by Mary Guinan
The country was emerging from the chaotic 1960s, when President John F. Kennedy, Senator Robert Kennedy, and civil rights leader Dr. Martin Luther King Jr. were killed by assassins’ bullets. The United States and the Soviet Union were entrenched in the Cold War, and multitudes were protesting the ongoing Vietnam War.
During my medical residency, I was beginning to have second thoughts about a career in academic medicine. The Smallpox Eradication Program again came to my attention, this time in a magazine article that described the implementation of the program and the participation of CDC. That federal agency was sending volunteers to the World Health Organization (WHO), which was leading the eradication program. I was captivated by the idea that a group of idealists had laid out a plan to eradicate smallpox from the world and that our government was a partner. If this mission worked, it would be the first time in history that a human disease was eliminated by the design of humans. Smallpox, a horrible disease feared by civilizations from earliest recorded history, would then be gone. It was an exhilarating idea.
I applied to CDC’s Epidemic Intelligence Service (EIS), a two-year program that trained participants in the control of disease outbreaks (and much more, I was to find out). I was accepted into the class of 1974, which began in July. I knew next to nothing about epidemiology and was never interested in a career in public health. But the EIS was my route to joining the smallpox eradication effort.
I was assigned to the Hospital Infections Program in Atlanta and began the work of an EIS officer. Every week at the mandatory EIS officers’ conference, there would be a call for volunteers for the Smallpox Eradication Program in India. I applied twice but was not selected; I was told that WHO was not accepting women into the program. I protested to the director of the EIS program, Philip Brachman, MD, who told me that it was not WHO but India that was not accepting women. I pointed out that the prime minister of India, Indira Gandhi, was a woman and asked whether she knew about this. I asked to speak to someone at WHO or in India to plead my case. Dr. Brachman said he would look into it. The next week, I was accepted. I was ecstatic.
On December 31, 1974, I joined ten physician volunteers in Delhi for a training course given by Bill Foege, MD, the director of the eradication program in India, and Dr. Nicole Grasset, a Swiss-French medical virologist-epidemiologist who directed the regional WHO office. We learned about the search (surveillance)-and-containment strategy for smallpox that Bill had begun in Africa. (This strategy, which Bill had used to great success in Africa, was conceived because of a smallpox vaccine shortage there. Basically, instead of vaccinating everyone—that is, mass vaccination—smallpox teams found smallpox patients, isolated them, and vaccinated their contacts and every unvaccinated person within a ten-mile radius.) This strategy was so successful that Bill continued to use and evaluate the method. Although there were a number of naysayers who did not believe that the method would work in India, Bill had promoted it, rather than mass vaccination, as the primary approach for eradicating the disease in that country. During his first year in India, the results were so impressive that one could actually imagine that smallpox would be eradicated.
Our group of volunteers finished our training in early January 1975 and reported to our assigned programs just at the start of Operation Smallpox Zero. By that time the eradication program was remarkably successful, and there was a great deal of optimism. Smallpox outbreaks were still occurring, but in only two states in India, in remote parts of Uttar Pradash (UP) and Bihar, in northeastern India close to Nepal. I was one of three sent to UP. Accompanying me were Walt Orenstein, MD, a fellow EIS officer, and J. Michael McGinnis, MD, from the Office on International Health in Washington, DC. We were met at the airport in the capital city, Lucknow, by Don Francis, MD, the director of the program in UP. When Don saw us, he said, “What am I going to do with three Americans?” It was the time of the Cold War, and it was an extremely sensitive issue that all units have approximately equal representations of American and Soviet epidemiologists. Three Americans would upset the balance in UP.
We joined a team of about twenty epidemiologists assigned to different areas to do surveillance and containment. Each of us was allocated various supplies and staff, including vaccine and bifurcated needles, sleeping bags, a jeep with driver, and a paramedical assistant, who served as navigator, cook, interpreter, procurer of food, and general all-around invaluable aide.
