House on Fire (22 page)

Because of his success at motivating large numbers of local health workers, he was eventually transferred to Lucknow to oversee, under the state medical officials, the smallpox operation for the entire state. Don, in turn, had the utmost praise for Rajendra Singh, the PMA who worked with him throughout his two years as a special epidemiologist:

When we first started together, [Rajendra Singh] was helpful, but rather quiet and respectful. He watched as I met with high-level officials to explain the new search and containment strategy. He watched
as I went to the field to do my own search for cases of smallpox. And he watched as I went to villages with outbreaks to evaluate the vaccination or, if there wasn't any, to vaccinate myself.

Soon, whether it was controlling an outbreak in a village or meeting with a high-level official in the state capital in Lucknow, Singh knew what to do.

In the villages I learned to turn to Singh to ask him how to proceed, especially in villages where there was some resistance to vaccination or ill-founded concerns. Standing as straight as an arrow, he would gently raise his hand before a protesting villager and say, “Gul suno” (Listen to what I am saying). Then, with personal force and gentle words, he would convince even the most resistant person of the good of what we were doing.

He had equal insight into the complexities of higher levels of the Indian government. He would rapidly assess what was behind the problems we confronted. Then, quietly and in private, would let me know exactly what was standing in my way and whether or not there was a way to address it.

Especially during the first year, when the program was failing and smallpox was everywhere, I don't ever remember him getting impatient or complaining of the long hours or the days-on-end away from home. Indeed, he was always there to help. When the weather got unbearably hot or when the road was so dusty that we couldn't see where we were going, he would urge us onward.

After smallpox, Singh returned to Pilibhit and headed up the District's immunization program. In 2008, while working on polio eradication, I visited Pilibhit and was fortunate to find him. He retired from government service to run his farm and a private pharmaceutical supply business.
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The foundation of quality improvement for the smallpox campaign was the monthly meeting held in every smallpox-endemic state. The monthly meetings brought workers from every district to the state capital—Patna for Bihar, and Lucknow for Uttar Pradesh. Attendees included between two and six people from SEARO and the Central Government, the state smallpox officer, state health and political leaders, district medical officers,
special epidemiologists, urban health officers for the largest cities, and several people from blocks that were of special concern. There might be fifty to one hundred attendees, and while the meeting could be completed in a day, many workers came a day early or stayed an extra day to replenish supplies or discuss special concerns with state and central officers. The meetings were usually conducted in a government meeting hall with ceiling fans but no air conditioning. Coffee and tea breaks were part of the tradition, and lunch was served in an adjoining room.

The meetings were primarily to review the work of the previous month and choose tactics and goals for the next. They were also an opportunity to get real-time feedback from field-workers, pursue scientific inquiry, evaluate what was working and what was not, replenish funds and provide payment, and recharge the field-workers' enthusiasm, which could evaporate after a month of hard work in trying field conditions. No small part of the meetings was the opportunity for foreign workers to leave their isolation out in the field and blow off steam.

The meetings always reminded me of reports of similar gatherings in the United States a century and half earlier, when mountain men working throughout the Rocky Mountains as well as local Native Americans would once a year bring their beaver furs to an annual rendezvous, often on the Green River in Wyoming. Both groups would sell their furs, buy supplies such as traps, ammunition, and coffee, find out what was happening in the rest of the world, and after a week or so make their way back to the field.

There was always a period of chaotic human Brownian movement as people greeted each other before settling down for the proceedings. The meetings began with a review of what had happened around the world during the previous month in smallpox eradication, thus incorporating the field-workers, in close to real time, in the global effort. A competitive feeling developed, since despite the massive problems we were facing, everyone hoped India would not be the last country in the world with smallpox. The next meeting item, a review of results from other states of India, similarly fueled both hope and a spirit of competition that their state would not see the last case of smallpox in India. Best strategies used in other states were also reviewed.

The meeting then shifted to district reports. Besides reporting the basics—the number of outbreaks at the beginning of the month, the number of new ones found, and how many had been contained and thus taken off the books—field-workers shared innovations in everything from how to find previously unknown cases to how they improved the productivity of health workers and daily laborers. Innovation was encouraged; when we identified effective new practices, we moved quickly to replicate them. At the same time, we tried to reward field-workers for being transparent about unproductive strategies so they could be discarded. We also found out which areas were overwhelmed with outbreaks and needed more supplies or people.

The meetings ended with two practices. The first was to distill lessons learned from the collective experience of all districts plus other states and forge this into a statement of new tactics to be tried the following month. Second, targets were set for the month by district and for the state. Only once during the program were the monthly targets actually met in Uttar Pradesh and Bihar, but knowing what we hoped for under ideal conditions served to motivate every worker, from the field to the central level. The end of each meeting also involved decisions on personnel placement and deliberate efforts to encourage each other to keep working in the face of tremendous odds.

Often the meetings revealed that some special epidemiologists were so beaten down that they needed special attention or to be replaced. These were tough people; they did not say they were depressed or overwhelmed. Most workers, regardless of how tired they were, were excited about sharing what they had been doing, the tricks they had developed, and the small successes they had experienced; some, however, were so overwhelmed that they could not get excited even over their own presentations. Just as the smallpox virus left a trail, so did depression. They tended to express frustration with their staff or district supervisors, or even the strategy itself. They might express anger about expectations, living conditions, or paperwork. Occasionally their behavior reached a point where the Indian authorities would ask for their removal.

