House on Fire (20 page)

Dutta was the epitome of deliberateness and common sense in both speech and action, and was totally unafraid of fieldwork and all of its discomforts. He was given the job of providing central government supervision for the smallpox program in Bihar state. During the intensified smallpox campaign, he traveled almost continuously, attending meetings, making field visits, analyzing data, and solving problems. Early in the program, he discovered that a leader of Bihar's state staff was diverting smallpox resources for his personal use. This man was listing vaccinators who did not actually appear at work. For the use of their names
on the employment rolls, they would receive their pay, despite no work, and split the money with him. Once this issue came to Dutta's attention, he was relentless in seeing to it that the man was replaced, despite the difficulties of removing an entrenched government leader.

Dr. Mahendra Singh was in a class by himself. As deputy assistant director-general of health services (smallpox), he had the longest institutional memory regarding smallpox of anyone in the ministry. He was the sole medical officer in smallpox at the central level from 1966 until 1972, with an impossible job: trying to hold back the relentless tide of smallpox virtually single-handedly. Before the government got serious about smallpox, Singh was working tirelessly to both fight smallpox and convince everyone from the central government level to the field that more resources were needed to do the job. Report after report showed his tenacity in promoting smallpox eradication before others accepted it as possible. For years he continued his uphill battle to tame smallpox; the obstacles were many, but he was never discouraged. He was the gold standard for a dedicated field-worker.

Two of the youngest members of India's central-level smallpox team were Drs. C. K. Rao and R. N. Basu. Rao, from NICD, was assigned to Uttar Pradesh as a central government supervisor because of his solid dependability and competence, and after his smallpox career he continued to be highly productive in the Indian medical service. Basu, who as assistant director-general of health services (smallpox) answered directly to Diesh, traveled widely to inspect field operations and continued to work in India and for WHO for three decades after the last smallpox case, using his experience and expertise for immunizations in general. Dr. R. R. Arora, a top epidemiologist at NICD, became a dependable and tenacious member of the team.

I was fortunate to work alongside some exceptional people in SEARO. Dr. Nicole Grasset's dedication was unsurpassed. The distinction between days, nights, and weekends seemed to be irrelevant to her as she charged
ahead with flair and courage. If Indian government officials at one level did not provide a positive response, she would go to the next higher level, and if that didn't work, she would go to the prime minister. Comfortable in any situation, and as charming as she was beautiful, she could endure the most difficult field conditions and also make sophisticated presentations at a conference or to the minister of health. Outcomes were her measure of a person, and she would give anyone a chance to contribute. She never lost her focus.

Grasset was also tough. During the drive back to our respective homes following an evening meeting with Diesh, I asked why she had been so subdued and seemed to hold back in promoting an idea she was developing. She responded that she was passing a kidney stone and was experiencing renal colic. This involves one of the most severe pains known and regularly incapacitates people, but it didn't stop her. Neither did her dedication to work keep her from appreciating the beauty around her. One time when we were waiting for a meeting to begin, she called my attention to the scene outside the seventh-floor hotel conference room in Lucknow. Outside, a light fog had covered the city, and streetlights shone like jewels through the fog. She said, “That is the way expatriate children see India, as a land of diamonds without the illness and pain and poverty.”

At the conclusion of the smallpox eradication effort, she drove from New Delhi back to Paris, through Pakistan, Afghanistan, and Iran. This was not an uncommon trip for two or more people to make; rarely did a single individual do it alone.

Dr. Zdeno Jezek, a physician originally from Czechoslovakia, was accustomed to working under difficult conditions and had spent some years in Mongolia. While smallpox eradication attracted many type-A personalities, Jezek was the type-A gold standard. He seemed to have a well-thought-out speech always formulated in his head, ready for any occasion. Once when a speaker merely mentioned his name, Jezek jumped to his feet and began a rapid-fire delivery of a speech. Full of enthusiasm for the work at hand, he led others to do things by example. If he was ever discouraged, we did not see it. Even before we finally had smallpox on the run, he continued day after day as if each day would be the turning point.

Dr. Larry Brilliant, an American physician, had come to the Indian subcontinent to find truth, not smallpox. He learned the language, studied the country, and studied himself. When his guru told him it was now time to share his gifts by working to eradicate smallpox, he went to SEARO looking for a job, and Grasset was clever enough to provide one. Brilliant brought to the work a sincere interest in India as well as the desire to make his life count and to use his training to promote health. He could inspire local workers to see that it was not just a job, but a way to do good that would ripple through the coming generations. That is what karma is about.
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It was more than good people that made the program succeed. An alliance formed between the Central Government and WHO that transcended all expectations. The reason for this alliance is complex. It may have formed because we traveled together, spending time with one another on trains and in jeeps, sharing lodgings, meals, and conversation. The rapport that develops through such experiences cannot be replicated by meetings in an office. We shared the moments of discouragement and the moments when things went right. The alliance formed not only because we developed respect for each other, but because we ended up trusting each other.

The shared travel was not a calculated choice. It happened almost by accident. In the beginning of the program, the WHO staff would travel between New Delhi and the state capitals by plane. One day Nicole Grasset and I were sitting at a table in the Patna airport, waiting for the daily flight from Patna to New Delhi. I said, “Nicole, does anything at the next table strike you as odd?” She looked at the two men, obviously pilots, seated at that table and answered, “No.” I responded, “We know there is only one flight to New Delhi. Therefore the pilot and copilot at the next table must be for our flight. And they are drinking beer!”

