House on Fire (29 page)

However, the truth that we came to know about smallpox is not necessarily the truth about other diseases. What is true is that each particular disease and its context must to studied in order to understand its vulnerabilities. Mass vaccination continues to be an important strategy for most vaccine-preventable diseases.

Spend the time and attention needed to systematically improve the tools as well as the techniques to deliver them.
WHO developed a better vaccine and adopted a superior vaccination technique, the bifurcated needle, both of which were essential to success. The program was also constantly refining the techniques used to efficiently track the virus and to encircle the virus with people immune to smallpox.

Coalitions are powerful.
Successful coalitions share certain characteristics, the first being a clear vision of the last mile of the journey, which in
this case was the total absence of smallpox cases and smallpox transmission. Yet the secret to the eradication of smallpox in India was that the members of the coalition team suppressed their individual egos for the sake of achieving a common goal. Moreover, the boundaries between the Central Government, the states, the districts, WHO, NGOs, public institutions, and private industry were obscured as the team formed with an unwavering focus on the desired outcome. This was clear to participants, yet has been missed by some recent historians.

Trust holds teams together.
It was trust that allowed for transparent discussion and productive arguments about tactics. It was trust in Drs. Mahendra Dutta and M.I.D. Sharma that allowed Dr. Karan Singh, India's minister of health, to support surveillance/containment when others were advising him to return to mass vaccination.

Social will is crucial.
Individual will leads people to seek the protection of vaccines, but it is the collective will that drives individuals to provide resources and opportunities for others to be protected. Government support for programs depends on the agreement of the governed. In theory, eradicating smallpox was possible from the time vaccine became available. It became easier as science and technology improved the tools and delivery techniques. But that was not enough. The 1970s became the last decade for smallpox because of social will—a collective agreement to remove the scourge from society.

Social will must be transformed into political will.
Every public health decision ultimately requires a political decision for implementation. Therefore, public health practitioners must provide politicians with the information needed for good public policy decisions.

Public health solutions rest on good science, but the implementation of those practices depends on good management.
Smallpox posed some intriguing scientific problems, but eradication depended on the managers. Countries often insisted that the consultants had to be physicians even if they were less effective in running field programs.
²
In both Africa and India, people trained in program management were extremely valuable.

Tactical flexibility is crucial.
Workers were encouraged to experiment with tactical approaches, which if effective could readily be replicated by other workers. Monthly meetings in every endemic state allowed
for rapid transfer of information. We didn't wait for annual reviews. Monthly meetings allowed us to refine tools and techniques as quickly as we could get information from surveillance and evaluations.

Allocate resources where they are needed.
It is crucial to have the ability to concentrate all available skills and resources on the point of need. In the words of a young Indian physician, “Put water on the house that is burning rather than on the other houses.”

Effective leadership is crucial.
The smallpox eradication program benefited immensely from effective leadership. Key in this area were unflagging dedication to the program's objectives, an ongoing willingness to use new information to improve the strategy, and the capacity to build coalitions.

Never give up.
Tenacity won't always bring success, but without it, success is impossible.

The measure of civilization is how people treat each other.
How people treat each other is the metric for a civilized nation, political party, society, university, or program. How we treat each other is also the measure of us as individuals. The smallpox eradication program was a civilized program in that it transformed potential smallpox patients into immune persons and protected unseen people in the generations to come.

Be optimistic.
The trouble with being an optimist, of course, is that people think you don't know what's going on. But it is the way to live. We were an optimistic group. I tell students there is a place for pessimism, and whenever they need it, they should contract for it—but don't put those people on their payroll. They will ruin your day.

Global efforts are possible.
The smallpox eradication effort proved that it is possible to choose a global objective and bring global resources to bear on it. Philosopher Will Durant once observed that the world was unlikely to join forces unless it feared an alien invasion. Smallpox demonstrated that problems short of an alien invasion can mobilize the world. Smallpox was a shared risk, and its removal required a shared effort. In the years since then, other problems—nuclear arms, polio, SARS, HIV, H1N1 flu (surrogates for an alien invasion)—have confirmed the power of understanding shared risks. Pursuing such problems is worth the effort both because of the inherent good in solving them and
because they provide practice in working together and breaking down unnecessary and unproductive social barriers.

The objective may be global, but implementation is always local.
The strategy for smallpox eradication did not change from country to country, but the local culture determined which tactics were most useful. Only the specific locality can provide information on who is sick, who is hiding from the vaccinators, when people are available for vaccination, how to hire watch guards, or how to secure the cooperation of the community. In all cultures, an approach of respect for local customs is needed.

Communications functions as the nervous system of successful coalitions.
Efforts to report from the search and containment workers to the PHC, then to the district, the state, and finally the central level improved continuously. The surveillance reports were collated and analyzed, and the results were shared widely through the systemic feedback, all the way back to the PHC staff doing the work. Local workers knew their position in the global effort. “We are all in this together” was a palpable feeling. This in turn engendered a pride in the work being done. Trust, effectiveness, and knowing the truth all depended on good communication systems.

