House on Fire

by William H. Foege

  Soon after, other things began to go right. The railway strike was settled that same day, and the other groups withdrew their strikes and strike threats. The monsoons arrived, and with them, a decrease in the transmission potential of smallpox.

  The search conducted during the first week of June finally brought good news and the information we needed to influence politicians. The number of outbreaks decreased by over a third from a month earlier (2,622 to 1,678), the number of pending outbreaks did not increase (remaining at slightly more than 4,000), and even the intensity of cases per outbreak seemed to be declining as the number of cases found dropped from over 14,000 in the April/May search to about 7,500 in the June search. The change was sufficiently dramatic that we had no problem convincing the politicians—including Bihar’s minister of health.

  Anyone who has lived in India or Africa through the dry season knows the incredible surge of emotions and energy that accompanies the first rain. People dance in the villages and celebrate. This was the feeling of the smallpox workers when the smallpox problem in Bihar finally began to decline in June 1974.

  ELEVEN Smallpox Zero

  The arrival of a new vision just when people think they have worked to the maximum gives them new energy, allowing them to push beyond their previous limit. In early August 1974, the smallpox leadership team sent out to the field-workers in Bihar a graph showing the decrease in outbreaks reported in June. The same graph was distributed to all smallpox workers in India on August 26 as part of the seventh SEARO surveillance report. The whole team could see that their work had now paid off: we were on the downhill slope.

  The turnaround in Uttar Pradesh happened at the same time as in Bihar, with 47 out of 54 districts infected in May and only 44 infected the next month. The number of new outbreaks peaked at 792 in June, one month later than expected, but then fell quickly: fewer than 50 new outbreaks were found four searches later.

  The improvement in evaluation techniques initiated earlier in 1974 continued to pay off through the summer. Effective evaluation allowed us to redeploy resources with confidence that the highest priority needs were being addressed. At last we understood the enemy. Attention placed on measuring the efficacy of the program, the effectiveness of the various components, and the efficiency of operations allowed us to predict what the virus would do next. The intelligence gathered allowed us to outflank a virus that had the supreme confidence of thousands of years of finding new victims without a break in the chain of transmission.

  Figure 14. Graph distributed to field-workers showing the June 1974 turning point, when outbreaks in India began to decrease (see the dotted line)

  Following a search, ten villages in a district were selected at random to determine whether searchers had visited. Attempts were also made to discover smallpox or chickenpox cases missed by the searchers. The time from onset of the first case until the outbreak was reported continued to decline. The percentage of outbreaks reported within twenty-one days of onset eventually reached 100 percent on a routine basis. A final test involved determining the source of the index case. Trails do grow cold, but most districts were reaching the target of tracing the origin of 90 percent of all outbreaks.

  Containment evaluation also permitted comparison between districts. The standard was that no new cases should be found more than twenty-one days after discovery of the outbreak. For those going longer than twenty-one days, a detailed analysis was undertaken—in effect, an outbreak autopsy, which had been standard teaching fare in the forensic public health field so close to the heart of Alex Langmuir at CDC. Such detailed analysis made it possible to determine that incomplete or delayed containment actions were the primary reason for new and continuing outbreaks.

  Assessment results were provided to states, districts, and PHCs by means of monthly reports. In addition, the results were discussed at every monthly state meeting and formed the basis for developing new tactics for the following month. By mid-1974, the results were dramatic, and resources were rapidly moved to correct the defects revealed by the evaluation techniques. In both June and July 1974, the number of outbreaks contained in Bihar exceeded the number of new outbreaks.

  Several vectors converged, allowing the program to attack the last vestiges of the virus with increased force. As the number of pending outbreaks declined, staff were freed up from containment work. Improvements in containment, search techniques, and evaluation all helped to reduce the number of outbreaks and cases. As the caseload decreased, more attention could be given to each outbreak, and field-workers were gratified to see outbreak after outbreak contained. There were fewer surprises, hence more predictability. And as the rains came, fewer people traveled, thus slowing transmission rates.

  THE BEST TIME TO WORK ON SMALLPOX IN INDIA

  Even as Uttar Pradesh and Bihar were experiencing turnarounds in June, other parts of India were reporting mixed results. By May, the tally in India was four smallpox-endemic states, two troublesome states (Assam and Orissa), eight low-incidence states still bothered by importations from other areas, and sixteen states and territories that were considered smallpox free.

  Madhya Pradesh looked like it might be the first of the four smallpoxendemic states to interrupt transmission. It was still reporting three to five hundred cases per month; however, the response from state health workers was good. West Bengal had seen a decrease in importations from neighboring Bihar and Bangladesh in March 1974 and a decrease in pending outbreaks from 550 in April to 450 in May. Again taking into consideration the response of state authorities, it appeared that West Bengal would be the second smallpox-endemic state to interrupt transmission.

  However, potentially major problems were brewing in two of the lowincidence states. Orissa was showing a rapid increase in cases, from 53 reported in January to 565 in May. The state authorities and a superb WHO epidemiologist were able to respond appropriately, and the problem was brought under control.

