House on Fire (28 page)

By November the number of pending outbreaks in India was below one thousand. Success was becoming a tangible possibility if the disease did not get out of control during the upcoming transmission season.

Repeatedly during the campaign (and even after successfully eliminating the disease), smallpox workers received reports claiming that the disease was still present in remote populations or in groups that had been overlooked. Every such report was taken seriously and investigated, and in every instance the report was shown to be inaccurate. Often an outbreak of chicken pox or some other rash disease had been mistaken for smallpox.

Finally, the ultimate search tool was deployed. As the number of cases declined, India began to offer a reward for the reporting of previously unknown cases of smallpox. SIDA funds were used for this innovation. The reward started small, at Rs. 10 (less than US $1.50), but even that amount was large enough to cause immediate problems. When new cases were reported to health workers, the health workers wanted to claim the reward themselves. The problem was solved by providing the reward to both the person who made the report and the health worker who forwarded the report. The health worker could not claim the reward until the informant had been identified.

Initially, people tried moving smallpox patients from an outbreak area to a different village in order to collect the reward, but investigators could quickly determine that the patient was not a member of that community. No reward was paid, and people soon gave up on the idea. As the number of cases declined, the reward was increased incrementally until, at about the time of India's last cases, the reward had been increased to US$1,000.

The reward was advertised, and the general public was quick to recognize the potential bounty. Surveys were conducted to determine the percentage of people who knew about the reward and about where to report a suspected case of smallpox to collect the reward. One survey late in the campaign revealed that more people knew about the smallpox reward than knew the name of the prime minister.

Surveillance reports for the last months of 1974 showed continuing gains. Even in Bihar, the number of new cases fell to 2,758 in October; 1,053 in November; and 527 in December. In terms of outbreaks, the year ended with only 282 pending outbreaks in all of India, and only six states reporting any smallpox cases at all. A total of twenty-four states and territories were now considered smallpox free. The investigation of outbreaks had determined that they could all be traced to human error in searches or containment. We now had an understanding of every chain of transmission in the country, and any surprises were due to the shortcomings of the workers, not a lack of understanding of the strength of the virus.

By late 1974, the smallpox program was looking so strong that it seemed very unlikely that anything could derail it. The May 1975 prediction for interruption of transmission still seemed accurate, so Paula and I began planning for our return to Atlanta in March.

A new intensification of the eradication program started in January 1975, under the code name “Operation Smallpox Zero.” Six points were considered essential:

1. Every new outbreak must be visited not only by a special epidemiologist and PHC, district, and state authorities, but also by a central government or WHO officer.
   
2. The size of a containment team will be increased to at least twenty workers.
   
3. Four watch guards will be assigned to every infected house so that there will be no break in coverage.
   
4. House-to-house searches, in addition to the usual monthly searches, will now be undertaken in a ten-mile radius around outbreaks.
   
5. Laboratory specimens will be taken from one or two patients per outbreak in order to isolate the virus.
   
6. Cross-notification to other PHCs will occur by special messenger to avoid the delay of using the postal service.
   

Clearly, much of this was inefficient and made little practical sense, but like Lawrence Atutu Ochelebe, who beat the snake that entered our house in Africa to an unrecognizable pulp, we practiced overkill with smallpox, showing no mercy. The smallpox virus had met its match.

By the end of January, the number of pending outbreaks in India had declined to 198. A month later that number was 147. The week ending February 22, only 16 new outbreaks were found in the entire country, the lowest level ever recorded. The smallpox team celebrated that record, only to have it eclipsed the following week with only 3 new outbreaks found. Before going to India, I had promised Dave Sencer, in consultation with Paula, that I would be gone from the CDC for one year and would not ask for an extension. It was agonizing to see the year evaporate, but in mid-1974 Dave, knowing what the program meant to both of us, offered to extend my time. We felt bound to the original agreement, though, and so left in March, with mixed feelings. We would not have left if any doubts remained about a speedy end to smallpox in India. On the other hand, we would miss being there for the last case. In the end, we concluded there would be no program benefits to our remaining.

We left India in March, each of us knowing in our own way that we had experienced a highlight of our lives. I had been immersed in helping to solve a problem of great importance, working alongside people of superb abilities and motivations. The hardships were overshadowed by the blessings, and I wondered if I would ever again have the opportunity to work with people of such exceptional character.

Figure 15.
Total outbreaks per week in India, January 1974 to May 1975

The last case was reported in May. And on June 12, 1975, Nicole Grasset was able to send a letter to all smallpox workers in the country to say that smallpox transmission had been broken the previous month.

It seemed almost anticlimactic. A virus that for millennia had spread such despair, inspiring religious ritual and even the worship of a goddess, was suddenly gone from the country. In twenty months, the surveillance/containment approach had proved itself ideally suited for eradicating a virus that had eluded the best efforts of mass vaccination programs for 175 years. It was the right tool for the task.

India was one of the toughest chapters in the global fight against smallpox, but victory over smallpox in India was not the end of the story. As the last cases of smallpox were being subdued in India, Bangladesh workers were in the middle of a nightmare.

