House on Fire

by William H. Foege

  We left India in March, each of us knowing in our own way that we had experienced a highlight of our lives. I had been immersed in helping to solve a problem of great importance, working alongside people of superb abilities and motivations. The hardships were overshadowed by the blessings, and I wondered if I would ever again have the opportunity to work with people of such exceptional character.

  Figure 15. Total outbreaks per week in India, January 1974 to May 1975

  The last case was reported in May. And on June 12, 1975, Nicole Grasset was able to send a letter to all smallpox workers in the country to say that smallpox transmission had been broken the previous month.

  It seemed almost anticlimactic. A virus that for millennia had spread such despair, inspiring religious ritual and even the worship of a goddess, was suddenly gone from the country. In twenty months, the surveillance/containment approach had proved itself ideally suited for eradicating a virus that had eluded the best efforts of mass vaccination programs for 175 years. It was the right tool for the task.

  THE ERADICATION OF SMALLPOX WORLDWIDE

  India was one of the toughest chapters in the global fight against smallpox, but victory over smallpox in India was not the end of the story. As the last cases of smallpox were being subdued in India, Bangladesh workers were in the middle of a nightmare.

  Earlier, the program in Bangladesh had been ahead of the program in India, and this information had even been used to encourage Indian workers at state meetings. In October 1974, as India still struggled with almost 1,000 outbreaks, Bangladesh had only 91 outbreaks on the books. But that month, a flood in Bangladesh, the worst in decades, decimated entire villages. People left their homes in search of food, relief, and shelter. The smallpox virus went with them, and by the end of January the outbreak count had increased from 91 to 572. This problem, already of enormous proportions, was then made worse when the government bulldozed urban slums, sending tens of thousands of refugees from urban areas to other parts of the country. The president of Bangladesh declared a national emergency.

  The international community responded, not least because as more countries became free of smallpox, the importance of each infected country increased. The CDC provided thirty epidemiologists, and thirty others were sent from twenty other countries. Rewards were advertised, and a massive response to each outbreak was launched. It worked. Cases decreased through the summer. On October 16, 1975, the first vesicles of Asia’s final case of smallpox began to form on a two-year-old Bangladeshi girl, Rahima Banu.

  Yet globally the fight still wasn’t over. As Rahima Banu was recovering, a single country, Ethiopia, remained on the smallpox list. Ethiopia had been off to a slow start. Variola minor, the strain of smallpox in Ethiopia, had a low mortality rate, and therefore smallpox was not regarded as a significant problem. Moreover, government attention had been on the political unrest that would eventually result in the overthrow of the monarchy in 1976. But now, as the last country with smallpox, Ethiopia could no longer ignore the problem. WHO helped arrange for supplies, helicopters, and several dozen foreign advisors. By early 1976, after a herculean effort, the country had become free of smallpox except for an area in the Blue Nile Gorge and in the desert of the south. By August, Ethiopia had eliminated the last cases.

  It seemed to be time for the world to celebrate. But Murphy’s Law (anything that can go wrong will go wrong) operates no less frequently in public health programs than elsewhere. At the last moment the tenacity of this virus, combined with the movement of people, again intervened. Drought in the south forced some Ethiopians to seek refuge in Somalia. In September 1976, smallpox cases were reported in Mogadishu, Somalia’s capital. Six months later, outbreaks were occurring around the country. National and international resources descended on the problem areas. Two dozen WHO epidemiologists and thousands of Somalian health workers carried out the now-familiar surveillance/containment procedures under what some consider the most difficult conditions of a hard decade. Again the strategy worked.

  In early October 1977, a couple with two small children, both with smallpox, approached the hospital in Merka, Somalia. They asked Ali Maow Maalin, an employee, for directions to the infectious disease ward. A considerate person, he took them to the ward rather than directing them. Although he had been vaccinated, it was evidently not an effective take. Two weeks later, on October 26, 1977, he developed the last smallpox rash that Africa would ever see. He recovered without transmitting the virus. The global chain of smallpox transmission was finally broken. Smallpox had been eliminated from the world because of a plan. It did not happen by accident.

  There was yet a final irony. After ten months of worldwide freedom from smallpox, the country that had provided the vaccine to the world had two final cases. Both were due to a virus that escaped from a laboratory—demonstrating again the challenge of containing this tenacious virus. On August 11, 1978, a woman in Birmingham, England, developed the first symptoms of smallpox and died a month later. Her mother developed symptoms on September 2, 1978, but recovered.2

  In medicine, the medical practitioner is obliged to apply the best knowledge of the times to each patient. In public health, the obligation is to apply the best knowledge to the entire human community. The purpose of public health is to promote social justice. By 1978, public health achieved its first complete success in social justice, applying the knowledge required for smallpox control to eliminate a disease for current humanity and for all future generations. Humanity will continue to hold its collective breath, hoping for the wisdom that prevents the virus from ever being released again—intentionally or unintentionally.

