House on Fire
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1. Coercion was never program policy. A 1995 article by Paul Greenough gives the erroneous impression that coercion was required for containment to work in the final elimination of smallpox. He recounts four instances in which two American epidemiologists used coercion plus a fifth instance in which an Indian government vaccinator used force to hold and vaccinate people. Green ough also quotes from the journal of an American smallpox worker who attempted unsuccessfully to persuade a woman to be vaccinated. The worker was ejected from the home by the woman’s husband. The cases cited are no doubt true, but they would have been aberrations, perhaps the result of the kind of frustration that anyone who has worked in the field can understand. Cultural sensitivity was emphasized in the training of smallpox workers in India and in the field was the norm rather than the exception. Certainly force was not needed for eradication. Greenough interpreted this aberration to be the norm. See P. Greenough, “Intimidation, Coercion and Resistance in the Final Stages of the South Asian Smallpox Eradication Campaign, 1973–75,” Social Science and Medicine 41, no. 5 (1995): 633–45.
2. R. N. Basu, Z. Jezek, and N. A. Ward, The Eradication of Smallpox from India (Geneva: World Health Organization, 1979).
TEN. WATER ON A BURNING HOUSE
1. Myron L. Belkind, Smallpox (New Delhi: Associated Press, 1974).
2. Letter from H. Gelfand to J. D. Millar, dated May 2, 1969. Author’s personal files.
3. Report in author’s personal files.
ELEVEN. SMALLPOX ZERO
1. Mahendra Dutta, personal communication, August 2, 2009.
2. F. Fenner, D. A Henderson, I. Arita, and Z. Jezek, Smallpox and Its Eradication (Geneva: World Health Organization, 1988), 1097.
CONCLUSION
1. This conclusion is based on a talk I gave in 2009 at the commemoration of thirty years of global freedom from smallpox held at the WHO regional headquarters in New Delhi.
2. From one standpoint, physicians are actually managers, taught to analyze a health problem in an individual, determine the objective for that person, plan a strategy to achieve the objective, monitor indicators to evaluate whether the management strategy is working, and make midcourse corrections to modify the strategy. However, physicians often miss this point and fail to apply their managerial skills beyond clinical medicine.
Glossary
CDC Centers for Disease Control and Prevention in Atlanta, Georgia. Known in earlier years as the Communicable Disease Center, the Center for Disease Control, and the Centers for Disease Control.
containment The response to finding a smallpox case or outbreak. The term initially referred to containing the smallpox virus so that it could not spread to others, but its meaning evolved to include a wide range of activities involving a local census, vaccination of potential contacts, watch guards at the houses of smallpox cases, etc.
EIS Epidemic Intelligence Service, a program at CDC that recruits people for two-year terms to study and respond to disease threats of all kinds. EIS officers figured heavily in smallpox eradication.
epidemiology The study of patterns of health, illness, and associated factors in the population as a whole.
fetisheurs Local medicine men in West Africa who treated individuals with smallpox. They represented a mixture of medical and religious beliefs and had learned how to propagate smallpox by collecting scabs from smallpox patients and inducing new outbreaks when they desired new patients.
herd immunity High immunity levels to a disease in a population, making it difficult or impossible for the disease agent to spread.
Indian government The responsibility for smallpox eradication involved the Central Ministry of Health in Delhi, state governments, districts (sub divisions of states), and blocks (subdivisions of districts). Blocks were inhabited by approximately one hundred thousand people. In general, Primary Health Centers coincided with blocks, and so provided health services for one hundred thousand people.
mass vaccination The systematic vaccination of all segments of the population in an attempt to develop herd immunity.
Nigerian government In 1966 the responsibility for smallpox eradication involved the National Ministry of Health in Lagos and four regions: the Northern Region, the Western Region, the Midwest Region, and the Eastern Region. The regions were subdivided into provinces. Later, Nigeria was subdivided into states.
searches The activities involved in finding cases of smallpox. Primary searches involved going through villages and urban areas looking for cases. Secondary searches were conducted at markets or festivals in an effort to obtain information on smallpox in the areas from which people had come. Tertiary searches focused on areas or populations deemed to have a high risk for smallpox cases, such as beggar communities, kiln worker communities, mobile roadway workers, etc.
