House on Fire (26 page)

The response of the Indian smallpox team in the Ministry of Health was beyond compare. They were diverted daily from the task of smallpox eradication to answer endless inquiries. The minister of health, Karan Singh, was totally supportive. Some of the people in between
were skeptics. Dr. J. B. Shrivastav, India's director-general of health services, was one such person. Though supportive publicly, he would privately say the smallpox effort was ill-conceived and doomed to fail, and he encouraged state ministers of health to abandon the approach. He had enough authority to be a problem.

In an interview with Myron L. Belkind, New Delhi bureau chief for the Associated Press, Shrivastav went public with his gloomy message. WHO workers had earlier told Belkind that despite the setbacks in Bihar, they had “all the necessary weapons: sufficient vaccine, adequate manpower and, most important, support from the Indian Government,” and they were still envisioning an end to smallpox in India in 1975. When Belkind mentioned this optimistic projection during the Shrivastav interview, Shrivastav said that a more realistic goal would be 1979. “I wish it to be so but let us be realistic,” Shrivastav said. “I'm an Indian and I know where I am situated.”
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Shrivastav was of course not alone. Despite the success of the surveillance/containment strategy in other countries, many public health workers still held the view that CDC epidemiologist Henry Gelfand expressed in his May 1969 letter to Don Millar: surveillance/containment should be the primary strategy only “under certain circumstances”; otherwise it might be misinterpreted to “justify fruitless and inefficient epidemic chasing in India and Pakistan.”
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Now here we were “epidemic chasing” in India. If leading smallpox experts didn't think surveillance/containment could work as the primary strategy in India, no wonder there was doubt.

The field-workers, so weary with the heat, long hours, and difficult field conditions, were vulnerable to suggestions that their efforts were futile. Field people and supervisors alike were well aware of the “field paranoia” syndrome. I have been on both sides of that syndrome and know it is real. When things go wrong in the field and you have been working to the maximum, you conclude that the problems must be because headquarters is not providing appropriate support. And, there may be some truth to this claim. At the same time, however, one becomes blind to one's own errors in allocating time or resources. Field paranoia was often apparent at monthly meetings, where workers often
expressed frustration with headquarters and made excuses for disappointing results.

One WHO special epidemiologist, originally from France but working in South America for the Pan American Health Organization, resigned with a sharp rebuke and stormed out of the country, saying his life was too valuable to waste on a strategy that couldn't work in Bihar, where he was assigned. Unaware of the expectation of a turning point in May or June, he wrote a long report in June stating that the current approach was failing and that his proposal for mass vaccination of the district, supported by many of the best smallpox experts in the world, had been rejected.
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In the midst of all of these problems, a great boost was given to the program in Bihar. Larry Brilliant was able to convince the heads of a giant corporation, Tata Industries, that the area around their plant in southern Bihar was one of the great problem areas of the state. Tata agreed to take on a large geographic sector, provide the medical and managerial staff, and work under the guidelines of the government's surveillance/containment program. Tata put some of its best staff on the project and stopped smallpox transmission in the area; by doing so, Tata freed up program personnel to be assigned elsewhere.

This amazing coalition of public and private sectors was a harbinger of the pharmaceutical philanthropy that would become commonplace a quarter century later. Merck contributed hundreds of millions of treatments of Mectizan for the control of onchocerciasis (a disease leading to blindness, the so-called river blindness) in Africa. Merck and GlaxoSmithKline contributed Mectizan and Albendazole to a global program for the control of lymphatic filariasis (a disease leading to swelling of legs and scrotum, also called elephantiasis). Pfizer provided Zithromax, an antibiotic, for the treatment of trachoma, a disease leading to blindness. Dupont enlisted one of its companies, Precision Fabrics, to provide filter cloth to strain drinking water for the prevention of guinea worm. GlaxoSmithKline and the Gates Foundation joined forces to develop a malaria vaccine. Merck and the Gates Foundation developed a demonstration program to show how twenty-first-century science could work in AIDS control in Botswana, reducing the HIV positivity rate of newborns from 35% to 3.5% in less than a decade.

The real price of the rising skepticism about the strategy didn't become obvious until Bihar's minister of health decided to halt the seven-month-old strategy in his state. Suddenly and unexpectedly, he simply withdrew his support. He had been supportive, but he was under intense political pressure from legislators and other political actors who had fallen prey to the power of the forces aligning themselves against the surveillance/containment strategy. The most politically expedient response was to return to the security of what India had done for over 170 years. Whether effective or not, the known was preferred over the unknown.

At first I thought he might be just testing us, but then it became clear he was serious. The weeks and months of hard work, the endless logistics and meetings, the hundreds of training programs and thousands of workers trained, the analysis and scheming, the constant jarring in a jeep, the sweaty nights under a mosquito net—they were about to become wasted effort. Did he have any idea that he was threatening to put the entire India program, indeed the entire global program, in jeopardy?

We would have to return to the basics and figure out a way to provide both the mass campaign required by the politicians and the things we knew would actually work. But I could not see at that moment a way to do that, certainly not with the resources available.

It wasn't the science that threatened to stop us. It wasn't even nature, per se. Rather, it was human nature: the human factors that involve strikes, job security, political concerns, turf. I remembered those words from graduate school: “When you tangle with culture, culture always wins.” As hard as the daily work had been, this was the only time I was discouraged and uncertain about the outcome. I thought we had lost the battle.

