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The Management of Smallpox Eradication in India
« on: November 10, 2022, 08:55:58 PM »

In preparation of a legal maneuvre against some anti-vaxxers we archive this book here. It is online and can be read for free at
http://www.zero-pox.info/other_docs/brilliant_mgmt_spox_india.pdf

So we think it to be fair use, and in the sense of our predecessors, to put the facts online on more sites, like this one.

Vaccination saves lifes!

http://www.zero-pox.info/other_docs/brilliant_mgmt_spox_india.pdf

[*quote*]
THE MANAGEMENT OF
Smallpox Eradication in India

Lawrence B. Brilliant
M.D., M.P.H.
Ann Arbor
The University of Michigan PressCopyright© by The University of Michigan 1985
All rights reserved
Published in the United States of America by
The University of Michigan Press and simultaneously
in Rexdale, Canada, by John Wiley & Sons Canada, Limited
Manufactured in the United States of America
1988
1987
1986
1985
4
3
2
Library of Congress Cataloging in Publishing Data
Brilliant, Lawrence B.
The management of smallpox eradication in India.
Bibliography: p.
l. Smallpox-India-Prevention. l. Title.
[DNLM: l. Smallpox-prevention & control-India.
WC 588 B857m]
RA644.S6B75
1985
614.5'21
84-29455
ISBN 0-472-10059-9
To Neem Karoli BabaForeword
Together Dr. Larry Brilliant and 1 visited West Bengal during the autumn of
1973. The purpose of our visit was to initiate, in collaboration with the state
smallpox eradication officials, the first trial in our smallpox eradication pro-
gram, namely a statewide search for hidden smallpox cases, mobilizing all
available health staff in West Bengal, which had a population of sixty mil-
lion. A similar trial also took place in the smallpox endemic states of Uttar
Pradesh, Bihar, and Madhya Pradesh at that time. Over 6,500 cases were
detected through this intensive search within a week, as compared to the
400 cases that were reported in the previous week.
The achievement was significant in the sense that the Indian smallpox
eradication program officials discovered for the first time in the history of
their campaign that they had seriously underestimated the magnitude of the
smallpox epidemics. This recognition led first to a redefinition of the prob-
lem, second to identification of the priority areas for surveillance and inten-
sive containment activities, and third to the mobilization of national and
international resources to deal with the devastating smallpox epidemics in
large areas of the Indian subcontinent.
Eighteen months of this intensified campaign accomplished the re-
cording of the last smallpox case in India; the date of onset of rash was May
24, 1975. Intensive surveillance for hidden smallpox cases continued, main-
taining the same number of national and international staff, until April,
1977. No more cases were detected.
In April, 1977, a Global Commission for the Certification of Smallpox
Eradication-a panel of sixteen experts on smallpox eradication-visited
India to review data and observe search activities in the slum areas, remote
accessible areas, and recently endemic areas in the country. On April 23,
1977, the commission certified that smallpox had been eradicated from
India.
Dr. Halfdan Mahler, director-general of the World Health Organiza-
tion, once referred to the success of the global smallpox eradication program
as a victory for program management. I feel that this is particularly true in
the Indian campaign. The campaign started in 1962, but despite substantial
efforts made by the program, until 1972 it was only partially successful, in
mainly the southern states. However, in 1973 a dramatic change occurred,
as already mentioned. From the management point of view, it could be said
that a basic managerial change brought a dramatic solution to the problems,
and the remaining objectives were accomplished in a short time.viii
Foreword
With the closure of the Indian smallpox eradication program, many
nationals left the program, and all the international staff left India during
1977 and 1978. It was thought that the experience gained in the Indian
campaign would be worth publishing, since it would be of great interest to
workers in other public health programs. The 1978 publication of Smallpox
Eradication from India by the South-East Asia World Health Organization
(WHO) Regional Office fulfilled this need. However, it was also thought
that the experience gained in India could be summarized from the manage-
ment point of view. Dr. D. A. Henderson suggested that such a document
could be a case study of the Indian smallpox eradication program.
In view of this, WHO requested that Dr. Brilliant write this book, The
Management of Smallpox Eradication in India, in consultation with several man-
agement experts who were interested in the program. The book has been
prepared for health officers who directly or indirectly participated in or were
interested in the global eradication of smallpox, as well as for those who
wish to study the eradication of VPDOOSR[ f rom a managerial point of view.
The latter include students and perhaps executives who wish to study the
analysis of the success of an international program.
Dr. Isao Arita
Chief, Smallpox Eradication Programme
World Health Organization, Geneva, Switzerland
Preface
After the eradication of smallpox from India, the veterans of that campaign
carried away with them a unique experience and many lessons. In the decade
since the last case of smallpox occurred in India, many of these smallpox
veterans have found new roles and have tried to apply the lessons learned
from their experience to their new tasks in public health. Each has tried to sift
the wheat from the chaff-learning which lessons from smallpox could be
applied to new jobs, new diseases, new environments.
Other health workers, unfamiliar with the details of smallpox eradica-
tion, have wanted to study its history, in particular to discover what lessons
can be learned about public health management from the smallpox eradica-
tion program. The literature on international development is full of accounts
of successful pilot projects that turned out to be unsuccessful national pro-
grams, and specialists in international relations repeatedly caution students
about the limitations of the special case. And smallpox eradication is indeed
a special case.
The field of international health, like any human endeavor, proceeds
through cyclic shifts of conviction and emphasis. A decade ago, the World
Health Organization (WHO) enthusiastically supported single-disease cam-
paigns and "categorical" or "vertical" eradication programs like those
mounted against smallpox, malaria, and yellow fever, seeing great promise
in a one-by-one attack on the ills that befall mankind. The focus of enthusi-
asm has recently shifted, and in much of WHO and the international health
community the single-purpose campaign has lost favor and instead "hori-
zontal" or "integrated" programs are currently preferred. Primary health
care has become an important philosophy, and "Health for all by the year
2000" is its slogan.
This shift from single-disease programs toward integrated primary
health care can be seen as part of a historic process-an earnest attempt to
reach into ever more subtle causes of ill health in the poorest communities
in the world. The declining attention to specific pathogens and rising atten-
tion to multiple risk factors of diseases and the environmental, social, and
political correlates and determinants of ill health parallel the movement in
medicine as a whole away from single-disease, single-pathogen syndromes
and magic bullet therapy toward a fuller appreciation of each person and his
health and general welfare.
But the debate between these philosophies of health management
may lose its constructive vigor in substituting slogans for scientific manage-x
Preface
ment, and there is a danger that the lessons of past experience may be lost
as well.
As in most highly polarized arguments, truth and reason probably lie
somewhere between the two extremes in this debate. There is no doubt that
the proponents of primary health care are motivated by the best kind of
goal, that of making health care relevant to the needs of the most under-
served communities in the world. Its achievement would certainly be an
improvement over any single-purpose campaign. Nevertheless, a simple
change from vertical to horizontal will not solve all the world's health prob-
lems, and some of the methods of sound management learned in the verti-
cal smallpox eradication program are applicable to any program, vertical or
horizontal. The combination of the intense commitment of the staff, the
intense concentration on one problem at a time, and the problem-solving
orientation of the smallpox program management led to the development of
innovations in planning the program and formulating strategy and in organ-
izing, implementing, and assessing the tactics of personnel management,
logistics, information, finance, and relevant research.
A carefully planned, sustained, and evaluated attack was successful
against one disease. It took more than a decade. Primary health care em-
bodies simultaneous efforts on many fronts to achieve "Health for all by the
year 2000." That leaves not much time to reach such an ambitious target-
only fifteen years from today. It is essential that the managers of primary
health care study and review the lessons learned from all past experience.
The case of smallpox provides many ways to study that experience.
The WHO smallpox unit in Geneva has prepared exhaustive documentation
on the smallpox eradication activities of more than sixty countries as weli as
on the global program. Several excellent texts are available that deal with
country-level programs in Bangladesh and India, and more are coming.
Additional books are planned on the history of smallpox in general and on
the history of eradication in particular.
To add to this growing reference library on smallpox, WHO felt that a
case study and analysis of lessons learned from the eradication of smallpox
in India would provide an otherwise unfamiliar reader with some readily
assimilated food for thought on those lessons that might apply to other
health management needs.
This book was not prepared for an audience that is already familiar
with smallpox or its eradication and certainly not for smallpox epidemiolo-
gists who experienced the eradication program by participating in it. This
case study has been prepared primarily for managers of other health pro-
grams or students in the health sciences who hope to learn from a study of
the management experience of smallpox eradication in India. Other readers
and managers outside the field of health who also hope to learn-or who
simply are motivated by the event to seek out its detailed history-may find
something of use in these pages. For these reasons, chapter 1 of this case
study is a chronology of smallpox eradication in India, presented in an
Preface
xi
informal narrative style. Chapter 2 analyzes aspects of program manage-
ment, and chapter 3 summarizes conclusions from the case study and analy-
sis, presenting the factors that argue against a broad generalization of les-
sons learned from smallpox eradication (such as the unique characteristics of
the virus or the nongeneralizable qualities of a vertical or categorical eradica-
tion program) and then presenting the case for the generalizability of certain
management lessons from the smallpox experience in India.
I hope that this material succeeds in bringing the experience of small-
pox eradication to life again for each reader and that it usefully highlights
some of the innovations and adaptations, successes and failures, and good
and bad lessons that were part of the India smallpox eradication experience.
And I hope that this experience ultimately helps all those who are seeking
the alleviation of suffering to improve the management of other programs,
whenever and wherever they are working.Acknowledgments
The idea for this book began with Dr. Isao Arita, chief of the World Health
Organization (WHO) global smallpox campaign; Dr. D. A. Henderson, his
predecessor in Geneva and now dean of the School of Hygiene and Public
Health, Johns Hopkins University; and Dr. Joel Breman, formerly with the
WHO smallpox unit in Geneva and now at the Centers for Disease Control
(CDC) Atlanta. I am very grateful to these three colleagues for suggesting
that I undertake this difficult but rewarding task. I am especially grateful to
Dr. Arita for his patient encouragement at each step of the way, as well as
for writing the foreword.
Professor James Austin of the Harvard School of Business Administra-
tion was the management expert whose work on the management of interna-
tional health programs formed the model for the case study approach and the
organization of the analysis in this book. From the early conceptual stage on,
he was a kind and insightful consultant. Professor David McClelland, also of
Harvard, helped by reminding me to view smallpox eradication per se from a
broader perspective and by making me reexamine and learn from my own
experiences instead of believing overmuch in academic theories. Professors
Ruth Simmons and George Simmons of the University of Michigan also
helped place the management of smallpox eradication in a more general
management and development framework by comparing it to their own ex-
tensive experience in family-planning program management in India. Profes-
sors Fred Munson, Robert Grosse, and Jan de Vries, also of the University of
Michigan, were likewise kind enough to read through one or more drafts and
offer suggestions.
I am most grateful to my colleagues in the smallpox eradication pro-
gram for taking the time to read and review various drafts of this manu-
script. Dr. Henderson's early critique of the conceptual outline helped me
reorganize my approach in a more practical fashion. His later comments
augmented and corrected my limited knowledge of smallpox history with
his wealth of experience. Dr. Breman was also kind enough to comment on
the draft with great clarity. Dr. T. Stephen Jones and Dr. Stanley 0. Foster,
both of CDC, meticulously read through various drafts and offered ex-
tremely valuable suggestions.
One of my major concerns about writing this book in Ann Arbor,
Michigan, was that it might easily be very far off the mark when again
viewed from New Delhi, India. My Indian colleagues and friends who com-
prised the government of India half of the smallpox team helped to narrowxiv
Acknowledgments
that distance by continuously giving many extremely valuable suggestions
and insights. I am grateful for the careful reading and helpful suggestions
given by Doctors M. I. D. Sharma, R. N. Basu, Mahendra Dutta, and C. K.
Rao. Dr. Sharma was kind enough to spend nearly one month carefully
checking and rechecking detail after detail of two drafts.
Zaffar Hussain, a paramedical assistant from Madhya Pradesh with
twenty years' field experience, read the manuscript and offered suggestions
for improving its relevance to fieldwork.
My wonderful wife Girija, in addition to helping organize the book
overall, wrote the first draft of the section on traditional health behavior.
Economists Ken Warner and George Simmons of the University of Michigan
helped Marianne Zebrowski enormously with conceptual problems when she
was writing the economic analysis. Marianne brought her talents as a policy
analyst to bear on the formidable task of analyzing costs and benefits of
eradication as she wrote the draft of the "Evaluation" section of chapter 2.
I was barely out of medical school when I was fortunate enough to be
allowed to work with the WHO smallpox unit in New Delhi in 1973. I had
been living in an ashram in the foothills of the Himalayas, studying with
Neem Karoli Baba. My teacher told me of the smallpox eradication program
and of the great good smallpox eradication would mean for the people of
India and sent me to volunteer to work with the WHO program. As our
friends say in India, "Bhagwan jo kuch karte hai, Hamare mangalam keliye
karte hai"-whatever God does, he does for the best.
I want to especially thank my WHO colleagues, who tolerated such a
brash young newcomer (I had never seen a case of smallpox before), gave
me a chance to work on the eradication of smallpox, and taught me about
the epidemiology and management of the disease: Doctors Nicole Grasset,
Bill Foege, Zdeno Jezek, Lev Khodakevich, Nick Ward; and Tony Scardaci,
John Drescher, Henry Smith, and David Olsen. I am especially grateful to
Dr. Grasset, whose dedication and commitment in her new field of blind-
ness prevention has remained a constant source of inspiration and led us to
create the Seva Foundation to continue health work in poor communities. I
cannot be considered an unbiased observer of the event described in this
case study, as my heart belongs to that most wonderful team and to those
days we shared. In addition, after the last case of smallpox, the colleagues
who remained on for the difficult task of documenting eradication produced
a remarkable book that has been a great reference for me (Basu, Jezek, and
Ward 1979).
This work was supported by a grant from WHO to the Seva Founda-
tion and by a Professional Development Fellowship from the American In-
stitute of Indian Studies. During this fellowship, I was on a leave of absence
from the faculty of the University of Michigan. My thanks to these organiza-
tions for their financial support and the confidence that went with it.
Sonya Kennedy of the Institute for Social Research is the literary al-
chemist who helped translate my leaden prose into more golden words.
Acknowledgments
xv
Karen Brackney and Judy Gallagher spent many blurry-eyed nights typing
draft after draft, and Kim Caldewey cheerfully checked references from the
smallpox archives.
To all of these, my warmest gratitude; but of course, I alone am
responsible for the opinions expressed in this book, which do not necessar-
ily represent those of the World Health Organization or the government of
India.Contents
1
1
8
34
51
68
77
Chapter 1
The Case Study
Before the National Smallpox Eradication Program
The National Smallpox Eradication Program Begins
The Intensified Campaign
From Smallpox to Zeropox
Certifying Eradication: The Two-Year Vigil
137 Analysis and Commentary
Chapter 2
Introduction to the Analysis
Statement of the Problem
The Causes of the Problem
System Definition
Setting Goals
Strategy Formulation
Implementing the Tasks
Management Style
145
145
147
152 Chapter 3
Conclusions
Lessons for the Future
Factors Unique to Smallpox Eradication in India
General Lessons from Smallpox Eradication in India
165
167 Appendixes
Appendix 1
The WHO-Government of India Plan of Operations and Addenda
Appendix 2
The Management of Smallpox Eradication: Organizational Charts
77
77
78
80
83
86
91
173
185 Notes
189 BibliographyChapter 1
The Case Study
Before the National Smallpox Eradication Program
From Time Immemorial
The global eradication of smallpox is a unique health achievement.
Once as pervasive as the familiar childhood diseases of measles,
mumps, and chickenpox, but far more deadly, smallpox has now
been eradicated worldwide. Its eradication from India was the cru-
cial step, for smallpox was especially stubborn and virulent there,
where Vario/a major killed one in every four who contracted it. It is
easy to see why the rapid eradication of smallpox from the place that
was for many years the world's principal endemic focus of the dis-
ease has been singled out as one of the great victories in the history
of public health: only twelve months separated a peak of more than
8,000 infected villages in May, 1974, and 188,000 cases in that year,
from the last indigenous case in May, 1975.
The eradication of smallpox in India is a major achievement
because of the setting in which it was accomplished. With a popula-
tion of 650 million, India is the world's second most populous coun-
try and the seventh largest in geographic area. Stretching from the
Himalayas in the north to the Indian Ocean in the south, India
embraces 14 major language groups and 1,652 mother tongues;
thousands of ethnic groups and over 200 tribes; and a social struc-
ture based on the caste system. The complexity and subtlety of
India's ethnic groups and languages may be unparalleled in any
other country in the world. Thirty-one states and union territories
(fig. 1) further complicate the setting.
The history of the people of India spans five millennia, dur-
ing which empires rose and fell, and many great religions
emerged-Hinduism, Buddhism, Sikhism, and Jainism, to men-
tion the best known. Contemporary India is home to most of the
world's major religions and is the site of several principal places
of religious pilgrimage.2
Smallpox Eradication in India
FIG. 1. Map of India showing states. (From R. N. Basu 1979.
Courtesy of World Health Organization.)
Over the centuries during which smallpox struck Indian
villages year after year, diverse and widespread legends, beliefs,
and practices developed, reflecting the varied religious traditions.
Smallpox was incorporated into the very fabric of Indian society-an
important factor that had to be considered.
In India, as in many traditional societies, smallpox was often
attributed to spiritual as well as physical forces (Imperato and Traore
1968; Morgan 1969; Mather and John 1973). The pantheon of Hindu
The Case Study
3
deities reflects a variety of divine attributes, and smallpox is tradi-
tionally regarded as the manifestation of one of the deities, the god-
dess Shitala, or Shitala-Ma, whose name means "the cool one," or
"cooling mother" (Maury 1969). In southern India her name is Mari-
amma (Mather and John 1973); in Maharashtra it is Mata-May (Jung-
hare 1975); in rural Bihar she is Bhagwathi (Hassan 1975); in Madhya
Pradesh she is Maharani; and in areas of eastern India she is Ai
(Jaggi 1973). Other names for her include Devi Mata, Maha-Mai, and
Jag Rani (Crooke 1968). In conventional Hindu theology, Shitala is
one of seven (sometimes nine) sisters (sometimes mothers), each of
whom is associated with a different disease. These diseases com-
monly include chickenpox, measles, mumps, and cholera.
Smallpox is attributed to the wrath of the goddess, which is
especially likely to occur should rituals in her honor be neglected. At
the same time, however, the goddess is regarded as having the
power to mitigate the severity of the illness. A popular Hindi poem
to Shitala says, "when the body burns with poisonous eruptions,
you make it cool and take away all pain" (Prabhudas et al. 1977).
In addition to such spiritual explanations of the disease, small-
pox is also attributed to excess heat in the body, to an imbalance of
hot and cold, or to impurity. In Ayurveda, the ancient Indian medi-
cal system, illness is commonly attributed to such humoral imbal-
ances (Babsham 1976). Traditional preventive measures include ap-
plication of herbs, flowers, or animal products, which are thought to
be cooling.
The most common traditional prophylaxis for the disease was
regular fulfillment of spiritual obligations to Shitala. Religious cere-
monies were periodically performed in her honor at temples dedi-
cated to her throughout the country, in the village environs, or in
the home.
The worship of Shitala sometimes conflicted with acceptance of
smallpox vaccination, since some Hindus felt that vaccination would
anger the goddess. Muslims did not worship Shitala, but some of
them felt vaccination interfered with surrender to God's will. Hindu-
ism, as the major Indian religion, was able to creatively integrate
traditional health beliefs into the modern vaccination program. The
vaccination pustule itself was sometimes honored as a manifestation
of the goddess, in the same way that the eruptions of the disease
were honored. In some parts of India, vaccination procedures ac-4
The Case Study
Smallpox Eradication in India
quired characteristics of a public religious ceremony, and songs in
Shitala's honor were sung while vaccinations were given (Hassan
1975). In the late nineteenth century, government vaccinators in
Bengal actually performed part of the Shitala worship when a child
was vaccinated (Crooke 1968).
Variolation, the practice of deliberate inoculation with smallpox
scabs and pustular material, was practiced in India, commonly in
areas bordering Pakistan, up through the early 1970s. This prophy-
lactic inoculation of the smallpox (Vario/a) virus historically predates
vaccination, which is the inoculation of the cowpox (vaccinia) virus.
Before the advent of vaccination, variolation was the only effective,
albeit dangerous, prophylaxis available. In India, the practice some-
times had religious overtones, since the local religious leader, often
a fakir, performed the variolation procedure.
Traditional curative practices for smallpox were varied, reflect-
ing the absence of any clearly effective intervention. When the dis-
ease appeared in a family, the household's regular habits of cooking
and cleaning were often changed. A special worship of Shitala was
often made at a nearby temple. The patient was given a special diet
and kept isolated, and herbs were applied. The most commonly
used herb was the neem plant (margosa, or Azadirachta indica), which
was considered to have intrinsic "cooling" properties. Branches of
neem were often hung outside the house of a smallpox patient.
Awareness of these traditional practices was later to be con-
structively incorporated into the eradication campaign. For example,
since the appearance of neem over the front door of a house was
often the only clue to an unreported outbreak, smallpox workers
looked for this telltale sign of hidden outbreaks and made regular
visits to Shitala priests as routine parts of the smallpox program's
efforts to detect outbreaks that might otherwise be missed. During
the early mass vaccination phase of the eradication program, the
phrase "worship the Goddess and also take a vaccination" was used
to accommodate both spiritual and epidemiological concepts of the
disease.
The traditional ideas about etiology, prevention, and treatment
of smallpox in India reflect the cultural and metaphysical setting in
which the disease appeared. These ideas, evolved over centuries',
form the backdrop against which the drama of smallpox eradication
unfolded. The sharp contrasts between these long-established tradi-
5
tional health beliefs and the rapid success achieved by the eradication
efforts provide important elements for a case study of the manage-
ment of a successful public health program in a traditional society.
1802-1962: 160 Years of Vaccinations
Jenner's discovery in Berkeley, England, in 1796 provided the weapon
that would be so successfully used against smallpox. However, the na-
ture of vaccinia and the relatively slow nineteenth-century travel and
communication media limited worldwide dissemination and use of
this innovation. The first vaccinations in England were given by arm-
to-arm passage, involving direct transmission from a human donor to
one or more vaccinees. Technical problems of producing the vaccine,
transporting it, and monitoring its potency were all reduced to the
availability of a suitable human donor. As the news of vaccination
spread and requests for technology transfer were received from other
countries, problems had to be solved in new ways. The Spanish gov-
ernment, for example, sent vaccine to their colonies in the New World
via a human chain of donors-twenty-two young boys from a found-
ling home were serially vaccinated arm-to-arm to maintain a chain of
infection during the long ocean voyage. However, such person-to-
person chains of transmission could not be maintained for the much
longer trip to India, and vaccine did not finally reach that country
until 1802. The first successful Indian vaccination was performed
that year in Bombay.
Twenty years later, systematic vaccination was being carried
out in Bombay. However, most of the recipients were Englishmen
residing there who thought of vaccination more in terms of personal
prophylaxis than public health. By 1854, the United Provinces (now
Uttar Pradesh) had established an active vaccination program. All
along, however, variolation was being practiced in some areas of
India, and it was not uncommon to see Englishmen vaccinated and
Indian villagers variolated. But variolation could actually cause
smallpox outbreaks as well as prevent them, and in 1870 the govern-
ment condemned it as a dangerous practice. Instead, the govern-
ment urged vaccination for all and in 1877 began to require vaccina-
tion reports.
Part of the reason for this attention to smallpox in those years
may have been the epidemic of 1873-74, which claimed over 500,000
lives. In 1880, the Bengal Vaccination Act was passed. The main6
Smallpox Eradication in India
thrust of this important law was to make vaccination compulsory in
the port of Calcutta and in areas administered by the lieutenant
governor of Bengal as well as to enforce vaccination of new arrivals
in the port. Under this law, public vaccination stations were estab-
lished, public vaccinators were appointed, and fines were to be im-
posed in the geographic areas covered by the law: 100 rupees ($12)
for adults who failed to vaccinate their children and 50 rupees ($6)
for adults who resisted vaccination themselves.
However, thirty years later, although vaccination had become
increasingly popular among the colonialists in India, there was little
evidence of its widespread acceptance in the villages of India. Vacci-
nation was still not required in more than 90 percent of the country.
And despite the fact that there was no systematic method for record-
ing smallpox deaths until 1911 (Seal 1975; Basu, Jezek, and Ward
1979), the annual average registered death rate from smallpox was
0.39 per 1,000 population in 1909, and this was likely to be gross
under-reporting.
After India achieved independence in 1947, the new govern-
ment responded to reports of inadequate vaccination cited by a 1946
British colonial inquiry panel, the Bhore Committee, and made vac-
cination against smallpox an important public health activity (Seal
1975). At about the same time, in 1949, the regional committee of
WHO called for compulsory primary and revaccination in all mem-
ber countries. Ten years later, calling smallpox "a major public
health problem in the Region," the regional committee stressed that
"the initiation of an eradication programme should receive the high-
est priority" (Basu, Jezek, and Ward 1979).
Smallpox vaccination activities followed the same epidemic
cycles as the disease itself, usually recurring with a five-to-seven-
year periodicity. A major epidemic in the 1950-51 season resulted in
410,819 notified cases, with 105,781 deaths, and stimulated national
concern about smallpox control. When the next cyclical peak oc-
curred in 1958, resulting in 168,216 recorded cases and 45,838
deaths, the national concern was intensified.
In 1959, at the eleventh annual meeting of the policy-making
World Health Assembly meeting in Geneva, Dr. V. N. Zhdanov, a
leading Soviet health official, introduced a resolution urging WHO
to launch a global campaign to eradicate smallpox from the face of
the earth. If WHO coordinated a global program, Zhdanov pre-
The Case Study
7
dieted, smallpox could be eradicated and "smallpox vaccination
would become redundant." This resolution-suggested by a man
who later served on the international commission that certified India
free from smallpox-was adopted by the assembly the following
year, but a major WHO effort did not emerge until eight years later,
when WHO appropriated $2.5 million from its regular budget and
sought the required funding assistance from several donor nations.
The combination of a major domestic epidemic and increased
international attention on smallpox was the catalyst for the govern-
ment of India to appoint an expert committee in 1958 to review the
alarming situation. This committee, under the auspices of the Indian
Council of Medical Research (ICMR), was charged with "suggesting
means for eradication of smallpox" (Basu, Jezek, and Ward 1979). In
June, 1959, the group recommended establishing a National Small-
pox Eradication Program (NSEP) "to vaccinate the entire population
[then about 430,000,000] within a period of 3 years" (Basu, Jezek,
and Ward 1979). But no national plans were drawn up. The only
vaccine available was in liquid form (lymph), which was not heat
stable, and few experienced epidemiologists were available to orga-
nize a successful vaccination program. Compulsory primary vaccina-
tion and revaccination were both required in only five states, com-
pulsory primary vaccination alone was required in nine states, and
no vaccination at all was required in the state of Assam and many of
the districts of the state of Orissa. The committee suggested starting
pilot projects in each state to obtain firsthand experience, argued in
favor of "intensive revaccination" because of a perceived "waning of
immunity after primary vaccination," and suggested that frag-
mented laws regarding immunization be made more uniform. Later
it was learned that a single vaccination provided a longer period of
immunity than had been thought. The committee was ahead of time
in one way-it foreshadowed a later surveillance-containment strat-
egy by urging early detection and notification of cases, with a
village-level official (Panchayat secretary) given the responsibility to
transmit information about smallpox cases by telegram or special
messenger.
The committee recommended a type of scratch method of vac-
cination with four insertions-that is, four separate vaccinations-
for primary vaccination and two for revaccination. Because of a high
vaccine failure rate and the perception that multiple insertions of8
Smallpox Eradication in India
vaccine increased the success rate, many vaccinators in India tradi-
tionally gave up to six inoculations at a single time. This was a slight
improvement over earlier practice and a welcome change from the
anachronistic method of using a scarifying device known as the
rotary lancet which frightened many from accepting vaccination and
often produced scars even with impotent vaccine (see fig. 2). But
even this reduction in number of insertions was not fully imple-
mented for a decade.
Finally, the expert committee recommended setting up an in-
frastructure for the NSEP: it calculated a need for recruitment and
training of at least 20,000 additional vaccinators, procurement of
vehicles, changeover to freeze-dried vaccine with proper storage and
distribution, and the organization oLvaccination campaign/health
education visits preceding or concurrent with the actual launching of
the campaign (Seal 1975).
One study (Rao 1959), performed in Madras, showed that most
neonatal vaccinations resulted in positive take rates with low levels
of complications. The practice of neonatal vaccination had been pre-
viously resisted by some villagers who believed there was a higher
risk of reactions in neonates and therefore preferred to vaccinate
their children at a later time. However, the government began a
moderately widespread practice of neonatal vaccination in Tamil
Nadu. It is not known how many vaccinations were given. National
tabulations of vaccinations were not begun until 1962, 160 years after
the first vaccination in Bombay.
The National Smallpox Eradication Program Begins
Smallpox in the Third Five-Year Plan,
(1961-62 to 1965-66)
In 1960, seventeen pilot projects were begun. Although their objec-
tive was to register and vaccinate each of the nearly 23 million in-
habitants of the pilot project areas in each state and in Delhi, when
the pilot projects came to an end on March 31, 1961, only half that
number had been vaccinated. But the beginnings of a national plan
were emerging, and the idea of the NSEP was firmly in place, hav-
ing been officially made a part of the Third Five-Year Plan, which
extended from 1961-62 to 1965-66. The Ministry of Health sane-
The Case Study
FIG. 2.
tion.)
9
The rotary lancet. (Courtesy of World Health Organiza-
tioned Rs. 68,900,000 ($8,600,000) to launch the NSEP. The USSR
made an initial contribution of 250 million doses of freeze-dried vac-
cine, the first installment of which arrived in February, 1962, and a
further donation of 200 million doses in 1964. The United States
Agency for International Development (AID) provided 10,000,000
rupees (about $1,200,000) to assist in payment of salaries and other
expenses.
In 1962, the first year for which national vaccination statistics
were recorded, 32.35 million vaccinations were reported; in 1963,
138.72 million-a fourfold increase. But there were inaccuracies in
the vaccination reporting system and problems with the sometimes
ineffective liquid vaccine; and despite the encouraging vaccination
statistics, reported smallpox incidence in 1963 soared to 83,438 cases
with 26,360 deaths, more than double the reported incidence at the
start of the NSEP in 1963. In 1963, India alone accounted for over 80
percent of all known cases in the world (although this is a very soft
figure because reporting inadequacies existed both in India and
worldwide), and the 31.6 percent case fatality rate that year was the
highest ever recorded in India. Something was wrong.10
Smallpox Eradication in India
The NSEP had been conceived of as a three-phase program of
preparation, attack, and maintenance. The preparation phase was to
be _an initial period of epidemiological studies of smallpox and pilot
projects to provide field experience. During the attack phase, each
sector of India's heterogeneous population was to be vaccinated; the
goal was to vaccinate 80 percent of the population within two years.
(The 1961 population of India was 439,234,771; 80 percent coverage
would have required 351,387,816 vaccinations.) No distinction was
made between primary vaccinations and revaccinations, although
the importance of vaccinating newborns was often emphasized. The
concept of "herd immunity" dominated smallpox eradicators' think-
ing at the time. Basically this meant that if enough people in a
community were vaccinated and therefore immune to smallpox the
disease could not perpetuate itself through the "herd" of people in
that community. WHO as well as many governments stressed high
vaccination coverage as the key to interruption of transmission.
Under a standard pattern of operations, each separate NSEP unit
was responsible for a population of about 3,000,000 and was sup-
posed to reach the target of 80 percent vaccination coverage.
The recorded numbers of vaccinations performed by the NSEP
in its first two years are quite impressive: over 324 million vaccina-
tions, of which more than 38 million were primary vaccinations.
Nevertheless, smallpox outbreaks continued unabated, despite the
apparent effectiveness of the NSEP vaccination effort, which was
measured only by the indication that a large proportion of the popu-
lation had been vaccinated. If, instead, the relation between vaccina-
tion and disease incidence in a population had been systematically
examined at this point, perhaps it might have pointed earlier to the
ultimately successful strategy of disease surveillance and contain-
ment vaccination that in fact did not emerge until several years later,
following an accidentally imposed test in the early 1970s.
From December, 1962, into early 1963, a large epidemic of
smallpox in Delhi prompted an independent assessment of the
NSEP by a specially appointed committee, which made some star-
tling findings. First, the total coverage of vaccinations in the commu-
nity was found to be 63 percent (as opposed to the more than 80
percent reported officially). Second, the success or take-rate of pri-
mary vaccinations was 86 percent; therefore, no more than 54 per-
cent (86 percent take-rate, multiplied by 63 percent vaccinated) of
The Case Study
11
the population had been effectively immunized during the cam-
paign. Of the 223 smallpox cases investigated in Delhi, 56 had never
been reported to the authorities and 188 of the victims (84.8 percent)
had never been vaccinated. And of course, there was as yet no
mechanism for careful epidemiologic investigation of such outbreaks
by smallpox program staff. As a result of these disclosures, the
Ministry of Health decided that the National Institute of Communi-
cable Diseases (NICO) should undertake a series of assessments in
various districts (Gelfand 1966). Their purpose was to verify the
accomplishment of representative districts that had reported reach-
ing the 80 percent attack phase goal.
In the meantime, with equipment provided by the United Na-
tions International Children's Emergency Fund (UNICEF), freeze-
dried vaccine was being manufactured in India for the first time. In
1962 the State Vaccine Institute in Patwadangar and the King's In-
stitute in Guindy began to produce freeze-dried vaccine. The Insti-
tute of Preventive Medicine in Hyderabad joined them in 1964, and
in 1967 the last of the four regional centers, the Vaccine Institute in
Belgaum, began production. Although these centers produced gen-
erally high quality vaccine, there was a need to monitor quality, as
there is in the production of any biologicals. Spot-checking was
necessary, and it was important that an outside agency indepen-
dently carry out systematic quality control. One of the recommen-
dations of the 1958 expert committee had called for monitoring the
quality of vaccine, but a proposed central-level vaccine-testing unit
did not begin functioning until it was later absorbed into the Na-
tional Reference Laboratory at the NICO. Getting central level qual-
ity control of vaccine continued to be a problem until quite late in
the program.
The NICO assessment was to become an important milestone
in the management of smallpox eradication in India. Independent
teams were assigned to areas with 1,000 to 5,000 houses, and during
a six-day period each team visited and interviewed a systematic
sample of 1,200-1,500 people. An attempt was made to determine
the coverage of the mass vaccination program and assess the current
percentage of vaccination of the resident permanent population. The
assessment teams found that vaccination coverage was exaggerated:
the actual coverage of the population was far lower than vaccination
reports. Even where the number of vaccinations was correct, it often12
Smallpox Eradication in India
reflected annual revaccinations of easily accessible sectors of the
population, such as school children and workers in industrial plants.
Meanwhile, many adults in urban slums and migrants in rural areas
had never been vaccinated. The equal emphasis on both revaccina-
tion and primary vaccination had been-quite literally, for thou-
sands-a fatal error in NSEP management policy. As a result, the
community as a whole lacked "herd immunity."
Assessment teams observed that vaccinators were poorly
trained, technically inefficient, and abrupt and callous in their ap-
proach to the public. The vaccinators' morale was often low: they
had been hired as temporary workers only for the attack phase,
without promise of continued employment. In certain areas, gross
discrepancies were found between the percentage of those reported
as immunized and the number actually vaccinated. In Chingleput,
a district that had claimed 84 percent coverage, assessment teams
found 65.6 percent; and in Banaras, a district of Uttar Pradesh that
had reported 87 percent coverage, they found 66.4 percent. In
many areas (some having claimed 100 percent vaccination) they
found as much as half the population without primary vaccination
(Gelfand 1966). Some local communities large enough to support
smoldering epidemics had been missed completely. In some in-
stances, persons deceased for several years before NSEP began had
been registered and recorded as having been successfully immu-
nized. In addition, since return visits to check take-rates were rare,
several vaccination campaigns had been carried out with either
poor quality vaccine or bad technique, in both cases affording no
community protection.
Besides inadequate vaccination coverage, the NSEP was also
taken to task for poor smallpox reporting. Many administrative and
previously unappreciated social pressures against reporting small-
pox came to light in the assessment. Village-level vaccinators, for
example, were often chastised by their supervisors whenever they
reported the presence of concealed epidemics. This was even more
true at the family level.
Cases are often hidden to escape detection: the patient and his family
often accept the disease as a visitation of the goddess Shitala
Mata .... and many wish to avoid compulsory hospitalization; the
family and neighbors often wish to avoid the investigation and vacci-
nation that may follow; the sanitary inspector may prefer not to know
The Case Study
13
about a small episode that might cause a considerable amount of vac-
cination work; and the local medical officer may fear to report an
outbreak that reflects upon the vaccination status of a community that
is his responsibility. (Gelfand 1966, 1644)
The assessment did not, however, criticize the overall goal of
the program, which was the prevailing global strategy at the time:
mass vaccination. Instead, it concluded the goal was "based upon a
plan that was generally reasonable within the context of public
health practice at the present time, but which had met many unanti-
cipated obstacles in practice" (Gelfand 1966, 1648). The assessment
team recommended (1) increasing the overall goal of 80 percent cov-
erage, thought to be too modest for an "eradication programme,"
and giving priority to the vaccination of infants, preschool children,
and the floating population (migrants, transients, and homeless
refugees who float from place to place); (2) insisting on the overall
importance of primary vaccination; and (3) abandoning the rotary
lancet, which was "time consuming and wasteful of vaccine, and
which gave a low take rate and high infection rate" (Gelfand 1966,
1648). In addition, the assessment team urged that vaccinators be
better paid and supported, that the results of vaccination be fol-
lowed up, that more emphasis be placed on the maintenance pro-
gram (maintaining high levels of vaccination coverage after the ini-
tial campaign), and that concurrent evaluation be added to program
implementation.
Also needed was a better indicator of performance than sim-
ply the number of vaccinations reported. It was suggested that
the data for monitoring progress should be provided by having
the special smallpox unit in the Directorate-General of Health Ser-
vice, Delhi, supervise all local NSEP units and gather the data to
monitor percentage of successfully immunized (as opposed to
number of vaccinations), as well as assess the validity of the peri-
odical reports of smallpox incidence. In 1964, after reviewi·ng the
NSEP report and the recommendations of the recently completed
WHO Expert Committee on Smallpox Eradication, the Central
Council of Health set a target of 100 percent vaccination for the
entire population. However, they failed to address the need for
new management techniques to reach the larger goal. There was
still no plan of operations.14
Smallpox Eradication in India
A Period without a Plan, 1961-69
The third of India's five-year plans ended in 1966, but the fourth did
not begin until 1969. The intervening years were difficult years for
smallpox eradication, but not only because there were no develop-
ment plans. The situation created by the recent Inda-Pakistan con-
flict, two successive years of severe drought, devaluation of the
currency, a general rise in prices, and scarcity of many resources
delayed the Fourth Plan and at the same time suppressed many
ambitious health programs.
The NSEP did not escape the tumult of the period. The flurry
of vaccinations that had resulted in a remarkable average of 127
million vaccinations per year for three years (1963-65) began to di-
minish as the attack phase moved on to the maintenance phase of
the program. The annual rate of vaccinations dropped 35 percent, to
83 million per year, in the 1966-69 period, while the reported inci-
dence of smallpox actually rose slightly, with 500 more cases re-
ported in 1967 than in 1963. However, there were successes, espe-
cially in the southern states; where the health infrastructure was
better developed and literacy higher than in the northern states; and
epidemics as large as those of 1950-51 and 1957-58 did not recur in
the first years of the NSEP as some had predicted they would given
the historic five-to-seven~year smallpox cycle. But two things were
becoming apparent: first, the target of 80 percent vaccination could
not be attained with the existing management of NSEP, and second,
greater vaccination coverage would not have been sufficient to inter-
rupt transmission.
After the 1966 World Health Assembly voted to create a global
smallpox eradication program, India did not immediately set up a
WHO-assisted campaign as nearly all of the thirty-four other small-
pox-endemic countries in the world started soon after. But in that
year India did make a substantial contribution to world smallpox.
The 32,616 cases reported there accounted for 35 percent of all the
smallpox reported in the world. Still, India counted on its large army
of trained health workers and the state NSEP programs to break the
back of smallpox without external assistance.
But the country's alarming situation prompted another assess-
ment of the NSEP, this time as a joint government of India-WHO
undertaking in October and November, 1967, and the close collabora-
The Case Study
15
tion that resulted laid the groundwork for future joint efforts. For this
assessment, eight experts from WHO joined a similar number from
the government of India and Indian institutions. They declared:
Mass vaccination alone does not constitute a smallpox eradication pro-
gramme. Rather the function of mass vaccination is to reduce the
incidence of the disease to a sufficiently low level to make it possible
for other measures-case detection and containment of outbreaks-to
eliminate the remaining endemic foci.
At that time, only four states and union territories (accounting
for less than 1 percent of the country) were reported free of small-
pox. The assessment team concluded, with some understatement,
that: "the NSEP is still, in most areas, far from achieving its objec-
tive of smallpox eradication."
The commission specifically cited the unsatisfactory procure-
ment, distribution, storage, and handling of vaccine. Refrigerators,
if present, were often not in working order. The commission re-
quested the central government to carefully monitor vaccine produc-
tion by each vaccine production unit, which had still not been done.
They asked each vaccine production institute to supply freeze-dried
vaccine each month to a defined group of states in order to bring
order to the chaotic distribution network. At the same time, some-
thing had to be done about the fourteen vaccine production units in
India which were still producing the expensive liquid vaccine, which
retained its potency for no more than forty-eight hours, was often
contaminated, and caused many ineffective vaccinations. An esti-
mated 35 million doses of this vaccine were still in stock, and they
were a liability, because impotent vaccine not only failed to stop
smallpox but also led to feelings that smallpox would not be eradi-
cated. In that same year, India produced 1.41 million ampoules of
freeze-dried vaccine and received nearly 6 million ampoules from
the USSR. 1
The rate of domestic production of freeze-dried vaccine in-
creased from 14 percent of annual requirements in 1966-67 to 50
percent only three years later, and India became self-sufficient in
1973. At the end of the program, India became a net exporter of
vaccine and was often called upon to donate vaccine to Bangladesh,
Bhutan, Nepal, and Sri Lanka.
The regional unevenness of the NSEP was still a great concern.16
Smallpox Eradication in India
While several southern states were making great progress, a few,
mostly in the north, were faltering. The Indian constitution made
health a "state subject," which meant the state and not the central
government was the implementing agency, and the center could not
easily impose standards of excellence or dictate program strategy or
tactics. In 1967 there was a larger than anticipated epidemic of small-
pox, which led to India's having an embarrassingly large share of
the world disease. This motivated the central government to reclas-
sify NSEP as a centrally sponsored program when the Fourth Five-
Year Plan was finally begun in 1969-74. The central government
could now prod lethargic states into action.
At about this time, there was a development more than 7,000
kilometers away that was to have important repercussions in India.
There had been a delay in the delivery of supplies for a mass vacci-
nation program in eastern Nigeria, and on December 4, 1966, Dr.
William Foege, an American advisor in Nigeria, began husbanding
his scarce supplies of vaccine by intensively vaccinating only in the
houses immediately surrounding newly reported cases. In each af-
fected village (except for two individuals who escaped vaccination)
the outbreaks ended within two or three weeks after vaccination
began. At a time when less than 50 percent of the population had a
vaccination scar, transmission was interrupted with a limited supply
of vaccine. This experience documented that an outbreak could be
extinguished by vaccinating people in a limited area around each
new case, even if the general area contained many unvaccinated
people.
A prerequisite for the success of this kind of intensive vaccina-
tion was the development of an effective surveillance system like
those gradually being established in Brazil, East Africa, and espe-
cially in Indonesia. Indonesia and India, both in the WHO South-
East Asia Region, had experienced similar administrative difficulties
with a target of 100 percent vaccination coverage and with getting
cases reported. A facial scar survey, carried out in Indonesia in
February, 1968, revealed that less than 7 percent of cases that had
occurred in 1967 were ever reported to the provincial health service.
Efforts were made to improve the notification rate, and as a conse-
quence the entire reporting system was monitored. Because of the
two nations' similar problems earlier, when a dramatically successful
surveillance-containment strategy was implemented on a wide scale
The Case Study
17
in Indonesia in 1969, it was a message to India. Smallpox incidence
in Indonesia plunged from 18,000 cases in 1969 to 2,158 cases in 1971
and to only 34 in 1972, the year transmission was interrupted. The
Indonesian success inspired many Indian smallpox workers.
India's birthrate of 34.4 per 1,000 was adding 22,000,000 new
and unprotected infants to its population each year. Subtracting the
estimated 10,000,000 annual deaths gives approximately 12,000,000
added population each year. From 1962 to 1970 an average of
14,900,000 primary vaccinations were recorded each year, not
enough to keep up with new births. But because of the large num-
ber of unvaccinated people in the country when vaccinations first
began, even if primary vaccinations were effectively carried out each
year at a rate that matched annual population growth, a large back-
log of approximately 25 percent of the population would have re-
mained unprotected.
But the Indonesian emphasis on case reporting was fresh in the
minds of Indian planners. When the Fourth Five-Year Plan did be-
gin in 1969, it was to emphasize surveillance. Along with this plan,
however, was to come another plan, and for smallpox a more impor-
tant one: the WHO-Government of India Plan of Operations for the
eradication of smallpox.
A Plan of Operations, 1970
Some management experts consider planning synonymous with
the formulation of strategies, because a plan outlines strategic ac-
tions in a program. Planning alone cannot ensure a successful pro-
gram, but it is a key element of sound program-management prac-
tices. The NSEP entered the decade of the 1970s with neither a
defined plan nor specific strategies, and the mass vaccination pro-
gram was faltering.
In their Basic Agreement of 1959, WHO and the government of
India stated a joint commitment to the eradication of smallpox. They
updated this agreement on September 9, 1970, with a new Plan of
Operations for the NSEP (see appendix 1). This plan, which pro-
posed new methods and guidelines for implementing the smallpox
campaign, represented an important agreement between WHO and
the government of India as well as an attempt to develop strategies.
The objectives of the plan were to achieve eradication and maintain
it through surveillance. Three needs were identified: (1) sufficient18
Smallpox Eradication in India
personnel, (2) application of prescribed technical methods and
procedures, and (3) freeze-dried vaccine. Also stressed were the
importance of retaining the potency of scarce vaccine through quick
transport, cool storage, and prompt use after reconstitution. ~he
government of India took reponsibility for organizing production
and distribution of the freeze-dried vaccine.
The plan established as a priority that all children under four-
teen (among whom most cases were occurring) be vaccinated, as
should those groups most likely to transmit diseases; in the case of a
smallpox outbreak, mass vaccination in the outbreak area ~hould be
mandatory in order to effectively contain the disease. It affmr~ed ~he
preferability of the bifurcated needle (a new method ~f dehvermg
vaccine by a needle that held just the right dose of vaccme between
two "bifurcated" prongs (see fig. 3), when available, to any other
means of inoculation, though this was honored more in the breach
than the observance.
The plan also recommended establishing a monthly review
process, with program evaluation to be performed by the state gov-
ernment, the government of India, and WHO, as deemed necessary
by the government of India and WHO. Surveillance an~ ?utbreak
containment, accompanied by health education and pubhc1ty, were
stressed as important components of the plan of action. The govern-
ment of India was given the responsibility of educating the public
about the disease and persuading citizens to report suspected cases,
and it was stipulated that the smallpox program would be handled
as a centrally sponsored national program until it reached the main-
tenance phase, when surveillance would be integrated into the basic
health services.
In the Plan of Operations, the resource commitments of both
parties were explicitly laid out. WHO agreed to provide epidemiol~­
gists and consultants from outside India to aid the government m
independently assessing the program and training personnel and to
offer fellowships, as necessary. It agreed to provide supplies and
equipment not manufactured in India, such as vehicles,. m~tor­
cycles, refrigerators, bifurcated needles, and spare parts. This s.hpu-
lation was later relaxed so that WHO could directly purchase ieeps
manufactured in India.
WHO also agreed to subsidize local costs, such as funds for
payment of salaries, travel, or per diems, and to provide additional
The Case Study
19
Needle is held perpendicular
to the arm
FIG. 3. The bifurcated needle. (Courtesy of World Health
Organization.)
assistance when mutually agreed upon. As time went on, WHO
broadened its funding support to include items such as gasoline.
The government of India agreed to provide (1) storage facilities
for, transportation for (before the plan transportation was rarely
available even when it was necessary to investigate outbreaks), and
distribution of WHO supplies and equipment; and (2) communica-
tions, fuel, maintenance, locally available spare parts, health educa-
tion, and incidental expenses necessary for the successful execution
of the program. It agreed to support the WHO international person-
nel with office accommodations and supplies as well as internal
transportation. (The latter meant that the government was respon-
sible for providing jeeps for WHO epidemiologists, but transporta-
tion was so essential, as it is in every health program, that when the
government was unable to provide it, WHO provided the jeeps
directly.) The government of India also agreed to provide assistance
in obtaining residential accommodations and other facilities.
The Plan of Operations supplied extra staff, supplies, and tech-
nical assistance and provided a revitalizing influx of resources for
the NSEP. Additional epidemiologists, consultants, and other tech-20
The Case Study
Smallpox Eradication in India
nical advisors with smallpox experience in countries that had al-
ready eradicated smallpox now became available. Having seen
smallpox eradicated elsewhere, they brought optimism and credibil-
ity to the Indian campaign.
Four WHO medical officers-the first WHO smallpox field staff
in India-arrived, with their optimism, in 1971. The jeeps and mo-
torcycles that were provided by WHO along with other supplies and
equipment gave the staff increased mobility, allowing them to better
supervise searches and outbreak containment. Surveillance workers
could now expect a specially trained smallpox field worker, the para-
medical assistant (PMA), to show up anywhere at any time. The use
of freeze-dried vaccine, emphasized as an important strategy in the
plan, improved vaccination take-rates to virtually 100 percent by
1971. In reaffirming the shift away from mass vaccination to surveil-
lance and identifying high-risk and highly mobile populations for
vaccination, the plan established a more efficient use of limited staff
and vaccine and increased the availability of such key resources as
transport and senior level epidemiologists-managers. 2
This move to a strategy of surveillance-containment, the most
important of the entire smallpox campaign, followed closely the rec-
ommendations of the recently completed WHO Expert Committee
on Smallpox Eradication, which had met in Geneva. Five years had
passed since the beginning of the WHO intensified global program.
The expert committee reviewed the accomplishments and problems
of the program and considered the strategy and tactics to be used in
the years to come. Its major conclusion was: "The experience of the
past 5 years clearly demonstrates that surveillance is the essential
element in the strategy for eradication," and it stressed that "report-
ing must be strengthened everywhere. Every suspected case must
be investigated at once, its source of infection traced and contain-
ment measures instituted promptly" (World Health Organization
Expert Committee on Smallpox Eradication 1972, 10-11).
The 1970 Plan of Operations laid the basis for continued co-
operation between the NSEP and WHO, allowing for the agreement
to be updated through periodic addenda, to adjust WHO support as
the program continued. With the flexibility of its provision for such
changes, the Plan of Operations became an agreed-upon set of op-
erational tactics that could be adjusted to incorporate any new, more
effective strategies developed in the field.
21
Working in the Dark, 1971-72
As it was to turn out, the 1970 joint WHO-government of India Plan
of Operations was little more than a point of departure. Despite its
sound strategy and the incorporation of experience from Africa and
Indonesia, a major element was missing. No one knew how much
smallpox was present in India or where it was. Without this
knowledge, resource needs could not be planned and targets could
not be established. A realistic timetable for eradication was still out
of reach.
India was not the only place with poor smallpox reporting at
that time. One study indicated reporting efficiency of only 1.3 per-
cent in rural areas of nqrthern Nigeria; another estimated less than 6
percent efficiency in West Java. Henderson (1976) suggested that the
131,418 cases of smallpox reported worldwide at the start of the
global program in 1967 might more accurately have been on the
order of 10 to 15 million cases, reflecting a global reporting efficacy
of 1 percent. Others estimated an 11.8 percent surveillance efficacy
in Bangladesh as late as 1972 (Hughes et al. 1980). It is very likely
that less than 1 case in 10 was reported to central health authorities
in India in 1967 (Basu 1974).
The NSEP had done little to encourage reporting of smallpox.
Under-reporting led to deceptively low mortality figures and in turn
to a feeling that smallpox was not a major health problem in India.
This produced a negative response from field workers. As less
smallpox was reported, fewer resources were allocated and fewer
vaccinators were available when an infected area was reported. The
fewer the number of vaccinators to visit an area, the fewer the cases
of smallpox that were found there. Only when smallpox happened
to come to the attention of the Ministry of Health because of a news-
paper report, a "call attention" motion in Parliament, or an interna-
tional exportation (between 1962 and 1974, ten outbreaks of small-
pox in Europe were imported from India) were more resources
devoted to the eradication effort. If more vaccinators had been sent
to infected areas, more smallpox might have been found, and in
turn more resources and vaccinators sent to each outbreak area,
until the foci were contained.
In some parts of the world, a case of smallpox would be quickly
brought to the attention of a health worker or doctor for curative and22
Smallpox Eradication in India
preventive action. In India, however, cases of smallpox were often
suppressed. The reasons were complex and rooted deeply in cultural
tradition and belief.
First of all, the public was aware of vaccination failures (e.g.,
from liquid vaccine made impotent by the heat). In addition, cer-
tain apparent failures influenced public perception. For example,
smallpox and chickenpox were often perceived to be the same
disease; in fact, both diseases have the same name in Hindi-
chechak (Morinis and Brilliant 1981). Their patterns of seasonal inci-
dence are identical, and since many of those vaccinated against a
smallpox outbreak would subsequently get chickenpox, it was not
unreasonable for some to conclude that vaccination must be use-
less. In addition, the incubation period of smallpox is seven to
seventeen days, and symptoms of smallpox may not develop for a
full two weeks. An infected but asymptomatic person, vaccinated
ten days after exposure, would still develop the well-known
symptoms of smallpox four days later, leading many to conclude
not only that the vaccine was worthless but that it could actually
cause smallpox.
Sometimes resistance to vaccination was really resistance to
badly trained or poorly motivated vaccinators, as the following anec-
dote illustrates.
The public vaccinator ... was a supercilious young man from Udai-
pur city ... , who had passed a course. in this speci~lty, and he re-
garded villagers as an inferior and stupid lot-especially whe.n they
refused to accept his scarifications. During his four day stay 1~ Del-
wara, the task degenerated into a hunt. I would see a herd of ch1ldr,en
and young mothers come bolting out of an alleyway with hilarity and
panic mingled in their shrieks, while the vaccinator pursued them,
brandishing the weapons of his trade. (Carstairs 1955, 108)
To encourage Indian smallpox workers, WHO often cited other
parts of the world where resistance to vaccination was mu~h g.reat~r
than on the subcontinent. The elimination of mass vaccmahon m
favor of containment also reduced resistance, since it was no longer
necesssary to vaccinate people in areas long free of smallpox. More-
over, since fewer numbers needed vaccination, proportionately
more effort could be given to each resistor. A survey of vaccination
resistance in Lucknow district in 1965 found that 18 percent of the
The Case Study
23
population resisted smallpox vaccination, forming what was termed
hard-core resistance to vaccination. It was noted that
Experience has shown that the resistance against the acceptance of
vaccinations and revaccinations can only be broken through personal
contacts and field demonstrations by vaccinating staff, including the
officers practicing on themselves. (Gupta, Bagga, and Suraiya 1965, 7)
This experience had come from the Pilot Project for Smallpox
Eradication in Sultanpur district, Uttar Pradesh, in 1962 (Gupta
1962). In this case, one of the NSEP pilot projects had paid good
dividends. The subsequent practice of demonstration vaccination,
whereby the vaccinator revaccinates himself in front of villagers to
allay anxiety about the vaccine, was of great help in subsequent
containment actions. This practice (with the less awesome bifur-
cated needle) plus better training of vaccinators, greater support
for their activities from higher officials, and the restricted number
and location of communities requiring intensive containment,
were all factors in reducing resistance in the Lucknow pilot pro-
ject from 18 percent to a negligible amount in the later stages of
the intensified campaign. It is also important to understand his-
toric reasons for villagers' skepticism about vaccination. One of
the common names of smallpox-bashanto-translates as "spring
sickness": it was in the spring that smallpox used to take its
greatest toll. The spring is also wheat harvest time in northern
India. According to the zamindari feudal system, still practiced in
some areas, agricultural laborers get one kilogram of wheat for
every sixteen that they harvest during the month of March. A
major portion of the year's earnings thus depends on one's physi-
cal ability to bring in a maximum harvest during March, and
when the vaccinator came to the village during the spring harvest
season, each adult wage earner had to make a choice. If he had
never had a vaccination before, it was fairly certain he would
experience a major reaction (swollen arm, fever, malaise) for two
days. The certain loss of work for those two days had to be
weighed against the far more remote possibility of a fatal or seri-
ous case of smallpox. Often, agricultural laborers chose to forego
the vaccine.
Naturally, some of these attitudes about smallpox carried over
to some Indian officials who also felt that nothing could be done24
Smallpox Eradication in India
about the disease. As Henderson (1976) said about the area in gen-
eral: "Support for the programme by health authorities was luke-
warm; so many efforts to control smallpox had failed over so many
years that the disease was widely considered inevitable and its elimi-
nation impossible" (p. 30). With such general resignation about the
inevitability of smallpox, why report the disease?
India and Ethiopia were the last of the endemic countries to
embark on a WHO-assisted program. In 1971, as noted above, the
first four WHO medical officers had reached India. Along with their
counterparts, the state program officers, they began to implement
the WHO-government of India Plan of Operations and stressed sur-
veillance and reporting. But it was a long and leaky channel of
communications from the villages to the Central Bureau of Health
Intelligence (CBHI) in Delhi, which compiled the weekly statistics.
Breman (1976) estimates that half of all cases detected at one level
were not passed on to the next level. There was a tendency to
conceal smallpox cases at all levels in the earlier days of the pro-
gram. Families concealed cases from health authorities out of respect
for Shitala-Ma and to avoid the arrival of vaccinators; vaccinators
suppressed outbreaks for fear they would be blamed for failing to
vaccinate 100 percent of the population; old cases detected in previ-
ously unknown outbreaks. were generally not included in reports.
Even after detection, officials did not adequately contain the disease
and did not feel they needed to report all outbreaks to the higher
authorities. In addition, the reporting system itself proved to be a
cumbersome procedure. Although the Plan of Operations called for
smallpox to be reported by "telegram or special messenger," more
than half of the states chronically reported late, sending reports by
ordinary mail.
The Plan of Operations called for the government of India to
"keep WHO informed of weekly incidence" (see appendix 1), but
before the reporting system could even begin to keep abreast of
smallpox trends, it had to be streamlined in two respects. First,
the absence of a report could mean either the absence of smallpox
or the absence of the reporter. Health officials often omitted the
burdensome weekly report when there was no disease to report.
But there was a critical need to keep weekly reporting channels
open. For the purpose of resource allocation decisions, the fact
that smallpox was not present in a primary health center (PHC),
The Case Study
25
district, or state was as important as the fact of its presence. A
weekly nil" report was made a requirement of the centrally
sponsored NSEP. Every Saturday, the 5,268 PHC medical officers
were supposed to send their weekly epidemic report (WER) forms
to the district, which forwarded them to the state on Wednesday;
the compiled reports were then sent to Delhi the second Monday
after the week in question. The signed report was marked "nil" if
no smallpox was detected; this was the beginning of a manage-
ment information system, a chain of information that ultimately
determined the placement of epidemiologists, the allocation of
jeeps, the movement of vaccine, and the attention of smallpox
epidemiologists at state, national, and WHO levels.
But another reporting problem existed. Until 1972, the system
required that cases detected months after their occurrence be added
as "supplementary reports" to the previous month's or previous
year's reports (Ministry of Health and Family Planning 1972; 1975).
Current cases were reported in the week they occurred, but investi-
gation of a new outbreak might yield previously undetected cases
with onset months earlier. This called for time-consuming amend-
ments and supplements to previous reports. The amendments be-
came so burdensome that they were simply ignored, or current
reports were delayed by recalculations of totals from several pre-
ceding months. This system encouraged massive under-reporting
and its corollary, complacency. From 1972 onward a uniform re-
porting system was put into practice under which all cases detected
during the week regardless of date of occurrence were included as
a lump sum in that week's report. To central officers in Delhi, an
epidemic of old, burned-out, but previously missed cases was as
potentially serious as a current epidemic, because it meant a weak
link in the chain of surveillance that stretched from villages in the
most remote parts of India all the way to New Delhi, as shown in
figure 4.
But even with a strengthened reporting network, improved
communications, and routinized weekly reports, the smallpox
leadership in Delhi was still working in the dark. As late as 1972,
"case detection was inadequate, and the reporting systems were
archaic; the importance of surveillance and containment was not
appreciated" (Henderson 1974). There was still a long way to go
from surveillance in the plan to surveillance in the field.
1126
The Case Study
Smallpox Eradication in India
21,161 Vaccinators and
Other Health/Nonmedical Workers
i
Primary Health Centers (PHC)
(5,268 notification posts)
~
District Health Officers
(356 units)
~
.
Smallpox Program Officers
(30 states and union territories)
'
Central Bureau of Health Intelligence (CBHI)
Ministry of Health (Delhi)
i
World Health Organization
The reporting network that stretched from peripheral
villages to New Delhi, as it was in 1971
FIG. 4.
In 1972, the worldwide number of smallpox cases jumped 69
percent over the 1971 figure, and India accounted for over 42 per-
cent of the world's reported incidence. In many Indian states, the
jump may have reflected improved surveillance and the new lump
sum reporting of old, previously unreported cases. The principal
endemic foci were in the north central region, within a 500-kilometer
radius of Delhi, and in the states of Bihar, Madhya Pradesh, Uttar
Pradesh, and West Bengal; over 79 percent of the 1972 cases were
reported from these four states.
In the south there had been an excellent record of achieve-
ment in smallpox eradication, apparently from mass vaccination. In
1971-72, Kerala and Tamil Nadu interrupted transmission, and
Karnataka and Maharashtra reported a considerably reduced small-
pox incidence.
However, major epidemics occurred in the Gulbarga district in
Karnataka. One of the four new WHO medical officers came to the
area and carefully investigated the outbreak, which had begun in
December, 1970, and continued through 1971, reaching a peak in
April, 1972. A total of 1,359 cases of smallpox with 123 deaths had
occurred in 1, 128 villages and 5 municipalities, but the initial out-
break had been deliberately concealed. One of the sparks of the
epidemic had ignited an outbreak in Kurkunta, a village on the
border of Andhra Pradesh. From a cement factory there the disease
27
had spread to a number of villages in Andhra Pradesh, where a
large outbreak began to develop. Andhra Pradesh authorities inves-
tigated and traced the source of the outbreak back to Gulbarga.
However, no smallpox case had been reported from Gulbarga in
1970 or the first eleven months of 1971. Field staff had in fact de-
tected smallpox, but the medical officers of the PHCs did not report
them to the state, perhaps due to fear of reprimand, which was a
common response to such reports. This deliberate concealment and
poor reporting led to the epidemic that brought attention from
Delhi. To contain the outbreak rapidly, prompt detection of all cases
in an area of two million people was required. All available health
personnel, not just smallpox health workers, were mobilized for a
weeklong, house-to-house search of the area. By carefully focusing
containment vaccination around each newly discovered case, they
eliminated smallpox from the district within weeks.
This experience appears to have provided India with its first
successful containment operation. Moreover, while it certainly re-
vealed the problems of incomplete reporting and concealment, it
also showed what could be accomplished by deploying health
workers ad hoc to conduct a thorough search of an outbreak area.
As in many similar episodes in the smallpox eradication program,
the leadership of the program highlighted the positive lessons,
transforming a liability into an asset. Skeptics had said surveillance-
containment might work in Africa, but not in India. The Gulbarga
experience proved the opposite: surveillance and containment could
work even in that densely populated country.
From October 30 to November 2, 1972, as Indonesia was fast
approaching the target of eradication while India was far away from
it, a WHO Inter-Country Seminar was held in New Delhi. The semi-
nar recommended that since previous experience had demonstrated
the effectiveness of surveillance as a means of achieving eradication,
full implementation of surveillance should be ensured. Every state
was to be considered either endemic or nonendemic. Priority would
be given to endemic areas, which would receive the largest amount
of available resources, although active searches would also be per-
formed in nonendemic areas in order to make sure they remained
smallpox-free. The occurrence of a suspected case in a nonendemic
area would be handled as a national public health emergency to
prevent the reestablishment of endemic foci.