SEARO Southeast Asia Regional Office, a WHO regional office responsible for India, Bangladesh, and other countries.
smallpox outbreaks From one to hundreds of cases in a geographic area, such as a village or a neighborhood in an urban area. New outbreak means an outbreak newly detected by searches or through the passive surveillance system, which would then be targeted for containment activities. Deleted outbreak refers to an outbreak that had now gone the requisite time without a new case of smallpox, usually four to six weeks. Pending outbreaks refers to all outbreaks still receiving containment attention. This category included new and active outbreaks; these remained pending until a period of no new cases had passed.
special epidemiologists Workers from elsewhere in India or other countries who focused on problem districts to provide supervision for search and containment activities.
surveillance The systematic monitoring of all information related to a disease, in this case smallpox. This term was often used in the restricted sense of attempting to find all cases of smallpox.
take A successful vaccination as evidenced by the appearance of a sore, crater, or blister at the site of a vaccination several days after the vaccination.
vaccination The act of transferring cowpox or vaccinia virus in order to induce immunity to smallpox. (Louis Pasteur later suggested that in order to honor Edward Jenner, all immunizations could be called “vaccinations” and all immunizing agents could be called “vaccines.”)
vaccine A preparation that improves immunity to a particular disease. The term vaccine comes from the term for cowpox (vaccinae). When cowpox was administered to humans, it provided protection from smallpox.
vaccinology The field of study dealing with vaccines.
variolation Also called inoculation, variolation refers to transferring smallpox virus itself from a patient with smallpox to a scratch or abrasion on a healthy person to induce immunity to smallpox. This would actually give the recipient a case of smallpox that was usually milder than if the virus had been acquired through the usual respiratory route. This practice predates vaccination by hundreds if not thousands of years. The danger was that the virus could then spread to others, causing outbreaks of smallpox.
virus A small infectious agent unable to replicate unless it is inside the living cells of another organism. (Smallpox is spread by a virus.)
watch guards Workers hired to stay at the homes of smallpox patients to vaccinate every person who came to visit.
WHO World Health Organization in Geneva, Switzerland. Policy is developed through annual World Health Assembly (WHA) meetings, attended by the ministers of health of all member countries.
Index
Abakaliki, Nigeria, 58–59
Accra, Ghana, 69–70, 84
Achari (Bihar program director), 171, 180
Ademola, Yemi, 27
Afghanistan, 83
Africa: Eradication Escalation effort in, 72–75, 85; mortality rates in, 7; smallpox transmission in, 38–39; surveillance and containment strategy in, 11; WHO eradication program in, 46–53. See also Nigeria
Akbar (Indian ruler), 88
American Management Association, 192
Anderson, James, 93
Anezanwu, A., 60–61, 67
Arora, R. R., 127
Assam (Indian state), 175, 176
assessment. See program evaluation
Atharva Veda (Hindo scripture), 89
attack phase, 98
Atutu Ochelebe, Lawrence, 35, 44, 183
Bangladesh, 11, 185
Banu, Rahima, 185
Basu, R. N., 97, 127, 153
belief in global eradication, 11, 26–27; program in Africa and, 47, 52–53; program in India and, 83–86, 161, 167–168. See also eradication of smallpox; surveillance and containment approach
Belkind, Myron L., 167
Bhattacharya, S., 143
bifurcated needle, 101–102, 109, 197, 205n30
Bihar (Indian state), 93, 177; decision by
Minister of Health in, 169–172; new outbreaks compared (1974 and 1975), 176–177; political matters in, 157–161; surveillance and containment approach in, 106, 111–112, 115, 119, 140, 147–148; turning point in, 161–162, 163–164, 172, 173
biological warfare: defense against, 18, 195–196; suspicions of workers and, 159
Birmingham, England cases (1978), 186
Blair, Vachel, 24
Bohannan, Laura, 38–39
Brazil, 83, 84
Brilliant, Girija, 206n1
Brilliant, Larry, 129, 168, 206n1
Bulle, Wolfgang, 29, 30, 71
Calcutta, India, 93
Carro, Jean de, 92
cases, number of, as metric, 118–119
CDC. See Communicable Disease Center (CDC)
Central Africa, 72–75
Chandragupta (ruler in India), 88
chickenpox, 42, 154, 181
children: push for mass vaccination of, 171, 180; repeat vaccinations and, 93, 99; as search informants, 117, 148–149; vaccine in India and, 92–93
church missions: evacuation from Enugu and, 66–69; medical work by, 28; Ogoja outbreak and, 54–55, 57–58
Clara Swain Hospital in Uttar Pradesh, 139
Clark, William, 10
Cleveland, Harlan, 117
coalitions, 130–131, 189–190, 191
coercion, 206n1
Communicable Disease Center (CDC): author’s position at, 84, 183; Bangladesh program and, 185; Epidemic Intelligence Service (EIS) training at, 18; eradication program in Africa and, 36–37, 46–53, 69, 72–73, 76, 77; managers in India, 131–134, 136, 160; name changes of, 200n2; oral history archive and, 206n5; smallpox eradication handbook of, 76; surveillance and containment approach at, 75–79; threat in New Mexico and, 19–22; WHO global program and, 84. See also Henderson, D. A.; Millar, Don; Sencer, David J.
