House on Fire

by William H. Foege

By the time smallpox peaked in April and May 1974, the program was able to send out evaluation teams. Building on the informal evaluation methods already in place, the teams used a marking system whereby containment teams were asked to make a mark on the door of each house they visited. The mark used was changed each month. An evaluation team later recorded the number of houses visited, and in a sample of houses, questioned the residents about what the searchers had asked as part of the search.

  Throughout early 1974, evaluation was becoming more systematized, and by April, it was feasible to formalize the evaluation criteria. The key indicator chosen for evaluating the efficiency of surveillance was the time from the onset of the first case in an outbreak until the outbreak was reported. Typically, the first report of an outbreak was actually the second generation of cases. The first, or index, case was often a solitary case that the family was able to keep hidden. Since the second generation of cases appeared approximately fourteen days after the index case, and allowing for the time required to submit reports, we chose twenty-one days as the expected time from the onset of the index case to the report. The percentage of outbreaks reported within twenty-one days was therefore the key indicator of good surveillance in a district. The key indicator for adequate investigation efforts was set at 90 percent of outbreaks traced to a known outbreak. The measure determined for adequate containment was no new cases more than twenty-one days after discovery of the outbreak. These few indicators or “vital signs” made it possible to quickly spot deficiencies in searching, investigating, and containing outbreaks; such weaknesses could be related to particular PHCs, districts, or even individuals.

  The WHO/New Delhi staff presented the evaluation plan to a visiting representative from WHO/Geneva. While WHO/Geneva was unfailing in its support of India’s program and could be counted on to provide personnel, resources, vaccine, and political assistance, its resources were stretched so thin that it could not fund the proposed evaluation program. The Geneva representative left New Delhi the night of this decision. The next day, as a demoralized WHO/New Delhi group reviewed the program, they decided that the effort was so important that they would seek funds from elsewhere. The evaluation program was instituted and became an indispensable management tool and the driver for quality improvement during the last phase of the campaign.

  A MOUNTAIN OF FORMS

  Each new refinement in search and containment methods required training, new procedures for reporting, and new forms, which had to be distributed on an ongoing basis to thousands of PHCs and districts. India’s vast bureaucracy, often maligned, was ideally suited for an operation of this scale. Indeed, once the power of the Indian bureaucracy was harnessed, there was no stopping the innovation and energy of the thousands who took on the challenge of defeating smallpox. Recordkeeping forms may seem like humble soldiers in such an effort, but the form itself became the driver that led to the actions needed to achieve the desired outcomes. Creating effective forms requires you to picture the desired results, how to achieve those results, and how to report on them. Forms proliferated, and in a very real sense we can say, in retrospect, that smallpox was suffocated by a mountain of paper.

  The following is a partial list of the forms that field-workers had to contend with:

  Searching

  Workers’ Schedule for Search Teams

  Workers’ Schedule for Urban Areas

  Smallpox Market Search Book

  Investigation

  Smallpox Outbreak Investigation and Containment Report (Form C)

  Containment

  Smallpox Containment Field Book for Containment Teams

  Smallpox Outbreak Summary Booklet for Containment Teams

  Daily Work Diary for Watch Guards and Vaccinators

  Market Search Form

  Reporting

  Urgent Notification of Smallpox Outbreak (postcard)

  Cross-Notification of Smallpox (postcard)

  Cross-Notification Book (outgoing—with four copies plus one retained form)

  Cross-Notification Book (incoming—with copies to be submitted when investigation complete)

  Weekly Epidemic Report Form (PHC to district)

  Hospital Weekly Epidemic Report

  Market Search Summary (PHC)

  Market Search Summary (district)

  Smallpox Weekly Epidemic Report (PHC to district)

  Supervisors’ Report Form

  Weekly Checklist for Special Epidemiologists

  Weekly Report Form for Special Epidemiologists

  Weekly District Report of Pending Outbreaks

  Evaluation

  Rural Search Assessment Form

  Urban Search Assessment Form

  Verification of Active Search Form

  District Search Summary Form

  State Search Summary Form

  Protocol and Instruction Forms

  Search Protocol—Instructions for Searchers

  Case Finding Form for Searchers

  Guidelines for Market Searches

  Search Assessment Protocol

  Model Operational Guide for Endemic States (September–December 1973)

  Operational Guide for Low-Incidence and Smallpox-Free States

  Operational Guide for Endemic States (June–September 1974)

  Guidelines for Eradication of Smallpox in Urban Areas

  Operational Guide for Smallpox Eradication (January–March 1975)

  Operation Smallpox Zero (after February 1975)

  Record keeping was essential for understanding what was happening, and people filled out forms to the best of their ability—a legacy, no doubt, of the British system in India. Workers at all levels were encouraged to provide feedback. The information on the forms was incredibly useful in guiding the program. At the monthly meetings, field-workers would hear that information handed back to them in the form of refinements to the strategy.