  Assam was a different matter. The 25 cases reported in January 1974 had not caused great alarm—after all, Bihar, by May of that year, was producing that many cases in under forty minutes. However, Assam had not received the same amount of attention as the highly endemic states; now the state was having trouble with containment, and recorded new cases increased every month thereafter, reaching a peak of 1,914 in June.

  Diesh and Sharma decided they needed to visit Assam and asked me to accompany them. Americans were not allowed to travel to that area of India at that time. Nevertheless, they asked me to fly with them as far as Calcutta on the chance that we could figure out a way to get me on a flight to Guwahati, the capital of Assam. Seeing this as a potential waste of time but also assuming they had a plan, I agreed.

  In fact, they had no plan at all. In Calcutta they attempted to buy a ticket to Guwahati for me. The ticket agent took one look at my passport and said that he could not sell me a ticket. Then, forty-five minutes before the flight was to leave, we experienced one of those serendipities that seemed to happen with ease around Dr. Diesh. Suddenly he spotted a minister from Assam, an old friend, and he went over to talk to him. Diesh explained the smallpox problem, introduced me as an outside expert, and presented the dilemma of getting me to Guwahati. The minister not only trusted Dr. Diesh but also happened to be married to an American. He traveled this route often, knew the agents, and had the authority to override the usual government directives. Within minutes I had a ticket to Guwahati. I was able to attend meetings in Guwahati and Shillong, see cases of smallpox, and participate in planning the response.

  From mid-1974 until the end of the year was the best time to be working on smallpox in India. Once the decline began, it was dramatic. In July, three states—Bihar, Uttar Pradesh, and West Bengal—reported 95 percent of all smallpox cases in India, with Bihar accounting for two thirds of them. But with Bihar containing over eight hundred outbreaks a week in May and June, the totals of pending outbreaks in India fell rapidly, from a peak of over eight thousand in May to fewer than six thousand in Ju
ly.

  Yet even as the smallpox program was finally showing obvious success, there were still attacks on the surveillance/containment strategy. Most of them involved people voicing criticism or doubt in talks or in conversations with the intent of undermining confidence, and they could be ignored. On occasion an attack was significant. In August 1974, J. B. Shrivastav, India’s director-general of health services, once again lobbied the minister of health, Dr. Karan Singh, to convince him that despite the apparent success, ultimately the strategy could not work and the country was accepting great risk by discontinuing mass vaccination activities. The minister, now concerned, traveled to Bihar, still the state with by far the largest percentage of smallpox, to declare a return to mass vaccination at a press conference—this at a time when we thought we had an agreement to continue surveillance/containment and were excited about the positive results.

  The minister was met at the airport in Patna by Dutta and Sharma. He told them that India did not need an “imported” strategy for smallpox, and that at the press conference he would announce that India would now return to the traditional mass vaccination campaign. Courage comes in many packages, and it was evident that day when Mahendra Dutta said if the minister wanted to do that he would have to fire Dutta first. The minister responded, “Do you realize you are speaking to a minister?” Dutta replied that yes he did, but this issue was so important that he could not remain silent.1

  Map 3. New smallpox outbreaks in Bihar, India, 1974 and 1975 compared.

  Left: New out breaks detected in the fourth search, January 28–February 2, 1974.

  Right: New outbreaks detected in the sixteenth search, January 27–February 1, 1975.

  The minister, surprised, listened to their account of the geographic areas that had become free of smallpox in the previous two months and the rapid progress in all districts of Bihar. To his credit, he trusted their briefing. He proceeded to the press conference, where he thanked the health workers of Bihar for the great work they were doing. He never mentioned mass vaccination. One more threat had passed.

  Another followed on its heels, however. Three weeks later, Shrivastav himself, dismayed that the minister had failed to heed his warning, traveled to Bihar to make a final effort to reverse the strategy. He talked about the dangers that the backlog of children not vaccinated during the past year presented to the country. Dutta, Sharma, and Achari told him they would focus on the backlog but only after the transmission of smallpox had been broken in Bihar. (In fact, once transmission had ceased, the push for vaccinating the backlog disappeared.)

  Also in August, a WHO meeting was held in New Delhi to share the smallpox eradication results from all countries in Southeast Asia. At one point, the teams from each country were invited to give their predictions for the coming months and estimate the date for the last case in their country. Speaking on behalf of the India team, I summarized India’s situation, including the value of the evaluation program for predicting how fast surveillance/containment practices were improving by district. Based on the evaluation data, we were predicting that the last case of smallpox in India would be detected in May 1975. At the end of that day’s meeting, workers from other countries questioned me privately. They could understand, they said, the need for optimism to keep morale high, but they were curious about my “real guess.” In fact, I was completely serious about the evaluation scheme’s prognostic abilities, which was now based on many months of experience. The prediction turned out to be accurate.

