House on Fire (14 page)

In a May 2, 1969, letter to Don Millar, then chief of the smallpox program at CDC, Gelfand voiced his doubts that the method that had been so successful in Africa would be applicable in South Asia:

It is a remarkable document, and its exposition and description of “Eradication Escalation” will make it a landmark in the history of disease eradication. . . .

In a luscious bowl of honey, however, one must look out for the rare fly that may be trapped and spoil the dish. I do have a tiny complaint, because I well know how some people in this world can quote out of context to select a point which will serve their own self interest or justify their own complacency. In about the middle of page 6 this sentence appears, “This approach (referring to search/investigation/control) is now considered of equal and, under certain circumstances, of
even greater importance
than systematic mass campaign activities.” I should rather see the underlining applied to a different phrase as follows, “This approach is now considered of equal and,
under certain circumstances,
of even greater importance than systematic mass campaign activities.”

I am sure that you had in mind the unusual nature of the circumstances pertaining in the West African program in the fall of last year: the unusually high ratio of epidemiologists to population, the caliber of the epidemiologists, the availability of special surveillance/control teams, the non-interruption of intensive and concurrent mass vaccination activities. Deliberately or stupidly misinterpreted, the emphasis given in the original sentence could be used to justify fruitless and inefficient epidemic chasing in India and Pakistan. Please don't give them the chance.
¹

The power of surveillance/containment to stop transmission had been demonstrated in 1968 and 1969 in the South Indian state of Tamil Nadu in a program directed by Dr. A. R. Rao, following the reports from West Africa in 1967. However, Rao introduced surveillance/containment after mass vaccination had already reduced smallpox to a few hundred cases. In essence, he had simply confirmed the WHO's original recommendation of using mass vaccination first, followed by surveillance and containment as a secondary strategy. It was a success for Tamil Nadu but did not actually test surveillance/containment as a primary strategy in an area of high population density.
²

In the spring of 1973, a breakthrough in thinking occurred in India. During the seasonal high-transmission period, which runs from January through May or June, major outbreaks were discovered in a district in South India believed to be free of smallpox. The health staff mobilized to do a house-to-house search to determine the extent of the epidemic. Two weeks of preparation led to a ten-day search, which a later assessment found to be surprisingly complete. The searchers discovered numerous unreported outbreaks, which were rapidly contained. The district became free of smallpox in a matter of weeks.

This experience demonstrated that India's large health staff could readily be mobilized for search and containment activities. More importantly, it showed that the smallpox virus in India played by international rules.

Soon after this, Dave Sencer told me that D. A. Henderson at WHO Geneva wanted to assign me to India as a consultant to the WHO regional office in New Delhi to help them apply the surveillance/containment strategy to smallpox-endemic South Asia. The first step was to visit India and meet with the Indian and WHO staff to determine their interest in having me join their program.

My coworkers at the CDC advised me not to go unless I had a solid contract with WHO and India that spelled out what would be provided and what my authority would be. Since I had no idea what the job would require, I found it impossible to specify details. In the end, there was no contract. As the eradication effort progressed, I was very happy that I had gone without preconditions. No one could have predicted the scope of the challenges and how job descriptions would morph dramatically to meet the needs of the moment. Almost any prior agreement would have hampered the effort.

In the summer of 1973, I visited New Delhi—my first time back in India since serving with the Peace Corps in 1963. I found that my interest in the country had not diminished. I met Dr. Nicole Grasset, director of smallpox eradication in WHO's Southeast Asia Regional Office (SEARO), and was immediately impressed by her enthusiasm and desire for success. I also met with the staff at the Government of India's Ministry of Health at Nirman Bhavan and at the National Institute of Communicable
Diseases. At their request, I addressed a meeting of state smallpox leaders gathered in New Delhi to plan a national strategy. I was asked to share the West African experience and to inspire the group to embrace the strategy that had worked so well in that setting. I was wearing, under my dress shirt, a T-shirt that said, in large letters, “Smallpox Zero.” At the high point of my talk I said that we would gird for this historic battle and settle for nothing less than . . . I undid my necktie and unbuttoned and pulled my shirt open so the audience could read “Smallpox Zero.” There was no reaction!

There was nothing to do but bring my talk to an anticlimactic close as I rebuttoned my shirt. It was not a great start. A year later, the same closing would have elicited applause and cheering. Timing is everything, and I was a year off.

In consultation with my family, I made the decision to go to India to work under Dr. Grasset as a CDC consultant. I arranged to spend an additional week in New Delhi, preparing for our move. However, I became so involved in smallpox discussions that in the end I had only the last day of my visit to make personal arrangements. With a great deal of help, a week's worth of activity was accomplished in that whirlwind day—a harbinger of what was possible in India.

I rented a ground-floor flat in Maharani Bagh, New Delhi, that came without furniture but would be fixed up, painted, and ready for our arrival in August. I arranged for air-conditioning units to be installed in the bedrooms. I went to two different specialty offices, where I rented furniture and a refrigerator. After reviewing recommendations by former WHO workers, I secured the services of a cook, N. Joseph, who in turn agreed to arrange for a gardener and a night watchman. I then opened a bank account, registered the children for school, and signed an agreement for an Indian-made car and a driver. I interviewed several drivers, as I wanted someone who was slow and careful so I could feel secure about our children. In Jit Singh I found the perfect person. I ended the day exhausted but energized, able to depart happily for the airport that night to return to Atlanta.

