THE MANAGEMENT OF Smallpox Eradication in India THE MANAGEMENT OF Smallpox Eradication in India Lawrence B. Brilliant M.D., M.P.H. Ann Arbor The University of Michigan Press Copyright© by The University of Michigan 1985 To Neem Karoli Baba 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 Foreword 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 Preface 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 After the eradication of smallpox from India, the veterans of that campaign could be a case study of the Indian smallpox eradication program. carried away with them a unique experience and many lessons. In the decade In view of this, WHO requested that Dr. Brilliant write this book, The since the last case of smallpox occurred in India, many of these smallpox Management of Smallpox Eradication in India, in consultation with several man- veterans have found new roles and have tried to apply the lessons learned agement experts who were interested in the program. The book has been from their experience to their new tasks in public health. Each has tried to sift prepared for health officers who directly or indirectly participated in or were the wheat from the chaff-learning which lessons from smallpox could be interested in the global eradication of smallpox, as well as for those who applied to new jobs, new diseases, new environments. wish to study the eradication of smallpox from a managerial point of view. Other health workers, unfamiliar with the details of smallpox eradica- The latter include students and perhaps executives who wish to study the tion, have wanted to study its history, in particular to discover what lessons analysis of the success of an international program. can be learned about public health management from the smallpox eradica- Dr. Isao Arita tion program. The literature on international development is full of accounts Chief, Smallpox Eradication Programme of successful pilot projects that turned out to be unsuccessful national pro- World Health Organization, Geneva, Switzerland 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 Preface xi ment, and there is a danger that the lessons of past experience may be lost informal narrative style. Chapter 2 analyzes aspects of program manage- as well. ment, and chapter 3 summarizes conclusions from the case study and analy- As in most highly polarized arguments, truth and reason probably lie sis, presenting the factors that argue against a broad generalization of les- somewhere between the two extremes in this debate. There is no doubt that sons learned from smallpox eradication (such as the unique characteristics of the proponents of primary health care are motivated by the best kind of the virus or the nongeneralizable qualities of a vertical or categorical eradica- goal, that of making health care relevant to the needs of the most under- tion program) and then presenting the case for the generalizability of certain served communities in the world. Its achievement would certainly be an management lessons from the smallpox experience in India. improvement over any single-purpose campaign. Nevertheless, a simple I hope that this material succeeds in bringing the experience of small- change from vertical to horizontal will not solve all the world's health prob- pox eradication to life again for each reader and that it usefully highlights lems, and some of the methods of sound management learned in the verti- some of the innovations and adaptations, successes and failures, and good cal smallpox eradication program are applicable to any program, vertical or and bad lessons that were part of the India smallpox eradication experience. horizontal. The combination of the intense commitment of the staff, the And I hope that this experience ultimately helps all those who are seeking intense concentration on one problem at a time, and the problem-solving the alleviation of suffering to improve the management of other programs, orientation of the smallpox program management led to the development of whenever and wherever they are working. 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.