Epidemic Archives - KFF Health News

A Physician Travels to South Asia Seeking Enduring Lessons From the Eradication of Smallpox

Céline Gounder — Fri, 29 Mar 2024 10:00:00 +0000

Smallpox was certified eradicated in 1980, but I first learned about the disease’s twisty, storied history in 1996 while interning at the World Health Organization. As a college student in the 1990s, I was fascinated by the sheer magnitude of what it took to wipe a human disease from the earth for the first time.

Over the years, I’ve turned to that history over and over, looking for inspiration and direction on how to be more ambitious when confronting public health threats of my day.

In the late 1990s, I had the opportunity to meet some of the health care professionals and other eradication campaign workers who helped stop the disease. I came to see that the history of this remarkable achievement had been told through the eyes mostly of white men from the United States, what was then the Soviet Union, and other parts of Europe.

But I knew that there was more to tell, and I worried that the stories of legions of local public health workers in South Asia could be lost forever. With its dense urban slums, sparse rural villages, complicated geopolitics, corrupt governance in some corners, and punishing terrain, South Asia had been the hardest battlefield the smallpox eradicators had to conquer.

I decided to capture some of that history. That work became a podcast, an eight-episode, limited-series audio documentary, called “Epidemic: Eradicating Smallpox.”

My field reporting began in summer 2022, when I traveled to India and Bangladesh — which had been the site of a grueling battle in the war on the disease. I tracked down aging smallpox workers, some now in their 80s and 90s, who had done the painstaking work of hunting down every last case of smallpox in the region and vaccinating everyone who had been exposed. Many of the smallpox campaign veterans had fallen out of touch with one another. Their friendships had been forged at a time when long-distance calls were expensive and telegrams were still used for urgent messages.

How did they defeat smallpox? And what lessons does that victory hold for us today?

I also documented the stories of people who contracted smallpox and lived. What can we learn from them? The survivors I met are not unlike my father, who grew up in a rural village in southern India where his childhood was shaped by family finances that limited access to opportunity. The stories he shared with me about the big social and economic divides in India fueled my decision to choose a career in public health and to work for equity. As we emerge from the covid pandemic, that connection is a big part of why I wanted to go back in time in search of answers to the challenges we face today.

Unwarranted Optimism

I sought out Indian and Bangladeshi public health workers, as well as the WHO epidemiologists — largely from the U.S. and Europe — who had designed and orchestrated the eradication campaigns across South Asia. Those smallpox leaders of the 1960s and ’70s showed moral imagination: While many doctors and scientists thought it would be impossible to stop a disease that had lasted for millennia, the eradication champions had a wider vision for the world — not just less smallpox or fewer deaths but elimination of the disease completely. They did not limit themselves to obvious or incremental improvements.

Bill Foege, a campaign leader in the 1970s, said by contrast today’s policymakers can be very reluctant to support programs that don’t already have data to back them up. They typically want proof of sustainability before investing in novel programs, he said, but real-world sustainability often only becomes clear when new ideas are put into practice and at scale.

The smallpox eradication visionaries were different from these cautious current leaders. “They had ‘unwarranted optimism,’” Foege said. They had faith that they could make “something happen that could not have been foreseen.”

In India, in particular, many leaders hoped their nation could compete with other superpowers on the world stage. That idealism, in part, stoked their belief that smallpox could be stopped.

During the smallpox program in South Asia, Mahendra Dutta was one the biggest risk-takers — willing to look beyond the pragmatic and politically palatable. He was a physician and public health leader who used his political savvy to help usher in a transformative smallpox vaccination strategy across India.

The eradication campaign had been grinding in India for over a decade. India had invested time and resources — and no small amount of publicity — into a mass vaccination approach. But the virus was still spreading out of control. At a time when India’s leaders were eager to project strength as a superpower and protective of the nation’s image on the world stage, Dutta’s was one of the voices that proclaimed to India’s policymakers that mass vaccination wasn’t working.

Dutta told them it was past time for India to adopt a new, more targeted vaccine strategy called “search and containment.” Teams of eradication workers visited communities across India to track down active cases of smallpox. Whenever they found a case, health workers would isolate the infected person, then vaccinate anyone that individual might have come in contact with.

To smooth the way for the new strategy, Dutta called in favors and even threatened to resign from his job.

He died in 2020, but I spoke with his son Yogesh Parashar, who said Dutta straddled two worlds: the in-the-trenches realities of smallpox eradication — and India’s bureaucracy. “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,” Parashar said.

A Failure to Meet Basic Needs

Smallpox workers understood the need to build trust through partnerships: The WHO’s global smallpox eradication program paired its epidemiologists with Indian and Bangladeshi community health workers, who included laypeople with training and eager and idealistic medical students. Those local smallpox eradication workers were trusted messengers of the public health program. They leveraged the region’s myriad cultures and traditions to pave the way for people to accept the smallpox campaign and overcome vaccine hesitation. While encouraging vaccine acceptance, they embraced cultural practices: using folk songs to spread public health messages, for example, and honoring the way locals used the leaves of the neem tree to alert others to stay away from the home of someone infected with smallpox.

Smallpox eradication in South Asia unfolded against a backdrop of natural disaster, civil war, sectarian violence, and famine — crises that created many pressing needs. By many, many measures, the program was a success. Indeed, smallpox was stopped. Still, in the all-consuming push to end the virus, public health writ large often failed to meet people’s basic needs, such as housing or food.

The smallpox workers I interviewed said they were sometimes confronted by locals who made it clear they had concerns that, even in the midst of a raging epidemic, felt more immediate and important than smallpox.

Eradication worker Shahidul Haq Khan, whom podcast listeners meet in Episode 4, heard that sentiment as he traveled from community to community in southern Bangladesh. People asked him: “There’s no rice in people’s stomachs, so what is a vaccine going to do?” he said.

But the eradication mission largely did not include meeting immediate needs, so often the health workers’ hands were tied.

When a community’s immediate concerns aren’t addressed by public health, it can feel like disregard — and it’s a mistake, one that hurts public health’s reputation and future effectiveness. When public health representatives return to a community years or decades later, the memory of disregard can make it much harder to enlist the cooperation needed to respond to the next public health crises.

Rahima Banu Left Behind

The eradication of smallpox was one of humankind’s greatest triumphs, but many people — even the grandest example of that victory — did not share in the win. That realization hit me hard when I met Rahima Banu. As a toddler, she was the last person in the world known to have contracted a naturally occurring case of variola major smallpox. As a little girl, she and her family had — for a time — unprecedented access to care and attention from public health workers hustling to contain smallpox.

But that attention did not stabilize the family long-term or lift them from poverty.

Banu became a symbol of the eradication effort, but she did not share in the prestige or rewards that came after. Nearly 50 years later, Banu, her husband, their three daughters, and a son share a one-room bamboo-and-corrugated-metal home with a mud floor. Their finances are precarious. The family cannot afford good health care or to send their daughter to college. In recent years when Banu has had health problems or troubles with her eyesight, there have been no public health workers bustling around, ready to help.

“I cannot thread a needle because I cannot see clearly. I cannot examine the lice on my son’s head. I cannot read the Quran well because of my vision,” Banu said in Bengali, speaking through a translator. “No one wants to know how I am living my life with my husband and children, whether I am in a good condition or not, whether I am settled in my life or not.”

Missed Opportunities

I believe some of our public health efforts today are repeating mistakes of the smallpox eradication campaign, failing to meet people’s basic needs and missing opportunities to use the current crisis or epidemic to make sustained improvements in overall health.

The 2022 fight against mpox is one example. The highly contagious virus spiked around the world and spread quickly, predominantly among men who have sex with men. In New York City, for example, in part because some Black and Hispanic people had a historical mistrust for city officials, those groups ended up with lower rates of Mpox vaccination. And that failure to vaccinate became a missed opportunity to provide education and other health care treatments, including access to HIV testing and prevention.

And so has it gone with the covid pandemic, too. Health care providers, the clergy, and leaders from communities of color were enlisted to promote immunization. These trusted messengers were successful in narrowing race-related disparities in vaccination coverage, not only protecting their own but also shielding hospitals from crushing patient loads. Many weren’t paid to do this work. They stepped up despite having good reason to mistrust the health care system. In some ways, government officials upheld their end of the social contract, providing social and economic support to help these communities weather the pandemic.

But now we’re back to business as usual, with financial, housing, food, health care, and caregiving insecurity all on the rise in the U.S. What trust was built with these communities is again eroding. Insecurity, a form of worry over unmet basic needs, robs us of our ability to imagine big and better. Our insecurity about immediate needs like health care and caregiving is corroding trust in government, other institutions, and one another, leaving us less prepared for the next public health crisis.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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What I Learned From the World’s Last Smallpox Patient

Céline Gounder — Wed, 08 Nov 2023 10:00:00 +0000

Rahima Banu, a toddler in rural Bangladesh, was the last person in the world known to contract variola major, the deadly form of smallpox, through natural infection. In October 1975, after World Health Organization epidemiologists learned of her infection, health workers vaccinated those around her, putting an end to variola major transmission around the world. The WHO officially declared smallpox eradicated in 1980, and it remains the only human infectious disease ever to have been eradicated.

Among infectious-disease doctors like me, Banu is famous as a symbol of the power of science and modern medicine.

And yet, beyond that distinction, Banu has largely been forgotten by the public. That fate is a reminder that, well after a global pandemic recedes from headlines in wealthy countries, its survivors have needs that go unmet. Although Banu survived smallpox, she’s been sickly her whole life. She was once bedridden for three months with fevers and vomiting, but she couldn’t afford to see a good doctor. The doctor she could afford, she recalled, prescribed her cooked fish heads. Banu also complains of poor vision: “I cannot thread a needle, because I cannot see clearly,” she told me, via a translator, during an interview in Digholdi, the village where she lives.

“I cannot examine the lice on my son’s head and cannot read the Quran well because of my vision,” she said.

In the years following smallpox eradication, journalists from all over the world traveled to interview Banu, but they petered out years ago. “Mother is so famous, but they do not take any follow-up of Mom to know whether she is in a good or bad state,” her middle daughter, Nazma Begum, told me.

Banu and her family are proud of her place in history, but their role in the eradication of smallpox speaks to the limits of merely fighting diseases. In his biography of the doctor and philanthropist Paul Farmer, author Tracy Kidder recorded a Haitian saying: “Giving people medicine for TB and not giving them food is like washing your hands and drying them in the dirt.”

After Banu and her family survived smallpox, the rest of the world dried its hands in the dirt — just as it did for the poorest victims of covid-19 and later the most marginalized people with mpox, formerly known as monkeypox.

I traveled to South Asia to speak with aging public health workers and smallpox survivors in South Asia for the audio-documentary podcast “Epidemic: Eradicating Smallpox.”

To meet Banu, I flew 14 hours to Delhi and another two hours the next day to Dhaka, then took a five-hour drive to Barishal, followed the next day by a 90-minute ferry ride and a two-hour drive to arrive in Digholdi. Banu and her family — her husband, their three daughters, and their son — share a one-room bamboo-and-corrugated-metal home with a mud floor. The home, which lacks indoor plumbing, is divided down the middle by a screen and a curtain. Water leaks in through the roof, soaking their beds. A bare bulb hangs from a wire overhead. Her in-laws used to live with them, too, but they have passed away.

Women in rural Bangladesh rarely work outside the home. Banu’s husband, Rafiqul Islam, pedals a rickshaw. Some days he earns nothing. On a good day, he might make 500 taka (not quite $5). Although the World Health Organization arranged for a plot of land in her name, Banu said, the family has nowhere to cultivate. “They gave me the land, but the river consumes that. Some of it is in the river,” she said. Cyclones and rising sea levels have led to coastal erosion and saltwater intrusion, and there have also been land disputes.

Begum, now 23, completed a year of college but then dropped out. Banu and her husband couldn’t afford the fees. Instead, they arranged for her to marry. Her mother’s fame “did not help me in any way in my studies or financially,” Begum told me.

The family’s financial life is precarious. Five hundred taka used to buy a 10-kilogram bag of rice and vegetables. During my visit in 2022, the instability of the Russia-Ukraine war created fluctuating oil prices, and Banu said that amount was enough to pay only for the rice.

Banu is well aware that thanks to vaccination, millions of people no longer die of smallpox and other infectious diseases. By one estimate, the eradication of smallpox has prevented at least 5 million deaths around the world each year. Vaccines remain one of the most cost-effective and lifesaving gifts of modern medicine. The Centers for Disease Control and Prevention estimates that the U.S. saves 10 times what it spends on childhood vaccination. But all this is cold comfort to Banu when she and her family are struggling to survive.

Every public health crisis leaves people behind. When I worked as an Ebola aid worker in Guinea in 2015, residents asked why I cared so much about Ebola when local women were hemorrhaging in childbirth and didn’t have enough to eat. They were right not to trust our efforts. Why should they upend their lives to help us defeat Ebola? They knew their lives wouldn’t be materially better when we declared victory and left, as we had done so many times before as soon as our own interests were protected. Their prediction was correct.

As the coronavirus pandemic winds down in the United States, Banu’s life is a reminder that illness has a long tail of consequences and doesn’t end with a single shot. The world’s most powerful nation hasn’t ensured equitable access for its own citizens to health care and lifesaving tools such as covid vaccines, Paxlovid, and monoclonal antibodies. The resulting disparities will get worse as the federal government finishes turning America’s emergency covid response over to the routine health care system. Many Americans can’t afford to stay home when they or their children are sick. Families lack support to care for young or elder family members or people with medical illnesses or disabilities. Many say their biggest worry is paying for groceries or gas to get to work.

Their plight is less extreme than Banu’s, but their suffering is real — and it is magnified worldwide. As long as vulnerable communities are deprived of holistic, comprehensive responses to mpox, covid, Ebola, or other public health emergencies to come, these people will have a reason to be suspicious, and enlisting their help to fight the next crisis will be that much harder.

A version of this article first appeared in The Atlantic in August 2022.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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Epidemic: The Scars of Smallpox

Tue, 07 Nov 2023 10:00:00 +0000

In 1975, smallpox eradication workers in the capital of Bangladesh, Dhaka, rushed to Kuralia, a village in the country’s south. They were abuzz and the journey was urgent because they thought they just might get to document the very last case of variola major, a deadly strain of the virus.

When they arrived, they met a toddler, Rahima Banu.

She did have smallpox, and five years later, in 1980, when the World Health Organization declared smallpox eradicated, Banu became a symbol of one of the greatest accomplishments in public health.

That’s the lasting public legacy of Rahima Banu, the girl.

Episode 8, the series finale of “Eradicating Smallpox,” is the story of Rahima Banu, the woman — and her life after smallpox.

To meet with her, podcast host Céline Gounder traveled to Digholdi, Bangladesh, where Banu, her husband, their three daughters, and a son share a one-room bamboo-and-corrugated-metal home with a mud floor. Their finances are precarious. The family cannot afford good health care or to send their daughter to college.

The public has largely forgotten Banu, while in her personal life she faced prejudice from the local community because she had smallpox. Those negative attitudes followed her for decades after the virus was eradicated.

“I feel ashamed of my scars. People also felt disgusted,” Banu said, crying as she spoke through an interpreter.

Despite the hardship she’s faced, she is proud of her role in history, and that her children never had to live with the virus.

“It did not happen to anyone, and it will not happen,” she said.

The Host:
Céline Gounder Senior fellow and editor-at-large for public health, KFF Health News @celinegounder Read Céline's stories Céline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board.
Voices From the Episode:
Rahima Banu The last person in the world to have a naturally occurring case of the deadliest strain of smallpox Nazma Begum Rahima Banu’s daughter Rafiqul Islam Rahima Banu’s husband Alan Schnur Former World Health Organization smallpox eradication program worker in Bangladesh Click to open the transcript Transcript: The Scars of Smallpox
Podcast Transcript Epidemic: “Eradicating Smallpox” Season 2, Episode 8: The Scars of Smallpox Air date: Nov. 7, 2023

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Céline Gounder: Just when you thought smallpox was gone someplace, it could roar back.

Alan Schnur: We were aware that in some other countries there had been celebrations and then later found, uh, there had been ongoing transmission that wasn’t detected.

Céline Gounder: The virus was persistent and slippery, but smallpox did end, and Alan Schnur was there when it did.

Alan Schnur: I was one of the team members who was the first international responders to the last case of variola major smallpox.

[Upbeat music begins playing.]

Céline Gounder: The beginning of the end was 1975 in Bangladesh. Alan was in the capital city of Dhaka, meeting with other fieldworkers from the World Health Organization. They were gathered in a Quonset hut. If you’ve ever seen a World War II movie, you know what it looks like: Picture a big tin can cut down the middle — resting on its side.

The meeting was uneventful, which was a change of pace. When Alan first came to Bangladesh, smallpox cases had exploded. The country was reeling from a war for liberation.

But by that day, the outbreak had fizzled.

Alan Schnur: Things had gone very quiet. No reports of any active smallpox cases despite searches going on for several weeks.

Céline Gounder: Alan remembers that the walls of the Quonset hut were covered with maps and manuals documenting their work, and they kept a running tally of suspected cases.

Alan Schnur: And there was a big zero up there on the wall staring down at us for this whole meeting. So we were feeling pretty good at the time.