communication, 130, 144, 191
community leaders, 45–46
Conrad, Lyle, 204n29
contagiousness of smallpox, 38
containment teams, 108–110, 115–117, 121
cowpox virus, 8–10, 92, 94
Cresswell, John, 93
cultural awareness: city life in Nigeria and, 43–45; foreign workers in India and, 110–111, 135–136, 138; importance of, 192; storytelling in Nigeria and, 62–63; village life in Nigeria and, 30–34, 43, 45–46; village wisdom about smallpox and, 74–75
detection of smallpox, 3–4, 77–78
Devi (Indian goddess), 89
Diesh, P., 125–126, 128, 130, 135–136, 145, 176–177
Directorate General of Helth Services (India), 103
district headquarters, 153–154
Dupont, 168
Durant, Will, 191
Dusthall, Anna, 92, 94
Dutta, Mahendra, 126, 130, 145, 169–172, 177, 180
Eastern Nigeria Ministry of Health, 59
EIS. See Epidemic Intelligence Service (EIS)
Emory University, 206n5
Enahoro, Peter, 67
Enugu, Nigeria: Eastern Nigeria eradication effort and, 43–44; wartime revisit to, 71
Epidemic Intelligence Service (EIS), 18
epidemiology, field of, 17–18
Eradication Escalation effort, 72–75, 85
eradication of smallpox: dream of, 8–11; origins of global program for, 10; proposed possibility for, 25–27; shift in primary strategy for, 53–59. See also belief in global eradication
Ethiopia, 185–186
Etzel, Ed, 160
evaluation teams, 154–155. See also program evaluation
Faith Tabernacle Church, 59
fetisheurs, 41–42
“field paranoia” syndrome, 167–168
financial support: cost in India and, 102;
USAID and, 46; WHA and, 10, 47–48. See also government support; pharmaceutical philanthropy
firefighting analogy, 15–16, 58, 78, 118, 171–172
Foege, David, 64, 66, 67, 75
Foege, Michael, 37, 43, 88, 157–158
Foege, Paula, 64, 75, 78
Foege, Robert, 88
Foege, William (Bill): arrests and, 66, 70–71; car incidents and, 113, 114; early experiences with smallpox, 19–24; education of, 16–18; influences in youth of, 12–16; public health work in Africa and, 28–37; research in Tonga and, 24–25; shingles incident and, 114–115; study with Weller and, 25–27; T-shirt incident, 87. See also Foege family
Foege family: in Denver, 19; in India, 87–88, 137–138, 157–158, 183–184; in rural Nigeria, 29, 30–35, 37; in urban Nigeria, 43–44; wartime Nigeria and, 66–68, 71
foreign workers, 110–111, 135–136, 159
forms, 109, 110, 155–157, 197
Foster, Stan, 37, 73
Francis, Don, 139
fraud, 126–127
“Friday Afternoon Reflections” (newsletter), 47
Frost, Wade Hampton, 17–18
Gandhi, Indira, 111–112, 161
Gardner, Pierce, 24
Gates Foundation, 168, 205n30
Gelfand, Henry, 36–37, 69, 75, 84–85, 167, 205n2
GlaxoSmithKline, 168, 205n30
global health field, 17
Glokpur, George, 53
goddess of smallpox, 89–90, 96, 152
Government of India, 98–100, 110, 140; alliance with WHO, 129–131; support from, 102–103, 161, 167
government support: as critical, 190; in India, 102–103, 161, 167
Grasset, Nicole, 86, 87, 105, 106, 127–128, 129, 184
Gray, Herman, 35
Greenough, Paul, 206n1
Greenwald, Peter, 24
Harvard University, Department of Tropical Public Health, 26–27
Hawking, Stephen, 188
health education, 63
