House on Fire (31 page)

30
. Shortly after obtaining the patent, Wyeth waived royalties on any bifurcated needles produced under WHO auspices. This act of corporate philanthropy in global health (later known as pharmacophilanthropy) was a defining moment for the smallpox eradication effort. Pharmaceutical companies would later increase their contributions to global health dramatically. Merck, for example, provided hundreds of millions of treatments of Mectizan to prevent river blindness, and GlaxoSmithKline provided Albendazole for the global lymphatic filiarises program. Merck teamed up with the Gates Foundation to bring twentyfirstcentury science to Botswana, demonstrating the ability to rapidly treat HIV infections and to reduce HIV positivity in newborns by over 90 percent. Unfortunately, the public has been inadequately versed about pharmaceutical companies' recent attempts to assist in the improvement of global health. Wyeth provided early leadership.

31
. S. Bhattacharya,
Expunging Variola—The Control and Eradication of Smallpox in India, 1947–1977
(New Delhi: Orient Longman, 2006), 147.

32
. Ibid.

SEVEN. UNWARRANTED OPTIMISM

1
. This fact was poorly understood in the debates surrounding the attempt to vaccinate U.S. citizens in 2002. Public health officials and others who had not participated in the smallpox eradication program insisted that surveillance and containment procedures could not work in the United States. Immunity levels, they argued, were extremely low on account of the cessation of routine smallpox vaccinations in the early 1970s. Given the realities of population density, however, surveillance and containment would have been less difficult in the United States than in most of the situations encountered in Bihar in 1974 because of fewer susceptible people per square mile.

2
. Henry Gelfand once theorized that the sex trade probably created the ultimate transmission problem with smallpox, since prostitutes could still work early in their illness, before they realized they were sick. Indeed, some outbreak investigations supported his theory.

3
. Minister of health's speech from author's personal files.

EIGHT. A GORGEOUS COALITION

1
. Larry Brilliant and his wife, Girija, went on to have stellar careers in public health and the business world. They were key to developing the Seva Foundation, which focused on remediating blindness in the subcontinent. Larry later wrote a book,
The Management of Smallpox Eradication in India
(Ann Arbor: University of Michigan Press, 1985). His work culminated in his leadership of the Google philanthropy effort.

2
. A. R. Rao,
Smallpox
(Bombay: Kothari Book Depot, 1972).

3
. Personal communication, Don Francis, January 16, 2009.

4
. S. Bhattacharya,
Expunging Variola: The Control and Eradication of Smallpox in India, 1947–1977
(New Delhi: Orient Longman, 2006).

5
. The CDC West and Central Africa program attempted to augment the archives by securing oral histories from the participants who returned for the forty-year reunion of smallpox warriors in 2006, held in Atlanta. This effort was so productive that oral histories were also obtained from people working in Asia who met in Atlanta in 2008, and an archive has been established at Emory University. For more details, see
http://globalhealthchronicles.org/smallpox
.

NINE. RISING NUMBERS, REFINING STRATEGY

1
. Coercion was never program policy. A 1995 article by Paul Greenough gives the erroneous impression that coercion was required for containment to work in the final elimination of smallpox. He recounts four instances in which two American epidemiologists used coercion plus a fifth instance in which an Indian government vaccinator used force to hold and vaccinate people. Green ough also quotes from the journal of an American smallpox worker who attempted unsuccessfully to persuade a woman to be vaccinated. The worker was ejected from the home by the woman's husband. The cases cited are no doubt true, but they would have been aberrations, perhaps the result of the kind of frustration that anyone who has worked in the field can understand. Cultural sensitivity was emphasized in the training of smallpox workers in India and in the field was the norm rather than the exception. Certainly force was not needed for eradication. Greenough interpreted this aberration to be the norm. See P. Greenough, “Intimidation, Coercion and Resistance in the Final Stages of the South Asian Smallpox Eradication Campaign, 1973–75,”
Social Science and Medicine
41, no. 5 (1995): 633–45.

2
. R. N. Basu, Z. Jezek, and N. A. Ward,
The Eradication of Smallpox from India
(Geneva: World Health Organization, 1979).

TEN. WATER ON A BURNING HOUSE

1
. Myron L. Belkind,
Smallpox
(New Delhi: Associated Press, 1974).

2
. Letter from H. Gelfand to J. D. Millar, dated May 2, 1969. Author's personal files.

3
. Report in author's personal files.

ELEVEN. SMALLPOX ZERO

1
. Mahendra Dutta, personal communication, August 2, 2009.

2
. F. Fenner, D. A Henderson, I. Arita, and Z. Jezek,
Smallpox and Its Eradication
(Geneva: World Health Organization, 1988), 1097.

CONCLUSION

1
. This conclusion is based on a talk I gave in 2009 at the commemoration of thirty years of global freedom from smallpox held at the WHO regional headquarters in New Delhi.

2
. From one standpoint, physicians are actually managers, taught to analyze a health problem in an individual, determine the objective for that person, plan a strategy to achieve the objective, monitor indicators to evaluate whether the management strategy is working, and make midcourse corrections to modify the strategy. However, physicians often miss this point and fail to apply their managerial skills beyond clinical medicine.

 

 

 

 

 

CDC
Centers for Disease Control and Prevention in Atlanta, Georgia. Known in earlier years as the Communicable Disease Center, the Center for Disease Control, and the Centers for Disease Control.

containment
The response to finding a smallpox case or outbreak. The term initially referred to containing the smallpox virus so that it could not spread to others, but its meaning evolved to include a wide range of activities involving a local census, vaccination of potential contacts, watch guards at the houses of smallpox cases, etc.