Even living in Africa did not adequately prepare us for the adventure of life in India. During the twenty months we were there, the children
never lost their fascination with it. The day after we arrived, Paula, myself, and our three boys, David, Michael, and three-year-old Robert, explored New Delhi in the rented car with Jit Singh as driver. Cows, camels, and bullocks walked in the streets alongside motor scooters, three-wheeler taxis, buses, and foot traffic. Affluent shaded residential areas stood in stark contrast to slum areas with houses made of discarded materials. We saw brightly colored flowers, saris in every color, and even colorful old buildings, such as the Red Fort. Stores of all kinds bore witness to the spirit of entrepreneurship and the thriving marketplace. Michael, now age seven, had his nose pressed to the window. Suddenly he turned and said, “This is the second best day in my whole life.” Surprised, I asked him, “What was the first best day?” He said, “Yesterday.”

An outsider should approach everything about India, including its history, ready to put preconceptions aside. India is overwhelming in its scope and confusing in its detail, as well as in the lessons it provides. Its history abounds with items never taught in U.S. schools, such as the efficiency of Chandragupta, who recaptured India from the Macedonian authority left by Alexander the Great to form the most powerful government in the world at that time. His organizational skills were impressive: he ordered his day into sixteen 90-minute periods. We hear little about the ruler Ashoka, who, after developing a reputation for cruelty, abruptly changed and based his government on the golden rule. We generally are not exposed to the decency of Krishna Raya, a contemporary of Henry VIII; the wisdom of Akbar, who created the most powerful empire of the time; or the paradox of Shah Jehan, who left a trail of ruthlessness and artistic beauty.

The religious, political, and artistic histories of India are matched by its scientific contributions. Astronomy and mathematics come immediately to mind. India is credited with inventing the zero. Indian medical sciences were describing the circulation of the blood before the time of
Harvey, and offered a medical creed before Hippocrates. Nalanda, a redbricked university whose ruins are in Bihar state, flourished for more than a millennium before Cambridge was even founded.

The history of smallpox in India is intertwined in the subcontinent's history and is no less ancient and complex. Smallpox was very likely present in India for a very long time, although evidence dating before the sixteenth century is circumstantial and mainly found in Hindu myths and Brahmin traditions. J.Z. Holwell, in his eighteenth-century
Account of the Manner of Inoculating for the Smallpox in the East Indies,
comments that the Brahmin caste maintained traditions concerning smallpox from time immemorial.
³
Smallpox was probably known in India at the time of Ramses V.
⁴
The
Atharva Veda,
an ancient Hindu scripture dated to the twelfth to tenth century
B.C.E.
, describes the worship of a deity whose protection was invoked on the outbreak of this disease. It also describes rituals and prayers to be done by Brahmins at the time of inoculation, or variolation, with smallpox.
⁵

Many cultures have believed that angry deities get their revenge by causing death and disease in humans. In India, smallpox was believed to be caused by Sitala-Mata, or Devi, the goddess responsible for pustular diseases.
⁶
The strength of this belief is evident in historical documents. For example, Hindu residents of Kanpur wrote an appeal when the colonial government decided to make vaccination compulsory in 1888: “The major portion of our community believes that small-pox is the direct expression of the wrath of the Goddess Bhawani or Shitala. It is not a malady that can be cured by medicine, and any attempt to check its progress will only enrage the Goddess, who is otherwise pacified by prayers and simple diet. The belief is founded on sacred texts . . . and . . . we believe that our just Government will not offend the religious feelings of its loyal subjects.”
⁷

The goddess was depicted in different forms and bears different names in different parts of the country. Because the annual increase in cases occurred in the springtime, in the eastern and northeastern regions the disease was called
basonto
(relating to the spring) or
guti basonto
(nodules appearing in the spring). In southern India, it was known as
peria ammai
or
doddamma
(big goddess) or
vaisuri noi
(disease with eruptions).

Figure 8.
A village smallpox goddess (far less elaborate than was typical)

As India's population density increased through the centuries, smallpox may have become an almost universal disease, a rite of passage, truly democratic in its disregard for caste or economic status. Cities were probably its major focus, especially during the low-transmission time of the year, during the monsoons. As travel increased again after the monsoons, the virus would be seeded to rural areas through commerce and family visits.

In India, as in Africa, variolation evidently existed for centuries, which meant that, religious beliefs notwithstanding, Indian society had long been aware that a simple operation could protect against smallpox. Holwell describes how a group of Brahmins traveled on a circuit to provide inoculations before the seasonal upswing of smallpox. They followed careful protocols, requiring an entire village to agree to inoculation before they would begin, and asking the village to remain isolated from other villages until the lesions had healed. Apparently the results were so good that the demand for variolation soon exceeded the Brahmin ability to respond. This led to an increase in the price charged for the procedure. The marketplace took over, less careful operators proliferated, entire villages were no longer inoculated at the same time, and outbreaks of smallpox resulted.
⁸
During the early days of vaccination, variolators often resisted vaccination because it competed with their livelihood, although some readily transferred their skills and became vaccinators.

While there is no question that smallpox had a long history in India, its full impact is less clear. Early records on smallpox mortality are simply unavailable. During the colonial period, the British attempted to collect data systematically, but their statistics are open to interpretation. We know, for example, that seventy-five years after Jenner's first vaccination in 1796, India recorded nearly two hundred thousand deaths in a single year. However, in that time of incomplete record keeping, the actual number had to be larger.