House on Fire (24 page)

Correcting this problem required an additional step. Before beginning vaccinations around an outbreak, the team took a census of surrounding households by asking an informant to list all the members of every household. In the evening, vaccinators or watch guards would concentrate on finding persons listed on the census form who had not yet been vaccinated. Explaining the rationale for vaccinations and enlisting the support of the infected village took a lot of time and effort.
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In fact, it was rare for anyone to refuse to be vaccinated. R. N. Basu writes, “In reality, resistance to vaccination in India remained a limited phenomenon without substantial influence on the program. . . . Generally speaking, less than 3% of the people . . . might be expected to refuse vaccination during a containment operation.”
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When someone did refuse, the risk was to the person not vaccinated, with little potential impact on eradication. If that person developed smallpox, he or she would be surrounded by vaccinated people and would be unlikely to easily transmit the virus.

The value of knowing the truth applied not only to the incidence of smallpox but also to the eradication program itself. In training programs, in field visits, at monthly meetings, and in sessions with health leaders, this motto was emphasized: “You get what you inspect, not what you expect.” Central and state program officers put this wisdom into practice by visiting district and PHC headquarters. Containment, as well as surveillance, improved when it was supervised and evaluated. Through
the first half of 1974, it became increasingly common to enter a district health office and see maps and charts on the wall regarding the smallpox situation. By May, this practice was also common at PHCs.

As the year began, smallpox leaders had an array of informal ways to measure the quality of the program; these methods provided the building blocks for an increasingly formalized evaluation system. PHCs could compare how many villages a worker said he or she had searched with what the supervisors later found. Supervisors could see the wall markings left by searchers. The number of chicken pox cases the searchers reported, too, was indirect evidence of their efficiency in reporting smallpox. The number of new cases the containment teams found indicated the efficiency or inefficiency of a search, as did the amount of time between the onset of an outbreak's first case and the reporting of that outbreak. From the beginning, field experience provided data that were used to update the informal evaluation practices that were in place.

By the time smallpox peaked in April and May 1974, the program was able to send out evaluation teams. Building on the informal evaluation methods already in place, the teams used a marking system whereby containment teams were asked to make a mark on the door of each house they visited. The mark used was changed each month. An evaluation team later recorded the number of houses visited, and in a sample of houses, questioned the residents about what the searchers had asked as part of the search.

Throughout early 1974, evaluation was becoming more systematized, and by April, it was feasible to formalize the evaluation criteria. The key indicator chosen for evaluating the efficiency of surveillance was the time from the onset of the first case in an outbreak until the outbreak was reported. Typically, the first report of an outbreak was actually the second generation of cases. The first, or index, case was often a solitary case that the family was able to keep hidden. Since the second generation of cases appeared approximately fourteen days after the index case, and allowing for the time required to submit reports, we chose twenty-one days as the expected time from the onset of the index case to the report. The percentage of outbreaks reported within twenty-one days was therefore the key indicator of good surveillance in a district. The
key indicator for adequate investigation efforts was set at 90 percent of outbreaks traced to a known outbreak. The measure determined for adequate containment was no new cases more than twenty-one days after discovery of the outbreak. These few indicators or “vital signs” made it possible to quickly spot deficiencies in searching, investigating, and containing outbreaks; such weaknesses could be related to particular PHCs, districts, or even individuals.

The WHO/New Delhi staff presented the evaluation plan to a visiting representative from WHO/Geneva. While WHO/Geneva was unfailing in its support of India's program and could be counted on to provide personnel, resources, vaccine, and political assistance, its resources were stretched so thin that it could not fund the proposed evaluation program. The Geneva representative left New Delhi the night of this decision. The next day, as a demoralized WHO/New Delhi group reviewed the program, they decided that the effort was so important that they would seek funds from elsewhere. The evaluation program was instituted and became an indispensable management tool and the driver for quality improvement during the last phase of the campaign.

Each new refinement in search and containment methods required training, new procedures for reporting, and new forms, which had to be distributed on an ongoing basis to thousands of PHCs and districts. India's vast bureaucracy, often maligned, was ideally suited for an operation of this scale. Indeed, once the power of the Indian bureaucracy was harnessed, there was no stopping the innovation and energy of the thousands who took on the challenge of defeating smallpox. Recordkeeping forms may seem like humble soldiers in such an effort, but the form itself became the driver that led to the actions needed to achieve the desired outcomes. Creating effective forms requires you to picture the desired results, how to achieve those results, and how to report on them. Forms proliferated, and in a very real sense we can say, in retrospect, that smallpox was suffocated by a mountain of paper.

The following is a partial list of the forms that field-workers had to contend with:

