S2E2 / Do You Know Dutta?

This season, The Epidemic Podcast is about the eradication of smallpox in South Asia. And to understand the breakout public health strategy that ultimately made eradication possible, we're taking a quick detour to West Africa. It was 1966, and Bill Foege found himself in Nigeria. The young physician and epidemiologist from Iowa was a long way from home, but in good company as part of a team of health workers sent to the region by the CDC. Their mission was to vaccinate as many people as possible to stop smallpox. They traveled from one remote location to the next on electric bikes. To coordinate the work and respond quickly to each new outbreak, they had two-way radios.

On December 4th, 1966, I got a message saying, "I think we have smallpox. Could you come and look?" We went to the place, 8 miles off of a road, and it was immediately clear that the first person I saw had smallpox. And so we started looking at what did we have in the way of vaccine. Ordinarily, you would have done a mass vaccination campaign around the area.

At the time, the standard procedure was to vaccinate every single person in the region. But there was a problem: there wasn't enough vaccine. Bill was still waiting on a big shipment. Without enough doses to vaccinate everyone, his team had to break protocol and get creative.

We knew what we should do, but we couldn't. So at 7 o'clock that night, with maps in front of me, I divided the area and sent runners to the villages to see if they had smallpox. 24 hours later, we got back on the radio And now I could pinpoint the exact villages where there was smallpox. And we used the rest of our vaccine on those areas. Much to our surprise, smallpox simply stopped in weeks. We just were so fortunate, so lucky, that with our limited vaccine, we were able to hit the right people. And by July, we were working on the last outbreak in all of eastern Nigeria.

The health workers began to wonder, Could this approach also work in other parts of the world? This new vaccine strategy, the innovation that Bill and his team stumbled upon out of necessity, came to be known as search and containment. That meant first searching for anyone with an active case of smallpox, then isolating the infected person, and finally tracking down and vaccinating everyone that person had come into contact with. It worked in West Africa. Could it work in South Asia? Getting locals there to adopt search and containment was going to take an ally, a leader with a big personality who knew the ins and outs of public health in India. Someone who could make things happen. Someone whose story you've probably never heard.

Things look very rosy and very nice in a textbook. You never get the feel of what actually happened, how much sweat it entailed, what blood it entailed.

I'm Dr. Saleen Gounder, and this is Epidemic. By 1973, countries from Nigeria to Brazil to Indonesia had recorded their final cases of smallpox. But in India, the campaign to end the disease was still grinding along. The population was roughly 600 million people, and the goal to vaccinate every single person in the country was daunting. Epidemiologist Bill Foege was older now, in his late 30s, and leading the CDC's global program to eradicate smallpox. He turned his attention to Bihar, a state in eastern India. It was the biggest smallpox hotspot in the world. There, Bill found an ally and a good friend in another physician, a man named Mahendra Dutta. Mahendra was in charge of the smallpox eradication program in Bihar.

He had a booming, loud voice.

That's his son, Yogesh Parashar, a pediatrician living in Delhi.

My father was known for his honesty. He would help people. He had that nature.

Mahendra Dutta died a few years ago, and Yogesh was just a boy during the eradication campaign. But his father shared stories from his years in the trenches fighting smallpox. And there was no battle bigger or more life-saving than persuading the vaccinators to change their way of doing things. After a decade of mass vaccination, smallpox raged on. Yogesh says his father could see that the strategy wasn't working quickly enough to stop the virus.

The standard way of doing things is not going to get us anywhere. Being nice, doing the right way is not going to get the disease away.

It was time to try something new, but getting India to adopt search and containment would prove challenging.

People who were trained in the previous school of thought could never believe that smallpox could be got rid of in this strategy.

Luckily, Mahendra could be very persuasive.

My father did all the dirty work. He got enemies also in the process. I'm sure he did, but that is what he did.