Our job was to go to our assigned area, find persons infected with smallpox (patients), immediately immunize all contacts of the patients, and then surround them with a ring of immunity, that is, the ten-mile radius of a patient’s village. We were to quarantine patients until the infection was no longer communicable, and vaccinate everyone within the prescribed radius. Smallpox spreads only from person to person. If you interrupt the chain of transmission with an immunized population, the virus has no place to go.
I had been assigned to Kanpur, which had been declared smallpox-free, and I would just be doing surveillance activities unless we found a smallpox case. Shafi, my paramedical assistant, and I would be going from village to village to show pictures of children with smallpox, promising a reward of 10 rupees for anyone who led us to a case.
But fate intervened. A few days before our arrival in UP, there were unconfirmed reports of smallpox cases in another area that had also been declared smallpox-free. Dr. Francis told me he was going to send me not to Kanpur but to Rampur Matras to determine whether the reported cases were actually smallpox. It was an amazing experience for me—having never seen a case of smallpox—to be the decision maker. But following the protocol we learned in Delhi, I examined the patient, a young Brahmin man, and declared he had smallpox.
The die was cast. I would be in Rampur Matras for the next two months, overseeing the vaccination program in the villages surrounding the case. The patient’s elders had brought him to a prostitute for his first sexual experience, which resulted in his contracting smallpox. The issue was quite sensitive, and the family refused to reveal the location of the prostitute.
Despite the caste system’s being banned in India, it was still intact in rural areas, and Brahmins were a high caste. Those from lower castes were not to touch a Brahmin. In order to get a sample of the pustules of the patient to send to Delhi for confirmation of smallpox, someone had to touch the young man. The father finally permitted me to take the sample. Shafi later told me it was because of my light skin color; lower castes were associated with dark skin.
I had only the tiniest of maps, and it was difficult to determine the ten-mile radius, so we just began vaccinating in the adjacent villages. Shafi started the process by putting out a call for local government vaccinators. How all this worked without any kind of telephone contact was always a mystery to me. But vaccinators arrived within a day.
They would be paid a good stipend for their work, over and above their regular pay. Shafi took care of the ledger, registering the vaccinators and keeping track of the days they worked. At the end of each week, I had to pay them. WHO had issued all epidemiologists a series of checks in rupees that could be cashed at local banks. Shafi and the driver (who liked to be called “Driver,” rather than his given name) always knew how to find the local bank, even in the most remote area. The first week we hired over thirty vaccinators. So I cashed several hundred rupees’ worth of checks and got small bills of 1, 5, and 10 rupees. I put the money in a travel belt, which I had brought with me from home. I kept the money belt under my shirt above my abdomen, where it wouldn’t be obvious. We followed this routine every week for two months. Sometimes I had more money than the belt could hold, and I would put the excess in the pockets of my pants.
If we came back from the bank after dark, we worried about roadblocks, and the possibility that thieves could stop us and take our money. Shafi prepared me in advance for a potential roadblock. He said my light skin would be a giveaway that I was a foreigner and would be more likely to have money. So I bought a large woolen shawl that covered my head and w
hole upper body, including my hands. Whenever we drove at night, I wore this shawl. In the months I was there, we were stopped only once at a roadblock. I was under the shawl, and I could not see nor understand the conversation. I did not move. Shafi was successful in getting us past the roadblock without incident.
Our work was often complicated by the local populace’s lack of understanding of the program or by logistical problems. Cultural issues arose on a daily basis. Driver was Hindu; he spoke only Hindi. My assistant, Shafi, was Muslim; he spoke Urdu, Hindi, and English. I did not speak Hindi or Urdu, but I did learn to read the Hindi symbols so that I could read road signs. (Driver was unable to read, so I would phonetically sound out the symbols so he knew which way to go.)