Effective evaluation methods are key to success.
Evaluation was the key to identifying and remediating deficiencies in the strategy. Evaluation was also crucial to knowing when each district and state would reach the tipping point of controlling smallpox faster than it was spreading. Evaluation made it possible to predict where resources were needed in advance rather than simply reacting to the information of the day. It was not an add-on; evaluation was a priority management tool that helped make effective use of scarce resources. The mantra from the American Management Association was repeated hundreds of times: “You get what you inspect, not what you expect.”

Humility does not mean fatalism.
In retrospect, achieving the eradication of smallpox might look inevitable. In fact, though, the chain of events included so many opportunities for failure that success was not a given—and we knew it. We had no guarantee of success and were humbled so often that humility became a daily emotion.
We didn't let that stop us.

 

 

Postscript

Over the years, on every return to India, I have searched the faces of people on the street, looking for pockmarks. Soon I could find no pockmarked face under the age of ten, then twenty, and now, no pockmarks are to be found on people under the age of thirty-five.

 

 

 

 

 

 

 

In 2002, the United States was concerned that Iraq might have weaponized the smallpox virus, and the U.S. government quickly moved to set up a prevention program. Crucial lessons from the global smallpox program seemed to be totally forgotten or ignored. The rather anemic response was a plan to vaccinate first responders, then medical personnel, and finally, in the event of smallpox, to vaccinate 10 million people in ten days.

Moreover, the public health leadership seemed to be oblivious to the potential for a complete breakdown of the social order. Even a single case of smallpox in the United States would have resulted in panic, with 300 million people demanding vaccination immediately, fighting to be part of the initial vaccination cohort.

Lessons learned from the global smallpox eradication effort could be used to formulate a technically sound plan that would ensure the quick containment of dozens, even hundreds, of simultaneous outbreaks in the United States, and to communicate that plan to the public:

1. Emphasize to the public that anyone vaccinated on the day of exposure or even within three days after exposure will be protected from the disease. Describe how a dozen or even a hundred outbreaks could be contained with relative ease. (The problems would come if many hundreds of outbreaks became apparent at one time. That would require the capacity for mass vaccination.)
   
2. Present the details of how everyone in this country could be vaccinated within three days, even in a worst-case scenario with thousands of cases discovered simultaneously throughout the country.
   
3. Decentralize the vaccination program to each of the three thousand counties in the country.
   
4. Designate every high school as a vaccination site, since people usually know the high school district they live in.
   
5. Calculate the number of people living in the catchment area of each high school to determine the number of vaccinations and therefore the number of vaccinators required to vaccinate everyone in three days.
   
6. Recruit in advance medical personnel, teachers, government workers, and volunteers to perform the vaccinations. The technique can be taught in fifteen minutes. A practice session in advance and a refresher session on the first day of vaccinations would be sufficient.
   
7. Plan to run the vaccination clinics twenty-four hours a day until everyone has been vaccinated. The procedure is so easy that the number of vaccinators could even be doubled so complete vaccination could be accomplished in two days, if needed.
   
8. Keep the vaccine in a central location, if there is concern about storage conditions, with advance plans to ship the vaccine overnight to each of the three thousand counties. Containers for shipping could be available; address labels could be affixed in advance.
   

This plan, using the lessons learned during the global program, would quickly contain dozens, even hundreds, of simultaneous outbreaks in the United States. Informing the public of the plan would prevent uncontrollable panic.

Figure 16.
Instructions given to field-workers for vaccinating with the bifurcated needle

 

 

 

 

 

ONE. A LOATHSOME DISEASE

1
. Donald R. Hopkins,
Princes and Peasants: Smallpox in History
(Chicago: University of Chicago Press, 1983).

2
. Donald R. Hopkins, personal communication, December 1979.

3
. G. Catlin,
O-Kee-Pa, a Religious Ceremony, and Other Customs of the Mandans
(1867. Centennial edition, edited by J. C. Ewers, New Haven, CT: Yale University Press, 1967).

4
. Elizabeth A. Fenn,
Pox Americana: The Great Smallpox Epidemic of 1775–82
(New York: Hill and Wang, 2001).

5
. Garry Wills,
Lincoln at Gettysburg: The Words That Remade America
(New York: Simon and Schuster, 1992).

6
. Hopkins,
Princes and Peasants
.

7
. Edward Jenner,
An Inquiry into the Causes and Effects of the Variolae Vaccinae, a Disease Discovered in Some of the Western Counties of England, Particularly Gloucestershire, and Known by the Name of the Cowpox
(1798. Reprint, Denver, CO: Nolie Mumey, 1940).

8
. Jefferson quoted in Hopkins,
Princes and Peasants,
310.

TWO. A SUCCESSION OF MENTORS

1
. Some years later, Ravenholt's interest in global fertility control led him to head up the population program at the U.S. Agency for International Development (USAID). For a compilation of Ravenholt's contributions, see “Adventures in Epidemiology,” January 15, 2009, at
www.ravenholt.com
.