Searching

1. Workers' Schedule for Search Teams
   
2. Workers' Schedule for Urban Areas
   
3. Smallpox Market Search Book
   

Investigation

1. Smallpox Outbreak Investigation and Containment Report (Form C)
   

Containment

1. Smallpox Containment Field Book for Containment Teams
   
2. Smallpox Outbreak Summary Booklet for Containment Teams
   
3. Daily Work Diary for Watch Guards and Vaccinators
   
4. Market Search Form
   

Reporting

1. Urgent Notification of Smallpox Outbreak (postcard)
   
2. Cross-Notification of Smallpox (postcard)
   
3. Cross-Notification Book (outgoing—with four copies plus one retained form)
   
4. Cross-Notification Book (incoming—with copies to be submitted when investigation complete)
   
5. Weekly Epidemic Report Form (PHC to district)
   
6. Hospital Weekly Epidemic Report
   
7. Market Search Summary (PHC)
   
8. Market Search Summary (district)
   
9. Smallpox Weekly Epidemic Report (PHC to district)
   
10. Supervisors' Report Form
    
11. Weekly Checklist for Special Epidemiologists
    
12. Weekly Report Form for Special Epidemiologists
    
13. Weekly District Report of Pending Outbreaks
    

Evaluation

1. Rural Search Assessment Form
   
2. Urban Search Assessment Form
   
3. Verification of Active Search Form
   
4. District Search Summary Form
   
5. State Search Summary Form
   

Protocol and Instruction Forms

1. Search Protocol—Instructions for Searchers
   
2. Case Finding Form for Searchers
   
3. Guidelines for Market Searches
   
4. Search Assessment Protocol
   
5. Model Operational Guide for Endemic States (September–December 1973)
   
6. Operational Guide for Low-Incidence and Smallpox-Free States
   
7. Operational Guide for Endemic States (June–September 1974)
   
8. Guidelines for Eradication of Smallpox in Urban Areas
   
9. Operational Guide for Smallpox Eradication (January–March 1975)
   
10. Operation Smallpox Zero (after February 1975)
    

Record keeping was essential for understanding what was happening, and people filled out forms to the best of their ability—a legacy, no doubt, of the British system in India. Workers at all levels were encouraged to provide feedback. The information on the forms was incredibly useful in guiding the program. At the monthly meetings, field-workers would hear that information handed back to them in the form of refinements to the strategy.

During these first months of 1974, I traveled often. When not on trains to and from state meetings, I traveled by car or jeep to make field visits. Sometimes these trips went without a hitch, and sometimes the unexpected occurred. At the beginning of April 1974, I took our middle son, Michael, then age eight, on a field trip to the northern districts of Bihar. On our return, we crossed the Ganges River, a distance of over a half mile, by loading our jeep onto a small ferry. The ferry was so crowded that Michael and I sat on top of our jeep while our driver managed somehow in the crowd. In the middle of the river there was suddenly a great deal of excitement as the ferry began taking on water and people began to bail water with buckets and pans.

Assuming a calmness I did not feel, I told Michael that if the ferry did sink, we would take off our shoes and slip into the water. I reminded him that he was a good swimmer and that the two of us would easily make it to shore. The ferry made it to the south bank, and I thought the highlight of the day was behind us. It turned out I was wrong.

It happened to be April 8, the day that the famous Gandhian Socialist J. P. Narayan, at age seventy-two, led a silent procession in Patna to protest corruption in government and injustices such as hunger and rising prices—part of the student protest movement known as the Bihar Movement. As we drove toward Patna, we were unaware that because of the protest, the city was under a curfew.

At a stop sign, long before reaching Patna, our jeep was surrounded by students caught up in the protest. They began rocking the jeep back and forth with every indication that they planned to turn it over. Assuming a false bravado for the second time that day, I tried to reassure Michael, telling him this happened all the time, and I rolled down the window to talk to the students. They demanded money, a request that to me seemed totally foreign to the ideals of J. P. Narayan. They stopped rocking the vehicle as I got out to talk to them. I said I had money for them all and began distributing the smallpox recognition cards, telling them how much I would pay for each case of smallpox they identified. I continued talking, urging them to become part of the solution, to go into the villages and urban areas to find cases, to do this for India, and not only for India but for the reward I would give when they brought me cases. They stopped to look at the cards and hear what I was saying. That encouraged me to more forceful exhortations. Then they began to back away, possibly out of embarrassment or fear. As I spoke louder and with more fervor about what India was trying to do to rid the country of smallpox, I realized I had gained control. Gradually they retreated and finally disappeared.

We cautiously resumed our trip into Patna, passing burning trucks and buses tipped on their sides. Few other vehicles were on the road, and absolutely none as we entered Patna. The streets were empty, and an eerie silence filled this usually loud and crowded city. At the Republic Hotel, where I usually stayed while in Patna, a guard recognized our vehicle and opened the gate. The hotel management had taken up carpets and anything that might burn in case Molotov cocktails were thrown through the gate into the hotel entrance. Michael and I, along with our driver, remained there until the curfew was lifted several days later.

It was a politically tense period in India in other ways as well. It was
the era of the Cold War and the Vietnam War, and the Indian government was somewhat suspicious of foreign workers, especially if their work took them into the villages. Indeed, in 1974, the newspapers in India began carrying stories that the malaria research work being conducted with U.S. resources and scientists in India was actually an effort by the CIA to develop biological warfare techniques. Once such stories start, they can become impossible to counter, even when they're groundless. The malaria studies were eventually suspended. About the same time, an American smallpox field-worker who was in New Delhi for a few days reported to me that during his meal at a restaurant the previous evening, a man sat down at his table and told him that the smallpox program would be next to receive that type of publicity. It never happened, but the warning served to keep us anxious.

As the early months of 1974 passed, more special epidemiologists joined the smallpox program until there were approximately one hundred special teams in the field. While they strengthened the regular health resources devoted to smallpox, and their effectiveness was a major factor in motivating the entire team and efficiently using field resources, there was also the constant worry that someone would embarrass or even jeopardize the entire program.

On one occasion, an American special epidemiologist who was working in the field and living in a military guesthouse sent me a commercial telegram. The military had asked him to seek other accommodations, and he was asking that we verify that he was not a CIA agent. It was a strange request but could not be ignored.

We at the WHO regional office would have been dismayed if the CIA had used any of our people and decided that we should be straightforward in asking if it did. I went to a friend at the U.S. Embassy and asked his advice. He asked another person—clearly, the head of CIA activities for the embassy—to join us. This person read the cable with concern and assured me that he knew nothing about this person.

He then asked, “How good is he?” I replied, “He is not that good.” The embassy official said, “There are two hundred people eagerly waiting to read your reply. If you send him home, it will be interpreted as confirmation that he is a spy. He just bought himself some additional time with
your program!” I sent the epidemiologist a bland reply discussing work and suggesting that he might want to move to a rest house.