I resolved to stop flying. It was easier, more dependable, and apparently safer to take overnight trains between New Delhi and either
Lucknow or Patna for monthly meetings. In addition, I could use the time on the train both before and after the meetings to analyze data. As it turned out, the real value was that the Indian smallpox leadership—Drs. Diesh, Sharma, and Dutta—also traveled on these trains, which provided the opportunity to talk in a casual setting. Soon we could predict each others' responses, and we found that we were thinking alike. As the insider-outsider barriers evaporated, an openness developed that helped to buffer both sides from problems within their own administrative structures. These train discussions, sometimes continuing in the sleeping compartments before we drifted off to sleep, helped us to work out the most difficult situations. When the Indian government could not provide an adequate per diem for the necessary field visits of Indian workers in the states, we faced that problem together and found a way for WHO to provide the funds. When all of the WHO resources had to go into surveillance and containment and WHO/Geneva could not provide additional money for evaluation, we were able to develop an approach with the Government of India.

The alliance formed to the point where it was unnecessary to develop guidelines on how we would operate. We reached decisions together. Our allegiance put us in a position of facing the world of problems united, rather than wasting effort in competing with each other. If anything, our competitive impulses were directed to competition with the virus. One of the lessons learned about collaboration is that the best ones begin with a clear vision of the last mile, rather than developing around a common interest and then laboring to define desired outcomes and identify a strategy. Smallpox eradication in India exemplified this. It also demonstrated a second important law for successful collaborations: the need to suppress egos and seek satisfaction in a shared outcome rather than holding individual power or protecting turf.

One distinction between the majority of collaborations and the ones that turn out to be especially productive is that the effective groups literally form a new substance. In chemistry, a mixture retains all the characteristics of the ingredients. A compound, on the other hand, forms a new substance with new characteristics, for example, when oxygen and hydrogen become water. The best alliances cannot be described simply
by identifying the members. The sum is something different; it is a new compound. The objective becomes a shared objective that supersedes competition for turf. The talents coalesce into something more powerful than simply the addition of talents.

At times the ministry's knowledge of its own country saved us from error. I argued early on for a reward system to help us find new cases of smallpox—an approach that had worked exceedingly well during the final phases of eradication in West and Central Africa. I thought we should implement such a system as soon as possible in India. The ministry people wanted to wait until we knew how much smallpox actually existed—we might not be able to afford rewards. They saved the program from disaster. With thousands of new cases found in the early searches, rewards at that time would have broken the bank.

As time went on, the alliance just grew stronger, which in turn attracted others to participate. Notable was the Swedish International Development Authority (SIDA), which provided resources at a critical time. SIDA's approach to assistance is one of the most enlightened among development agencies. Before committing SIDA to the smallpox effort, J. E. Tranneus, director of the New Delhi SIDA office, was careful to evaluate the program, the strategy, and the probability of success. Following his review, SIDA made a grant with no strings attached. We were free to use the money in any way we felt advisable. The only stipulation was that we had to provide adequate accounting for how it was used.

From the very first days of the eradication program in Africa, it was obvious that fighting smallpox was not just a medical or scientific endeavor but was very much a matter of management. We did need science; we needed to make scientific observations to understand the epidemiology of smallpox, the role of population density, the impact of cultural practices, the influence of climate, the vulnerabilities of the virus, and the impact of public health tools and experiences. And, of course, we needed to document our clinical observations. However, the real problems were
in implementing the strategy: developing routines, documenting the implementation of those routines, hiring the right people, supervising, motivating, and evaluating. We needed managers, administrators, and logistics experts—people who knew how to solve problems and how to get things done. The program would not fail for lack of scientists, but it could fail—even with the best strategy—if we didn't attract the very best managers.

When commodities or people were needed, my first thought was to ask David Sencer, the director of CDC. He always found creative ways to provide the needed people, equipment, and support. Over the smallpox years, he developed a reputation for delivering on every request made of him. CDC smallpox workers soon realized that if you asked him for something, you had better be able to use it, because you would be stuck with whatever you had requested.

It has been said that genius is seeing one's field as a whole. Sencer saw the public health world as a whole. He understood that a healthy United States required a healthy world and that involving domestic public health workers in the global smallpox eradication program directly benefited the health of Americans. Addressing smallpox internationally obviously reduced the risk of smallpox importations to the United States, reduced risks for Americans traveling, and reduced the costs incurred by vaccinating the entire U.S. population. But there were other benefits. Don Millar, by this time in charge of the domestic program for immunization, was instrumental in sending many CDC staff members to the Indian program. He once wrote me that if his three-month loan of people for the program in India did nothing to improve smallpox eradication, he still wanted me to request them because they returned to the United States as different people. Once they had faced the problems of a developing country, they were unwilling to put up with the simpler barriers they encountered in domestic program implementation. The investment of domestic resources therefore seemed absolutely logical, and Sencer was willing to send CDC workers to help in the global effort.

In November 1973, shortly after the first search, I sent a telegram to Sencer stating that we needed a capable manager to help us develop administrative systems to handle the overwhelming situation we were
facing in India. It was indicative of Sencer's interest that I received a phone call within a few days from his deputy at the CDC, William Watson, who asked if he would be acceptable as that manager. Watson had served in the U.S. Army during World War II and then earned a degree in political science, after which he worked under Johannes Stuart, whose combined interests in political science and public health translated into his effort to stem the postwar rise in sexually transmitted diseases. Stuart recruited college graduates to trace the partners of people discovered to have a sexually transmissible disease and get them to treatment before they in turn could become transmitters. It was, of course, a form of surveillance and containment, and it required combining the attributes of a detective with the sensitivity of a psychiatrist and the insights of a political scientist, a person who could see connections. Stuart's cadre of highly educated activist public health workers eventually became the managerial backbone of CDC, and Bill Watson became a father figure for this group.