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Re: The Management of Smallpox Eradication in India
« Reply #1 on: November 10, 2022, 08:58:59 PM »

28
Smallpox Eradication in India

The group advised that staff and supplies from the smallpox
program should under no circumstances be diverted to other pro-
grams-a point of major importance because smallpox program
resources were continually being diverted to other health programs
(especially family planning), making it difficult if not impossible for
the smallpox program to meet its goals. In areas where surveillance
teams had not been formed, state or national teams were to be
created as soon as possible and provided with transport.
In order to effectively contain smallpox outbreaks, staff were to
vaccinate 100 percent of all contacts and persons in the immediate
area, and were to make follow-up visits to ensure that no persons
had been missed. Lower socioeconomic urban areas (where vaccina-
tion coverage was lower) were to be given special attention. Once an
area became free of smallpox, an active search for cases was to be
carried out by visiting schools, markets, shopkeepers, religious and
other local leaders, health stations and other sources of information;
in addition, the smallpox recognition card was used in order to
obtain better information on cases. This card, developed out of field
experience in Indonesia, was a photograph of a child with a typical
case of smallpox; by highlighting recognizable signs of the disease
for a medically untrained search worker and the community, it be-
came one of the most important weapons against case suppression.
The seminar also stressed the problem of failure to identify and
confirm the source of infection, particularly when state lines had to
be crossed. Written cross-notification was inefficient, as often some
identifying information would be omitted or villages wrongly identi-
fied owing to phonetic spelling; district staff receiving the informa-
tion were often uninterested or occasionally were themselves sup-
pressing information; and so on. Any time an outbreak could not be
traced to another known outbreak it meant that some unknown
active smallpox cases were likely being hidden from epidemiolo-
gists. If they went undetected, active foci could persist and continue
to spread infection.
The seminar further noted that this problem could only be over-
come by creating state surveillance teams charged with the responsi-
bility for investigating the source of infection for all outbreaks, par-
ticularly those whose source was outside the infected district. Until
an adequate number of state teams could be constituted, district staff
had to be directed to pursue and positively identify the source of
The Case Study
29
infection in adjacent districts, whether or not state borders inter-
vened. If this were done in company with the district staff of the
district exporting smallpox, immediate containment measures could
be undertaken. The seminar believed that if outbreak investigation
were not actively pursued and supported by the state and national
program staff, transmission could not be interrupted in India.
The November, 1972, seminar concluded on a positive note.
Provided that such a surveillance component is implemented in the
programmes of India and the adjacent countries, it is possible that the
incidence of smallpox could reach zero within 18 months. (Henderson
1976, 31)
The general strategy was developing for the intensified cam-
paign that began in September, 1973, especially the ideas of active
search and containment; surveillance teams to take responsibility for
investigating sources of infection; and dividing the country into en-
demic and nonendemic regions for a progressive constriction of the
endemic area. As predicted, the change in strategy in favor of sur-
veillance would be the key. Without knowing where the cases were,
everyone had been working in the dark. Once search and contain-
ment became the strategy for eradicating smallpox, it was, as the
global commission's final report stated: "only a matter of time and
colossal effort" (Global Commission for the Certification of Smallpox
Eradication 1979).
The last endemic case of smallpox in India occurred in May,
1975, less than twenty months later.
As the Health Planners Saw It, 1973
One goal of this case study is to provide a basis for understanding the
differences in perspective that produced different priorities for health
planners and program managers. A WHO smallpox administrator in
Geneva looking at India in 1973 saw a single country that accounted
for 57.7 percent of the reported global incidence of smallpox (and by
the following year it would account for 86.1 percent). But to the
planner in the Indian Ministry of Health (Sanjivi 1971) or to the
Health Cell in the Ministry of Planning, smallpox was not the major
health problem in the country. This is part of the old debate between
"vertical" and "integrated" approaches to health administration
(Basu and Khodakevich 1977; Sharma 1973; Jezek and Basu 1978).30
Smallpox Eradication in India
The 1972 WHO Inter-Country Seminar in New Delhi had sum-
marized the state of the art of smallpox eradication. One of the semi-
nar's major contributions was to create a climate of optimism. It made
it seem possible that India could indeed eradicate smallpox in less
than two years by concentrating its great resources of trained public
health workers on breaking chains of transmission within endemic
areas and fighting a defensive battle against importations into non-
epidemic states. This strategy, however, was still not completely ac-
cepted by many in the government of India. There were two basic
problems in convincing Indian health planners and policy makers.
One was skepticism about the effectiveness of the strategy. Another
was disagreement over the relative priority of spending resources on
smallpox as opposed to other diseases. Yet planners agreed that in
the long run, if eradication were possible, it would yield a much
greater benefit than its cost. So in one sense both problems were in
fact the same: the planners doubted that the new strategy could suc-
ceed in eradicating smallpox. Also there were many-in WHO as well
as in the government of India-who felt that eradication could never
really be achieved, so that mass vaccination was the best way to at
least make some gradual improvements.
Part of the complacency in the official attitude toward eradica-
tion was due to the fact that there had been an apparent year-by-year
reduction in reported smallpox: from 83,943 cases in 1967 to 30,295 in
1968, 19,139 in 1969, 12,341 in 1970, and 16,166 in 1971. From the
Indian health planners' perspective, the trend was clearly a declining
incidence. On paper, smallpox seemed to be disappearing at about
the same rate as reported NSEP vaccinations were gaining cumulative
momentum toward a perceived herd immunity. Neighboring Burma
had eradicated smallpox and credited mass vaccination (World
Health Organization 1977). Bangladesh was reported free of smallpox
in 1971, although returning refugees from the Salt Lake Camp near
Calcutta had reinfected the country in 1971-72. Most importantly in
the eyes of Indian health planners, the Indian southern states had
done very well with their NSEP, and it seemed only a matter of time
before the Northern States followed suit.
The complacency with which Indian health planners seemed to
await smallpox decline reflected the realities of dealing with compet-
ing demands for health resources in India. However high a priority
it was for the world community as a whole, smallpox eradication
The Case Study
31
was not a priority for India so long as the number of cases appeared
to be declining. The relative impact of smallpox was negligible; other
major diseases, such as malaria, were returning in epidemic form
and demanding the attention of health planners and the political
level at the Directorate General of Health Services (World Health
Organization, Regional Office for Southeast Asia 1978).
An important prescription for India's future health-planning
efforts was put forth in a health-planning monograph (with a fore-
word by the then president of India, V. V. Giri) published in 1971,
when the first WHO smallpox medical officers were arriving in the
country (Sanjivi 1971). This document argued against "copying
other countries" by either adopting their system of medical care or
accepting their list of priority diseases. In this proposed health plan,
smallpox was very low on India's own list of priorities.
It is impossible to make judgments about relative disease im-
portance in India in 1973, but a comparison of smallpox deaths with
estimated deaths from other causes is useful, since health planners
must consider relative disease mortality rates. Of the estimated
population of 600,000,000, there were an estimated 10,000,000
deaths, one-third (3,500,000) of which were infant deaths. Even after
the fivefold increase in reporting as a result of the nationwide active
searches, smallpox deaths in 1973 totaled 15,434 (0.15 percent of
India's total deaths). By contrast, Indian health planners estimated
that tuberculosis claimed approximately 500,000 (5 percent). Another
very large share, perhaps as many as 1,000,000 deaths (10 percent)
was due to tetanus. Consider also the reported pattern of morbidity
for the same year (bearing in mind the distortion caused by prob-
lems in under-reporting). Reported cases of whooping cough totaled
195,819, of cholera 40,819; and the estimates of malaria incidence ran
close to 4,000,000 cases. The prevalence of leprosy was an estimated
3,720,000, of tuberculosis 5,000,000. And overall, the life expectancy
in much of India was less than fifty years, with infant mortality close
to 140 deaths per 1,000 live births. Diarrhea, not reportable as a
specific disease category, may have accounted for up to half of the
childhood deaths (Research and Reference Division, Ministry of In-
formation and Broadcasting 1975; Central Statistical Organization,
Department of Statistics, Ministry of Planning 1977).
In 1973 India had a gross national product of approximately $66
billion, roughly $110 per capita. Total central government expendi-32
Smallpox Eradication in India
tures were $2 billion, of which $168 million (8.4 percent) went to
health (Nyrop et al. 1975; Publications Division, Ministry of Informa-
tion and Broadcasting 1978). While this amount was only $.25 per
capita, it was large by developing countries' standards.
Thus the competition for health resources in 1973 was tremen-
dous. Expenditures on smallpox in that year were approximately
$3.3 million out of $35 million allocated for communicable diseases.
Nearly five times as much, $17 million, was spent on malaria,
which, since it is handled through a centrally sponsored national
program, provides one of the few comparable expenditure classifica-
tions. Other health programs are less comparable, because health in
India is a state subject, with more health outlays at the state than at
the central level.
It is important to bear in mind the various perspectives on
smallpox that existed in 1973. On the one hand, there were the
continual differences between the epidemiologists and the health
planners, or rather between the technical level and the political
level. Epidemiologists-disease control officers-are supposed to
control whatever disease they are responsible for; health planners
are supposed to be sensitive to the total health care needs of the
population. The situation was further complicated by the fact that
reliable data for making rational health-planning decisions were
unavailable.
Similarly, the perspective of the World Health Organization
Smallpox Eradication Unit in Geneva was quite different from that of
the health planner in New Delhi. The global eradication of smallpox
would not eliminate malaria or diarrhea from India, nor was it in-
tended to. Armed with resolution WHA 19.16, which made small-
pox eradication a regular WHO budget expense for the first time,
the Geneva smallpox unit was determined to succeed in implement-
ing its mandate to eradicate smallpox from the world; salient to that
goal was the fact that India accounted for more than half of the
world's reported smallpox. Furthermore, nearly every subsequent
World Health Assembly had reiterated that smallpox eradication
was "a priority" and through resolutions WHA 21.21, WHA 22.34,
WHA 25.45, and WHA 26.29 had continually stressed the need for
all endemic countries to further intensify eradication efforts and
make smallpox eradication national priorities as well as the global
priority of WHO.
The Case Study
33
Although India had supported those resolutions, and the
WHO smallpox unit was in a sense only implementing India's own
policy, still many policy makers felt that smallpox eradication was
more a priority for the United States or USSR than fo~ India, which
had so many competing public health priorities.
Such differences in perspective are inherent in any disease-
control program, and shouid be kept in mind as background to the
discussion of management issues. Understanding the perspectives of
both those who were determining world health policy in Geneva and
those who were making national health policy in New Delhi provides
insight into both the epidemiological and the management impact of
the strategy of search and containment. To the planner in New Delhi,
from whom the disease remained partially hidden through non-
reporting, it appeared statistically far less important in India than it
was, especially relative to other national health issues.
It is clear that eradication of smallpox in fact yielded enormous
economic benefits to India. But for India's health planners, occupied
then by emergencies and competing political demands on scarce
resources, the long-term benefits from disease eradication were not
a great motivation. Health planners are sensitive to immediate politi-
cal realities, and the benefits of smallpox eradication would be real-
ized only at some future time when the $3 million annual expendi-
tures for smallpox could be applied to other health problems. In the
meantime, however, the cost of putting so many scarce resources
into one program rather than into many health needs was high.
Smallpox eradication expenditures looked large to the health
planners in 1973, but in reality the excess costs of eradication over
continued smallpox control programs was marginal, and the benefits
were to be enormous. But it was not easy to convince health plan-
ners of the economic wisdom of this decision, and moreover, they
were not convinced that the strategy would work at all. Surveil-
lance-particularly an active search that used all of India's health
workers-was a major gamble. Only smallpox eradication would
yield the prize; smallpox control could not.
The availability of a workable strategy of surveillance and con-
tainment was to change all the calculations of the health planners.
Once India agreed to the strategy of active case search (that is, going
out into the villages to find hidden smallpox instead of waiting for
cases to come to the notice of health officials), a cumulative series of34
Smallpox Eradication in India
events was set in motion. The subsequent action of the government
in making reporting a commendable action rather than one that
might lead to reprimands or punishment and in providing rewards
for reporting encouraged health workers and the general public to
change old habits of concealing cases (Global Commission for the
Certification of Smallpox Eradication 1979). In the following year
(1974), when active case searches throughout all of India became one
of the major activities of the health services, enough smallpox would
be found to satisfy the demands of both project management and
health planners. The meticulous house-to-house searches that began
that year detected one of the last great epidemics in history, and
smallpox, no longer a hidden epidemic, emerged as both important
and urgent. Health planners, policymakers, and epidemiologists
joined together to gamble on eradication.
The Intensified Campaign
An Optimistic Beginning, Spring, 1973
There was reason for optimism as 1973 began. The tropical tempera-
tures that rapidly inactivated liquid vaccine had become unimpor-
tant due to the advent of sufficient locally produced freeze-dried
vaccine (and India had discarded its stockpile of dangerously unreli-
able liquid vaccine). The rotary lancet was finally being replaced by
the simple bifurcated needle. The weekly reporting system was im-
proving, and with the new changes in vaccination techniques even
newly trained vaccinators working in remote villages in 120-degree
heat achieved vaccination take-rates approaching 100 percent. Effec-
tive vaccination, the major weapon against smallpox, was in readi-
ness for the smallpox eradication campaign. The new strategy of
surveillance and containment, written into the 1970 Plan of Opera-
tions, had been reaffirmed at major regional smallpox meetings in
1970 and 1972. Experience within India itself-in Gulbarga and a
pilot area in Uttar Pradesh-confirmed that it could work. A plan for
dividing the country into endemic and nonepidemic regions, for
organizing active surveillance, and for providing rapid and effective
vaccination in response to discovery of outbreaks seemed practical.
Careful epidemiological analysis was fast changing old notions
about smallpox, and the secrets of smallpox transmission were being
The Case Study
35
discovered. Even in densely populated India, the disease was not
nearly as contagious as people had thought. The virus is transmitted
only from person to person. There is no vector (such as the mos-
quito for malaria, which still resists public health interventions), and
despite popular fears about infected bedding, such fomites were
proven not to be of any great epidemiological significance. It ap-
peared increasingly possible that by concentrating India's effective
vaccine on high-risk populations in the endemic regions of the coun-
try and restricting vaccination activities to infected villages, enough
links could be broken in the chain of transmission to break the back
of the disease. Tracing all known sources of infection backward to
previously undetected outbreaks and following people potentially
exposed to the virus forward to possible new outbreaks completed
the epidemiologic system. Management adopted an effective, scien-
tific strategy for smallpox eradication, and it made excellent cost-
effective sense from any perspective. Vaccine was a potent resource,
to be carefully allocated. With surveillance to identify the high-risk
groups, the intensified campaign consisted essentially of the strat-
egy and tactics for delivering vaccine to those at highest risk and
doing so effectively and efficiently. Now the strategy and the tactics
only needed to be implemented.
Carrying out the plan required both personnel and transport,
and transport was crucial both for using personnel and for providing
supplies. In recognition of the critical and constantly recurring need
for reliable transportation, the First Addendum to the 1970 Plan of
Operations was a WHO contribution of fifty-one Toyota land
cruisers and forty-seven Honda motorcyles. The Second Addendum
added ten Volkswagen buses, and the Third Addendum prepared
for a course to train the forty program officers in the new strategy.
On January 8, 1973, the Fourth Addendum was signed, providing
vehicles to the four WHO long-term staff members. A month later,
the Fifth Addendum established provisions for WHO assistance for
the coming two years of an intensified campaign: consultants, tem-
porary advisors, fellowships, training courses, and more supplies
and equipment.
But there was a major unresolved problem: the WHO long-
term staff, with only smallpox to worry about, were able to devote
their full time to tracing contacts, studying the epidemiology of the
disease, and supervising preparations for the intensified campaign,36
Smallpox Eradication in India
but the district and state level epidemiologists who were to imple-
ment the NSEP had many priorities competing for their time and
attention. Additional WHO long-term staff were needed.
At the World Health Assembly meeting in Geneva in May,
1973, the chief of the WHO Smallpox Eradication Unit met with the
secretary to the government of India's Ministry of Health to discuss
planning for the "intensified smallpox campaign" scheduled to be-
gin in a few months in India and the three other endemic countries
(Bangladesh, Ethiopia, and Pakistan). The World Health Assembly
had once again stressed that smallpox eradication was the top con-
cern of WHO and its member states, but special apprehensions were
voiced about India. Pakistan was doing very well (except in Sind
province), and Ethiopia was expected to interrupt transmission
within one year, but many in attendance at the assembly feared that
India would remain the last place on earth with smallpox. On the
other hand, pointing to the recent successes in Haryana, Rajasthan,
Gujarat, and many southern states, the WHO smallpox unit was
confident that with India's well-developed health infrastructure, and
given due attention by national and state levels, an intensive pro-
gram could readily achieve success in India.
A coordinated, concerted dual strategy was worked out. First,
a special program was established for the principal endemic states of
Uttar Pradesh, Bihar, West Bengal, and Madhya Pradesh, to reduce
sharply the incidence of disease in these four states, which had
accounted for over 79 percent of the smallpox reported in India in
1972. This reduction was to be accomplished during the low trans-
mission season between September and December-of 1973, with the
hope of eliminating persistent foci over the succeeding twelve
months. Second, there was to be continuing, defensive effort in the
other states where incidence was low, to eliminate remaining foci
before the year's end and to maintain their smallpox-free status
through rapid detection and containment of any imported cases
(NSEP, Government of India, and WHO 1973). This second target
area contained over half the population of India, although during
the previous year fewer than one case in twenty had occurred there.
Although the entire area was considered nonendemic, these twenty-
six states and union territories were further classified as either small-
pox-free (seventeen states and union territories that had either
reported "nil" cases or occasional importations that all had docu-
The Case Study
37
mented sources outside the state) or low incidence areas (nine states
and union territories that surrounded highly endemic states and
could not trace every outbreak to an importation from an outside
state). The defensive effort in the nonepidemic states was to be vital.
There had been an observation that smallpox epidemics-known to
occur in five-to-seven-year cycles-moved through India in a clock-
wise fashion. Though data was incomplete, a decision was made to
post extra WHO advisors in West Bengal, Madhya Pradesh, Bihar,
and Orissa to defend against the next round of smallpox. It was the
correct strategy.
For the principal problem states, a three-phase program was
planned. The first phase (added to the overall plans almost as an
afterthought) involved conducting an active search for outbreaks in
municipal areas during the summer of 1973, to eliminate the urban
foci that often sustained chains of smoldering infection through the
monsoon season, disseminating the disease to the rural areas in the
autumn. From September through December, 1973, a second phase
(thought by WHO to be the most important part) was to consist of
three weeklong, statewide searches. Since these three searches
would require more vaccinators, all health and family-planning
workers were to be deployed for each one. The third phase, to be
adapted to the results of the searches, was expected to be a
mopping-up operation from January to December of 1974. Some
optimists believed that if each of the three successive searches un-
covered fewer and fewer cases, they could hope for a new year
without smallpox in 1975.
It was agreed (later confirmed in the Sixth Addendum to the
Plan of Operations) that four additional long-term WHO medical
officers would be assigned to the intensified campaign in India to
assist at the state level in each of the four most endemic states.
Because it was immediately vital to increase the mobility of the
smallpox teams, an exception had to be made to the usual WHO
policy under which the host nation was expected to provide any
locally manufactured goods. Indian-made jeeps met the demand of
immediacy; in order to allow WHO to purchase these vehicles, a
compromise was reached under which the government of India re-
laxed its excise taxation rules, WHO purchased Indian-made jeeps
with foreign exchange, and at the same time the government of
India increased the monthly gasoline allowance for smallpox jeeps.38
Smallpox Eradication in India
Municipal areas, until then semiautonomous in their smallpox activi-
ties, were also brought under the control of the central NSEP.
One problematic detail remained, that of not enough leader-
ship at the top of the program. During a 1972 inspection visit to
India, the chief of the global program had noted:
In no other eradication programme anywhere in the world are there
so many "privates" and "sergeants" and so few officers. Failure to
develop a reasonable surveillance programme, a more sophisticated
and far more successful approach to smallpox eradication than the
previous strategy of mass vaccination, can be ascribed in large mea-
sure to this deficit. (Henderson 1972, 8)
The difficulties of India's assistant director-general (smallpox)
in coordinating a disease-control program in twenty states with
20,000 vaccinators and many local languages and different health
systems were already enormous. Now, with simultaneous searches
to be made in four states and a defensive action being fought in the
nonepidemic areas, strengthened leadership was needed at the cen-
tral level in New Delhi (Henderson 1972).
The government agreed to provide at least one state-level In-
dian epidemiologist for each of the four priority states and to aug-
ment the central level where the entire NSEP had been functioning
with only two full-time medical officers and little support staff. A
central appraisal team of top Indian epidemiologists was drawn
from other programs and institutes throughout the country. WHO
paid a per diem and provided transportation. The officers who were
recruited-the director of the NICO and two of his deputies and the
assistant director-general (cholera)-joined the director of the CBHI,
the assistant director-general (vaccine production), and the assistant
director-general (smallpox) and his deputy to become the officers
and leaders of what was to become India's largest health army.
This was to be the first of many reminders that men were more
valuable than money. Perhaps more than any other management
decision, it was the allocation of the finest epidemiologists in the
country to leadership posts in the program that led to victory over
smallpox. These Indian officers (officially labeled "central appraisal
officers"), together with four counterpart epidemiologists (French,
Czechoslovakian, and two Americans) and an administrative officer
in SEARO, constituted what became known as the central appraisal
The Case Study
39
team. This was the top management team which, along with WHO
in Geneva, developed the strategy and plan of operations for the
intensified campaign. A special relationship grew among this team.
As they shared train compartments and dusty jeep rides, their
hopes rising or falling inversely with the epidemic curve, they devel-
oped a unique friendship and camaraderie. Many were later to ac-
knowledge this shared sense of responsibility as one of the deepest
personal lessons from the campaign.
Beginning in June, 1973, the multinational group held frequent
meetings to prepare, review, and revise six drafts of the Plan of
Operations before a "Model Operational Guide for Endemic States"
and "Model Operational Guide for Non-Epidemic States" were fi-
nally approved for the autumn campaign. These documents, issued
under the joint auspices of WHO and the government of India,
outlined a three-month plan of operations for mounting an ambi-
tious drive to find every case of hidden smallpox in the endemic
areas. To do this, twenty-two special teams were created, twenty of
which would work in the endemic states. Half of the teams were
headed by Indian epidemiologists recruited by the government of
India from Indian institutes or from retirement. The other half were
headed by non-Indian epidemiologists recruited by WHO.
A total of 230 epidemiologists from thirty-one countries 3 other
than India would eventually head such teams. As many as 90 epide-
miologists would be in place at one time, but as the autumn cam-
paign began, there were less than one-quarter of that number (Basu,
Jezek, and Ward 1979). Each epidemiologist worked in a zone cover-
ing an average of five or six districts (occasionally more than 10
million people per zone) and had as his peers or counterparts the
regional, division, or district health officers responsible for the area.
The special teams conducted training sessions, explained and organ-
ized the search for disease, supervised the implementation and eval-
uation of surveillance activities, oversaw rumor collection and the
diagnostic verification of all detected rash-with-fever cases, and,
when smallpox was detected, organized outbreak containment and
cross-notification. Since the special active case search required the
participation of all health and family-planning staff, it was a large
organizational job; there were many managerial tasks and diplo-
matic missions to be performed in addition to epidemiology.
From August to September, at the state level, the epidemiolo-40
Smallpox Eradication in India
gists and PMAs were given drivers and vehicles for their areas.
Funds were distributed for gasoline, vehicle repair, travel allow-
ances, and supplies-including the various search forms, smallpox
recognition cards, and of course vaccine and bifurcated needles. A
state-level presearch briefing was held for the special team members
in every state. The special team members then repeated these pre-
search briefings at divisional, district, and primary health center
levels. The organizational plan was the same: one search worker
could visit one village in about one day. The hundred or so villages
in each Primary Health Center (PHC) had to be divided among all
available staff, usually fifteen to twenty health workers. A search
schedule determined which worker would be in which village on
which date. Supervisors had to be assigned workers to check upon
at random, and those who served as PHC doctors had to be pre-
pared to travel to verify many outbreaks of rash-with-fever, which
meant training them in smallpox differential diagnosis.
Line listings of existing outbreaks and colored posters showing
chickenpox and how it differed from smallpox were glued to the
walls of all health centers. At each briefing session and training
session, the experience of Africa was intoned over and over: it was
possible to eradicate smallpox in India. Africa had done it. Indonesia
had done it, and Pakistan would soon be free. India might be the
last country to eradicate smallpox: the campaign was described as a
race with neighboring countries and competition with nearby dis-
tricts. Radio, press, and other media were invited in to tell the
public where to report cases of smallpox. There was creative excite-
ment in the air. In the Saharanpur district of Uttar Pradesh, the
district magistrate led a parade of 5,000 Youth Congress volunteers
who went door-to-door on "search parties" along with an elephant
on whose sides were painted brightly colored slogans urging
villagers to report smallpox.
The plan was simple: The search worker was to find all small-
pox and chickenpox cases occurring within the last two months by
visiting (1) children and teachers in schools, (2) the village head
man, postman, and chowkidar (watchguard), (3) tea shops and the
market area, ( 4) two or three randomly selected houses in each of
the eastern, western, and central parts of the village, and especially
(5) the bastis (lower socioeconomic class areas), which historically
had much smallpox. Smallpox recognition cards were used and
The Case Study
41
shown to village leaders, pan (betel nut) sellers, housewives, and
children to see if they knew of any smallpox in the community.
Whenever the teams went along the road to their next village, they
were to stop at brick kilns, bus stands, migrant camps, melas (festi-
vals), and market areas to gather rumors of pox diseases. It was an
all-out attempt to find smallpox (NSEP, Government of India, and
WHO 1973).
It should be remembered that the intensified campaign was to
have three phases. The first phase had been carried out in July and
August of 1973 as a "municipality drive," an attempt to clear the
urban areas and municipalities of residual foci. It was only a half-
hearted effort. The second phase, the "autumn campaign," had as
its goals to "dramatically reduce smallpox incidence" by active
search and containment during the postmonsoon period of low
smallpox incidence. The findings from the autumn campaign
searches were to provide the planning basis for the third or the
"final attack" phase, which was expected to last from January to
December, 1974.
The special teams, half of them led by Indians and half by
WHO epidemiologists, organized the first searches of the highly
endemic states during September and December.
Indian-led teams were assigned to sensitive border areas (along
the India-China border); WHO-led teams frequently did better in
state capitals, where the global implication of success and failure
was a politically apparent matter. Both Indian-led and WHO-led
teams did well, with similar rates of success and failure. There were
ten special teams in Uttar Pradesh, eight in West Bengal, four in
Bihar, and four in Madhya Pradesh. In addition to the eight long-
term WHO medical officers in the country, four WHO short-term
consultants were assigned to the Indian smallpox project, and four
WHO medical officers were attached to the regional office at
SEARO. Another two WHO medical officers from Geneva head-
quarters were leading special teams in West Bengal and Uttar Pra-
desh. These special team leaders helped plan presearch briefing
meetings from state to PHC levels, transported supplies and equip-
ment, and made payments to drivers, PMAs, and local vaccinators.
The first search was held in West Bengal. The supplies and
equipment needed for that one state included: 100 copies of the
Operational Guide; 10,000 small recognition cards and 3,000 large42
Smallpox Eradication in India
recognition cards; 100 copies of each district map, to be used to plan
search workers' schedules; 3,000 copies of the searchers' village-by-
village schedules (PHC Form 1); 16,000 copies of the actual form for
recording results of the village visit (PHC Form 2); 400 copies of the
line listing of outbreaks, to be pasted on the wall of every PHC and
district (District Form 1); and 3,000 copies of the special "search"
edition of the weekly reporting forms that went from PHC to district
level. 4
The role of "special epidemiologist" had become increasingly
administrative, requiring attention to such details as hand-carrying
the correct number of various proformae. More than 15 million pro-
formae of various kinds were printed, packaged, and dispatched
from SEARO in 1974 alone. This was quite a departure from usual
WHO procedures, and considerable difficulties arose at every level
within WHO about such an activist role.
The results of the first search in West Bengal included only
nine districts; the others could not be searched because of floods.
Only forty-seven cases of smallpox were detected. In Delhi, program
management was not certain whether a good search had found the
few cases that existed or a poor search had missed many. But West
Bengal appeared to be less heavily infected than had been expected.
The massive follow-up search conducted throughout the state
in October identified only 143 infected villages, and Calcutta, which
so many had feared harbored persistent foci, seemed to have far less
smallpox than even the most optimistic had hoped.
The First Shock, Autumn, 1973
While early reports from West Bengal looked encouraging, in the
Hindi-speaking areas of the Indo-Gangetic plain, the historic heart-
land of smallpox, more smallpox was found than anyone had
thought existed in all of India.
In Uttar Pradesh, the organizational sessions were held in
Lucknow on September 27 and 28. The governor, who had been
personally interested in the campaign by an Indian saint named
Neem Karoli Baba who predicted that smallpox would be eradicated
"soon," chaired the session. The week before the search, Uttar Pra-
desh had reported only 354 cases occurring in twenty-one of the
fifty-five districts of the state. The weeklong search was to be con-
ducted from October 15 to October 20, 1973. No one knew what
The Case Study
43
might be found when over 27,000 workers searched the 140, 102
villages in Uttar Pradesh. 5
In New Delhi, program managers waited-WHO staff in the
modern five-story SEARO office building and Indian Ministry of
Health officials at Nirman Bhavan, the building that housed the
Directorate-General of Health Services. All cases were to be reported
by telegram to both the government of In'dia at Nirman Bhavan and
the WHO smallpox unit in SEARO. Early in the morning of the first
day, all was quiet. By midday, the telegrams started to come in, and
all the lines of the WHO telex were soon tied up. The typical report
was: "SMALLPOX OUTBREAK IN VILLAGE RAMPUR, DISTRICT
LUCKNOW, U.P. SEVEN CASES ONSET FIRST CASE AUGUST 21
LATEST CASE SEPTEMBER 30. CONTAINMENT IN PROGRESS.':
The smallpox staff read the first few messages avidly to discern a
pattern, but they were soon overwhelmed by the flood of telegrams.
In the first search in Uttar Pradesh alone, 5,989 cases were dis-
covered in 1,525 villages and urban areas from forty-five districts.
This was seventeen times as much smallpox as had been reported a
week before. Elsewhere the pattern was the same. In Bihar, there
were 614 new outbreaks with 3,826 cases, and in Madhya Pradesh,
120 new outbreaks with 1,216 cases. Special containment teams had
been created at block, district, and state levels, but the number of
foci detected was levels of magnitude greater than had been ex-
pected (see fig. 5). A dam had burst.
If the smallpox team had thought they had a problem before,
now they knew they did. Two lessons emerged from the first search
of Uttar Pradesh. First, it was possible to mobilize India's latent
health resources to reach the villages; and second, a shocking
amount of smallpox had gone unreported, despite two solid years of
work to improve reporting.
The all-India searches clearly identified problem areas: over 90
percent of the total disease incidence was located in four states:
Uttar Pradesh, Bihar, West Bengal, and Madhya Pradesh. In accor-
dance with the strategy of using resources on the basis of priority,
these four states had been correctly classified as high risk, while the
rest of India was considered either nonepidemic or smallpox-free.
With search operations going quite well but with an unprecedented
number of smallpox outbreaks being detected and contained, the
effort had to be further intensified for the high-transmission season44
Bihar
Cases
5,000
4,000
Uttar Pradesh
Cases
7,000
1
3,000
3
2,000
1
6,000 12,000
5,000 10,000
4,000 8,000
3,000 6,000
1,000
40 42 44 46 48 50 52
Weeks
0
India
Cases
14,000
1
4,000
2,000
1,000
0
The Case Study
Smallpox Eradication in India
2
3
40 42 44 46 48 50 52
Weeks
2,000
0
40 42 44 46 48 50 52
Weeks
FIG. 5. The shock: impact of active searches on reporting
of smallpox cases, India, 1973. 1 = first active search; 2 = second
active search; 3 = third active search. (From R. N. Basu 1979, 153.
Courtesy of World Health Organization.)
that was approaching. The autumn campaign of 1973 blended into
the 1974 yearlong phase three without decreasing its tempo. Re-
sources were in short supply. The WHO regular budget was
stretched to its limit to provide funds to continue the intensified
autumn campaign activities through the following year. Far more
money was needed than had been budgeted. But when the People's
Republic of China declined to accept the $900,000 budgeted for
WHO program assistance to that country, the director-general of
WHO, after consultation with the Chinese, courageously agreed to
make this money available for smallpox in India.
The money problems were compounded by transportation
problems that plagued the program during 1973-74, the period of
the Middle East crisis and the oil embargo. WHO resources were
straining to meet the rising costs of transportation, and these prob-
lems were increased by a series of transport-worker strikes. At the
end of 1973, a strike by Indian Airlines workers threatened deliver-
ies of vaccine, search forms, and epidemiologists. Use of road and
railway transport was accelerated, but a strike of railway workers for
several weeks in early 1974 further compounded the problems of
moving supplies and equipment to the periphery. Material had to be
sent by jeeps and trucks, but in April, 1974, the costs of gasoline and
petroleum products in India nearly doubled overnight, threatening
45
to interrupt the supply of gasoline needed for campaign transporta-
tion and creating severe financial difficulties for the program. Dur-
ing all of this, larger stockpiles of material, vaccine, bifurcated
needles, operational guides, and so on, had to be maintained at
state and district levels and regularly replenished in anticipation of
strikes and floods.
In the early part of 1974, search operations were going well,
but the incidence of smallpox soared, and by May the monthly inci-
dence had reached 48,833 cases, a record month. There was substan-
tial skepticism from all sides about the direction of the program. It
was difficult to explain to the press, the public, and the politicians
why, if things were going so smoothly, the incidence of smallpox
appeared to be reaching all-time highs. Some high-ranking interna-
tional epidemiologists, brought to India as WHO consultants, be-
came overwhelmed by what they saw in the field and criticized the
strategy of search and containment, suggesting a return to mass
vaccination.
The southern states, which had done well all along since the
inception of the NSEP, continued to show good results, but cynics
countered by questioning whether any of the four endemic states
had shown any promising results. Madhya Pradesh, because of its
central geographical location, low population density, and relatively
light smallpox epidemic became a pivotal state: a quick and decisive
victory there would encourage the workers in other states and quiet
the skeptics.
Madhya Pradesh had delayed its initial search until early No-
vember because of the rains and extensive floods. The first search
revealed 192 outbreaks in seventeen of the state's forty-five districts,
with a total of 1,216 cases. Most of the outbreaks were in the north-
ern and eastern districts of the state, bordering the smallpox-
afflicted areas of Bihar and Uttar Pradesh. The second search con-
ducted throughout the state in December, 1973, revealed 215 cases
and 53 new outbreaks.
By March of 1974, during the spring season, when the highest
smallpox incidence would normally be expected, Madhya Pradesh
was almost at target zero after five monthly searches of its 10 mil-
lion households. One small disease focus, persisting in Shahdol
district, one of the most underdeveloped tribal areas of the state,
appeared to be all that stood in the way of "zero" in one of the46
Smallpox Eradication in India
endemic states and deprived the central level of a much-needed
morale boost at a critical time. But there were problems in other
states, particularly Bihar (one of India's least developed states), and
the season of greatest smallpox virulence was at hand. Madhya
Pradesh was about to be invaded by smallpox from Bihar; the
worst was yet to come.
The Darkness before Dawn, Summer, 1974
In March, 1974, reports of smallpox began arriving from areas of
Madhya Pradesh that had been thought free of the disease. Investi-
gations indicated that these were not old, hidden outbreaks missed
in earlier searches, but fresh importations from Bihar. The source of
infection was traced to Tatanagar, an industrial city in southern
Bihar. Adivasis (tribals) from Madhya Pradesh had traveled to that
city, 200-500 miles from their homes, in search of seasonal employ-
ment. Struck with fever, they had returned to their native villages,
where they subsequently developed the characteristic rash of small-
pox. The disease spread, and within one month a shower of impor-
tations from Tatanagar had reinfected hundreds of households in
Madhya Pradesh. Hopes for an early victory were smashed.
Madhya Pradesh was not the only state beset by importations
of smallpox from Tatanagar. Within a short time, Tatanagar threat-
ened to reinfect much of India that had only recently been freed
from smallpox. Smallpox officers in seven other Indian states plus
Nepal reported over 2,000 cases and as many as 500 deaths linked to
travelers coming from the Tatanagar railway station.
The town of Jamshedpur, founded in the early 1900s by Jam-
shedji Tata, was one of the first towns in India devoted to heavy
industry. Jamshedpur and Tatanagar, the adjacent railway station,
were both named after their founder and continue to serve as one of
the headquarters of Tata Industries. With the ancillary steel-based
industries that adjoin the Jamshedpur industrial works of the Tata
Iron and Steel Company (TISCO), the area is often referred to as the
Pittsburgh of India. The relatively high income of the private sector
industries contrasts with the neighboring areas of southern Bihar
and northern Orissa, and therefore invites large numbers of
poverty-stricken beggars and transients to pass through the Tatana-
gar train station seeking subsistence. The Tatanagar railway station
would become infamous as the world's greatest exporter of small-
The Case Study
47
pox. Despite the many investigations implicating Tatanagar as the
source of the epidemic, the official weekly health records of the city
showed only seven cases of smallpox reported. It was a classic ex-
ample of case suppression.
Tata Industries were very proud of their city. A showplace of
India, it had won several national awards as one of the most pro-
gressive in the country. The administration of the city was entirely
in the hands of Tata Industries, and they were distraught that their
city had become the focus of such unpleasant international atten-
tion. When top management was informed that the TISCO doctor
had failed to detect one of the largest hidden smallpox epidemics,
Tata and WHO entered into an agreement to quell the epidemic in
Tatanagar. WHO provided technical guidance, Tata gave material,
manpower, and management, and thus began one of the most ambi-
tious urban campaigns in the Indian smallpox program. Within
seventy-two hours, 50 doctors, 200 paramedical supervisors, 600
search workers, fifty vehicles, and other facilities were mobilized
and the campaign started.
It was the first large-scale effort on the part of WHO to enlist
the cooperation of local industries and private citizens in the effort.
WHO's role as an international agency had limited its official contact
to Indian government officials. But Tata provided something beyond
men and resources that made the established strategy of search and
containment more effective than it had been in the past: they pro-
vided an example of good management.
Tatanagar was only one of many problems being faced by the
smallpox central command at that time. The number of outbreaks
was increasing each week. The ratio of optimists to skeptics, always
high in the past, was showing signs of erosion at every level. The
sixth search conducted in Bihar in May was depressing. Of 69,836
villages searched, 2,622 were found with new outbreaks (3.75 per-
cent of all villages). All thirty-one districts in the state were infected
with smallpox; in eleven districts, 100 percent of all blocks were
infected. One district, Monghyr, had 498 total active outbreaks, and
Bhagalpur had 555 infected villages.
The WHO Southeast Asia regional smallpox surveillance report
dated June 1, 1974, carried a large world map on the front cover
showing what smallpox workers were facing in the villages of Bihar
and Uttar Pra desh. While one-quarter of the world's smallpox was
048
Smallpox Eradication in India
shown coming from Ethiopia, Bangladesh, and Pakistan combined,
fully three-quarters was found in the two Indian states of Bihar and
Uttar Pradesh. At that stage in the program, India represented 82
percent of the known smallpox in the world. Although nine states
and nine union territories were classified as smallpox-free, heavy
battles were being fought against the disease in Uttar Pradesh and
Bihar. The June surveillance report featured a note on the industrial
area of Jamshedpur/Tatanagar, which by then had exported as many
as 300 outbreaks of smallpox to other areas of India and Nepal.
Many of those areas had previously been smallpox-free. Smallpox
was reestablishing beachheads throughout India.
The number of active outbreaks contained (that is, removed
from the list of "pending active outbreaks") had increased fivefold,
from 107 in December, 1973, to 511 in May, 1974. The number of
new outbreaks detected (added to the list of pending outbreaks) in
the same period had multiplied even faster, increasing from 162 to
689. More pending outbreaks on the list meant more demand for
containment staff and resources. More epidemic fires were being
found than were being extinguished.
The sixth search in Uttar Pradesh in May detected 797 new
outbreaks, with 1,759 villages still containing active smallpox, but in
Uttar Pradesh, despite an increase in the total number of outbreaks,
problem areas were becoming increasingly circumscribed. Unlike ~i­
har, where every district was infected, 82 percent of all outbreaks m
Uttar Pradesh were located in only fifteen of the fifty-four districts.
Unfortunately, in the season when smallpox incidence was still ris-
ing every week, the number of outbreaks contained per week was
not increasing.
West Bengal was still struggling to clear up extensive foci that
developed during the months of March and April. Despite a declin-
ing incidence, by mid-May there were still 444 foci known to be
active in the state. Three-quarters of the foci were reported by only
five districts, however, and had there been no importations West
Bengal would have been making much better progress. Between
January and April, 1974, over 386 importations into West Bengal
were reported, over 342 of them from the neighboring state of Bihar.
It was clear that the fate of the smallpox eradication program in
parts of West Bengal depended greatly on making progress in Bihar.
Madhya Pradesh, the hope of the program in the early part of the
The Case Study
49
year, had also suffered repeated setbacks. Between March and May
the number of outbreaks nearly doubled, mainly from the large
number of importations from Tatanagar as well as from intrastate
movements of adivasi chetuas (migrant wheat harvesters). For the
state as a whole, the delay time in reporting new outbreaks was 18.6
days after the onset of the first case. This means that the average
case was detected comparatively quickly. Two years earlier, in Gul-
barga, outbreaks had escaped detection for more than a year; how-
ever, in a time of rapidly disseminating disease from the industrial
areas of southern Bihar, 19 days was too long to wait.
Even Nepal was suffering from the onslaught of exportations
of smallpox from India. In the first six months of the year, of 109
outbreaks of smallpox in that country, 102 were traced directly to
importations from India. Over 90 percent of the importations in the
late spring came from Bihar.
May and June are usually the hottest months in India, with
daytime temperatures well over 100° F; conditions are especially
difficult just before the welcome monsoon rains break from the
sky, drenching the parched land with their cooling showers. May
and June of 1974 were also the hottest, most difficult months in the
campaign for smallpox eradication in India: a new case of smallpox
was being detected there every minute, and the outbreak in Ta-
tanagar was threatening smallpox-free states with a deluge of im-
portations. There was flooding in the north, drought in the south,
and the fear of famine throughout Bihar, causing population migra-
tions that threatened to spread smallpox into new areas. It was the
time of Jaya Prakash Narayan's civil disobedience movement
against the government of Bihar. Strikes and civil disturbance
threatened the system with total breakdown. During one critical
period, all the government doctors in Bihar went on strike, and
strikes by Indian Airlines and the railroad virtually halted vaccine
shipments.
There was severe criticism of the basic program strategy from
the political level; the national and international epidemiologists in
the field were frustrated, tired, and skeptical; and many sup-
porters in the general public were losing faith. The loss of confi-
dence permeated parts of the WHO SEARO bureaucracy, and one
of the highest-ranking officials felt compelled to write an internal
memo expressing serious doubts about the basic strategy and sug-50
Smallpox Eradication in India
gesting that perhaps the program should be scrapped. His argu-
ment was that of a health planner. Although he felt that eradica-
tion was possible, he pointed out that many other countries had
become free of smallpox by mass vaccination, without the large
scale, foreign-assisted, extraordinary efforts that were being put
into action in India apparently without much success. He pointed
out competing demands on the same health staff: malaria, drought,
and floods. He felt that if it became necessary to continue on be-
yond the end of 1974, the extra costs of a sustained intensified
campaign would outweigh the benefits, and the entire strategy
should be revised and the program managers replaced with doctors
who were less fanatic about smallpox (see chapter 2 for a complete
analysis). And then two explosions set off a chain reaction of inter-
national news coverage.
On May 18, 1974, India tested its first atomic device under-
ground in Pokhran in Rajasthan. At the same time, smallpox out-
breaks shot to a peak of 8,664 infected villages, with 11,000 cases
reported in a single week. India captured many worldwide news-
paper headlines with this double explosion. International news-
paper reporters had flown to India from their Singapore or Hong
Kong bases, interrupting their coverage of the Vietnam War to cover
India's atomic explosion, arriving in India just as newspapers there
broke headline stories of the fresh smallpox epidemic. From the
Vietnam War to the atomic explosion to the smallpox explosion, the
international journalists brought the story of India's epidemic to
worldwide attention.
NEW DELHI, India AP-
A virulent smallpox epidemic, described as India's worst of the cen-
tury, has killed an estimated 30,000 persons this year, the World Health
Organization said Wednesday. The disfiguring scourge has attacked
103,830 Indians since Jan. 1, 20% more than the number of cases in all
of last year, the organization reported. The outbreak has surged from
village to village despite an intensive detection and vaccination drive
launched last October with the aim of wiping out the dread disease by
this summer.
This may not have really been India's worst smallpox epidemic
of the century, but it has been correctly called the last great epidemic
of smallpox in the world, and no one who fought in the campaign
The Case Study
51
against smallpox in India will easily forget the months of May and
June, 1974. It appeared it would take a miracle to eradicate smallpox.
A miracle and a colossal human effort.
From Smallpox to Zeropox
A Colossal Effort, June, 1974, to December, 1974
It is not possible to know whether the 1974 outbreak was greater
than the epidemic of 1875, or even epidemic seasons as recent as
those of 1967. Because of substantial improvement in reporting effi-
ciency, the annual incidence figures are not comparable. Retrospec-
tive estimates indicate that Bangladesh improved surveillance from
11.8 percent in 1972 to 83 percent in 1975, and if we assume a similar
improvement in surveillance in India, it is possible that the 1974
epidemic was modest in comparison to earlier peaks. But in absolute
terms, it was a tremendously large and terrifying epidemic of small-
pox. Moreover, it occurred as India was emerging as a nuclear
power, and there was a painful contrast between the successful
nuclear achievement and the failure to eradicate an ancient disease.
Newspapers editorially asked, "How can one justify the occurrence
of a smallpox epidemic of these proportions in 1974?"
Of course the answer is that the epidemic of reports created by
excellent surveillance was magnifying the visibility of the real epi-
demic. One result of the painful publicity was attention from higher
political levels, and with that attention came the assistance neces-
sary to eradicate smallpox.
Herein lies an important lesson. Ignorance can be bliss (at least
for a while), but the painful knowledge acquired through a sensitive
surveillance system may have a highly motivating effect. It can cer-
tainly bring resources.
On June 11, 1974, the board of directors of Tata Industries,
parent company of TISCO and other Jamshedpur/Tatanagar indus-
trial concerns, agreed to provide approximately Rs. 4.7 million
($500,000) to assist in eradicating smallpox from the area, provided
the government of India and the Bihar state government both
agreed to such private industry support. 6 The secretary of Bihar
approved in principle, Prime Minister Indira Gandhi agreed, and a
WHO memo summarized the establishment of a semiautonomous52
Smallpox Eradication in India
WHO-Tata-government of India-Bihar state smallpox consortium,
to be called the Chhotanagpur Smallpox Eradication Program.
The assistance offered by Mr. Tata is a very important component in
the total planning for the eradication of smallpox, and based upon the
non-availability of comparable alternative resources ... it is urgently
necessary. (Brilliant 1979, 40)
On June 17, 1974, with 119,419 cases to date in India that year,
the WHO-government of India central level smallpox team met with
the secretary of health and director-general to outline an emergency
program for all of India, but especially for Bihar. The director-
general repeated that the government target for eradication was
1979. WHO claimed the end of the current year was still possible
with more staff.
Those discussions, later formalized as Addendum 13 of the
Plan of Operations, resulted in a realistic reappraisal of the person-
nel and money needed to eradicate smallpox. It was decided to try
to more than double the number of special epidemiologists, from the
50 who were in the field at the time to more than 100. WHO would
initially provide 12 international epidemiologists and 6 operations
officers; the government of India would attempt to locate 40 epide-
miologists to go immediately to the affected areas, but if that were
impossible, WHO would recruit more international epidemiologists.
Six central-level surveillance teams were set up and given re-
sponsibility for groups of states; they were to respond to emergency
notices of smallpox as they developed. State surveillance teams were
given the go-ahead to enter neighboring states, especially if in hot
pursuit of the source of infection. 7 Continuing senior-level manage-
ment was assured as well when the secretary agreed that the director
of the NICO could be freed from malaria control duties and allowed to
lead the smallpox eradication program full time. Although the deci-
sion to take key staff away from malaria may have slowed down that
program, it allowed smallpox to be quickly eradicated. When small-
pox was completed, a new cadre of excellent health officers was avail-
able to work on malaria, diarrhea, vaccine-preventable diseases,
blindness, and other health programs. The importance of such excel-
lent senior-level leadership cannot be overemphasized.
Recruitment of 300 additional containment teams was author-
ized; headed by young Indian doctors, most were to be sent to
The Case Study
53
Bihar. WHO was given permission to hire helicopters and private air
transport if needed, because of the Indian Airlines strike. And the
vaccination check-post at the infamous Tatanagar railway station
was ordered reestablished.
Now there was an urgent need for ground transportation for
these teams-nearly 375 jeeps were required. After unsuccessful at-
tempts were made to hire jeep fleets, WHO agreed to purchase 100
new Indian vehicles and hire 275 more; to pay for gasoline, oil, and
lubricants; and to fund travel costs of.the new epidemiologists and
central surveillance teams. The new provisions in Addendum 13
were estimated to require $1,406,531 if the intensified efforts were
successful within three months, and WHO had budgeted only
$48,602 for supplies and equipment for the entire year and only
$266,966 for personnel. The Swedish International Development
Agency (SIDA) was approached through its sympathetic representa-
tive in India. SIDA had already given a substantial amount to the
program after a personal and unofficial appeal from Dr. Nicole Gras-
set, the WHO smallpox unit team leader. This time a much larger
sum was needed, and the Swedish government once more proved
to be the major benefactor of the program, eventually giving in
excess of $10 million for smallpox eradication in India.
Nature also became a benefactor; the monsoon rains came, and
with them the long-anticipated but nevertheless dramatic seasonal
reduction of smallpox transmission. But now was the time not to
relax but to harness all resources.
For several weeks, the WHO office in New Delhi resembled a
college. Over 100 junior medical officers were trained in smallpox
epidemiology using case-study smallpox training exercises plus field
trips to the outskirts of Delhi. Groups of epidemiologists passed
through, usually en route to Bihar, stopping in Delhi to get a week's
training, an advance of several thousand rupees (several hundred
dollars) to be used in the field (an imprest cash account), supplies,
and equipment.
On June 21, 1974, the chief secretary of the state of Bihar sent a
special letter to all district magistrates informing them that they
were to assume complete responsibility for carrying on and organiz-
ing the campaign in their districts. In effect the Indian administra-
tive service (IAS)-India's very competent district magistrates-had
given up hope that doctors alone could handle the epidemic and54
Smallpox Eradication in India
took over command of the emergency epidemic control activities
from the normal medical authorities, relieving the civil surgeon and
district medical officers.
In the midst of this storm of activity, management needed a
navigational beacon by which to measure and direct activities. That
beacon was assessment.
From June, 1974, the infected village or urban mohalla (an urban
neighborhood similar to a small village in the city) became the most
closely watched assessment index. For brevity, these active foci were
called pending outbreaks. They were "pending" on the list of active
outbreaks maintained at each PHC and district, state, and central
smallpox office. A pending outbreak was a village or mohalla in
which any case of smallpox had an onset date recent enough to be
considered still potentially infective itself or the source of infection
for an incubating case. If no new cases had been found at the end of
the pending outbreak period (four weeks, subsequently extended to
six weeks) the outbreak was removed, often with great fanfare, from
the list of pending outbreaks.
This way of identifying high-risk areas was really a form of
prevalence measurement, something analogous to measuring the
prevalence of risk of smallpox spread. It was an ideal management
tool because for every outbreak, regardless of size, the same re-
sources-a jeep, vaccine, proformae, gasoline, and containment
staff-were needed to search every house in the village or mohalla,
conduct a census and record the findings in meticulous detail in
specially prepared containment books, and make periodic revisits.
This index of program performance was the lighthouse that guided
the smallpox staff through the rough and stormy seas of the small-
pox cycles. Since efficient resource allocation was the most pressing
management decision, the use of pending outbreaks was an excel-
lent management control-provided all the outbreaks were found.
An award system was introduced, in which individuals re-
ceived cash payment for reporting previously unknown smallpox
outbreaks. To make sure that happened, another series of assess-
ment measures was developed, based on the success of publicity
about the Rs. 1,000 ($120) reward, which was an important motiva-
tor to get the population to report smallpox and on the thorough-
ness of the house-to-house search. Complete detection of smallpox
depended on an informed public, thorough periodic searches, and a
The Case Study
55
good network of secondary surveillance, which included market-
place surveillances, visits to schools and hospitals, and so on. The
search was assessed by revisiting a sample of villages. The sample
was not random; rather, the areas known to be weakest (with lowest
performance on other assessment criteria), along with those most
difficult to reach, were preferentially assessed. Thus the estimate
was not of the average search effectiveness but was skewed down-
ward, since the weaker areas were assessed more often. Since the
surveillance system was only as strong as its weakest link, this form
of assessment gave a more useful evaluation of it. This strategy
allowed assessors to function also as second-level supervisors for
problem areas. Assessment forms, guidelines, and job descriptions
were drawn up. Assessors recorded what percentage of people in-
terviewed could answer three questions in the affirmative: (1) Had
they seen a search worker? (2) Did they know about the reward that
was offered for any case of smallpox detected in India? and (3) Had
they seen the smallpox recognition card?
Then came the tabulation of assessment. Each district was ana-
lyzed for percent of villages reported to have been searched in
which people had actually seen the search worker. When there was
a discrepancy between a searcher's report and the villager's mem-
ory, the villager's memory was given precedence, the reasoning be-
ing that if the search worker had been so easily forgotten the job had
not been properly done.
The knowledge of the reward, however, was not an assess-
ment of the search worker alone. It also assessed the effectiveness of
an intensified publicity campaign that for several months had been
directed from Delhi. If everyone knew of the reward (which was
more than several months' salary for many), there seemed little
likelihood that many cases could be kept hidden for long. Over the
following six months, knowledge of the reward rose dramatically,
showing the cumulative effect of a multimedia approach using ra-
dio, leaflets, word-of-mouth, rickshaws with loudspeakers in the
cities, and puppeteers and announcements at weekly local markets.
The higher the index of public knowledge of the reward in an area,
the safer the smallpox staff felt.
Another assessment index proved important. As smallpox dis-
appeared, surrogates for smallpox were looked for. Since some
villagers lumped smallpox with chickenpox in a single category, and56
Smallpox Eradication in India
the reward was bringing out all hidden cases of any rash with fever,
it was decided to assess reporting efficiency not just for smallpox but
for chickenpox and measles as well. Neighboring areas might differ
from each other in their smallpox epidemiology due to better or
worse vaccination activities, but it was reasoned that in the absence
of any effective interventions for measles and chickenpox, the distri-
bution of those diseases should be universal. Thus, if a district re-
porting little or no chickenpox was sandwiched between two others
reporting much chickenpox, something was clearly wrong. The as-
sessors turned into detectives.
Although each of these indices had a different implication for
smallpox activities, the complete series of assessment indices added
up to a comprehensive overview of the system's performance in
each given area. This provided quantitative data to measure the
progress of search operations. Apart from numbers of vaccinations
administered, it was the first time such a quantitative supervisory
evaluation had been initiated in India.
The ninth active search in Bihar was the week of July 18-24,
the tenth, September 22-28, and the eleventh, October 27 to No-
vember 2. With each successive search, techniques became refined.
In Bihar, with the operations in the north under the supervision of
the district magistrates and with assistance from Tata administrators
in the south, the assessment figures from the previous search were
used to focus search activities for the following month. Each search
was preceded by a state review meeting, district presearch meeting,
and PHC-level planning meeting; it was at these meetings that the
search schedules were drawn up and plans made for concurrent and
postsearch assessment. (Many of the WHO epidemiologists being
debriefed as they were leaving India said that these presearch meet-
ings, particularly at the most peripheral levels, gave them the most
confidence in the progress of the program, because it was there that
careful village-by-village search plans were outlined, with attention
to assigning the most experienced staff to the most difficult areas.)
In southern Bihar, the eighth search had shown both encourag-
ing and discouraging signs. Although fewer villages were searched
because the monsoons made them inaccessible, pending outbreaks
showed a 45 percent increase, due to improved surveillance efficacy.
This region of 20,000 villages had 1,000 outbreaks of smallpox.
By mid-August, the all-India emergency campaign was in full
The Case Study
57
swing; eighty-four epidemiologists from India and WHO were as-
signed and working at state and district levels to supervise and
coordinate the active search; sixty-five were in Bihar, the rest in
other states. To provide overall coordination, some twenty-five ad-
ditional professional staff from the central government were mobil-
ized to work full time. These included supply officers, administra-
tive officers, and operational officers (men who performed a dual
task as administrators and field epidemiologists) as well as senior-
level epidemiologist-managers. This was a" far cry from the 1972
lament that there were only two officers in the Nirman Bhavan
smallpox headquarters.
In Chhotanagpur, for the week ending August 24, there had
been 777 outbreaks at the start of the week, 250 new ones dis-
covered, and 198 contained: a total of 829 on the pending list. This
figure might have been discouraging but for the greatly improved
assessment indices, which showed that the surveillance system was
becoming extremely efficient. However, the unexpected struck.
There was a drought in the south, and, as if in cruel counterpoint,
floods in the north.
Throughout India, the active search was improving. During the
monsoon, few smallpox foci remained outside the heavily affected
areas of Bihar, Uttar Pradesh, Assam, and the border areas of
Orissa, West Bengal, and Madhya Pradesh. Good work was being
done in the south, which became free of smallpox in September
1974. In the northwest, the lingering foci in Jammu and Kashmir
were eliminated.
After the monsoons, the pace of progress quickened. Uttar Pra-
desh, with nearly as much smallpox as Bihar but a much more devel-
oped health infrastructure requiring far fewer emergency resources,
plunged from 866 outbreaks in July to 45 by year's end. The last case of
smallpox in Madhya Pradesh had onset of rash December 23, 1974. As
the first endemic state to reach the elusive target zero, Madhya Pra-
desh vindicated the strategy of search and containment.
Assam, which had recorded only eighty-seven foci in July, con-
tinued to have new outbreaks. The problem seemed to be that con-
tainment was ineffective. Vaccination around outbreaks was slow
and inconsistent. In Bihar, which was experiencing similar prob-
lems, zealous epidemiologists occasionally made night raids to vacci-
nate a whole village at a time. Night halts by the teams in each

58
Smallpox Eradication in India

infected village became more and more common, especially after a
Tata accountant calculated that gasoline costs to and from infected
areas exceeded the costs of paying travel allowances for the teams to
stay overnight.
A major problem was that infected households continued to
receive countless visitors. The system of watchguards (a local resi-
dent paid to ensure that all visitors to an infected household were
vaccinated), informally developed by paramedical assistants up to
that point, was tightened. A watchguard's book was printed. Each
visitor to an infected household was stopped by one of the around-
the-clock watchguards. All visitors were revaccinated, regardless of
previous vaccination status, and their names and addresses were
recorded.
Poor families presented a special problem in application of
quarantine. The poor had few reserves. Several weeks' isolation,
which deprived them of whatever daily income they might other-
wise obtain, was an unimaginable hardship. A young American epi-
demiologist purchased food for an entire family for several weeks to
keep them at home. He sent the bill to WHO. At first the WHO
administrators were incredulous: was the World Health Organiza-
tion to pay for villagers' meals? (It did pay.) Paying for food, stop-
ping of migration of potential carriers of smallpox was needed to
protect public health. The smallpox unit stressed to the WHO Fi-
nance Unit the cost-effectiveness of rapid eradication, and the need
for tightened isolation security around each of the decreasing num-
ber of cases became more and more obvious. With fewer smallpox
outbreaks dotting the map, more time and resources could be de-
voted to each dot.
Operation Smallpox Zero, December, 1974, to May, 1975
From a peak of 8,664 infected villages in May, 1974, the epidemic
curve fell consistently to 3,267 in August and to 980 in October; by
November it had reached 343. The use of pending outbreaks or
infected villages rather than smallpox incidence as a unit of mea-
surement was to prove an important management innovation. Dis-
ease-control officers usually monitor the disease incidence (number
of new cases reported in a particular time period). Using pending or
active outbreaks or infected villages was a way of measuring the
prevalence measure (number of villages infected at a given time)
The Case Study

59

that indicated active foci potentially capable of transmitting the vi-
rus. From the perspective of resource allocation it matters less if
there are three or thirty cases of smallpox in a village than if villages
hundreds of miles apart are found to be infected. The same contain-
ment team in the same jeep is needed, and the same number of
vaccinations are given.
Epidemiologists like to see the epidemic curve, the graphical
line of a disease over time, reach zero. And by November, 1974,
smallpox epidemiologists in India were becoming confident, begin-
ning to argue about just when the last case would occur. Pakistan
had reached zero, with its last case on October 16, and for a time it
looked as if India might have caught up with Pakistan despite a
much later start. A countdown to zero was begun; the monthly
surveillance newsletter listed pending outbreaks to "count down" to
the zero which was expected shortly.
Cases of smallpox declined from 3,806 in October to 1,533 in
November and 893 in December. There was substantial progress in
Bihar, which had halved the monthly reported number of new cases
each month in the autumn; but then some disturbing trends were
noted. Orissa and Uttar Pradesh showed no signs of interrupting
transmission. In fact, the number of new outbreaks detected sud-
denly stopped declining. A plateau was reached, with 213 new out-
breaks detected in India in December, compared with 275 in Novem-
ber (fig. 6).
This plateau was of great concern to project managers, because
of the impending high-transmission season. The winter was fast
approaching, and because the smallpox virus survives longer in dry,
cool air, and because both pilgrimages and migrations increase in
the dry season, it was the season of rapid transmission. Each of the
infected foci represented a potential Tatanagar, which in this high-
transmission season could rapidly disseminate smallpox and erode
program gains. It had happened before in other countries. The
worst trend was seen in active outbreaks. At the year's end, there
were still more than 200 outbreaks pending in Bihar, a sufficiently
high number to cause anxiety.
Word came that Bangladesh had suffered yet another tragic
reversal. Floods in :\1ymensingh and Jamalpur caused large popula-
tion dislocation. The Dacca bastis (slums) had been cleared over-
night, and the poor families occupying these makeshift residences
Logged
Stoppt die deutschen Massenmörder!
Stoppt die österreichischen Massenmörder!
Stoppt die schweizer Massenmörder!

