S2E4 / Speedboat Epidemiology

In the early 1970s, smallpox was still stalking parts of South Asia. India had launched its eradication program more than a decade before, but public health workers couldn't keep up with the virus. Enter the bifurcated needle.

It was a marvelous invention in its simplicity. It looks like a little cocktail fork.

You dip the prongs into a bit of vaccine.

And you would just prick the skin about 12 or 15 times and until there was a, A little trace of blood, and then you'd take another one.

It barely took 30 seconds to vaccinate someone. And it didn't hurt.

No.

Well, it didn't hurt too much.

It was just like a pinprick rapidly done on your forearm. You had a huge supply with you, and you just went about and dug, dug, dug, vaccinated people. Carry hundreds with you at one go.

And you can train somebody in a matter of minutes to do it.

Easy to use, easy to clean, and a big improvement over the twisting teeth of the vaccine instrument health workers had to use before. The bifurcated needle was maybe 2.5, 3 inches long, small but sturdy enough for rough-and-tumble fieldwork.

It was made of steel, and it used to come in something that looked like a brick. It was just like one of those gold bricks that you see in the movies.

And may be worth its weight in gold. That cocktail fork was among the pioneering innovations that helped public health workers wipe out a centuries-old virus.

You had the bifurcated needle, you had the sterile water, and you had the freeze-dried vaccine, and you could mix them up and off you'd go.

Ah, but getting there wasn't always that easy. I'm Dr. Celine Gounder, and this is Epidemic. On this episode, we're exploring what it took to deliver the smallpox vaccine to the people and all the remaining places that needed it most. In South Asia, Bangladesh was a major battleground in the campaign to stop smallpox. We spoke with a man who helped lead an eradication team there.

My name is Md.

Shajul Haque Khan. For our interview, Shajul Haque Khan invited me to his home in Barisal. That's in south-central Bangladesh. We sat at a table in the courtyard, and his granddaughter, Kashfiya, who looked like she was around 10 years old, stood close by. Kashpia, so nice to meet you. Kashpia, I'm Celine. Hello. Hello. Are you gonna listen to us? Kashpia wanted to hear her granddad's stories, and I got the impression that was also important to Shahdul. As the two of us did our best to communicate through a translator, with neighbors, chickens, and street noise all around, Shahdul wanted me to understand why he was with me and the significance of the smallpox campaign.

The purpose of saying these things is that we needed all this effort. We put a lot of hard work and effort behind smallpox eradication.

Very hard work. You must be very proud of what you helped accomplish.

Yes, of course. Of course, I can say that we are proud to say that we've eliminated smallpox from this country.

The job was to hunt down smallpox and stop it. In a country packed with people, crisscrossed by rivers, edged with mangrove forests, and dotted with remote lowland river islands. And then there were the monsoons. It rained a lot.

Uh, well, we got wet, to state the obvious.

That's Tim Minor. He was an officer with the World Health Organization in Bangladesh.

My legal name is Howard Minor, but I was the third Howard, so I got nicknamed Tim.

Shahdoul and Tim worked together for several months in 1974. The public health strategy was called search and containment, and a big part of that meant figuring out how to get the vaccine from one community to the next.

And occasionally you have to park your motorcycle, take your shoes and socks off, and walk across a leech-infested paddy field to get to the next case.

The work depended on local knowledge, and Shahdul was the local knowledge. He was the lead Bangladeshi member on the eradication team. And when they arrived at a village that had a suspected case of smallpox, often Shahdul went in first, with Tim a few steps behind.

Someone would bring out some chairs, and sometimes we would have tea and biscuits. Or if they didn't have tea and biscuits, then somebody would climb up and get a coconut and chop off the top. Watch me drink it and dribble the coconut milk all over myself, and everybody had a good time.

Dr.

Minor called me little brother. I was younger then. How old was I? 21 or 22 years old?

He referred to me as Dr. Minor even though I'm not a physician. That's how he referred to me.

Shahdul had been working in public health before he joined the smallpox effort. He offered guidance on culture and occasionally gave Tim a hand on rickety bamboo bridges.

Most of the time I escorted him across the bamboo bridge. I took his bag and held his hand and helped him across.

You learn to walk and not look down and just, you know, hang on to the poles. And fortunately, I never fell in.

We didn't let him fall.

The team was based on a hospital ship called the Niramoy. It had all the basics: a couple of cabins, a space to perform surgery, plus a few comforts like a generator they'd turn on in the morning for showers, a cook who picked up fresh fish at the market every day.

I would have a duta chai, a tea with milk, and kachemurich piaz is scrambled eggs with chilies.

The hospital ship hauled supplies from port to port, and everywhere they went, they towed a speedboat along with them.

We would receive reports of cases, and we would get down from the ship in our speedboat, and the speedboat driver would take us as far as the boat could go, and we would walk, do the investigation, and find out who the contacts were and vaccinate the village and surrounding areas.