  POLITICAL MATTERS

  During these first months of 1974, I traveled often. When not on trains to and from state meetings, I traveled by car or jeep to make field visits. Sometimes these trips went without a hitch, and sometimes the unexpected occurred. At the beginning of April 1974, I took our middle son, Michael, then age eight, on a field trip to the northern districts of Bihar. On our return, we crossed the Ganges River, a distance of over a half mile, by loading our jeep onto a small ferry. The ferry was so crowded that Michael and I sat on top of our jeep while our driver managed somehow in the crowd. In the middle of the river there was suddenly a great deal of excitement as the ferry began taking on water and people began to bail water with buckets and pans.

  Assuming a calmness I did not feel, I told Michael that if the ferry did sink, we would take off our shoes and slip into the water. I reminded him that he was a good swimmer and that the two of us would easily make it to shore. The ferry made it to the south bank, and I thought the highlight of the day was behind us. It turned out I was wrong.

  It happened to be April 8, the day that the famous Gandhian Socialist J. P. Narayan, at age seventy-two, led a silent procession in Patna to protest corruption in government and injustices such as hunger and rising prices—part of the student protest movement known as the Bihar Movement. As we drove toward Patna, we were unaware that because of the protest, the city was under a curfew.

  At a stop sign, long before reaching Patna, our jeep was surrounded by students caught up in the protest. They began rocking the jeep back and forth with every indication that they planned to turn it over. Assuming a false bravado for the second time that day, I tried to reassure Michael, telling him this happened all the time, and I rolled down the window to talk to the students. They demanded money, a request that to me seemed totally foreign to the ideals of J. P. Narayan. They stopped rocking the vehicle as I got out to talk to them. I said I had money for them all and began distributing the smallpox recognition cards, telling them how much I would pay for each case of smallpox they identified. I continued talking, urging them to become part of the solution, to go into t
he villages and urban areas to find cases, to do this for India, and not only for India but for the reward I would give when they brought me cases. They stopped to look at the cards and hear what I was saying. That encouraged me to more forceful exhortations. Then they began to back away, possibly out of embarrassment or fear. As I spoke louder and with more fervor about what India was trying to do to rid the country of smallpox, I realized I had gained control. Gradually they retreated and finally disappeared.

  We cautiously resumed our trip into Patna, passing burning trucks and buses tipped on their sides. Few other vehicles were on the road, and absolutely none as we entered Patna. The streets were empty, and an eerie silence filled this usually loud and crowded city. At the Republic Hotel, where I usually stayed while in Patna, a guard recognized our vehicle and opened the gate. The hotel management had taken up carpets and anything that might burn in case Molotov cocktails were thrown through the gate into the hotel entrance. Michael and I, along with our driver, remained there until the curfew was lifted several days later.

  It was a politically tense period in India in other ways as well. It was the era of the Cold War and the Vietnam War, and the Indian government was somewhat suspicious of foreign workers, especially if their work took them into the villages. Indeed, in 1974, the newspapers in India began carrying stories that the malaria research work being conducted with U.S. resources and scientists in India was actually an effort by the CIA to develop biological warfare techniques. Once such stories start, they can become impossible to counter, even when they’re groundless. The malaria studies were eventually suspended. About the same time, an American smallpox field-worker who was in New Delhi for a few days reported to me that during his meal at a restaurant the previous evening, a man sat down at his table and told him that the smallpox program would be next to receive that type of publicity. It never happened, but the warning served to keep us anxious.

  As the early months of 1974 passed, more special epidemiologists joined the smallpox program until there were approximately one hundred special teams in the field. While they strengthened the regular health resources devoted to smallpox, and their effectiveness was a major factor in motivating the entire team and efficiently using field resources, there was also the constant worry that someone would embarrass or even jeopardize the entire program.

  On one occasion, an American special epidemiologist who was working in the field and living in a military guesthouse sent me a commercial telegram. The military had asked him to seek other accommodations, and he was asking that we verify that he was not a CIA agent. It was a strange request but could not be ignored.

  We at the WHO regional office would have been dismayed if the CIA had used any of our people and decided that we should be straightforward in asking if it did. I went to a friend at the U.S. Embassy and asked his advice. He asked another person—clearly, the head of CIA activities for the embassy—to join us. This person read the cable with concern and assured me that he knew nothing about this person.

  He then asked, “How good is he?” I replied, “He is not that good.” The embassy official said, “There are two hundred people eagerly waiting to read your reply. If you send him home, it will be interpreted as confirmation that he is a spy. He just bought himself some additional time with your program!” I sent the epidemiologist a bland reply discussing work and suggesting that he might want to move to a rest house.

  Through the months, the political climate improved. So when I received a request one day in April to see the American ambassador, Daniel Patrick Moynihan, I assumed he wanted a status report on the smallpox program. I walked through the huge front door of the embassy, as always aware of the sudden transition from extreme heat to air-conditioning. I expected this to be fun, and was surprised to see the embassy physician, Dr. Ed Etzel, pacing the floor. He had been waiting for me. He grabbed my arm and said he had some advice: Moynihan thought one hundred times faster than anyone in the embassy, I should know that Moynihan was very angry with me, and I should not say a word. “Don’t argue,” he said, “because he will be merciless.”