Revolution jetzt. Sonst ist es zu spät.

Pangwall

  • Jr. Member
  • *
  • Posts: 1333
Re: The Management of Smallpox Eradication in India
« Reply #2 on: November 10, 2022, 09:02:47 PM »

60
Smallpox Eradication in India

The Case Study
400
300
\ \./ .
100
35
37
39
41
43
45
47
49
51
Week Number, 1974
FIG. 6. Operation Smallpox Zero - new smallpox outbreaks
detected by week in India as of the start of Operation Smallpox
Zero (December, 1974)
were removed by the truckload to the rural areas. With them, on
their return to the villages, went smallpox, seeding the country with
an epidemic that would take one more year to conquer. With the
rising epidemic curve in neighboring Bangladesh, the plateau in
India, and rumors of "unusually virulent strains" of smallpox, it was
clear that something had to be done.
In the district of Caya, the number of outbreaks actually
multiplied fivefold during December, from sixteen to seventy-five.
Was this the result of poor work, or was it the beginning of
massive transmission in the high season? Careful assessment
showed poorly conducted search operations and inadequate con-
tainment in Caya. Outbreaks had been crossed off the pending
list while cases were still active, and the result was satellite out-
breaks. Once again, the infected foci concept proved its value as a
monitor. Caya is a major international pilgrimage site, and there

61

were fears of long-distance spread. A senior WHO smallpox epi-
demiologist arrived on the spot, and intensive and prolonged con-
tainment activities began.
Whenever an oubreak was discovered, twenty to twenty-five
vaccinators would arrive in the infected village, and containment
vaccination would be completed within forty-eight hours, with
twenty-four-hour watchguards posted at every infected household
and food brought in. It was, in effect, a household quarantine.
Entire villages were also cordoned off when necessary. Instead of
a handful of vaccinators, a battalion of NSEP vaccinators, supple-
mented by ad hoc smallpox workers (paid only a WHO per diem
of five to seven rupees-less than a dollar), would rush to each
newly discovered infected village and camp there until no active
case remained. Including Caya, 102 new outbreaks were dis-
covered in Bihar in January, 1975. Though that was fewer than
the 147 newly discovered in December, some of the outbreaks
were ominous.
The largest outbreak of the season was detected at Pawa Puri
village near Caya, eighty-eight kilometers from the state capital.
This village is an important pilgrimage site for Jains because Lord
Mahavira, sixth century B.C. founder of the Jain religion, died there.
Forty houses in this village were found to be infected in early Janu-
ary. The outbreak was detected at the apex of the pilgrimage season,
in a special pilgrimage year-the 2500th anniversary of Mahavira's
death. More ominous was the fact that antivaccination sentiment
runs high among Jains, who believe in ahimsa (nonviolence: it was
the Jain concept of nonviolence that Gandhi adapted to the freedom
struggle), which is interpreted to mean protecting animals-and all
living things-from harm. Jains wear special shoes to minimize the
chances of accidently killing insects and are strict vegetarians, and
some wear white masks to prevent them from accidently inhaling a
flying insect. Their opposition to vaccination stems from the pain
inflicted on cows or buffaloes in the course of producing vaccine.
The Pawa Puri outbreak was unusual in its explosiveness. The
epidemiologist stationed at Nalanda had first received a report of the
outbreak in early January, 1975. Smallpox staff went to Pawa Puri,
where they found sixteen cases of smallpox. Except for the index
case, all had had onset of rash between January 7 and 12, and half
had come down with smallpox on the same day. The average small-

62
Smallpox Eradication in India

pox case usually led to two or three cases in the next generation,
depending on seasonal and other factors (Foege et al. 1971). But
investigation suggested that one case had infected eight others.
Eight secondary cases developing on the same day from one index
case was quite unusual. Was it because of the high-transmission
season?
During the infective period of the index case, nearly 2,000 pil-
grims had visited Pawa Puri village from all over India and from as
far away as London. There was concern that many might have re-
turned to their homes incubating smallpox, and a retrospective list-
ing of all pilgrims was prepared. WHO began an around-the-clock
effort to alert health personnel in all parts of the country. Over 2,500
telegrams were sent in twenty-four hours.
The entire village was quarantined by Bihar military police.
Twenty-four-hour watchguards were posted at the infected houses
and at key areas in the village. A community kitchen was set up, with
initial capital provided by a WHO epidemiologist, to feed patients so
they would not leave their homes for food. Pilgrims were not allowed
to enter sacred pilgrimage areas until they were vaccinated, but since
many Jains did not believe in vaccination, the situation was difficult
to control. When pilgrims were refused entry for lack of vaccination,
the custodian of the sacred places objected. As had happened so
often in India, however, local spiritual leaders came to the rescue.
The Jain muni (religious leader) of the area made an exceptional ges-
ture of support, and vaccination was accepted by nearly all in his
community. Although the outbreak had been exported to five adja-
cent villages, Pawa Puri, an unusual and never fully understood anom-
aly, was under control by the end of February.
The district of Gaya, near Pawa Puri, reported 214 cases of
smallpox in January, and 18 from February through April. These
cases were to be the last ever in the ancient pilgrimage sites near
Caya. The success in Gaya and Pawa Puri showed that energetic
containment could stop smallpox even in the high-transmission sea-
son. The innovations were rapidly institutionalized. Operation
Smallpox Zero was declared-the final push.
Operation Smallpox Zero was launched at the beginning of 1975
with a new and stricter set of operational procedures. The village-by-
village searches, still made every month in endemic states, were
changed to house-to-house. In the state capital of Patna, where exten-
The Case Study
63
sion of an epidemic from the infectious disease hospital was feared,
there was actually a room-to-room search. Each case of rash with fever
was treated as a case of smallpox until proven otherwise by either a
differential diagnosis from a higher-level officer or a negative labora-
tory result. A rumor register was kept at each PHC. Every rash and
fever case was recorded and monitored, and laboratory specimens
were taken from the first cases in every suspected outbreak. All uncer-
tain diagnoses were followed with containment, as was any chicken-
pox outbreak with a death. Twenty-four-hour watchguards (increased
from two per house to four) were posted, and all villages within 10
miles (16 kilometers) of a case of known or suspected smallpox were
searched. This sometimes required as many as 300 search workers.
Everyone within a 1-mile (l.6-kilometer) radius was vaccinated. (This
sometimes involved 4,000 to 5,000 people in the rural areas and up to
80,000 in densely populated cities.) A new target was set: no new cases
should occur more than twenty-one days after initial outbreak detec-
tion. Any outbreak that persisted for a longer period was visited
personally by one of the nine central appraisal officers, who investi-
gated the causes of containment failure and instituted remedies. Mar-
ket searches were intensified. A medical officer was posted to live in
every infected village. Rapid vaccination (vaccinating everyone in an
infected village within forty-eight hours) paid off with an unexpected
dividend: resistance to vaccination was markedly reduced because by
the time vaccination side effects appeared (usually after two-to-eight
days), everyone had already been vaccinated.
To match the increased program needs, increasingly rigorous
outbreak detection targets were set. But repeated assessment re-
vealed that containment, even more than detection, was the prob-
lem (see fig. 7). The tactics shifted from active search to active con-
tainment, and house-to-house searches were intensified within the
ten-mile radius around each outbreak. The searches were repeated
two weeks later to detect any secondary cases that might have been
in the incubation period during the first search. Visitors and poten-
tial visitors (all known relatives residing in the district) were listed
and contacted by search workers. Any outbreak not traced to its
source was grounds for a visit from the state program officer or
central appraisal team, and investigation and vaccination of all po-
tential contacts was intensified.
It paid off. The number of cases in each outbreak, a goodThe Case Study
Good containment
Unprotected person
Bad containment
Affected households
FIG. 7. Good and bad containment vaccination. (Data courtesy
of World Health Organization.) Good containment vaccination:
500 vaccinations done within two days after cases detected; not
one unprotected person remains in the immediate area surround-
ing the infected households. Bad containment vaccination: 1,500
vaccinations done within five days after cases detected; some
unprotected people still remain in houses immediately around
the infected households.

65

measurement of both the delay in detection and effectiveness of
containment, began to decrease. Whereas the average size of an
outbreak in May, 1974, was approximately seven cases, by January,
1975, it was less than five cases, and one outbreak in three was a
solitary case. Each month saw a 40 percent decrease in the number
of pending outbreaks. Except for the renewed threat from Bangla-
desh, expectations of zero were increasing. High-risk areas were
outlined in red on district maps throughout India. Several risk fac-
tors were identified: Bengali-speaking communities, the jute indus-
try, fishermen who worked in Bengali areas, sites of refugee camps
in 1971, and proximity to Bangladesh. For more than a year, a line
listing of all outbreaks in India was sent each week to the PHC level
and above, showing source of infection, first and last case, and
number of cases.
Operation Smallpox Zero was a refinement and intensification
of existing surveillance and containment. Perhaps more importantly,
it was extremely innovative in the area of quality control. Since mid-
1974 the smallpox program had been continuously assessed at every
level. When outbreak containment had been the key activity, assess-
ment of containment measures pointed out deficiencies that existed
in the actual implementation of set plans. Through the knowledge
obtained from such assessments, reasonable standards had been es-
tablished for the optimal rate at which a village could be vaccinated to
minimize secondary spread. An optimal radius of immunity was de-
termined, and the number of people needing vaccinations was calcu-
lated. These criteria were established on the basis of practical experi-
ence in achieving interruption of secondary transmission.
Operational research was used to establish the number of vil-
lages around the case to be searched to detect secondary outbreaks.
Careful analysis of outbreaks that failed to meet program standards
because containment was not rapid enough showed that satellite
outbreaks most frequently occurred within a sixteen-kilometer ra-
dius. Consequently, thoroughly searching the sixteen-kilometer ra-
dius around each case became the new program target.
With the disappearance of known outbreaks, the program em-
phasis began to change to intensified surveillance. The sentinel indi-
cators for quality control also changed. As secondary surveillance
and search organization became the focus of the program, assess-
ment of surveillance efficacy became the major smallpox activity of66
Smallpox Eradication in India
district officials and epidemiologists. There was a change in search
strategy. In addition to detection in rash-with-fever cases, and espe-
cially detection and investigation of chickenpox cases, a second im-
portant function was added to the job of the search worker, who
was now to educate the public more intensely than had been pos-
sible in the early stages of the program. This involved rewriting the
search worker's job description during Operation Smallpox Zero. In
addition to going door-to-door to inquire about the existence of rash-
with-fever cases and displaying a recognition card to each person,
the worker would now be expected to prominently announce the
increased reward for the first reporting of an outbreak, to tell the
villagers where to report a case of smallpox, and to inform the com-
munity on the progress of the campaign.
The assessment done to evaluate the searchers' performance
evolved along the same pattern. Instead of monitoring the output of
the searcher (number of villages visited or number of reward posters
pasted onto houses), the outcome of the performance was carefully
monitored. Individual interviews of large numbers of persons from a
representative sample of villages were conducted. In the May, 1975,
assessment alone, 4 million people were interviewed about the effec-
tiveness of the search workers' job. Search efficiency was expressed
as the percentage of the villagers who actually recalled the searchers'
visit to the village, had seen the recognition card, and knew about
the reward for reporting smallpox and where to report a case.
Here was a change in assessment strategy or quality-control
monitoring similar to the change that occurred when the program
moved from a vaccination campaign to an eradication effort. After
1972, instead of monitoring the number of people vaccinated the
NSEP started to monitor trends in actual disease incidence. A more
sophisticated measure of this was outbreaks pending in the infected
areas. When there was no more smallpox to use as a quality-control
index, a new assessment technique evolved to assist in determining
how likely it was that a hidden case of smallpox could stay unde-
tected. It was of great importance that the community know that
smallpox should be reported, know what it looked like, know where
to report it, and know that there was a reward; and so this index,
the outcome of the search, rather than a simple monitoring of num-
ber of villages visited, became more significant. Special emphasis in
this assessment was given to high-risk areas-areas considered to be
The Case Study
67
more vulnerable to importations from Bangladesh and identified as
such through the preparation of risk maps of each district.
The importance of assessment cannot be overemphasized. It
was done at many levels by epidemiologists, state program officers,
district health officials, PMAs, state surveillance teams, and junior
medical officers. After each search, the results were compiled and
made available for comparison. Singled out for additional resources
were areas that were late or deficient in reporting (as indicated by an
unexplainable lower incidence of chickenpox than their neighbors)
or districts that did not achieve a predetermined target percentage of
villages searched or of knowledge within the population of the
search, the recognition card, the reward, or where to report a case of
smallpox. When assessment results showed that a district did not
meet minimal targets, that district was searched again, and the en-
tire mechanism of presearch briefings-villages allocated to each
search worker, supervisors' responsibilities, search week, reevalua-
tion of results, and so on-was repeated. This is the essence of
negative feedback in a management control system. The search was
either satisfactory or it was redone until it became so.
In May, 1975, there were 25 known pending outbreaks in In-
dia, compared to 8,600 one year before. Eighteen were in West Ben-
gal and the eastern states; most were 1-case or 2-case outbreaks
imported from Bangladesh, which exported a total of 32 outbreaks to
India in the first six months of 1975. So rapid was containment that
in nearly half of these outbreaks there was no secondary case. The
average number of cases per outbreak was 3.9, and the average
reporting lag between the onset of first case and the report reaching
the medical officer was thirteen days. From the 32 importations,
except for 7 in Assam that created secondary satellites, there was
only a single secondary spread, and that was in West Bengal.
April 7, 1975, was World Health Day. The theme was "Small-
pox-Point of No Return." To commemorate the day, an all-India
search was conducted. Approximately 115,000 health workers
searched house-to-house in each of India's 615,000 villages and urban
areas: no smallpox was found. Operation Smallpox Zero was working.
On May 17, 1975, the last known indigenous smallpox out-
break in India occurred in Pachera village, Katihar District, Bihar.
Manjho, an eight-year-old boy, developed rash on that day. But
surveillance activities did not stop with Pachera. The special68
Smallpox Eradication in India
searches of the border areas continued, and on May 24, 1975, the
last known smallpox patient in India developed rash. Saiban Bibi, a
thirty-year-old homeless Bangladeshi, had come in contact with a
case of smallpox in the village of Thauri, Sylhet district, Bangla-
desh. She developed rash while living on the Karimganj railway
station platform in Cachar district in Assam, where she was beg-
ging for food. On May 28, 1975, containment activities began,
along with an active search of the entire district. There were no
secondary cases, but no one knew whether to expect more impor-
tations from Bangladesh.
Certifying Eradication: The Two-Year Vigil
The Realm of the Final Inch, 1975-77
Perhaps the hardest task in the smallpox eradication program was
maintaining the constant vigilance and intensive two-year surveil-
lance period that had to follow the hoped-for last case in each
country. The monthly progress reports, sent by the chief of the
Global Smallpox Eradication Program to staff around the world,
highlighted this critical and difficult time. In "Progress Report 32-
Target Zero," sent just after it was hoped that the last case had
been found on the lhdian subcontinent, D. A. Henderson dis-
cussed the difficulties of keeping the work going: "Although the
situation is highly encouraging, we are entering a most critical
phase where optimism and/or complacency could prevent us from
reaching our final goal." He quoted Professor Holger Lundbeck,
director of the Swedish National Bacteriological Laboratory. Lund-
beck had written a cautionary note that Solzhenitzyn's "rule of the
final inch," from The First Circle, might well have been written with
smallpox eradication in mind.
The rule of the final inch. The realm of the Final Inch. In the Lan-
guage of Maximum Clarity it is immediately clear what that is. The
work has been almost completed, the goal almost attained, everything
seems completely right and the difficulties overcome. But the quality
of the thing is not quite right. Finishing touches are needed, maybe
still more research. In that moment of fatigue and self-satisfaction it is
especially tempting to leave the work without having attained the
apex of quality. Work in the area of the Final Inch is very, very com-
plex and also especially valuable, because it is executed by the most
The Case Study
69
perfected means. In fact, the rule of the Final Inch consists in this: not
to shirk this crucial work. Not to postpone it, for the thoughts of the
person performing the task will then stray from the realm of the Final
Inch. And not to mind the time spent on it, knowing that one's pur-
pose lies not in completing things faster but in the attainment of
perfection. (Solzhenitzyn 1976, 161)
In India, smallpox activities did not stop with the discovery of
Saiban Bibi, as they had not stopped with the containment of Pach-
era village. Throughout India, smallpox workers searched intensely
and somewhat nervously all around their areas, fearful that some-
where, somehow, a hidden case of Variola major might place them
and their programs in the company of three villages, one in Indone-
sia, one in Brazil, and one in Nigeria, with one unhappy event in
common: all had stumbled at the threshold of the realm of the final
inch. Months after smallpox had been thought to be eradicated in
each of these countries, an outbreak had been discovered. 8 In fact, it
was nearly part of the legend of smallpox that the last case might
only be found on the eve of eradication celebrations.
The smallpox staff in India, however, believed they would not
suffer such a fate; the surveillance system established there was by
far the most sensitive that had been developed up to that time.
Still, when six weeks had passed after the onset of Saiban Bibi's
rash and the last outbreak was ticked off the active list, it was not
without trepidation that the WHO staff agreed to hold a large
celebration on August 15, 1975, India's Independence Day. The
government staff hoped to link the attainment of zero pending
outbreaks with Independence Day by holding a celebration honor-
ing India's independence from smallpox. Dr. Halfdan Mahler,
director-general of WHO in Geneva, was to attend. Significant me-
dia attention was expected.
The plan called for the then health minister, Dr. Karan Singh,
to present a large murthi (statue) of Lord Shiva, the god of destruc-
tion, to WHO, representing the gratitude of generations of Indians
who would henceforth be free of the destruction of smallpox. This
gift would be sent to Geneva to grace the lobby of the WHO head-
quarters building. After the ceremony, Mahler was scheduled to fly
on to Dacca, to meet with Sheikh Mujib Rahman, president of Ban-
gladesh. Smallpox eradication in Bangladesh had not fared as well
as in India, and many in WHO thought that the government in

70
Smallpox Eradication in India

Dacca would need to change certain policies if smallpox were ever to
be eradicated from that country.
Many smallpox veterans did not sleep the night of August 15,
fearful of a last-minute discovery of a hidden outbreak. Although
events of a different order erupted, no outbreak of smallpox was
reported. That night, Sheikh Mujib was assassinated, and the gov-
ernment of Bangladesh closed the airports and sealed the borders.
Rumors of civil unrest and refugee movements circulated in New
Delhi. Mahler went home to Geneva.
Within days, rumors that there might be a massive return of
refugees increased. In 1971, an estimated 10 million had streamed
across the Bangladesh-India border, carrying smallpox from India to
Bangladesh. This time, they might carry smallpox from Bangladesh
to India. In the first six months of 1975, there had already been
thirty-two detected importations from Bangladesh, and although
two-thirds of these were detected within fifteen days of onset of the
first case and more than half were limited to a single case by rapid
containment action, the earlier experience was still remembered
with apprehension. In November, 1971, refugees returning to the
newly created Bangladesh from Salt Lake Camp for refugees near
Calcutta had seeded the infant nation with dozens of simultaneous
outbreaks. Like a malignant cancer, the disease had spread through-
out Bangladesh, overwhelming the smallpox program. It took nearly
four years to recover from that experience. A return visit to India of
the infection might overwhelm the sustained popular support
needed for the final inch.
The potential epidemic had to be prevented from entering India.
WHO and government of India smallpox eradicators turned eastward
to the Bangladesh border and mounted an intensive surveillance ef-
fort in Bengali-speaking areas. The old maps were taken out and
studied for a clue to possible migration routes, dozens of surveillance
posts were set up at border crossings, and special searches were
conducted in designated high-risk areas. A special effort was
mounted to control importations among the pavement dwellers of
Calcutta, thought at the time to be recent migrants from Bangladesh.
(After careful study of the floating population, however, it was con-
cluded that most were semipermanent, with closer ties to Bihar than
to Bangladesh; but still surveillance was intensified.)
The two-year period of waiting and watching thus began omi-
The Case Study
71
nously. But in some degree, it had been established for just such
reasons. The WHO Expert Committee on Smallpox Eradication had
established the two-year period of active surveillance because
twenty-four months was three times longer than any smallpox out-
break had previously eluded detection by a smallpox program. The
realm of the final inch demanded meticulous attention to detail at
the very end of the journey.
In India, there was little problem keeping up the momentum of
searches as long as smallpox continued in Bangladesh, which shares
with India a horseshoe-shaped border more than 1,000 kilometers
long. And when Rahima Banu of Kuralia village on Bhola Island
became the last case of endemic Variola major 9 in the world (with
onset on October 16, 1975), the elation felt in Bangladesh was shared
by 100,000 search workers throughout India. Almost miraculously,
India had kept her independence from smallpox, without a single
importation after August 15. And yet another eighteen months of
active surveillance were required before an international commission
would visit India to certify eradication.
Maintaining an esprit de corps and motivating themselves, col-
leagues, and others to work toward eradication had become a way
of life for smallpox workers. People spoke of two infections, the
virus of smallpox and the infection of zeropox, which began as the
telex callback code in Chhotanagpur but soon became a shorthand
term for the infectious enthusiasm of the eradicator.
In many ways, the smallpox eradication program was what
sociologist Max Weber has called a "charismatic organization," quite
different from the formal organizational structure commonly asso-
ciated with WHO. But getting governments and workers motivated
to eradicate smallpox was one thing. It was another to motivate the
repetitive searches for two years, when there was no smallpox in
India and none in Bangladesh and few personal or professional re-
wards other than the satisfaction of completing a job well done. This
period of waiting, searching, and pressing on was one of the most
difficult times, and yet it had to be borne. It was truly the final inch.
From August 15, 1975-the date of the independence from small-
pox celebrations-until the arrival of the specially constituted interna-
tional certification team, three all-India searches were carried out. Each
was a house-to-house search of more than 100 million households.
These searches, carried out in October and November of 1975, March72
Smallpox Eradication in India
and April of 1976, and October and November 0£1976, again employed
over 100,000 health workers throughout the country. No smallpox was
detected. From December, 1975, to February, 1976, a special series of
searches was carried out in the border areas with Bangladesh and in
districts with cultural or religious links to Bangladesh. Urban areas
were searched during the three national searches and again in August,
1976, when a special monsoon search of 2,641 urban areas was con-
ducted. Some remote and difficult-to-reach areas that had been missed
during regular searches posed special surveillance problems. During
1975-77, special assessment surveys or special searches were carried
out in Ladakh, Sikkim, Tripura, Mizoram, and Andaman and Nicobar
Islands, and some difficult areas of central India. Facial pockmark
surveys were also conducted. No smallpox cases with onset later than
Saiban Bibi's were detected.
The three final all-India searches conducted in 1975-77 covered
an average of 98.5 percent of the more than half-million villages in
India in each search. Although no smallpox was found, chickenpox
had certainly not been eradicated. The instructions to search
workers to report all cases of fever with rash led to a high of 118,642
reported outbreaks of chickenpox, in which 379,297 cases were de-
tected in the spring, 1976, search. The monitoring of reported chick-
enpox was a useful index of surveillance efficacy, but very sensitive
to seasonality. A more important index was provided when the
assessment teams that checked a sample of the villages found that
95.8 percent, 94.5 percent, and 97.0 percent had in fact been visited
by a search worker in the three respective searches.
The search assessment itself had by this time become an im~
pressive additional surveillance tool. In the final all-India search,
nearly one-sixth of all villages in the country were revisited by an
assessment team evaluating the efficacy of the search. In the final
search, 107,409 villages were assessed-a very impressive figure
when one recalls that the first all-India search had actually been a
search of 241,074 villages in the endemic area and 40,418 villages in
the nonepidemic states. Put another way, final spot assessment be-
came so rigorous that nearly half as many villages were visited by an
assessment worker at the end as had been visited by a search
worker in the initial comprehensive searches three years previously.
In the spring, 1976, search, 682, 151 out of a scheduled 692, 189
villages were searched, along with 1,322 municipal areas. A staff of
The Case Study
73
142, 176 people was mobilized to visit each house in every village. Six
months later this colossal effort was repeated one last time. In au-
tumn, 1976, three years after the first autumn campaign, the largest
search of all was carried out by 152,441 health workers, including
malaria and family-planning staff, who searched 668,332 villages,
99.1 percent of the villages targeted for search. They detected 20,076
outbreaks of chickenpox, with 41,485 cases. When 8,048 assessors
visited 107,409 villages to check the work of the searchers, they found
that 104,596 (97 percent) of the villages had been properly visited by
search workers. Further, in 86 percent of 3,051,743 households that
were visited by the assessors, someone had seen the search worker
come to their house; 79 percent of the families knew where to report a
case of rash with fever; 83 percent knew of the reward.
Increasing attention to assessment was the control that allowed
program managers to quickly spot deficient areas and allocate scarce
resources most efficiently, assigning jeeps, epidemiologists, and
state surveillance teams to the areas with the poorest assessment.
Thus the assessment performed the role that business analysts usu-
ally assign to quality-control measurements, assembly-line spot-
checks, or marketing feedback indices. From the first search to the
last, indices rose steadily, reflecting increasing surveillance quality.
Equally important, however, for the two-year postsmallpox pe-
riod, were the results of laboratory specimens that were taken from
cases of rash with fever, studied, and found to be diseases other
than smallpox. During 1975, 702 specimens were examined, of
which 141 had been positive for smallpox. In 1976, 640 specimens
were examined, and none was smallpox. Bihar, the most problem-
atic state during the intensified campaign, submitted 172 specimens
from cases of rash with fever in 1976. All were negative for small-
pox. By the end of November, 1976, the rumor registers were
packed with names and addresses-1,951,487 cases had been en-
tered as suspected rash-with-fever cases, visited, and examined;
833,412 cases of chickenpox were found.
And one more number. Zero cases of smallpox were found.
And that, after all, was the most important statistic of all.
The Certification of Eradication, 1977
No matter how good eradication looked on paper, it had to be certi-
fied in the field by an international panel of outside experts. Closing
74
Smallpox Eradication in India