Céline Gounder: Not a single case of smallpox across the entire country. The team was starting to let themselves feel optimistic. Maybe they’d stamped out the disease here.

[Upbeat music ends.]

Alan Schnur: And then there was a telegram received saying one smallpox case found in Kuralia village in Bhola.

[Suspenseful music begins playing.]

Céline Gounder: The next morning, Alan and the head of the W–H–O mission in Bangladesh took a slow boat through snaking canals to Bhola Island.

[Ambient sounds of a boat on the water play in the background.]

Céline Gounder: Day turned into night. Night into day.

Another boat, then a Land Rover.

Alan Schnur: And the last half-mile, we had to walk to the house where the case was.

Céline Gounder: Finally, they made it.

Alan Schnur: It was a very simple house, certainly poorer than the average Bangladeshi house.

Céline Gounder: Inside was the patient, a little girl. Rahima Banu.

Alan Schnur: She was very scared. She was trying to hide behind her mother’s sari. So she was frightened and trying to to run back inside the house, but her mother kept her there.

Céline Gounder: There’s an iconic photo of Rahima and her mother from that day. Sitting on her mother’s hip, Rahima looks wary. But Alan says all around her there was an air of excitement among the public health workers.

This could finally be it: the last person with naturally occurring variola major smallpox.

Alan Schnur: And we didn’t find any more active cases after Rahima Banu.

[Suspenseful music fades out.]

Céline Gounder: The WHO continued to monitor Bangladesh for a couple of years, but that’s where the story ends for the deadliest version of smallpox. With Rahima Banu, the girl.

She became a symbol of — a poster child for — one of public health’s greatest achievements. But she did not share in the prestige or rewards that came after.

In this final episode of our series “Eradicating Smallpox,” I travel to Bangladesh to meet with Rahima Banu, the woman. We’ll hear how smallpox shaped her life and wrestle with some of the questions that her reality demands of public health.

I’m Dr. Céline Gounder, and this is “Epidemic.”

[“Epidemic” theme music plays then fades to silence.]

[Ambient sounds of chickens squawking in the courtyard outside of Rahima Banu’s home play.]

Céline Gounder: Many people have tracked down Rahima Banu since 1975.

I’m just the latest in a line of public health specialists and curious journalists.

She lives in a village not far from where smallpox workers found her nearly 50 years ago.

As I enter the courtyard of her home, there are clothes hanging on the line. The house is made from bamboo and corrugated metal. The mud stairs that lead inside are dotted with moss.

Inside is one giant room with a partition. On the far side are cots where the family sleeps. On the near side is a table, where I sit with Rahima.

She introduces herself while her husband and two of her daughters sit behind her.

[Rahima speaking in Bengali fades under English translation.]

Rahima Banu: I am Rahima Banu from Bangladesh. Rahima Banu of smallpox fame.

Céline Gounder: Rahima wears a cobalt-blue scarf with white flowers — it’s draped over her head and shoulders and modestly tucked under her chin. A small gold stud sparkles from her nose.

[Sparse music begins playing softly.]

Céline Gounder: She has only a few memories of smallpox. She remembers health workers drawing blood from her fingers, for example. But most of the story that’s made her famous, she knows only from what she’s been told.

[Rahima speaking in Bengali fades under English translation.]

Rahima Banu: There were lesions like this all over the body. My mother said that if you poked them with a lemon cutter, the water rolled down all over the body. As the juice of the dates rolled down when being cut, my blood also dripped like that.

Céline Gounder: While Rahima recovered from smallpox, her family was forced to stay at home while the health workers set a mile-and-a-half radius where they monitored every fever and vaccinated every person.

Two guards monitored the doors of Rahima’s home 24 hours a day. Otherwise, Rahima says, her father would have tried to leave to go find work. He was the lone income earner in the family.

[Rahima speaking in Bengali fades under English translation.]

Rahima Banu: If he had run away, the disease would have spread to other places. That’s why they did not allow us to go anywhere.

Céline Gounder: Alan Schnur says he hired Rahima’s father so the family would have food and an income while they were isolated. And later — a small group of public health workers tried to cobble together some kind of sustainable support for Rahima’s family.

But, eventually the WHO’s help ended. And, ultimately, attempts to prop up the family’s future fell through.

[Sparse music swells, then fades to silence.]

Céline Gounder: Little Rahima grew up. She married and had a family of her own.

The scars of smallpox are visible on her face, but they are faint. Mostly you notice her eyes. They are warm; her slight smile is welcoming.

But Rahima says when visitors like me come to visit, they mostly want to know one thing: Is she still alive?

[Rahima speaking in Bengali fades under English translation.]

Rahima Banu: But no one wants to know how I am living my life with my husband and children, whether I am in a good condition or not, whether I am settled in my life or not.

Céline Gounder: The stories about Rahima are not usually about her life today. They’re about her place in history — as an international symbol of one of the crowning achievements of public health.

But listening to Rahima speak, I’m caught off guard by the pain in her voice.

[Rahima speaking in Bengali fades under English translation.]

Rahima Banu: I feel ashamed of my scars. People also felt disgusted. [Rahima cries.]

Céline Gounder: Rahima is in tears. My reporting partner, Redwan, asks Rahima’s daughter to bring some water.

Redwan Ahmed [in Bengali]: Will you give her some water?

[Solemn music begins playing.]

Céline Gounder: She is around 50 years old when I visit — and the faded pockmarks on her body are perhaps the least of what smallpox left behind. Rahima begins to talk about the emotional scars smallpox left on her family, her life.

And how living in poverty has made things even harder. As an adult, when she had health problems, there was no outside care. No public health workers bustling around, ready to help.

She tells me about a time when she had intense vomiting and fevers.

[Rahima speaking in Bengali fades under English translation.]

Rahima Banu: I was bedridden for three months, but I still could not go to a good doctor because I could not afford it.

Céline Gounder: Rahima says the doctor she did see prescribed her cooked fish heads. She also had trouble with her vision for years.

[Rahima speaking in Bengali fades under English translation.]

Rahima Banu: I cannot thread a needle because I cannot see clearly. I cannot examine the lice on my son’s head. I cannot read the Quran well because of my vision.

[Solemn music fades out.]

Céline Gounder: Rahima and her husband, Rafiqul Islam, have four nearly grown children, three daughters and a son.

The couple’s marriage was arranged, and Rafiqul didn’t know Rahima had had smallpox.

After he found out, people would taunt him, saying he’d married a cursed girl. Still, Rafiqul accepted her.

His family did not.

[Somber music begins playing.]

Céline Gounder: Rahima says her in-laws thought her scars — or smallpox itself — would be passed on to her children.

[Rahima speaking in Bengali fades under English translation.]

Rahima Banu: My father-in-law and mother-in-law never touched my children with their fingers like one touches other children.

My father-in-law, mother-in-law, sister-in-law, and brother-in-law never saw me in a good light.

Céline Gounder: Rahima says she is still living in that suffering. Rafiqul becomes tearful as we sit around their table listening. And at times he gets up and stands behind the partition, as if he doesn’t want us to see his emotion.

Rafiqul says he felt powerless watching how his family treated his wife.

[Rafiqul speaking in Bengali fades under English translation.]

Rafiqul Islam: Do you get it? As a husband, I couldn’t do anything to stop my parents or my siblings. One of my sisters did most of the abuse. I couldn’t do anything but stand in a corner as she was abused.

[Somber music ends.]

Céline Gounder: Their middle daughter is named Nazma Begum. She is tall like her dad — you can tell she’s an eager student. For most of Nazma’s life, people like me have come here to talk with her mother about smallpox.

I ask Nazma what it’s like to be the child of an international symbol.

[Nazma speaking in Bengali fades under English translation.]

Nazma Begum: The good effect is that it is nice to see that you and other people come here. When people come, I like that a lot. The way I feel nice when guests come — it is the same feeling. Apart from that, there was no other effect. It did not help me in any way in my studies or financially.

Céline Gounder: The family’s only income is the money Rafiqul earns peddling a rickshaw. On a good day, he brings home 500 takas — not quite 5 U.S. dollars.

Sometimes he brings home nothing.

Nazma finished a year of college, but her parents can’t afford to pay for her education anymore. She seems desperate to go back to school, but at the time of my visit, the family had arranged for her to get married instead.

The cost of a dowry is less than the cost of sending her to school. It’s a common story here in Bangladesh. But, Nazma says, the people who seek out her mother to talk about smallpox are not really curious about Rahima’s children.

[Nazma speaking in Bengali fades under English translation.]

Nazma Begum: What are their children doing? Up to what class have they studied? In what condition are they living? What do their children want? I think that’s what they should have asked more about. But in this matter, they have no interest or do not want to know.

[Reflective music plays softly.]

Céline Gounder: Nazma is talking to me, but maybe she’s indicting me, too.

Journalists, public health experts, and government officials — we all return to Rahima again and again. Whenever there’s a big anniversary. Or when we’re looking for smallpox lessons — to get through the latest pandemic. And it is a story worth telling.

But then we leave. And Rahima is left behind.

We write up our reports, or publish our podcasts — then raise money around that research and journalism.

In these sometimes sanitized stories, the reality of Rahima’s life after smallpox is left out.

She goes back to her family that can’t afford to see a doctor or send their daughter to university.

It feels extractive — as if we take from Rahima only what we need. And I can’t help but wonder whether I owe her something more.

[Reflective music fades out.]

Céline Gounder: There’s this moment from my time with Rahima that I found later, when I was reviewing the tape from the interview. Initially, I missed it because I don’t speak Bengali. While I was adjusting my recording levels, Rahima and the interpreter are talking about how she’ll introduce herself, and she says maybe we could publish that her son is looking for work.

[Clip of Redwan and Rahima speaking Bengali plays in the background.]

Céline Gounder: It’s such a simple request, so core to what’s on her mind and what she wants.

The interpreter is skilled and polite. He tells her he can’t promise anything but maybe it will come up in the interview.

Of course, it doesn’t — at least not exactly. But at the end of our time together, I ask Rahima what she thinks people should know about her experience.

[Optimistic music begins playing.]

[Rahima speaking in Bengali fades under English translation.]

Rahima Banu: Who wants to know about me? My only dream was to make my son a man. And I wanted to repair the condition of my house, live a better life with my family, and keep my children well. This is my only dream. If I had some financial ability, I would have arranged my daughter’s marriage to a better family. It is the pride of my heart.

It is my dream. And it is my pride. This is my imagination.

Céline Gounder: There is one way, though, that Rahima says her role in history has helped her family.

Her children did not get smallpox. They don’t live with those particular scars.

[Rahima speaking in Bengali fades under English translation.]

Rahima Banu: It did not happen to anyone, and it will not happen.

[Optimistic music fades out.]

[“Epidemic” theme music plays.]

Céline Gounder: “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, and me.

Bram Sable-Smith was scriptwriter for the episode, with help from Zach Dyer and Taunya English.

Redwan Ahmed was our translator and local reporting partner in Bangladesh.

Our managing editor is Taunya English.

Oona Tempest is our graphics and photo editor.

The show was engineered by Justin Gerrish.

We had extra editing help from Simone Popperl.

Voice acting by Rashmi Sharma, Priyanka Joshi, and Paran Thakur.

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 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 our podcasts.

And subscribe to our newsletters at kffhealthnews.org so you’ll never miss what’s new and important in American health care, health policy, and public health news.

I’m Dr. Céline Gounder. Thanks for listening to this season of “Epidemic.”

[“Epidemic” theme fades to silence.]

Credits
Taunya English Managing editor @TaunyaEnglish Taunya is senior editor for broadcast innovation with KFF Health News, where she leads enterprise audio projects. Zach Dyer Senior producer @zkdyer Zach is senior producer for audio with KFF Health News, where he supervises all levels of podcast production. Taylor Cook Associate producer @taylormcook7 Taylor is associate audio producer for Season 2 of Epidemic. She researches, writes, and fact-checks scripts for the podcast. Oona Tempest Photo editing, design, logo art @oonatempest Oona is a digital producer and illustrator with KFF Health News. She researched, sourced, and curated the images for the season.
Additional Newsroom Support

Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chief Gabe Brison-Trezise, deputy copy chiefChris Lee, senior communications officer

Additional Reporting Support

Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh

“Epidemic” is a co-production of KFF Health News and Just Human Productions.

To hear other KFF Health News podcasts, click here. Subscribe to “Epidemic” on Apple Podcasts, Spotify, Google, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENT
This story can be republished for free (details).

Epidemic: What Good Is a Vaccine When There Is No Rice?

Tue, 24 Oct 2023 09:00:00 +0000

The 1970s was the deadliest decade in the “entire history of Bangladesh,” said environmental historian Iftekhar Iqbal. A deadly cyclone, a bloody liberation war, and famine triggered waves of migration. As people moved throughout the country, smallpox spread with them.

In Episode 7 of “Eradicating Smallpox,” Shohrab, a man who was displaced by the 1970 Bhola cyclone, shares his story. After fleeing the storm, he and his family settled in a makeshift community in Dhaka known as the Bhola basti. Smallpox was circulating there, but the deadly virus was not top of mind for Shohrab. “I wasn’t thinking about that. I was more focused on issues like where would I work, what would I eat,” he said in Bengali.

When people’s basic needs — like food and housing — aren’t met, it’s harder to reach public health goals, said Bangladeshi smallpox eradication worker Shahidul Haq Khan.

He encountered that obstacle frequently as he traveled from community to community in southern Bangladesh.

He said people asked him: “There’s no rice in people’s stomachs, so what is a vaccine going to do?”

To conclude this episode, host Céline Gounder speaks with Sam Tsemberis, president and CEO of Pathways Housing First Institute.

He said when public health meets people’s basic needs first, it gives them the best shot at health.

The Host:
Céline Gounder Senior Fellow & Editor-at-Large for Public Health, KFF Health News @celinegounder Read Céline's stories Céline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board.
In Conversation With Céline Gounder:
Sam Tsemberis Founder, president, and CEO of Pathways Housing First Institute @SamTsemberis
Voices From the Episode:
Shohrab Resident of the Bhola basti in Dhaka Iftekhar Iqbal Associate professor of history at the Universiti Brunei Darussalam Shahidul Haq Khan Former World Health Organization smallpox eradication program worker in Bangladesh Click to open the transcript Transcript: What Good Is a Vaccine When There Is No Rice?
Podcast Transcript

Epidemic: “Eradicating Smallpox”

Season 2, Episode 7: What Good Is a Vaccine When There Is No Rice?

Air date: Oct. 24, 2023

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

[Ambient sounds from a ferry play softly.]

Céline Gounder: I’m on a boat in southern Bangladesh, headed toward Bhola, the country’s largest island.

We’re traveling by ferry on calm waters. But my head spins — and my stomach roils just a bit — as I imagine how these same waters nearly destroyed Bhola Island.

[Tense instrumental music begins playing.]

It was 1970.

In November, under an almost-full moon and unusually high tides.

The island was hit by one of the most destructive tropical storms in modern history: the Bhola cyclone.

[Shohrab speaking in Bengali fades under English translation.]

Shohrab: There were floods. Back then there weren’t any embankments to stop the water from rising.

Céline Gounder: Counterclockwise winds, torrential rains, and treacherous waves swept entire villages into the sea. People held onto whatever they could to keep their heads above water.

[Shohrab speaking in Bengali fades under English translation.]

Shohrab: I remember at that time the water level rose so high that people ended up on top of trees. The water had so much force. Many people died.

Céline Gounder: The Bhola cyclone killed some 300,000 people. And for those who survived, there wasn’t much left to return to. Hundreds of thousands of people lost their homes, their farms, and their access to food.

The man whose voice you’ve been hearing was one of the survivors.

[Shohrab speaking in Bengali fades under English translation.]

Shohrab: My name is Shohrab. I am 70 years old.

Céline Gounder: Shohrab was a teenager when the cyclone hit. And in the days and weeks after the storm, he and his family joined a mass migration of people who fled southern Bangladesh.

They traveled about a hundred miles north from Bhola Island to the streets of Dhaka, the busy capital of Bangladesh.

There, they settled in a makeshift community, a kind of unsanctioned encampment dubbed the Bhola basti.

In Bengali that word,“basti,” means settlement — or “slum,” in some translations.

The residents forged a community, but soon, the poor people there — and what they built — would be seen as a threat to the effort to keep smallpox in check.

Not just in South Asia — but around the world.

I’m Dr. Céline Gounder. This is “Epidemic.”

[“Epidemic” theme music plays.]

[Ambient sounds from the Bhola basti, including voices of people speaking Bengali, play softly.]

Céline Gounder: More than 50 years after the cyclone, Shohrab lives in the same area in Dhaka.

I interviewed him at a tea stall near his home. It’s the kind of place where men gather to gossip and share stories over hot drinks.

Inside there’s a colorful display of snacks and sweets hanging from the ceiling. Just outside we sat on well-worn wooden benches.

And as we sip our tea, he tells me about life in the encampment in the 1970s …

[Sparse music plays softly.]

[Shohrab speaking in Bengali fades under English translation.]

Shohrab: I used to rent a place there. Five or six of us used to live in one room. Sometimes it was eight people in a room.

Céline Gounder: To cover his portion of the rent he worked as a day laborer, doing odd jobs here and there. Over time the basti became home.

