House on Fire (25 page)

Through the months, the political climate improved. So when I received a request one day in April to see the American ambassador, Daniel Patrick Moynihan, I assumed he wanted a status report on the smallpox program. I walked through the huge front door of the embassy, as always aware of the sudden transition from extreme heat to air-conditioning. I expected this to be fun, and was surprised to see the embassy physician, Dr. Ed Etzel, pacing the floor. He had been waiting for me. He grabbed my arm and said he had some advice: Moynihan thought one hundred times faster than anyone in the embassy, I should know that Moynihan was very angry with me, and I should not say a word. “Don't argue,” he said, “because he will be merciless.”

I entered the ambassador's office in a state of confusion—what was going on? The ambassador was standing at the side of his desk with an angry look on his face. With no niceties or greeting whatsoever, he said, “I have evidence in this folder that you are spreading smallpox rather than stopping it.” Wow, I thought, what an opening gambit! He went on to explain that India's Communist Party was likely to announce that the United States had sent spies into India under the guise of working on smallpox. The office of the prime minister had asked for a meeting with him that afternoon for an explanation. I saw the presence of so many Americans in India as a scientific issue, but to him it was political, particularly given the number of Americans in the states of Bihar and Uttar Pradesh, near the Nepalese border. He was now in a difficult diplomatic position.

He continued heatedly at some length, without pause. I thought about Ed Etzel's advice, to keep silent, and realized that there was no alternative. Abruptly, he stopped and asked me again what I had been thinking and how in the world had I managed to get these people into Bihar near the border with Nepal without the embassy even knowing?

In fact, wanting to be cautious, I had made all of my requests to Dave Sencer for additional people from the CDC through embassy channels, rather than WHO channels, precisely so the embassy would know what was happening. For a fleeting moment, I considered telling him it was
all spelled out in embassy cable traffic, but immediately thought better of it.

Instead, I began by describing how the world now had a chance for a historic first in eliminating smallpox, and the key to global success was India, and the key to success in India was Bihar. Bihar, I continued, had the highest rate of smallpox transmission recorded in the global program, with one thousand new cases a day in that single state. We had no choice but to put our attention in the place with the problem. Without enough epidemiologists, the effort would fail.

To my amazement, the ambassador made a complete about-face. He became truly interested and began asking questions. Finally, referring again to his impending meeting with Prime Minister Indira Gandhi, he asked, “What should I ask of her to speed up the program?” The Government of India—supportive of the program all along—subsequently deepened its support even more.

What I told the ambassador was no exaggeration. In the first four months of 1974, India reported more than sixty-seven thousand cases of smallpox, and over two thirds of them were in Bihar. When the numbers of outbreaks declined in Bihar, they would decline for the entire country.

A solid month before the official figures showed a decrease in pending outbreaks, smallpox officers knew eradication was possible and indeed only a matter of time. This became obvious by watching the increase in containment outcomes. In Bihar in January 1974, outbreaks were being taken off the pending rolls at the average rate of 107 per week. One month later, outbreaks were being retired at an average rate of 152 per week. This rate increased to averages of 403 per week by March and 596 outbreaks per week by the end of April.

Throughout this time, the number of new smallpox outbreaks increased dramatically, so the number of pending outbreaks continued to increase. But that, we knew, would not continue indefinitely. We were gaining.

New outbreaks measured new findings at that point in time and therefore reflected the current activity of the smallpox virus, while retired outbreaks indicated containment work that had been completed one to three months earlier—an outbreak had to be free of new cases for a month before it could be removed from the pending list. Thus there would always be a lag in the number of outbreaks removed from the books. In other words, the program was doing better on the ground than the numbers showed.

The searches had become more efficient; the average time from discovery of an outbreak until the last case in that outbreak was going down. Containment was growing more efficient, too. The average time from report of each outbreak to its closing out was also decreasing. Finally, the number of outbreaks removed from the pending list was increasing each week. By this time, no special insight was needed to envision the point at which the contained outbreaks would exceed new outbreaks. Once the pending outbreak list began to decline, it would do so at an accelerating rate. As the outbreak numbers declined, additional experienced troops could be assigned to contain each remaining outbreak, and containment efficiency would improve even more. The natural decline in the transmission rate once the rains arrived in June would assist the rapid clearing of larger and larger geographic areas.

The turning point was not far away. In early April, the number of contained outbreaks in Uttar Pradesh improved significantly, and in the space of a month it increased from approximately 100 per week to an average of over 250 per week. This was absolutely amazing progress. Because there was a four-week waiting period (of no transmission) before an outbreak was removed from the pending list, these numbers reflected program improvements going back to February. When we analyzed the trends, we could predict that the containment capacity in Uttar Pradesh would overtake the discovery of new outbreaks in May.

As for Bihar, the fact that over five hundred outbreaks were removed from the pending list each week in April was incredibly encouraging. In this area of high transmission rates—the virus was claiming over one thousand victims a day—we could project a decisive turnaround within four to six weeks. We knew we were close. The numbers told the story.