the books on smallpox required a careful and systematic process of
deliberation-certification of eradication-by specially constituted
international commissions convened by WHO. WHO established
certain requirements to be met in order to formally certify a country
as smallpox-free. The procedures included two years of active sur-
veillance after the last detected case of smallpox, followed by a visit
by an international commission to examine documentary evidence
provided by the country and assess the validity of the documenta-
tion through personal field experience. The definition and criteria
for smallpox eradication were established in 1972 by the Expert
Committee on Smallpox Eradication, which stated:
Recent experience indicates that in all countries with a reasonably effec-
tive surveillance programme, residual foci can be detected within 12
months of apparent interruption. Thus, in countries with active surveil-
lance programmes, at least 2 years should have elapsed after the last
known case . . . before it is considered probable that smallpox trans-
mission has been interrupted.
On the basis of this recommendation, four international com-
missions had already been constituted by WHO to certify smallpox
eradication in the Americas (1973), Indonesia (1974), West Africa
(1976), and Pakistan and Afghanistan (1976).
In preparation for the international commission's visit to India in
1977, the government of India created a National Smallpox Assess-
ment Commission to perform an internal technical audit of the NSEP
and its ongoing surveillance activities. The purpose of this innovative
commission, which was composed of both Indian and international
health workers, was to fully examine the surveillance process, to
establish that no smallpox foci had occurred in India since May, 1975,
to motivate staff to maintain careful surveillance until the arrival of the
international commission, and to recommend a plan to further
strengthen surveillance during the period of January through March,
1977. Such a national initiative was further proof of the government's
commitment to go the final inch to ensure eradication.
At a review meeting held on January 20-21, 1977, the national
commission reported that it found no evidence of smallpox in any of
the areas visited by its members. While generally satisfied with the
progress of surveillance programs in the state, the commission rec-
ommended that the NSEP strengthen surveillance activities during
The Case Study
75
the final three months before the evaluation of the program by the
international commission. It reiterated that all suspected smallpox
reports and chickenpox deaths must be fully investigated and that
the diagnosis for other cases in each such outbreak confirmed by
laboratory tests. By the end of February special searches were to be
carried out by two or three basic reporting units in each district. The
evaluation criteria for the efficiency of surveillance was the number
of rash-with-fever cases (especially chickenpox) reported during the
following three months, since the incidence of such cases was ex-
pected to steadily increase from January through March, based on
previous epidemiological experience.
Documentation of surveillance activities was to be presented in
the form of maps, charts, and files arranged sequentially, and the
commission recommended that briefings be held at state, district,
and PHC levels in order to review surveillance strategy and the
requisite documentation. Supervisory staff at the state and district
levels were encouraged to motivate local health workers to continue
to perform careful surveillance. Large amounts of publicity about the
reward were continued, along with press releases to educate the
health staff and the public about the importance of the coming visit
by the international commission.
In response to the recommendations of the national commis-
sion, a series of reports was prepared for review by the international
commission, documenting smallpox epidemiology, vaccination pro-
cedures, surveillance, suspected cases, and the use of resources at
all levels. Upon studying the reports of the central government and
the National Smallpox Assessment Commission, the individual
members of the international commission went into the field to exam-
ine firsthand the effectiveness of surveillance activities and the ex-
tent of community awareness about smallpox.
On April 23, 1977, the international commission declared India
free of smallpox.
Based on its observation of the sensitivity of the country's sur-
veillance system, the commission concluded that any transmission of
smallpox would have been detected had it occurred since May, 1975.
But India was still theoretically threatened with importations from
neighboring countries, and the international commission rec-
ommended that primary vaccinations be continued until worldwide
eradication was reached. Surveillance for suspected cases and labora-76
Smallpox Eradication in India
tory confirmation of suspected cases were also to be continued until
global eradication, to further ensure the validity of that certification.
The commission also urged that the experience of personnel
from NSEP be analyzed and used as a lesson for other disease-pre-
vention programs; that documentation of the program and lessons
learned from it be used to provide a basis for epidemiological re-
search and for training health personnel in the control of communi-
cable diseases; and that the central government's report on smallpox
eradication be published and made available to health workers
throughout the world.
One important historical footnote brings the story full circle.
The WHO-appointed international commission included Professor
V. N. Zhdanov, the USSR emissary who had proposed in 1958 that
smallpox be targeted for global eradication, as well as Dr. David
Sencer, director of the United States CDC, which had lent the pro-
gram many outstanding epidemiologists. 10
The announcement of India's final liberation from smallpox
touched off celebrations all around the world, both public and pri-
vate. Perhaps the most deeply felt celebrations were of two kinds.
The first, of course, took place in villages like Pawa Puri, Tatanagar,
Pachera village, and Karimganj railway station, where smallpox his-
tory was made. The other celebrations were those in the homes of
100,000 Indian smallpox workers and in the thirty home countries of
the international smallpox veterans who had learned so much from
each other, from the disease that was their adversary, and from
India herself while they managed to eradicate smallpox.
Chapter 2
Analysis and Commentary
Introduction to the Analysis
The case study presented in chapter 1 was a chronology of the
management of smallpox eradication in India. In this chapter the
management of the program will be analyzed using a conceptual
framework developed by Professor James Austin. Austin has used
this framework to analyze successes and failures in international
programs dealing with family planning (Austin 1979), malnutrition
prevention (Austin 1978), and xerophthalmia prevention (Dutta,
Arora, and Rao 1975). The framework, slightly modified to apply to
smallpox eradication, starts with general definitions and moves
through management issues down to the specifics. The chronologi-
cal case study will be taken apart and reorganized following the
framework indicated by the chapter sections. Of necessity, many
key points will be repeated. This redundancy may be disconcerting
for readers familiar with the history of smallpox in India, but for
readers new to the subject it is important to review the eradication
effort from the vantage point of historical development as well as by
placing it within an analytic framework.
Statement of the Problem
India had for centuries been one of the heartlands of smallpox.
Smallpox had swept the world in great epidemics, often reemerging
from the Indian subcontinent. From time immemorial, great epi-
demics recurred in India with a five-to-seven-year periodicity. Even
after the arrival of vaccine in the country in 1802, there were devas-
tating recurrences such as the epidemics of 1873-74 (500,000 deaths
estimated), 1950-51 (105,782 deaths), and 1958 (45,838 deaths). Ex-
portations to Europe and other countries in Asia were common
(from 1961-73, ten importations to Europe were traced to India, and
twenty-one of the last twenty-seven importations into Europe were
7778
Smallpox Eradication in India
traced to the Indian subcontinent). By the middle of the twentieth
century, national and international expert committees were fre-
quently convened to consider the problem. The Bhore Committee,
1949, and the ICMR Expert Committee, 1959, pointed out problems
with program planning and management. National assessment com-
missions (NICD assessment, 1963-64; joint WHO-Government of
India assessment, 1967) pointed out serious managerial problems
with implementation; and even the international WHO expert com-
mittee, 1972, specifically recognized that "India presents special
problems" for the organization of a successful smallpox eradication
program.
The Causes of the Problem
The virus Variola major is propagated best in densely populated
areas.
As man is the sole host of the Variola virus and no animal reservoir
exists, continuous transmission of Variola virus in the human popula-
tion required aggregates of susceptible individuals such as first oc-
curred about 5,000-6,000 years ago when agricultural development
made it possible to support populations of more than 500 living to-
gether in one place (F. Fenner, personal communication). The disease
apparently spread in all directions from the eastern part of Asia along
with population movements due to trade, religious and political con-
flicts and exploration. (Arita 1979, 295)
Dr. I. Arita has suggested that the major problem in eradicat-
ing smallpox might be not the numbers of people vaccinated, but
the density of unvaccinated susceptibles (D. A. Henderson, personal
communication). In most of Africa, for example, while many were
unvaccinated, population density was low, leading to a decreased
overall density of susceptibles. In densely populated Asia, however,
even though a high percentage of people had been vaccinated, the
higher population density created a density of susceptibles that may
have been greater than in any other part of the world. The actual
propagation, epidemic force, or infection intensity could be related
to this density of susceptibles times a factor for climate and a factor
for frequency of interpersonal contacts. India's densely populated
areas and high mobility (as many as 6 million people are on a train
or bus or bullock cart traveling from one place to another at any
Analysis and Commentary
79
given moment), its periodic large gatherings (e.g., the famous
Kumbh mela, which attracts tens of millions every twelve years, or
the Jagganath Car festival in Puri, Orissa, which attracts nearly a
million every May), and its frequent smaller festivals or melas all
provide ideal conditions for transmission. The seasonal peak of
smallpox corresponds to the warm dry season, which lasts from
March to June in most of India, and also to the marriage and travel-
ing seasons.
In addition to these epidemiological problems, there were
many management problems. India continued to use liquid vaccine
long after it had been abandoned in other countries. A lack of refrig-
eration facilities impeded the early phases of the program until
freeze-dried vaccine became dependably available throughout the
country. India was very slow to adopt the bifurcated needle. Older
methods of immunization such as the rotary lancet were not de-
pendable and left large, disfiguring scars from bacterial infection,
which caused resistance to vaccination and frequently created a false
sense of confidence about successful immunization among those
who had been vaccinated. With over 80 percent of the population
living in rural villages and only infrequently having contact with
health services, the technical problems were compounded by the
logistical problems of providing effective delivery of vaccine to the
periphery. A cumbersome reporting system made it difficult to get
news of smallpox cases to the center. Finally, India's high birth rates
added as many as 21 million infants to the susceptible population
each year, new fuel for the fires of epidemic smallpox. Even if a 100
percent vaccination rate had been achieved through an annual visit
to every house in the country, each year's tens of millions of unvac-
cinated newborns could have supplied new links to continue the
chain of transmission.
The multiplicity of ethnic groups, languages, customs, and as-
sociated health beliefs in India is unmatched in any other country.
The staggering number of relatively autonomous health and medical
organizations at national, state, and municipal levels also com-
pounded difficulties, as did the relative administrative separateness
of cantonment areas, border areas, and tribal areas.
In brief, smallpox in India represented one of the most tena-
cious problems to be faced by the global campaign, and nearly all
observers acknowledged that one of the most intractable difficulties80
Smallpox Eradication in India
was administration. Delays and inefficiencies did not lend them-
selves to a successful emergency campaign.
Management practices in India had developed from the manag-
ing agency system imported by the British East India Company. The
system was highly centralized with a rigid social structure. The In-
dian civil service, which became the administrative model for India,
was a classic example of British rule-little delegation of real author-
ity, a narrow span of control, and a wide social gulf from top to
bottom.
In the Directorate of Health and in the health field, there was a
chronic shortage of professionally trained administrators. Most pro-
grams were headed by physicians who had excellent technical quali-
fications but lacked management skills and experience. Coordinating
a multiplicity of relatively autonomous smallpox organizations re-
quired several high-level managers, and at least until 1972-73, there
were no more than one or two senior-level program managers in the
office of the assistant director-general (smallpox), who as head of the
NSEP was responsible for smallpox eradication in the nation.
The understaffed NSEP administration, not surprisingly, was
having difficulty providing annual vaccinations to every one of the
150 million houses in the country! Compounding this management
bottleneck were social and cultural issues unique to India. Percep-
tions about the inevitability of the disease existed in many villages
and among certain health administration leaders. The average
villager dared not dream of the eradication of smallpox; in the cul-
tural framework of traditional India, that was a metaphysical contra-
diction. Within the Ministry of Health and within WHO many skep-
tics also doubted that smallpox could be eradicated, and many
health planners and some policy makers questioned whether eradi-
cation was economically justifiable.
System Definition
The smallpox eradication network involved the central government
of India, the various state governments, and Indian nongovernmen-
tal organizations (NGOs) as well as international agencies and bilat-
eral donors. Organization chart 1 in appendix 2 shows these institu-
tions and their roles as they evolved from 1962 to 1974.
From the periphery of India's more than half million villages
Analysis and Commentary
81
and over two thousand cities, through local, regional, and state gov-
ernments, to the Directorate-General of Health Services, smallpox
eradication efforts touched every level of government. The many
semiautonomous agencies-the municipal boards, cantonment
(armed forces) health directorates, railway health administration, and
private industrial health concerns-complicated the system. For ex-
ample, in one important epidemic area, there were fifteen autono-
mous political units-small company towns, corporations, railway
colonies, or unincorporated urban areas-with a total population of
approximately 800,000 people. Each unit was administered sepa-
rately. There was no single administrative authority for public health.
All of the units of the urban complex reported irregularly to the dis-
trict medical officer of health (DMOH). Responsibility for reporting
smallpox cases in border areas, the mobile population, and other
high-risk groups was unclear.
The NSEP, with over 100 smallpox eradication areas, was an
attempt to bring such autonomous entities together and organize an
independent single line of command. A program officer was ap-
pointed for every state in the newly established posts of assistant or
deputy director of health services (smallpox). From the district level
down to the PHC there were no special NSEP officers, although
20,000 vaccinators were appointed. The NICO (which had organized
the 1963-64 assessment) played a role by deputing trained epidemi-
ologists and would later serve as the vaccine quality-control refer-
ence laboratory in addition to doing smallpox diagnostic laboratory
testing. The four vaccine institutes were regional vaccine suppliers
although a central officer, the assistant director-general (vaccine),
was responsible for monitoring the quality and quantity of vaccine
produced. The ICMR was to oversee research projects dealing with
smallpox and had jointly organized the assessment of 1959. In the
early part of the program, before the intensified campaign, there
was little involvement of medical schools or NGOs. However, after
1974 organizations like the Lions and Rotary clubs, public sector
corporations like the Hindustan Steel Company, and private sector
companies like Tata began to play important roles in key areas.
Multilateral agencies such as WHO and UNICEF, which played
important roles later, had very limited roles before 1970. With the
exception of a small grant from United States AID in the mid 1960s
and substantial vaccine donations from the USSR in 1962 through82
Smallpox Eradication in India
1973, bilateral donors did not have much of a role until the intensi-
fied campaign. Oxford Famine Relief (OXFAM), whose $100,000 do-
nations of jeeps, volunteers, and supplies was to prove very impor-
tant in 1974, became involved only after the epidemic of 1974. The
WHO team was successful in mobilizing increasingly greater inter-
national and private resources during the intensified campaign; this
was especially true after the epidemic of 1974.
This network of interested agencies must be distinguished from
the formal government organization chart, which is shown in charts 2-
4 in appendix 2. The simple organization chart for 1962-69 (chart 2)
was inadequate to meet the growing need for surveillance and report-
ing. The 1970 structure (chart 3) shows the increasing emphasis given
to the partnership, with the 1973 intensified campaign (chart 4) requir-
ing even more cooperation, as exemplified by the emergence of the
joint central command. It must be remembered that smallpox was a
state subject in India, which meant the actual work of the intensified
campaign was carried out at the state level. Charts 5-9 show the
organizational pattern of smallpox work at the state, directorate, dis-
trict, PHC, and municipality levels. While the example is that of Uttar
Pradesh, similar structures could be found in other states. Like most
government organizational charts, these contain a plethora of abbre-
viations and job titles that may puzzle the reader, but the charts are
presented not so much for their detailed organizational components as
to give the reader a feel for the complexities involved in supervising
and coordinating such a vast army. This system was not a static one,
and it grew wider and broader as the campaign continued. Increas-
ingly, a dynamic temporary system of smallpox eradication was being
grafted onto the permanent organizational tree.
The following provides one example of organizational changes
that occurred as the program developed in 1974. In the Tatanagar/Jam-
shedpur epidemic, although over 300 exportations were documented,
there was little notice of the outbreak in Tatanagar area itself. One of
the reasons was the multilayered administrative structure-the many
autonomous units without an effective single line of command. The
company doctor at TISCO had been negligent in reporting smallpox;
the local Bihar state government, with 33 percent of its PHC medical
posts vacant, could not mount an effective surveillance program. With
the intensification of smallpox efforts, many community leaders vol-
unteered to join the expanding mobilization. The discovery of the
Analysis and Commentary
83
smallpox epidemic catalyzed vigorous community participation in the
program. Rotary Club, Lions Club, Ramakrishna missions, Youth
Congress, the local blood bank (they provided free cooked meals for
600 volunteer surveillance workers for one week) all provided assis-
tance; the local industrialists in both the public sector (Hindustan Steel,
Bihar Mines, and others) and the private sector TISCO, Tata Electrical
and Locomotive (TELCO), Indian Tube Company, Usha Martin Black,
and others) got volunteers from their factories, paid their salaries and
expenses, and set up a central command headquarters in the Jamshed-
pur town hall. Improved community awareness of the size of the
problem led to an unusual degree of cooperation between sectors and
among many varied groups.
Because it was discovered that the initial surveillance reports
had seriously underestimated the size of the outbreak, an active
search operation was organized in the second half of May, 1974. Of
1,203 villages within a forty-five-kilometer radius of Jamshedpur,
760 were searched. The search showed that 456 (approximately 60
percent) had as many as 726 active smallpox cases. When these new
cases were combined with the 1,479 cases discovered in the urban
areas, it meant that 2,005 cases of smallpox had been discovered
through increased community participation in this one limited area
alone. In Austin's framework, system usually means institutions. As
the smallpox program developed and grew, the system widened to
include many institutions, agencies, and organizations from all
sectors of Indian life.
Setting Goals
Austin points out four principles of goal setting that characterize
good management of successful projects in the developing world.
Goals, whether for the total system or the individual institution,
should meet four fundamental requirements if they are to be of maxi-
mum utility: Goals should be specific .... Goals should be measur-
able .... Goals should be realistic .... Goals should be dynamic ....
(Austin 1979)
Explicit goals are a prerequisite for effective management-they
serve as guidelines for strategy formulation, motivating instruments,
and as a basis for subsequent evaluation or concurrent assessment.84
Smallpox Eradication in India
Both vaccination programs and eradication campaigns lend
themselves to goals which are specific and measurable. For instance,
before the strategy was changed to surveillance and containment,
specific goals had been first to vaccinate 80 percent and later to
vaccinate 100 percent of the population. Although specific and mea-
surable, these goals were not realistic. Even in a militaristic setting
like an army it would be difficult to achieve 90-95 percent vaccina-
tion. There are always exceptional reasons to avoid vaccination.
Such vaccination rates are even more unrealistic for an entire coun-
try. In the Indian context, with limited penetration into the periph-
ery by the health services, 100 percent vaccination was unrealistic.
With India's 21 million new births every year it would have been
necessary to continue to visit every person and every home in India
each year for vaccination alone, and even then 21 million unvacci-
nated babies would have entered the population in each one-year
interval.
This rather inflexible early goal was shifted to a set of strategies
routinely called surveillance and containment. In 1970-72, goal set-
ting in the area of reporting procedures was developing. Every
PHC, district, and state was to collect and pass along all smallpox
reports each week. This was a measurable, realistic, and specific
goal. It was also dynamic, part of an improving surveillance system.
As the program evolved, the goal of good reporting was extended as
the site of the most peripheral reporting unit was refined from each
PHC to every village and finally to every home in India. The fre-
quency of reporting also changed. Although routine weekly report-
ing was still required, more attention was paid to periodic search
reports, whether monthly or bimonthly or (later) even less frequent.
The 1970 Plan of Operations had been weak in setting goals.
The only containment goal mentioned in it is that mass vaccination
should be performed when an outbreak was discovered.
As the case reporting and surveillance became more and more
effective, specific, quantifiable containment goals (called targets) be-
came an important part of the program-especially in Operation
Smallpox Zero. In August, 1973, the goal was to find as many hid-
den cases as possible and vaccinate the thirty households closest to
each infected house. By January, 1974, the target was to vaccinate
fifty households around each case, and later in that year the entire
village was to be vaccinated and two watchguards posted to prevent
Analysis and Commentary
85
contact between the smallpox cases and potentially unprotected in-
dividuals. Searches were conducted as far as 10 miles (16 kilometers)
around the infected house to detect hidden cases. As the numbers of
outbreaks decreased and more resources could be focused on each
one, a supplementary second search was added to the containment
requirements, to be carried out two weeks later because an incubat-
ing, asymptomatic case could have been missed in the first search.
Saturation vaccination was increased to include everyone living
within 1 mile (1.6 kilometers) of each case, and additional watch-
guards were posted. Careful outbreak investigation was made an
additional target. The meticulous care afforded individual outbreaks
reached a peak in 1974-75. In one outbreak in Pawa Puri village in
Bihar, nearly 2,000 telegrams were sent to people suspected of hav-
ing been in contact with an active case.
Each newly adopted epidemiologic measure aimed at contain-
ing the spread of smallpox became a target in its own right. For
example, by 1975, any outbreak having secondary cases more than
twenty-one days after the onset of the first case was considered a
containment failure and was visited by a senior-level central apprais-
al officer who may have traveled 2,000 miles just to assess the work
in the outbreak. Not only were these measurable targets, but they
were reasonable ones that increased in sophistication only as the
number of outbreaks decreased or increased staff became available.
Because they were reasonable targets it was also reasonable to take
stern administrative action when they were not met.
Another set of targets not unlike those of an advertising cam-
paign was established for health education. A high level of public
knowledge of the importance of reporting hidden cases was
needed. Each district and state aimed at attaining a specified target
knowledge level, defined as the percent of people knowing of the
existence of the reward for reporting smallpox. The first target was
set at 50 percent of the population. Assessment teams questioned
nearly half a million people to see if they knew about the reward.
When they found that target had been achieved (see tables 5 and 6)
the target was promptly raised to 67 percent in June/July, 1975 and
finally to 80 percent during Operation Smallpox Zero in 1975. The
goals were dynamic and increasingly stringent as outbreaks became
fewer and more resources could be shifted from containment activi-
ties to health education during the periodic nationwide searches.86
Smallpox Eradication in India
The purposes of these targets were to increase surveillance,
supervision of the active search, extent of publicity and reward in-
formation, and speed and coverage of vaccination.
This type of goal setting-specific, quantifiable, realistic, dy-
namic, and flexible-lent itself to measurable progress. Because each
program activity now had a yardstick for measuring good perfor-
mance, it was possible to spot poor performance areas and concen-
trate on them, so that resources were allocated more accurately.
Most of these targets, however, were intermediate objectives or
operational goals. Targets were fluid and flexible, changing as the
program became more sophisticated. There were in reality at least
two tiers of goals. The highest goal was realistic, measurable, and
explicit, but unchanging. From the beginning of the intensified
smallpox campaign, it remained the same, an inspiring and motivat-
ing target of the campaign: targ~t zero.
Strategy Formulation
Strategies and tactics are components of program management that
affect the attainment of its goals, the final outcome of the program.
Once goals are established, program management must plan how
they will be achieved. Strategies provide a plan of action that guides
management toward goal attainment.
We can think of two types of strategy formulation in the
smallpox story: political strategies and technical or epidemiological
strategies.
Political Strategies
For the most part, the formulation of political strategies originated
with the active entry of WHO into the smallpox program. Once an
international agency became involved in the national program, com-
parisons with programs in other countries became inevitable. There
was a global competition to avoid being the last country infected
with smallpox.
.
The political strategy of the smallpox unit was straightforward.
Smallpox had been declared a priority by the World Health Assem-
bly, and the government of India had subscribed to the resolution
making smallpox eradication a high priority. However, this political
commitment from the government had not been translated into
Analysis and Commentary
87
manpower, jeeps, and a workable system. The major political strat-
egy was to motivate decision makers to make smallpox a real prior-
ity. Only this would free the needed resources, permit the rule
breaking that would be required, and encourage a sustained com-
mitment from the technical staff. Fortunately, there was a conver-
gence between the epidemiological strategy (searching for all cases)
and the political strategy (making smallpox a priority). As the search
detected more cases, the true size of the problem became more
apparent and political pressure to control the epidemic mounted.
Concern and embarrassment combined to open doors and provide
access to political decision makers.
Once India began nationwide searches, a cumulative series of
events was set in motion. This process kept going on and on, in-
creasing its effect with each search. In management jargon, such a
process is called an "iterative" or positive feedback loop. This posi-
tive feedback loop might be thought to have replaced an earlier,
negative feedback loop that had been operative before the intensi-
fied campaign. The earlier feedback loop fostered suppression of
smallpox reports, and the apparently diminishing incidence of
smallpox led to consequent removal of health resources from the
smallpox network. The sensitivity of the reporting system increased
at least tenfold from 1972 to 1975, creating a sense of urgency that
convinced health planners, policy makers, and politicians of the im-
portance of smallpox eradication. Likewise, interest and support
from well-known individuals, the media, and the political level pro-
vided motivation for the workers. Personal messages issued by the
prime minister, governor, and chief secretaries as well as religious
and cultural leaders exhorted the team to work harder and better.
It was important-essential-to keep morale in the field high
by supporting the efforts of the search worker. These often unsung
heroes were the people who had to travel an extra mile or to make
yet another search of an area long believed free of smallpox. The
weekly surveillance reports that were widely circulated and closely
followed helped by stimulating interdistrict or interstate competition
to eradicate. Finally, there was the rarely spoken possibility that
India might be the last country on earth with smallpox. This was
perceived as a national disgrace: Prime Minister Indira Gandhi had
said that "smallpox is a disease of economic backwardness." Fears
of trade embargoes, international quarantine, and loss of tourist88
Smallpox Eradication in India
revenue, while never explicitly mentioned, provided a constant in-
centive for India.
The interest generated from the political level made it possible
to attract more resources and increase community involvement from
outside the health sector. During the peak epidemic year :197 4, for
example, there were 188,003 cases of smallpox to be found and
contained by 20,000 NSEP workers. A short-term infusion of addi-
tional staff was needed, and the political strategy of increasing
smallpox's priority was directed at this need. For example, once the
governor of Uttar Pradesh announced his personal commitment to
eradication, other public officials in the state could not refuse to
support it; in Bihar, once the chief secretary made smallpox eradica-
tion part of the duties of the chief civil authority, the district magis-
trate, and removed it from the hands of the district medical officers,
the program gained extra managerial know-h"ow and access to high-
level political figures.
Epidemiological Strategies
Once the goal of eradication was established, several epidemiologi-
cal strategies were tried: (1) 80 percent vaccination coverage with
lymph vaccine, (2) 80 percent vaccination coverage with freeze-
dried vaccine, (3) 100 percent vaccination coverage with freeze-
dried vaccine, (4) passive surveillance with mass vaccination
around outbreaks (the 1970 Plan of Operations), (5) surveillance
and containment (active case search, identifying high-risk popula-
tions, containment vaccination, with concurrent assessment).
When the NSEP was established in 1961, India embraced the
global WHO-promoted strategy of mass vaccination. Because the
objective of this strategy was to vaccinate every individual in the
country (the target was initially 80 percent, herd immunity being
thought to be sufficient to interrupt transmission), its evaluation
criteria were based on program inputs and outputs (i.e., the amount
of vaccine imported or produced, the number of people vaccinated,
and so on). These were misleading indicators, however, for even as
health workers reported more successful vaccinations, smallpox out-
breaks were increasing.
This was, however, the state of the art in the 1960s. It was
logical to assume that if all susceptibles became immune, transmis-
sion of the disease should be stopped. In fact, this strategy had been
Analysis and Commentary
89
successful in Burma, the Middle East, and elsewhere, including the
Sudan. The 1958 WHO expert committee report, which had declared
"The target must be to cover 100% of the population" (World Health
Organization Expert Committee on Smallpox Eradication 1972), pro-
vided technical justification for mass vaccination. Thus the stan-
dards adopted by the Indian government were internationally ac-
cepted ones.
In India by the late 1960s, the mass vaccination program was
successful in achieving the highest vaccination coverage rates of any
of the smallpox endemic countries in the world, but it was unsuc-
cessful in its ultimate goal of interrupting transmission. The mis-
placed concern for vaccination coverage created a paradoxical atti-
tude among the program staff who followed this tragedy: they were
more worried about the percentage of vaccination coverage or the
number of unvaccinated children than they were about the occur-
rence of smallpox cases.
However, by around 1970 the program staff (mainly Indian)
started to seriously question why transmission was continuing de-
spite such high vaccination coverage. This is where the concept of
density of susceptibles is important. For example, in area A, where
only 100 persons live in one square kilometer, vaccination coverage
of 50 percent leaves only 50 susceptibles. On the other hand, in area
B, where 1,000 persons live in one square kilometer, 90 percent
vaccination coverage still leaves 100 susceptibles, which is no differ-
ent from the number there would have been in area A if no vaccina-
tions had been done at all there. The lesson here is that in densely
populated areas such as urban slums, even 90 percent vaccination
would leave enough susceptibles to maintain transmission.
The alternative to 90 percent vaccination was surveillance and
containment, which had been implemented in West Africa, Brazil,
and Indonesia. It had been shown there that transmission was inter-
rupted more quickly and at much less cost than it would have been
if the mass vaccination approach had been used.
From 1970 to autumn, 1973, WHO made substantial efforts to
introduce and develop the strategy of surveillance and containment
into India through seminars and visits by consultants and by in-
creasing the number of WHO epidemiologists assigned to India
from four to eight. However, the results were not satisfactory.
In the autumn of 1973, two weeks of active search were carried

Analysis and Commentary

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Stoppt die deutschen Massenmörder!
Stoppt die österreichischen Massenmörder!
Stoppt die schweizer Massenmörder!

Revolution jetzt. Sonst ist es zu spät.

Pangwall

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Re: The Management of Smallpox Eradication in India
« Reply #3 on: November 10, 2022, 09:03:59 PM »

90
Smallpox Eradication in India

out in the four endemic states by mobilizing all primary health
center staff. Until the autumn of 1973, ad hoc mobilization of health
service staff had been done for active searches and for occasiona!!
epidemic control, but the staff of Muzzafanagar district, Uttar Pra"
desh, working along with Dr. S. Moukhopod, a WHO epidemioh
gist from the USSR, proved that assigning the entire PHC staff for
two weeks made it feasible to visit all the villages in order to detect:
any hidden smallpox. It was also seen that a municipality search
could be effective during the rains, since the team could concentrate
their efforts in accessible urban areas when the transmission rate
was low.
Thus, the epidemiologic strategy of the 1973 intensified cam-
paign developed from practical field experience and a better under·
standing of smallpox epidemiology. Following Austin's conceptual
framework, this strategy development can be seen as (1) accurately
assessing the magnitude and nature of the problem, (2) tracing the
cause of the problem correcting, (3) understanding and working
with the existing system, and (4) forming workable political and
epidemiologic strategies.
The results of the autumn search were dramatic. First, it was
obvious that the sheer amount of smallpox had been disastrously
underestimated both by India and WHO. Second, a most effective
way was developed to discover hidden foci. Third, and psycho-
logically very important, Indian and WHO field staff agreed that
with a sufficient number of containment teams smallpox could be
eradicated.
The surveillance and containment strategy evolved over time.
The measurement of its success no longer was the number of people
with vaccination marks, but rather the number of people with small-
pox. Although the difference in objective appears subtle, the new
emphasis on outcome (smallpox incidence) was a breakthrough in
the thinking of NSEP planners. With the new emphasis, the strategy
became harmonious with the ultimate goal of decreasing smallpox
incidence to zero.
The many specific tactics of surveillance and containment in
India-active search and containment, dividing India into endemic
and nonendemic areas, individual risk-area analysis, forward trac-
ing the chain of infection or backward tracing the source of infec-
tion-are part of a generic lesson that has applicability beyond the
91
smallpox eradication experience. Whether it is called scientific man-
agement, selective epidemiological control, or surveillance, it is dis-
tinguished from simple distribution of services in that it depends
on the measurement of outcome: the reduction of morbidity and
mortality.
Even the concurrent assessment that developed later in the
program was a refinement of this epidemiologic strategy, which was
used to allocate resources on the basis of priority. Priority was re-
lated to risk of smallpox: the geographic areas at greatest risk had
most priority. Risk was in turn defined by reference to certain epide-
miologic indicators. For example, late in the program, when small-
pox was disappearing, chickenpox surveillance was used as a surro-
gate for smallpox surveillance and monitoring chickenpox incidence
was a management device for detecting areas with weak surveillance
systems. One finding from chickenpox reporting in May, 1975, was
that the district of Dumka in Bihar reported no chickenpox, while
neighboring districts reported a great deal. Program managers
reasoned that Dumka was at higher risk of having hidden smallpox,
because if it did not report chickenpox, its surveillance system was
not capable of finding smallpox either. On this epidemiologic basis,
a special surveillance team was sent to Durnka to search for hidden
smallpox. The distribution of knowledge of the reward could then
be assessed and mapped, and it was clearly shown that Dumka had
a much lower general knowledge level than its neighbors, confirm-
ing earlier fears raised by Dumka's lower chickenpox reports.
Seen in this context, epidemiologic measurements such as risk
ratio and attributable risk have a great value in guiding disease
control efforts. One enduring result of the marriage between epide-
miology and the management sciences was a growing mutual re-
spect for the value of both systems.
Implementing the Tasks
The journey to eradication can be seen metaphorically as a voyage
beset with many obstacles. Goals and strategies provide the man-
ager with destination points and a navigation map. Concurrent as-
sessment provides a sextant to chart progress in relation to the stars,
but down-to-earth tasks are needed each day to keep the ship work-
ing and moving mile by mile toward its destination.92
Smallpox Eradication in India
Task implementation in smallpox was a dynamic process, con-
stantly recycling lessons learned through hundreds of natural ex-
periments in remote villages. As fast as these innovations could be
shared at monthly progress review meetings in each state, they were
disseminated at the next presearch meetings to the most peripheral
PHC levels. As the epidemiologic situation changed, the specific
tasks changed. But the need for attention to detail did not change.
Eradication, as one person put it, demanded perfection in detail and
compulsive attention to specific tasks.
Tactics are methods used to implement strategy. Developing
tactics involves attention to each program component-such as the
procurement and distribution of supplies, management information
systems, personnel management, financial management and bud-
geting-as well as research and development. An international
health program also involves diplomacy and knowledge about inter-
governmental affairs. These latter, along with leadership, motiva-
tion, and management style, are considered in the section entitled
"Management Style."
This section on task implementation is organized according to
the functional components of the smallpox eradication program.
Tactics will be discussed with reference to two periods: first,
1961-73, when the goal of eradication was just being articulated
and the NSEP created; second, 1973-75, when the intensified cam-
paign was in full swing.
Organizational Tactics
Formal organization charts, such as those shown in appendix 2,
rarely reveal the actual working structure of an organization. Access
to top decision makers is frequently so important that knowing
whose offices are closest to the director's office may be more infor-
mative than seeing which box on the formal organizational chart is
directly next to that of the director. In India, where organizational
hierarchies are the legacy of British colonialism, requests and ap-
provals as well as operational plans must come through a series of
proper channels.
In the smallpox eradication program in India, the hierarchical
relations of the organization chart were often breached. The success
of the program relied on an understanding of the informal organiza-
tional structures of both government of India and WHO. A per-
Analysis and Commentary
93
sonal, persistent approach to administrators, politicians, bilateral do-
nors, and Indian philanthropists characterized the organizational
tactics of the smallpox team. An informal atmosphere, a group deci-
sion-making process, and an open, decentralized style characterized
the operating relations of the joint WHO-government of India cen-
tral command that emerged gradually over the months of intimate
working together in field and office (see charts 2-4 in appendix 2).
This frequently resulted in "level jumping," a term used in India to
refer to the process of circumnavigating the formal chain of com-
mand. In the Directorate-General of Health Services, for example, if
a junior officer goes straight to the director-general, or an assistant
director-general goes personally to the health secretary or minister,
they are level jumping. Nearly every senior Indian health official
identified level jumping as one of the reasons for the smallpox pro-
gram's success. Although level jumping cannot be a prescription for
success in other programs (if everyone goes around the system, the
system itself is destroyed) it is important to distinguish between the
formal organization seen on paper and the informal organization
that played such a key role in smallpox eradication.
Government of India-Health Structure
The program officer for the NSEP was the assistant director-general
of health services (smallpox). Above his rank in the formal organiza-
tional chart were a deputy director-general (public health), a com-
missioner of health (approximately equal to an additional director-
general), and then the director-general of health services. But the
organizational chart does not stop there. In India, as in most other
commonwealth countries, technical leadership in a ministry (such as
the medical officers in the Directorate-General of Health Services)
are below two other levels of bureaucracy, the administrative and
the political. In the administrative level, there were usually two
assistants, such as the deputy and additional secretaries, both of
whom usually outranked the technical officers, and above them was
the secretary. In India, the phrase "the government has agreed"
usually means a formal letter signed by someone from the adminis-
trative level, usually with the rank of at least under-secretary. The
administrative level in the government of India is made up of sev-
eral cadres. The higher-ranking administrative personnel (such as
the secretary of health) come through the IAS, an elite corps of94
Smallpox Eradication in India
professional administrators; the under-secretaries usually come from
the central administrative services. Both are part of the permanent
government of India administrative structure.
The highest level is the political level, where the minister of