  The work became easier as it became more predictable. With fewer surprises, the approach became one of overkill in both surveillance and containment. Nor was this the time to determine minimum inputs needed or assess maximum efficiencies across various approaches. Instead, having worked so hard to get to the current position, everyone now went overboard. Much of the work was of low efficiency. Indeed, much of it was redundant, some outright unproductive, but we were in no mood to take chances. Watch guards at each smallpox house were doubled, and searches were repeated. The vaccination circle gradually increased from the infected household itself to surrounding houses and then the entire village. Over one thousand outbreaks per month were being removed from the pending numbers for the country as a whole. The system was becoming more efficient at the same time as the size of the problem was decreasing. Madhya Pradesh, the largest state in India, had gone three weeks without a new case of smallpox. West Bengal was down to fourteen active outbreaks. Nevertheless, the high-transmission season was about to begin, and the New Delhi leadership team was especially worried about Assam, in the northeast, which had sixty-seven pending outbreaks.

  By November the number of pending outbreaks in India was below one thousand. Success was becoming a tangible possibility if the disease did not get out of control during the upcoming transmission season.

  Repeatedly during the campaign (and even after successfully eliminating the disease), smallpox workers received reports claiming that the disease was still present in remote populations or in groups that had been overlooked. Every such report was taken seriously and investigated, and in every instance the report was shown to be inaccurate. Often an outbreak of chicken pox or some other rash disease had been mistaken for smallpox.

  Finally, the ultimate search tool was deployed. As the number of cases declined, India began to offer a reward for the reporting of previously unknown cases of smallpox. SIDA funds were used for this innovation. The reward started small, at Rs. 10 (less than US $1.50), but even that amount was large enough to cause immediate problems. When new cases were reported to health workers, the health workers wanted to claim the reward themselves. The problem was solved by providing the reward to both the person who made the report and the health worker who forwarded the report. The health worker could not claim the reward until the informant had been identified.

  Initially, people tried moving smallpox patients from an outbreak area to a different village in order to collect the reward, but investigators could quickly determine that the patient was not a member of that community. No reward was paid, and people soon gave up on the idea. As the number of cases declined, the reward was increased incrementally until, at about the time of India’s last cases, the reward had been increased to US$1,000.

  The reward was advertised, and the general public was quick to recognize the potential bounty. Surveys were conducted to determine the percentage of people who knew about the reward and about where to report a suspected case of smallpox to collect the reward. One survey late in the campaign revealed that more people knew about the smallpox reward than knew the name of the prime minister.

  OPERATION SMALLPOX ZERO

  Surveillance reports for the last months of 1974 showed continuing gains. Even in Bihar, the number of new cases fell to 2,758 in October; 1,053 in November; and 527 in December. In terms of outbreaks, the year ended with only 282 pending outbreaks in all of India, and only six states reporting any smallpox cases at all. A total of twenty-four states and territories were now considered smallpox free. The investigation of outbreaks had determined that they could all be traced to human error in searches or containment. We now had an understanding of every chain of transmission in the country, and any surprises were due to the shortcomings of the workers, not a lack of understanding of the strength of the virus.

  By late 1974, the smallpox program was looking so strong that it seemed very unlikely that anything could derail it. The May 1975 prediction for interruption of transmission still seemed accurate, so Paula and I began planning for our return to Atlanta in March.

  A new intensification of the eradication program started in January 1975, under the code name “Operation Smallpox Zero.” Six points were considered essential:

  Every new outbreak must be visited not only by a special epidemiologist and PHC, district, and state authorities, but also by a central government or WHO officer.

  The size of a containment team will be increased to at least twenty workers.

  Four watch guards will be a
ssigned to every infected house so that there will be no break in coverage.

  House-to-house searches, in addition to the usual monthly searches, will now be undertaken in a ten-mile radius around outbreaks.

  Laboratory specimens will be taken from one or two patients per outbreak in order to isolate the virus.

  Cross-notification to other PHCs will occur by special messenger to avoid the delay of using the postal service.

  Clearly, much of this was inefficient and made little practical sense, but like Lawrence Atutu Ochelebe, who beat the snake that entered our house in Africa to an unrecognizable pulp, we practiced overkill with smallpox, showing no mercy. The smallpox virus had met its match.

  By the end of January, the number of pending outbreaks in India had declined to 198. A month later that number was 147. The week ending February 22, only 16 new outbreaks were found in the entire country, the lowest level ever recorded. The smallpox team celebrated that record, only to have it eclipsed the following week with only 3 new outbreaks found. Before going to India, I had promised Dave Sencer, in consultation with Paula, that I would be gone from the CDC for one year and would not ask for an extension. It was agonizing to see the year evaporate, but in mid-1974 Dave, knowing what the program meant to both of us, offered to extend my time. We felt bound to the original agreement, though, and so left in March, with mixed feelings. We would not have left if any doubts remained about a speedy end to smallpox in India. On the other hand, we would miss being there for the last case. In the end, we concluded there would be no program benefits to our remaining.