The fact that a single smallpox outbreak in a European country would be seen as an emergency, with untold resources deployed, provides some insight into the work required to address almost 5,000 outbreaks simultaneously in a single state. Workers in Bihar were stretched to the absolute limit. The situation had turned a corner on paper, but the physical demands continued. No one had ever experienced a public health operation of this magnitude before. (We did not know it yet, but through May, about 100 new outbreaks would occur per day, producing 1,000 new cases of smallpox per day.) One had to be an optimist with a feel for numbers to be ecstatic at the same time that Bihar had over 5,000 known smallpox outbreaks and had just reported over 11,600 new cases of smallpox in a single week.
Figure 13. Average number of new and contained out breaks per week, Bihar, India, January to May 1974
I thought back to a conversation the previous fall with D. A. Henderson. WHO/Geneva was programming its computers for the 1974 global smallpox surveillance program, and Henderson asked me to estimate the highest number of cases that we would have in any state of India during any week in 1974. Based on the reports in previous years, I replied: fewer than a thousand cases. Three digits in the column for cases per week per state would be sufficient. WHO, with an abundance of caution, decided to allow for a fourth digit. I saw no harm in adding a digit, so didn’t protest. Now we were in the embarrassing position where even four digits was insufficient.
The number of pending outbreaks continued to rise, but we were euphoric because we could now see the breakthrough on the horizon. The gap was quickly narrowing between new outbreaks detected and outbreaks removed from the rolls. The psychological boost, which we were already feeling because of demonstrated success, would fuel even harder work on the part of everyone (figure 13).
A STRIKE, A BOMB, AND DOUBTS
Then, seemingly out of nowhere, a series of disasters came crashing down around our house of elation. On May 8, the railway workers went on strike. The program would have to hire trucks and drivers to move supplies. But that was not the real problem. India’s railway system, a British legacy, was the backbone for transportation of goods and people, with a reputation for running on time. The railway was said to be the biggest housing project in India, with 1 percent of the country’s population on trains at any one time. The workforce maintaining this system was enormous and had the largest, most powerful union in the country.
Other workers watched the railway union to see what was possible. The real implications of the railway strike became obvious when half of the vaccinators in Bihar went on strike to protest wages. The other half named a date later in the month when they would join their colleagues. The district medical officers followed suit, announcing a date in early June when they too would leave work. These decisions were made before the smallpox leadership team even knew there was a problem.
We quickly sorted through the options. There weren’t many. Could we form our own health army by hiring thousands of daily laborers, using experienced workers as supervisors, and run the entire program under the auspices of district magistrates or other nonhealth segments of government? Meetings with district medical officers were not encouraging. Some were willing to help, but there was no way to re-create the size and expertise of the workforce being lost.
In utter frustration, and totally out of character, I lost my temper one day while talking to one district medical officer. I had asked if he would help me find the kinds of people I would need to hire when the strike occurred and develop plans to immediately switch to this alternate system when government workers left their jobs. With a condescending air, he said, “If there is no strike we would be wasting our time to develop an alternative plan. If, on the other hand, there is a strike I would have no interest in an alternative plan.” I slammed my fist down on his desk with such force that books fell and dust rose. “What kind of a man are you, anyway?” I bellowed. The sudden fear in his eyes provided a small measure of gratification but no support, and I abandoned the effort with extreme frustration.
At least, I told myself, there is some comfort in knowing that things could not get worse. And then, from an entirely unexpected direction, the program was hit with a problem that could not have been anticipated by even the most diligent planners. On May 18, 1974, India detonated its first nuclear device. Reporters from around the world came to India to report on the event. When they ran out of new ways to report the same story, they looked for others. Suddenly, smallpox in Bihar became world news. Few of the dispatches bothered to explain that the program had greatly improved the accuracy of India’s smallpox surveillance system or that the largest response the world had ever launched against smallpox was already under way.
In response to this negative publicity, India’s legislators began asking very pointed questions about the quality of the health services, and some feared that India had become an international failure in the effort to eradicate smallpox. The international publicity and the attention of parliament now placed pressure on political leaders in the states.
Those supporting the new strategy were clearly on the defensive. The smallpox alliance was convinced that the vast number of cases, especially in Bihar, resulted from three things. First, it was the seasonal high period. Second, the efficiency of surveillance had finally cast a strong spotlight on what might have been happening every year—only no one knew it before. The truth of smallpox in Bihar was at last revealed. Third, there may well have been an unusually high number of cases that year, but there was no way to test this, since no year in the past had ever had such efficient surveillance. Convinced that containment procedures were rapidly gaining on the head start experienced by surveillance, we now wondered if we would get the opportunity to prove that assumption. We longed for the anonymity that had surrounded the smallpox program before the news crews arrived.