But Shohrab’s new home was likely seen as an eyesore by outsiders — and by the Bangladeshi government.

Such settlements often lack running water, or electricity, or access to proper sanitation. Those conditions spotlight suffering — and for local leaders that spotlight can be uncomfortable.

But, public health experts had a different concern: that the settlement of Bhola migrants in Dhaka would become a deadly stronghold for smallopox. Cramped and unsanitary living conditions put the residents at high risk.

I ask Shohrab if he remembers seeing or hearing about people with smallpox when he first arrived.

[Shohrab speaking in Bengali fades under English translation.]

Shohrab: I wasn’t thinking about that. I was more focused on issues like where would I work, what would I eat, etc.

Céline Gounder: As he tried to rebuild his life, other things — like food and shelter — were more urgent.

[Music fades to silence.]

Widening beyond that one migrant encampment in Dhaka, researchers say the picture was similar in cities and villages all across the country.

Bangladesh was hit with a series of crises. Environmental historian Iftekhar Iqbal says each brought human suffering — and that each was a blow to the smallpox eradication effort.

Iftekhar Iqbal: Seventies was really a time when, the coming of the smallpox couldn’t come at a, at a more unfortunate time.

Céline Gounder: In 1970 the Bhola cyclone hit. In 1971, just four months later, the country fought a bloody liberation war. Then, in 1974, heavy rain and flooding triggered a famine. And in 1975 there was a military coup.

Iftekhar Iqbal: The 1970s was the deadliest decade in the history of Bangladesh.

Céline Gounder: This period is when the country became Bangladesh — winning its independence from Pakistan in the liberation war. But residents of the young nation faced cascading upheaval and turmoil. And too much death.

[Instrumental music plays softly.]

On the global stage stopping smallpox was important, but many in Bangladesh were just trying to make it to the next day.

Daniel Tarantola: No. 1 priority is food and food and food. And the second priority is food and food and food.

This was an area where survival was always in question.

Céline Gounder: That’s Daniel Tarantola.

He’s from France and arrived in the region with the mission of helping to eradicate smallpox, but he says the people in front of him needed help with many other things.

Besides hunger, some of the villages he visited were dealing with two epidemics: smallpox and cholera.

Daniel Tarantola: And we were not equipped to do anything but smallpox containment and smallpox eradication. By design or by necessity, we didn’t have the means to do anything much more than that.

Céline Gounder: Over the course of this season we’ve talked about big, complicated issues — like stigma and bias, distrust, or First World arrogance — that threatened to derail the smallpox eradication campaign. We’ve documented the public health workers who found a way around those roadblocks.

But sometimes the need is so big, so entrenched, that your inability to meet it can be demoralizing. I sometimes felt that during my own fieldwork: battling HIV and tuberculosis in Brazil and southern Africa, and during an Ebola outbreak in Guinea, West Africa.

Daniel Tarantola says in South Asia the best he could do was focus on the task at hand.

Daniel Tarantola: Meaning that you had to set up a program to eradicate smallpox or at least eliminate it from Bangladesh and at the same time not get … if I can use the word distracted, um, by other issues that prevailed in Bangladesh.

[Music fades out.]

Céline Gounder: Those were tough emotional realities for health workers and the people they wanted to care for.

But …

Daniel Tarantola: The level of resilience of this population is absolutely incredible given the number of challenges that they have had to survive.

Céline Gounder: One of the main ways people survived the upheaval in Bangladesh was by picking up and moving away from the things trying to kill them.

Remember how Shohrab fled to Dhaka after the cyclone?

Well, mass migration is a survival strategy — but one that can worsen disease.

When the cyclone refugees from Bhola landed in that under-resourced basti in Dhaka, all smallpox needed was an opportunity to spread.

[Solemn music begins playing.]

That opportunity came in 1975 when the Bangladeshi government decided to bulldoze the Bhola basti.

Daniel Tarantola says it was a bad idea.

Daniel Tarantola: We knew there was smallpox transmission in this particular area and therefore they should wait until the outbreak subsides before dismantling the shanties.

Céline Gounder: Government officials did not wait for the outbreak to subside. They bulldozed the basti anyway.

Daniel Tarantola: That resulted in a wide spread of smallpox.

Céline Gounder: Here’s environmental historian Iftekhar Iqbal again.

Iftekhar Iqbal: This eviction is considered one of the policy errors that led to the second wave of postwar smallpox.

Céline Gounder: In the wake of that eviction in 1975, thousands of people scattered. Some surely returned back home to Bhola.

[Music fades out.]

Céline Gounder: Public health’s failure — the government’s failure — to meet the basic need for safety, for food and housing, delayed the goal to stop the virus.

Shahidul Haq Khan, the Bangladeshi public health worker and granddad we met in Episode 4, says he learned that lesson over and over as he urged people to accept the smallpox vaccination.

Their frustration with him — and by extension public health — was clear.

[Shahidul speaking in Bengali fades under English translation.]

Shahidul Haq Khan: There was no rice in people’s stomachs, so what is a vaccine going to do? “You couldn’t bring rice? Why did you bring all this stuff?” That was the type of situation we had to deal with.

[Atmospheric music begins playing.]

Céline Gounder: What good is a vaccine when there is no rice?

Next up, I speak with Sam Tsemberis, founder of Pathways Housing First Institute. It’s an organization that advocates for meeting people’s basic needs first, so they’ll have the best shot at health.

But in the beginning, he found out convincing institutions was easier said than done:

Sam Tsemberis: I try to explain this rationale that I’m telling you, like people need housing first and then services. The hospital is like, “No, no, we’re in the hospital business. We’re not in the housing business.”

Céline Gounder: That’s after the break.

[Music fades to silence.]

Céline Gounder: One of my mentors was Dr. Paul Farmer, the legendary doctor and anthropologist whose work in Haiti was documented by Tracy Kidder in the book “Mountains Beyond Mountains.” Paul always pushed us to look beyond the symptoms to root causes. It’s a lesson we keep having to learn in public health again and again.

Sam Tsemberis is one of the first to apply it to homelessness. He’s the CEO of a nonprofit called the Pathways Housing First Institute. The organization promotes a model of addressing homelessness that begins with putting people into housing.

That idea seems pretty obvious. But back when Sam first started working on homelessness — in New York City in the 1980s — the prevailing model was more like a staircase. People had to work their way up to show they were ready for, or even worthy of, housing.

Sam Tsemberis: If you showed up applying for housing, you had to acknowledge you had a mental illness, you had to demonstrate that you were taking medication, and that you understood why you were taking medication. And you also had to have — if you had any history of alcohol or substance use, you also had to demonstrate a period of sobriety.

It was a very tough regimen to get into housing.

Céline Gounder: Sam said he quickly realized that wasn’t working, even though it was the only approach at the time.

Sam Tsemberis: I was working very hard to help people navigate that. I was doing street outreach. So, “Come come to the shelter, come to the hospital, come to a treatment program, a drop-in center,” hoping that they would engage and successfully make it up the stairs and get housing eventually.

And what began to emerge was that even if people were willing to take the first step — let’s say go to detox or go to the hospital — far too many people ended up returning to the street, which was, which was a signal that, you know, something was wrong with this system. It’s like, why are people falling back?

And the stories on the street were compelling. You know, people would say, “No, I don’t need to go to detox. What I need is a safe place to stay.”

Or, “Yeah, I’ve been diagnosed with schizophrenia, but … you know, and I still hear voices, but I don’t pay attention to them. Right now, I’m just cold, I’m tired, I’m hungry, I need a place to be safe. I need to go inside. That’s what I need first.”

And the repeated pleas for safety, security, a place to call home, from people that had tried and failed and tried and failed that staircase system is what compelled me to, you know, try something different, because what we were doing wasn’t working. And that’s when we started this housing-first approach.

Céline Gounder: Can you explain: What is that, and what’s its impact?

Sam Tsemberis: Housing-first is the answer to a question that we ask people. “OK, what is it that you want?” And people would inevitably say, “I want a place to live, isn’t it obvious?”

So our job as providers, then, was to figure out a way to have a program that we can get money for rent, and money for case management services, and give people who had previously no opportunity to get into housing on their own terms, and also offer the kind of clinical or social or emotional support that’s needed after people get housed.

Céline Gounder: So how did you pilot or how did you jump-start this effort? What did that look like?

Sam Tsemberis: So we ended up having to start our own nonprofit agency, apply for a grant, and we, with fingers crossed, we started to take people that were actively using and in some cases actively symptomatic and put them into apartments of their own and visit them a lot, not knowing how it would turn out.

What we found, much to our shock and surprise, very pleasant surprise, is that 85% of the people we housed, even in that first year, remained housed. And we thought, well, you know, we’re onto something here.

Céline Gounder: So instead of insisting that people be treated for addiction and mental health issues before they got into housing, you gave them housing first. And that was really sort of the measure of success.

Sam Tsemberis: Yes.

Céline Gounder: How successful was the program in treating addiction and mental health?

Sam Tsemberis: The addiction and mental health treatment outcomes were modestly better for the housing-first group that didn’t require to be in treatment. But you know, their treatment was no worse and a little better than the group that required treatment and sobriety.

And there, a measure called the overall quality of life, you know, like, how happy are you with living in the community, with your contacts with relatives, and so on. The group that went into housing first had a significantly higher quality of life than the treatment-first group.

Céline Gounder: So I know there are people out there who will say, Well, you didn’t solve their addiction issue or their mental health issue; how is that a success? How would you respond to that criticism?

Sam Tsemberis: This was never advertised as a program that cures addiction or cures mental illness. Recovery, in some ways, is not abstinence. Recovery, at least in the mental health business, is having a life in spite of your diagnosis.

The main thing is you’re no longer homeless. You know, you don’t have to be on the street until you’ve cured your illness. Because if that was the case, people would likely die on the street before they cured their illness because we don’t have cures for some of these illnesses.

Céline Gounder: So, Sam, Dr. Paul Farmer was a mentor of mine, actually, over the course of my training. And in Tracy Kidder’s biography of Paul, there’s a quote of one of Paul’s colleagues, Haitian colleagues, who says that, “Giving people medicine for tuberculosis and not giving them food is like washing your hands and drying them in the dirt.”

Sam Tsemberis: That is so on target for what all of these issues are about. I think of homelessness, actually, as a poorly named term for all of the systemic failures that people have faced in order to end up homeless.

We need to get, you know, take care of the emergency, put everyone in housing, but that’s sort of the beginning of the job. Then the real work starts to address the root causes that contribute and continue to increase the problem as opposed to just dealing with the symptom all the time.

[“Epidemic” theme music begins playing.]

Céline Gounder: Next time, on the series finale of “Epidemic: Eradicating Smallpox” …

Rahima Banu.

Redwan Ahmed: Rahima Banu.

Daniel Tarantola: Rahima Banu.

Iftekhar Iqbal: Rahima Banu.

Larry Brilliant: The last case …

Steve Jones: The last case …

Alan Schnur: The last case of variola major smallpox. I think this time we’ve got it.

Céline Gounder: “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, Bram Sable-Smith, and me.

Saidu Tejan-Thomas Jr. was scriptwriter for the episode.

Redwan Ahmed was our translator and local reporting partner in Bangladesh.

Our managing editor is Taunya English.

Oona Tempest is our graphics and photo editor.

The show was engineered by Justin Gerrish.

We had extra editing help from Simone Popperl.

Voice acting by Susheel C. and Pinaki Kar.

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 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 our podcasts.

And subscribe to our newsletters at kffhealthnews.org so you’ll never miss what’s new and important in American health care, health policy, and public health news.

I’m Dr. Céline Gounder. Thanks for listening to “Epidemic.”

[“Epidemic” theme fades out.]

Credits
Taunya English Managing Editor @TaunyaEnglish Taunya is senior editor for broadcast innovation with KFF Health News, where she leads enterprise audio projects. Zach Dyer Senior Producer @zkdyer Zach is senior producer for audio with KFF Health News, where he supervises all levels of podcast production. Taylor Cook Associate Producer @taylormcook7 Taylor is associate audio producer for Season 2 of Epidemic. She researches, writes, and fact-checks scripts for the podcast. Oona Tempest Photo Editing, Design, Logo Art @oonatempest Oona is a digital producer and illustrator with KFF Health News. She researched, sourced, and curated the images for the season.
Additional Newsroom Support

Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chief Chris Lee, senior communications officer

Additional Reporting Support

Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh

Epidemic is a co-production of KFF Health News and Just Human Productions.

To hear other KFF Health News podcasts, click here. Subscribe to Epidemic on Apple Podcasts, Spotify, Google, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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This story can be republished for free (details).

Epidemic: Bodies Remember What Was Done to Them

Tue, 10 Oct 2023 09:00:00 +0000

Global fears of overpopulation in the ’60s and ’70s helped fuel India’s campaign to slow population growth. Health workers tasked to encourage family planning were dispatched throughout the country and millions of people were sterilized — some voluntarily, some for a monetary reward, and some through force.

This violent and coercive campaign — and the distrust it created — was a backdrop for the smallpox eradication campaign happening simultaneously in India. When smallpox eradication worker Chandrakant Pandav entered a community hoping to persuade people to accept the smallpox vaccine, he said, he was often met with hesitancy and resistance.

“People’s bodies still remember what was done to them,” said medical historian Sanjoy Bhattacharya.

Episode 6 of “Eradicating Smallpox” shares Pandav’s approach to mending damaged relationships.

To gain informed consent, he sat with people, sang folk songs, and patiently answered questions, working both to rebuild broken trust and slow the spread of smallpox.

To conclude the episode, host Céline Gounder speaks with the director of the global health program at the Council on Foreign Relations, Thomas Bollyky. He said public health resources might be better spent looking for ways to encourage cooperation in low-trust communities, rather than investing to rebuild trust.

The Host:
Céline Gounder Senior fellow & editor-at-large for public health, KFF Health News @celinegounder Read Céline's stories Céline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board.
In Conversation With Céline Gounder:
Thomas Bollyky Director of the global health program at the Council on Foreign Relations @TomBollyky
Voices From the Episode:
Chandrakant Pandav Community medicine physician and former World Health Organization smallpox eradication worker in India @pandavcs1 Gyan Prakash Professor of history at Princeton University, specializing in the history of modern India @prakashzone Sanjoy Bhattacharya Medical historian and professor of medical and global health histories at the University of Leeds @joyagnost Click to open the transcript Transcript: Bodies Remember What Was Done to Them
Podcast Transcript Epidemic: “Eradicating Smallpox” Season 2, Episode 6: Bodies Remember What Was Done to Them Air date: Oct. 10, 2023

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Céline Gounder: In the early 1970s, all around the world, worries about overpopulation were mounting.

Politicians warned about the dangers.

Richard Nixon: Our cities are gonna be choked with people. They’re going to be choked with traffic. They’re gonna be choked with crime. … And they will be impossible places in which to live.

Céline Gounder: And news outlets repeated the claims. A 1970 news analysis from The New York Times described “two avenues” to deal with the problem of overpopulation.

Voice actor reading from NYT article: “… one is persuasion of people to limit family size voluntarily, by contraception, sterilization or abortion. The other is compulsory, through such means as large‐scale injection of at least temporary infertility drugs into food or water.”

Céline Gounder: Popular books like “The Population Bomb” suggested an impending, apocalyptic future. Pulpy paperbacks were passed around — capturing people’s imagination and stoking fears.

Two million copies of “The Population Bomb” were sold. And the author landed on late-night television, his dire predictions becoming entertainment for Americans sitting at home on their couches.

Meanwhile, on the other side of the globe, India — with its growing population — was in the crosshairs of the world’s anxieties.

[Solemn music plays.]

Céline Gounder: In the early ’50s, India had launched a family planning program.

Narrator of Indian Family Planning Film: There are 5 million more mouths to feed every year. … If our population continues to grow unchecked at the present alarming rate, we cannot solve our problems of food and shelter.

Céline Gounder: And that state-sponsored campaign got political and financial backing from international organizations like the World Bank and American foundations like Ford and Rockefeller.

Health workers were dispatched across India to get people to have fewer children.

Sometimes voluntarily.

Sometimes for a monetary reward.

Sometimes using force.

Violence and coercion created distrust.

In this episode, we’ll explore how that distrust affected the public health campaign to stop smallpox.

And ask: What is the path to restoring trust?

I’m Dr. Céline Gounder and this is “Epidemic.”

[“Epidemic” theme music plays.]

Chandrakant Pandav: Ready? Good afternoon. My name is Dr. Chandrakant Pandav. This is a recording in my office at New Delhi.

Céline Gounder: Chandrakant Pandav’s office is decorated with his academic degrees, lantern lights, and floral wallpaper. There are photos of Mahatma Gandhi, Mother Teresa, and various Hindu deities framed in gold.

And on his desk is a small saffron-white-and-green flag.

Chandrakant Pandav: Most important, I have India’s flag always in front of me.

Céline Gounder: And what’s the reason for that?

Chandrakant Pandav: Patriotism, mera desh mahaan.

Céline Gounder: Mera desh mahaan — “My great Nation”— he says in Hindi. Chandrakant was so eager to share his pride that at one point he picked up the flag and waved it around a bit.

He could barely contain his love for his country — and its culture.

He even got up out of his chair, turned on a song, and started dancing.