Tim calls it speedboat epidemiology. The work required a willingness to go wherever and everywhere the virus took up residence. By and large, people welcomed them and were glad to get the vaccine.

They know about smallpox. They've been dealing with it in all of their lives, and they have lost family members to the disease.

Still, the task was huge. To find and vaccinate every person with smallpox and all the people that person had come in contact with. In modern-day public health, the work gets done with cell phones and spreadsheets, maybe social media. In Bangladesh in 1974, they had none of that. Shadul and Tim had the speedboat, motorbikes, and their feet to cover a territory that took them all the way down to the coast.

First there's Barishal.

Lata Sabli.

Then there's Faridpur.

Dhonkupara.

Then there's Patuakhali.

Evankua Gata.

People were constantly on the move, maybe for seasonal work or better opportunities. That made contact tracing tricky. During one investigation, Tim identified a man who'd been exposed to the virus, but he'd left the region for Dhaka. The capital was densely populated. A city of 2 million in 1974. And smallpox was highly contagious. So Tim called a colleague on the shortwave radio to see if he could track down the man in Dhaka.

Well, it's not just a street address or a zip code or anything like that, as you can well imagine. He lived in a busti or a slum, and I described it as best I could. You know, you enter by the big tree and turn left at the tea stall and walk the path and then start calling out for the family name.

They found the guy and vaccinated him. Tim says the man had smallpox, but the virus hadn't quite erupted yet, so it was a pretty mild case.

Because of his immunization, it's somewhat miraculous, the needle in the haystack.

In Bangladesh, people weren't likely to just show up at a local clinic to get the vaccine, so the team took the vaccine to the people. At its best, public health follows and bends to the rhythm of the culture. For example, after Ramadan, as Muslims began to break the fast for Eid—

where people go back to their villages and visit and bring presents and gifts and food—

the team went to ports where steamer ships departed, asking in Bengali if travelers had come into contact with anyone with the disease's distinctive pustules.

Gudi bishonto, bishonto roogi.

Which means smallpox patient.

Have you seen any? Gudi bishonto, bishonto roogi.

Tim says he relied on his team to figure out how best to make the person in front of them comfortable.

What would you do? What do you think should be done in this case? And I don't think this is done often enough. It was a real partnership. It was real working together.

Well, a partnership, yes, but Shahdol Haqq Khan says the search and containment program was pretty strict. His work was meticulously checked and checked again. Remember, he was maybe 21 or 22 years old with a big responsibility on his shoulders, and Tim Minor was a tough boss.

At any cost, we had to vaccinate all. There was no other way.

Sometimes Shahjul had to return to the same home over and over, or hang out if the man of the house was still in the fields working.

We had to wait until they returned. Otherwise, Dr. Minor would again take us back there, no matter how late.

One evening, Shaddul returned to the hospital ship after a day of door-to-door canvassing and had to give a not-so-great report to Tim.

I couldn't vaccinate a pregnant woman in Dankupara. This was the first time that I couldn't vaccinate someone. I couldn't convince her at all. He immediately told us to pack up. He stopped the work and said, "Let's go." Immediately, at that very moment, We were working basically 24/7 if need be.

The team headed to the speedboat. It was late and it was freezing. Shaddoll remembers the bite of the cold air as they blasted across the water toward the woman's village.

I fully understood why this woman hesitated to be vaccinated. She was expecting a child and she didn't want to do anything to jeopardize her life or the life of the unborn child. So We were very gentle in talking with her and answering her questions. It was time well spent.

The woman agreed to take the vaccine.

That day was one of the most memorable of my life.

Many on the team considered their outreach to women fundamental to success in South Asia because women talk. What they say, what they believe, echoes.

They get together, they do the laundry, they do the cooking, they share good times and bad times. This woman who was vaccinated probably showed her vaccination and either in her family or in the village. And that's the importance of getting one person, especially a pregnant woman, who will tell others. About immunization.

Public health workers trying to end smallpox across South Asia mostly had the same tools: the vaccine, that bifurcated needle, and a strategy—on paper. But squashing the virus required tactics specific to each community, its needs, its culture, its worries, and its terrain. Smallpox eradication workers went to great lengths to to meet people where they were. But Joe Osmundson, who's a public health advocate in New York City, told me that's not an approach we see nearly enough in public health today.

Celine, it's not your first time at the rodeo. It's like we've all been through this again and again and again. We know what the problems are, and yet we seem reluctant to actually do the right thing, which is to build processes that meet people where they're at.

After the break, more on what it looks like to bring public health directly to those who need it most. Mpox, formerly known as monkeypox, is a highly contagious virus. Last summer, Mpox cases spiked around the world, spreading quickly, predominantly among men who have sex with men. Mpox spreads through physical contact. It causes a painful blistering rash and, in extreme cases, it can be deadly. My colleague Joe Osmundson acted as a community liaison for the New York City Department of Health to help coordinate a culturally appropriate response to mpox.