Mahendra Dutta was a gifted political strategist who built relationships with magistrates and commissioners throughout his work in public health. He was an insider who moved comfortably through the halls of power in India. Once, over dinner and a glass of whiskey—Shivus Regal, to be specific—a senior official told Mahendra to come to him in the future if he ever needed a favor. Later, when it was time to build support for search and containment, Mahendra knew exactly how to cash in on that promise.

My father gifted him the Shivus Regal. I was regal. Now, do you remember you had told me that if I need any help, I should come to you? And here I am asking for help now. This is how he did it.

You might call it Dada diplomacy. Using charm and his extensive personal network, Mahendra recruited a staff of workers dedicated to the new strategy of search and containment instead of trying to change the minds of people invested in the old ways of doing things.

So practically, a parallel health system was set up. The stakes were high. Any outbreak was an emergency because if you don't move within hours and contain it, you do not know how many contacts will be there, how much it would spread, and your work would increase exponentially.

Instead of waiting for smallpox cases to be reported, the workers headed out into the community to look for them.

At first, we went and we talked to the village headman, the teachers, and some children. And gradually we went from that to actually going house by house in every village.

But some cases were still falling through the cracks.

And so we developed secondary surveillance teams who would go around to the markets with a smallpox identification card.

There were WHO cards which had photographs of cases of smallpox, their face, their body, and so on. So the people would go out and ask the students, ask the people in the market, have you seen such a person with this kind of an illness? This was one way of actively searching.

Everyone was willing to help.

The vehicle driver would also ask. Why would the foreign epidemiologist ask? The vehicle driver will talk in the local language, ke, I'm looking for this. They will tell him, yes, this is here.

And as soon as a case was identified, a team of containment workers would spring into action, isolating the patient, tracking down their recent contacts, and vaccinating anyone they could have transmitted the virus to. By 1974, the scale of the smallpox surveillance operation was gigantic. Over 100 million households across India were visited every single month in the search for active cases. Over 130,000 field workers were mobilized.

At that point, we were having 1,500 new cases of smallpox a day in Bihar.

To manage all these moving pieces, the workers documented their efforts meticulously.

I mean, you can't imagine the millions of forms that we had. We had forms for everything, forms for the containment teams, Forms for the assessors, forms for the watch guards. I often said we've just buried smallpox in forms.

Search and containment was working in Bihar. Mahendra and Bill could finally see a path to eradication. Then they hit a very public stumbling block that threatened to derail their work. In May of 1974, journalists from all over the world flooded into the country to cover a major news event. Here are a few lines from a New York Times article from that time.

India conducted today her first successful test of a powerful nuclear device. The surprise announcement means that India is the 6th nation to have exploded a nuclear device.

The code name for the nuclear bomb test was Operation Smiling Buddha, and with it, the country joined a short list of superpowers All eyes were on India. And those international journalists, on the hunt for interesting things to report, came across another big story: smallpox cases appeared to be exploding.

And then suddenly, the newspaper articles come out saying, here's India working on nuclear weapons and they can't even control smallpox.

In actuality, the new search and containment strategy was just a lot better at uncovering cases of smallpox. But those glaring headlines, accurate or not, put the eradication program in the spotlight. Indian health officials were worried, and they threatened to pull their support for search and containment. The famous Dada diplomacy was about to be put to the test.

The Minister of Health for all of India came to Patna, and Mahendra Datta went to the airport to meet him.

He said, I have to address a meeting and it would be difficult to talk to you separately, so why don't you get into my car?

During the ride, the Minister of Health told Mahendra that he was on his way to a press conference to announce that the smallpox program would switch back to the strategy of mass vaccination. To Mahendra, giving up on search and containment meant giving up on their best shot at eradication.

And that's when Mahendra Dada said, before you do that, you have one more thing to do. And he said, what's that? He said, you have to fire me.

My father tells the minister that if we are going to follow vaccinating everyone, then I think I should give you my resignation.

And the minister was irate. He said, "Do you know who you're talking to?" And he said, "I do, and that's how important this is." Mahendra told him the latest figures.

He explained how the team was finally slowing the virus, that things were coming under control, and the health minister listened.