health officially has final say. A variety of assistants to the minis-
ter-special assistants, or the minister's personal assistant-wield
great authority.
In the beginning of the program, the smallest matters, includ-
ing the visits of the NSEP officer out of New Delhi to an outbreak,
required permission from the administrative level. Simply moving
from place to place while investigating smallpox spread required
administrative approval. In the case of internationals working in
certain states, permission from the political level was required to
follow a source of smallpox infection. The technical level staff had
responsibility for the program but little real authority to run it.
Later in the program, especially after the active searches began
to reveal large-scale epidemics of smallpox in 1973, several factors
increased the political power of the technical level Indian smallpox
team: (1) the emergency epidemic, with its nationwide press cover-
age and parliamentary "call attention" motions; (2) the WHO resolu-
tions calling on all countries to make smallpox eradication national
priority; and (3) the foreign components of the program-the WHO
medical officers, the readily available jeeps, and the independent
funding sources. The independent funding made it possible for
technical level staff to go to the minister for authorization to break
rules without having to ask for new funding for the rule breaking.
Such level jumping, although strongly discouraged by many, was a
prime organizational tactic. The smallpox unit in WHO made use of
a parallel approach: independent funding also made it possible for
WHO smallpox staff to go to the regional director for authorization
for many exceptions to WHO rules.
The Complex WHO Formal Organization
The regional director of SEARO was extremely supportive of the con-
cept of smallpox eradication. As president of the twentieth World
Health Assembly in 1967, he had said, "Eradication of smallpox is
within our reach. The achievement of this important undertaking
now depends exclusively on our will and determination." In the for-
mal organizational structure of WHO, the smallpox unit was organi-
Analysis and Commentary
95
zationally distant from the regional director's office. At the beginning
of the program, the team leader (officially regional advisor for small-
pox) and other medical officers (officially medical officers of the inter-
country Smallpox Eradication and Epidemiological Advisory Team)
had to report to two regional advisors in communicable diseases
(RACDs). The RACDs in turn reported to two assistant directors
(AD), one responsible for smallpox as a disease, and another respon-
sible for disease control in India as a country. If both ADs approved a
request, for example, the paper was then routed to two others: the
chief of administration and finance (CAF) for administrative and bud-
get implications, and the director of health services (OHS) for techni-
cal approval. Dr. Nicole Grasset, the WHO team leader, vividly re-
calls the complexities of the organization's formation.
The team leader remembers that when she received her briefing on her
arrival in India (in 1970), most of the staff made her understand that (a)
the eradication of smallpox would be a very difficult task and would take
one or more decades and, (b) she must realize that it was essential that
she know how to resign herself to things being done slowly in India-
especially in relation to national administrative procedures. She began
taking this advice and resigned herself, as did all the SEARO staff, to the
fact that it took approximately three months to get the clearance of a
consultant to permit him to go to the field-she resigned herself to the
fact that, even when she wanted a minor action approved, the request
had to be agreed upon by two CD's (who rarely between them agreed,
therefore, a compromise had to be obtained between the views of three
persons, two of whom had no or little knowledge of smallpox methodol-
ogy successfully used in other continents). The "compromise" then had
to be approved by the AD of the country for which the action was to be
taken, then by the DHS, and sometimes the RD (plus an administrative
unit such as personnel or finance in most cases). Later the WHO small-
pox team leader, with the help of the WHO unit in Genev,a, was able to
institute a formalization of "level jumping" such that the smallpox unit
was given priority and was removed from the "communicable disease
unit" and the Assistant Directors, and allowed to report directly to the
DHS. (Grasset 1972, 41)
The Informal Organization-the Government of India-
WHO Joint Leadership Team; the Smallpox High Command
Often an informal organization develops at the top management
level in an intensive campaign. The joint WHO-government of In-
dia team, which was often called the central command or the small-
pox high command, developed into such a joint leadership team.96
Smallpox Eradication in India
The WHO side of the smallpox high command was composed
of the WHO medical officers from the SEARO regional office and the
WHO operations officer attached to the team. Although these four
medical officers were nominally part of the Smallpox Eradication
and Epidemiological Advisory Team and were in fact responsible for
the smallpox eradication program in all eleven countries of the
South-East Asia Region, in reality they spent most of 1973-75 work-
ing in India.
The Indian side of the high command was composed of the
central level appraisal officers from the government of India and the
NICD, which deputed its top three epidemiologists to aid the pro-
gram. These officers included the assistant director-general (small-
pox) and his deputy, the assistant director-general (cholera), the
director of the NICD (who later became the government's acting
commissioner of health), and two deputy directors of NICD.
An important element of most WHO programs at this time was
the concept of counterparts. Originally linked to the need for devel-
oping national competence after temporary international programs
fulfilled their mission, the concept of counterpart developed into
national control of international programs and later into national
self-reliance in management of health programs. In the smallpox
eradication program, after some preliminary problems, the counter-
part system worked very well, and the smallpox high command
developed into a model of international cooperation in all ways-
technical, political, and personal.
Led on the Indian side by the commissioner of health or the
acting commissioner of health and on the WHO side by the small-
pox unit team leader of the Smallpox Eradication and Epidemiologi-
cal Advisory Team, the titles and offices merged into an informal
leadership partnership which, with its members trusting and liking
each other, provided the impetus and the inspiration for eradicating
smallpox from India.
At the highest level, this shared sense of purpose expressed
itself in true international collaboration. Sharing train rides together
back and forth from infected areas, attending monthly progress re-
view meetings in every state in India, jointly making plans, assess-
ing organizational tactics and strategy, and watching the incidence
of smallpox wane or wax with the success of the efforts to overcome
it led to a very unusual solidarity among the central command.
Analysis and Commentary
97
The organizational charts and the charts of institutional roles
fail to convey the sense of personal dedication and leadership that
characterized the program participants who became emotionally
tied to the success of the campaign. Many participants undertook
personal initiatives beyond their job descriptions. There are many
examples of such personal initiatives, but a few deserve special
mention.
The team leader, Dr. Grasset, wrote personal letters to Prime
Minister Gandhi on two separate occasions, asking her to send a
message that could be used to encourage the health staff or to inau-
gurate one of the regional and rtational meetings. In both instances,
the prime minister wrote the requested messages, which had a great
motivational effect for the workers.
In 1973, when the first search of the endemic states in India
was being planned, officials in Uttar Pradesh refused to undertake a
single-purpose search for smallpox only. They preferred an inte-
grated approach in which the smallpox search worker would also
perform ten additional health activities (e.g., taking blood for ma-
laria, distributing condoms for family planning, distributing vitamin
A, and so on). All these are extremely valuable health activities, but
the integration and proper performance of so many activities would
have required more supervision than was available, and earlier ex-
perience had shown that multipurpose visits of this type would
simply not work without additional supervision. A well-known reli-
gious leader, very supportive of smallpox eradication, helped a
WHO medical officer arrange an unofficial appointment between the
governor of Uttar Pradesh and the smallpox team. The governor
understood that if smallpox could be eradicated quickly, many re-
sources would be released for malaria and family planning. He gave
smallpox eradication priority, and invited all the highest health offi-
cials of Uttar Pradesh and the central level officers to the state meet-
ing that he opened with inspirational speeches defending the short-
term, single-purpose smallpox search strategy.
At the peak of the smallpox epidemic, one of the key Eastern
European medical officers was informed by his home ministry of
health that he could not have an extension of his stay in India and
would have to return to his country. The team leader personally
visited that nation's ambassador to India and convinced him that it
was essential that this medical officer remain in India until smallpox98
Smallpox Eradication in India
was eradicated. The personal request for an extension was granted,
and this important epidemiologist was allowed to stay.
At a time when the northern states were heavily infected and
all the trains in the country had gone on strike for a long period, it
was virtually impossible to travel from New Delhi to the infected
areas. Supplies and equipment could be transported by plane, but
program staff had to find other transportation. The team leader per-
sonally contacted the head of Indian Airlines, who allowed smallpox
program staff high priority to travel by air, along with vaccine.
A direct appeal from the smallpox unit to the New Delhi-based
regional director of UNICEF, the sympathetic local head of SIDA, and
J. R. D. Tata, the chairman of the board of direct9rs of Tata Industries,
led to extrabudgetary funding for the program. Personally motivated
WHO staff made requests to OXF AM, to local Rotary and Lions clubs,
and so on, that brought extra funds and greater community participa-
tion. Over 90 percent of WHO smallpox funds in 1974-75 were the
result of fund-raising efforts of WHO smallpox staff.
These direct personal appeals are examples of the informal or-
ganizational structure of the smallpox team. That informal structure
became part of the reputation of the smallpox unit, which was quite
different from the usual impression of international bureaucracy.
A special relationship embraced the joint WHO-government of
India enterprise, and the teamwork between the two-the organiza-
tional tactics-acquired an additional dimension of international di-
plomacy. There was a certain Mount Everest effect in smallpox eradi-
cation; it was a challenging first to be accomplished, and it attracted a
certain type of leader. The quest for eradication galvanized and ex-
cited smallpox workers, regardless of whether they were from the
government of India, were from communist or capitalist states, or
were physicians or administrators. The counterpart system, whereby
WHO international and national program officers were teamed,
worked to the best advantage of both. Within the central command, it
was common for Indian epidemiologists to level jump within their
bureaucracy by saying "WHO suggests that .... "Within WHO, it
commonly occurred that after joint concurrence between government
of India and WHO smallpox workers, the WHO smallpox staff would
go to the regional director with the statement "the Government of
India requests that .... " Both halves of the central command prac-
ticed this mutually beneficial ventriloquism. Each used the other side
Analysis and Commentary
99
to bolster their common desire for more resources and faster adminis-
trative action. This "using each other" is in the best tradition of diplo-
macy and is one of its purposes.
Another of its purposes is to bring about a compatibility of aims; only
the amateur or the insecure thinks he can permanently outmanoeuvre
his opposite number. In foreign policy one must never forget that one
deals in recurring cycles and on consecutive issues with the same
people; trickery sacrifices structure to temporary benefit. Reliability is
the cement of international order even among opponents; pettiness is
the foe of permanence. (Kissinger 1979)
But in the smallpox program, the government of India team
and the WHO smallpox unit grew beyond any kind of diplomatic
contest. There was mutual respect, born of long, hard days in the
field sharing victory and defeat. Like an international mountain-
climbing expedition, each group depended on the other to watch its
smallest step, protect it from unseen dangers; at the end were the
highest pinnacles of success, which they would share.
Logistics
Logistics involves the means of "getting there." In the smallpox pro-
gram getting there included the physical flow of vaccine, needles,
jeeps, gasoline, posters, reporting forms, operational guides, wall
charts, and personnel.
Before the intensified campaign, WHO had played a limited
role as far as logistics were concerned. Under the 1970 Plan of Op-
erations, distribution of supplies was a government of India func-
tion. Apart from assisting with organizing the four vaccine produc-
tion institutes (UNICEF provided supplies and equipment; WHO
provided technical consultants), WHO's role was limited to that of
purchasing supplies and equipment not available in India. The gov-
ernment of India was responsible for arranging local travel for con-
sultants; for providing supplies (typewriters, office equipment) for
WHO medical officers; and for dispatching forms, needles and
needle holders, vaccination kits, and so on.
After the intensified campaign, many of these functions were
centralized in the WHO regional headquarters (SEARO) and in ad-
ministrative offices at state level. A new class of WHO consultants,
the operations officers (the majority were public health advisors100
Smallpox Eradication in India
from the CDC who had begun their careers as venereal disease
investigators in the United States), served a dual function, occasion-
ally working as epidemiologists at district levels or serving as supply
officers, administrative officers, or logistics officers at state levels. In
the SEARO headquarters, a stream of unusually gifted administra-
tors rotated in three-to-six-month assignments. There were often
two such administrative officers within the SEARO smallpox unit, a
personnel officer and a budget and finance officer. WHO itself has
units specifically devoted to personnel (PER), medical supplies (MS),
budget and finance (BF), and administrative services (AS). To some
extent, having administrative officers within the smallpox unit
created a parallel internal system; but the administrative demands of
the greatly increased smallpox unit required a separate logistical
organization. In 1974, the smallpox unit hired over 100 consultants
to work in India, more than all other consultants to all other WHO
programs. A smallpox unit personnel manager was essential. On the
supply side, 1 million bifurcated needles were imported and dis-
patched to the districts, 16 million forms prepared, printed, and
shipped. The presence of trained and experienced administrative
officers in the SEARO smallpox unit was without question one of
the most important reasons for the smooth functioning of logistics.
One key input into the smallpox eradication program was es-
sential: potent, dependable vaccine. Although, unlike needles and
transport, vaccine production and delivery remained a government
of India function, it provides a good example of how the combined
WHO-government of India team handled logistics at various stages
of the program.
To many outsiders, the eradication of smallpox is synonymous
with vaccine, and it is true that vaccine-provided protection was the
major weapon in the battle against the disease. The availability of
such an effective biological weapon sets smallpox apart from dis-
eases like malaria and cholera, which are usually grouped with
smallpox in India.
In one sense, all over the world vaccine was a product to be mar-
keted and distributed in a way analogous to the distribution of goods
and services in a centrally planned economy and somewhat similar to
marketing in a private sector corporation. The logistics of vaccine pro-
duction, distribution, and quality control were analogous to the re-
spective management parameters in other programs and industries.
Analysis and Commentary
101
As the program developed, vaccine management became incre-
mentally more sophisticated. In the period 1961-73, attention was
placed on input; that is, the provision of enough vaccine. Donations
from the USSR predominated, with 650 million doses given begin-
ning in 1962. Many countries also contributed vaccine through
WHO, but not all was of acceptable potency. Finally, as late as 1969,
an estimated 32 million doses of low-potency, Indian-manufactured
liquid vaccine still remained in stock.
Beginning in the 1960s, a major goal of the government oflndia
was to become rapidly self-sufficient in the manufacture of high-qual-
ity, heat-stable vaccine. With the help of WHO and UNICEF, which
supplied equipment, four centers in India were equipped to produce
freeze-dried vaccine.
Table l shows India'.s drive to become self-sufficient in
freeze-dried vaccine. By 1970, India was producing 50 percent of
its requirements, and despite initial WHO concern about consis-
tency and quantity of vaccine, by 1973 vaccine was no longer
being imported.
From 1961 to 1972, one major NSEP objective was to maintain
enough vaccine, needles, and supplies to carry out mass vaccina-
tion. Although vaccine production and importation were increased,
quality control was difficult to achieve.
Experience throughout the program indicated that even one
case of smallpox following an unsuccessful vaccination caused by
low-potency vaccine could generate disbelief in vaccination. Only
high-quality, heat-stable vaccine would do the job. In 1965, a central
level smallpox vaccine testing unit was proposed, but did not begin to
function until very late. In 1972, only one-third of the batches pro-
duced in the vaccine institutes were being monitored at the central
level. In the ten-year period from 1965 to 1975, only 2.1 percent of all
batches tested from India were rejected because of low initial po-
tency, and less than 1 percent were rejected for lack of bacterial steril-
ity. From 1969 to 1976, 241 batches were tested by WHO reference
laboratories outside India. Only 9 (3.7 percent) were substandard.
The double monitoring system (using randomly selected vaccine
batches) paralleled quality-control mechanisms adopted in produc-
tion lines and factories throughout the world.
If procurement, production, and quality control of vaccine re-
sembled a factory administration, in the management of delivery ofAnalysis and Commentary
Smallpox Eradication in India
102
TABLE 1. Availability of Freeze-Dried Smallpox Vaccine
in India, 1961-62 to 1974-75, in Millions of Ampoules
Received
from USSR•
Year
1961-62
1962-63
1963-64
1964-65
1965-66
1966-67
1967-68
1968-69
1969-70
1970-71
1971-72
1972-73
1973-74
1974-75
1.62
5.69
6.79
6.80
5.78
5.99
4.50
4.55
4.80
1.82
1.65
2.10
1.30
Indigenous
Productionb
0.04
0.09
0.48
1.42
1.41
2.35
3.57
2.88
2.56
3.52
5.86
8.81
9.52
Total
1.62
5.73
6.88
7.28
7.20
7.40
6.85
8.12
7.68
4.38
5.17
7.96
10.11
9.42
"One ampoule of Russian vaccine consists of 20 doses.
.
.
bOne ampoule of Indian vaccine was to consist of 15 doses, but it was often possible to get
more than this number from each ampoule.
effective vaccination the major analogy is to marketing. Factors in
delivery of vaccination included:
1. the technique of administration (rotary lancet, bifurcated
needle, jet injector, single or double insertion);
2. administration of the vaccination (itinerant vaccinators,
state-level vaccinators, watchguards, and supplementally
hired WHO vaccinators); and
3. target population (initially British colonists in the cities, later
all those living in an epidemic situation in the countryside,
neonates, and finally, with increasingly sophisticated selec-
tive vaccination, the population at risk).
These factors have to be looked at in the context of the
changing goals and strategies of the vaccination program in India.
By the beginning of the intensified program, a more heat-sta~le,
freeze-dried vaccine had been introduced, which made vaccme
quality easier to maintain. Primary vaccination take-rates rose to
103
virtually 100 percent, allowing more effective use of a single vacci-
nation. The important change in management evaluation was a
shift from monitoring the number of people vaccinated to moni-
toring the immunization status of the population, using vaccina-
tion scar surveys.
As the strategy shifted from mass vaccination to surveillance
and containment there were concomitant changes in the way vac-
cine delivery was assessed. Initially, output was important: the
number of people vaccinated. A refinement of this was monitoring
the vaccination status of the population and later its immunity sta-
tus. Instead of evaluating vaccine potency, delivery systems, and
the method of vaccination independently, all were simultaneously
assessed at the point of delivery by surveying vaccination take-rates
in the field.
Communications
Managerial communications fall into two major and several minor
categories. The major categories are internal communications
within the operating system and external communications be-
tween the operating system and the rest of the world. In the case
of international programs, the internal/external dichotomy be-
rnmes somewhat more complicated. But it is useful to think of
rnmmunications in the smallpox program as internal or external,
as outlined below.
Internal Communications:
1. education, training, and periodic review of personnel in the
program
2. the management information system (MIS) of surveillance,
disease reporting, data analysis, and financial and logistical
information and appropriate responses
3. communication between the WHO smallpox unit and other
WHO units
4. communication between NSEP and certain branches of the
Indian government
5. communication between NSEP officials and the WHO small-
pox unit (informal contact between members of the central
command)104
Smallpox Eradication in India
External Communications:
l. health education, publicity about the reward, news releases
about program progress
2. official communication between WHO/government of India
and bilateral donors.
_3. official communication between the government of India
and WHO
In the following section the three most important components
of this communications system-staff training, the MIS, and health
education-are examined.
Training. Rapid, effective communications were the key to
monitoring the changing epidemiologic picture, keeping all levels
of staff informed of progress, keeping 'optimism and morale high,
and quickly learning of problems that needed to be dealt with,
Training all levels of participants in the smallpox program was
one of the key ingredients in its success. Epidemiologists, espe-
cially academic epidemiologists, often lack field experience in rural
societies; carefully preparing them for a three-to-six-month field
assignment made the difference between a good, productive expe-.
rience and one beset with problems. In most of the training pro-
grams, the entire operational guide was read aloud, paragraph by
paragraph. Two field exercises were administered. The first was a
hypothetical smallpox outbreak. The trainee's task involved tracing
the source of infection, finding all contacts, and carrying out thor-
ough containment operations. An example may be helpful. True
to real life, the source of the infection in the exercise was from an
infectious disease hospital. Many academic epidemiologists ex·
pressed dismay that such an unlikely source of infection had been
chosen for a field training exercise. Once they reached the field,
however, they understood why poorly guarded smallpox isolation
hospitals created notorious smallpox dissemination hospitals. In
the second exercise, the trainee (who may have been a professsor
of epidemiology from the USSR, a retired Indian epidemiologist,,
or a young doctor from the United States) was to play the role ot
the chief of a state smallpox program. As the program officer o!i
Amber province, he had to beware of importations of smallpox
from Greenville, investigate sources of infection from Yellow, and
Analysis and Commentary
105
worry about inconsistent reporting from one of his own town-
:ships, Redstone.
Through these two teaching exercises, the field was brought to
the classroom, but that was not enough. The entire training group-
usually ten to fifteen people-then went out to the real field, to a
nearby village, selected in advance because of a chickenpox out-
break. Since in India no vaccination was contraindicated at that
time, the population in the chickenpox outbreak was then vacci-
nated or "contained" by the trainees, and the team moved to the
PHC headquarters, examined records chronicling the history of
smallpox in that PHC, and critically evaluated the surveillance sys-
tem before moving back to New Delhi. The field trainer was often a
paramedical assistant-a lower grade of staff in the Indian context,
but some?ne who really knew village-level epidemiology. Training
was practical, not theoretical; consistent from New Delhi throughout
the chain of command; taught by a field worker, not an administra-
tor; and for those unfamiliar with English, taught at a speed and in a
language they could understand.
Once the epidemiologists were trained, it was their job to ad-
minister the same training exercises at divisional, district, and PHC
levels. Each well-trained epidemiologist or program officer had a
multiplier effect; conversely, if techniques were not properly learned
and passed on, errors would be magnified. Monthly review meet-
ing~ provided a means for updating the original training, for intro-
ducmg new targets or new financial regulations, and for disseminat-
ing a_ stream of new innovations-market searches, watchguards,
containment books, rumor registers, and so on-that developed out
of the experience of the more progressive areas. This operational
research was a continuous process, each epidemiologist adding his
or her experience in a constant process of refining technique.
. Management Information System (MIS). The management infor-
mation system is the pulse of an organization. A strong and healthy
MIS reflects a strong and healthy management. A weak MIS reflects
a moribund program. In the smallpox eradication program, no one
ever spoke of a management information system, but the system
that was developed gradually over time was nonetheless particularly
robust.
The MIS provides managers with the data necessary to make
strategic decisions. To design an effective MIS, the manager has to106
Analysis and Commentary
Smallpox Eradication in India
decide what information is needed, how it can be effectively and
efficiently collected, and what will be done about it once it is tabu-
lated. Some are elaborate, computer-based systems generating oper-
ating schedules, time motion efficiency studies, and daily logs of
minutia; others are broad-based and general systems using the "im-
portant event" or "milestone" concept. In the smallpox program, no
one actually sat down to design an MIS; rather, an attempt was
made to determine what information was needed and to design a
simple system to gather it.
Although many aspects of the NSEP grew and matured quantita-
tively once the intensified campaign began, the MIS was a qualitative
leap forward, as shown in tables 2 and 3. Before 1973, managers of the
NSEP did have a flow of information from the field to guide their deci-
sions; although that information was not always reliable, it was suffi-
cient to classify states as epidemic, endemic, or nonendemic and was
enough to focus attention on the problems of case suppression.
The epidemiological portion of the MIS was, of course, surveil-
lance. The experience with surveillance and containment in Brazil,
Indonesia, and Nigeria showed the value of incoming information
about smallpox for efficient resource allocation. Foege's report on the
Nigeria experience defined surveillance to include three specific com-
ponents: a system for data collection, a system for data analysis, and a
system for response. The primary purpose of a disease surveillance
system was "to determine all aspects of occurrence and spread of the
disease in order to control that disease" (Foege 1976). This is the
epidemiological portion of the MIS. In theory, data collection includes
minimally necessary data from the mortality registration system, hos-
pital and physician morbidity reports, laboratory reports, individual
case investigations, population surveys, studies of animal reservoirs,
and demographic data on the population under surveillance or at
risk. Analysis involves determining the natural history of the disease,
discovering trends and changes in trends, determining points of vul-
nerability, and determining the effects of intervention on the disease.
A system for response, to complete the surveillance arc, includes
the health service's response to the collected, collated, and analyzed
data. The information should be disseminated to two groups: those
who need it for administrative program planning and decision making
and those who are involved in continuing data collection. Since the
reason for collecting, analyzing, and disseminating information on a
107
'f ABLE 2. Components of the Management Information
(MIS) in the Indian Smallpox Eradication Program
:~ystem
\115: Surveillance
WER (weekly epidemiological
report) smallpox incidence report
from PHC-district-state-center
CBHI (Central Bureau of
Health Intelligence)
weekly reports
of smallpox incidence
WHO WERs (weekly epidemiologic
report) published from Geneva,
showing district-by-district
smallpox incidence
Target zero newsletter-chief,
smallpox eradication unit,
WHO Geneva, giving
global overview and
highlighted special lessons
for smallpox staff
SWER (special WER for search weeks)
Epidemiologists' weekly reporting
form (smallpox prevalence-
number of infected villages,
supplies and equipment
requests, financial needs, problems
encountered, innovations, and
suggestions from experience)
Search summaries (for each state
the tabulations of the SWERs
and results of each monthly
progress review meeting-feedback
for the state)
Newsletter-SEARO surveillance
report giving status of smallpox
in the region (feedback for the
whole program)
Surveillance team monthly reports
Market search reports
Before After
x x
x x
x x
x x
1973
1973
x
x
x
x
x
x
disease is to control that disease, appropriate action becomes the ulti-
mate response goal and the final assessment of the earlier steps of the
surveillance system. Under the intensified strategy in 1973, India was
divided into three areas: smallpox-free states, nonepidemic states, and108
Smallpox Eradication in India
Analysis and Commentary
TABLE 3. Financial Components of the Management Information
System (MIS) in the Indian Smallpox Eradication Program
MIS: Financial Data
Imprest account summaries
Budget reviews from
the WHO Budget and
Finance Officer (BFO)
-a "control" of funds
actually disbursed against
targets
Financial control reports
-made by administrative
officers in smallpox unit,
expenditures versus authorizations
Before
1973
After
1973
x
x
x
endemic states. Areas in India were ranked for selective resource
allocation based on an assessment of their risk or probability of
being the focus for disease. Although one can stretch the meaning of
surveillance and containment to incorporate assigning priority to
areas, surveillance and containment as used in the program at that
time meant surveillance to detect which villages had smallpox and
containment of the detected outbreaks.
There were some broader implications of surveillance.
1. When there was an outbreak of smallpox in the Yadav milk
deliverer's community, for example, the Yadav communities
in adjacent villages were selectively searched. Extension of
smallpox from community to community was traced by
searching high-risk areas.
2. When the Indian program moved in 1975 to a defensive
action protecting India from importations from Banglci-
desh, certain places were considered high-risk areas and
given priority attention: border areas with Bangladesh; re-
mote and inaccessible communities such as Ladakh, Sik-
kim, and the Andaman and Nicobar Islands and others.
In addition, risk maps were made for each area and pref-
erence was given to searching certain areas again, based
on risk assessment.
109
In fact, even the containment of an outbreak at a village is a
subset of a more generic management principle-efficient resource
allocation. In the case of village-level containment, this meant defin-
ing risk by geographic proximity to a case of smallpox. Tracing con-
tacts (to the extreme of sending out 2,000 cables to warn of possible
exposure in the case of Pawa Puri) and tracing sources of infection
(even to the extent of having state surveillance teams cross state
borders in hot pursuit of the source) were all logical extensions of
the identification of risk areas and concentration of resources on
people at greatest risk of getting smallpox.
While most of the MIS information about high-risk areas came
from the weekly reports from PHC to state levels, additional infor-
mation was provided by the weekly reports of the special epidemi-
ologists. These reports, which covered the entire geographic area of
India, included three major elements.
1. Smallpox prevalence. The reports identified active foci,
risk factors, newly detected outbreaks, outbreaks that had
been removed from the list of active foci because four to
six weeks had passed without cases, and total pending
outbreaks.
2. Assistance and supplies required. In each weekly report the
epidemiologist in the endemic areas or the state program
officers in nonepidemic areas placed their orders for profor-
mae, recognition cards, posters, needles, vaccine, and so
on.
3. Problems and suggested solutions. Each epidemiologist was
asked to list potential problems and obstacles every week.
The first news of strikes, drought, floods, population migra-
tions, or a breakdown in regular communications often
came from a scribbled note at the bottom of the weekly
reporting form. More important, each reporter was asked to
suggest ways of solving or avoiding problems.
These reporting forms were simple and regular, and they were
read and responded to with great care. Because they were short and
important they never got lost in in-trays no matter how hectic other
things were that day in the office. Longer reports would have been
set aside.110
Smallpox Eradication in India
To simplify the system, the epidemiologist's weekly report was
in the shape of an aerogram-"inland letter," as it was called in
India-similar to a large postal card. Since little effort was required
and no long narrative or explanation was asked for, a reasonable,
quantifiable target was set: to have every epidemiologist or program
officer complete this form each Saturday. This target was progres-
sive. As the program matured, more pertinent controls were built
in, such as listing the names of outbreaks with no known source of
infection, the names of villages with cases more than twenty-one
days after detection, and so on.
This stable, simple reporting system augmented the formal
weekly reporting system (shown in fig. 4), which reported the num-
ber of new cases detected in each PHC, district, and state. It was
another example of the creation of a parallel smallpox system. Al-
though the new reporting system was enhanced and supported,
only smallpox data came through it; it was this weekly epidemiolo-
gists' report-a separate, independent source of information-that
both confirmed the epidemiological status of the area and gave
needed details about management requirements and potential
bottlenecks.
The epidemiologists' weekly reports were read simultaneously
by the medical officers in SEARO and the smallpox office in the
Ministry of Health (initially, duplicate copies were sent by mail or
telegram; later, by telephone or special messenger to both ad-
dresses); a third copy was sent to state headquarters in the endemic
states. Supply needs were then passed to the WHO administrative
officers, who attended to requests from the field (often, "Please wire
Rs. 3,000 immediately.").
Requests from the field were accorded high priority, and a
twenty-four-hour turnaround was not uncommon. The epidemiolo-
gists in the field initially asked for supplies well in advance in order
to stockpile such things as needles, fearing long delays, but rapid
and dependable responses from SEARO minimized the need for
such insurance orders for additional unneeded supplies and thus
reduced hoarding and pipeline wastefulness.
On this single form, several managerial systems were com-
bined: the MIS, epidemiological surveillance system, logistics con-
trols, and some financial reporting. This was the irreducible mini-
mum information needed in Delhi to change tactics and even
Analysis and Commentary
111
strategy of the program. It is an important lesson for other
programs.
Health Education. The health education component of the small-
pox program needed to deliver at least four messages to the villages:
(1) smallpox was a disease that should be reported; (2) smallpox
should be reported to the PHC or health worker; (3) there was a
reward; and (4) when there was an outbreak, people who are at risk
of smallpox should be vaccinated.
Before 1973, health education consisted mostly of large wall
posters, with occasional films about the disease. During the intensi-
fied campaign, all available media were used: handbills were
printed, advertising the reward in many languages; large posters
were continuously printed; radio messages were prepared (occasion-
ally with a tape-recorded announcement by a local leader urging
reporting); and signs were painted on the back of rickshas, or even,
when absolutely necessary, leaflets were airdropped by airplanes
and helicopters. However, word of mouth was the most effective
advertisement, since 80 percent of the country is illiterate. Smallpox
workers painted slogans on the walls of ten houses in each village.
The slogans, written with wet geroo, a saffron-colored, chalklike
compound, lasted for months. More important, even if villagers
could not read the slogans, the children inquired about them and
passed the word. This word-of-mouth advertising was formalized
after Operation Smallpox Zero began, when new job descriptions for
search workers included informing one person in each house about
the smallpox program and the need to report any case of rash with
fever.
The health education message had changed over time. Viewed
chronologically, the messages reflected the gradual evolution of
smallpox strategy: first came "take vaccination" or "worship the
Devi and take vaccination too"; second, "report smallpox"; third,
"report smallpox, there is a reward of (Rs. 25; 50; 100; 500; 1,000-
the reward was gradually increased as the numbers of outbreaks
decreased) to the person who first 11 reports a case of smallpox"; and
fourth, "report any case of fever with rash" and "report to the
PHC."
Assessment techniques (to be discussed later) were aimed at
checking the performance of the health educators who were in effect
advertising the current message or slogan.112
Smallpox Eradication in India
Financial Management
In most WHO programs, the financial officer is responsible for one
~unction: disbursing and accounting for funds. This involves budget-
mg; actually disbursing cash; assessing accuracy of records; auditing;
and .calculating value received. The financial function usually does
not mvolve generating funds. The smallpox unit deviated substan-
tially from the usual WHO program in that the staff to a large extent
generated funds from outside the regular budget of WHO. Funds
were sought for the WHO Special Voluntary Fund for Health Pro-
~otion and from domestic sources within India. Fund-raising activi-
ties were remarkably successful. Without the extra funds brought in
by WHO fund raising, it is doubtful that eradication would have
been achieved, certainly not as rapidly as it was.
Approaches were made to several governments, to private phi-
lanthropists, to Indian corporations, and to other international
agencies. Although WHO itself showed some resistance to fund-
raising efforts by project staff in the beginning, that approach has
been institutionalized to some extent. Malaria programs in India
have approached SIDA for funding along more or less the same
lines, and the prevention of blindness program, the diarrhea control
program, and immunization programs increasingly rely on extra-
budgetary sources. Incr~asingly, bilateral aid funds are being chan-
neled through WHO, increasing the position of the organization and
decreasing the government's difficulties with coordinating many bi-
lateral aid agencies.
Just as important as the international funds were the donated
domestic funds. The rupee equivalent of $500,000 given by Tatas
was worth much more than the dollar amount because of the man-
agement skills that were donated along with it. Tata accountants
calculated, for example, that it was cost-effective to pay for a medical
officer and team to stay overnight in infected villages rather than
paying for gasoline for a second round trip. Night vaccinations were
an absolute necessity in contacting many working-age men, but
medical officers had refused to stay overnight for want of accommo-
dations. Some of the money saved on gasoline could be spent on
s~~port services to make the most economical use of each village
v1s1t. Moreover, although it was not a large dollar amount, Indian
philanthropy brought many externalities that are not associated with
Analysis and Commentary
113
foreign aid. In obtaining the domestic financial contributions of the
Lions, Rotary, Tatas, TISCO, TELCO, and others, the WHO-gov-
ernment of India team also carried out the important function of
building community support.
On the funds disbursement side, there were many innova-
tions. As usual, a detailed operating budget was prepared by the
central team. The accounting system (the financial part of the MIS)
made it possible to compare actual and budgeted expenditures. Per-
haps even more important was the flexible method by which funds
were used in the field. The use of imprest accounts permitted an
epidemiologist to carry large cash advances into the field for use in
the program according to established guidelines (for example, pay-
ing per diems for locally recruited staff, paying for gasoline, hiring
watchguards in the village where there was an outbreak, paying for
printing of reward publicity, and so on) and to account for the
specific authorized uses of these cash advances later. This was a
very unusual innovation in the WHO financial accounting system
and in fact created substantial initial controversy in the organization.
But without the readily available cash, it would have been impossi-
ble, for example, to pay for gasoline for jeep travel.
The use of imprest accounts in the field with postexpenditure
justification of disbursements replaced the cumbersome process of
seeking approval for an expenditure weeks or months before the
funds were disbursed. Dr. P. Deish, the government's former com-
missioner of health, credited the flexible financial policies of WHO as
one of the most needed and valuable characteristics of the program.
For the campaign not only enough finances were required but there
"'.'as need for tremendous flexibility in incurring expenditure. Provi-
s10n was made to spend money on petrol, oil and lubricants, mainte-
nance of vehicles, publicity, employment of workers and for giving
reward to those reporting smallpox. Check and control limits for these
were laid down. For undertaking effective containment of detected
outbreaks, there was no limit. The objective was to eliminate the focus
as quickly as possible. During the period July 1973 to December 1975,
the Government of India spent Rs 102 million (about $12.5 million
U.S. dollars), the State Governments spent another Rs 94 million
(about $12 million U.S. dollars) and during the same period the
WHO's contribution was Rs 67 million (about $8 million U.S. dollars).
WHO's contribution was about 20 percent of the total. (SIDA's contri-
bution about Rs 60 million-$7.5 million U.S. dollars). Understanding114
Smallpox Eradication in India
WHO financial controllers found ways of expediting financial matters
and delegating considerable financial powers to workers in the periph-
ery. (Deish 1978, 10)
Budgeting, usually such an important part of standard financial
function, was of less importance in the smallpox program, simply
because financial forecasting was completely dependent on the epi-
demiological situation. More smallpox meant greater resource re-
quirements; financial forecasting thus became dependent on epide-
miological forecasting.
Management Controls
The control system is intended to assure the manager that opera-
tions are proceeding according to the implementation design (Austin
1979). There were both financial and operating controls, and they
were either preventive or curative. In the case of smallpox eradica-
tion, there is overlap between management controls and epidemio-
logic assessment. For simplicity, epidemiologic assessment is con-
sidered separately below under the section entitled "Evaluation."
In the early days of the NSEP, prior to the intensified cam-
paign, all of the financial controls were handled through the govern-
ment of India. NSEP funds were established as a part of the routine
five-year planning exercise; thus the preventive and curative finan-
cial controls were those of the government of India. A five-year .
budget established how much money could be spent; strict financial
guidelines prevented over-use of budgeted funds-in fact, in most
of those years the NSEP had been unable to use all the funds bud-
geted for it.
In the operating (logistic) area, the major issue was vaccine.
Until late in the campaign, vaccine institutes were so poorly orga-
nized that some states were overstocked with vaccine and others
poorly stocked. As for the epidemiologic control function, this
rested with the CBHI. The routine weekly WERs, which were to
have been sent from PHC to district to state to the CBHI, were
poorly organized. It was not unusual for states such as Bihar to be
several months late in submitting the district reports that had been
accumulating at the state capital. A control system would consider
the delinquent or absent reports to be a warning and contact the
delinquent reporting unit to demand updated reports. In 1972,
Analysis and Commentary