 

 

 

 

As the month of May began, a hot month in Bihar even by Indian standards, the number of smallpox outbreaks skyrocketed along with the temperature. The sixth search (April 29–May 4) had revealed 2,622 new outbreaks, the highest one-week total we would see. This brought the pending outbreak total to 4,921. The pending figure would have been even higher except that containment teams were by now so efficient that they were removing over 800 outbreaks per week from the pending list. More important, the number of new outbreaks was only slightly greater than the findings one search earlier, while the containment ability had doubled in two months. For the smallpox worker who knew what to look for, the expected tipping point was thus palpable at the beginning of May.

The fact that a single smallpox outbreak in a European country would be seen as an emergency, with untold resources deployed, provides some insight into the work required to address almost 5,000 outbreaks simultaneously in a single state. Workers in Bihar were stretched to the
absolute limit. The situation had turned a corner on paper, but the physical demands continued. No one had ever experienced a public health operation of this magnitude before. (We did not know it yet, but through May, about 100 new outbreaks would occur per day, producing 1,000 new cases of smallpox per day.) One had to be an optimist with a feel for numbers to be ecstatic at the same time that Bihar had over 5,000 known smallpox outbreaks and had just reported over 11,600 new cases of smallpox in a single week.

Figure 13.
Average number of new and contained out breaks per week, Bihar, India, January to May 1974

I thought back to a conversation the previous fall with D. A. Henderson. WHO/Geneva was programming its computers for the 1974 global smallpox surveillance program, and Henderson asked me to estimate the highest number of cases that we would have in any state of India during any week in 1974. Based on the reports in previous years, I replied: fewer than a thousand cases. Three digits in the column for cases per week per state would be sufficient. WHO, with an abundance of caution, decided to allow for a fourth digit. I saw no harm in adding a digit, so didn't protest. Now we were in the embarrassing position where even four digits was insufficient.

The number of pending outbreaks continued to rise, but we were euphoric because we could now see the breakthrough on the horizon. The gap was quickly narrowing between new outbreaks detected and outbreaks removed from the rolls. The psychological boost, which we were already feeling because of demonstrated success, would fuel even harder work on the part of everyone (
figure 13
).

Then, seemingly out of nowhere, a series of disasters came crashing down around our house of elation. On May 8, the railway workers went on strike. The program would have to hire trucks and drivers to move supplies. But that was not the real problem. India's railway system, a British legacy, was the backbone for transportation of goods and people, with a reputation for running on time. The railway was said to be the biggest housing project in India, with 1 percent of the country's population on trains at any one time. The workforce maintaining this system was enormous and had the largest, most powerful union in the country.

Other workers watched the railway union to see what was possible. The real implications of the railway strike became obvious when half of the vaccinators in Bihar went on strike to protest wages. The other half named a date later in the month when they would join their colleagues. The district medical officers followed suit, announcing a date in early June when they too would leave work. These decisions were made before the smallpox leadership team even knew there was a problem.

We quickly sorted through the options. There weren't many. Could we form our own health army by hiring thousands of daily laborers, using experienced workers as supervisors, and run the entire program under the auspices of district magistrates or other nonhealth segments of government? Meetings with district medical officers were not encouraging. Some were willing to help, but there was no way to re-create the size and expertise of the workforce being lost.

In utter frustration, and totally out of character, I lost my temper one day while talking to one district medical officer. I had asked if he would help me find the kinds of people I would need to hire when the strike occurred and develop plans to immediately switch to this alternate system when government workers left their jobs. With a condescending air, he said, “If there is no strike we would be wasting our time to develop an alternative plan. If, on the other hand, there is a strike I would have no interest in an alternative plan.” I slammed my fist down on his desk with such force that books fell and dust rose. “What kind of a man are you, anyway?” I bellowed. The sudden fear in his eyes provided a small
measure of gratification but no support, and I abandoned the effort with extreme frustration.

At least, I told myself, there is some comfort in knowing that things could not get worse. And then, from an entirely unexpected direction, the program was hit with a problem that could not have been anticipated by even the most diligent planners. On May 18, 1974, India detonated its first nuclear device. Reporters from around the world came to India to report on the event. When they ran out of new ways to report the same story, they looked for others. Suddenly, smallpox in Bihar became world news. Few of the dispatches bothered to explain that the program had greatly improved the accuracy of India's smallpox surveillance system or that the largest response the world had ever launched against smallpox was already under way.

In response to this negative publicity, India's legislators began asking very pointed questions about the quality of the health services, and some feared that India had become an international failure in the effort to eradicate smallpox. The international publicity and the attention of parliament now placed pressure on political leaders in the states.

Those supporting the new strategy were clearly on the defensive. The smallpox alliance was convinced that the vast number of cases, especially in Bihar, resulted from three things. First, it was the seasonal high period. Second, the efficiency of surveillance had finally cast a strong spotlight on what might have been happening every year—only no one knew it before. The truth of smallpox in Bihar was at last revealed. Third, there may well have been an unusually high number of cases that year, but there was no way to test this, since no year in the past had ever had such efficient surveillance. Convinced that containment procedures were rapidly gaining on the head start experienced by surveillance, we now wondered if we would get the opportunity to prove that assumption. We longed for the anonymity that had surrounded the smallpox program before the news crews arrived.