Earlier, the program in Bangladesh had been ahead of the program in India, and this information had even been used to encourage Indian workers at state meetings. In October 1974, as India still struggled with almost 1,000 outbreaks, Bangladesh had only 91 outbreaks on the books. But that month, a flood in Bangladesh, the worst in decades, decimated entire villages. People left their homes in search of food, relief, and shelter. The smallpox virus went with them, and by the end of January the outbreak count had increased from 91 to 572. This problem, already of enormous proportions, was then made worse when the government bulldozed urban slums, sending tens of thousands of refugees from urban areas to other parts of the country. The president of Bangladesh declared a national emergency.

The international community responded, not least because as more countries became free of smallpox, the importance of each infected country increased. The CDC provided thirty epidemiologists, and thirty others were sent from twenty other countries. Rewards were advertised, and a massive response to each outbreak was launched. It worked. Cases decreased through the summer. On October 16, 1975, the first vesicles of Asia's final case of smallpox began to form on a two-year-old Bangladeshi girl, Rahima Banu.

Yet globally the fight still wasn't over. As Rahima Banu was recovering, a single country, Ethiopia, remained on the smallpox list. Ethiopia had been off to a slow start. Variola minor, the strain of smallpox in Ethiopia, had a low mortality rate, and therefore smallpox was not regarded as a significant problem. Moreover, government attention had been on the political unrest that would eventually result in the overthrow of the monarchy in 1976. But now, as the last country with smallpox, Ethiopia could no longer ignore the problem. WHO helped arrange for supplies, helicopters, and several dozen foreign advisors. By early
1976, after a herculean effort, the country had become free of smallpox except for an area in the Blue Nile Gorge and in the desert of the south. By August, Ethiopia had eliminated the last cases.

It seemed to be time for the world to celebrate. But Murphy's Law (anything that can go wrong will go wrong) operates no less frequently in public health programs than elsewhere. At the last moment the tenacity of this virus, combined with the movement of people, again intervened. Drought in the south forced some Ethiopians to seek refuge in Somalia. In September 1976, smallpox cases were reported in Mogadishu, Somalia's capital. Six months later, outbreaks were occurring around the country. National and international resources descended on the problem areas. Two dozen WHO epidemiologists and thousands of Somalian health workers carried out the now-familiar surveillance/containment procedures under what some consider the most difficult conditions of a hard decade. Again the strategy worked.

In early October 1977, a couple with two small children, both with smallpox, approached the hospital in Merka, Somalia. They asked Ali Maow Maalin, an employee, for directions to the infectious disease ward. A considerate person, he took them to the ward rather than directing them. Although he had been vaccinated, it was evidently not an effective take. Two weeks later, on October 26, 1977, he developed the last smallpox rash that Africa would ever see. He recovered without transmitting the virus. The global chain of smallpox transmission was finally broken. Smallpox had been eliminated from the world because of a plan. It did not happen by accident.

There was yet a final irony. After ten months of worldwide freedom from smallpox, the country that had provided the vaccine to the world had two final cases. Both were due to a virus that escaped from a laboratory—demonstrating again the challenge of containing this tenacious virus. On August 11, 1978, a woman in Birmingham, England, developed the first symptoms of smallpox and died a month later. Her mother developed symptoms on September 2, 1978, but recovered.
²

In medicine, the medical practitioner is obliged to apply the best knowledge of the times to each patient. In public health, the obligation is to apply the best knowledge to the entire human community. The
purpose of public health is to promote social justice. By 1978, public health achieved its first complete success in social justice, applying the knowledge required for smallpox control to eliminate a disease for current humanity and for all future generations. Humanity will continue to hold its collective breath, hoping for the wisdom that prevents the virus from ever being released again—intentionally or unintentionally.

 

 

 

 

 

 

The smallpox program justified its own existence by the results it produced: lives set free, misery prevented, and resources made available for other activities. The program also offers lessons that are applicable to similar public health projects.
¹

Smallpox eradication did not happen by accident.
Stephen Hawking, in his book
A Brief History of Time,
says the history of science is the gradual realization that things do not happen in an arbitrary fashion. This is a cause-and-effect world, and smallpox disappeared because of a plan, conceived and implemented on purpose, by people. Humanity does not have to live in a world of plagues, disastrous governments, conflict, and uncontrolled health risks. The coordinated action of a group of dedicated people can plan for and bring about a better future. The fact of smallpox eradication remains a constant reminder that we should settle for nothing less.

Seek the truth.
The purpose of surveillance systems is to discover the
truth. Once the truth was known concerning where the smallpox virus was at a given point in time, it was possible to eliminate it. The strategy of mass vaccination is founded on the assumption that it is not possible to know where a virus is. Therefore one must assume that it could be anyplace, and the appropriate response is to protect everyone to achieve herd immunity. That logic works with most infectious diseases, but not with smallpox.

Every earlier review of the smallpox problem in India recommended high vaccination coverage of every segment of the population. Experts from India, from WHO, and from the CDC all concluded that since 80 percent coverage was not being achieved, the goal needed to be increased to 100 percent. That makes no sense. If you can't reach 80 percent, you certainly can't reach 100 percent. The herd immunity concept was promoted yet remained unexamined.

Knowledge is power, and even a little knowledge of the truth goes a long way. Even less-than-perfect surveillance in the early months of the new strategy, October to December 1973, followed by poor containment efforts, was still relatively effective in reducing virus transmission. Once surveillance and containment reached near perfection in May 1974, the result was a rapid decline from extremely high levels of smallpox to zero smallpox in twelve months. This is a feat unprecedented in public health history.