S2E5 / The Tata Way

To help us tell the next chapter of the smallpox eradication history, we went to someone who's lived a lot of lives: a civil rights activist, a Deadhead, a disciple of guru Neem Karoli Baba, a tech entrepreneur, and an epidemiologist.

Hi, I'm Larry Brilliant, and I had the great honor of working on the WHO smallpox eradication program.

Larry was looking for his place in the world as a young man. It took him all over the United States and beyond.

Hoping that I would find something that was better than capitalism, that helped the poorest and most vulnerable communities.

That calling eventually led him to India and the campaign to end smallpox.

In those days, the world really wanted a victory in global health. So we wanted, as a world, to eradicate smallpox.

At one point, when government reports suggested that smallpox was getting worse, not better, a young Larry still believed his team could beat the disease. Many said that version of him from 50 years ago was perhaps brilliant, but also impatient and a bit brash. So when one honcho at the World Health Organization headquarters in Geneva said he would eat a truck tire if they ever managed to get rid of smallpox, Larry and his boss, a Swiss-French epidemiologist named Nicole Grasset, took the bet. A few years later, after the WHO declared victory over smallpox in 1980, Nicole and Larry mailed the skeptic a tire all the way from India with a little note saying, "As agreed, here is the Land Rover tire.

Please inform us the bouquet and the texture, and should you need ketchup or mustard or any other condiments, we would be happy to add them to this." What happened to the tire? We never know. He never responded.

Larry's laughing now, but there were lots of dark days before that win. 1974 was a particularly tough year for the eradication program, and Larry was about to find himself in the middle of one of the worst smallpox outbreaks anyone could remember. To stop it, he would have to become a detective and follow the clues to the source of the surge. And once he solved that mystery, he'd need to stand up to one of the most powerful companies in India. I'm Dr. Celine Gounder, and this is Epidemic. The year started off well. The new search and containment strategy was working. It was working so well that Larry and his team were convinced they had eliminated smallpox in their area. The reports from 3 statewide searches had come back. Not a single case had been found. Soon, they'd be ready to declare the region free of smallpox.

And we did one more search, and we found 15 villages that were infected with smallpox.

That last search was supposed to be a victory lap, Now the race had started all over again. Larry dispatched teams to find out where the cases were coming from.

No one had any idea what it was.

Then finally, a break.

We went into a little village and we were able to find that the first case was a young man in his 20s, and he had gone someplace for work and came back with smallpox.

Larry asked the rest of the team if they had found anything similar.

All of them came back yes.

They found a pattern, a clue. All the cases originated with a young person who had been away from home looking for work. But where had they gone? If Larry's team was going to stop the outbreak, they had to figure out where the workers got infected. When the first clue surfaced, Larry was with another smallpox campaigner, a local partner, Zafar Hussain.

Who knew more about smallpox than I did. He knew more about smallpox than anybody.

Larry and Zuffer were running out of options. So Zuffer tried one last thing.

When they were preparing this boy's body for cremation, Zuffer asked in the humblest way for permission to go through his pockets. And he did. And he found in the boy's pockets a railway ticket. From the Tatanagar railway station.

Tatanagar. They had found the source of the outbreak.

Your attention please.

Train number 13302, Tatanagar-Dhanbad Sonialekha Express, is on platform number 1. In the summer of 2022, I followed Larry's journey to Tatanagar. The city, also known as Jamshedpur, is in the eastern end of India. The train station is a knot of railroad tracks. The platforms are full of vendors selling food. You have to dodge bales of cargo on the way to the train. Chhatinagar's name comes from the family and the company that dominates the area: Tata.

It was known as the Pittsburgh of India.

Steel, iron, locomotives. Tata was a household name. It still is. The conglomerate's dozens of businesses span heavy industry and telecommunications to aerospace. Ever ride in a Land Rover? Tata. A Jaguar? Tata. Fly Air India? That's part of the Tata Group too. In the '70s, people looking for work in Tata factories took trains to Tatanagar. Thousands and thousands of people passed through the train station every day. For many, the city was a vision of India's future.

So when you thought of Tatanaga, we thought of Tatas in those days, you thought of wealth, power, modernity, cleanliness, all of those things.