  Conclusion

  The smallpox program justified its own existence by the results it produced: lives set free, misery prevented, and resources made available for other activities. The program also offers lessons that are applicable to similar public health projects.1

  Smallpox eradication did not happen by accident. Stephen Hawking, in his book A Brief History of Time, says the history of science is the gradual realization that things do not happen in an arbitrary fashion. This is a cause-and-effect world, and smallpox disappeared because of a plan, conceived and implemented on purpose, by people. Humanity does not have to live in a world of plagues, disastrous governments, conflict, and uncontrolled health risks. The coordinated action of a group of dedicated people can plan for and bring about a better future. The fact of smallpox eradication remains a constant reminder that we should settle for nothing less.

  Seek the truth. The purpose of surveillance systems is to discover the truth. Once the truth was known concerning where the smallpox virus was at a given point in time, it was possible to eliminate it. The strategy of mass vaccination is founded on the assumption that it is not possible to know where a virus is. Therefore one must assume that it could be anyplace, and the appropriate response is to protect everyone to achieve herd immunity. That logic works with most infectious diseases, but not with smallpox.

  Every earlier review of the smallpox problem in India recommended high vaccination coverage of every segment of the population. Experts from India, from WHO, and from the CDC all concluded that since 80 percent coverage was not being achieved, the goal needed to be increased to 100 percent. That makes no sense. If you can’t reach 80 percent, you certainly can’t reach 100 percent. The herd immunity concept was promoted yet remained unexamined.

  Knowledge is power, and even a little knowledge of the truth goes a long way. Even less-than-perfect surveillance in the early months of the new strategy, October to December 1973, followed by poor containment efforts, was still relatively effective in reducing virus transmission. Once surveillance and containment reached near perfection in May 1974, the result was a rapid decline from extremely high levels of smallpox to zero smallpox in twelve months. This is a feat unprecedented in public health history.

  However, the truth that we came to know about smallpox is not necessarily the truth about other diseases. What is true is that each pa
rticular disease and its context must to studied in order to understand its vulnerabilities. Mass vaccination continues to be an important strategy for most vaccine-preventable diseases.

  Spend the time and attention needed to systematically improve the tools as well as the techniques to deliver them. WHO developed a better vaccine and adopted a superior vaccination technique, the bifurcated needle, both of which were essential to success. The program was also constantly refining the techniques used to efficiently track the virus and to encircle the virus with people immune to smallpox.

  Coalitions are powerful. Successful coalitions share certain characteristics, the first being a clear vision of the last mile of the journey, which in this case was the total absence of smallpox cases and smallpox transmission. Yet the secret to the eradication of smallpox in India was that the members of the coalition team suppressed their individual egos for the sake of achieving a common goal. Moreover, the boundaries between the Central Government, the states, the districts, WHO, NGOs, public institutions, and private industry were obscured as the team formed with an unwavering focus on the desired outcome. This was clear to participants, yet has been missed by some recent historians.

  Trust holds teams together. It was trust that allowed for transparent discussion and productive arguments about tactics. It was trust in Drs. Mahendra Dutta and M.I.D. Sharma that allowed Dr. Karan Singh, India’s minister of health, to support surveillance/containment when others were advising him to return to mass vaccination.

  Social will is crucial. Individual will leads people to seek the protection of vaccines, but it is the collective will that drives individuals to provide resources and opportunities for others to be protected. Government support for programs depends on the agreement of the governed. In theory, eradicating smallpox was possible from the time vaccine became available. It became easier as science and technology improved the tools and delivery techniques. But that was not enough. The 1970s became the last decade for smallpox because of social will—a collective agreement to remove the scourge from society.

  Social will must be transformed into political will. Every public health decision ultimately requires a political decision for implementation. Therefore, public health practitioners must provide politicians with the information needed for good public policy decisions.

  Public health solutions rest on good science, but the implementation of those practices depends on good management. Smallpox posed some intriguing scientific problems, but eradication depended on the managers. Countries often insisted that the consultants had to be physicians even if they were less effective in running field programs.2 In both Africa and India, people trained in program management were extremely valuable.

  Tactical flexibility is crucial. Workers were encouraged to experiment with tactical approaches, which if effective could readily be replicated by other workers. Monthly meetings in every endemic state allowed for rapid transfer of information. We didn’t wait for annual reviews. Monthly meetings allowed us to refine tools and techniques as quickly as we could get information from surveillance and evaluations.

  Allocate resources where they are needed. It is crucial to have the ability to concentrate all available skills and resources on the point of need. In the words of a young Indian physician, “Put water on the house that is burning rather than on the other houses.”

  Effective leadership is crucial. The smallpox eradication program benefited immensely from effective leadership. Key in this area were unflagging dedication to the program’s objectives, an ongoing willingness to use new information to improve the strategy, and the capacity to build coalitions.