  I entered the ambassador’s office in a state of confusion—what was going on? The ambassador was standing at the side of his desk with an angry look on his face. With no niceties or greeting whatsoever, he said, “I have evidence in this folder that you are spreading smallpox rather than stopping it.” Wow, I thought, what an opening gambit! He went on to explain that India’s Communist Party was likely to announce that the United States had sent spies into India under the guise of working on smallpox. The office of the prime minister had asked for a meeting with him that afternoon for an explanation. I saw the presence of so many Americans in India as a scientific issue, but to him it was political, particularly given the number of Americans in the states of Bihar and Uttar Pradesh, near the Nepalese border. He was now in a difficult diplomatic position.

  He continued heatedly at some length, without pause. I thought about Ed Etzel’s advice, to keep silent, and realized that there was no alternative. Abruptly, he stopped and asked me again what I had been thinking and how in the world had I managed to get these people into Bihar near the border with Nepal without the embassy even knowing?

  In fact, wanting to be cautious, I had made all of my requests to Dave Sencer for additional people from the CDC through embassy channels, rather than WHO channels, precisely so the embassy would know what was happening. For a fleeting moment, I considered telling him it was all spelled out in embassy cable traffic, but immediately thought better of it.

  Instead, I began by describing how the world now had a chance for a historic first in eliminating smallpox, and the key to global success was India, and the key to success in India was Bihar. Bihar, I continued, had the highest rate of smallpox transmission recorded in the global program, with one thousand new cases a day in that single state. We had no choice but to put our attention in the place with the problem. Without enough epidemiologists, the effort would fail.

  To my amazement, the ambassador made a complete about-face. He became truly interested and began asking questions. Finally, referring again to his impending meeting with Prime Minister Indira Gandhi, he asked, “What should I ask of her to speed up the program?” The Government of India—supportive of the program all along—subsequently deepened its support even more.

  PREDICTING THE TURNING POINT

  What I told the ambassador was no exaggeration. In the first four months of 1974, India reported more than sixty-seven thousand cases of smallpox, and over two thirds of them were in Bihar. When the numbers of outbreaks declined in Bihar, they would decline for the entire country.

  A solid month before the official figures showed a decrease in pending outbreaks, smallpox officers knew eradication was possible and indeed only a matter of time. This became obvious by watching the increase in containment outcomes. In Bihar in January 1974, outbreaks were being taken off the pending rolls at the average rate of 107 per week. One month later, outbreaks were being retired at an average rate of 152 per week. This rate increased to averages of 403 per week by March and 596 outbreaks per week by the end of April.

  Throughout this time, the number of new smallpox outbreaks increased dramatically, so the number of pending outbreaks continued to increase. But that, we knew, would not continue indefinitely. We were gaining.

  New outbreaks measured new findings at that point in time and therefore reflected the current activity of the smallpox virus, while retired outbreaks indicated containment work that had been completed one to three months earlier—an outbreak had to be free of new cases for a month before it could be removed from the pending list. Thus there would always be a lag in the number of outbreaks removed from the books. In other words, the program was doing better on the ground than the numbers showed.

  The searches had become more efficient; the average time from discovery of an outbreak until the last case in that outbreak was going down. Containment was growing more efficient, too. The average time from report of ea
ch outbreak to its closing out was also decreasing. Finally, the number of outbreaks removed from the pending list was increasing each week. By this time, no special insight was needed to envision the point at which the contained outbreaks would exceed new outbreaks. Once the pending outbreak list began to decline, it would do so at an accelerating rate. As the outbreak numbers declined, additional experienced troops could be assigned to contain each remaining outbreak, and containment efficiency would improve even more. The natural decline in the transmission rate once the rains arrived in June would assist the rapid clearing of larger and larger geographic areas.

  The turning point was not far away. In early April, the number of contained outbreaks in Uttar Pradesh improved significantly, and in the space of a month it increased from approximately 100 per week to an average of over 250 per week. This was absolutely amazing progress. Because there was a four-week waiting period (of no transmission) before an outbreak was removed from the pending list, these numbers reflected program improvements going back to February. When we analyzed the trends, we could predict that the containment capacity in Uttar Pradesh would overtake the discovery of new outbreaks in May.

  As for Bihar, the fact that over five hundred outbreaks were removed from the pending list each week in April was incredibly encouraging. In this area of high transmission rates—the virus was claiming over one thousand victims a day—we could project a decisive turnaround within four to six weeks. We knew we were close. The numbers told the story.

  TEN Water on a Burning House

  As the month of May began, a hot month in Bihar even by Indian standards, the number of smallpox outbreaks skyrocketed along with the temperature. The sixth search (April 29–May 4) had revealed 2,622 new outbreaks, the highest one-week total we would see. This brought the pending outbreak total to 4,921. The pending figure would have been even higher except that containment teams were by now so efficient that they were removing over 800 outbreaks per week from the pending list. More important, the number of new outbreaks was only slightly greater than the findings one search earlier, while the containment ability had doubled in two months. For the smallpox worker who knew what to look for, the expected tipping point was thus palpable at the beginning of May.