But the scene Larry and Zephyr saw when they arrived was very different. They found a station boiling with smallpox. Bodies wrapped in cloth were stacked like cords of wood, some small enough to be children. As the crowd swirled around Larry, an older man about to buy a train ticket caught his eye.

He had given the couple of rupees and he had just gotten the ticket, and his hand was filled with pockmarks. And you could just imagine that that man's about to get on a train and go back home to die in his home village, and that will be another outbreak that will be started.

Larry was overwhelmed.

You could understand that The feeling of powerlessness, anger, anger at the Tatas for letting this happen, anger at God. I said to Zuffer, you know, what do we do? And he said, we've got to find the head of the Tatas.

At the time, that meant Rucy Modi, who was the managing director of Tata Steel. Larry and Zuffer got the address of a home in a suburb outside the city. As they drove in the dark, Larry was thinking about the person he was about to confront.

So I had a terrible fear that the Tatas would turn a deaf ear or already knew about it.

Tatanagar was basically a company town. Tata ran the city. It was in charge of lots of things that governments would otherwise do.

And I had this image of a company that just didn't care.

It was nearly midnight by the time they arrived at the home of the Tata Steel executive.

And I, I ran up to the front door with Sufford pulling me back, don't go, don't go. And I pounded on the door and the door opened.

An attendant answered the door. He was not impressed with Larry's WHO credentials.

The attendant tried to turn them away and I kind of pushed my way in and One of these huge Tibetan Mastiff dogs that they had grabbed my hand and wouldn't let me go.

By now, the ruckus was too much to ignore. The company managing director, Rucy Modi, came to the door.

So who the hell are you? What are you doing here at my house at midnight? And while this dog still had my arm in his mouth, I told Rucy, I said, you know, your company is sending death all over the world. You're the greatest exporter of smallpox in history.

That got Ruci's attention. He ordered his dog to let go of Larry's hand.

And he'd been trained not to bite off the hand, thank God.

Ruci invited Larry and Zephyr in. When they all sat down together at the dinner table, Larry explained the situation: mysterious smallpox cases popping up all over India, the train ticket in the man's pocket that led them to Tatanagar, the chaos they found at the train station. Rusi said he had no idea what had been going on, but Larry had his doubts.

It seems improbable that the head of the, the Tatas wouldn't know about it, but I actually think they did not know about it. It wasn't that they were willfully ignorant, they just didn't know about it, that that reporting relationship didn't exist.

Rusi asked what could be done. Larry made up a number, something close to asking for half a million dollars, he estimates. It would cover 4x4 trucks, equipment, and personnel to contain the outbreak. But as influential as Rucimodi was, this was a big ask.

So he called up Bombay and spoke to Mr. Tata, JRD Tata.

[NOISE] Jahangir Ratanji Dadavoy Tata, or JRD, was the Tata in Tata Industries.

He was probably a combination of Steve Jobs and, I don't know, the CEO of GM when GM was a big deal.

JRD ran his business empire according to how he interpreted the values set out by its founder, Jamsetji Tata. His speeches and public statements suggest that Jamsetji believed that his company should serve a higher purpose. The well-being of the community and the nation was supposed to be a driving force behind the company. Not just profits. That approach to business was called the Tata Way. But Larry wondered, would this tycoon really help? Larry and Rucie explained what was needed, and JRD said yes.

And by 2 o'clock that afternoon, I had 200 Jeeps and all the different Tata companies, Tata Iron and Steel, Tata Locomotive, all their CEOs, And most of their executives showed up at this one site that became the smallpox office.

Larry took that yes he got from Tata and ran with it.

I decided without talking to anybody— again, youthful enthusiasm— I had decided that what I was going to do is to quarantine the city.

This was no small undertaking. More than 600,000 people were living in the area. That's like trying to quarantine Washington, D.C. The trains stopped running. The buses stopped running. The only ticket in or out was proof you'd been vaccinated: a smallpox vaccination scar.

And bear in mind, I hadn't asked permission to do this, which is, you know, clearly a failing on my part. But it was an emergency.

Not everyone thought it was an emergency. Larry's decision was controversial. When a member of Parliament got caught up in the quarantine and was forced to get vaccinated, there was a big uproar. People accused the WHO of overstepping its authority. Friends of Larry's in the Indian government told him the pushback almost got him deported and maybe even risked getting the entire WHO program kicked out of the country. But Larry had made powerful friends in India's health system and with the Tatas.