The first level of response was to plan a visit to their area of work. Some people simply needed someone to witness the situation, to offer
ideas, or to commend their actions. Misery, like poverty, can be endured when shared. However, sometimes this was not sufficient; some needed a face-saving way of going home early. Usually, they welcomed the suggestion that they had worked too hard and needed relief. How could they communicate this to others? By saying they had become ill and had to return. They were relieved to be going home but had not been able to make that decision for themselves.

A recent book on the Indian campaign, authored by S. Bhattacharya and based on his review of WHO archives, comments on the high level of dissension in the smallpox program. Bhattacharya says that dissension is evident in the records within WHO, in conflicts between WHO and Indian workers, between smallpox and other health programs, between the central and state governments, and between health workers and non–health workers. He also describes the tendency of WHO to attempt imposing its will on India.
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While these comments contain some truth—there were strong differences of opinion within WHO, within the regional office, and within India's Central Government—dissent was far from being the driving force. In fact, the climate of the program in the field was quite the opposite—exhausting, frustrating, and confusing, certainly, but remarkably positive and collegial even during the most difficult periods.

Yes, the staff at WHO/Geneva had strong opinions on how things should be done, but any attempt to impose their views would have failed. On the other hand, no suggestion from Geneva or elsewhere was ever discarded untested simply because it came from outside the country. Indeed, international policies were tested every month in every state, and the monthly meetings provided feedback on what worked and did not work under local conditions. No suggestion from outside of the country was incorporated into the program without validating its appropriateness for India. The interchange between people on field visits, the collegiality of district and PHC meetings, and the fine-grained texture of the daily work were not necessarily captured in the archival record.
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While dissent was real and even encouraged, the actual story is how the months of intense and continual involvement of workers at every level, as well as the constant stream of communications in real
time to everyone involved, promoted a level of trust that overcame any disagreements.

In retrospect, I would say that rarely in my half century of global health experiences have I seen such an effective coalition of workers as the one that developed in India. The core of that coalition was the monthly meetings. Representatives from the Central Government, state ministries of health, and other key state agencies all heard the reports from the villages. The usual communication and relational limitations of a hierarchical system were avoided; everyone attended the meetings. The team concept extended from every village all the way to Geneva. In facing the common goal of stopping a deadly disease that itself had no regard for rank or status, the usual governmental barriers gave way to a new kind of order and openness.

Indeed, in my view, the single most important reason for the successful eradication of smallpox, after decades of ineffectual efforts in India, was the seamless coalition that developed between India's smallpox program leaders and the array of international participants involved. A coalition can have great energy yet yield poor outcomes because people stake out their own turf. This did not happen in the India smallpox eradication program. Rather, the key groups joined together—a chaotic collaboration in the beginning but increasingly disciplined, coordinated, and purposeful. Over time, dozens of other groups and special interests joined too, including UNICEF, bilateral agencies, health and nonhealth government agencies, nongovernmental organizations, church groups, laboratories both in India and abroad, corporations, and various volunteers. If a coalition can be described as beautiful, this group became absolutely gorgeous, a model for all future national and global health efforts. The result—the eradication of smallpox—was not an accident.

 

 

 

 

The first four months of 1974 were whipsaw months. The seasonal low point for smallpox transmission had passed, and transmission was now naturally increasing. At the same time, the searches were becoming more efficient. While this efficiency was a source of great pride for the smallpox workers, especially the search teams, it also meant that the reported smallpox numbers rose dramatically.

Boring to some, the numbers were fascinating to the smallpox leadership team. Many evenings after dinner I would say good-bye to my family and head to the New Delhi station to catch the overnight train to Lucknow or Patna. The hours before sleep were spent talking with Diesh or Sharma or Dutta or preparing for the upcoming meeting. I was endlessly analyzing numbers, looking for clues regarding what was working and what needed to be changed. What should be emphasized at the state meeting or with the state health authorities? Where did we need to place more people or resources? I was always looking for something
encouraging in the figures, both to bolster my hopes and to share with field-workers, who needed inspiration in the face of overwhelming problems.

Numbers consumed our days, became our compass, and guided our actions. American investors check throughout the day to see what the Dow is doing, and sports fans turn on the news each morning to find out the statistics for their favorite team. With the same fervor we scanned the reports of new, pending, and contained outbreaks from each major search as well as from the supplementary searches that gradually became standard in high-risk areas during the interim weeks. Even the passive reporting system, which had lost its credibility in light of what the searches revealed, provided some information.

New outbreaks gave us a measure of how much spread was still occurring. The number of pending outbreaks, which included all outbreaks with active cases as well as all outbreaks that had not yet completed four weeks without a new case, indicated how many workers were needed in a given area at any point in time. When an outbreak area went for four weeks without a new case of smallpox detected, it was declared “contained” and could be retired from the list of pending outbreaks.

Because an outbreak remained on the pending list for a month after the last case, that list emptied slowly. In fact, the list could show an increase even as the number of outbreaks was decreasing. Likewise, a report of an outbreak containment referred to work actually done a couple of months earlier. This overvaluation of pending outbreaks and delayed gratification of contained outbreaks was intentional, building in margins of security. It was much safer to make truth prove itself than to guess at the truth.