I was a woman traveling with two men who were not my family members, an extremely unusual occurrence in Indian culture. This area of UP was 99 percent illiterate. Most of the people in the area had never seen a foreigner nor even heard of America. They did not have a concept of another country or language and thus could not understand why I did not understand them. (Occasionally, when Shafi was asked where I was from, he would say, “Oh, she’s from Lucknow.”)
I was a source of great curiosity. I had anticipated some of this and had dyed my blond hair black before I left the United States so that I wouldn’t be too conspicuous. I had had several outfits made for me in Lucknow—wide pants with pockets and long shirts, or Kurtas, much like what the Muslim women wore. Indian women wore saris, and I could usually distinguish whether we were in a Muslim or Hindu village by the women’s clothing.
The women welcomed me. In fact, often in a Muslim village the women would insist I come into their huts because they could not come out. Staying inside was part of their practice. Shafi would not be allowed in. In the hut, I used a kind of sign language with the women, and I learned a lot—that most of the women were pregnant, for example, and that they had babies every year. When we were vaccinating, if I saw a child of about one year old in a hut, I would look around for a baby; somewhere, perhaps hidden in a blanket, there was almost always another baby. The women in turn would pat my abdomen and ask where my babies were. While I was there, several babies were born and named America.
I stayed in mud huts or camped out in the various villages we visited. It was very cold. I thought India would be extremely hot, but UP is in the north, and it was cold. When I arrived at the Delhi airport, it was 3 degrees Celsius (37 degrees Fahrenheit), and I did not have warm clothes. So I had a quilt made in Lucknow, which I used both as a shawl and as a blanket for warmth.
And there were rats. They occasionally came into my hut at night, which terrified me. One morning, I found one in my purse. When I told Driver, he just opened the purse and let the rat out. Indians respected life and tried not to kill anything.
Shafi had a small, oil-heated stove on which he cooked our meals. He and Driver ate with their fingers. I never managed to do this, but Shafi, as usual, was prepared. He brought with him an old spoon that I used. Driver’s Hindu beliefs forbade him to eat out of the same plate as Shafi and me. Because we had only one plate, we would find leaves that Driver could use as a plate.
One day, while crossing one of the numerous rivers intersecting the villages, I rolled up my pants above my knees, took off my shoes, and waded across. No one was there when I started across, but about fifty villagers had gathered by the time I got to the other side. All appeared to be in a state of shock, staring at me in complete silence. To my immense embarrassment, I remembered that in this cultural setting a woman showing her legs was highly inappropriate. The story spread, although I don’t know how, and months later, when I returned to WHO headquarters in Delhi, I received considerable ribbing about it.
It could take weeks for the results from the smallpox lab, so during the remainder of my time in India, I continued working as if all the suspect cases we found were truly smallpox. We hired family members to care for the patient (so they would not leave the hut), and we hired three vaccinators to guard each hut. They worked eight-hour shifts. Anybody who went in the hut had to be vaccinated. We returned for surprise inspections to make sure that a guard was on duty.
I kept on this way—culturing, sending off the samples, hiring vaccinators—and learned something the first few weeks of vaccinating. If we went to a village, talked to its leader, and said we wanted to vaccinate everyone, we found that we were often missing people. So we came up with a different strategy. We would first take a census of the village, writing down everyone’s name and approximate age. Taking a census implied that resources might be coming, so the people were very cooperative. The next day we vaccinated everyone on the list.
About this time, Don Francis came from Lucknow to visit me. He was worried.
“Listen,” he said, “this place was declared free of smallpox and you are sending off all of these samples saying there’s smallpox. Are you sure?”
“As sure as I can be,” I answered.
“Are you sure?” he repeated. “Because you’re causing a political problem for the public health leader of the area who has declared it free of smallpox.” The cultures eventually all came back positive.
While Don was there, he also checked the vaccination rates in the villages where we had finished vaccinating. He would walk through the village asking the children to show him their smallpox vaccination. He did not find a single unvaccinated child.
