House on Fire (21 page)

Upon his arrival in India, Watson went to work on setting up a management system, addressing matters such as adequate training programs, sufficient transportation for field-workers (including a way to have vehicles repaired out in the field), and distribution of funds to those who would need them—the practical issues big and small that can become serious obstacles if not thought through. He was succeeded by an equally outstanding manager, Stuart Kingma, who was the kind of person who not only built his own telescope but also ground the lens himself. Kingma was a superb and creative craftsman whose talents transferred easily to administration. A compulsive manager, Kingma left no possibility unstudied. Watson and Kingma were followed by a continuous flow of top-notch CDC managers assigned to the SEARO in New Delhi on three-month assignments.

Once Bill Watson had set up the basic management structure, it was a matter of adjusting as needed. We had a framework, and succeeding CDC managers were expert at maintaining the right balance between attending to the never-ending daily needs of the program and keeping their eye on the big picture. The smallpox eradication effort in India would not have worked without these individuals: they got funds to the
teams in the field, secured supplies to print and distribute thousands of forms, developed joint approaches between WHO and the Indian government, assured oversight, moved workers in and out of the field (and the country), and responded to thousand of requests from field-workers needing more vaccine, more bifurcated needles, or approval to purchase supplies. It was never ending.

To deal with the overwhelming numbers of cases unearthed through surveillance, the program in India needed, alongside managerial expertise at the central level, additional public health professionals in the field. India's fourth five-year plan for eradicating smallpox, initiated in 1969, included a category of workers called “special epidemiologists.” Some were trained epidemiologists who had worked on smallpox or other diseases. Others were medical specialists in internal medicine or infectious diseases. Some were public health managers, and some were simply people who had worked in public health programs in India or around the world and developed a reputation for solving problems; these were taught smallpox epidemiology as part of their orientation. As with the workers in the Africa program, many found their life's calling by working for a period of three months to several years as special smallpox epidemiologists.

They were the smallpox program cavalry—highly mobile, able to inspire, and in charge of particularly difficult geographic areas with high smallpox rates. Each special epidemiologist was provided with a vehicle, a driver, and a health worker—a paramedical assistant (PMA) who if necessary also acted as an interpreter—as well as funds to use for expenses, including hiring day laborers. Each three-person team was assigned to assist in a state, a collection of districts, or even a single district where smallpox transmission was especially high.

Initially these consultants were mainly Indians and included just a few outsiders. Some of the most knowledgeable and capable smallpox workers in the world were in India. A. R. Rao, who had published a textbook on smallpox, was without peer in the world.
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But just as a
prophet often lacks credibility in his or her own community, it proved difficult to make full use of India's own expertise, including that of Rao. In any case, even India did not have enough experts for the scale of the problem that we on the smallpox team now knew we were facing. Epidemiologists from other countries could augment India's resources, and the SEARO team had already requested WHO/Geneva to send sixty more. However, bringing more foreign experts to help with what India saw as its own smallpox problem was a sensitive matter for this newly independent country. My several attempts to discuss this delicate matter with Dr. Diesh were unsuccessful. He could easily see where the conversation was going and expertly changed the subject.

On one of those overnight train trips back to New Delhi, in late 1973 or the first weeks of 1974, the topic of bringing more epidemiologists from other countries came up again. In the hour just before we arrived back in New Delhi, we found agreement on the point that India clearly had the ability to eradicate smallpox without additional outside workers. However, if we were interested in speed—in India not being the last country to stop smallpox—then the credibility and energy of outside workers were assets not to be overlooked. This view of the situation so excited Diesh that he decided to go directly from the train station to see the minister of health, Karan Singh, to make the case.

Later in the day, I encountered a very subdued Dr. Diesh, the only time in two years that I saw him discouraged. Even before Diesh stated the reason for his visit, the minister asked why foreigners were working on smallpox in India when India itself had so many experts. Taken aback, Diesh said nothing about bringing in more outside people and simply reported on the monthly meeting we had just attended.

By now, however, Diesh and I were both convinced that bringing in more foreign expertise was the right thing to do, and we discussed ways of making the case. Within the week, Diesh had regained his footing and he revisited the minister to make his case. Yes, India could do this without any outside people or resources, but acquiring experts from around the world would increase the chance of an early success—perhaps even during the minister's time in office. And, drawing on the help of the international community would demonstrate the Indian government's
commitment to eradicating this disease. Diesh succeeded in convincing the minister that making this a global effort rather than an Indian effort alone would greatly accelerate eradication. The minister agreed, but asked that a balanced approach be used, one that would increase the numbers of foreigners and Indians simultaneously.

Following the first search, SEARO had asked WHO/Geneva for sixty more special epidemiologists (this included both medical officers and managers doing fieldwork). Now that the Government of India had approved that estimate and requested the additional expertise, consultants joined the team through arrangements made by Geneva, as well as from various parts of India itself.

During the ensuing months, thirty countries provided 235 consultants, with the United States providing 100 of them. With its experience managing the first successful regional smallpox eradication effort in West and Central Africa, the CDC now became a source of both long-term and temporary personnel for the eradication effort in India. People with experience in the Africa program were eager to see the same techniques applied in a more difficult situation, and we in India needed them.

The new recruits, who were usually seconded for three months or more, came first to New Delhi for a three-day training course. For eighteen months, I had the privilege of being involved in the training of all international as well as Indian special epidemiologists. The training course included a review of smallpox, the technical aspects of search and containment (even as we were learning them), a case study, information on the procedures they were expected to follow, and details on forms, reporting, and the role of monthly meetings.

