House on Fire (17 page)

In fact, India was on the threshold of discovering the truth about just how pervasive smallpox was, which was the first step in loosening the virus's historic grip on the country. A new surveillance approach would provide that truth.

 

 

 

 

By the end of the summer of 1973, my family and I had settled into a new life in New Delhi. Everything was an adventure at first—money, school, shopping, the making of friends, and we adjusted once more to the heat and humidity of the tropics. I began work with the WHO smallpox team headed by Dr. Nicole Grasset at the SEARO office, which was in charge of the smallpox program for all of South and Southeast Asia. There was never any question, however, that our main focus was on India. We worked closely with health officials in the Central Government's Ministry of Health in New Delhi. As decisions were made, various people from both offices moved in and out of what became an informal leadership team for India's smallpox eradication effort.

India had been rapidly moving toward using the surveillance/containment strategy in its smallpox program, and SEARO's assignment was to help the country implement this method nationally and especially in the endemic states. As the program unfolded, the populous
state of Uttar Pradesh, directly east of New Delhi, and its neighboring state to the southeast, Bihar, emerged as having the most challenging smallpox conditions. Dr. Grasset asked me to concentrate my efforts on those states while advising on the programs elsewhere in the country. The other two smallpox-endemic states were Madhya Pradesh and West Bengal. Containing the virus in these states would go far toward eradicating it in the country as a whole.

Map 2.
Northern India

By October, the smallpox leadership team had organized the first searches in Uttar Pradesh, Bihar, and West Bengal. That matter-of-fact statement disguises an incredible amount of work accomplished by a huge army of
people. From the beginning, extremes dominated the work in India. First was the heat, which for much of the year was stifling, a fact of life that had to be ignored to be endured. A second factor was the size of the population, which was well beyond the experience of any U.S. public health worker. In 1973, Uttar Pradesh had 88 million people in fifty-four districts; Bihar had 56 million in seventeen districts (later thirty-one, as the state reorganized during the campaign). A third was the population density. While related of course to population numbers, the crowding factor presented challenges of its own. The areas of highest smallpox transmission in India were also the areas of highest population density. In many districts, the goal of 80 percent vaccination coverage through mass vaccination risked leaving more people susceptible to smallpox in every square mile than would be found in the United States if no one was vaccinated.
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What exactly was a search? The specifics varied by state and time, but searches were usually conducted monthly in the endemic states. For the six days of the typical search, a vast team comprising every health worker available (except those designated for the containment work that would follow) was mobilized to help find cases of smallpox. At the end of the six days, the daily hires were released, people working in other programs such as malaria and family planning went back to their regular responsibilities, and most of the other smallpox searchers were deployed to augment the containment teams.

A state meeting was scheduled to take place about two weeks after the search. This allowed enough time to assemble and digest the reports and prepare for the meeting, where refinements would be made for the next search, scheduled for one or two weeks later. The ministry and WHO staff worked quickly to develop guidelines as well as the forms required to implement those guidelines. A high level of trust and efficiency soon developed among the individuals involved.

Planning a search required developing a search protocol to be followed in an entire state, including estimates of personnel requirements at each level. Health officers could then arrange to borrow as many workers as possible from other programs and hire day laborers to make up the difference. We also developed model operational guides for both smallpox-endemic states and non-endemic areas.

Training courses were required at every organizational level. A training session was held in New Delhi for the health officers who would be overseeing smallpox operations in each state. This was followed by training sessions in each state for representatives of all the districts in the state. These district officers would then hold training sessions for each public health center (PHC, or block) in their district.

Each district had, on average, twenty such health centers with about one hundred thousand people in the catchment area for each center. For Uttar Pradesh and Bihar combined, there were 1,462 PHCs serving about 145 million people. Therefore, each district needed to train hundreds of people, and all of them needed to follow a similar protocol, keep records, report findings through a chain of command, and then assist in directing the containment workers as they were sent to control the outbreaks reported. The task of maintaining quality control throughout this hierarchy, and especially from the district training sessions to the almost 1,500 PHC training sessions, was overwhelming. Supervision followed the same pattern as the training—the district medical officers supervised quality in the PHCs, the state health officers supervised and evaluated the districts, and central government smallpox officers supervised the states. In the state of Uttar Pradesh alone, preparations for the first search required over 60 training sessions simply to get down to the district level, and an additional 930 training sessions at the district and PHC levels. I would sometimes think: this is a lot like the logistics of war.