The Tatas, at every stage of that, lobbied for me to be able to stay.

Tata leaders helped keep Larry out of trouble, and they made sure their own factories followed his rules too.

They literally closed down the assembly lines for locomotives, and they stopped making iron and steel. They stopped the coal mine, and all of their workers came to work on this for almost 6 months.

Local government, businesses, and community groups all stepped up, Even a flying club offered to drop leaflets from the air so people would know how to identify and report any smallpox cases. Two months later, the smallpox outbreak was contained.

I'd never seen anything work that well. None of us had. There's no question that they put public health ahead of profits because they closed down and diverted all their managers to helping smallpox be eradicated. Now, you could argue that they would have lost more had they gotten branded with the reintroduction of smallpox through the world. You could argue that it was enlightened self-interest. But it seemed to me much more than that.

The Tata way, perhaps. Working with the Tatas made a big impression on Larry.

Watching the way you could combine public health with its moral compass, with the resources and management skills of the Tatas, that was quite something. And the Tatas were the first I'd ever seen like that. And as a young person still formulating my own worldview, it changed me, of course, forever.

JRD Tata's support of the smallpox eradication campaign came at a critical time. But smallpox wasn't the only public health campaign the tycoon backed. He also used his power and money to further population control in India.

As the standard of living of the people increases and they want their children educated, etc., it'll be here, it'll happen here, but too late.

That's a clip of JRD on the Indian television program Conversations in 1987. Talking about the need to curb India's birth rate.

And therefore, one must find some ways of accelerating the process.

JRD used his business to make that vision a reality. In the 1970s, the Indian government was offering its citizens cash payments if they would get sterilized as part of its population control efforts. JRD doubled it for his employees and their spouses. From 1975 to 1976, Tata Steel claimed to have carried out 20,000 sterilizations. That's troubling for me as a public health professional. Offers of cash in a very poor country can be coercive. And it makes the legacy of the Tata Way complicated. The company's far-reaching influence and philanthropy also created the university where my own father studied, an opportunity that gave him a career in the United States. And ultimately shaped my life and career. The resources of private enterprise, they can be marshaled for good and bad alike. We saw that at the beginning of the COVID pandemic. Businesses weren't always on the same side as public health, but they can be powerful allies.

The partnerships are critically important with public health officials, with research institutions, and at the same time, the sort of magic of free enterprise can be extraordinarily helpful.

When we come back, we'll speak with NBA Commissioner Adam Silver and virologist David Ho about the basketball league's response to COVID and its investment in public health. That's after the break.

Hey there.

An Arm and a Leg is a show about why healthcare costs so freaking much and what we can maybe do about it. I'm Dan Weissmann. I'm a reporter and I like a challenge. So my job on this show is to take one of the most enraging, terrifying, depressing parts of American life and bring you a show that's entertaining, empowering, and useful.

Where there is money, there'll be scams.

I'm not gonna lie, we can't win them all. But it turns out we don't have to lose them all either.

I was so determined, like, I was not going to go through all of this for nothing.

You have to be willing to tell people in authority sometimes that you believe they're wrong.

I'm not scared of these fools. That's when The politicians really started getting involved and they passed the law.

It's like reading the postscript in a Dickens novel almost. Be like, oh yeah, hey look, now we can't chain children to factory machines. Like, what?

Wait, what?

That was legal before?

You can catch An Arm and a Leg at armandalegshow.com or wherever you get podcasts.

On March 11, 2020, two basketball teams were getting ready to start a game in Oklahoma City. The arena was packed. Players from the Utah Jazz and the Oklahoma City Thunder were warmed up, and nothing seemed out of the ordinary. But then the coaches and the referees had a meeting, and everyone on the court walked back to their locker rooms. ESPN and NPR captured what happened next.

The fans here in the arena don't know what's going on.