The three-day briefing also included practical things learned by other special epidemiologists. For example, drivers or other people could remove petrol from vehicles during the night, sometimes even during daytime stops, and sell it for extra revenue. Many workers had tried to solve this problem by having a lock made for the petrol tank. But a clever driver could have a key made, even if the epidemiologist retained the original key. And four or five liters of fuel could easily be removed without detection, especially since the driver had to travel an unknown distance, after dropping off the epidemiologist, to find his own quarters
for the night. The solution was to provide accommodations for the driver wherever the epidemiologist spent the night, and to fill the tank at the end of the day and again first thing in the morning, with the driver paying for any petrol added in the morning that exceeded one liter. The driver himself thus had to secure the tank in a way that prevented others from removing fuel.

The teams of short-term epidemiologists brought a continuing supply of fresh energy and new eyes to the operations. The special epidemiologists turned out to be invaluable in providing the flexibility the program needed in responding to shifting conditions and the changes in tactics that followed each monthly meeting. It took good planning to be able to use three-month assignees effectively, especially when most of the foreign recruits were experiencing India for the first time. It required adaptation on their part, but the training program was of sufficient quality that the results were far better than many predicted.

Problems occasionally arose, especially involving the diplomacy of non-American foreigners being supervised by Americans, who in turn were working under the direction of the host country, India. Given the Cold War politics of the day, the situation was especially sensitive if the Indian officials were displeased by a Soviet worker. It was much easier, and less political, for an American to send another American home. Yet the problems were generally worked through to a successful conclusion.

In an attempt to get to know the trainees, I invited many of them to spend an evening at our home. As the program progressed, I sometimes invited foreign workers who had stopped in New Delhi on their way home after their time in the field. On average, Paula and I had guests two to four nights per week. Joseph, our cook, provided home-cooked meals of great variety and was remarkably flexible about adding more places for visitors at a moment's notice. We were generously rewarded by witnessing the breadth of experience and high motivation of people from around the world who had come to India to make a contribution. Our children loved the opportunity to engage with a kaleidoscope of new people, especially those from other countries.

Unexpectedly, these evenings also provided opportunities to assess the relative strengths of and make assignments for these temporary
workers. On occasion, a new worker's affinity for alcohol would raise a red flag in my mind. Others expressed false bravado regarding their ability to solve any problem in the field. A few complained about their hotel room in New Delhi, raising immediate suspicion that they would not fare well in the field. Over the ensuing year, many short-term volunteers arrived, were trained, worked for three months, were observed over two or three monthly progress meetings, and were then debriefed. A few workers were unable to adapt and were retired early. Eventually, it became clear that certain qualities were indicators of how they would do. These observations improved the chances of placing the most likely to succeed workers in the most difficult situations. The experience also provided me with a lifelong approach to evaluating candidates for positions.

The first quality was absolute integrity. These short-term epidemiologists would be handling large sums of money to pay daily workers, hire vehicles, provide fuel, and the like. There was no efficient way to verify how many day laborers they had hired or how many vehicles they had rented, and resources were simply inadequate for inspecting travel vouchers and weekly expenditure forms in real time. In any case, a worker would likely be gone before any discrepancy was spotted, so it was important to start with people who did not require that type of supervision.

A second quality was cultural sensitivity. The workers would be operating in someone else's culture. How they treated coworkers, patients, village leaders, school teachers—in short, everybody—was crucial to their access to people, the type of information they collected, and the work climate they would leave behind.

A third quality was optimism. The assignees were about to enter a world of work that was stressful and a climate that could be debilitating, with few amenities to soften the day. They were about to experience poverty and, in a small way, share the pessimism that is daily reality for so many. A pessimist transplanted into such a situation was not likely to thrive and be productive. Even an optimist would feel despair at times. Many workers later described their three months in the Indian smallpox program as the most difficult work they had ever done and yet, to their own surprise, the most satisfying.

Fortunately, all three qualities are easily researched, even though they are not found in the usual résumé or recommendations by supervisors. It is not that hard for people to assemble an impressive résumé and list references who will give them a positive review. Coworkers and subordinates are rarely listed by an applicant, yet they are the ones who can say immediately whether the person under consideration is trustworthy, sensitive to others in the work environment, or optimistic.

One of the early special epidemiologists, Dr. Don Francis, became for me the prototype of the person needed to defeat smallpox. He later had a distinguished career in infectious diseases, designing and supervising the first human trials testing an AIDS vaccine in the United States and Thailand. Francis began his India work in Bareilly, Uttar Pradesh.

This was an area of many smallpox outbreaks. Don resided initially in living quarters belonging to the Clara Swain Hospital, which was a place of historical significance because it had been built by the first woman medical missionary to India. Clara Swain left the United States in 1869, arriving in Bareilly on a January morning in 1870 after an all-night trip in a horse-drawn wagon. She began seeing patients that same day. By the end of the year, she had established her credentials as a doctor and was also training local students. By 1874, she had established the Women's Hospital and Medical School, the first in Asia. She went to see the Nawab of Rampore, who had publicly said he would not allow a Christian missionary in his city. He was so charmed by this determined young woman that he gave her forty-two acres for the hospital and school. Now Don Francis was building on that legacy by using the medical complex as the base for his smallpox activities.