health workers, 73, 86, 102–103, 115; evaluation of personnel and, 137–139; “field paranoia” syndrome and, 167–168; strike by, 165–166; suspicions of, 159–161; tactical flexibility and, 190–191; training of, 59, 106–111. See also containment teams; search teams; special epidemiologists
Henderson, D. A., 19; CDC and, 24, 46, 202n5; program in India and, 86, 102, 164; surveillance and containment strategy and, 75; WHO eradication program and, 27, 30, 46, 48–49
Henderson, Ralph (Rafe), 204n29
herd immunity, 53, 74, 189. See also mass vaccination
history of smallpox, 5–8; in Africa, 39–42; in India, 88–92
Holwell, J. Z., 89, 91
Hopkins, Donald, 5–6, 73, 93, 94
households, 110, 151–153
human impacts of smallpox, 5–6
humility, value of, 192
Hunter, John, 8
Hunter, R. W., 93
index case, 17–18, 154
India, 11; beginnings of program in, 86–88; CDC managers in, 131–134; containment improvements in, 151–153; core alliance in, 129–131, 166; dissension in, 143–144; early vaccination efforts in, 92–97; first search in, 111–117; history of smallpox in, 88–92; key team members in, 123–127; last case in, 184; later searches in, 117–119, 147–148; main themes of program in, 122; monthly meetings and, 140–144, 169–172; nationwide pr
ograms in, 98–104; Operation Smallpox Zero in, 182–184; outbreaks compared (1974 and 1975), 176–177, 182, 184; rural vs. urban disparities in, 93, 96–97; scientific contributions of, 88–89; SEARO team in, 127–129; skepticism about strategy in, 83–86; smallpox goddess in, 89–90, 96; smallpox incidence in, 97, 100; special epidemiologists in, 134–140; strike by health workers in, 165–166; surveillance improvements in, 148–150; turning point in, 161–162, 163–164, 177. See also Bihar; Uttar Pradesh
Indian Council of Medical Research, 98
Indonesia, 83
injections, attitudes toward, 45. See also vaccination, resistence to
inoculation. See variolation
instruction sheets, 109, 156–157, 197
international community, assistance from, 11, 52. See also financial support; World Health Organization (WHO)
Ismach, Aaron, 50
James, S. P., 95
Jefferson, Thomas, 10
Jehan (Indian Shah), 88
Jenner, Edward, 8–10, 47, 92, 93
jet injector, 26, 45, 49, 50–52; vaccine dilution and, 24–25, 204n29
Jezek, Zdeno, 128
Johns Hopkins School of Hygiene and Public Health, 17–18
Joseph, N. (cook), 87, 137
Journal of International Health, 75
Kingma, Stuart, 133
Kohlstedt, Jim, 14
Kohlstedt, Shirley, 14
Lagos, Nigeria, 63–65, 64, 70, 71
Laney, Jim, 58
Langmuir, Alex, 18, 27
leadership effectiveness, 191
Lewis, Meriwether, 10
Lichfield, Mary, 44
Lichfield, Paul, 44, 58, 60, 70
Lincoln, Abraham, 7
Lucas, Adetokunbo, 63
Lutheran Church—Missouri Synod, 29
Lythcott, George, 201–202n1
Madhya Pradesh (Indian state), 106, 121, 176
maintenance phase, 98
Malin, Ali Maow, 186
management system in India, 133–134 mass vaccination: Abakaliki pilot project and, 58, 59; campaign in India and, 99–104; with other diseases, 78–79, 189; phases of, in India, 98; as primary strategy, 53–54, 59, 65–66, 74, 75–77; threat of return to, 169–172, 177, 180
Mather, Cotton, 41
Maulana Azad Medical College in Delhi, 124
McPherson, Dr., 94