And within a few minutes, when they had reached the venue, the health minister was addressing the other officials, And he said, "We have a new strategy of search and containment which is very successful, has been tried in a number of countries, and we will bring forth this strategy and get rid of the disease." All he did was praise the smallpox workers for what they had done, never said a word about switching back to mass vaccination.

That's how close we came, I think, to losing the program in India. And of course, if we lost it in India, we lost it every place.

If India, with its population of over 600 million people, failed to stop smallpox, then the virus would have remained a threat to the entire world.

My father has done the dirty job of saying what is to be said and got away with it. He diplomatically bought time, allowed the search and containment to go on and get smallpox zero.

While some of his American collaborators have been celebrated around the world for their work to end smallpox, Mahendra Dutta's story and his contributions aren't well known outside of India. But we managed to find this recording of his voice.

In public health, community approach Your conviction, your devotion, and team effort. That's what matters the most.

That's Mahendra Dutta in 2008, when he was in his late 70s. He and Bill Foege sat down to reminisce about the history of smallpox eradication as part of a CDC event. The two old friends reflected on what they'd learned together.

I think that's the lesson of smallpox in India. That the team worked as a unit. It was a coalition in truth.

Devoted efforts, team efforts always mattered in community health work.

Search and containment was one of the public health innovations that made eradication possible. That and the collaboration among international health workers and local public health leaders. Here, we followed the story of Mahendra Dutta, but there were many names, thousands, working together toward a common goal. I have a friend who thinks about that a lot. Madhukar Pai is a community medicine physician, an epidemiologist, and he teaches global health. His big thing is he wants rich countries to stop trying to use their own lens to solve health problems around the world. He says that just doesn't work. He's calling for a radical shift, but it is hard to give up on power and privilege, right?

No powerful person ever wants to give it up.

More from Madhu after the break. Wiping out smallpox nearly 50 years ago required the skill of thousands of local people who are largely unrecognized in any history book or podcast. Putting locals in the driver's seat is one part of a growing movement to decolonize public health. That term might sound wonky, but Madhu Karpai, a professor of epidemiology and global health at McGill University, says decolonizing public health is exactly what's needed to get to health equity around the world. But Madhu is frankly pretty pessimistic about the current system.

I sometimes wonder how the hell we did eradicate smallpox. I mean, today I don't think we would have, honestly. If there was a virus like smallpox today, there's zero chance of eradicating it.

So what was it about smallpox eradication that allowed us to do it?

I think those were simpler days, right? And when WHO said, you know what, let's just get all together and just help end this disease. That collaboration was unprecedented in smallpox, but I think it was in the end remarkable numbers of people, you know, essentially armies of community health workers, vaccinators, frontline staff, field workers. I mean, that was a mobilization kind of an effort that I think we definitely tried to do during COVID but probably not as unified as we could have been.

We did try to do something like that. It was called COVAX. It was an alphabet soup of international groups from GAVI to the WHO that wanted to pool buying power and scientific resources. COVAX was an attempt to make sure that there was COVID vaccine for the whole world. So why did COVAX fail?

First of all, I think COVAX was conceived by Global North white people, and it was conceived with all good intent, but essentially The Global South was left behind even in the design of COVAX. Now that in essence is global health, right? That is privileged people in the Global North are constantly making decisions thinking that we know best.

In case our audience isn't familiar with that term, when Madhu says Global North, that's a shorthand for talking about wealthy industrialized nations.

Relying on the Global North time and time and time again is doomed as an idea because we've seen there is no end to our greed and myopia and self-centeredness.

What would that have looked like, centering international efforts to provide vaccines to low-income countries?

To me, centering on them rather than us and saying, what do you need from us to succeed in your plan, right? How can we be allies to you? You need to get behind that and respect the desires and the aspirations of Global South countries. If there is a new pandemic and there's a new vaccine or medicine, that technology should be transferred very quickly. That's what allyship genuinely is about, and that's what our country should have done. We could have been allies as countries, right? We should have given the vaccine recipe. We should have helped out way better with the vaccine donation. The opportunity of a lifetime to be good allies, but we left it on the table.