[Video of Chandrakant dancing to upbeat music playing.]

Céline Gounder: A twist of the hand here, a little shimmy there; he did a few hand mudras with a look of delight on his face.

I couldn’t help but smile along with him.

[Dance video continues playing, Céline and Chandrakant laugh.]

Céline Gounder: But even with all that joy, when the music stopped and he shuffled back to his chair, you’re reminded that Chandrakant is in his 70s, with more than 50 years of experience in public health.

[Video of Chandrakant dance video fades out.]

Céline Gounder: He was one of thousands of people asked to take part in the smallpox eradication program in the early and mid-’70s. He didn’t hesitate when he got the call.

Chandrakant Pandav: I said, this is the time to serve my India. Because India has spent so much of money on my education and making me a doctor, so I came from this culture strong, strong ethical background that your life is not for yourself. Money is … doesn’t matter. Serve the society.

Céline Gounder: Chandrakant led a team of smallpox eradication workers. He says nearly every person he talked to about taking the smallpox vaccine seemed to have the same worry, the same questions.

Chandrakant Pandav: “What is this vaccine? What is this you’re doing us? Maybe it’s a population control measure.” So the strongest question they had: “This is the government of India’s new policy for sterilization?”

Céline Gounder: Sterilization. The government’s decades-long family planning campaign was very much top of mind.

Decades later, when Chandrakant thinks about the program — and the unethical tactics India used — the pride melts off his face.

Chandrakant Pandav: It was a very aggressive strategy, unfortunately. I don’t want to go into that period. It was very aggressive.

Céline Gounder: Chandrakant didn’t want to talk about it. But you can’t tell the story of smallpox eradication success without talking about the family planning policies that came first.

Without talking about the state-sponsored coercive tactics that were commonplace and accepted by many.

Without acknowledging the violence of forced sterilizations.

Public health doesn’t happen in a vacuum.

And India’s approach to family planning eroded trust in public health workers for years.

So — in this season all about smallpox — we’re going to spend some time this episode diving into the details of the family planning program.

Gyan Prakash: My name is Gyan Prash and I’m professor of history at Princeton University.

Céline Gounder: Gyan has spent years studying India’s family planning campaign and the various tactics the government used to sterilize millions of people.

The government would pay people to get sterilized, and after natural disasters, like a drought, when many were desperate, any amount of money could be a powerful motivator. Patients might receive fewer than 100 rupees as compensation — which translates to only a few days’ wages, according to a 1986 article published in the journal “Studies in Family Planning.”

Gyan Prakash: It was a very small amount, but it mattered; it mattered to the poor. It was coercive, because it was between going hungry and, and not going hungry.

Céline Gounder: And if you chose not to get sterilized, Gyan says, the government found other ways to twist the screw. Families would receive food rations for up to only three children — any child beyond that would not be allotted food.

Gyan Prakash: Which punishes families which have more than three children.

Céline Gounder: At one point, the government began to prioritize men for sterilization.

Vasectomies were sometimes pushed on men, according to a 1972 report from The Associated Press.

Céline Gounder: Gyan says India’s family planning campaign created an atmosphere of intimidation and harassment that was nearly impossible to escape.

Gyan Prakash: You know, sending district authorities, backed by police, to the countryside and hold sterilization camps. So, I mean, the entire state machinery was mobilized to get people to the sterilization table.

Céline Gounder: Some of the harshest treatment during the sterilization campaign was aimed at Muslims and Indigenous populations like Adivasi tribes living in remote and rural parts of the country. I spoke to Sanjoy Bhattacharya about this.

Sanjoy Bhattacharya: I’m a historian of medicine with a deep interest in health policy, national, international, and global. And I’m the head of the School of History at the University of Leeds, United Kingdom.

Céline Gounder: Sanjoy says marginalized communities were often scapegoated.

Sanjoy Bhattacharya: That global narrative of overpopulation took the shape of, oh, Muslims have more children than Hindus, therefore Muslims are the problem behind Indian overpopulation. So we need to control the Muslim birthrate. What sterilization did was to violently sterilize men from a certain community who were blamed for a population problem that was a general population problem.

Céline Gounder: Sanjoy says many Adivasi and Muslim communities, in particular, lost trust in the government. This distrust lingered and simmered for years.

Imagine for a moment that for decades government trucks have descended on your village unannounced. Tents were set up. Equipment was unloaded. Workers fanned out to talk to village leaders.

This is what it looks like when Indian health workers showed up to sterilize you and your people.

And then, in the early 1970s, more government trucks arrived, maybe with familiar faces at the wheel. Maybe it’s some of the same public health workers.

They unload similar sharp-edged tools and set up their tents, but this time they promise it’s not for sterilization, it’s for a smallpox eradication program. You’d have a hard time trusting them.

Sanjoy Bhattacharya: And 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, people’s bodies still remember what was done to them.

Chandrakant Pandav: They were treated like animals. Coercion, coercion, coercion.

Céline Gounder: That’s community medicine physician and longtime public health leader Chandrakant Pandav again. He says when he arrived in the northern region of the state of Bihar, he knew these communities had every reason to doubt his team.

So first he worked to earn people’s trust.

Chandrakant Pandav: So when you sit with the leader of the village, along with the batch of people there, you talk to them, you explain to them.

Céline Gounder: And Chandrakant says it’s helpful to think of yourself more as a guest than a guest of honor.

Chandrakant Pandav: You don’t sit on a chair. Céline, I didn’t sit on a chair. I sat next to them to make them feel that I’m part of that community.

Céline Gounder: It sounds like convincing the village leader was enough to convince the villagers.

Chandrakant Pandav: It is the first step.

Céline Gounder: Another important step, he says, was to learn the local traditions around smallpox. Locals in Bihar faced the disease for many years, and they’d developed their own ways of dealing with it.

They would tie the leaves of a neem tree outside the homes of infected people.

The neem tree is said to have medicinal properties. Displaying its leaves outside homes where an active infection was present alerted others to stay away — a strategy designed to slow disease spread.

It didn’t stop the virus — it wasn’t effective in the same way as vials of vaccine or the bifurcated needle — but the traditions needed to be honored.

So Chandrakant and the other public health workers adopted some of the local strategies.

Chandrakant Pandav: So it was a very good combination of ancient medicine, ancient practice, with modern approach. Very good combination.

Céline Gounder: Another tradition his team tapped into was folk songs. They frequently used drums, songs, and the public address systems to communicate with people about smallpox.

Music was an especially good match for Chandrakant’s lively personality.

Remember all that joy for India I witnessed in his office in New Delhi — the flag? The dancing? Imagine that harnessed on behalf of his mission to wipe out smallpox.

In fact, he still remembers some of those folk songs nearly half a century later.

Chandrakant Pandav: Because it’s part of me, every atom, every molecule residing [sings folk song in Hindi]. So, it became an important method of communication. I come back again and again, Céline, to the same point: Establish a rapport and instill a sense of faith, anything is possible.

Céline Gounder: Chandrakant was able to pave the way for acceptance of the smallpox vaccine and rebuild trust in public health. But he was one charismatic man. His approach, his compassion were admirable — and it worked, where he was, with the people in front of him.

But the Indian government broke trust with tens of millions of its citizens during the family planning campaign. It makes me wonder about what it might look like to repair trust at that level, across the public health system, across an entire country.

Maybe that would mean an apology. Maybe that would be some kind of reparation to victims for the damage done to their bodies.

My friend and colleague Tom Bollyky says there’s no single silver bullet for rebuilding trust.

Tom Bollyky: That is too big of a mission for public health. We have enough challenges as it is. Instead of planning for how do we rebuild trust, we should be planning for dysfunction.

Céline Gounder: That’s after the break.

[Music fades out.]

Céline Gounder: Distrust and mistrust in the government became something of a defining feature of the response to the covid pandemic here in the United States. And while that might have taken many Americans by surprise, it was totally predictable to Tom Bollyky. He’s the director of the global health program at the Council on Foreign Relations. Bollyky says trust in the U.S. has been deteriorating since Watergate, and that decline accelerated around the 2008 financial crisis. Mistrust here divides along racial lines. It’s lower among African Americans, for example. And most notably, mistrust tends to be partisan. But it didn’t start that way during the covid pandemic.

Tom Bollyky: I think we all forget that there was, for a period of time, a surprising level of political consensus. Almost all states imposed protective policy mandates and most states imposed them at the same time. But as the fall stretched out, you saw some of those mandates and responses become more politicized.

And the moment I regret is, I think there was a moment, when the Biden administration came in and there was an attempt to reset and I … myself and many others really again focused on this message of following the science. But I do feel like perhaps we missed a opportunity to try to pull in some people across partisan lines at that moment.

Céline Gounder: So, as I’m hearing you describe this, restoring trust seems like a really massive undertaking.

I wonder whether you think that’s even the right framework that we should be using to think about this challenge.

Tom Bollyky: Such a great question. No, I think it isn’t. I think if we set an agenda for public health to rebuild the cohesiveness of our societies, to make us have a better relationship with our government, with each other, we will fail.

That is too big of a mission for public health. We have enough challenges as it is. Instead of planning for how do we rebuild trust, we should be planning for dysfunction. That’s really what preparedness is about.

Céline Gounder: So what are some of the ways that public health officials can reach skeptical communities?

Tom Bollyky: Through kinship networks and, uh, local leaders has been important. In some other public health crises, like HIV, people have used soap operas.

Céline Gounder: I remember being in South Africa in the early 2000s. There was a soap opera called “Soul City.” We pulled a clip of it, and there’s this one scene where a husband comes home to find his wife has placed a romantic gift by their bedside. He opens it up and sees condoms.

[Music]

“Soul City” clip: Woman: So that we can have safe sex. Man: Safe sex. Woman: I can’t have sex with you while I’m anxious about getting sick. Or, would you prefer I use condoms maybe? Man: We don’t need condoms. Woman: I do.

Tom Bollyky: I was in South Africa and the country was riveted. People really talked about it. It took, it took hold. Uh, they did a nice job of making it interesting, like weaving in the themes you wanted to weave in about people getting tested and talking to their partners and loved ones about their circumstances.

I know, Céline, you were very involved in the Ebola response, in 2013 through 2016. You know, there is high levels of mistrust in government in those post-conflict settings that were most affected in that epidemic.

Céline Gounder: People there don’t trust government, they think that people who serve in government do so to enrich themselves and their family and friends.

When I was in Guinea during the Ebola epidemic, they said Ebola was a hoax, that it was just a way for government officials and international organizations to enrich themselves. And yet, we were able to make some inroads convincing people to comply with Ebola control measures, so hand-washing, testing, safe burials.

Much of that was done through imams and other religious and community leaders.

Tom Bollyky: Those are the types of strategies we should be deploying when the next health crisis emerges, but not simply waiting until that happens. We need to start to build the infrastructure, the relationships. Again, even if it isn’t around fundamentally transforming, you know, communities, relationships with the government, or even how community members feel about, uh, one another, because interpersonal trust, social trust is a big part of this, too.

It’s about building the connections, the networks, about starting to engage individuals in these programs or through those institutions so that when the crisis emerges, you’re not building that from scratch.

Céline Gounder: Well, and to your point, as we prepare for the next pandemic, do you think we’ve learned those lessons about trust or are there things we’re still getting wrong?

Tom Bollyky: I think there is a greater appreciation for trust as an important issue. You hear that messaging. What I worry about is we’re not seeing it reflected yet in where the money is going. Where the money is going by and large is to developing vaccines faster, better vaccines in the future. But if really the lessons we’re drawing from this crisis are that developing a vaccine instead of in 326 days in 250 days … if we really think that would have made a difference in this pandemic, we haven’t been paying attention.

Céline Gounder: Next time on “Epidemic” …

Daniel Tarantola: They did not consider smallpox as the major issues among the many issues they were confronting. … No. 1 priority is food and food and food. And the second priority is food and food and food.

CREDITS

Céline Gounder: “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, Bram Sable-Smith, and me.

Saidu Tejan-Thomas Jr. was scriptwriter for the episode.

Swagata Yadavar was our translator and local reporting partner in India.

Our managing editor is Taunya English.

Oona Tempest is our graphics and photo editor.

The show was engineered by Justin Gerrish.

We had extra editing help from Simone Popperl.

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

This episode featured clips from National Education & Information Films Limited

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 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 our podcasts.

And subscribe to our newsletters at kffhealthnews.org so you’ll never miss what’s new and important in American health care, health policy, and public health news.

I’m Dr. Céline Gounder. Thanks for listening to “Epidemic.”

[“Epidemic” theme fades out.]

Credits
Taunya English Managing editor @TaunyaEnglish Taunya is senior editor for broadcast innovation with KFF Health News, where she leads enterprise audio projects. Zach Dyer Senior producer @zkdyer Zach is senior producer for audio with KFF Health News, where he supervises all levels of podcast production. Taylor Cook Associate producer @taylormcook7 Taylor is associate audio producer for Season 2 of Epidemic. She researches, writes, and fact-checks scripts for the podcast. Oona Tempest Photo editing, design, logo art @oonatempest Oona is a digital producer and illustrator with KFF Health News. She researched, sourced, and curated the images for the season.
Additional Newsroom Support

Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chiefGabe Brison-Trezise, deputy copy chiefChris Lee, senior communications officer

Additional Reporting Support

Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh

“Epidemic” is a co-production of KFF Health News and Just Human Productions.

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Epidemic: The Tata Way

Tue, 26 Sep 2023 09:00:00 +0000

In spring 1974, over a dozen smallpox outbreaks sprang up throughout the Indian state of Madhya Pradesh. Determined to find the source of the cases, American smallpox eradication worker Larry Brilliant and a local partner, Zaffar Hussain, launched an investigation.

The answer: Each outbreak could be traced back to Tatanagar, a city run by one of India’s largest corporations, the Tata Group.

When Brilliant arrived at the Tatanagar Railway Station, he was horrified by what he saw: people with active cases of smallpox purchasing train tickets. The virus was spreading out of control.

Brilliant knew that to stop the outbreak at its source, he would need the support of the company that ran the city. But he wasn’t optimistic the Tata Group would help.

Still, he had to try. So, Brilliant tracked down a Tata executive and knocked on his door in the middle of the night.

Brilliant’s message: “Your company is sending death all over the world. You’re the greatest exporter of smallpox in history.”

Much to his surprise, the leaders of Tata listened.

Episode 5 of “Eradicating Smallpox” explores the unique partnership between the Tata Group and the campaign to end the virus. This collaboration between the private and public sector, domestic and international, proved vital in the fight to eliminate smallpox.

To conclude the episode, host Céline Gounder speaks with NBA commissioner Adam Silver and virologist David Ho about the basketball league’s unique response to covid-19 — “the bubble” — and the essential role businesses can play in public health. “We need everyone involved,” Ho said, “from government, to academia, to the private sector.”

The Host:
Céline Gounder Senior fellow & editor-at-large for public health, KFF Health News @celinegounder Read Céline's stories Céline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board.
In Conversation With Céline Gounder:
Adam Silver Commissioner of the NBA David Ho Director and CEO of the Aaron Diamond AIDS Research Center
Voices From the Episode:
Larry Brilliant Former World Health Organization smallpox eradication worker in India @larrybrilliant Click to open the transcript Transcript: The Tata Way
Podcast Transcript  Epidemic: “Eradicating Smallpox” Season 2, Episode 5: The Tata Way Air date: Sept. 26, 2023

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

TRANSCRIPT

Céline Gounder: 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.

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

[Light music begins playing softly]

Céline Gounder: Larry was looking for his place in the world as a young man. It took him all over the United States. And beyond …

Larry Brilliant: Hoping that I would find something that was better than capitalism … that helped the poorest and most vulnerable communities.

Céline Gounder: That calling eventually led him to India — and the campaign to end smallpox.

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

Céline Gounder: 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:

Larry Brilliant: “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.”

Céline Gounder: What happened to the tire?

Larry Brilliant: We never know. He never responded. [laughs]

[Music fades out]

Céline Gounder: 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. Céline Gounder, and this is “Epidemic.”

[Epidemic theme music plays]

Céline Gounder: 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 three statewide searches had come back. Not a single case had been found.

Soon, they’d be ready to declare the region free of smallpox.

[Suspenseful music begins playing]

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

Céline Gounder: 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.

Larry Brilliant: No one had any idea what it was.

Céline Gounder: Then finally … a break.

Larry Brilliant: 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.

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

Larry Brilliant: All of them came back “yes.”

Céline Gounder: 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, Zaffar Hussain …

Larry Brilliant: … who knew more about smallpox than I did. He knew more about smallpox than anybody.

Céline Gounder: Larry and Zaffar were running out of options. So, Zaffar tried one last thing.

Larry Brilliant: When they were preparing this boy’s body for cremation, Zaffar 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.

Céline Gounder: Tatanagar.

They had found the source of the outbreak.

[Suspenseful music fades out]

[Ambient sounds and an announcement from the Tatanagar Railway Station play]

Céline Gounder: In the summer of 2022, I followed Larry’s journey to the 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.

Tatanagar’s name comes from the family … and the company … that dominates the area: Tata.

Larry Brilliant: It was known as the “Pittsburgh of India.”

[Upbeat music begins playing]

Céline Gounder: 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.