We don't know what's going on. And so as soon as we get any kind of information, We will certainly pass it along. The NBA has suspended its entire season. That decision came last night after a player with the Utah Jazz tested positive for COVID-19. I don't think I'm alone in saying that was the moment a lot of people realized that the COVID pandemic was real and would upend our lives. For NBA Commissioner Adam Silver, the challenge also presented an opportunity for the league to form business partnerships and model a path forward. To learn more, I called up Silver and Dr. David Ho, a professor of medicine at Columbia University who's advised the NBA on health issues since the 1990s when he served as the doctor for NBA superstar Magic Johnson when Johnson was diagnosed with HIV. David, thinking back to early 2020, how were you assisting Adam and the rest of the NBA in terms of research and in terms of their decision-making?

Adam and the league put together a team, and there were numerous discussions prior to the first case. And so there was a sort of an anticipation that the virus would get to the U.S. and, you know, hit everyone at some point. And remember, by the third week of January, China already locked down. Wuhan City. So that really taught us how severe this outbreak might be.

The shutdown could not have come at a worse time for the NBA. The regular season was winding down, and they were about to begin the playoffs to crown an NBA champion. Those playoffs generate a lot of money. But then in the summer of 2020, the NBA came out with a bold idea to restart their season at Disney World. It's been called the bubble. Adam, from your perspective, how would you explain to maybe another CEO of a company how you set up the bubble and what this was?

It was a partnership with Disney. We were fortunate that they had available this physical campus, several hundred acres as part of Disney World that was otherwise completely shut down because of the pandemic. So they had the hotel rooms, they had existing courts, they had facilities for training. I mean, a lot of it we needed to modify and bring in significant other equipment, but the, the fundamentals were there already. And at, at the peak of the so-called bubble, we had about 1,500 people there that included, um, players, coaches, team and league personnel.

Now, leading up to the return to play, the NBA and the Players Association helped finance a saliva-based COVID test with Yale, which would later be called SalivaDirect. And they got emergency authorization from the FDA for this. NBA players even helped in the trials. Adam, why did the NBA support this initiative?

Frankly, Dr. Gounder, because we were desperate for a, a methodology under which we could return to play. And for me, this was a, a function of the private sector looking for an opportunity to partner with major research institutions. As you said, in this case it was the Yale School of Public Health, but, you know, finding a way where we'd be in position to do rapid testing on a large-scale basis. And certainly there were a lot of nervous people. And there were never any guarantees that we would have zero cases, which we turned out to have down in the bubble. But it seemed like a wise decision at the time.

David, how can some of those innovations that were developed to restart the season be made to reach the broader public?

Yeah, I think the public is aware of the success of the NBA bubble. But it's probably not aware of the fact that NBA published 10 scientific papers because of their COVID response. And for example, with the daily testing after the bubble, the infected individuals were captured and tested every day. So we have a trajectory for the viral load of infected people. That's just one example. And another would be correlates of protection. NBA had at one point drawn blood. And we were able to measure antibodies and then MBA followed everyone and knew which person got infected and which ones did not. And from that you could discern a certain antibody level was protective. These type of contributions are not well known to the public, but it's amazing. It was more successful than many academic groups on the scientific front.

Adam, what would you change about the NBA's response to COVID, if anything?

If we had to do it again, I would have focused a bit more on mental wellness issues around our players living in that environment over long periods of time. We were very restrictive in terms of who could live in the bubble, meaning initially there were no family members permitted. And I think that the impact of the isolation was fairly profound. So we learned as we went that given the importance of the mental health issues for our players and for others in the community, on balance, we were better off allowing more family members in.

In the next public health crisis, how do you think that the private sector should respond and partner in solving?

For a pandemic, we need everyone involved, you know, from government to academia to the private sector. Government alone can't address this, and nor could the medical community alone. So it has to be a partnership.

Next time on Epidemic. There are tales of how villages would empty when rumors would spread that these teams were coming Ostensibly to vaccinate, but maybe really to sterilize. I mean, bodies still remember what was done to them. 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 Zach Dyer, Taylor Cook, Bram Sabel-Smith, and me. Swagata Yadavar was our translator and local reporter. Our reporting partner in India. Our managing editor is Tanya English. Una Tempest is our graphics and photo editor. The show was engineered by Justin Garrish. We had extra editing help from Simone Poprel. Music in this episode is from the Blue Dot Sessions and Soundstripe. News clips from ESPN and NPR were 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 X, formerly known as Twitter, Instagram, and TikTok, and find me on X @CelineGounder. On our socials, there's more about the ideas we're exploring on the podcast, 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.