We did our work and once a month went to Lucknow for a meeting. I would check into my hotel the night before the meeting and have my first bath in a month, get my laundry done, and then eat dinner with my colleagues.
Dr. Foege would come up from Delhi for this session, and each of us would present our data on the number of outbreaks we had found and how we had contained them. Bill would share the results from Bihar. A little competition developed among us concerning whether Bihar or UP would reach Smallpox Zero first. Each month, the outbreaks continued to go down dramatically. It was apparent we were approaching the goal of zero smallpox cases. Dr. Foege’s book, House on Fire (1), captures the excitement of those days and gives an extensive account of the worldwide smallpox eradication effort.
At the monthly meetings, Walt Orenstein and I would have dinner together. We are both from New York, and we would share stories about how our team would not understand our humor. We would say something we thought was funny, and they would stare at us blankly. We had lots of laughs about this, and we became lifelong friends.
When the smallpox workers were at the hotel in Lucknow, vendors would come and peddle their wares. A particular rug dealer, who was called the “rug walla,” would target Walt and me. The rug walla would come to the hotel with his assistant, who was laden with rugs. He would stand outside the window of the restaurant where we were eating and have his assistant hold up one of at least five or six rugs. We would shake our heads yes or no, depending on whether we liked each one. Every month he came and found us, and eventually the rug walla’s persistence paid off. Walt and I both bought a number of rugs and had them sent back to the States.
Walt and I also exchanged information about successful techniques to be used in the field. One was an approach of another colleague, who found unvaccinated children by offering candy. We brought a large quantity of paper-covered toffees back with us to the field. When we walked through the villages, we would ask the children to show us their smallpox vaccination scars. If they had one, we gave them a toffee. If they didn’t, we first vaccinated them and then gave them a toffee. This approach proved very successful. When children saw us coming, they would run to us to get the toffee.
After we finished the work in Rampur Matras, I was assigned to Kanpur, which was still smallpox free. I continued the surveillance process. By now the reward was 100 rupees, and I think that it reached 1,000 rupees before the end of the campaign. Unfortunately, my request to CDC to stay in India until the goal of zero cases was reached was denied. I left in April to return to my EIS officer position.
In May, Uttar Pradash
was declared smallpox-free. It was one of the most exciting experiences of my life. The program had worked. And I was hooked. I decided to embark on a career in public health. I doubt I would have considered such a career had it not been for those idealists who conceived of the worldwide Smallpox Eradication Program, convinced world leaders that it was important, worked tenaciously to ensure the effort was successful, and gave people like me the chance to participate. I had found something to believe in.
THREE
A Gift of an Elephant
EARLY one morning in a small village in a remote area of India, our smallpox eradication team was preparing for the day’s work when we spotted a fast-moving vehicle coming toward us on the dirt road. Although we had been in the area for about two or three weeks, I had never seen another vehicle there besides the Mahindra Mahindra jeep that was our main mode of transportation. The road was full of potholes after the rainy season, and dirt was swirling as the car bumped up and down.
All work stopped, and both villagers and smallpox workers watched in silence as the black, dirt-covered Mercedes pulled up beside me. A well-dressed, ebullient young man jumped out. He smiled, introduced himself in perfect English, and asked me what I was doing. After I explained that we were smallpox eradication workers, he said he had heard about us and thought it was a fantastic mission, and he wanted to help. Specifically, he had heard that we were having difficulty getting transportation back and forth across the rivers that intersected the smallpox-infected villages. This was true. The rivers were too deep for our jeep to traverse, and our means for crossing rivers were unpredictable.
The young man was called Raj Sahib (pronounced Raj Sob) by the locals, a term of deference used to refer to Indian men of middle and upper classes. As we talked, the whole village assembled around the Mercedes, keeping a respectful distance. Raj Sahib then announced, in English, that he was presenting me with an elephant. He said that the elephant swam and that she would solve our river-crossing problem.