[Music fades out]

Larry Brilliant: So, when you thought of Tatanagar, when you thought of Tatas, in those days, you thought of wealth, power, modernity, cleanliness, all of those things.

Céline Gounder: But the scene Larry and Zaffar saw when they arrived was very different.

They found a station boiling with smallpox. Bodies wrapped in cloth were stacked like cords of wood.

[Somber music begins playing softly]

Céline Gounder: Some small enough to be children.

As the crowd swirled around Larry, an older man about to buy a train ticket caught his eye.

Larry Brilliant: 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.

Céline Gounder: Larry was overwhelmed.

Larry Brilliant: You gotta understand that the feeling of powerlessness, anger, anger at the Tatas for letting this happen, anger at … God?

[Music fades out]

Larry Brilliant: I said to Zaffar, you know, what do we do?

And he said, we’ve got to find the head of the Tatas.

Céline Gounder: At the time, that meant Russi Mody, who was the managing director of Tata Steel.

Larry and Zaffar got the address — 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.

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

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

Larry Brilliant: And I had this image of a company that just didn’t care.

[Instrumental music begins playing]

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

Larry Brilliant: And I, I ran up to the front door, with Zaffar pulling me back: “Don’t go, don’t go.”

And I pounded on the door. And the door opened.

Céline Gounder: An attendant answered the door. He was not impressed with Larry’s WHO credentials. The attendant tried to turn them away.

Larry Brilliant: 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.

Céline Gounder: By now, the ruckus was too much to ignore. The company managing director, Russi Mody, got up and came to the door.

Larry Brilliant: “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 Russi, I said, “You know, your company is sending death all over the world. You’re the greatest exporter of smallpox in history.”

Céline Gounder: That got Russi’s attention. He ordered his dog to let go of Larry’s hand.

[Music fades out]

Larry Brilliant: And he’d been trained not to bite off the hand, thank God.

Céline Gounder: Russi invited Larry and Zaffar 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.

Russi said he had no idea what had been going on.

But Larry had his doubts.

Larry Brilliant: It seems improbable that the head of 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.

Céline Gounder: Russi asked what could be done. Larry made up a number. Something close to asking for half a million dollars, he estimates. It would cover 4×4 trucks, equipment, and personnel to contain the outbreak.

But, as influential as Russi Mody was, this was a big ask.

Larry Brilliant: So he called up Bombay and spoke to Mr. Tata, J.R.D. Tata.

Céline Gounder: Jehangir Ratanji Dadabhoy Tata — or J.R.D. — was the “Tata” in Tata Industries.

[Sparse percussive music begins playing]

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

Céline Gounder: J.R.D. 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 Russi explained what was needed.

And J.R.D. said yes.

[Music fades out]

Larry Brilliant: 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.

Céline Gounder: Larry took that “yes” he got from Tata and ran with it.

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

Céline Gounder: 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.

Larry Brilliant: 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.

Céline Gounder: 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.

[Grandiose music begins playing]

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

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

Larry Brilliant: 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 six months.

Céline Gounder: 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.

Larry Brilliant: 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 in the world; you could argue that it was enlightened self-interest, but it seemed to me much more than that.

Céline Gounder: The Tata Way, perhaps.

[Music fades out]

Céline Gounder: Working with the Tatas made a big impression on Larry.

Larry Brilliant: Watching the way you could combine public health with its moral compass, with the resources and management skills of 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.

[Reflective music begins playing]

Céline Gounder: J.R.D. 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.

J.R.D. Tata: As the standard of living of the people increase and they want their children educated, et cetera, it’ll be here, it’ll happen here, but too late.

Céline Gounder: That’s a clip of J.R.D. on the Indian television program “Conversations” in 1987 talking about the need to curb India’s birth rate.

J.R.D. Tata: […] and therefore one must find some ways of accelerating the process.

Céline Gounder: J.R.D. 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.

J.R.D. doubled it for his employees and their spouses.

From 1975 to 1976, Tata Steel claimed to have carried out 20,000 sterilizations.

[Music fades out]

Céline Gounder: 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.

[Bouncy music beings playing]

Céline Gounder: The resources of private enterprise — they can be marshaled for good and bad alike.

We saw that at the beginning of the covid-19 pandemic. Businesses weren’t always on the same side as public health. But they can also be powerful allies.

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

Céline Gounder: 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.

[Music fades out]

Dan Weissmann: Hey there! “An Arm and a Leg” is a show about why health care costs so freaking much. And what we can maybe do about it.

[Upbeat music begins playing]

Dan Weissmann: 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.

“An Arm and a Leg” Guest 1: Where there’s money, there’ll be scams.

Dan Weissmann: I’m not gonna lie … we can’t win ‘em all. But it turns out, we don’t have to lose them all either.

“An Arm and a Leg” Guest 2: I was so determined. Like, I was not going to go through all of this for nothing.

“An Arm and a Leg” Guest 3: You have to be willing to tell people in authority sometimes, that you believe they’re wrong.

“An Arm and a Leg” Guest 4: I’m not scared of these fools.

“An Arm and a Leg” Guest 5: That’s when politicians really started getting involved and they passed the law.

“An Arm and a Leg” Guest 6: It’s like reading a postscript in a Dickens novel almost. Like, “Hey look! Now we can’t chain children to factory machines.” Like, “What? Wait, what? That was legal before?”

[Music fades out]

Dan Weissmann: You can catch “An Arm and a Leg” at armandalegshow.com or wherever you get podcasts.

Céline Gounder: 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.

ESPN Clip: 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 game tonight has been postponed. You are all safe.

NPR Clip: The NBA has suspended its entire season. That decision came last night after a player with the Utah Jazz tested positive for covid-19.

Céline Gounder: 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 has 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?

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

Céline Gounder: 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, how would you explain to maybe another, uh, CEO of a company, how you set up the Bubble and what this was?

Adam Silver: It was a partnership with Disney. Uh, 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 fundamentals were there already. And at the peak of the so-called Bubble, we had about 1, 500 people there — that included players, coaches, team, and league personnel.

Celine Gounder: 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?

Adam Silver: Frankly, Dr. Gounder, because we were desperate for a methodology under which we could return to play. And for me, this was 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 would 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, um, you know, it seemed like a wise decision at the time.

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

David Ho: 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 the infected people.

That’s just one example. And another would be correlates protection. NBA had one point drawn blood and we were able to measure antibodies and then NBA follow everyone and knew which, 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, are not well known to the public, but it’s amazing. Uh, it was more successful than many academic groups on the scientific front.

Céline Gounder: Adam, what would you change about the NBA’s response to covid, if anything?

Adam Silver: 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.

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

David Ho: 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 medical community alone. So, it has to be a partnership.

[“Epidemic” theme music begins playing]

Céline Gounder: Next time on “Epidemic” …

Sanjoy Bhattacharya: 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.

Céline Gounder: “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 Sable-Smith, and me.

Swagata Yadavar was our translator and local reporting partner in India.

Our managing editor is Taunya English.

Oona Tempest is our graphics and photo editor.

The show was engineered by Justin Gerrish.

We had extra editing help from Simone Popperl.

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

News clips from ESPN and NPR.

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 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 podcasts.

And subscribe to our newsletters at kffhealthnews.org so you’ll never miss what’s new and important in American health care, health policy, and public health news.

I’m Dr. Céline Gounder. Thanks for listening to “Epidemic.”

[“Epidemic” theme fades out]

Credits
Taunya English Managing editor @TaunyaEnglish Taunya is senior editor for broadcast innovation with KFF Health News, where she leads enterprise audio projects. Zach Dyer Senior producer @zkdyer Zach is senior producer for audio with KFF Health News, where he supervises all levels of podcast production. Taylor Cook Associate producer @taylormcook7 Taylor is associate audio producer for Season 2 of "Epidemic." She researches, writes, and fact-checks scripts for the podcast. Oona Tempest Photo editing, design, logo art @oonatempest Oona is a digital producer and illustrator with KFF Health News. She researched, sourced, and curated the images for the season.
Additional Newsroom Support

Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chief Gabe Brison-Trezise, deputy copy chiefChris Lee, senior communications officer

Additional Reporting Support

Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh

“Epidemic” is a co-production of KFF Health News and Just Human Productions.

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Watch: Thinking Big in Public Health, Inspired by the End of Smallpox

Mon, 18 Sep 2023 09:00:00 +0000

One of humanity’s greatest triumphs is the eradication of smallpox. Many doctors and scientists thought it was impossible to eliminate a disease that had been around for millennia and killed nearly 1 in 3 people infected. Smallpox is the first and only human disease to be wiped out globally.

KFF Health News held a web event Thursday that discussed how the lessons from the victory over smallpox could be applied to public health challenges today. The online conversation was led by Céline Gounder, physician-epidemiologist and host of “Eradicating Smallpox,” Season 2 of the Epidemic podcast.

Gounder was joined by:

Helene Gayle, a physician and epidemiologist, is president of Spelman College. She is a board member of the Bill & Melinda Gates Foundation and past director of the foundation’s HIV, tuberculosis, and reproductive health program. She spent two decades with the Centers for Disease Control and Prevention focusing primarily on HIV/AIDS prevention and global health.

William “Bill” Foege was a leader in the campaign to end smallpox during the 1970s. An epidemiologist and physician, Foege led the CDC from 1977 to 1983. He appears in the virtual learning series “Becoming Better Ancestors: Applying the Lessons Learned from Smallpox Eradication.” Foege is featured in Episode 2 of the “Eradicating Smallpox” docuseries.
click to open the transcript Transcript: Thinking Big in Public Health, Inspired by the End of Smallpox
Note: This transcript was generated by a third-party site and may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the web event.

TRANSCRIPT

[The video trailer for season 2 of the Epidemic podcast, “Eradicating Smallpox,” begins to play]

Céline Gounder: Bangladesh 50 years ago, we were on the cusp of something big, something we had never done before. We were about to wipe smallpox off the planet. It’s one of humanity’s greatest triumphs. One public health has yet to repeat. I’m Dr. Celine Gounder. I’m a physician and epidemiologist.

This season of Epidemic, we’re going to India and Bangladesh, where smallpox made its last stand, to understand how health workers beat the virus. The question I’m asking, “How can we dream big in public health again?” From KFF Health News and just human productions, Epidemic, eradicating smallpox. Listen wherever you get your podcasts.

[Video trailer ends]

Céline Gounder: Good morning everyone, and thanks for joining us today. I’m Dr. Celine Gounder. I’m editor-at-large for Public Health at KFF Health News and I’m the host of the Epidemic Podcast. In today’s conversation, we’re going to talk about lessons to be learned from the eradication of smallpox and how those can be applied to public health challenges today. The eradication of smallpox is one of humanity’s greatest triumphs. Many doctors and scientists thought it was impossible to eliminate a disease that had lasted for millennia and killed nearly one in three people infected. Smallpox remains the first and only human disease to be wiped out globally.

Just a few logistical details before we get started. The briefing is being recorded and the link to the recorded version will be emailed to everyone later today. We also have ASL interpretation available. To access it, please click on the globe icon in your Zoom control panel and select ‘American Sign Language.’ A screen will appear and you will be able to view the interpreter. Questions should be entered using the Q&A function on Zoom and can be sent in during the discussion.

I’d like to move forward with introducing our panelists today. Dr. Bill Foege is an epidemiologist and physician and was a leader in the campaign to end smallpox during the 1970s. Foege is featured in episode two of the Eradicating Smallpox docuseries, and he’s also featured in the Nine Lessons series produced by the Becoming Better Ancestors Project. The Nine Lessons, available at ninelessons.org, is a virtual learning series about how the lessons from smallpox eradication could be applied to COVID and other public health and societal challenges.

Also, joining us today is Dr. Helene Gayle, who’s also an epidemiologist and physician. She’s the president of Spelman College. She’s also a board member of the Bill & Melinda Gates Foundation and past director of the Foundation’s program on HIV, Tuberculosis and reproductive health. She spent two decades with the Centers for Disease Control and Prevention, focusing primarily on HIV AIDS prevention and Global Health.

So welcome and thank you for joining us today, Bill and Helene. I’d like to start with talking about some of the challenges we face in science communication. And as we’ve seen during the COVID pandemic, one of the big challenges is balancing reassurance with uncertainty. And before I ask you my questions, I’m going to play a clip of Dr. Tony Fauci speaking about this as part of the Nine Lessons series. So let’s give that a listen.

[Video clip from the Nine Lessons series begins to play]

Tony Fauci: If you have a static situation with nothing changing and you get one opinion one day, and then a week later you change, that’s flip-flopping. When you have a dynamic situation that’s evolving week to week and month to month, as a scientist, to be true to yourself and to be true to the discipline of science, you have to collect data as the situation evolves, which almost invariably will necessitate your changing policy, changing guidelines, changing opinion. And that’s exactly what happened with things like mask wearing. We didn’t know until weeks and weeks into the outbreak that a lot of the transmission was by people who were without symptoms. It was that that made the CDC and all of us say, “We really don’t need to be wearing masks.” As soon as we found out that, A, there was no shortage, B, we were getting good data, that outside of the hospital setting masks did work, and three, we found out that 50% of the infections were transmitted from someone who had no symptoms. When you put all those three things together, then the science tells us everybody should be wearing a mask.

[Video clip ends]

Céline Gounder: Bill, how did this play out in the smallpox eradication program, specifically this idea of scientific certainty, uncertainty, and science communication?

Bill Foege: This is actually a balance that goes far beyond public health and medicine and almost everything we do. And on the one hand, you have to have enough certainty in order to get other people to follow you. There’s a book by Gary Wills on Leadership, and it’s entitled Certain Trumpets. He takes this from the Bible verse that says, “If you hear an uncertain trumpet, who would gird for battle?”

So you have to have enough certainty. The other side of that though is Richard Feynman, the physicist who said, “Certainty is the Achilles heel of science.” If we believe something is true, we stop looking for other answers to why this is happening. And I think in smallpox, we always tried to present certainty in what we were doing. And all the time we worried about what could go wrong, what if we lose political support? I didn’t see HIV coming, but boy, if I had, that would’ve been a big problem to deal with.

Céline Gounder: Helene, don’t you think public health officials should still be confident in expressing, particularly in an emergency, what we know and their recommendations for managing a public health crisis, and how do you balance that confidence and reassurance with the lack of certainty?

Helene Gayle: So I think, and building on some of the things that Bill said, I think part of it is building the confidence in the communicator. And I think one of the things, and I point to Tony Fauci, is one of those people who I think Americans developed a sense of confidence with him because of his willingness and ability to say when we were wrong and what we know and when we knew it. And so I think recognizing that a lot of this is about building trust and building trust in the message as well as in the messenger. I think that’s where some of the ability to be confident, letting people know that you’re trying to give them the information as soon as you have it, but also being honest that this is evolving.

A message is just a slice in time. And I think it’s important that we remember that we’re creating a narrative every time we open our mouths and thinking about what’s the narrative that we’re creating and being consistent in that narrative. So I think the consistency, building that trust, being able to say what you know and what you don’t know is what really I think builds the confidence in the messages. I think what we saw through this pandemic as well, the COVID pandemic as well as past, are people who are unwilling to admit what they know and what they don’t know, unwilling to go back and explain why we said something when we said it and why we’re making that explanation of why we’re now changing, as I think Tony Fauci did very clearly about mask wearing.

So I think all of those things that really are about building trust and confidence are what can make us better in our communication as public health officials.

Céline Gounder: So it still amazes me that the global health community decided to take on smallpox eradication. We often hear about sustainability, cost-effectiveness, those kinds of economic concepts. What does it mean, Helene, for a program to be sustainable? And when we say sustainable, for whom?

Helene Gayle: Well, I think what we hope when we talk about sustainability is that efforts that are important for the short run can be sustained over the long run. And I think what we see so often in public health is that we have this massive surge of resources, personnel, effort, that then we let go of in between times.

So each time we have a pandemic, we have to create this big surge all over again. What we need in public health is to be able to have that kind of long-term, sustainable approach, understanding that there will be times when we have to have those surges, but not letting everything go in between time. When you say for whom, it’s really about how do we create a system and have a system that is in place that gets us not only at the times of great need and crisis, but is there for the public’s health for the long-term. And that’s what I hope we can move to as we think about public health in America and around the world.

Céline Gounder: Bill, does that sound like that’s a “sustainable goal” and should we be setting our public health goals based on what some think is sustainable or not?

Bill Foege: Well, sustainability is a problem that I often had because people require evidence of sustainability before they’ll fund something, but you don’t know what is sustainable until you try and do it. One of the lessons that I learned in the seventies was, in this country, the appropriations for measles would go up when there were lots of measles cases and they would go down when cases were reduced.

And inevitably, when they would go down, then the numbers had come up again. And so we had these variations. And we made a decision in the 1970s what would happen if we could interrupt transmission once, and that changes everything. Now the norm would be no transmission, and you could sustain the appropriations and it worked. We finally did that. So sustainability is something that bothers me. The pragmatists demand this, and I understand where they’re coming from, but there was a fellow by the name of Harlan Cleveland who was an American diplomat. He was our ambassador to NATO for many years. And late in his life, he became interested in global health and he was astonished at what happened with so few resources. And he came to the conclusion that global health workers are fueled on unwarranted optimism. And I like that phrase, because that is in fact what we do, is we become very optimistic and we make something happen that could not have been foreseen, that it would happen.