If you had to give a grade to our global health response to COVID, what would it be and why?

I would probably give it a D because I think as humankind, we genuinely failed. There's no reason at all so many people people should have died. That's inexcusable. The fact that 2.3 billion people, mostly in low-income countries, middle-income countries, have not received even one dose is a very telling statement on how this all unfolded. That's political failure. It's got nothing to do with science, technology, or availability or money.

So let's say another pandemic hits us tomorrow. How is that going to play out then?

Exactly like it played out in COVID. I do not expect anything different, honestly, which is bloody sad, really.

You said before that the big global health programs have good intentions. So what should they be doing differently?

Global health, as you know, is full of these examples where the Global North person always gets the, you know, the shining credit and the medal on the wall. We need to kind of flip the switch and recenter global health away from this what I call default settings in global health to the frontlines, right? People on the ground, people who are Black, Indigenous, people who are in communities, people who are actually dealing with the disease burden, people who are dying off it, right? People who have actually lived experience of these diseases that we are talking about, right? Having them run it is the most radical way of reimagining and shifting power in global health.

As Madhu and I were talking, he reminded me about Bill Feaghy. He's the American eradication worker from Iowa we already met in this episode, the one who worked closely with local partners like Mahendra Dutta. But near the end, he stepped out of the spotlight. I asked Bill about this. You left India before smallpox was declared eradicated. And as I understand it, that was important to you to no longer be in the country at the time. Why is that?

I had the feeling that it should be an Indian victory, that foreigners should be happy and pleased that they had a chance to be part of it, but don't get carried away with being celebrated.

People like Feige are the exception in global health and not the norm. Finding ways to completely disappear and then center on people who really matter, I think, is a great gift. The ability to do Dr. Fagin's ego suppression work or allyship work, that's where the next frontier lies. And I'm not sure if we are ready for it, right? Because it is hard to give up on power and privilege, right? No powerful person ever wants to give it up.

So if you had a call to arms to your colleagues about preparing for the next pandemic, what would you say?

Anything that is led by Global South, anything that is led by communities must be on top of the agenda because that is how this is all going to work. So I don't think climate change or conflicts or COVID will be magically solved by Global North institutions or individuals. So decenter, decenter, decenter away from us and be good allies to the Global South. Everybody's agreed that we got to do better, you know, we've got to decolonize global health, but it isn't meaningfully moving the needle in the right direction because when rubber hits the road, our allyship only goes so far as just talking about it, which is not allyship at all in the first place.

Next time on Epidemic. We have to achieve zero pox. So it was our motto, zero pox. Eradicating Smallpox, our latest season of Epidemic, is a co-production of KFF Health News and Just Human Productions. Additional support provided by the Sloan Foundation. This episode was produced by Taylor Cook, Zach Dyer, Jenny Gold and Me. Our translator and local reporting partner in India was Swagata Yadavar. Tonya English is our managing editor. Una Tempest is our graphics and photo editor. The show was engineered by Justin Garrish. We had extra support from Vicki Merrick. Music in this episode is from the Blue Dot Sessions and Soundstripe. Audio of Mahendra Dutta via the Global Health Chronicles recorded at the David J. Stensor CDC Museum at the US Centers for Disease Control and Prevention. We're powered and distributed by Simplecast. If you enjoyed the show, please tell a friend and leave us a review on Apple Podcasts. It helps more people find the show. Follow KFF Health News on Twitter, Instagram, and TikTok, and find me on Twitter @CelineGounder. On our socials, there's more about the ideas we're exploring on the podcasts and Subscribe to our newsletters at kffhealthnews.org so you'll never miss what's new and important in American healthcare, health policy, and public health news. I'm Dr. Celine Gounder. Thanks for listening to Epidemic.

It was great to work with you then, and it's great to hear you reminisce now.

I'm also pleased that I'd work with you.