115

WHO urged the establishment of a weekly "nil" (no cases) report
from those PHCs that claimed to have no smallpox. This was the
beginning of the establishment of a control function in the epidemio-
logic system. Previously, the absence of any report could have been
understood as indicating either the absence of smallpox or the ab-
sence of the reporter. Using "nil" reports established a control func-
tion: the absence of a nil report could only mean a laggard reporting
system.
After the 1973 intensified campaign began, the program rapidly
expanded and material systematic control procedures became more
critical (Austin 1979). Rapid growth made direct supervision of all
staff impractical. A system of supervision from the primary search
worker up to the state program officer was required. This control
system, which developed slowly, by a process of trial and error, is
shown in table 4.
At the most peripheral level, the presearch meetings held at
PHCs established a plan for each of the approximately twenty
searches carried out in the endemic areas. Each borrowed supervisor
(malaria supervisor, sanitary inspector, family-planning supervisor,
and so on) supervised three or four search workers. With an average
of one hundred villages per PHC and ten to twenty PHC staff, each
worker had an average of one village or one urban mohalla to search
in one day. A mohalla is a city area about the size of a village of 400
to 1,000 people. With a schedule (PHC Form 1) and a daily reporting
performa (PHC Form 2), the worker went from house to house in
his assigned villages. In the early stages of the intensified campaign,
the supervisor also visited about one or two villages a day and was
• thus able to physically assess the work done in approximately one-
third of all villages.
Later, as the program neared its conclusion, these supervisors
were joined by PHC medical officers who left their other duties at
the PHC to visit villages and make an independent evaluation of
some rash-with-fever cases. A triage system was established. The
sensitivity of the surveillance system at the most peripheral level
(the percentage of actual smallpox cases detected) was increased
with each successive search, while the specificity (the percentage of
negative cases correctly identified as negative cases) was decreased
with each successive search. In addition to their supervisory func-
tions, higher-level staff, from inspectors to medical officers, were116
Analysis and Commentary
Smallpox Eradication in India
TABLE 4. Epidemiologic Control, Supervision, and Assessment
in Typical Primary Health Center (PHC) or Block
Number of villages in block
Number of villages searched by primary
search worker during each search•
Number of villages supervised by primary
supervisor
Number of villages supervised or
assessed by PHC medical officer
Number of villages assessed by district
officers
Number of villages assessed by
other (outside) assessment workers
100
98
33
15
2
2
•An average of 2% of villages were missed in each search; rotation of the staff and repeat visits
to missed villages ensured uniform complete coverage.
asked to check the diagnosis of cases. The increasing sensitivity and
decreasing specificity resulted in the detection of hundreds of thou-
sands of nonsmallpox rash-with-fever cases, all of which required
verification.
There was another management control at the PHC level. The
PHC-level search worker had to obtain the signature or thumb print
of the village head man for every village he was to visit, and had to
write the reward slogan on ten houses. In the early days of the
program, when supervision was less sophisticated, the first-level
supervisor simply checked to be sure that the village head man's
signature or thumb print was accurate and counted the reward slo-
gans in the village.
The financial controls were established through guidelines
authorizing the amount of money that could be spent for gaso-
line, for hiring special search workers, for reward publicity, and
for the rewards themselves. The imprest account system allowed
the epidemiologists to make on-the-spot distributions of cash,
making it unnecessary for repeat visits to headquarters to get
more funds. It was not possible to require a person in the field to
submit a purchase order to someone in the finance department for
approval. Rather, the financial department made periodic compari-
son of actual and budgeted expenditures. When actual expendi-
tures exceeded budgeted allocations, the finance officer (who trav-
117
eled from SEARO in New Delhi to the state-level monthly prog-
ress review meetings) could make decisions and take actions to
handle excess expenditures. These deviations from the budget
were, in turn, a critical input into future financial decision mak-
ing. Comparing budgeted to actual expenses was important in
understanding the interrelatedness of financial control and operat-
ing control. In the smallpox eradication program, giving financial
control to the operating level staff-the special epidemiologists-
weakened preventive control over fund disbursement, but the
trade-off-a decentralized ability to respond to a rapidly chang-
ing environment and epidemiological situation-facilitated the
program goals.
Research
Research carried out in India was mostly of the operational variety:
data were gathered because they were needed to plan, implement,
or evaluate the program, not for the sake of fundamental science.
Research in India was problem-oriented, both to ensure research
relevance and to answer immediate questions for the program. For
example, in 1975, when India was nearing zero incidence but Ban-
gladesh continued to have large epidemics, there was grave concern
about Calcutta. Especially problematic was Calcutta's floating popu-
lation, a constantly shifting mass of poverty-stricken migrants, ru-
mored to number more than 100,000, who were thought to have
come from Bangladesh. A research project carried out on the streets
of Calcutta showed that (1) the number of pavement dwellers was
probably closer to 10,000 than 100,000; (2) they were a stable popula-
tion who had lived on the pavements of Calcutta for decades; and
(3) their ties were mostly to Bihar, which was now smallpox-free,
rather than to Bangladesh. This finding reassured the smallpox staff,
but more important, it allowed project management to release re-
sources allocated to surveillance of the incorrectly presumed high-
risk pavement dwellers and direct them where they were really
needed, at border surveillance posts. Another example was the re-
search effort aimed at determining the extent to which market sur-
veillance could replace house-to-house searches. Research projects
were carried out in several areas of Bihar and Madhya Pradesh,
simultaneously comparing the surveillance reports gathered by
searchers at the weekly markets and in the more elaborate house-to-118
Analysis and Commentary
Smallpox Eradication in India
house searches. It was shown that although market searches could
not replace house-to-house searches, they were effective supple-
ments, providing a useful way of assessing the house-to-house
searches.
Early in the program, studies in Tamil Nadu showed that
neonatal vaccination was effective and produced few harmful se-
quelae; later field studies showed that a single insertion of small-
pox vaccination was as effective as the two, four, or even six
insertions of vaccine used earlier. Field studies with the bifurcated
needle proved its superiority to the rotary lancet, as earlier field
trials of freeze-dried vaccine had shown its superiority over liquid
lymph.
A pilot project in several districts of Uttar Pradesh in early
1973 expanded and refined the Gulbarga experience of house-to-
house search, using staff from many different programs; this ex-
periment was instrumental in providing experience for the opera-
tional guide drawn up for the autumn, 1973, intensified campaign.
Analysis of data from outbreaks that had failed to meet established
targets for either early detection or prompt containment showed
that secondary or satellite outbreaks were commonly within a ten-
mile (sixteen kilometer) range of the primary outbreak. This led to
the establishment of a safe zone, wherein all houses within sixteen
kilometers were searched (early in the program, only once; later,
twice) to be sure satellite outbreaks had not escaped the surveil-
lance system. Operational research also pinpointed the need for
watchguards, for closing disease-spreading infectious disease hos-
pitals, and for careful attention to finding all smallpox contacts. As
outbreaks decreased, each newly detected one became more impor-
tant, containment became more sophisticated, and more resources
could be devoted to each of them. At each stage of program refine-
ment, operational research identified the next step to be taken to
stop the spread of smallpox.
Gathering demographic statistics and studying trends of
smallpox over time were an integral part of the epidemiology and
of project-planning implementation and evaluation. Perhaps, how-
ever, it was in the field of evaluation that research was most
appropriate. Much of the research data gathered later in the
smallpox program were compiled explicitly to provide the interna<
tional certification commission with the information they needed
119
to evaluate the outcome of the program and declare smallpox
eradicated from India.
There were many research questions of interest that were
never investigated because the program went forward with the
single purpose of eradication. Smallpox disappeared from India so
rapidly that many of its secrets will always remain hidden. When
research efforts are initiated explicitly to alleviate a problem rather
than for research investigation purposes, many interesting questions
will remain unanswered. But the important problem will be solved:
for example, there is no smallpox left in India.
Evaluation
Three kinds of program evaluation are important to our case study:
process, outcome, and economic. Most program evaluations focus on
outcome evaluation, measuring the extent to which a program suc-
ceeds in reaching its final goals, such as landing on the moon or
eradicating smallpox. Process evaluation, on the other hand, involves
analyzing individual program components. (Program evaluators also
refer to these techniques as "formative evaluation" [studying how to
make a program work better] and "summative" evaluation [studying
how well a program works] [Russi and Williams 1972].) It is apt to be
considered an internal matter, part of administrative monitoring. In
the smallpox program this process evaluation was called assessment,
and outcom'e evaluation was known as "certification of eradication."
Certification was itself the major program evaluation in the sense of
evaluating whether the program accomplished its goals. Economic
evaluation, which consists of analyzing program costs and benefits
and cost-effectiveness, will be treated last in this section.
Process Evaluation or Assessment
Management has been metaphorically compared to a long journey
toward a set goal; strategies provide the plan, and specific operating
tasks are the day-to-day travel instructions. Landmarks, milestones,
and warning flags are needed to prevent deviations from the plan or
to alert the manager to potential deviations. These warning flags
and milestones were provided by assessment.
Assessment was accomplished by combining process evalua-
tion and management control. For example, in spreading the word
about the reward, the program was in effect advertising it. In a

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Stoppt die schweizer Massenmörder!

Revolution jetzt. Sonst ist es zu spät.

Pangwall

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Re: The Management of Smallpox Eradication in India
« Reply #4 on: November 10, 2022, 09:05:06 PM »

120
Smallpox Eradication in India

commercial marketing operation, in order to evaluate the process of
reaching potential customers a random probability sample of differ-
ent areas of interest would be drawn, and the percentage of those
knowing about the item being advertised (the reward) would be
calculated. In addition, an effort would be made to find out how
they learned about the reward, and the media habits of those who
knew and did not know about the reward would be compared. In
fact, far more attention would be paid to the 15 to 40 percent who
did not know about the product, and their media habits and demo-
graphic characteristics, than to those who did know about it. An
attempt would be made to reach them with publicity. In the small-
pox program, instead of random samples, which would have been
far better statistically for assessing the public's knowledge of the
reward, skewed samples were drawn, placing heavier emphasis on
areas where the assessment system had produced warning flags.
Areas with known weaknesses in surveillance were assessed more
frequently. Although this led to lower assessments of knowledge of
the reward (or other assessment parameters, such as the percent of
those who had seen the recognition card, the percent who had actu-
ally seen a search worker, and so on) than would have been ob-
tained from random population-based data, the smallpox surveil-
lance system was only as strong as its weakest link; preferential
assessment of the weakest link was a good supervision strategy in
this case.
The assessment data that was gathered became increasingly
more elaborate as searching methods were refined and the absence
of active smallpox permitted containment resources to be diverted to
the search operations. During the two-year period of active surveil-
lance that followed the last case of smallpox, for example, several
hundred thousand rash-with-fever cases were recorded in PHC-level
rumor registers. At the end of each search, a PHC or municipality
search summary report was added (a new form, PHC search sum-
mary Form 3). The number of search workers from each of the
various programs was recorded, and each case of rash with fever
(chickenpox, measles, or other disease) was recorded. In areas with
no smallpox, searchers concentrated on the population at highest
risk. Results were assessed at the PHC level by the PHC medical
officer, who was instructed to personally assess one village and one
mohalla assigned to each worker. Since the average PHC had nearly
Analysis and Commentary

121

fifteen workers, this meant that in the final searches there were two
levels of supervision at the PHC level: 1 in every 3 villages was
visited by the supervisor, and it was intended that 1 in every 7
would be assessed by the PHC medical officer. With an average of
100 villages per PHC, this meant that 100 were visited by a search
worker, 33 were visited in addition by a supervisor, and 15 more
were visited in addition by the medical officer (see table 4).
This hierarchy of supervision continued above the PHC level.
The district medical officer was instructed to assess the work in the
PHCs. At least 5 schools and 10 villages per PHC (chosen from
various parts of the PHC, with special attention to including places
that were difficult to reach) were to be assessed, and approximately
100 or 200 people in each block were to be questioned at random
about their knowledge of the reward and whether they had seen a
search worker during the search period. Each special epidemiologist
was asked to personally assess 75 villages or mohallas, 25 schools,
and 10 markets. State surveillance teams, district mobile squads, and
market search teams were supposed to assess 100 villages and mohal-
las, 30 schools, and 10 markets. District-level medical officers were to
assess at least 2 villages or urban areas, 1 school, and 1 market in
each PHC in their district.
This hierarchical assessment and supervision system provided
significant milestones. When aggregated, the assessment statistics
from May, 1975, and July, 1975, showed the results of this well-
organized system. Over half a million people were surveyed (tables
5 and 6) to assess the quality of surveillance. The assessment sys-
tem, in a sense, became a search in itself.
This assessment guided program managers in deciding where
to increase emphasis. If less than 95 percent of all the villages as-
sessed in a block had been searched, the search was continued or
repeated until all villages had been searched. Depending on how
great the risk of smallpox was thought to be in a poorly searched
area, the re-search was either "punitive" or carried out because of a
genuine program need. In areas thought to be smallpox-free, a puni-
tive re-search was carried out, making the same staff devote an extra
week to the task. In poorly searched, high-risk areas, the re-search
was done by diverting staff from other blocks that had been well
searched or by hiring ad hoc search workers from the community.
Concurrent assessments started during the search itself. The122
Smallpox Eradication in India
TABLE 5. General Smallpox Knowledge in the
Population at Large, June and July, 1975, in Percentage
Individuals
Interviewed
State
Bihar
Uttar Pradesh
West Bengal
Assamb
Tripurab
Total
(Target)
227,182
23,252
102,808
142,047
12,751
508,042
Knew
about Latest
(July) Search
72%
60
64
79
88
73
(67)
Knew
Had Seen
Knew
about Recognition Where to Report
Suspected Cases
Card
Reward'
63%
53
64.4
72
81
66.7
(67)
65%
53
69
74
70
66.2
(SO)
60%
44
47.9
65.8
70
59.5
(50)
~ c ro~~E~~
rf)
~
t--..
0
'In districts that had only recently introduced the Rs. 1,000 reward, assessment results reflect general
knowledge of either the Rs. 100 reward or the Rs. 1,000 reward.
b Assam and Tripura figures are for June search; other states are from July search.
effectiveness of the search was determined and expressed in terms
of the percentage of households where anyone had seen a search
worker come to their house during the search, had seen the recogni-
tion card, knew about the reward for reporting smallpox cases, and
knew where to report. When risk maps of each district were pre-
pared, the high-risk areas identified were given special emphasis in
0\ ...
~
0
~ t:--.. lf) '<:::ti
crr5c00ir)~
.5
the assessment.
Outcome Evaluation or Certification of Eradication
The most important step in program evaluation is to identify and
define measurable goals with which outcome achievements may be
compared. Without a quantifiable goal, a target to aim for, progress
is very difficult to measure. This is true for measuring the final
outcome of a program as well as for monitoring each step along the
way toward the final goal.
In the long history of attempts to prevent or conquer smallpox
in India, three general goals developed in succession: (1) individual
prophylaxis, (2) disease control, and (3) disease eradication. These
goals were not always pursued in the context of government pro-
grams. From time immemorial until the late 1800s, when the Bengal
Vaccination Act mandated smallpox vaccination, smallpox prophy-
laxis was an individual choice among options, with a personal goal
of individual protection. Whether the method was to propitiate a
tj!'
T-1
"'
(li
"' bO
~
0 -
"'
b< :;;124
Smallpox Eradication in India
goddess, apply herbs, or follow special diets, efforts were directed
more toward preventive than curative goals, though a few curative
measures-such as donkey's milk and neem-were sometimes
used.
With the arrival of vaccine in India in 1802, a form of protection
more effective than herbs and safer than variolation became avail-
able. Nevertheless the concept of smallpox as a public health prob-
lem and government-organized programs to reduce morbidity and
mortality among the general public did not develop until much later.
Even vaccination programs set up in Bombay in the 1800s and later
in the United Provinces (now Uttar Pradesh) were established
mainly to encourage individual protection for as many people as
possible. It was not until the Bengal Vaccination Act that the goal of
smallpox activities of India shifted from individual prophylaxis to a
broader public health goal of disease control.
In 1959, almost eighty years later, the expert committee estab-
lished the target of eradication, with its plan for an NSEP. This same
committee had had a difficult time evaluating earlier smallpox activi-
ties because of the lack of quantifiable targets for smallpox control.
After subsequent agreement between WHO and the government of
India, the goal of smallpox eradication was confirmed, and the
NSEP was established. Program effectiveness would be judged by
the absolute, quantifiable target of eradication: zero smallpox.
No national statistics exist on the number of people who were
either variolated or vaccinated before 1962. Even after individual
protection from smallpox became a government function, at least in
some parts of India, there was no possibility of measuring progress
until either output (number of vaccinations performed) or outcome
(incidence of smallpox) was recorded. Further, the output statistics
were inadequate measurements of protection, because available vac-
cine was often too weak to provide a sufficient level of immunity.
The NICO program evaluation in 1963 introduced a new measure-
ment of effectiveness-the percentage of the population adequately
immunized (percent vaccinated multiplied by vaccine efficacy). Al-
though this was an improved and a quantifiable target, it was still an
output measurement. The outcome-smallpox incidence-was not
being monitored.
When the NSEP was established; the goal ostensibly switched
from individual protection to eradication, with targets of 80 percent
Analysis and Commentary
125
and later 100 percent vaccination coverage. The government was
generally pleased with the increasing amount of reported vaccina-
tion coverage, but these targets were never reached, nor did small-
pox incidence decrease appreciably (much less reach eradication).
When the joint WHO-government of India Plan of Operations
of 1970 recommitted India to the goal of eradication, the reported
incidence of smallpox was decreasing. But the measurement tool-
the reporting system-was not accurate. The apparent effectiveness
of the program was an illusion that was shattered when increasingly
accurate measurement uncovered a high number of unreported
cases, raising reported smallpox cases to seemingly epidemic levels.
Before 1970, the NSEP was neither making effective progress toward
the final goal of eradication nor even adequately defining the problem
so that measurable targets could be set.
In 1977, when the International Commission to certify smallpox
eradication in India convened (see the section in chapter 1 entitled
''The Certification of Eradication, 1977"), the success of the program
was measurable: it had met a quantifiable goal, the attainment of
zero incidence of smallpox in India.
The certification of smallpox eradication in India was the pro-
gram evaluation of the intensified campaign (1973-75). In 1977, after
a two-year surveillance period failed to detect a single case of small-
pox, the certification procedure (Ministry of Health and Family Plan-
ning 1975) confirmed that the measurement of program outcome
(zero incidence) met the prescribed goals (eradication). In that sense,
the program was 100 percent effective. Two years later, in 1979, a
global commission certified the entire world free of smallpox, further
attesting to program effectiveness in India (Global Commission for
the Certification of Smallpox Eradication 1979).
Economic Evaluation 12
An economic analysis of the costs and benefits of eradicating small-
pox is an important element of the broader analysis of the case
history. Many of the things that worked for the eradication program
resulted from investments predicated on confidence in an unusually
profitable outcome-smallpox eradication. In order to determine
which of the strategies and tactics of the eradication program may be
economically feasible for other disease control programs, some un-
derstanding of economic concepts and terms is useful. 13126
Smallpox Eradication in India
First, it is important to keep in mind that the costs and benefits
referred to in this analysis are those of program results rather than
of the disease per se and that a benefit is a negative or averted cost,
while a cost is a negative or forgone benefit. For example, smallpox
treatment costs saved by preventing disease would be considered a
benefit, while the loss of productivity due to vaccination complica-
tions would be a program cost. As a further example, high smallpox
mortality rates mean many premature deaths, in the sense that aver-
age life expectancies are not fulfilled. Although the full human
tragedies of these deaths cannot be measured, the resulting loss of
productivity to society can be, and it provides a way of analyzing
the costs and benefits of health intervention programs. If loss of
productivity from disease mortality is avoided because of a success-
ful program, one of the benefits of the program can be measured by
the resulting increase in productivity. 14
The social welfare, or social efficiency, of smallpox eradication
may be seen from two perspectives: the costs and benefits of eradi-
cation itself and the costs and benefits of components of the eradica-
tion program. The following section will discuss economic issues
inherent in the debate over control versus eradication, and the final
section in this discussion will look more closely at the efficiency of
the strategies and tactics that were developed to reach the intended
goal.
Costs and Benefits of Smallpox Eradication
Before the creation of the NSEP, the goal of smallpox activities in
India was to control rather than to eradicate the disease. Control and
eradication differ in assumptions about final outcome, in their needs
for resource allocations, and in the ways in which costs and benefits
accruing to each may be perceived.
Disease control is the more common approach to battling any
disease. For some diseases (such as cataracts or cancer), there is no
choice between eradication and control, because we do not have the
technical or administrative means for eradication. In other instances,
as for malaria, the control option is chosen because the economic
costs of pursuing eradication are very high.
Control programs generally involve smaller start-up costs than
eradication programs, especially since available funds can be allo-
cated annually into a control program to produce relatively propor-
Analysis and Commentary
127
tionate results, which can be improved (within the limits of techni-
cal feasibility) as more resources are allocated to the program.
However, disease control programs require continuing allocations
of resources because the level of program effectiveness must be
maintained in order to prevent an increase in the disease incidence.
Thus, ongoing program costs must be subtracted from benefits as
they accrue in the future. In fact, future benefits of the program are
largely dependent on the continued payment of recurrent costs;
moreover, where population growth rates are high, increased allo-
cations of resources will be needed in order to maintain the same
level of program effectiveness.
For a disease eradication program, costs of the program stop
when the targeted disease is completely eliminated, while benefits
may continue to accrue indefinitely in terms of economic savings
and human suffering prevented. Although eradication involves
higher initial investments-both in terms of direct costs and in the
diversion of scarce managerial talent and resources from other pro-
grams into the eradication effort-the future benefits accruing from
successful eradication will eventually outweigh the higher start-up
and operational costs.
A key determinant in the economic preferability of the control
or the eradication option, then, is the time frame within which the
decision maker wants to have some measure of return that maxi-
mizes the investment of currently available resources. Because lim-
ited resources must be distributed across a multitude of society's
needs, the political time line for the evaluation of social programs is
often rather short.
For example, a public health decision maker may have $9 mil-
lion available for all health programs over three years. If it takes,
hypothetically, $9 million to eradicate smallpox in three years, then
the decision maker can (1) invest $3 million a year into a program to
;eradicate smallpox or (2) invest $1 million a year in a control pro-
gram designed to vaccinate high-risk groups and reduce the inci-
dence of smallpox to levels deemed socially acceptable. If he chooses
rhe three-year smallpox control option, $2 million a year will still be
l.eft to put into other disease control measures-for example, an
integrated primary health care service that might concentrate on a
program for control of diarrhea (or another major health problem
.that causes loss of life and productivity). However, maintaining this128
Smallpox Eradication in India
level of combined disease control will require continuing yearly in-
vestments of $1 million for the smallpox control, plus $2 million for
the diarrhea control (assuming stable prices for vaccine and oral
dehydration and stable secular trends), over an indefinite amount of
time.
On the other hand, what if the entire $9 million is invested in a
three-year program that results in the eradication of smallpox? After
the $9 million investment, there would be no need to maintain a
vaccination program, and thus in all future years the entire health
program budget-say it continues at the rate of $3 million a year-
may be put toward other disease control programs. In nine years, it
may be argued, the eradication program would pay for itself.
$9,000,000 total costs
$l,OOO,OOO/year
= 9 years to recoup costs
However, this assessment is not completely accurate, since
other benefits were forgone when the decision maker no longer had
$2 million for each of the three years to put into diarrhea prevention
measures. Over the three years, he has lost the benefits of $6 million
that might have been invested in a diarrhea program. As a result the
health system may have borne what economists call opportunity
costs in the form of preventable deaths and suffering caused by
diarrhea, a net increase in hospital and/or other health care costs, a
net increase in work days lost as a result of diarrhea, and so on.
Another consideration is that money that is put into a disease
eradication effort might instead be put into goods for immediate
consumption. People put more value on current consumption of
food and other needs than on future consumption. This is especially
true in less affluent societies or in times of scarcity. This reduction in
the value of benefits (and costs) over time is called "discounting." 15
For these reasons it may, in fact, take longer than the hypo-
thetical nine years to reap the full economic benefits of the eradica-
tion of the disease. Health planners, serving a public that is inter-
ested in seeing immediate short-term results, are often unwilling to
promote a policy that will not generate net economic benefits for
many years. As a result, disease control programs may appear more
attractive than disease eradication programs, even though the latter
may have greater long-term benefits.
Analysis and Commentary
129
The Indian central government health budget allocated an
average of Rs. 38.3 million ($4.5 million) annually to smallpox from
1973 to 1977 (Basu 1974). With that budget constraint, the alterna-
tives that achieved the most vaccination output would probably
have been control programs. With input from the states and in-
creased input from WHO, total expenditure equalled approximately
Rs. 100.3 million ($12.4 million) per year from 1973 to 1977 for the
smallpox eradication program.
There was a threshold point at which smallpox eradication be-
came economically feasible and preferable. 16 The higher start-up
costs of a smallpox eradication program are due in part to the in-
creased opportunity costs of shifting (even for very short times)
health workers already committed to malaria and family-planning
programs into participation in intensified activities such as the week-
long active searches. Also included in higher initial costs are oppor-
tunity costs of diverting scarce high-level health managerial skill to
smallpox. When the government of India assigned its top epidemi-
ologist managers to the smallpox eradication program, other pro-
grams lost their services for a time.
Inherent in the measurement of opportunity costs is the
amount of marginal benefit derived from placing additional funds
into a program to promote elimination of the disease rather than
reduction of its harmful sequelae. In the case of a disease that has a
low morbidity rate or few harmful sequelae, an eradication program
may not be justified, even if such a goal is possible, due to the
limited ultimate benefits that may be derived from relatively large
inputs of resources. Eradication of staphylococcus, for example, falls
into this category.
Smallpox was an attractive candidate for eradication, since an
effective vaccine was available and the disease had only human-to-
human transmission. But the full benefits of smallpox eradication in
each country required global eradication to remove threats of impor-
tations. If one country's program failed, the threat of continued
outbreaks would negate many of the benefits that would result from
global eradication. The eradication of smallpox in India provided
many international benefits that gave donor nations and the global
community incentives to promote the eradication, rather than the
control, of smallpox in India and the other endemic countries.
The costs and _benefits of carrying out a disease eradication130
Analysis and Commentary
Smallpox Eradication in India
effort in a particular country may therefore be seen from three differ-
ent perspectives: (1) that of the individual country, (2) that of donor
nations, and (3) that of the global community.
Costs and Benefits for India
Costs. The costs to India for the eradication program included direct
program costs, indirect medical costs and lost productivity resulting
from vaccination complications, and opportunity costs of applying
valuable health resources to smallpox eradication rather than to
other health or social programs. Included in direct program costs
were: vaccine production and distribution; provision of health
workers to perform vaccinations and surveillance; provision of mo-
bile containment teams; publicity and rewards; administrative over-
head; airfare; jeeps; spare parts; gasoline; and consultants.
From 1970 through 1973, the Indian central government expen-
ditures for direct costs were Rs. 96.5 million ($12,781,000, or
$3, 195,250 per year). From 1974 to 1977, the country increased its
expenditures to Rs. 162.8 million ($19,026,000, or $4,756,500 per
year). States provided even more program funds-Rs. 180 million
($22.5 million) during each of the two periods. 17
Although direct costs may be fairly easily ascertained from the
program archives, indirect costs are much more difficult to estimate. 18
They include losses to the economy as a result of program imple-
mentation. For instance, a worker in the field may miss two days of
harvesting rice because his arm is swollen from a vaccination. The
value of each day of harvest is worth Rs. 10 on the market, resulting
in a loss of Rs. 20 of productivity because of "absenteeism" from the
fields. A WHO estimate of indirect smallpox program costs to India
calculates indirect costs of the program from 1970 through 1977 as Rs.
36 million ($4.8 million) per year, or roughly half of the direct pro-
gram costs. 19
Besides direct and indirect program costs, however, the appli-
cation of Indian health resources to the smallpox campaign resulted
in important opportunity costs, since benefits that would have ac-
crued to alternative uses of available resources were foregone. For
instance, personnel were borrowed in large quantities from other
programs such as malaria, family planning, and leprosy in order to
assist smallpox staff during active searches and during the peak of
containment periods. Approximately 100,000 health workers 20 were
131
taken from other health programs for a total of nearly 10 million
work days to perform searches, which, at Rs. 75 per week, meant
that approximately Rs. 150 million ($20 million) were diverted from
other programs to smallpox. For the period 1973-76, this totaled
about $4 million per year. As a result of these reduced resources,
other public health programs may have functioned less effectively,
and, for example, may have failed to prevent cases of malaria or
provide services to leprosy patients. These costs are included in the
opportunity costs shown in table 7.
Benefits. The economic benefits resulting from smallpox eradica-
tion include, of course, the treatment costs of cases averted after the
disease had been eliminated. They also include the increase in pro-
ductivity resulting from a reduced death rate and from illnesses
averted. These are often called human capital benefits and commonly
include preservation of wages and productivity that would be lost
through absenteeism, savings of the replacement costs of lost labor
associated with absenteeism, and the replacement costs of labor.
The economic productivity lost each year as a result of prema-
ture deaths due to smallpox may be conservatively estimated at $96
21
million. Productivity lost as a result of morbidity (one month's
incapacitation per case) is roughly $0.2-2.0 million per year. 22
Basu estimates that the intensified campaign saved $132.2 mil-
lion from July, 1973, to December, 1975, as a result of decreased
requirements for hospital beds, staff time, and drugs (Basu 1974;
Basu, Jezek, and Ward 1979)-roughly $52.8 million in treatment
costs saved each year as the result of eradication. (This average is,
naturally, a conservative figure, since savings were likely to be
higher in 1975 when no cases were treated than in 1973 when inci-
dence was high.) When combined with savings in economic produc-
TABLE 7. Summary of Average Annual
Domestic Costs of the Indian Smallpox
Eradication Program, 1970-73
Category
Direct
Indirect
Opportunity
Total
Cost (in U.S. $)
$8.4 million
4.8 million
4.0 million
$17.2 million132
Analysis and Commentary
Smallpox Eradication in India
tivity, the benefits to India from eradication may be estimated at
roughly $150 million per year. The estimated annual benefits to In-
dia resulting from the eradication of smallpox are summarized in
table 8.
Many externalities have resulted from the Indian campaign.
These are benefits that have accrued as a result of the program but
were not original objectives of the eradication effort. They include
the management skills developed by Indian medical personnel and
health administrators in the course of successfully eradicating small-
pox, increased public optimism and acceptance of health programs,
and other benefits that were left behind when the NSEP was termi-
nated. Dutta, Arora, and Rao (1975, 211) have noted that
Success of the campaign produced a tremendous impact on the mor-
ale and productivity of the general health services and increased the
prestige of the health workers and health programmes. It also led to
increased emphasis on early case finding which is an essential prereq-
uisite to a disease control or eradication programme as one of the most
important functions of the general health services.
These are benefits that go beyond economic analysis. Even
population control efforts may have benefited from smallpox eradi-
cation, if the child survival hypothesis 23 is correct; it suggests that if
child mortality due to diseases like smallpox is decreased, parents
will have fewer "replacement births" and "insurance births," and
the birth rate will go down (Taylor, Newman, and Kelly 1976).
At the same time, the conquest of smallpox has increased In-
dia's status in the global health community and helped the country
avoid censure. The elimination of smallpox is likely to result in im-
provements in the quality of life in India in many ways.
Some might argue that India would have gained more from a
gradual eradication of smallpox rather than an intensified smallpox
eradication program, because a control level of program effective-
ness would have been more economical in the long run due to high
opportunity costs brought about by mobilizing from other programs
the many health workers needed for the large-scale searches of .
every home in India. However, as costly as it was to search an
enormous number of households in India (searches done as often as
every month in endemic states), a rough estimation of costs and
benefits suggests that marginal costs of the intensified campaign
133
TABLE 8. Summary of Annual .Benefits of the Indian
Smallpox Eradication Program, 1970-73
Category
Economic productivity
(from premature deaths)
Economic productivity
(from incapacitation)
Reduced medical care
Total
Benefit (in U.S. $)
$96.0 million
0.2-2.0 million
52.8 million
$149.0-150.8 million
were quickly recouped. We can divide the marginal, or additional,
costs of the intensified eradication program (as opposed to the ex-
penditures of the NSEP during 1970-73) by the marginal benefits
gained by eradication that were not being realized by the NSEP
before the intensified campaign . The numerator consists of the mar-
ginal expenditures India made on the intensified eradication pro-
gram (1974-77) that were over and above the 1970-73 NSEP levels.
The denominator reflects the marginal productivity gained as a re-
sult of fewer deaths and illnesses after the eradication of smallpox.
Marginal costs of an intensified eradication pro-
gram to central government and states (1974-77)
$3,437,000
$28,927,288/yr.
Marginal productivity
+ Marginal productivity
due to deaths averted/yr.
due to illness
prevented/yr.
=
43.4 days
According to this calculation, the marginal cost of the intensi-
fied program was paid for by increased productivity alone in 43.4
days without smallpox. 24 To summarize: each year, India recoups its
total investment in smallpox eradication by a tenfold margin. Every
six weeks without smallpox, India receives an economic benefit
equal to the extra direct cost of the central government and states
expenditures for the intensified campaign.
Costs and Benefits for Donor Nations
For donor nations, the cost of smallpox eradication was the direct
.cost to their respective national budgets of contributing money,
manpower, or supplies such as vaccine to the support of the global
program, including the India campaign.