Céline Gounder: So this also reminds me about a conversation we had on the podcast with, believe it or not, a science fiction writer. Her name is adrienne maree brown, and we spoke with her about how she imagines world’s, possibilities different from our own. So let’s hear a short clip of that now.

Where do you find the inspiration to think up, to dream up the world’s that are so wildly different from our present reality?

[Audio clip from episode 1 of the “Eradicating Smallpox” begins to play]

adrienne maree brown: Saying that stuff is just the way it is. That’s one of the greatest ways that those who currently benefit from the way things are keep us from even imagining that things could be different. For centuries in this country, we were told that slavery was just the way things are and that it could never be any different. And yet there are people in those systems who said, “This isn’t right, this isn’t fair. Something else is actually possible.”

So a lot of the work of radical imagination, for me, is the work of saying, can we imagine a world in which our lives actually matter and we structure our society around the care that we can give to each other, the care that we need.

[Audio clip ends]

Céline Gounder: Bill, you just talked about unwarranted optimism and you told me once, in fact, I think more than once to bet on the optimist. But to go back to what you were saying about the pragmatist, doesn’t it make more sense on some level to be pragmatic and realistic if you want to get things done? And how would realism have gotten in the way of efforts to eradicate smallpox?

Bill Foege: Well, I think realism would have kept us from trying many things that we’ve tried. And the clip you just showed about an imagination that goes beyond realism is so important. If I would be director of CDC again, if I had a problem, I would try to get six comedians to come to CDC and I present them with the problem because they think in a different world than realism. And so I think it just makes sense to be unrealistic that we can do these things.

Céline Gounder: Helene, what about you? How did you balance thinking big versus being pragmatic when you were leading public health programs over the course of your career?

Helene Gayle: Well, I didn’t bring in comedians, but I think maybe I missed the boat on that. I love that idea. I like to think that I was able to combine the two. I think if you don’t think big, you will only achieve small progress. So I think you have to have big goals, but big goals can also be chunked into bite-sized pieces. So I think mixing the practical of what are the short-term games that are necessary to get to those big goals, both, give you a sense of what’s pragmatic and possible, but also keeps you inspired towards the bigger goal.

I think it’s also the case in public health where oftentimes we are operating with very difficult political situations. And again, sometimes you have to be the realist and understand what the limits are, but at the same time not give up on what’s your ultimate goal, what’s your ultimate vision, and keeping that front and center, it’s incredibly important, particularly as we think about how we inspire, back to the unwarranted optimism, how we inspire public health workers to keep going. People don’t get inspired by the short term, “Did I get my stock in today?” They get inspired by, “I’m part of eradicating a disease or stopping a pandemic.” So I think we have to combine the two.

Bill Foege: I might say that in India, we would have a meeting every month in the endemic states and go over what we had learned that month, and we would end the meeting by setting goals for the next month. We never once reached those goals until the last month. They were always beyond what we could do, but they gave us a vision of what we hoped we could do.

Céline Gounder: So this also reminds me of another aspect of goal setting. In another episode of the podcast, we spoke with a global health expert, Dr. Madhu Pai at McGill University, and he pointed out that historically it’s been white men in Europe and in the United States who’ve really driven the agenda in global health. Here’s just a short clip from Madhu.

[Audio clip from episode 2 of the “Eradicating Smallpox” begins to play]

Madhukar Pai: We need to flip the switch and recenter global health away from this, what I call default settings in global health, to the front lines. 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, people who have actually lived experience of these diseases that we’re talking about, having them run it is the most radical way of re imagining and shifting power and global health.

[Audio clip ends]

Céline Gounder: So Bill, who set the smallpox eradication goals? Was this local or global experts or both? Was it local communities and how were those different perspectives weighed and balanced in the program?

Bill Foege: Well, the global goal was set by WHO. It was originally conceived by the Soviet Union and presented to WHO, and it got only three votes the first time. Later, when the Soviet Union and the United States combined their efforts, they were able to convince the World Health Assembly and WHO took this on. So the global goal was set by WHO, but countries had the ability to say no. And Ethiopia went for a long time not becoming part of the program, they had other priorities. And these are legitimate priorities that World Bank once had a discussion on whether we should get into polio eradication or not. And I agreed to be part of the debate, even though I hate debates. I agreed to be part because I wanted to know what were the strongest arguments against polio eradication. And for me, there were two of them.

One was that this would distract from other global health efforts. People would focus on this. But the other one came from an African leader who said, “This is neocolonialism. You’re telling us how to spend our money on a disease problem and not allowing us to make that decision.” My counter to that was, “I understand that, but I also understand when Gandhi said his idea of the golden rule was that he should not be able to enjoy what other people could not enjoy.” And so I said, “If I can enjoy the fact that my children, my grandchildren, and now my great-grandchildren are free of polio, I have an obligation as a parent to share that with everyone.”

Céline Gounder: Helene, very often it’s scientific experts, physicians, epidemiologists who really lead the goal setting. Is there anything wrong with this technocratic approach to public health goal setting, and isn’t that just “following the science?”

Helene Gayle: Well, it’s obviously following the science at a macro level, but I think, while it’s important to set these global goals and these big overarching goals, it’s also very important to listen to the people whose health we’re actually trying to have an impact on. And I can remember, during the HIV pandemic, where once people realized how important it was to mobilize resources, there was an unprecedented amount of resources available for HIV, and we got from several countries around the world, the pushback just as Bill was talking about, because they said, “Malaria is a bigger problem for me. We have more people who die from malaria, from measles, from other infectious diseases. So where are our resources for the things that are making the biggest difference for our people?”

So I think it’s great to set the global goals and to be able to have these big overarching goals, but we can’t do that in the absence of also listening to the national and local needs and making sure that we’re thinking flexibly about how we use our resources so that what we do really meets the greatest needs of people on the ground.

Céline Gounder: Bill, you once quoted Einstein to me who said, “Perfection of means and confusion of goals seem, in my opinion, to characterize our age.” So are government officials and public health leaders somehow confused about public health goals while being overly focused on perfecting public health tools?

Bill Foege: I think so. You can’t stop scientists from trying to enlarge their area of knowledge. This is what scientists do. They try to figure out what is right and what is wrong. And so yes, we do confuse this. And it doesn’t matter whether you’re talking about a person, a state, a nation or the world, we devalue health until the day we lose it, and then suddenly it becomes so important. And so this idea of conveying what should happen ahead of time so we don’t lose health is problematic. But yes, it’s much easier to concentrate on the specifics and lose our sight of where we’re actually going with this.

Céline Gounder: Can you just give an example of this attempt to perfect a public health tool?

Bill Foege: Well, with vaccines, you see that people keep improving the vaccines, but don’t improve how to get them to everyone. The clip you showed on white people, mainly white men, making the decisions on global health in the past, is so true. And I’ve just finished reviewing the history of global health, and I think the one thing that was most destructive of global health was colonialism. Some people try to justify it on the basis of it brought new science and so forth, but just think of this country and the fact that colonialism killed off so many people that the slave trade became so important.

And so today, we’re still operating with the effects of colonialism in this hemisphere. Not seeing the vision of the big goal and concentrating on small things, it’s easier for all of us to do.

Céline Gounder: Helene, do you agree that public health officials are confused about the goals? And if so, why and how?

Helene Gayle: Well, I think it’s hard to talk about public health officials as a monolith, and it’s part of the challenge, particularly in this country, is that we have such a disjointed public health system. And I think we would benefit from having a much different public health system, such that people can individualize their roles, what they want to focus on, et cetera. But at a national level, and I would argue even at the global level, that there is a system that is consistent about what’s most important and what’s most important to deliver on.

So I do think that there’s a lot of inconsistency in our system. I think we have a fragmented public health system, and we would really benefit by having something that really had a much more of a network that is coordinated than what we have today.

Céline Gounder: I just got back actually from vacation in Morocco and I happened to be staying in the Medina in Marrakesh the night of the earthquake. And it’s now been estimated that nearly 3,000 people have died in that earthquake or from that earthquake, to date. I felt it, but the building where I was staying sustained hardly any damage. And to date, I haven’t heard of any tourists or expats having been reported dead or seriously injured. Now, this was not an infectious disease outbreak, but it is a public health crisis of a kind, and some are more likely to be hurt and die than others. What does this tell us about, Bill, how to build resilience into the system and how was this done in the context of smallpox?

Bill Foege: Well, the resilience is a difficult thing because we think locally. Well, wherever you are in the world, you’re both local and global. So I keep telling students, wherever you’re working, you’re working on global health. And so start thinking that way of how do we incorporate all these people. And see, you’re absolutely right. It doesn’t take an infectious disease. It takes a disaster to show what the social problems are that are causing this. Michael Osterholm once said, “One of the best fire departments we have is at the Minneapolis airport.” He said, “If we go 10 years or 15 years without a crash, no one will reduce their budget.” This is the kind of resilience that we need in public health. The last appropriations hearing that I had as director of CDC was chaired by Senator Hatfield from Oregon. He was the chair of the entire Appropriations Committee, but he asked permission, as a favor to me, to actually share this last one.

He asked me a question that I was not expecting, which is the one you just asked. He asked, “If you were in charge, how would you improve the sustainability of public health?” And I told him that there were three things I would do. Number one, I would identify any program that has a positive benefit cost ratio, that is, for a dollar invested, you save more than a dollar, plus you improve health. Because if you don’t do that, you’re agreeing to spend money and have the disease both. And I said, “If you took these programs,” and I said, “In order to avoid infighting between the Congress and the executive branch, I put this totally in charge of Congress.” You decide when a program has a positive benefit cost ratio. And now it doesn’t compete with other things in the budget, it becomes something that’s an entitlement. We need this because it is cheaper and it improves health.

Number two, I said, “I would index public health to healthcare expenditures, because the ratio of public health to healthcare keeps going down every year.” I said, “I would accept whatever it is right now and say we have to index our public health spending to that.”

And the third, I would come up with mechanisms to improve and reward programs that benefit outcomes. Today, we benefit access and process, but not outcomes. And so, if we could benefit outcomes, it would change the way the insurance companies work and other programs work. So those three things I think would provide sustainability and public health we don’t have now.

Céline Gounder: Helene, how was resilience built into the system in the context of HIV and or TB?

Helene Gayle: I’ll answer that in a minute, but I just want to add on and taking from the example that you gave from Morocco that I think in many cases we’re talking about sustainability and resilience, but we’re also talking about equity. At the end of the day, the reason you probably were less likely to get impacted was you were probably staying in a building where the construction had been done in a way that it was as sustainable and not prone to the conditions of earthquake. And the people who are likely to have lost their lives were probably living in substandard building situations. So I think every time we think about sustainability and resilience, we also have to think about equity and are we making sure that the way in which we design our programs take equity into consideration, because that’s ultimately what is going to make populations and people have the kind of resilience that’s necessary.

I think when I look at the programs like tuberculosis and HIV, I think what we tried to really do was to build up systems as we went along, because the best way to make sure that our efforts were sustainable and had resilience built into them was to actually build systems, not just focus on the program or the effort that we were doing.

So in HIV, clearly when I look back on the public health infrastructure that was built, the human capacity that was developed as a result of HIV, that’s what starts building in resilience because you’re not just building for the HIV pandemic, but you’re really using those dollars in ways that can help to strengthen systems. And that’s what I think we have the kind of resilience and sustainability that we’re talking about.

Céline Gounder: Lately, I’ve been thinking a lot about this concept of “Wicked problems.” And for people who are not familiar with this term, it goes back to the management literature several decades ago. And these are complicated, they’re messy, they’re context specific problems. People may not agree that there is a problem or what the problem is, they disagree on what caused it. And with wicked problems, there’s no one right solution, just some that might be less bad, might often create new problems. And so, these are very much about values and not just science. Bill, how would you apply this idea of wicked problems to public health challenges like smallpox or COVID?

Bill Foege: Well, wicked problems turns out to be a good expression of, a great picture of this. And when I think of vaccines, for instance, in the beginning, in 1796 of the smallpox vaccine, and how they’ve improved in numbers and types, when I was born, my baby book shows I have got only two vaccinations. Children today will get 18 or 19 or 20 different vaccinations. And you look at the future of this, we now have two vaccines against cancer, one against liver cancer and one against cervical cancer. We’re going to see more vaccines against neoplasms. You look at the possibility of having vaccines in the future for certain heart diseases or even for addiction, alcoholism and drug addiction, and the possibilities are so great. And yet at the same time, we have more and more people who don’t trust science, don’t trust government, and they become anti-vaxxers.

So this is the real challenge of vaccines. It will continue to be the foundation of global health, but we have to figure out how to get people incorporated in the solutions. Vashon Island in Puget Sound had a reputation for very low immunization uptake, and many of the people on the island were the hippies of the sixties and they didn’t trust government and so forth. The New York Times actually had a front page article on the rate of immunization in children, and I think about 19% were not being immunized.

Now, they would not listen to the health officers of Seattle or anyone else of authority coming in, but two parents who had been Peace Corps volunteers started their own program of finding out from people what would it take for you to change your mind. What is it that you don’t know that you wish you knew? The vaccination rate decreased from 81%, or increased from 81% up to 88%, 89%. They were doing something at a grassroots level that we could not have done from the top down. And so, there are solutions to wicked problems, but they sure do require energy and organization and the ability to respect culture.

Céline Gounder: Helene, is there a way we can better align people who have different sets of values around some of the same public health goals or strategies when it comes to some of these wicked problems, whether that is COVID or some of the other problems facing us today, whether it may be climate change or disinformation. Bill mentioned some of the challenges with anti-vaxxers and anti-science.

Helene Gayle: Well, this is another time where I think we should bring in the comedians, but I do think, maybe not the comedians, but to take a point from what you were saying earlier, Bill, I do think looking at how do you find the common ground? And sometimes there’s only 5% of common ground, but you can start with that and continue to grow from there. I think oftentimes, we approach these things that are adversarial in a counter adversarial way. So if somebody’s hostile, we up the hostility, instead of thinking, “All right, where can we find common ground? What are the things that we all agree upon?”

And sometimes it’s just the simple fact that we agree that saving lives is a high value and you can start from there and begin to develop the proof points that make nonbelievers believers. So I think we don’t do enough of thinking about where we find common ground, and instead, go to our corners and think by continuing to insist on what we believe and think that that’s what’s going to convince people, versus starting from where we all have a common belief and building from there. I don’t know any other way to do it. It’s not a magic bullet. It won’t work all the time. But I also think there has to be a point at which you recognize there are some people who you will never get on your side, and if you continue to try to wait for that to happen, you’ll get stuck and not move forward.

So there’s always a certain point when you just need to keep moving forward, understanding that if you demonstrate effectiveness, that may be the most likely way of bringing others along.

Bill Foege: When I’ve had an opportunity to meet with anti-vaxxers, I always start with the fact that I know no parent does this, withholding vaccines, to hurt their child.

Helene Gayle: Exactly.

Bill Foege: They do it only because they believe it’s the best thing for their child. And so if you can start there, you’re in a different position than if you just say, “Well, don’t you read the literature? Don’t you listen to…?” So I think understanding that there’s a reason why people feel this way is the beginning.

Céline Gounder: So earlier we were talking a bit about public health tools and this desire to perfect public health tools, but at the same time, innovations in medical technology were in fact key to eradicating smallpox, especially a simple little tool called the bifurcated needle. Here’s a clip of some smallpox eradication workers discussing this tool from episode four of the podcast.

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.

[Audio clip from episode 4 of the “Eradicating Smallpox” podcast begins to play]

Tim Miner: It was a marvelous invention. In its simplicity, it looks like a little cocktail fork.

Céline Gounder: You dip the prongs into a bit of vaccine.

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

Céline Gounder: It barely took 30 seconds to vaccinate someone. And it didn’t hurt.

Yogesh Parashar: No.

Céline Gounder: Well, it didn’t hurt too much.

Yogesh Parashar: It was just like a pin prick rapidly done on your forearm. You had a huge supply with you and you just went about and dot, dot, dot, vaccinated people. Carry hundreds with you at one go.

Tim Miner: And you could train somebody in a matter of minutes to do it.

Céline Gounder: 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 two and a half, three inches long, small but sturdy enough for rough-and-tumble field work.

Yogesh Parashar: 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.

Céline Gounder: And maybe worth its weight in gold.

[Audio clip ends]

Céline Gounder: So, Bill, public health officials say, in the context of COVID, that we now have the tools to diagnose and treat and prevent COVID, but are these tools enough for us to declare victory over COVID when not everyone has access to those tools? And in the context of smallpox, how did non-biomedical tools compliment biomedical innovations like the bifurcated needle?

Bill Foege: Well, going back to what Helene said, we have to be thinking of this globally and everyone and realize that these tools for smallpox, that is the vaccine, at least some way of giving it, existed long before WHO decided to have a program. But the people that were getting smallpox were the ones who were disenfranchised. They were the ones who were unemployed, in poverty, who had bias, that sort of thing. And so, it was very important to include the non-technical things. And in smallpox, I can tell you that every school and every church and every chief of a village and every volunteer that became involved was part of the solution of this.