EIS
Epidemic Intelligence Service, a program at CDC that recruits people for two-year terms to study and respond to disease threats of all kinds. EIS officers figured heavily in smallpox eradication.

epidemiology
The study of patterns of health, illness, and associated factors in the population as a whole.

fetisheurs
Local medicine men in West Africa who treated individuals with smallpox. They represented a mixture of medical and religious beliefs and had learned how to propagate smallpox by collecting scabs from smallpox patients and inducing new outbreaks when they desired new patients.

herd immunity
High immunity levels to a disease in a population, making it difficult or impossible for the disease agent to spread.

Indian government
The responsibility for smallpox eradication involved the Central Ministry of Health in Delhi, state governments, districts (sub divisions of states), and blocks (subdivisions of districts). Blocks were inhabited by approximately one hundred thousand people. In general, Primary Health Centers coincided with blocks, and so provided health services for one hundred thousand people.

mass vaccination
The systematic vaccination of all segments of the population in an attempt to develop herd immunity.

Nigerian government
In 1966 the responsibility for smallpox eradication involved the National Ministry of Health in Lagos and four regions: the Northern Region, the Western Region, the Midwest Region, and the Eastern Region. The regions were subdivided into provinces. Later, Nigeria was subdivided into states.

searches
The activities involved in finding cases of smallpox. Primary searches involved going through villages and urban areas looking for cases. Secondary searches were conducted at markets or festivals in an effort to obtain information on smallpox in the areas from which people had come. Tertiary searches focused on areas or populations deemed to have a high risk for smallpox cases, such as beggar communities, kiln worker communities, mobile roadway workers, etc.

SEARO
Southeast Asia Regional Office, a WHO regional office responsible for India, Bangladesh, and other countries.

smallpox outbreaks
From one to hundreds of cases in a geographic area, such as a village or a neighborhood in an urban area.
New outbreak
means an outbreak newly detected by searches or through the passive surveillance system, which would then be targeted for containment activities.
Deleted outbreak
refers to an outbreak that had now gone the requisite time without a new case of smallpox, usually four to six weeks.
Pending outbreaks
refers to all outbreaks still receiving containment attention. This category included new and active outbreaks; these remained pending until a period of no new cases had passed.

special epidemiologists
Workers from elsewhere in India or other countries who focused on problem districts to provide supervision for search and containment activities.

surveillance
The systematic monitoring of all information related to a disease, in this case smallpox. This term was often used in the restricted sense of attempting to find all cases of smallpox.

take
A successful vaccination as evidenced by the appearance of a sore, crater, or blister at the site of a vaccination several days after the vaccination.

vaccination
The act of transferring cowpox or vaccinia virus in order to induce immunity to smallpox. (Louis Pasteur later suggested that in order to honor Edward Jenner, all immunizations could be called “vaccinations” and all immunizing agents could be called “vaccines.”)

vaccine
A preparation that improves immunity to a particular disease. The term
vaccine
comes from the term for cowpox (
vaccinae
). When cowpox was administered to humans, it provided protection from smallpox.

vaccinology
The field of study dealing with vaccines.

variolation
Also called
inoculation, variolation
refers to transferring smallpox virus itself from a patient with smallpox to a scratch or abrasion on a healthy person to induce immunity to smallpox. This would actually give the recipient a case of smallpox that was usually milder than if the virus had been acquired through the usual respiratory route. This practice predates vaccination by hundreds if not thousands of years. The danger was that the virus could then spread to others, causing outbreaks of smallpox.

virus
A small infectious agent unable to replicate unless it is inside the living cells of another organism. (Smallpox is spread by a virus.)

watch guards
Workers hired to stay at the homes of smallpox patients to vaccinate every person who came to visit.

WHO
World Health Organization in Geneva, Switzerland. Policy is developed through annual World Health Assembly (WHA) meetings, attended by the ministers of health of all member countries.

 

 

 

 

 

Abakaliki, Nigeria,
58–59

Accra, Ghana,
69–70
,
84

Achari (Bihar program director),
171
,
180

Ademola, Yemi,
27

Afghanistan,
83

Africa: Eradication Escalation effort in,
72–75
,
85
; mortality rates in,
7
; smallpox transmission in,
38–39
; surveillance and containment strategy in,
11
; WHO eradication program in,
46–53
.
See also
Nigeria

Akbar (Indian ruler),
88

American Management Association,
192

Anderson, James,
93

Andhra Pradesh (Indian state),
124

Anezanwu, A.,
60–61
,
67

Arora, R. R.,
127

Assam (Indian state),
175
,
176

assessment.
See
program evaluation

Atharva Veda
(Hindo scripture),
89

attack phase,
98

Atutu Ochelebe, Lawrence,
35
,
44
,
183

Bangladesh,
11
,
185

Banu, Rahima,
185

Basu, R. N.,
97
,
127
,
153

belief in global eradication,
11
,
26–27
; program in Africa and,
47
,
52–53
; program in India and,
83–86
,
161
,
167–168
.
See also
eradication of smallpox
;
surveillance and containment approach

Belkind, Myron L.,
167

Bhattacharya, S.,
143

bifurcated needle,
101–102
,
109
,
197
,
205n30

Bihar (Indian state),
93
,
177
; decision by

Minister of Health in,
169–172
; new outbreaks compared (1974 and 1975),
176–177
; political matters in,
157–161
; surveillance and containment approach in,
106
,
111
–
112
,
115
,
119
,
140
,
147–148
; turning point in,
161–162
,
163–164
,
172
,
173