I'm a microbiologist by training, but I also just do tons of advocacy and activism as a queer person who believes in equal access to the best biomedicine available.

As mpox cases were increasing, we knew we needed to vaccinate those at highest risk as quickly as possible. Joe's plan: mobile vans to quickly bring Mpox vaccines to places where high-risk people already were.

Our idea was to go to commercial sex venues because commercial sex venues self-select for people with a large number of sexual partners. And if you give them the best possible immunity, that protects not just the people at the party, but all the other people in the larger sexual network that they connect with.

What is a commercial sex venue?

It's basically a non-household space where people gather for sex. So when you have public venues where people gather, you have the opportunity to meet them where they're at, to provide education, to provide condoms, to provide access to HIV testing and access to healthcare. So many queer people don't have affirming doctors, don't feel comfortable asking about sexual health with their physicians. So you can put a van outside with affirming physicians and actually provide that preventative care that actually stops the infection.

Did you run into any obstacles in doing this outreach, setting up the mobile vans?

So there is a huge amount of mistrust in this community, uh, for city officials, for good reason. For many decades, there was a group inside the New York City Department of Health that had undercover people who would go to these parties and find violations and close them down. So really it was only me and a couple other people doing outreach on site.

How did it work? What was the scene like and what was your role in that? Yeah.

So when I was there, I would go inside the club and, you know, there's a little line area where people get dressed or undressed and I would just hang out there and people would have a lot of questions. So because again, they perceived me as being like a part of their community, it was very easy to talk to people and just ask, you know, hey, have you had your vaccine yet? Have you had both doses? If not, you know, it'll take 15 minutes. I can walk you down to the van and get you that dose tonight.

Were these mobile vaccination vans successful?

We find them to be massively successful. Once the city was able to get the vans there, people were so grateful to be able to get a shot on site. We were giving 60, 80 doses per event when the event might only have 140 people. So we were vaccinating 60% of these parties. That's the other magic of the mobile units was that you had queer people talking to queer people. And even queer people of color talking to queer people of color and offering the care in terms that that community knows how to respond to and also just has more inherent trust with.

But at the same time, in New York City, mpox vaccination rates have been disproportionately low in Black communities as well as Hispanic communities. What could public health leaders have done from the start to ensure more equitable vaccine distribution, and what should they be doing now?

Yeah, it was a remarkable sort of mistake that not just New York, but many cities made where they said, we'll build the foundation and then worry about equity later because this is an emergency. So we'll open up a brick-and-mortar in Chelsea, and then we'll get the vaccine vans up at, you know, Brooklyn Pride, a Bronx health clinic. You know, we'll do that later. We know that if you don't do equity as the foundation, you will be chasing disparities.

What can we say about who's been vaccinated and who remains unvaccinated?

Black people are under-vaccinated. They also have a higher rate of advanced HIV infection, and mpox plus advanced HIV means really severe disease and even death. 90% of mpox deaths have been in Black people, Black queer people with advanced HIV. And we need something brand new because we've been failing these folks for years. They have so many horrific experiences with their healthcare providers. Or they don't have insurance or they're underemployed or they live super far from the nearest healthcare clinic. When people have difficulties accessing care, it spreads to every disease state from HIV to mpox to primary care, et cetera.

How can we apply this model of health outreach beyond mpox?

The model that we're trying to build is a mobile unit that delivers all sorts of sexual and primary healthcare opportunities. They're opportunities, you know, if someone's getting a COVID vaccine, give them the flu vaccine at the same time. The literature shows that these interventions work.

What else is there beyond vans? Are there other strategies when it comes to reaching people where there are that we haven't employed that we should be thinking about?

We have affirming clinicians, affirming Black queer clinicians all over this city. Their expertise should be fostered. For years, there's been this model of health officials talk to community, and that's outreach. And we're done with that. We have experts, we have clinicians, we have epidemiologists, we have scientists who are in the community, who know the science just as well as health officials, and communication needs to go two ways.

That was Joe Osmundson, a microbiologist at New York University and the author of the book Virology.

The sexiest public health outreach worker of all time. A face made for radio.

Next time on Epidemic: Your company is sending death all over the You're the greatest exporter of smallpox in history.

You've got to stop this. 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, and me. Redwan Ahmed was our translator and local reporting partner in Bangladesh. Managing Editor Tanya English was scriptwriter for the episode, with help from Stephanie O'Neill. Una Tempest is our graphics and photo editor. The show was engineered by Justin Garrish. Voice acting by Pinaki Kaur. We had extra editing help from Simone Poprel.

Music in this episode is from The Blue Dot Sessions and Soundstripe.

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.