extra day to replenish supplies or discuss special concerns with state and central officers. The meetings were usually conducted in a government meeting hall with ceiling fans but no air conditioning. Coffee and tea breaks were part of the tradition, and lunch was served in an adjoining room.

  The meetings were primarily to review the work of the previous month and choose tactics and goals for the next. They were also an opportunity to get real-time feedback from field-workers, pursue scientific inquiry, evaluate what was working and what was not, replenish funds and provide payment, and recharge the field-workers’ enthusiasm, which could evaporate after a month of hard work in trying field conditions. No small part of the meetings was the opportunity for foreign workers to leave their isolation out in the field and blow off steam.

  The meetings always reminded me of reports of similar gatherings in the United States a century and half earlier, when mountain men working throughout the Rocky Mountains as well as local Native Americans would once a year bring their beaver furs to an annual rendezvous, often on the Green River in Wyoming. Both groups would sell their furs, buy supplies such as traps, ammunition, and coffee, find out what was happening in the rest of the world, and after a week or so make their way back to the field.

  There was always a period of chaotic human Brownian movement as people greeted each other before settling down for the proceedings. The meetings began with a review of what had happened around the world during the previous month in smallpox eradication, thus incorporating the field-workers, in close to real time, in the global effort. A competitive feeling developed, since despite the massive problems we were facing, everyone hoped India would not be the last country in the world with smallpox. The next meeting item, a review of results from other states of India, similarly fueled both hope and a spirit of competition that their state would not see the last case of smallpox in India. Best strategies used in other states were also reviewed.

  The meeting then shifted to district reports. Besides reporting the basics—the number of outbreaks at the beginning of the month, the number of new ones found, and how many had been contained and thus taken off the books—field-workers shared innovations in everything from how to find previously unknown cases to how they improved the productivity of health workers and daily laborers. Innovation was encouraged; when we identified effective new practices, we moved quickly to replicate them. At the same time, we tried to reward field-workers for being transparent about unproductive strategies so they could be discarded. We also found out which areas were overwhelmed with outbreaks and needed more supplies or people.

  The meetings ended with two practices. The first was to distill lessons learned from the collective experience of all districts plus other states and forge this into a statement of new tactics to be tried the following month. Second, targets were set for the month by district and for the state. Only once during the program were the monthly targets actually met in Uttar Pradesh and Bihar, but knowing what we hoped for under ideal conditions served to motivate every worker, from the field to the central level. The end of each meeting also involved decisions on personnel placement and deliberate efforts to encourage each other to keep working in the face of tremendous odds.

  Often the meetings revealed that some special epidemiologists were so beaten down that they needed special attention or to be replaced. These were tough people; they did not say they were depressed or overwhelmed. Most workers, regardless of how tired they were, were excited about sharing what they had been doing, the tricks they had developed, and the small successes they had experienced; some, however, were so overwhelmed that they could not get excited even over their own presentations. Just as the smallpox virus left a trail, so did depression. They tended to express frustration with their staff or district supervisors, or even the strategy itself. They might express anger about expectations, living conditions, or paperwork. Occasionally their behavior reached a point where the Indian authorities would ask for their removal.

  The first level of response was to plan a visit to their area of work. Some people simply needed someone to witness the situation, to offer ideas, or to commend their actions. Misery, like poverty, can be endured when shared. However, sometimes this was not sufficient; some needed a face-saving way of going home early. Usually, they welcomed the suggestion that they had worked too hard and needed relief. How could they communicate this to others? By saying they had become ill and had to return. They were relieved to be going home but had not been able to make that decision for themselves.

  A recent book on the Indian campaign, authored by S. Bhattacharya and based on his review of WHO archives, comments on the high level of dissension in the smallpox program. Bhattacharya says that dissension is evident in the records within WHO, in conflicts between WHO and Indian workers, between smallpox and other health programs, between the central and state governments, and between health workers and non–health workers. He also describes the tendency of WHO to attempt imposing its will on India.4

  While these comments contain some truth—there were strong differences of opinion within WHO, within the regional office, and within India’s Central Government—dissent was far from being the driving force. In fact, the climate of the program in the field was quite the opposite—exhausting, frustrating, and confusing, certainly, but remarkably positive and collegial even during the most difficult periods.

  Yes, the staff at WHO/Geneva had strong opinions on how things should be done, but any attempt to impose their views would have failed. On the other hand, no suggestion from Geneva or elsewhere was ever discarded untested simply because it came from outside the country. Indeed, international policies were tested every month in every state, and the monthly meetings provided feedback on what worked and did not work under local conditions. No suggestion from outside of the country was incorporated into the program without validating its appropriateness for India. The interchange between people on field visits, the collegiality of district and PHC meetings, and the fine-grained texture of the daily work were not necessarily captured in the archival record.5 While dissent was real and even encouraged, the actual story is how the months of intense and continual involvement of workers at every level, as well as the constant stream of communications in real time to everyone involved, promoted a level of trust that overcame any disagreements.

  In retrospect, I would say that rarely in my half century of global health experiences have I seen such an effective coalition of workers as the one that developed in India. The core of that coalition was the monthly meetings. Representatives from the Central Government, state ministries
of health, and other key state agencies all heard the reports from the villages. The usual communication and relational limitations of a hierarchical system were avoided; everyone attended the meetings. The team concept extended from every village all the way to Geneva. In facing the common goal of stopping a deadly disease that itself had no regard for rank or status, the usual governmental barriers gave way to a new kind of order and openness.

  Indeed, in my view, the single most important reason for the successful eradication of smallpox, after decades of ineffectual efforts in India, was the seamless coalition that developed between India’s smallpox program leaders and the array of international participants involved. A coalition can have great energy yet yield poor outcomes because people stake out their own turf. This did not happen in the India smallpox eradication program. Rather, the key groups joined together—a chaotic collaboration in the beginning but increasingly disciplined, coordinated, and purposeful. Over time, dozens of other groups and special interests joined too, including UNICEF, bilateral agencies, health and nonhealth government agencies, nongovernmental organizations, church groups, laboratories both in India and abroad, corporations, and various volunteers. If a coalition can be described as beautiful, this group became absolutely gorgeous, a model for all future national and global health efforts. The result—the eradication of smallpox—was not an accident.

  NINE Rising Numbers, Refining Strategy

  The first four months of 1974 were whipsaw months. The seasonal low point for smallpox transmission had passed, and transmission was now naturally increasing. At the same time, the searches were becoming more efficient. While this efficiency was a source of great pride for the smallpox workers, especially the search teams, it also meant that the reported smallpox numbers rose dramatically.