The search teams were initially instructed to approach village leaders, mail carriers, schoolteachers, and students and to question people at tea shops or markets. In addition, they were to select two houses at random in the east, west, and central parts of the village to question the inhabitants. Each searcher had “recognition cards,” small cards with the picture of a child with smallpox, to show potential informants. The look of disease is so distinctive that people knew immediately if they had encountered it recently.

Plans for containment efforts ran right alongside the preparations for the massive search effort. Containment teams were taught, forms developed, operating procedures agreed upon. There was, of course, no way of knowing how much smallpox the search teams would find.
We based our containment plans on the current numbers of smallpox cases—and doubled it. According to the plan, containment teams in the PHCs would be the primary responders. District teams were ready to respond in case some PHCs had more outbreaks than their own containment teams could visit. State teams would assist where a district had more outbreaks than it could handle. We anticipated that containment teams would respond by vaccinating all susceptible members in households with smallpox as well as people in the twenty to thirty nearest households; this was included in the operational guide. A single-page instruction sheet was developed on vaccination techniques, use of the bifurcated needle, the preferred site of vaccination, and the sterilization of bifurcated needles after use (see
figure 16
).

Figure 10.
A search team member in India seeks information on smallpox using a recognition card

In theory, since most smallpox transmission probably occurred within the home or in other intimate settings, vaccinating the susceptible people in households with smallpox cases would significantly reduce the probability of transmission.
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The next most efficient vaccination activities would include other households in the neighborhood, family members in other neighborhoods, and other villagers who might have visited the sick person. Children who attended school during their first days of symptoms might also have transmitted the virus to others at school.

In general, different people were assigned to search operations and to containment operations. Asking the search workers who found smallpox to immediately begin containment operations might seem more efficient. It would avoid a delay in responding to an outbreak and avoid an extra trip to the village for the workers. However, experience in Africa had shown that this strategy was actually less efficient because there was a decided tendency to underreport cases if positive reports meant more work for the searcher.

Preparations required thousands of instruction sheets, training exercises, and reporting forms to be printed and distributed to thousands of searchers. But there was more. Although English is one of India's two national languages (the other is Hindi), not everyone reads or speaks English. So each form had to be translated into one or more of India's many regional languages. The training of supervisors and evaluators required additional forms and instruction sheets. This seemingly endless cycle of writing, translating, printing, training, and traveling might have seemed boring, but everyone involved was invigorated with the prospect of trying a new strategy under Indian conditions, despite the tremendous amount of work involved and the considerable risks.

The Central Government, states, districts, and PHCs were all agreeing to disengage health workers from other important activities for six days a month. They were also agreeing to a dramatic change in the way India approached smallpox. There was no guarantee that a strategy that had worked in Africa could work in an area with such high population densities. The variety of cultural differences in India, and the patterns of travel, with many people on trains and roads at any one time, also posed challenges. Not the smallest of the risks was the insertion of foreigners
into village situations. Foreign workers were regarded with suspicion, and the smallpox team worried constantly that some kind of misunderstanding might embarrass or even jeopardize the entire operation.

Looking through the records from those times decades later, I am struck by how often I was optimistic while simultaneously having no idea what I was talking about. For example, because the first three searches were scheduled during the low-transmission months, I had written in the operational guide, “During October and November, the number of outbreaks will probably be small”—words that would come to haunt me. Just as naïve were the guideline words suggesting that every outbreak should be immediately reported by messenger without waiting until the end of the six-day search period. It would have been impossible, even in India, to enlist the thousands of messengers required to fulfill that mandate.

All of the planning culminated in an army of thousands of workers in Uttar Pradesh and Bihar fanning out for a reality test. The first search for Uttar Pradesh and Bihar was scheduled for October 15–20, 1973. Other states chose other start dates depending on local events. The prime minister, Indira Gandhi, put out a proclamation urging people to support the effort. The minister of health for Bihar opened the organizing meeting for the first search with words that evoked the image of a general sending troops into battle:

We are meeting today to launch the final phase of smallpox eradication in Bihar State. The world is now depending on our success in this venture and I request your best efforts to see that we do not fail. . . .

Chief emphasis during the next three months will be placed on two activities. The first activity is to find all cases of smallpox. . . . The second activity involves control of each outbreak with the help of health staff at block and district levels and by special State teams and WHO teams. Since this strategy has worked well in 27 countries over the past 6 years I fully endorse applying the strategy in Bihar State and
propose the highest priority be directed towards smallpox until it has disappeared.

I must caution you that the key ingredient of the campaign will not be words or money or vaccine but will instead be the dedication with which each of you approaches this historical campaign.