Bihar's monthly smallpox meeting was scheduled for Monday, May 27, and the minister planned to announce his decision at the meeting. M. I. D. Sharma, Mahendra Dutta, and I met with the minister several times in his office and even at his home over the weekend. Over the months we
had met with him often to brief him on progress, ask him to speak to the field-workers, and report the results of monthly meetings. But the meetings held that weekend reached an intensity not experienced in the past. Sharma and Dutta had the advantage of knowing the system, knowing how hard to press and when to back off. We begged the minister to give us another month to prove our strategy. A firm commitment to a date might well have swayed him, but we didn't have a precise date.

We pointed out that the strategy of mass vaccination had been unsuccessful in India for the better part of two centuries. He had tried the new strategy for a scant seven months. We were asking not for an extended period of time, but only for one more month. He in turn said that he understood our concerns but that the pressure was coming from everywhere, including his superiors in New Delhi, to revert to mass vaccination. We were unable to provide him with a single example in his entire state where a district was showing a decline in pending outbreaks. That is the point that separated us. We could see the inevitability of eradication as containment improved and new outbreaks increased but at a decreasing rate. The political pressure he was receiving required a decrease in the pending smallpox outbreaks in a few districts, not simply a promise that this would happen soon.

He kept returning to a single, worn argument: he had allowed us to pursue this new course, unproved in India, for seven months. During that time, no mass vaccinations had been done, and a backlog of unvaccinated children had been building. That backlog must now be addressed. He had no recourse now but to attend our monthly meeting on Monday and tell the assembled staff of his decision.

With a profound sense of resignation, Sharma, Dutta, and I entered the meeting room on that hot, sticky Monday morning for the monthly routine. After seven months of intensive activities in Bihar, the staff in the field had increased, and eighty or ninety people crowded the room. Ceiling fans provided some air movement, but when the room temperature exceeds
body temperature, even air movement doesn't yield much comfort. But these were field-workers, accustomed to hardship, and I watched with appreciation and some awe as they pressed on despite the heat.

I sat at the front table with Sharma, Dutta, and Achari (director of the smallpox eradication program for the state of Bihar), gazing at this roomful of very weary faces. The meeting opened with the usual greetings, followed by reviews of the world smallpox situation and the situation in the rest of India, a description of the programs in key states, and a summary of new and potentially useful ideas that had come out of other state meetings. Finally, we got to the review of the smallpox situation in Bihar, including the pressures that were on the minister of health to change the strategy. We shared the fact that the minister was preparing to ask us to change the strategy and return to mass vaccination. We also shared our discouragement in being unable to change his mind.

The minister suddenly appeared, flanked by an entourage, and strode to the front table. He was given the floor immediately, and he described the problem as he saw it. Bihar was now faced with fifty-seven hundred pending outbreaks involving every district of the state. He acknowledged that hundreds of outbreaks a week were being retired and that the heroic efforts of the workers had no precedent in public health history. But: the number of new outbreaks found each week was even higher, so the number of pending outbreaks continued to increase. It was clear to him that we were losing the battle. He saw no alternative but to revert to mass vaccination, and to do it quickly, before the backlog of unvaccinated children increased even more. At meeting's end, he declared, we would return to the strategy of mass vaccination in Bihar. We all knew this was coming, yet hearing the words actually uttered was shocking. Their impact began to sink in, and the room became very quiet.

One of the field-workers, a young Indian physician, raised his hand. He looked too young even to be a medical school graduate, and he was very thin, the epitome of a dedicated field-worker. He did not appear to have the needed gravitas for the moment, and I worried that a mistake was in the making. But the physician stood and, with great deference, addressed the minister. He was shaking as he described himself as just a poor village man. But, he said, when he was growing up, there were
things you could depend on. For example, if a house is on fire in a village, no one wastes time putting water on the other houses, just in case the fire spreads. That is the mass vaccination strategy. Instead, as in the surveillance/containment strategy, they rush to pour water where it will do the most good—on the burning house.

Despite the heat of the day, a chill went up my spine as this man condensed all the work, discussions, discoveries, and massive human effort of the previous seven months into a few words and the indelible image of a house on fire.

The minister hesitated and stared at the group for some time. And then the unimaginable happened. He changed his mind on the spot. This man of public authority, who over the weekend had resisted the combined persuasive powers of Drs. Sharma, Dutta, and myself, this man who had entered the meeting room thirty minutes earlier with such presence and purpose, now seemed subdued, almost bewildered. He pointed out the great personal and political risk of his changing his mind. But he said, in a small voice, “I'll give you one more month.”

Soon after, other things began to go right. The railway strike was settled that same day, and the other groups withdrew their strikes and strike threats. The monsoons arrived, and with them, a decrease in the transmission potential of smallpox.

The search conducted during the first week of June finally brought good news and the information we needed to influence politicians. The number of outbreaks decreased by over a third from a month earlier (2,622 to 1,678), the number of pending outbreaks did not increase (remaining at slightly more than 4,000), and even the intensity of cases per outbreak seemed to be declining as the number of cases found dropped from over 14,000 in the April/May search to about 7,500 in the June search. The change was sufficiently dramatic that we had no problem convincing the politicians—including Bihar's minister of health.

Anyone who has lived in India or Africa through the dry season knows the incredible surge of emotions and energy that accompanies the first rain. People dance in the villages and celebrate. This was the feeling of the smallpox workers when the smallpox problem in Bihar finally began to decline in June 1974.

 

 

 

 

The arrival of a new vision just when people think they have worked to the maximum gives them new energy, allowing them to push beyond their previous limit. In early August 1974, the smallpox leadership team sent out to the field-workers in Bihar a graph showing the decrease in outbreaks reported in June. The same graph was distributed to all smallpox workers in India on August 26 as part of the seventh SEARO surveillance report. The whole team could see that their work had now paid off: we were on the downhill slope.