134
Smallpox Eradication in India

Let us look at one donor for whom complete figures are avail-
able. The United States provided $2.1 million per year during the
ten-year global program, with benefits accruing at a substantially
higher rate. According to one economist, Norman Axnick of CDC
(Spring 1975), United States expenditures in 1968 to prevent a single
case of smallpox were approximately $150 million. 25 Due to inflation,
the comparable figure (in 1978 dollars) would have been over $300
million had not India and other nations achieved eradication.
Thus, the annual benefit of $300 million (in 1978 dollars) con-
tinuing into the future significantly dwarfs the United States contri-
bution of slightly more than $3 million per year (in 1978 dollars),
which, in fact, ceases now that smallpox has been eradicated. Even at
a very high rate of discount, the United States has regained its invest-
ment many times over. Conservatively, it recoups its total ten-year
international contributions to global eradication ($21 million) every 26
days that the world is free of smallpox.
As a result of the successful eradication of smallpox, other
nations have now eliminated their own programs for smallpox vacci-
nation and the surveillance of incoming travelers. Resources that
they allocated to vaccine production can be shifted to other impor-
tant disease-control efforts, and they retain the economic benefit of
costs forgone in treating unexpected outbreaks of smallpox in their
own countries.
In terms of net economic benefits, smallpox eradication is
clearly one of the best investments that developed countries have
had an opportunity to make. In a 1977 speech in Dacca, Bangladesh,
WHO's director-general, Dr. Halfdan Mahler, stated that smallpox
eradication is a $2 billion gift from the less developed countries
(LDCs) to the developed world. Actually, it is probably an annual
gift of $2 billion!
Costs and Benefits for the Global Community
The global community as a whole, and the United Nations in par-
ticular, benefits enormously from mankind's first victory over a
killer disease. Benefits include those economic gains that accrue to
donor nations and to endemic nations in particular, as well as bene-
fits from the new, heightened optimism about the potential of inter-
national health programs. Despite ideological differences in orienta-
tion between the vertical or independent program approach of
Analysis and Commentary
135
smallpox eradication and the current integrated primary health care
philosophy of WHO, it is doubtful that a proposed goal of "Health
for all by the year 2000" would have been contemplated if the world
had retreated from the goal of smallpox eradication as it had re-
treated from the goal of malaria eradication. The total direct costs of
global eradication were roughly $312 million. 26 If savings resulting
from the global eradication of smallpox are over $1.2 billion per year,
then the world recoups its total twelve-year expenditures on small-
pox eradication every at least four months. (This figure, of course,
does not include indirect costs or the positive and negative externali-
ties that resulted from global smallpox eradication.) It is staggering
to think that the program costs of eradicating a disease that has
caused so much misery for so many centuries can be regained in so
short a period, and by all parties concerned.
Of the $50 million cost of India's smallpox eradication cam-
paign from 1972 through 1976, WHO contributed $11 million (22
percent) of the funds. Approximately $1 million (2 percent) came
from WHO' s regular budget, while $10 million (20 percent) came
from the voluntary fund, the bulk of which was provided by SIDA.
When WHO Director-General Mahler visited Washington,
D.C., in 1978, President Carter stated that if WHO had never
achieved anything except the eradication of smallpox, it would be
reason enough for the U.S. to pledge continuous commitment to its
work. This statement reflects an important positive externality-
increased public support for both national and international public
health programs, which has resulted from the eradication of small-
pox. Smallpox eradication has brought together individuals from all
over the world in a successful effort to work for a common goal, and
the spirit it generated may encourage other UN projects. In develop-
ment meetings, there is increasing emphasis on mutually beneficial
cooperation, rather than assistance. In the case of smallpox, global
eradication was a cost-effective way to improve health conditions for
India as well as for donor nations, each of whom probably recouped
their marginal investment in the first few smallpox-free months.
Economic Efficiency of Program Management
The efficiency of the smallpox eradication program may also be
viewed in terms not only of its overall goals, but also of each pro-
gram component, i.e., strategies, procurement and distribution of136
Analysis and Commentary
Smallpox Eradication in India
vaccine, management information systems, personnel management,
finances, and concurrent evaluations.
Since the entire cost of the intensified campaign was recouped
during virtually each month without smallpox, it is not too farfetched
to say that each month's delay nearly doubled the cost of the pro- .
gram. Although no such explicit statement could be made during the
campaign, there was unequal knowledge of the order of magnitudes
involved, and this led to another conflict. Program management
stressed that time was money in the eradication campaign. This sense
of urgency was generally not shared outside the program.
Some examples are useful here. In 1972, a government of India
program officer was not permitted to travel by air, thus necessitating
train rides of up to three days to visit certain outbreaks. By 1974 all
senior staff traveled by air. When an outbreak was detected in the
early part of the campaign, a cross-notification had usually been sent
by regular mail. As the campaign intensified, cross-,notifications
were made by telephone. In fact, much of the program communica-
tions in the later stages were carried out by telephone (a request for
urgent supplies or authorization to spend additional unauthorized
amounts of money could travel from the field to Delhi and from
Delhi to Geneva and back to the field in seventy-two hours). Tele-
phone bills for the smallpox unit in Delhi were much higher than for
those of other units in WHO. In the case of a disease that could be
eradicated, insistence on use of the less expensive but much slower
and unreliable postal system would surely have exemplified the
penny-wise and pound-foolish false economies that plague many
similar endeavors.
The same may be said of extra expenditures in the field to pay
for watchguards used to isolate smallpox cases, to procure and de-
liver food daily so that no one from an infected house had to leave
to go to the market, to ship vaccine by air rather than train, to make
routine use of photocopy machines rather than risk the loss of criti-
cal documents. Even providing each WHO medical officer in the
field with a typewriter, which was not usual WHO procedure, was
later seen as cost-effective against the background of tremendous
economic savings by eradication.
Ultimately, both India and the donor nations regained their
investments in the first few smallpox-free months. However, there.
had been a continuing problem about whether WHO should provide
137
funds for gasoline for Indian jeeps in the program. Without gaso-
line, surveillance teams could not visit outbreaks, vaccine could not
be delivered, assessment could not be supervised. Delays would be
inevitable. The costs of gasoline had to be seen against the overall
economic profitability of rapid eradication. The same is true for extra
manpower at every level. Naturally, these calculations may not ap-
ply to other types of programs. Efficiency for disease eradication is
quite different from efficiency for continuous primary health care,
and this analysis is not intended to imply that what was efficient in
the smallpox eradication program is necessarily economically effi-
cient or even feasible for other programs.
Expediency had another externality, this one negative. Many
long-held rules were broken in order to quickly implement the
smallpox program, since every minute delayed might mean another
exposure to smallpox and a prolongation of the campaign. Excep-
tions to standard practices placed a strain on the system. Other
programs with less obvious benefit-to-cost ratios had to follow the
prescribed rules; 27 smallpox got exceptional treatment.
This has, as might have been expected, produced some nega-
tive externalities, or backlash. Some WHO administrators resented
the frequent exceptions that the smallpox team insisted on. The
speed and enthusiasm of younger workers were not always easily
assimilated by the WHO administration. Many rules were broken.
There were smallpox enthusiasts and antagonists at many levels of
administration. As the disease slips into history, however, and the
uniqueness of the program becomes apparent, the backlash dimin-
ishes. Increasingly, it is hoped there is agreement that the economic
and human returns on the investment made by all parties more than
justified the speed and exceptional efforts made in the exceptional
smallpox eradication effort.
Management Style
The role of management includes integrating all the preceding com-
ponents. Some of those components can be measured, but manage-
ment style is more difficult to quantify. It is difficult to assess the
critical elements of leadership and dedication.
Several explanations have been given for the dedication of the
senior level staff. First was the Mount Everest effect-the challenge138
Smallpox Eradication in India
of achieving a medically important and inspiring humanitarian first.
In bureaucracies beset with problems of prestige and pensions, it
took a very special kind of person to work toward eradicating his
own career. Once smallpox was eradicated, there would be fewer
career opportunities for smallpox experts!
'· Another source of commitment was the infectious enthusiasm
of eradication. Elsewhere it has been called the zeropox virus, and
the infection it produced was not unlike the fervor of a charismatic
organization.
Smallpox eradication was a special purpose campaign with
high motivation. Alvin Toffler (1970, 122) predicts the future belongs
to such programs-organizational structures aimed toward special
purpose campaigns, which he calls "adhocracy." The adhocracy
uses special purpose personnel, and this was certainly the case in
the smallpox program, where unusual people who enjoyed moving
from place to place, free from many long-term personal relation-
ships, and who did not like to be office-bound were often best
suited for the campaign in the field.
The management style of the Indian smallpox campaign became
especially distinct during the intensified campaign in 1973, when
there was a need for many Indian and foreign epidemiologists. In
personnel management, finding such people was of paramount im-
portance. First, in selecting potential epidemiologists, emphasis was
on special purpose personnel. Indian epidemiologists were usually
over fifty, while internationals were often in their twenties and
thirties. WHO (or rather the smallpox unit in Geneva) recruited the
best young epidemiologists from many different countries rather than
depending on careerists. The younger epidemiologists brought fresh
ideas; in addition, they did not expect the high salaries that more
senior physicians do, a considerable further benefit, as WHO per
diems and salaries are low compared to those usually paid in devel-
oped countries. By contrast, Indian special epidemiologists were fre-
quently retired ("but not tired"), well-respected health officials from
nearby states who could be quickly mobilized. The constant move-
ment of people-whether of Indians from one state to another or of
internationals from their home countries to India-freed the workers
from any long-standing personal relationships and redirected their
primary allegiances to the independent, informal smallpox organiza-
tional structure.
Analysis and Commentary
139
With carefully recruited, highly motivated, loyal special pur-
pose personnel working in the campaign, it was possible to decen-
tralize decision making, delegate responsibility by function, and
provide fertile grounds for creative problem solving in autono-
mous, regional programs assessed on the basis of the incidence of
smallpox. Periodic review meetings provided the opportunity to
rapidly communicate successful innovations from the most periph-
eral field stations to program units throughout the entire country
and to maintain enthusiasm.
Those epidemiologists or junior medical officers who were not
able to effectively contribute were sent home, regardless of whether
home was in Bombay, New York, or Moscow. Unlike a permanent
health program where such transfers or terminations can rarely be
carried out expeditiously, the smallpox program employed tempo-
rary staff, and even when the inevitable political pressure mounted
to keep someone, the temporary assignment rarely lasted long
enough to cause harm. On the other hand, a program officer who
was dynamic and might undiplomatically run afoul of a state's po-
litical sensitivities could often be kept on-political force from the
state capital was met with political force from New Delhi.
There was another advantage of shifting Indian epidemiologists
from their home states to others. It was often much easier for an
01,1.tsider to take appropriately strong action than for a local, who
might feel long-term social or political pressures against doing what
the immediate situation required. The benefits conferred by the use of
outsiders were obvious in comparison to situations involving high-
level officials in their home states, where they did not feel free to
make hard decisions or to break rules because they knew they would
have to continue to work in the same place years later with the people
whose rules they had broken. The internationalists or retired Indians
from other states could return to their home states having done a
good job and keep their memories of excellence without later being
penalized for their enthusiastic support of the smallpox program.
This cross-fertilization also added an element of outside assessment.
The internationals sometimes brought with them the extra ad-
vantage of having seen smallpox eradicated in another country, and
by intoning their experiences over and over _again, they convinced
others that it was possible to eradicate smallpox by using surveil-
lance and containment.140
Smallpox Eradication in India
To make sure staff functioned at their peak, procedures for
training were developed. National and international epidemiolo-
gists, junior medical officers, and even state surveillance teams went
through week-long training periods upon entry at WHO, SEARO, or
the Ministry of Health, and also at the state level in endemic states.
For internationals, this training highlighted cultural and demo-
graphic characteristics. During their briefing, they were introduced
to all the proformae and search materials that would be used and
went through training exercises in which they simulated taking
charge of field programs in hypothetical districts or states. They
were also instructed in the art of fund disbursements (the imprest
account holders had a very important role to play as fund disbursers
in the field) and in the epidemiology of smallpox.
Their written job descriptions required them to submit weekly
reports so that progress in their areas could be monitored in New
Delhi. These periodic reports included monitoring new outbreaks
detected, old outbreaks contained, and pending outbreaks. In addi-
tion, field epidemiologists were expected to bring their imprest ac-
counts up to date each month, submitting receipts for all funds
disbursed at the monthly meetings held in the capital of each state.
Personnel management ended with debriefing sessions held in
New Delhi for departing epidemiologists. In addition to completing
the accounting for their imprest accounts and preparing turnover
notes to be used for briefing their replacements, the epidemiologists
were asked to describe what, in their opinions, were the strengths
and weaknesses of the program in their area. This form of debriefing
became more sophisticated toward the end of the program and in-
cluded questions that changed over time to meet shifting program
needs. One of the most important questions was "What is the weak-
est geographical area in your area of responsibility?" Others in-
cluded "What is the thing that the WHO and government of India
high command is doing worst?" and "What is the best thing that we
are doing?"
For example, analysis of twenty debriefing forms from the pe-
riod just before the last case was found shows that the single most
commonly cited best thing being done was the presearch meetings
at the PHC levels. This attention to planning the search at the most
peripheral level was reported as a reason for feeling optimistic about
the thoroughness of the search. As for the weakest element in the
Analysis and Commentary
141
program, the results were more varied, but usually dealt with the
way WHO paid its staff, or occasionally with the fact that the actual
job in the field turned out to be much more administrative than the
epidemiologists had been led to expect, or that initial training in
New Delhi was too short.
Nearly all of the field personnel reported that the support that
they received from headquarters was superb and rapid. The supervi-
sion they received was only occasionally a field visit from a senior
officer; it was, however, a careful analysis of the assessments of
their area using management controls to ensure that operations
were proceeding according to design. The warning flags of the sys-
tem allowed project management in New Delhi to oversee from a
distance, assuring maximum decentralization and regional auton-
omy and encouraging innovations while ensuring uniform quality
work.
The esprit de corps and friendships that evolved between the
Indian and WHO team leaders was perhaps unprecedented in a
health campaign in India. Victory over smallpox was the common
goal. Each group had to surmount obstacles within its own bureau-
cracy, and each used its counterpart to help overcome its internal
problems, through level jumping or informal private appeals or by
stressing the other side's strong feelings. In reality, there was no
"other side"; rather, there was a shared sense of purpose, and the
brotherhood of comrades-in-arms. Inspired participants were willing
to work long hours under difficult circumstances, to forgo vacations,
and even on occasion to use their own salaries to fund aspects of the
program. The willingness to take on a variety of nonprofessional
tasks, routine or innovative, managerial or epidemiological, center
stage or backstage, is especially noteworthy.
This led to the slogan "management by ·inspiration" and was
studied by T. S. Jones (1976), one of the participants in the Indian
smallpox campaign, who felt that this motivation came from three
major sources.
1. a common goal that was attainable in the near future
2. a sympathetic group of co-workers who shared and encour-
aged belief in the goal
3. an emergency-like work situation (the program was often
referred to as being on a war footing) with the concomitantAnalysis and Commentary
143
increase in output and unification that such disaster situa-
tions invoke. (P. 10)
N
Jones regards the smallpox eradication program as similar to
the charismatic authority model described by Weber (1958). A char-
ismatic organization depends on a special sense of mission to attract
participants and is held together "by the perceived extraordinary
nature of its purpose" (p. 15). It continues only as long as this sense
of purpose remains. The possibility of eradicating a hideous, often
fatal disease provided purpose enough.
Paradoxically, as shown in table 9, the same features of the
program that created this motivation and sense of purpose also
limited its stability. As the target of zero smallpox came closer and
closer to reality, the sources of motivation and dedication began to
recede. Fewer cases required less staff, decreasing the critical mass
of sympathetic co-workers. After the last case, as the smallpox-free
interval lengthened, the tone of the campaign shifted from that of an
emergency-like situation to one of careful but less exciting and less
romantic meticulous surveillance. Although the humanitarian and
professional satisfaction of each phase of the program was the same
in theory, meeting the enemy face-to-face and seeing actual cases of
smallpox were far more powerful incentives than reporting "nil"
cases week after week after week. It took a different personality to
continue to go the final inch toward certification of eradication.
The motivational component of the eradication program will be
one of the most difficult to carry over to other public health pro-
grams, especially those maintenance programs, such as primary
health care, that must sustain constant effort year after year. If the
smallpox campaign had stretched out for decades rather than years,
the unique special purpose of the campaign might well have
changed, and with it the personnel it attracted and the nature of
their commitment, and perhaps even the final outcome.
On the other hand, it may perhaps be possible to re-create the
same specialness of purpose throughout WHO by adopting some of
the same principles of motivated leadership. After all, health for all
is the most lofty and inspiring target that health workers could work
toward.Chapter 3
Conclusions
Lessons for the Future
The purpose of this book is to examine what was learned from the
experience of a successful health program and to make those lessons
useful to managers of future programs. Since this necessarily implies
different diseases, different programs, and different countries,
smallpox eradication cannot be offered as a model. The reader must
read the case study, go through the analysis, and draw his own
conclusions about which lessons are relevant for any particular prob-
lem, culture, or program.
In chapter 1 the chronology of the smallpox eradication pro-
gram in India was reviewed, and in chapter 2 the management
issues involved in the program were analyzed. In this chapter con-
clusions about management tools that worked in the smallpox eradi-
cation program are discussed and lessons for the future are sug-
gested. WHO is continuing to document the lessons learned by
many participants in the smallpox campaign, and there are likely to
be as many different views as there were participants or observers.
As the success of the Indian smallpox eradication program
grew increasingly secure, Dr. M. I. D. Sharma (acting commissioner
of health for the government of India) began opening the monthly
progress review meetings with his own list of important factors in
the smallpox success story.
This list of recipes, presented in table 10, illustrates one way to
look at the lessons learned from smallpox eradication. Within this
list are many lessons unique to smallpox and some unique to
India-or perhaps unique to eradication programs in India. But also
included are many lessons that can be applied to other disease con-
trol programs, to the organization of primary health care, and even
to problems beyond the health sector.
The lessons from smallpox eradication that are most important,
naturally, are the ones that can be applied to other programs. When-
145Conclusions
TABLE 10.
Review of Recipes for Eradication of Smallpox in India
Ram a Hindu name for God, an incarnation of Lord Vishnu
Rahim a Muslim name for God
Resources manpower, jeeps, and money from WHO, SIDA, and others
Reporting the weekly epidemiologic reporting system, the surveillance re··
ports, the management information system that allowed target<·
ing of resources
Rewards for stimulating improved case detection
Recruitment of good epidemiologists from around the world
Retired (but not tired) Indian epidemiologists (the employment on an
unusual basis by WHO of Indians to work in India ... tapping:
India's vast army of specialists retired at age 55 or 58 according:
to Indian government regulations)
Responsible
and resourceful
staff at all levels
Routine
supervision of all facets of the program
Regular
communications a regular surveillance newsletter to keep everyone informed of
progress and problems
Rains the monsoon that brought down seasonal transmission
Recognition
cards that helped the search worker find smallpox
Relevant
research field and operational research, innovations from the field-
market searches, watchguards, as well as freeze-dried vaccine,
bifurcated needle, and so on
Re-search Going back and doing the search over again if it was not good
enough the first time
Rapid
containment of outbreaks
Rapid
administrative
action to get personnel hired and fired; to move supplies and paper-
work across the country or across the office
Rigorous
assessment to find weak spots in the strategy and implementation of the
program
Review
meetings the presearch training sessions at PHC, district, and state lev-
els to prepare the search and the postsearch progress review
meetings each month
Rules especially the rule that any outbreak that persisted more than
21 days after detection and still had secondary cases had to be
visited by senior level staff
147
TABLE 10.-Continued
Regulations
especially regulations like flexibility of fund disbursal through
the use of the imprest accounts
And the routine
breaking of
rules and
regulations ...
ever this subject is discussed within the international health commu-
nity two positions emerge: one, that smallpox eradication was a
unique, unreproducible event, with very few useful lessons for
others; the other, that smallpox eradication provides a good model
or lesson for other programs.
The truth probably combines elements of both positions. As a
participant in the smallpox eradication program and one who was
profoundly affected by the experience, this author cannot be con-
sidered an objective, unbiased observer. However, in the remarks
that follow, an honest attempt has been made to take an even-
handed aproach and to distinguish those aspects of the Indian
smallpox eradication program that were unique to it from those that
can provide general management lessons for other disease control
programs.
Factors Unique to Smallpox Eradication in India
In the economic development literature, much attention has been
paid to the limitations of the special case. There is a concern that
each nation and each program has specific characteristics that are
unique and should not be copied by other countries or other pro-
grams. For smallpox and its eradication, at least three categories of
uniqueness must be considered: (1) the unique epidemiology of
smallpox; (2) the unique economics and politics of eradication (as
opposed to disease control); and (3) the unique psychology of small-
pox eradication.
The Global Commission for the Certification of Smallpox Eradi-
cation (1979) has identified six epidemiological characteristics of
smallpox that facilitated eradication (see fig. 8). There are additional
epidemiologic characteristics of smallpox that although perhaps not148
Smallpox Eradication in India
1. The recognition of smallpox cases is a comparatively
simple matter. Subclinical infections, although recognized
as occurring among partially immune persons, are not im-
portant since the individuals so infected do not transmit
infection.
2. Smallpox is transmitted solely from person to person.
There are no known animal reservoirs.
3. The transmissibility of infection is low and epidemics
develop slowly. Between each generation of cases there is an
interval of two to three weeks. In most circumstances when
transmission occurs, one individual infects between one and
five others.
4. Possibly infected individuals can be readily identified
because transmission requires close contact between in-
fected and susceptible persons, most commonly in the
home, hospital, or school.
5. The number of chains of transmission at any one time is
usually relatively small.
6. With the development of a surveillance system that
discovers and traces all outbreaks promptly, small but rapid
and thorough containment actions can break the transmis-
sion chains and smallpox can be eradicated within a rela-
tively short time.
FIG. 8.
Characteristics of smallpox facilitating eradication
unique, limit the general application of program techniques. First,
there are no important biological vectors (as in the case of malaria
and yellow fever) and no environmental reservoirs of the disease (as
in the case of polio and tetanus). The smallpox program was fortu-
nate in that it could deal with humans only, avoiding problems of
mosquito resistance and the formidable difficulties of environmental
control.
This was not only of epidemiologic importance, it was also
extremely significant from a managerial perspective. The smallpox
program did not have to change cultural habits and traditions be-
yond inculcating the need to report smallpox and accept vaccination.
As difficult as it was to deal effectively with cultural beliefs about
smallpox, it would have been much more difficult for programs like
diarrhea control, where sanitation and economic issues predomi-
Conclusions
149
nate; or for xerophthalmia, where changes in diet are important; or
for family planning, which deals with intimate events that have
been traditionally free of state interference. It is far easier to achieve
public cooperation in reporting smallpox and taking a vaccination
than to change fertility, diet, and fecal habits that have been cen-
turies in the making.
Another factor important to smallpox eradication and rare else-
where is so obvious it might be overlooked: the availability of a
potent vaccine. Of course, good management was the crucial ele-
ment in creating a climate that permitted development of abundant,
reliable, locally produced, heat-stable vaccine and encouraged the
dissemination of a recent innovation, the bifurcated needle. How-
ever, effective biologicals for many health problems still elude sci-
ence, and whenever the lessons learned from smallpox are raised in
the company of family planners, malariologists, or primary health
theorists, the absence of any equivalent to smallpox vaccine is often
cited for the argument that lessons learned from smallpox are not
generalizable.
Throughout the smallpox program new lessons were learned in
the area of vaccine development. WHO encouraged multiple sources
of production, and UNICEF provided many countries with the tech-
nical know-how and resources to produce vaccine on a regular basis
and also provided travel assistance that permitted vaccine produc-
tion experts to visit other laboratories around the world, to share
techniques, and to establish common minimum standards of po-
tency and stability. These are certainly important lessons for pro-
grams that have vaccine delivery as part of their strategy. Vaccine
management in smallpox has provided lessons for the Expanded
Program in Immunization (EPI) in India, and if eventually vaccines
are developed against other diseases like malaria and leprosy, the
vaccine-related lessons from the smallpox program will be more gen-
erally relevant.
Another factor that limits, to some extent, the generalizability
of the smallpox eradication experience is the communicability of
smallpox. Some of the international cooperation, as well as some
significant donations from the private sector, no doubt derived from
altruistic motives. However, the feeling of vulnerability to conta-
gion, requiring constant vigilance at airports, surveillance at border
crossings, and attention to immunization levels, loosened govern-
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Re: The Management of Smallpox Eradication in India
« Reply #5 on: November 10, 2022, 09:05:23 PM »