  Never give up. Tenacity won’t always bring success, but without it, success is impossible.

  The measure of civilization is how people treat each other. How people treat each other is the metric for a civilized nation, political party, society, university, or program. How we treat each other is also the measure of us as individuals. The smallpox eradication program was a civilized program in that it transformed potential smallpox patients into immune persons and protected unseen people in the generations to come.

  Be optimistic. The trouble with being an optimist, of course, is that people think you don’t know what’s going on. But it is the way to live. We were an optimistic group. I tell students there is a place for pessimism, and whenever they need it, they should contract for it—but don’t put those people on their payroll. They will ruin your day.

  Global efforts are possible. The smallpox eradication effort proved that it is possible to choose a global objective and bring global resources to bear on it. Philosopher Will Durant once observed that the world was unlikely to join forces unless it feared an alien invasion. Smallpox demonstrated that problems short of an alien invasion can mobilize the world. Smallpox was a shared risk, and its removal required a shared effort. In the years since then, other problems—nuclear arms, polio, SARS, HIV, H1N1 flu (surrogates for an alien invasion)—have confirmed the power of understanding shared risks. Pursuing such problems is worth the effort both because of the inherent good in solving them and because they provide practice in working together and breaking down unnecessary and unproductive social barriers.

  The objective may be global, but implementation is always local. The strategy for smallpox eradication did not change from country to country, but the local culture determined which tactics were most useful. Only the specific locality can provide information on who is sick, who is hiding from the vaccinators, when people are available for vaccination, how to hire watch guards, or how to secure the cooperation of the community. In all cultures, an approach of respect for local customs is needed.

  Communications functions as the nervous system of successful coalitions. Efforts to report from the search and containment workers to the PHC, then to the district, the state, and finally the central level improved continuously. The surveillance reports were collated and analyzed, and the results were shared widely through the systemic feedback, all the way back to the PHC staff doing the work. Local workers knew their position in the global effort. “We are all in this together” was a palpable feeling. This in turn engendered a pride in the work being done. Trust, effectiveness, and knowing the truth all depended on good communication systems.

  Effective evaluation methods are key to success. Evaluation was the key to identifying and remediating deficiencies in the strategy. Evaluation was also crucial to knowing when each district and state would reach the tipping point of controlling smallpox faster than it was spreading. Evaluation made it possible to predict where resources were needed in advance rather than simply reacting to the information of the day. It was not an add-on; evaluation was a priority management tool that helped make effective use of scarce resources. The mantra from the American Management Association was repeated hundreds of times: “You get what you inspect, not what you expect.”

  Humility does not mean fatalism. In retrospect, achieving the eradication of smallpox might look inevitable. In fact, though, the chain of events included so many opportunities for failure that success was not a given—and we knew it. We had no guarantee of success and were humbled so often that humility became a daily emotion. We didn’t let that stop us.

  Postscript

  Over the years, on every return to India, I have searched the faces of people on the street, looking for pockmarks. Soon I could find no pockmarked face under the age of ten, then twenty, and now, no pockmarks are to be found on people under the age of thirty-five.

  APPENDIX A Plan in the Event of

  Smallpox Bioterrorism

  In 2002, the United States was concerned that Iraq might have weaponized the smallpox virus, and the U.S. government quickly moved to set up a prevention program. Crucial lessons from the global smallpox program seemed to be totally forgotten or ignored. The rather anemic response was a plan to vaccinate first responders, then medical personnel, and finally, in the event of smallpox, to vaccinate 10 million people in ten days.

  Moreover,
the public health leadership seemed to be oblivious to the potential for a complete breakdown of the social order. Even a single case of smallpox in the United States would have resulted in panic, with 300 million people demanding vaccination immediately, fighting to be part of the initial vaccination cohort.

  Lessons learned from the global smallpox eradication effort could be used to formulate a technically sound plan that would ensure the quick containment of dozens, even hundreds, of simultaneous outbreaks in the United States, and to communicate that plan to the public:

  Emphasize to the public that anyone vaccinated on the day of exposure or even within three days after exposure will be protected from the disease. Describe how a dozen or even a hundred outbreaks could be contained with relative ease. (The problems would come if many hundreds of outbreaks became apparent at one time. That would require the capacity for mass vaccination.)

  Present the details of how everyone in this country could be vaccinated within three days, even in a worst-case scenario with thousands of cases discovered simultaneously throughout the country.

  Decentralize the vaccination program to each of the three thousand counties in the country.

  Designate every high school as a vaccination site, since people usually know the high school district they live in.

  Calculate the number of people living in the catchment area of each high school to determine the number of vaccinations and therefore the number of vaccinators required to vaccinate everyone in three days.

  Recruit in advance medical personnel, teachers, government workers, and volunteers to perform the vaccinations. The technique can be taught in fifteen minutes. A practice session in advance and a refresher session on the first day of vaccinations would be sufficient.