Now, on the other hand, I can’t quite give up on smallpox eradication, even now, 40 plus years later. And I keep thinking of ways we could have improved. Nowadays, I would train dogs to pick up the scent of smallpox, because sometimes you would have beggar communities, people actually at the railroad station covered with a cloth with smallpox, but nobody knew that, but a dog would’ve picked that up right away. I’ve even come to the conclusion, if we were well enough organized, we could get rid of smallpox without vaccine and without the technical tools, the bifurcated needle, the jet injector and so forth. You would simply get people who are sick with smallpox and you would isolate them immediately and then you would follow all of their contacts. And the first symptom in a contact would get isolated and so on. And if you were organized well enough, you could get rid of smallpox without vaccine. So the tools are very important, but they’re not the last word.

Céline Gounder: Well, and in fact, that’s the approach that was used for Ebola. And now we have a vaccine. But most of the Ebola control efforts during the West African epidemic were really about that, identifying and isolating.

Helene, are we overly reliant on biomedical tools? And if we are overly reliant, should we pave the way for greater use of non-biomedical tools?

Helene Gayle: Well, as we know, the social determinants of health contribute more to health status than access to healthcare itself. So access to healthcare, including all the biomedical advances is necessary but not sufficient. I think we have to continue to think about why do we have some of the gaps in health that we know already exists. We look at the COVID pandemic as an example, where we know that the populations that were at greatest risk outside of age are people who lived in houses that were overcrowded or who had jobs that put them at risk, low wage earners, et cetera. So I think we have to think about both things. And I think back to your earlier question that is about people’s trust and mistrust, part of the trust in people being willing to access some of our biomedical tools comes from feeling that the rest of their needs are also being taken care of.

So if we just think of populations as we’ve got these great tools and we are going to give you these tools when your greatest challenge is whether or not you’re going to be able to feed your children at night or whether or not you’re going to have a roof over your head, you’re not going to be as eager and the uptake of our biomedical tools will not be as great. So I just think it’s about combining both and making sure that we’re thinking about some of these root causes that will also be part of helping to enhance, focusing on those will also be part of enhancing people’s trust and belief in some of the other approaches, that biomedical approaches that we know also make a huge difference.

Céline Gounder: Public health is different from clinical medicine, in that it focuses on the public or the ‘we’ so to speak, while clinical medicine focuses on the ‘I’ or the patient. There seems to be very little appetite in this moment for thinking about the ‘we.’

Bill, is there anything wrong with that? And if so, how do we shift that perspective that thinking about ‘we’ and public health and beyond?

Bill Foege: People often say clinical medicine deals with the numerator, the people that come to clinics and hospitals for care, while public health deals with the denominator. That’s simplistic because the denominator includes the numerator. And so, public health really is concentrated on everybody, on the ‘we’ and how to get everybody together on this.

There are two things from history that always impressed me. Confucius was asked by a student once, “Could you tell us in one word how best to live?” And Confucius said, “Is not reciprocity that word.” And so, this is ‘we’ that everybody’s dealing with each other. And then Gandhi said, his idea of the golden rule was that he should not enjoy something not enjoyed by everyone, the ‘we.’

So we keep hearing this from the wise people of history to stop thinking about just ourselves. Gandhi also said, “We should seek interdependence with the same zeal that we seek self-reliance.” And then he added in a soft voice, “There is no alternative.” And this is true. There is no alternative. And we’ve just got to take that approach in school, that’s much of school is built around how to improve your self-reliance, how to develop, how get money in the future and so forth. And we have to figure out how to teach interdependence.

Céline Gounder: Helene, should we be moving from an ‘I’ to a ‘we’ framing? And if so, how do we do that?

Helene Gayle: I think we have to. I think we recognize, and when we have pandemics, it’s very obvious. You can’t just think about what’s happening to you as an individual without recognizing that if we don’t stem transmission for something like a COVID, all of us are at risk.

So I think this sense of reciprocity is critical as we think about it. And it’s more broadly in our society. We can’t think that crime happens in one part of the city and it won’t also impact our economy, the economy of the city overall and ultimately impact other neighborhoods. I think we continue to think that we can wall off problems when we have to realize how interconnected we are, whether it’s health, whether it’s our economies, whether it’s the issue of climate change. I think as a species, we’re at a point where the ‘I’ thinking is having huge impacts for all of us. And unless we start having that ‘we’ mindset, we really are not going to be able to tackle some of these difficult wicked problems.

Bill Foege: If I could add one thing that Will Durant once said, ‘We will never do things globally unless we fear an alien invasion.” And what we’ve come up with are surrogates for alien invasions. So we see nuclear weapons as threatening of all of us. So we think ‘we.’ But there are other things. Our synthetic biology might be another one of these. Climate change may be a third one. We have four or five things that could totally eliminate people and we should be thinking ‘we’ in order to solve those problems.

Céline Gounder: So I’m now going to shift gears a little bit and take some of the questions our audience has been sending in. The first comes from Paurvi Bhatt who asks, “As we try to deal with new pandemics and eliminate older ones, how can we balance attention spans, science and safety in a world where “failing fast” and disruption define how we think about innovation?”

Helene, do you want to take a stab at that one?

Helene Gayle: Well, I just think we have to stay the course and continue to find ways. And we started out talking about health communications. I think we need to get better at our communications and in keeping people engaged in issues, because we are living in this 24/7 news cycle and a new issue coming up all the time. I think we as health professionals have an obligation to make sure that we are keeping these issues that are front and center in people’s minds and continuing to share what progress is happening. I think when people recognize there’s progress and you’re not just telling the same old story, I think you can keep people engaged, but I think it’s on us to do a better job in that regard.

Céline Gounder: Bill?

Bill Foege: I tell students now, and it took me a long time to reach this conclusion, that whenever they’re faced with these big problems, to think of three things.

Number one, try to get the science right. We’ve talked about you can’t always do that and you have to apologize and go back, but try to get the science right.

Number two, add art to the science. Will Durant says, “The first scientist that we know by name was Imhotep in Egypt, who was a physician and an artist and designed the step pyramid.” Because he said, “Then you get creative common sense at its best.” It was Huxley that says science is simply common sense at its best. So you get creative common sense at its best.

And then I go back 700 years to Roger Bacon who did a report for the Pope. And he said, “One of the problems with science is it has no moral compass.” And so you have to develop scientists with a moral compass. And when you do this, now you have moral creative common sense at its best, and this is a great approach to wicked problems.

Céline Gounder: Is public health science with a moral compass?

Bill Foege: It’s supposed to be. And sometimes we see it drifting off, but in general, public health people have a social mind that they’re trying to do this with a moral compass, including everyone.

Céline Gounder: Our next question comes from Merina Pradhan. Can you touch upon how the message needs to be as simple and brief as possible? Dr. Fauci’s message was very on point from a public health point of view, but how many in the general population would be able to assimilate that? Helene?

Helene Gayle: I would just say we have to tailor the message to the audience. When I saw the background that Dr. Fauci was talking against, I think he was talking to an audience of people who could incorporate that message. I might be wrong, but I think regardless, the point is if you’re sitting and talking to a group of public health professionals, you have one message. If you’re talking to the general public, you have another.

And I think it is true that we sometimes get confused with our own language because there’s so many nuances to public health that we put out these messages, that by the time we’re done, it’s hard to know. Do you believe yes, or do you believe no? So I agree. I think we have to keep it simple, but I think we also have to keep it truthful. And sometimes that’s a real challenge with the nuances of public health messaging. But I think again, tailoring it to the different audiences and recognizing that hopefully you have more than one bite at the apple, if you will, to make it short and concise, but then have other opportunities where you can explain it in greater detail.

Céline Gounder: Bill, this question is for you, from Mark Rosenberg, one of the new epidemics is the public health crisis of gun violence, now the leading cause of death for children and teens in the United States. Are there lessons from the eradication of smallpox that could be applied to help solve this new epidemic?

Bill Foege: I think all of the lessons from smallpox, knowing the truth, having coalitions, making sure that you progressing in the right way, having respect for culture, all of these things do apply. But I would end that answer, with becoming better ancestors, we’re saying that the ultimate expression of love from any of us is to become a better ancestor. And we certainly can do better on gun violence. And don’t put up with the discussion that says this is due to mental health problems and this and that, when other countries don’t have the same problem and they have just as much mental health problems as we do, but they don’t have the guns available.

Céline Gounder: Helene, this is a question from Ayo Femi-Osinubi. “Bill mentions that we don’t know what is sustainable till we try. How would you approach sustainability for pandemic preparedness in the midst of trying to prioritize basic health service delivery?”

Helene Gayle: Well, I think that the two aren’t necessarily in opposition. I think we need to have basic health services and building on basic services, making sure that we are thinking about how are those services available and sustainable so that when we have crises, public health crises, those systems are there and functional in a way that allows us to ramp up for public health emergencies.

So I think those things are not in opposition. It’s what I was talking about earlier. I think we need a more clear and comprehensive public health system that doesn’t just get ramped up every time we have a crisis, that it’s there, that it’s stable, that we have the kind of workforce that we need, that we have the kind of tools that we need, and that those are in place and that we build upon those than the other services that are important for individual care.

So again, I go back to a lot of this is about how we build systems that can be sustained and that are flexible and nimble so that they can respond when we have these public health crises.

Céline Gounder: So one last question. I’m going to give this one to Bill from David Torres. “I teach my global health students about the history of smallpox eradication. Given the coercive nature of the final push to vaccinate some people for smallpox and today’s resistance to and mistrust of public health measures, including vaccination campaigns and masking for COVID, would the elimination of smallpox be conceivable today? And if so, how would it be accomplished?”

Bill Foege: It would be very difficult today because of HIV and not knowing about immune systems, but you could still do it. The question about coercion, we hear this often, and most of this comes from one paper by Dr. Greenough, where he has interviewed people who worked on smallpox who used coercion. They would break into huts at 2:00 in the morning with the police officer to do that. None of that was necessary.

And so particular people were so enthusiastic about smallpox eradication that they did this. But think about it for a moment. If you have a village with three people who have refused vaccination, if they get smallpox, everyone around them is already vaccinated. They’re the ones that suffer. You don’t have to go in and use coercion. And so, when I’ve talked to other people who worked in smallpox, they’re surprised that anyone used coercion. You don’t have to do that, and that’s part of respecting the culture, is that you find other ways to do this.

Céline Gounder: Well, I really want to thank both of you, Bill and Helene for joining us today and for answering all of my questions, the audience’s questions. Between the two of you, you have over a century’s worth of wisdom in public health, and I always love hearing what you both have to say about these issues.

I just want to remind the audience that a recording of the event will be posted online later today and that all registrants will be sent an email when the recording is available. Also, please check out the podcast, Epidemic. It’s available on Apple, Spotify, wherever you get your podcasts. Season two is the season on eradication of smallpox. And also check out the Nine Lessons at ninelessons.org. And thanks everyone for joining us today.

Helene Gayle: Thank you.

Bill Foege: Thank you.

Season 2 of the ‘Epidemic’ Podcast Is ‘Eradicating Smallpox’

The eight-episode audio series “Eradicating Smallpox” documents one of humanity’s greatest public health triumphs.

By the late 1960s and early 1970s, smallpox was gone from most parts of the world. But in South Asia, the virus continued to kill. Public health heroes had to conquer social stigma, local politics, and more to wipe out the 3,000-year-old virus, an achievement many scientists thought was impossible.

Host Céline Gounder traveled to India and Bangladesh and brought back never-before-heard stories, many from public health workers whose voices have been missing in the coverage of the history of smallpox eradication. Gounder brings decades of experience working on tuberculosis and HIV in Brazil and South Africa; Ebola during the outbreak in Guinea, West Africa; and covid-19 in New York City at the height of the pandemic.

Season 2 of “Epidemic” is a co-production of KFF Health News and Just Human Productions.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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Journalists Recap How Smallpox Was Wiped Out and How Opioid Settlement Cash Is Being Paid Out

Sat, 09 Sep 2023 09:00:00 +0000

Céline Gounder, KFF Health News’ senior fellow and editor-at-large for public health, discussed the podcast “Epidemic: Eradicating Smallpox” podcast on NPR’s “Shortwave” on Aug. 30. Gounder also discussed new covid variants, vaccines, and the new season of the “Epidemic: Eradicating Smallpox” podcast on Lemonada Media’s “In the Bubble With Andy Slavitt” on Aug. 23.

Click here to hear Gounder on “Shortwave”

Click here to hear Gounder on “In the Bubble With Andy Slavitt”

Listen to “Epidemic: Eradicating Smallpox”

KFF Health News senior correspondent Aneri Pattani discussed the latest developments in opioid settlement funds being distributed across the country on WFAE’s “Charlotte Talks With Mike Collins” on Aug. 30.

Click here to hear Pattani on “Charlotte Talks With Mike Collins”

Read Pattani’s “Meet the People Deciding How to Spend $50 Billion in Opioid Settlement Cash”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENT
This story can be republished for free (details).

Epidemic: Speedboat Epidemiology

Tue, 29 Aug 2023 09:00:00 +0000

Shahidul Haq Khan, a Bangladeshi health worker, and Tim Miner, an American with the World Health Organization, worked together on a smallpox eradication team in Bangladesh in the early 1970s. The team was based on a hospital ship and traveled by speedboat to track down cases of smallpox from Barishal to Faridpur to Patuakhali. Every person who agreed to get the smallpox vaccination was a potential outbreak averted, so the team was determined to vaccinate as many people as possible.

The duo leaned on each other, sometimes literally, as they traversed the country’s rugged and watery geography. Khan, whom Miner sometimes referred to as “little brother,” used his local knowledge to help the team navigate both the cultural and physical landscape. When crossing rickety bamboo bridges, he would hold Miner’s hand and help him across. “We didn’t let him fall,” chuckled Khan.

Episode 4 of “Eradicating Smallpox” explores what it took to bring care directly to people where they were.

To conclude the episode, host Céline Gounder speaks with public health advocate Joe Osmundson about his work to help coordinate a culturally appropriate response to mpox in New York City during the summer of 2022. “The model that we’re trying to build is a mobile unit that delivers all sorts of sexual and primary health care opportunities. They’re opportunities!” exclaimed Osmundson.

The Host:
Céline Gounder Senior fellow & editor-at-large for public health, KFF Health News @celinegounder Read Céline's stories Céline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board.
In Conversation with Céline Gounder:
Joe Osmundson Public health advocate and clinical assistant professor of biology at New York University @reluctantlyjoe
Voices from the Episode:
Tim Miner Former World Health Organization smallpox eradication program worker in Bangladesh Shahidul Haq Khan Former World Health Organization smallpox eradication program worker in Bangladesh Click to open the transcript Transcript: Speedboat Epidemiology
Podcast Transcript

Epidemic: “Eradicating Smallpox”

Season 2, Episode 4: Speedboat Epidemiology

Air date: Aug. 29, 2023

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

TRANSCRIPT

Céline Gounder: 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.

[Metallic ding sound]

[Light instrumental music begins playing]

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

Céline Gounder: You dip the prongs into a bit of vaccine …

Tim Miner: And you would just prick the skin about 12 or 15 times until there was a little trace of blood and then you’d take another one.

Céline Gounder: It barely took 30 seconds to vaccinate someone.

And it didn’t hurt.

Yogesh Parashar: No.

Céline Gounder: Well … it didn’t hurt too much.

Yogesh Parashar: It was just like a pinprick, rapidly done on your forearm. You had a huge supply with you and you just went about and — dot, dot, dot — vaccinated people, carry hundreds with you at one go.

Tim Miner: And you could train somebody in a matter of minutes to do it.

Céline Gounder: 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 and a half, 3 inches long.

Small, but sturdy enough for rough-and-tumble fieldwork.

Yogesh Parashar: 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.

Céline Gounder: And maybe worth its weight in gold.

[Light instrumental music fades to silence]

Céline Gounder: That “cocktail fork” was among the pioneering innovations that helped public health workers wipe out a centuries-old virus.

Tim Miner: 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.

Céline Gounder: Ah, but getting there wasn’t always that easy.

I’m Dr. Céline Gounder, and this is “Epidemic.”

[Epidemic theme music plays]

Céline Gounder: 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.

Shahidul Haq Khan: My name is MD Shahidul Haq Khan.

Céline Gounder: For our interview, Shahidul Haq Khan invited me to his home in Barishal. That’s in south-central Bangladesh. We sat at a table in the courtyard, and his granddaughter, Kashfia, who looked like she was around 10 years old, stood close by …

Céline Gounder: Kashfia. So nice to meet you, Kashfia. I’m Céline.

Kashfia: Hello.

Céline Gounder: Hello. [Céline chuckles.] Are you going to listen to us?

Céline Gounder: Kashfia wanted to hear her granddad’s stories, and I got the impression that was also important to Shahidul.

As the two of us did our best to communicate through a translator — with neighbors, chickens, and street noise all around — Shahidul wanted me to understand why he was speaking with me and the significance of the smallpox campaign.

Shahidul Haq Khan: [Shahidul speaking in Bengali]

English translation: 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.

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

Shahidul Haq Khan: [Shahidul speaking in Bengali]

English translation: Yes, of course. Of course, I can say that we’re proud to say that we’ve eliminated smallpox from this country.

Céline Gounder: 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.

[Rain sounds fade in]

Céline Gounder: And there were the monsoons. It rained A LOT.