150
Smallpox Eradication in India

ment purse strings and encouraged several countries to agree to
send their most talented epidemiologists and doctors thousands of
miles away to participate in smallpox eradication. The resources that
were made available to smallpox eradication were in part motivated
by self-concern, some of which could be translated into economics.
It is clear (see the section in chapter 2 entitled "Evaluation") that
donating money, vaccine, and manpower was at least as much in
the interest of the donors as it was in the interest of the recipient
countries. Dr. Halfdan Mahler has called smallpox eradication a $2
billion gift from the developing world to the developed world. Cer-
tainly there were gifts in both directions, but the point is that it will
be difficult to duplicate the level of international aid and collabora-
tion that the nature of this disease stimulated. Leprosy, which is as
disfiguring and frightening a disease as smallpox, nevertheless does
not convey the sense of immediate emergency that smallpox does.
Yellow fever, which is as deadly as smallpox, does not perhaps
evoke such deep-seated psychic dread as smallpox. And of course,
primary health care, which will touch more lives and has the poten-
tial to benefit far more people than eradication of any of these dis-
eases, is a far less dramatic effort.
In many parts of the world, there was a strong public will to
eradicate smallpox. The disease, terrifying in its appearance and
tragic in its consequences, has gripped the imagination of mankind
for as long as records exist. The support given to the smallpox pro-
gram is in part traceable to the general public determination to con~
quer this ancient scourge. This was certainly true at the highest
political level in India. Dr. V. T. H. Gunaratne, former regional
director of SEARO, stressed this.
Of the lessons learned from the eradication of smallpox; most impor-
tant is that it is the commitment, the perseverance and the will of our
Member States which are the prime determinants of success in the
field of health. (World Health Organization, Regional Office for South-
East Asia 1978, 105)
Another aspect of the unique psychology of smallpox was the
enormous attraction involved in the potential "first" of eradicating a
disease that had been a major worldwide scourge for centuries. This
drama is not unique to smallpox. Elements of it are seen in reports of
the early efforts to eradicate malaria, in efforts to eradicate yellow
Conclusions
151
fever, and even among some people working to eradicate yaws. This
charisma and esprit de corps can certainly be re-created in future
eradication programs, but prolonged international interest in disease
control programs is more difficult to sustain. As important as char-
isma, however, are the economic realities of a disease eradication
program when compared to the economics of a maintenance program
of disease control. Despite the limitations of the simplistic cost-benefit
analysis presented in this book, it is obvious that compared to disease
control, eradication presented enormous economic advantages for
both the smallpox-endemic countries and the nonendemic potential
donor countries. These payoffs not only helped mobilize resources
for the eradication program, they also justified extraordinary speed
(and the extra costs speed creates, such as special delivery of parcels,
airfreight instead of sea mail; air travel instead of train; and most of
all, administrative priority to all things marked smallpox). This speed
was cost-effective because eradication was possible. Because eradica-
tion was possible, a temporary organization could be established,
with temporary staff, temporary offices, and a sense of urgency. It is
much more difficult to generate a feeling of urgency and to make the
same cost-effectiveness arguments in the case of cataract or leprosy or
even childhood deaths from diarrhea-not because the consequences
of the diseases are less tragic, but because the benefits of program
success are less dramatic.
The commitment to urgency was justified by the psychology,
economics, and epidemiology of smallpox eradication, and it in turn
provided money, manpower, and momentum to the smallpox eradi-
cation campaign. Although other diseases in today's environment
may not be able to generate that commitment of money, manpower,
and momentum, one factor that was responsible for the eradication
of smallpox certainly can be reproduced, and that is the manage-
ment. The economic, political, and psychological urgency of small-
pox eradication was no doubt unusual, if not unique, and facilitated
program development. However, a review of the case study of
smallpox eradication in India (as well as globally) makes it clear that
it was the program management that was responsible for organizing
the manpower, raising the money, and perpetuating the momen-
tum. The management of the comparatively advantageous elements
of the nature of smallpox is what made it possible to eradicate small-
pox from India in 1976 instead of much later, and good management152
Smallpox Eradication in India
is what overcame equally important comparative disadvantages: the
tenacity of the disease in densely populated India; the cultural tradi-
tions that hid cases and resisted vaccination; the ease of transmis-
sion and high attack rates; and the tremendous pessimism that had
developed about all disease eradication programs after the previous
well-known failures in programs to eradicate malaria and yellow
fever. Within the management of smallpox eradication there are les-
sons to be learned that are relevant to many areas of public health
and international program management.
General Lessons from Smallpox Eradication in India
When one reviews the many arguments against using smallpox
eradication as a model for other programs, it becomes clear that
although smallpox is not a model, the lessons learned in the eradica-
tion effort are very important. The marriage of good management
and good epidemiology (in about equal measure), which forms the
essential lesson of this case study, also formed the essence of the
smallpox eradication program in India (and elsewhere). Unless this
marriage and its offspring of management and epidemiologic inno-
vations are understood and respected, other programs are not likely
to take advantage of the lessons learned from smallpox eradication.
With this in mind, some general lessons from the case study
that seem relevant to other health programs will be reviewed here
(following the outline presented in chapter 2).
The first step in any program is to understand and analyze the
problem. Problem definition must be qualitative and quantitative. It
must be a dynamic process, capable of continuously changing as the
problem itself changes over time. In the case of smallpox, it was this
constant process of redefining the problem to take new develop-
ments into account that led first to the creation of a system for
recording vaccination (when the problem was redefined as "not
enough vaccination"), later to disease reporting (when the problem
was redefined as "too much smallpox"), and finally to a sensitive
surveillance system (when the problem was redefined as "smallpox
must be eradicated"). Monitoring vaccination reports, graphing the
annual incidence of smallpox, and later deleting infected villages
from the list of pending outbreaks-all these were epidemiologic
interpretations of the management problem. This epidemiologic
Conclusions
153
management is as needed for monitoring progress toward vector
control in malaria as it is in monitoring progress toward "Health for
all by the year 2000." The important lesson is that once a problem
begins to be understood and analyzed, it is possible to monitor
changes in that problem. In case of public health, such constant
monitoring of the state of the problem is called surveillance.
Investigating the causes of the problem means studying both
the epidemiologic and the managerial causes. In an epidemiological
sense, when we seek the causes of the problem we must ask about
descriptive epidemiology: how many cases, where are they located,
what is the seasonal periodicity, what are the secular trends, what
proportion of reported cases are coming to the attention of the au-
thorities (what is the sensitivity and specificity of the surveillance
system), . what is the case-fatality rate and the incidence of other
complications. In short, we are making an epidemiological study of
the problem.
From the management perspective, we need to assess both the
system and the management environment, test existing strategies
for any weaknesses, determine what potential management bottle-
necks may be present that prevent the implementation of important
tasks. In both cases, data gathered should be simple enough to use
but sophisticated enough to meet the needs of decision makers. An
epidemiologic program always gathers data about the enemy,
whether the enemy is a single disease or a broad spectrum of ill-
nesses. Good management for such a program must ensure that
data are built into the management information system, and the
data must be used to test the feasibility of strategies and to formu-
late tactics.
To achieve this integration, disease-control officers must be
both scientists and managers. A political determination to achieve
health for all is essential, but without an integration of epidemiology
and health management the problem cannot adequately be defined,
analyzed, and overcome.
The case study given above provides many good examples of
the way an integrated epidemiological and management approach
made it possible to understand and analyze the problem at hand
and act on the information. Early in the program, data were avail-
able to show that the spring was the time of the high incidence peak
of smallpox (as the name of smallpox in Bengali, Bashanto, or "spring154
Smallpox Eradication in India
visitor," implies). An autumn campaign was decided on, to take
advantage of the fact that the lowest period of incidence wa~ the
monsoon, during which viral survival rates were low and the isola-
tion imposed by washed-out bridges and impassably swollen rivers
reduced transmission. The program management incorporated the
seasonality of smallpox into program planning: the first autumn
campaign was an attempt to get surveillance and containment mov-
ing as soon as the monsoon receded, before smallpox had a cha~ce
to build up its epidemic force. Likewise, the first push of Ope~at~on
Smallpox Zero was set in motion just before the high transmission
period began, to avoid facing an epidemic resurgence of smallpox
with insufficient staff.
The specific month-by-month seasonality of smallpox is not
generalizable to all diseases, but there is a generalizable lesson. In
studying the seasonality of the disease, program managers were
looking for the weakest points in their adversary, smallpox-even
personifying it and gathering resources as a good general g_athers
troops. The seasonality was unique, but the general lesson is that
good disease management requires that the magnitude and c~arac­
teristics of the disease(s) be learned. Basing strategy and tactics on
epidemiologic data is good management.
Even the surveillance and containment strategy was an
example of this marriage. A good manager must kno"'_' how t~ e~fi­
ciently allocate scarce resources (vaccine) on the basis of pnonty
(risk factors). Once the reporting system was integrated into a man-
agement information system, it produced and transmitted t~e sur-
veillance information that allowed program managers to defme the
problem and continuously refine their approach in peri?dic review
meetings during which both new information and resulting changes
in strategy and tactics were disseminated.
Many other innovations of the smallpox program-for
example, active case search and market surveillance-can be traced
to this mixture of epidemiology and management. All were develop-
ments based on a refinement of understanding of the problem of
smallpox, a periodic redefining and measuring of the problem.
In any public health program, the system in which the pro-
gram is to be carried out must be understood in its br~ade~t ~ot~n­
tial sense. Its real potential, not its imaginary or historic hmits,
should be respected. The WHO-government of India relationship at
Conclusions
155
the beginning of the program was sometimes as adversarial as it was
collegial. The colleagues on both the WHO and government of India
teams could only use each other later and help each other level jump
because they had studied and understood the political and adminis-
trative system they and their counterparts were in. Likewise, the
courageous acts of the team leader in finding funding from SIDA,
the Tatas organization, and other sources had to be initiated infor-
mally, from outside the limited official system, in order to get the
resources needed to achieve the goal of eradication. The last of Dr.
Sharma's guideline recipes (table 10) is to regularly break rules and
regulations, but this cannot be done beyond certain limits. A good
manager is a good game player who understands the real limits of
the system (which are not necessarily those given in the rule book)
and acts within them. It might have been against the rules to under-
take personal appeals like those made to Prime Minister Gandhi, the
Tatas, and the government of Sweden, but because of the costs and
benefits involved, it was almost as if the written rules of the govern-
ment of India and WHO were partially suspended in the case of
smallpox. With everyone understanding that, no real rules were
broken. Managers in other programs must be sensitive to the differ-
ence between the formal system (and its written rules) and the real
system as it is understood by its insiders.
There are risks in ignoring rules and breaking regulations, and
the willingness to take those risks might have been greater in a
temporary program that was not, for most of the participants, a
lifetime career. One would expect less rule breaking in a permanent
system, not just because the usual rules are more appropriate for
long-term programs but because the long-term career risks are
higher for the managers. There is no lesson, as there is no rule, that
tells one when to break rules. However, to some extent, experience
from smallpox eradication does corroborate an important aphorism:
You can't make an omelet without cracking a few eggs.
Program goals should have several tiers or levels of subtlety.
The first-level goals (objectives) should be specific, measurable, real-
istic, dynamic, and flexible. Input from the field, from an MIS,
should provide the incremental information to define and redefine
program goals. In the case of smallpox, the goal matured over time
from that of 100 percent vaccination to that of zero smallpox. A
second tier of goals (targets) should be time-bound whenever pos-156
Smallpox Eradication in India
sible, and should be specific numerical targets. In the case of small-
pox, some examples might be surveillance coverage (how many
villages had been searched within a certain time period), surveil-
lance effectiveness (how many outbreaks of smallpox eluded the
searcher), and extent of reward knowledge (how many people knew
of the reward at a certain point in time). Although few of these
specific targets are directly transferable to other programs, a multi-
tiered approach to goal setting is useful elsewhere, for it allows
managers to use epidemiologic assessment of secondary goals and
to keep sight of the primary objective.
For example: in the case of primary health care, a statement of
primary goals ("Health for all by the year 2000") has been made.
Individual time-bound targets have not yet been specified, but
presumably they will be forthcoming for each specific disease and
each intervention; they will be the ingredients that make up the
program. Once the components of health are defined, however,
epidemiologic targets will be of great importance in helping policy
makers reach specific targets for each component of the program
without diluting the political and motivational goals of the lofty,
important, but difficult to measure objective of health for all.
Planning any program is in part an exercise in strategy formu-
lation. Strategies can be political, managerial, and epidemiological.
Good planning must take into account economic realities and politi-
cal costs and benefits. In the case of smallpox eradication in India,
epidemiologic strategies (improve surveillance) converged with po-
litical strategies (motivate high-level Indian government officials to
allocate more resources to smallpox). Whether this convergence was
by design or accident, it is an important lesson for all programs:
technical and political strategies must be harmonious.
Planning must also be flexible. One of the strengths of the
epidemiologic strategy of surveillance and containment is that the
specific techniques (e.g., active search, dividing India into endemic
and nonendemic areas, making risk assessments of various com-
munities, careful epidemiologic tracing of contacts and index cases)
are nothing more than an application to disease control of sound
management principles of resource allocation. One overriding char-
acteristic that distinguished the program based on this strategy
was a constant evaluation of the progress based on the outcome of
the program (the number of cases, of pending outbreaks, of in-
Conclusions
157
fected states, and so on) rather than on output (the number of
vaccinations given, of epidemiologists put into the field, and so
on). Outcome-oriented strategies are applicable to all programs in
the field of health. "Health for all by the year 2000" is certainly an
outcome-oriented goal, and it is to be hoped that the strategies will
also be outcome-oriented, based on sound epidemiologic and
managerial principles.
Tactics in public health must always be dynamic, not static,
changing to meet the ever-changing political, economic, managerial,
and epidemiological situation. Information from the field is con-
stantly recycled; lessons learned in remote areas are brought to plan-
ners and implementers as refinements and improvements in tactics.
A major lesson from the smallpox program that applies to many
others is the need for continual attention to new detail, a continuous
reformulation of tactics.
In any bureaucracy there are both formal and informal hierar-
chies. Both will be used by the good manager. Often, the formal
hierarchy adds legitimacy to a program but it is the informal heirar-
chy that gets things done. The most essential part of this informal
organization is the central or top management team. It is in this
group, however it is defined, that interpersonal relationships are so
important. When the program is an international one, diplomacy
and tact are often more important at this level than technical issues.
The smallpox program was able to break many rules and regulations
because its informal team of top management had strongly shared
identical views. Both halves of the team reinforced mutually desired
tactics by calling on the formal legitimacy of their counterparts to
bolster their position within their own organization. However, this
approach has serious limitations. In the case of a temporary program
like smallpox, much of the rule breaking was tolerated because the
tail (smallpox) would only wag the dog (the health system) for a
short period. When many different programs simultaneously prac-
tice such organizational tactics, a health care system can degenerate
into warring feudal kingdoms. For example, the fiefdom of malaria
eradication could battle the fiefdom of filariasis control for the use of
the spraying teams each needs. Battles between specific programs to
obtain exemptions from the rules lead to backlash, as general admin-
istrators and planners lose patience with such power struggles and
fights for preeminence. An honest look at WHO in the postsmallpox158
Smallpox Eradication in India
years must acknowledge some degree of backlash against the zest of
the eradicators. Programs that do not have eradication as their goal
and that are not shorFlived cannot afford to risk such backlash.
Attention must be paid to a thorough and realistic evaluation of the
boundaries of the system in which the program is working.
One of the most important lessons from smallpox eradication
was the need for well-trained, nonmedical operations officers and
administrative officers. In the smallpox program, the epidemiolo-
gists were the team leaders, and in the field they looked after logis-
tics implementation in their areas. However, at central offices, in
Delhi, and in the state capitals, there were operations officers who
applied good management principles to the flow of vaccine, sup-
plies, personnel, and money. These logisticians appeared to the epi-
demiologists to be magicians in their ability to sort out tangled lines
of supply. Too many health policy makers think of administrative
officers as a luxury. Having the properly trained people to handle
the logistics is a necessity in any kind of program. Logisties manage-
ment requires the same expertise in management controls as disease
management-the same attention to detail in defining the problem
and its causes, understanding the organizational system, setting
proper goals, formulating appropriate and effective strategies, im-
plementing tasks, and evaluating the work done.
Communication within the organization and between the or-
ganization and the outside world needs to be consistent, rapid, and
honest. Staff training is a key aspect of communications often mini-
mized by programs that do not realize that each badly trained per-
son can propagate errors up and down the line of communication.
In the smallpox program, practical field training was important, and
the use of case studies was very helpful.
Once in the field, staff need to be part of a regular communi-
cation system. Surveillance newsletters and periodic review meet-
ings keep program staff involved in disseminating new tactics or
refining old procedures. A flow of simple, regular information from
each person in the field is vital to keeping a management informa-
tion system that is usable. Too much information from the field can
overload the central office and obstruct the appropriate response,
which must be rapid and dependable in order to keep field staff
well supported. In the smallpox program, it is generally ac-
knowledged that the vast majority of such important innovations
Conclusions
159
as recognition cards, watchguards, the reward, and containment
books came from field staff, and a major role of managers is that of
stimulating field staff to creatively tackle problems as they arise. If
management tries to discourage complaints, as happened in the
early days of case suppression, it will suppress the knowledge that
the problem exists, but the problem itself seldom goes away. An
attitude of problem-oriented practical experimentation in the field,
with dependable support from the center, is a prerequisite to prob-
lem solving in many programs. There is an implied arc in this
system. Information comes from the field in a simple form, and the
health service responds to the collected, collated, and analyzed
data. The information is returned to those who need it for adminis-
trative decision making and to those involved in continuing data
collection. Although the management information system that de-
veloped in the Indian smallpox program was unique to that pro-
gram, the circumstances by which it developed and the needs that
stimulated its development are similar to those in many other pro-
grams. A study of the management information system and the
surveillance network may be helpful to other program managers.
Communication between the program and the public must be
honest, and it must flow in both directions. It is essential that pro-
gram staff be fully knowledgeable about the community's beliefs
about disease and its causation. The cultural interpretations of small-
pox varied so dramatically every hundred miles that the various
traditional views needed to be learned by the Indian as well as the
foreign smallpox staff. Other countries and programs may have dif-
fering problems, but the way disease is perceived by the community
must be understood and respected. Likewise, health education (in-
forming the community of the program's view of disease and pre-
vention) must be emphasized-and its effectiveness evaluated. It
was not enough simply to advertise the fact that smallpox should be
reported and that there was a reward. Periodic assessment of the
impact of health education (the number of people who knew about
the reward) was as important as evaluating the stability of the vac-
cine. The messages of health education must also be dynamic, not
static, so they will evolve as the program evolves. Establishing hon-
est, regular, and reliable two-way communication between the pro-
gram and the people is of great importance to all concerned.
Many WHO smallpox program staff were personally involved160
Smallpox Eradication in India
in raising money that was used in the program. This lesson may not
be possible or appropriate to apply in many programs, but for some
it is an important one. On the other hand, in many programs it is
harder to spend money than to raise it. Inefficient financial practices
that impede the appropriate use of budgeted funds create one of the
greatest obstacles to improving public health in many developing
countries. Flexible financial policies do not mean laxity, excessive
generosity, or sloppy financial controls; they imply such innovations
as the imprest accounts that allowed financial officers to exercise
curative rather than preventive controls, often circumventing time-
consuming levels of bureaucratic pro forma approvals that had been
required before gasoline could be purchased or health education
posters printed. A practical problem is that few government health
staff are at ease handling money; corruption is rarely talked about
and difficult to deal with at all levels. Health programs make elabo-
rate controls to prevent corruption, usually because it is nearly im-
possible to discipline people caught misusing money. However,
such preventive measures against corruption often prevent program
implementation as well. The approach in the smallpox program was
to increase good staff recruitment, to carefully train the staff about
allowable expenditures, to motivate them, and to exercise stringent
curative financial controls each month. There is obviously a trade-off
here, but the imprest account system allowed team leaders to dis-
burse funds up to a certain limit with no prior approval. This al-
lowed for decentralized decision making and rapid response by field
teams when problems were encountered. The use of imprest ac-
counts in the field with postexpenditure justification of disburse-
ments and strict personnel actions in cases of misuse or corruption
was an improvement over the cumbersome process of seeking ap-
proval months before funds could be disbursed. Such a system
worked for a temporary program. It is not clear how well it would
work for a permanent one, but it is certain that in many countries
and many programs existing financial control systems choke off ini-
tiative and stifle program implementation.
Assessment-that is, concurrent evaluation-of progress to-
ward management and epidemiologic goals is an essential part of
any program. One chain of assessment in the smallpox program
consisted of assessing vaccine quality, quantity produced, distribu-
tion to storage and health centers, use in the field, and effectiveness
Conclusions
161
(as judged by scar surveys). In other programs there will be other
things to assess, but the need for assessment is clear. In the small-
pox program there was resistance at first to the idea of spending so
much time and so many resources assessing work already done
when it was obvious that there was still much more work to do.
Some felt that it would be better to put it off until the end of the
program, so that there would be more progress to show on the
evaluation. However, the purpose of assessment is not simply to
show progress, but rather to feed information into the management
information system in order to continuously change the tactics
needed to meet program goals. Resource allocation decisions cannot
be made as effectively without a system of continuous assessment-
of personnel recruiting decisions, purchase of supplies and equip-
ment, budgeting to meet likely program requirements, and even the
decision whether to seek extraordinary outside funding. These deci-
sions must be based on realistic assessments of the program's
strengths and weaknesses. There is another reason to invest the
time and money to have regular assessments. Assessment in the
field provides supervision and encouragement to staff and creates a
standard of excellence and good morale that should never be under-
estimated. Many people lament the expert committees, advisory
committees, and assessment committees that proliferate in many
programs. The case study here clearly shows that such periodic
outside review was important in developing strategy and tactics in
the NSEP and could yield a similar dividend in other programs.
As a program expands, developing systematic epidemiologic
and management control procedures is very important as a means of
avoiding the gulf that often separates the field from the office when
direct supervision of all staff has become impractical. Controls like
the weekly "nil" report to separate absences of smallpox from the
absence of the reporter are certainly generalizable lessons, w.hereas
scar surveys and surveillance of surrogates like chickenpox were
specific for smallpox. But the general concept of management con-
trols is vital to a program's health.
Research carried out in the smallpox program in India was of the
problem-oriented variety. Operational research was more important
than basic science in the case of smallpox because the scientific ele-
ments for disease control were already in place. Research was carried
out to gather the data that were needed to plan, implement, or evaluate162
Smallpox Eradication in India
the program. Because management and epidemiology were inte-
grated, the program could control and organize its own research. In
other programs, research may often follow a more laissez-faire ap-
proach than it did in smallpox. There, research proposals to count the
number of pox in various types of smallpox cases were ignored in favor
of research that helped measure the risk of the floating population in
Calcutta. The management of a program must be able to encourage,
fund, and support research-minded colleagues who can find answers
to the program's most pressing questions. Often this effort is enhanced
by a decentralized approach, which encourages local problem-solving
initiatives. Other types of coordinated research that are important are
pilot projects that test field methods, clinical trials of vaccines and
therapeutic agents, and so on. These and other categories of research
need to be integrated into program management.
Many programs lose momentum and are prematurely declared
to be successful. This occurred from time to time in the smallpox
program, with many countries announcing eradication prematurely.
It did not occur in India, but it might well have, because it is a
reaction that reflects human nature. The realm of the final inch, the
meticulous attention to detail for a two-year period of painstaking
and sometimes unrewarding surveillance, is one of the most reveal-
ing aspects of the smallpox programs. In the malaria eradication
program, there were countries that came very dose to eradication,
only to see the parasite come back with a frightening resurgence.
Many ambitious health care targets of the 1950s have been aban-
doned because the sheer will and perseverance to pursue them on
and on was lacking. Smallpox, it must be remembered, was a tem-
porary program and might have faced similar problems had it
droned on for decades. But the momentum was sustained for two
years beyond the finishing line. This period of built-in evaluation
acted also as an assurance that the work of eradication would not
falter at the final threshold of success. The use of outside evaluators
and the importance given to outside evaluation was another incen-
tive to keep up high standards of work. As in all of the program,
evaluation at this stage was based on outcome, not on output.
The use of outside consultants, whether from other areas of the
same country or from other countries through WHO, was important
in smallpox eradication and is likely to play an important role in
other projects. Facing the social and political pressures in one's
Conclusions
163
home area often inhibits objectivity and direct action, but visitors
from another state or nation do these jobs well, knowing that since
they can return to their homes elsewhere, they will not face the
inevitable penalties and repercussions of their honest criticisms.
There is one aspect of the style of management of the smallpox
program that is generalizable but undefinable: the characteristic of
good leadership. Much has been written about what makes a good
leader, and there are many different opinions. Leaders are often
charismatic, able to communicate their enthusiasm and commitment
to the task at hand. The triumph of the zeropox virus over the
smallpox virus was a victory for leadership. Even in the blackest
days of the campaign, the leadership remained confident of victory.
It is beyond the scope of this book to attempt to deal with the
personalities and qualities of leadership in smallpox eradication, be-
yond stressing the important fact that outstanding leadership played
a vital role in smallpox eradication and good leadership is a neces-
sary ingredient in any successful program.AppendixesAppendix 1
The WHO-Government
of India Plan of Operations
and Addenda
On September 9, 1970, the World Health Organization (WHO) and
the government of India agreed upon a general Plan of Operations
for the eradication of smallpox. The agreement was based upon the
relationship between WHO and the government of India that was
established in the basic agreement of July 16, 1952.
The objectives stated in the Plan of Operations were: (1) the
eradication of smallpox by vaccination surveillance and containment
measures and (2) the maintenance of achieved eradication.
Methods proposed for reaching the goal of eradication were
based on three basic needs: personnel, technical methods and proce-
dures, and vaccine. The plan stipulated the importance of providing
adequate staff; of applying technical methods and procedures as
contained in the manual of instructions prepared by the directorate-
general of health services; and of using vaccine that was freeze-dried
and of prescribed potency and stability.
The plan of action stated that overall technical direction
would be provided by the Directorate-General of Health Services,
with each state preparing detailed plans of actions in consultation
with the Directorate-General. It also provided general guidelines
for the operation of the smallpox program in India, including as-
pects such as vaccine transportation and storage, vaccination per-
formance, program evaluation, surveillance and containment,
health education and publicity, and the duration of assistance
from WHO.
Vaccine was to be transported by air, or if that were not possi-
ble, by the most rapid means of transport. All supply points were to
retain in stock one month's worth of vaccine, and vaccine was to be
stored in refrigerators. In the field, where refrigerators were not
available, vaccine was to be kept in a cool place, but was to be used
within one week. It was to be kept moist and was to be used within
six hours after reconstitution.
167168
Appendix 1
Vaccination was to be given to all children under fourteen, but
priority was also to be given to urban communities and groups most
likely to transmit disease. Revaccination was to be done selectively,
also targeting high-risk groups. Mass vaccination was to be manda-
tory in the case of a smallpox outbreak. Vaccinators were to inspect
all primary vaccinations for success, record all failures, and revacci-
nate if necessary. It was stressed that the bifurcated needle was to
be used wherever possible.
A review of the progress of the program was to be done every
month, and scar and pockmark surveys were to be carried out
periodically.
Surveillance and outbreak containment was to be carried out
from the beginning of the campaign. The program was to include
the detection and prompt reporting of smallpox cases and suspected
cases and the immediate initiation of containment action by specially
designated mobile teams.
Health education and publicity were recognized as necessary
components of the program, since it was important to increase con-
sciousness among the public and to promote voluntary vaccination
and prompt notification of cases. The plan recommended that co-
operation of the health unit in each state or territory be sought for
the development of an education program to encourage vaccination
and case notification.
Assessment was to be done by the state government, the gov-
ernment of India, and WHO at intervals deemed necessary by the
government of India and WHO.
Duration of assistance from WHO for implementing the project
was planned initially for two years, with automatic extensions until
international assistance by WHO ended.
For the administration and assignment of responsibilities for
the eradication campaign, WHO and the government of India
agreed that the program would be handled as a national program
until it reached the maintenance phase, when it would be handed
over to basic health services. The government would organize pro-
duction and distribution of freeze-dried vaccine, provide health
education, and supply reports to WHO as agreed. WHO would be
represented by SEARO.
The Plan of Operations also stipulated the resource commit-
ments of both parties:
Appendix 1
169
Commitments of WHO
l. Personnel-WHO agreed to provide four epidemiologists
2.
3.
4.
5.
plus three short-term consultants for three months each in
1970 and 1971 to assist in the assessment of the program and
training of personnel, as well as to provide the cost of travel
for WHO personnel within the country while on duty.
Supplies and equipment-WHO would supply vehicles,
motorcycles, refrigerators, bifurcated needles, and spare
parts that were not available in India, as and when required
through addenda to the plan of operation, with titles re-
tained by WHO.
Fellowships-as necessary.
Local costs-WHO would provide funds for payment of
salaries, travel, per diems, and contingencies for additional
full-time personnel up to Rs. 1,125,000 per year.
Additional assistance-personnel and financial and techni-
cal assistance would be provided when mutually agreed
upon.
Commitments of the government
l. Appropriate facilities for storage, internal transportation,
2.
3.
4.
5.
6.
7.
and distribution of WHO supplies and equipment would be
arranged by the government.
Necessary telephone, telegraph, and postal communications
would be supplied for project personnel.
Fuel, maintenance (including staff), spare parts, and regis-
tration and related charges required for the vehicles pro-
vided by WHO would be supplied by the government.
Activities for health education of the public and public infor-
mation would be performed.
Necessary incidental expenses would be provided.
Office accommodations, furniture, equipment, stationery,
secretarial assistance, telephones, and telegraph and postal
communication for international personnel would be made
available by the government.
Transportation at the duty station for international person-
nel would be provided.170
Appendix 1
8. Assistance in obtaining suitable residential accommodations
for international personnel during the period of their official
duties in India would be provided.
9. Such other facilities as agreed upon between the govern-
ment and WHO would be provided.
The government of India agreed to report progress of the project
to WHO, to notify WHO of estimated costs to the government of
carrying out commitments, to make evaluation facilities available to
WHO, and to assume responsibility for dealing with claims brought
by third parties against WHO and its representatives.
After the original Plan of Operations, WHO and the govern-
ment of India agreed on twenty addenda to aid the implementation
of the program between December, 1970, and December, 1976.
These addenda were formalized through exchanges of letters that
addressed matters such as the assignment of personnel, increases in
supplies and equipment, and other additional assistance that
needed to be provided as the program intensified.
Almost half of the addenda authorized the provision of vehi-
cles and supplies, such as jeeps to transport field workers through
difficult terrain and refrigerators for the storage of vaccine. (First,
Second, Seventh, Tenth, Eleventh, Fourteenth, Fifteenth, Seven-
teenth, and Eighteenth Addenda).
The Third Addendum (September 15, 1971) allowed for the
establishment of a training course on smallpox eradication for pro-
gram officers at the state level and medical officers at the district
level in the northern states, where smallpox incidence was greatest.
The intensified course was planned to last three days and included
approximately forty-five participants.
The Fifth Addendum (February 14, 1973) provided technical staff
to the project in 1973 and 1974. For both years, four epidemiologists
were to be provided, along with three epidemiologist-consultants for
three months in 1973 and two months in 1974 and two additional
temporary advisors for one week in 1973. In both 1973 and 1974, three
two-month fellowships for training in surveillance activities were to be
provided, and another training course, to be held for one week in 1973
with forty participants, was planned. Subsidies for salaries, travel, per
diems, and a contingency for additional personnel employed full time
at national and state levels were set at $50,000 in 1973.
Appendix 1
171
In the smallpox campaign in India, WHO exhibited flexibility in
its operating policies, which improved its ability to respond to spe-
cial needs of the program on the subcontinent. Through the Fourth
Addendum in January, 1973, WHO for the first time authorized the
use of local subsidies to cover expenses of gasoline and minor re-
pairs of vehicles. At the same time, it specifically provided one jeep
to each of the four WHO medical officers assigned to the project in
India. In September, 1973, WHO significantly altered its assistance
policy as stated in the Plan of Operations by authorizing the pur-
chase of thirty-seven jeeps of Indian manufacture for use in the
program in that country as part of an increased effort to eliminate
endemic foci (Seventh Addendum).
By June, 1973, the government of India was planning an inten-
sive three-month autumn campaign, focusing on the most highly
endemic areas of India. The purpose of the autumn campaign was to
"accelerate the elimination of smallpox in the highly endemic states
of India and to prevent importations in the smallpox-free areas." In
order to aid this intensified effort, the Sixth Addendum (June 14,
1973) authorized that an additional four medical officers be assigned
for two years to assist the program at the state level.
Recognizing the importance of continuing to strengthen the
campaign during the critical pre-monsoon period of 1974, WHO and
the government agreed to assign five WHO consultants as replace-
ments, plus an additional six consultants for the three months from
March until the monsoon (Ninth Addendum). During this period
the government further intensified the active search and outbreak
containment campaign.
In May, 1974, the Twelfth Addendum provided replacements
for the 11 WHO consultants provided by the Ninth Addendum and
the 7 other medical officers (who would be away during the mon-
soon months) in order to maintain increased staffing during June-
August. For the "substantially increased effort in the eradication
programme" described in the Thirteenth Addendum of July, 1974,
WHO agreed to supply approximately 103 special epidemiologists, 9
administrators and operations officers, 81 surveillance teams, and 45
special containment teams throughout the monsoon period and un-
til the end of December.
By 1975, as the intensified campaign was winding down, WHO
and the government were implementing plans for resource needs172
Appendix 1
for a year at a time. In the assistance planned for 1975 in the Six-
teenth Addendum, four epidemiologists for the year and eighteen
months of consultants were provided, as well as two fellowships for
the training of national staff in surveillance. The Nineteenth Adden-
dum provided assistance for 1976, including four epidemiologists for
twelve months each and two consultants for three months each. The
Twentieth Addendum, providing assistance for 1977, also provided
four epidemiologists for one year each and allowed four consultants
for six weeks each. The subsidies for salaries, travel, per diems, and
contingencies for additional personnel rose from only $100,000 in
1975 to $150,000 and $314,000 in 1976 and 1977 respectively, when
the subsidy also included the cost of increased reward publicity after
eradication was believed to have been reached.
Appendix 2
The Management
of Smallpox Eradication:
Organizational Charts......
'I
""
CHART 1.
Smallpox Eradication Network in India, Institutional Roles, 1962, 1970, and 1974
Collection and
Dissemina lion of
Information
Coordination
1962 1970 1974 1962 1970 1974
x x x x x x
x x x x x x
x x x
GOVERNMENT OF INDIA:
institutions with direct
responsibility to OCHS
(central) Ministry
of Health
state ministries
of health
district health
offices, PHCs
GOVERNMENT OF
!NOIA/ST A TES:
serniautonornous institutions
National Institute of
Communicable Diseases
Indian Council on
Medical Research
vaccine production
institutes
medical schools
x
x
1970 1974
x x
x x
1962
x
1970 1974
x x
x x
x
x
x
x
x
x
x
x
x
x
BILATERAL DONORS
SIDA, USSR, United States AID
INTERNATIONAL
VOLUNTARY
ORGANIZATIONS
OXFAM
......
x
Financing
x
INDIAN NONGOVERN-
MENTAL ORGANIZATIONS
corporate philanthropists
(Tata organization,
coal mines, etc.)
other philanthropical
organizations (Rotary,
Lions clubs)
~
1962
x
army cantonments,
municipal corporations,
railway, etc.
INTERNATIONAL AGENCIES
WHO
UNICEF, others
Provision of
Goods and
Services
OCHS = Directorate-General of Health Services
PHC = Primary Health Center
SIDA = Swedish International Development Agency
AID = Agency for International Devefopment
x
x
x x
x x x x
x x
x
x
x
x......
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Chief, WHO Global
Smallpox Eradication - - - Regional Director, SEARO
Program, Geneva
~
Chief, WHO Smallpox Program
for Southeast Asia
Director-General of
Health Services, India
i
(counterpart) Head, Government of India
National Smallpox Eradication
Program
(counterpart) State Deputy Directors of
Health Services for Smallpox
~
WHO Medical Officers (long-term)
assigned to Southeast Asia
Regional Office to coordinate
India Program
t
WHO State Program Officers
(State Epidemiologists)
~ional
Mldical Officers
and District Medical Officers
State Surveillance -
Teams
i
Paramedical
Assistants
......
"' "'
i
t
PHC Medical Officers
CHART 3. WHO - Government of India Smallpox Eradication
Program Organizational Chart, 1970-72
Vaccinators......
'I
00
Chief, WHO Global
Smallpox Eradication -
Program, Geneva
Director-General of
Health Services, India
Regional Director, SEARO
Chief, WHO Smallpox Program (counterpart)
for Southeast Asia
Head, Government of India
National Smallpox Eradication
The
Program
"Central Command" WHO Medical Officers (long-term)
'
assigned to Southeast Asia
.
""'
Governmen~ of! Infdf.ia
Regional Office to coordinate (counterpart)
India Program
Central Appra1sa 0 1cers
I
I
I
I
-
WHO State Program Officers
(State Epidemiologists)
(co
un
ter
par
l
t)
State Deputy Directors of
Health Services for Smallpox
Epi~emiologists
-
l .
District
(Both National and
International)
.
Divisional Medical Officers
and District Medical Officers
State
Surveillance~----
'
PHC Medical Officers
Teams
Param~dical
Assistants
'
Vaccinators
Search Workers
CHART 4. WHO - Government of India Smallpox Eradication
Program Organizational Chart, 1973-77
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I
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I I
f --
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Heallh
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I
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at Kanpur
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(Medical
Care)
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(Planning & Evaluation)
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(Health)
I
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BCG Officer
r- --
I
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Asst.
Director
(FP)
Personnel
Administration
I
r- - ----
-
Deputy Director
(Women)
Deputy
Director
(Tech.)
Asst.
Asst.
Director Director Entomologist
(Filaria (Smallpox)
Control)
Asst. Director
(HW)
Asst. Director
(Health &
Family-
Planning
Educ.)
Asst. Director
(MCH)
Deputy Director
(Training & FP)
Deputy Director
(Nursing)
,-
I
Health Education
Officer
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HW = Health Worker
CHART 6. Organizational Pattern at the Directorate Level,
1973-77, Uttar Pradesh Example
~
Joint
Director
(FP)
I
Joint Director
Deputy Director
(Civil Defense)
Asst.
Senior Accounts Joint
Director
Officer
Director
(Vital
(Stores &
Statistics)
Supplies)
Asst.
Director
(Rural Health)
,---·-1
Joint Director
(Personnel)
Executive
Engineer
Deputy
Director
(Homeo)
,1,
~
I
Controller
Deputy
Joint
Joint Director
Food &
Director
Director
(Health &
Patwadangar Drugs (Communicable
Family
Diseases)
Planning)
Add'! Director
(FP)
Add'! Director
(Administration)
I
I
: o : :
;:;·
PlState
Government
Primary Health Center
Medical Officer
Electorate of
Municipality
I
Sanitary
Inspector
\
Health Inspector
mily-Planning
Field Staff
/
/
Members of
Municipal Board
I
/~
//
/ /
BHWs
(8 in maintenance phase or
malaria house visitors
in nonmaintenance phase)
~
\
\
\
Smallpox
\supervisor
, I
Vaccinators
(3 in maintenance phase;
4 in nonmaintenance phase)
Of the 879 primary health centers in Uttar Pradesh, 673
were in maintenance phase in 1973 and 202 were in non-
maintenance phase. BHWs and vaccinators were under
the sanitary inspectors, health inspectors, and smallpox
supervisors. Although sanitary inspectors were not of
higher rank than health inspectors or smallpox super-
visors, in practice this was usually the case.
~
President
Municipal
Chlef
Medical Officer - - -
Sanitary Inspector
I
of Health.._
'\
-. ._
Sanitary Inspectors
'\
._ ._ (fixed area of
'\
responsibility;
'\ \
approximately 1 to
\ 20,000-30,000 population)
" \
I
Senior Cleaner
(Jamandars)
\
'
I
'-sweepers
(Bhungis)
CHART 9. Organizational Pattern of Smallpox Program for
Municipal Boards, 1973-77, Uttar Pradesh Example
CHART 8. Organizational Pattern at Primary Health Center
Level, 1973-77, Uttar Pradesh Example
182
183Notes
1. A Russian ampoule contains twenty doses, while an Indian ampoule
contains fifteen. The Russian vaccine established quite a reputation for
potency in India. Although occasionally spurned by villagers because of
its perceived strength (many revaccinations with the Russian freeze-
dried vaccine gave a positive take because the liquid vaccine used for the
primary vaccination had been ineffective), its effectiveness helped moti-
vate the change to domestic production of freeze-dried vaccine.
2. In addition, this focus on high-risk populations offered some of the
excitement of curative medicine and relieved some of the monotony of
routine vaccinations. This change-from vaccinating 600 million people
to fighting a visible enemy, a disease, an outbreak of smallpox-pro-
vided a more positive atmosphere for the field staff.
3. Afghanistan, Australia, Austria, Belize, Bolivia, Brazil, Canada, Czecho-
slovakia, Denmark, Ethiopia, France, Ghana, Indonesia, Japan, Mexico,
Nepal, the Netherlands, Norway, Poland, Romania, Singapore, Sri
Lanka, Sweden, Switzerland, the United Kingdom, the United States, the
USSR, West Germany, Yemen, and Yugoslavia. It is doubtful that any
"UN army" ever had representation from so large and diverse a group of
nations.
4. Copies of all of the proformae used during the searches are reproduced
in the book The Eradication of Smallpox from India (Basu, Jezek, and Ward
1979).
5. The global commission felt that "the most innovative concept" in the
Indian campaign was this "search week" program.
6. The request was made unofficially by two SEARO medical officers,
mindful that the available government resources in Bihar were not ade-
quate to contain the huge and growing epidemic in the 100-mile radius
around Jamshedpur.
7. This capability was an important point first raised in the 1972 WHO
seminar and now implemented.
8. The intervals during which smallpox remained undetected were: in
Brazil, four months; in Nigeria, five months; in Botswana, from two to
six months (three separate episodes); in Indonesia, eight months (large
numbers of cases had occurred that were known to lower-level health
staff but administrative confusion in reporting kept the outbreak hid-
den). In Nigeria, information about the cases was known to have been
intentionally suppressed.
9. Two types of smallpox were of epidemiologic importance. The last
185186
Notes
Notes
endemic case of Variola major, which kills 1 in 5, occurred in Bangla-
desh. The last case of Variola minor, which kills 1 in 100, occurred in
Somalia.
10. In addition, the distinguished scientists on the Commission included: Dr.
J. Kostrzewski (Warsaw, Poland); Dr. J. Cervenka (Bratislava, Czechoslo-
vakia); Dr. W. A. B. de Silva (Colombo, Sri Lanka); Dr. F. Fenner (Can-
berra, Australia); Dr. H. Flamm (Austria); Lt. Gen. R. S. Hoon (New
Delhi, India); Dr. T. Kitamura (Tokyo, Japan); Dr. W. Koinange-Karuga
(Nairobi, Kenya); Dr. H. Ludbeck (Stockholm, Sweden); Dr. A. M. Mus-
taqual Huq (Bangladesh); Dr. D. M. MacKay (London, United Kingdom!;
Dr. M. F. Polak (Nijimegen, Holland); Dr. R. Roashan (Kabul, Afgham-
stan); and Dr. U Thein Nyunt (Rangoon, Burma).
11. Later there were two rewards, one to the general public who reported
and a duplicate reward to the health worker receiving the report.
12. The economic analysis presented here is that of M. C. Zebrowski, a
policy analyst formerly at the University of Michigan. I am grateful to
her for providing her analysis and for drafting this section.
13. Economists refer to "economic efficiency" (also called "Pareto optimal-
ity") as a state of equilibrium in a perfectly competitive eco~10my, in
which no one can be made better off without someone else bemg made
worse off. However, when the desired result is to maximize welfare,
rather than economic gain, the concept of economic efficiency is not
very useful because it does not allow one to address the issue of dispar-
ately distributed costs and benefits among the population. Con~e­
quently, a policy analyst must somehow measure t~e level of social
efficiency that represents the level of costs and benefits to the general
public welfare, and in order to measure the level of social welfare re~ult­
ing from a health program, costs and benefits must be translated i_nto
some comparable unit, such as national currency. Where market pnces
are unattainable or inappropriate, shadow prices must be calculated.
Pareto optimality is an economic term more useful to theory than appli-
cable to practice, for it assumes not only perfect competition but also the
absence of externalities. Externalities, defined as uncompensated costs
and benefits that accrue as a result of an action, are generally quite
widespread. For example, the Tata family offered both staffing and
managerial skill to the smallpox program to aid the containment of
smallpox in Jamshedpur. After the epidemic was overcome and the Tata
help was ended, the health workers involved in this campaign no doubt
retained managerial knowledge that the Tata staff had taught them;
however, this social benefit is not included in economic gains to society,
because it cannot be easily estimated.
14. The question of the economic value of lost productivity in a situation of
underemployment is controversial and is beyond the scope of this
analysis.
15. The discount rate in the private sector is usually the market rate of
16.
17.
18.
19.
20.
21.
22.
187
interest, i.e., the rate at which a person can gain the most by investing
his available resources. In order for him to be willing to defer consump-
tion, his personal discount rate must be lower than the prevailing mar-
ket rates; otherwise he would prefer to spend his money now. The
social rate of discount is usually much lower than the market rate, for
society generally does place a high value on future consumption; how-
ever, economists do not agree on the appropriate social rates of discount
for various social programs.
It could not have been predicted beforehand just where that threshold
would be, because no one knew how many resources would be needed
to eradicate.
The percentage of funds supplied by each source for the period from
when WHO first began giving assistance to the NSEP until eradication
was as follows: central government 34 percent (1970-73), 36.7 percent
(1974-77); states 63.6 percent (1970-73), 40.7 percent (1974-77); WHO
2.4 percent (1970-73), 21.3 percent (1974-77); and bilateral donors 1.3
percent (1974-77). Most of the 21.3 percent that WHO contributed in
1974-77, however, was donated by SIDA to WHO specifically for the
Indian smallpox program.
The India smallpox program archives are available on microfilm at
WHO, Geneva. See Hughes et al. 1979.
WHO memorandum, J. F. Wickett to record, January 17, 1978. Again,
there is the problem of loss of productivity in a situation of less than full
employment.
The actual figures were 63,890 workers during the searches in 1973,
80,847 in 1974, 116,829 in 1975, 134,412 in 1976. Of these, approximately
80 percent were searchers, 17 percent supervisors, and 4 percent medi-
cal officers who assessed field operations. Only 21, 161 were vaccinators
or supervisors on the NSEP payroll; the rest were deputed from the
malaria, trachoma, leprosy, and family-planning programs or dispen-
sary or PHC staff.
These calculations are based on age-specific morbidity and mortality
rates found in an analysis of 23,546 cases during the intensified cam-
paign (1974-75) and a multiplier using the average yearly death toll of
22,036 with 46,512 nonfatal additional cases (the reported averages be-
fore the NSEP began). These figures are no doubt conservative due to
under-reporting and population growth. We have also assumed a fifty-
year life expectancy at birth, and a per capita gross national product
(GNP) of $110 per year. Expected years of life remaining at each age
were calculated from life tables in government of India sources based on
the 1970-71 census.
According to Basu, Jezek, and Ward (1979), only 2 to 10 percent of all
smallpox cases that occurred before 1972 were ever reported. This
means that the original calculation of $0.2 million per year in productiv-
ity lost as a result of morbidity may, in fact, be as much as $2 million per188
Notes
year. (Nonfatal smallpox cases were much less likely to be reported than
were deaths due to smallpox.)
23. The hypothesis says that as long as parents cannot expect all their chil-
dren to survive (due to ubiquitous diseases that cause childhood mortal-
ity) they will not voluntarily reduce fertility unless external sanctions,
forces, or incentives are imposed. The correlate is that improved infant
and childhood survival rates and the elimination of obvious and accus-
tomed childhood killers like smallpox will motivate families to reduce
fertility.
24. It should be noted that this calculation includes only direct program
costs and only those benefits related to productivity; other marginal
costs and benefits are very difficult to calculate.
25. It is interesting to note that the estimated annual savings for smallpox
eradication in the United States in 1968 ($150 million) was the same as
the savings to India in 1980 ($150 million).
26. This figure, stated in Annex 14 of the Global Commission Report (Global
Commission for the Certification of Smallpox Eradication 1979), includes
WHO regular budget and voluntary fund expenditures, bilateral aid,
and an estimated figure for national expenditures.
27. Some mistakes were brought about by this sense of urgency. Once the
smallpox unit at SEARO sent an order to Geneva for items not available
in India-photocopy paper, electric typewriter ribbons, and the like.
The order, to be airshipped to New Delhi, inadvertently contained other
office supplies, including paperclips. It is easy to understand the out-
rage felt by the chief of administration and finance upon checking the
order and finding that paperclips had been airfreighted from Geneva to
New Delhi, certainly not the best example of appropriate technology,
thrift, or good management. But such mistakes were the exception, and
in a program that imported 6,696,750 bifurcated needles and thousands
of other items, such errors are to be expected.
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