The response of the Indian smallpox team in the Ministry of Health was beyond compare. They were diverted daily from the task of smallpox eradication to answer endless inquiries. The minister of health, Karan Singh, was totally supportive. Some of the people in between were skeptics. Dr. J. B. Shrivastav, India’s director-general of health services, was one such person. Though supportive publicly, he would privately say the smallpox effort was ill-conceived and doomed to fail, and he encouraged state ministers of health to abandon the approach. He had enough authority to be a problem.
In an interview with Myron L. Belkind, New Delhi bureau chief for the Associated Press, Shrivastav went public with his gloomy message. WHO workers had earlier told Belkind that despite the setbacks in Bihar, they had “all the necessary weapons: sufficient vaccine, adequate manpower and, most important, support from the Indian Government,” and they were still envisioning an end to smallpox in India in 1975. When Belkind mentioned this optimistic projection during the Shrivastav interview, Shrivastav said that a more realistic goal would be 1979. “I wish it to be so but let us be realistic,” Shrivastav said. “I’m an Indian and I know where I am situated.”1
Shrivastav was of course not alone. Despite the success of the surveillance/containment strategy in other countries, many public health workers still held the view that CDC epidemiologist Henry Gelfand expressed in his May 1969 letter to Don Millar: surveillance/containment should be the primary strategy only “under certain circumstances”; otherwise it might be misinterpreted to “justify fruitless and inefficient epidemic chasing in India and Pakistan.”2 Now here we were “epidemic chasing” in India. If leading smallpox experts didn’t think surveillance/containment could work as the primary strategy in India, no wonder there was doubt.
The field-workers, so weary with the heat, long hours, and difficult field conditions, were vulnerable to suggestions that their efforts were futile. Field people and supervisors alike were well aware of the “field paranoia” syndrome. I have been on both sides of that syndrome and know it is real. When things go wrong in the field and you have been working to the maximum, you conclude that the problems must b
e because headquarters is not providing appropriate support. And, there may be some truth to this claim. At the same time, however, one becomes blind to one’s own errors in allocating time or resources. Field paranoia was often apparent at monthly meetings, where workers often expressed frustration with headquarters and made excuses for disappointing results.
One WHO special epidemiologist, originally from France but working in South America for the Pan American Health Organization, resigned with a sharp rebuke and stormed out of the country, saying his life was too valuable to waste on a strategy that couldn’t work in Bihar, where he was assigned. Unaware of the expectation of a turning point in May or June, he wrote a long report in June stating that the current approach was failing and that his proposal for mass vaccination of the district, supported by many of the best smallpox experts in the world, had been rejected.3
In the midst of all of these problems, a great boost was given to the program in Bihar. Larry Brilliant was able to convince the heads of a giant corporation, Tata Industries, that the area around their plant in southern Bihar was one of the great problem areas of the state. Tata agreed to take on a large geographic sector, provide the medical and managerial staff, and work under the guidelines of the government’s surveillance/containment program. Tata put some of its best staff on the project and stopped smallpox transmission in the area; by doing so, Tata freed up program personnel to be assigned elsewhere.
This amazing coalition of public and private sectors was a harbinger of the pharmaceutical philanthropy that would become commonplace a quarter century later. Merck contributed hundreds of millions of treatments of Mectizan for the control of onchocerciasis (a disease leading to blindness, the so-called river blindness) in Africa. Merck and GlaxoSmithKline contributed Mectizan and Albendazole to a global program for the control of lymphatic filariasis (a disease leading to swelling of legs and scrotum, also called elephantiasis). Pfizer provided Zithromax, an antibiotic, for the treatment of trachoma, a disease leading to blindness. Dupont enlisted one of its companies, Precision Fabrics, to provide filter cloth to strain drinking water for the prevention of guinea worm. GlaxoSmithKline and the Gates Foundation joined forces to develop a malaria vaccine. Merck and the Gates Foundation developed a demonstration program to show how twenty-first-century science could work in AIDS control in Botswana, reducing the HIV positivity rate of newborns from 35% to 3.5% in less than a decade.
BIHAR’S MINISTER OF HEALTH
The real price of the rising skepticism about the strategy didn’t become obvious until Bihar’s minister of health decided to halt the seven-month-old strategy in his state. Suddenly and unexpectedly, he simply withdrew his support. He had been supportive, but he was under intense political pressure from legislators and other political actors who had fallen prey to the power of the forces aligning themselves against the surveillance/containment strategy. The most politically expedient response was to return to the security of what India had done for over 170 years. Whether effective or not, the known was preferred over the unknown.
At first I thought he might be just testing us, but then it became clear he was serious. The weeks and months of hard work, the endless logistics and meetings, the hundreds of training programs and thousands of workers trained, the analysis and scheming, the constant jarring in a jeep, the sweaty nights under a mosquito net—they were about to become wasted effort. Did he have any idea that he was threatening to put the entire India program, indeed the entire global program, in jeopardy?
We would have to return to the basics and figure out a way to provide both the mass campaign required by the politicians and the things we knew would actually work. But I could not see at that moment a way to do that, certainly not with the resources available.
