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,
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