It wasn’t the science that threatened to stop us. It wasn’t even nature, per se. Rather, it was human nature: the human factors that involve strikes, job security, political concerns, turf. I remembered those words from graduate school: “When you tangle with culture, culture always wins.” As hard as the daily work had been, this was the only time I was discouraged and uncertain about the outcome. I thought we had lost the battle.
Bihar’s monthly smallpox meeting was scheduled for Monday, May 27, and the minister planned to announce his decision at the meeting. M. I. D. Sharma, Mahendra Dutta, and I met with the minister several times in his office and even at his home over the weekend. Over the months we had met with him often to brief him on progress, ask him to speak to the field-workers, and report the results of monthly meetings. But the meetings held that weekend reached an intensity not experienced in the past. Sharma and Dutta had the advantage of knowing the system, knowing how hard to press and when to back off. We begged the minister to give us another month to prove our strategy. A firm commitment to a date might well have swayed him, but we didn’t have a precise date.
We pointed out that the strategy of mass vaccination had been unsuccessful in India for the better part of two centuries. He had tried the new strategy for a scant seven months. We were asking not for an extended period of time, but only for one more month. He in turn said that he understood our concerns but that the pressure was coming from everywhere, including his superiors in New Delhi, to revert to mass vaccination. We were unable to provide him with a single example in his entire state where a district was showing a decline in pending outbreaks. That is the point that separated us. We could see the inevitability of eradication as containment improved and new outbreaks increased but at a decreasing rate. The political pressure he was receiving required a decrease in the pending smallpox outbreaks in a few districts, not simply a promise that this would happen soon.
He kept returning to a single, worn argument: he had allowed us to pursue this new course, unproved in India, for seven months. During that time, no mass vaccinations had been done, and a backlog of unvaccinated children had been building. That backlog must now be addressed. He had no recourse now but to attend our monthly meeting on Monday and tell the assembled staff of his decision.
A YOUNG PHYSICIAN SPEAKS UP
With a profound sense of resignation, Sharma, Dutta, and I entered the meeting room on that hot, sticky Monday morning for the monthly routine. After seven months of intensive activities in Bihar, the staff in the field had increased, and eighty or ninety people crowded the room. Ceiling fans provided some air movement, but when the room temperature exceeds body temperature, even air movement doesn’t yield much comfort. But these were field-workers, accustomed to hardship, and I watched with appreciation and some awe as they pressed on despite the heat.
I sat at the front table with Sharma, Dutta, and Achari (director of the smallpox eradication program for the state of Bihar), gazing at this roomful of very weary faces. The meeting opened with the usual greetings, followed by reviews of the world smallpox situation and the situation in the rest of India, a description of the programs in key states, and a summary of new and potentially useful ideas that had come out of other state meetings. Finally, we got to the review of the smallpox situation in Bihar, including the pressures that were on the minister of health to change the strategy. We shared the fact that the minister was preparing to ask us to change the strategy and return to mass vaccination. We also shared our discouragement in being unable to change his mind.
The minister suddenly appeared, flanked by an entourage, and strode to the front table. He was given the floor immediately, and he described the problem as he saw it. Bihar was now faced with fifty-seven hundred pending outbreaks involving every district of the state. He acknowledged that hundreds of outbreaks a week were being retired and that the heroic efforts of the workers had no precedent in public health history. But: the number of new outbreaks found each week was even higher, so the number of pending outbreaks continued to increase. It was clear to him that we were losing the battle. He saw no alternative but to revert to mass vaccination, and to do it quickly, before the backlog of unvaccinated children increased even more. At meeting’s end, he declare
d, we would return to the strategy of mass vaccination in Bihar. We all knew this was coming, yet hearing the words actually uttered was shocking. Their impact began to sink in, and the room became very quiet.
One of the field-workers, a young Indian physician, raised his hand. He looked too young even to be a medical school graduate, and he was very thin, the epitome of a dedicated field-worker. He did not appear to have the needed gravitas for the moment, and I worried that a mistake was in the making. But the physician stood and, with great deference, addressed the minister. He was shaking as he described himself as just a poor village man. But, he said, when he was growing up, there were things you could depend on. For example, if a house is on fire in a village, no one wastes time putting water on the other houses, just in case the fire spreads. That is the mass vaccination strategy. Instead, as in the surveillance/containment strategy, they rush to pour water where it will do the most good—on the burning house.
Despite the heat of the day, a chill went up my spine as this man condensed all the work, discussions, discoveries, and massive human effort of the previous seven months into a few words and the indelible image of a house on fire.
The minister hesitated and stared at the group for some time. And then the unimaginable happened. He changed his mind on the spot. This man of public authority, who over the weekend had resisted the combined persuasive powers of Drs. Sharma, Dutta, and myself, this man who had entered the meeting room thirty minutes earlier with such presence and purpose, now seemed subdued, almost bewildered. He pointed out the great personal and political risk of his changing his mind. But he said, in a small voice, “I’ll give you one more month.”
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