[Bouncy, upbeat music begins playing softly in the background]

[Rain sounds fades out]

Tim Miner: Uh, well, we got wet. [Tim chuckles.] To state the obvious.

Céline Gounder: That’s Tim Miner. He was an officer with the World Health Organization in Bangladesh.

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

Céline Gounder: Shahidul 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.

Tim Miner: 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.

Céline Gounder: The work depended on local knowledge, and Shahidul 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 Shahidul went in first, with Tim a few steps behind …

Tim Miner: 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 and watch me drink it and dribble the coconut milk all over myself, and everybody had a good time.

Shahidul Haq Khan: [Shahidul speaking in Bengali]

English translation: Dr. Miner called me “little brother.” I was younger then. How old was I? 21 or 22 years old.

Tim Miner: He referred to me as “Dr. Miner,” even though I’m not a … a physician. That’s how he referred to me.

Céline Gounder: Shahidul 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.

Shahidul Haq Khan: [Shahidul speaking in Bengali]

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

Tim Miner: You learn to walk and not look down and just, uh, you know, hang onto the poles. And, fortunately, I never fell in.

Shahidul Haq Khan: [Shahidul speaking in Bengali]

English translation: We didn’t let him fall.

[Bouncy, upbeat music fades out]

Céline Gounder: 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.

Tim Miner: I would have a doodh cha, a tea with milk, and a kacha morich pyaz — scrambled eggs with, uh, chiles.

Céline Gounder: The hospital ship hauled supplies from port to port. And everywhere they went, they towed a speedboat along with them.

Tim Miner: 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.

Céline Gounder: 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.

Tim Miner: They know about smallpox. They’ve been dealing with it, you know, all of their lives. And they have lost family members to the disease.

Céline Gounder: Still, the task was huge: to find and vaccinate every person with smallpox — and all the people that person had come in contact with.

[Subtle music begins playing]

Céline Gounder: In modern-day public health, the work gets done with cellphones and spreadsheets, maybe social media. In Bangladesh in 1974, they had none of that.

Shahidul and Tim had the speedboat, motorbikes, and their feet to cover a territory that took them all the way down to the coast.

Tim Miner: First there’s Barishal …

Shahidul Haq Khan: Latachapli …

Tim Miner: … then there’s Faridpur …

Shahidul Haq Khan: … Dankupara …

Tim Miner: … then there’s Patuakhali.

Shahidul Haq Khan: … and Kuakata.

Céline Gounder: 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.

[Ambient Dhaka street noises play in the background]

Tim Miner: 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 basti, 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.’

Céline Gounder: 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.

Tim Miner: Because of his immunization. It is somewhat miraculous, the needle in the haystack.

[Music fades out]

Céline Gounder: In Bangladesh, people weren’t likely to just show up to 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 …

Tim Miner: Where people go back to their villages and visit and bring presents and gifts and food.

[Ambient sounds of the water from a port in Bangladesh play]

Céline Gounder: The team went to ports where steamer ships departed, asking in Bengali if travelers had come in contact with anyone with the disease’s distinctive pustules.

Tim Miner: Guṭibasanta, uh, basanta rōgī.

Céline Gounder: Which means “smallpox patient.”

Tim Miner: Have you seen any guṭibasanta and basanta rōgī?

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

Tim Miner: ‘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.

Céline Gounder: Well, a partnership, yes. But Shahidul Haq 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 Miner was a tough boss.

Shahidul Haq Khan: [Shahidul speaking in Bengali]

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

Céline Gounder: Sometimes Shahidul 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.

Shahidul Haq Khan: [Shahidul speaking in Bengali]

English translation: We had to wait until they returned.

Shahidul Haq Khan: [Shahidul speaking in Bengali]

English translation: Otherwise, Dr. Miner would again take us back there, no matter how late. [Shahidul laughs]

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

[Tense music begins playing]

Shahidul Haq Khan: [Shahidul speaking in Bengali] … a pregnant, uh, …

English translation: I couldn’t vaccinate a pregnant woman in Dankupara. This was the first time that I couldn’t vaccinate someone.

Shahidul Haq Khan: [Shahidul speaking in Bengali]

English translation: I couldn’t convince her at all. He immediately told us to pack up. He stopped the work and said, “Let’s go.”

Shahidul Haq Khan: [Shahidul speaking in Bengali]

English translation: Immediately. At that very moment.

Tim Miner: We were working basically 24/7, if need be.

Céline Gounder: The team headed to the speedboat. It was late. And it was freezing. Shahidul remembers the bite of the cold air as they blasted across the water toward the woman’s village.

Tim Miner: I fully understand, 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.

Céline Gounder: The woman agreed to take the vaccine.

Shahidul Haq Khan: [Shahidul speaking in Bengali]

English translation: That day was one of the most memorable of my life.

[Music fades to silence]

Céline Gounder: 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.

Tim Miner: 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 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.

Céline Gounder: 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.

[Staccato music begins playing]

Céline Gounder: Smallpox eradication workers went to great lengths 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.

Joe Osmundson: Céline, it’s not your first time at the rodeo. [Celine laughs] Um, 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.

Céline Gounder: After the break, more on what it looks like to bring public health directly to those who need it most.

[Music fades to silence]

Céline Gounder: 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.

Joe Osmundson: 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.

Céline Gounder: 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.

Joe Osmundson: 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.

Céline Gounder: What is a commercial sex venue?

Joe Osmundson: It’s basically a nonhousehold space where people gather for sex.

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 health care.

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.

Céline Gounder: Did you run into any obstacles in doing this outreach? Setting up the mobile vans …?

Joe Osmundson: So, there is a huge amount of mistrust in this community 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.

Céline Gounder: How did it work, what was the scene like, and what was your role in that?

Joe Osmundson: Yeah, so, when I was there, I would go inside the club and, you know, there’s a little line, an 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.

Céline Gounder: Were these mobile vaccination vans successful?

Joe Osmundson: 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 people 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.

Céline Gounder: But, at the same time, in New York City, mpox vaccination rates have been disproportionately low in Black communities.

Joe Osmundson: Mm-hmm.

Céline Gounder: 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?

Joe Osmundson: 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.

Céline Gounder: What can we say about who’s been vaccinated and who remains unvaccinated?

Joe Osmundson: Black people are undervaccinated. They also have a higher rate of advanced HIV infection, and mpox plus advanced HIV means really severe disease and even death. Ninety percent 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 health care providers, or they don’t have insurance, or they’re underemployed, or they live super far from the nearest health care clinic.

When people have difficulties accessing care, it spreads to every disease state, from HIV to mpox to primary care, etc.

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

Joe Osmundson: The model that we’re trying to build is a mobile unit that delivers all sorts of sexual and primary health care opportunities. They are opportunities! You know? If someone’s getting a covid vaccine, give them a flu vaccine at the same time. The literature shows that these interventions work.

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

Joe Osmundson: 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 talking to community. And that’s outreach. And we aren’t 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.

Céline Gounder: That was Joe Osmundson, a microbiologist at New York University and the author of the book “Virology.”

Joe Osmundson: The sexiest public health outreach worker of all time! [Laughter] A face made for radio. [Laughter]

[“Epidemic” theme music begins playing]

Céline Gounder: Next time on “Epidemic” …

Larry Brilliant: Your company is sending death all over the world. You’re the greatest exporter of smallpox in history … You’ve got to stop this.

Céline Gounder: “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 Taunya English was scriptwriter for the episode — with help from Stephanie O’Neill.

Oona Tempest is our graphics and photo editor.

The show was engineered by Justin Gerrish.

Voice acting by Pinaki Kar.

We had extra editing help from Simone Popperl.

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 health care, health policy, and public health news.

I’m Dr. Céline Gounder. Thanks for listening to “Epidemic.”

[“Epidemic” theme fades out]

Credits
Taunya English Managing editor @TaunyaEnglish Taunya is senior editor for broadcast innovation with KFF Health News, where she leads enterprise audio projects. Zach Dyer Senior producer @zkdyer Zach is senior producer for audio with KFF Health News, where he supervises all levels of podcast production. Taylor Cook Associate producer @taylormcook7 Taylor is associate audio producer for Season 2 of Epidemic. She researches, writes, and fact-checks scripts for the podcast. Oona Tempest Photo editing, design, logo art @oonatempest Oona is a digital producer and illustrator with KFF Health News. She researched, sourced, and curated the images for the season.
Additional Newsroom Support

Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chief Gabe Brison-Trezise, deputy copy chiefChris Lee, senior communications officer

Additional Reporting Support

Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh

Epidemic is a co-production of KFF Health News and Just Human Productions.

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Epidemic: Zero Pox!

Tue, 15 Aug 2023 09:00:00 +0000

In 1973, Bhakti Dastane arrived in Bihar, India, to join the smallpox eradication campaign. She was a year out of medical school and had never cared for anyone with the virus. She believed she was offering something miraculous, saving people from a deadly disease. But some locals did not see it that way.

Episode 3 of “Eradicating Smallpox” explores what happened when public health workers — driven by the motto “zero pox!” — encountered hesitation. These anti-smallpox warriors wanted to achieve 100% vaccination, and they wanted to get there fast. Fueled by that urgency, their tactics were sometimes aggressive — and sometimes, crossed the line.

“I learned about being overzealous and not treating people with respect,” said Steve Jones, another eradication worker based in Bihar in the early ’70s.

To close out the episode, host Céline Gounder speaks with NAACP health researcher Sandhya Kajeepeta about the reverberations of using coercion to achieve public health goals. Kajeepeta’s work documents inequities in the enforcement of covid-19 mandates in New York City.

The Host:
Céline Gounder Senior Fellow & Editor-at-Large for Public Health, KFF Health News @celinegounder Read Céline's stories Céline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board.
In Conversation with Céline Gounder:
Sandhya Kajeepeta Epidemiologist and senior researcher with the NAACP’s Thurgood Marshall Institute @SandhyaKaj
Voices from the Episode:
Bhakti Dastane Gynecologist and former World Health Organization smallpox eradication program worker in Bihar, India Steve Jones Physican-epidemiologist and former smallpox eradication campaign worker in India, Bangladesh, and Somalia @SteveJones322 Sanjoy Bhattacharya Medical historian and professor of medical and global health histories at the University of Leeds @JoyAgnost Click to open the transcript Transcript: Zero Pox!
Podcast Transcript Epidemic: “Eradicating Smallpox” Season 2, Episode 3: Zero Pox! Air date: Aug. 15, 2023

Editor’s note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

TRANSCRIPT

Céline Gounder: When the World Health Organization set out to eradicate smallpox, enthusiastic young doctors and public health workers from all over the world showed up and spread out across the Indian subcontinent.

We had the chance to speak with some of them …

[Music begins]

Yogesh Parashar: People never believed that the world would be free of smallpox, especially India.

Larry Brilliant: There’s no reason to believe you could cure it.

Alan Schnur: This is a terrible disease.

Bill Foege: I was struck immediately by the smell. It was similar to a dead body.

Yogesh Parashar: Any outbreak was an emergency.

Bhakti Dastane: That itself was motivation for us.

Chandrakant Pandav: I said, this is the time to serve my India.

Larry Brilliant: We all seemed so confident that we could do it.

Alan Schnur: That kept all of us in smallpox eradication working long hours under rigorous conditions.

Chandrakant Pandav: It had to be done.

Hardayal Singh: Our duty was to vaccinate each and every person by hook and by crook.

[Music fades out]

Céline Gounder: By hook or by crook, vaccinate everyone. These smallpox eradication workers had a shared sense of duty. And they had a slogan: “zero pox!”

Bhakti Dastane: We have to achieve zero pox, so it was our motto: zero pox.

Céline Gounder: That refrain … it became a way for workers to greet one another, even replacing the usual hellos. It was a constant reminder of their shared goal.

Rajendra Deodhar: Whenever one Jeep crosses the other, we used to greet one another as “zero pox.”

Céline Gounder: You’ve just heard the voices of Alan Schnur and Drs. Yogesh Parashar, Larry Brilliant, Bhakti Dastane, Bill Foege, Chandrakant Pandav, Hardayal Singh, and Rajendra Deodhar. We’ll be hearing more from each of them throughout this podcast season.

So, this group of former eradication workers are grayer now. They’re mostly in their 70s. But you can still hear the youthful enthusiasm in their voices. You can feel that sense of purpose.

This episode is about what happened when this zealous bunch encountered hesitation.

Well, actually more than hesitation … real, everyday people, right in front of them, who were skeptical of the vaccine.

And just how far would the eradication workers go to stop smallpox?

I’m Dr. Céline Gounder, and this is “Epidemic.”

[“Epidemic” theme music]

Céline Gounder: By the early ’70s, smallpox was coming under control in most of the world. But in India, the disease remained stubbornly entrenched in several areas, including the state of Bihar — in the East.

In some pockets of the region, a lot of people were skeptical about getting the vaccination.

The eradication program sent in a stream of dedicated smallpox workers — on bicycles and in 4×4 trucks — to prowl the countryside and cities.

Bhakti Dastane was among them.

Bhakti Dastane: I’m Dr. Dastane, so I’m a gynecologist and I went to this, uh, WHO [World Health Organization] program, smallpox eradication program, when I was an intern.

Céline Gounder: Bhakti answered the call in 1973. She was a year out of medical school, maybe 27 or 28 years old, and had never cared for anyone with smallpox. She had never even seen an actual smallpox case before.

But she was inspired to help and, when she arrived in Bihar, the program coordinators were surprised to see her.  They had been expecting a man. Bhakti and another female physician showed up instead.

[Music starts]

Bhakti Dastane: We were only two lady doctors on that program, the smallpox eradication program. So we have to show them that ladies also can do as good as the gents.

Céline Gounder: Proving they were “as good as the gents” in almost every situation — that was their first task, the thing they had to do before they could get down to the work of finding patients.

Bhakti and a team of about six to eight volunteers went house to house lugging vaccination kits, searching for people with smallpox and anyone they could vaccinate.

Mostly, the men of the household didn’t even want to talk to a female doctor.

Bhakti Dastane: This thing was very new for them, for any female to go and talk to the male people in the house. They don’t give the importance to the female. So they don’t open up and don’t share the things with you. So, it took some time to develop this, uh, trust in them.

[Music ends]

Céline Gounder: In Bhakti’s mind, she was offering health to the people of Bihar, saving them from a deadly disease.

But locals didn’t really see it that way.

Some believed that if they accepted the vaccine, they would anger the Hindu goddess Shitala Mata, and some people from marginalized minority groups — including Muslims and the Indigenous Adivasi — had good reasons not to trust public health workers handing out unsolicited medical advice.

Bhakti Dastane: My reaction was not to get angry. I knew this resistance is going to come. So, I was prepared to convince patiently. And I said, “OK, not today. I will come tomorrow also.”

Céline Gounder: And, over time, she had some success.

One family patriarch thought vaccination was a curse — and told his family this:

Bhakti Dastane: He said, “Don’t listen to her, even if you think she’s saying the right thing.” So, for that person, I said, “OK, I’ll leave it like this.” And then, next day, just went there, not to talk about the smallpox or anything, just spend a day with them.

After three, four days, then he started listening to me. “OK. Now I think you are a good doctor, so, OK. What is it you want us to do?”

Céline Gounder: What Bhakti wanted was to get his entire family vaccinated. And she did it.

[Music comes up under Bhakti]

Bhakti Dastane: And once you put a trust in one family, then the neighborhood also get convinced and then your work becomes easy.

Céline Gounder: Building trust makes the work go easier. That’s a pillar in public health.

But sometimes it can take months and even years to gain the trust of a community. And sometimes … there’s a tension between what’s expedient and what’s ethical.

Health workers are supposed to be patient, but epidemics are not patient.

Smallpox didn’t wait for trust and respect. It kept spreading. And lives were lost.

The smallpox warriors wanted to get to zero pox. And they wanted to get there fast.

Fueled by that urgency, their tactics were sometimes aggressive — and sometimes, crossed the line.

[Music fades out]

Céline Gounder: Passion and frustration collided for Bhakti when she was working in Patna, the capital of Bihar.

People there would sometimes take off in the other direction as soon as they saw the vaccine volunteers.

So, to keep the locals from fleeing, Bhakti added two uniformed police officers to her team.

Bhakti Dastane: Two people, which were at the end of the road, so they couldn’t run away.

Céline Gounder: She resorted to intimidation, Bhakti says. But not violence.

Bhakti Dastane: Hold down and that, that I didn’t do. But scare them with the police or any other thing: “You have to do this, and you have to take this.” Up to that. But not physical force. I, I never used physical force.

Céline Gounder: But other health workers did.

Steve Jones: My name is T. Stephen Jones, and — I go by Steve Jones — and, I had the good fortune to work on smallpox eradication in three countries.

Céline Gounder: Steve was a true believer.

Steve Jones: The idea that you could get rid of this plague that had caused deaths and disfiguration over centuries was just such an astounding idea that I wanted to be able to say that I had been part of it.

Céline Gounder: When he arrived in Bihar in 1974, there was so much work to do.

[Music starts]

Céline Gounder: Juggling more than a hundred different smallpox outbreaks at once. And for each case, he had to survey and vaccinate the 20 or 25 households surrounding the infected home.

Steve says he did a lot to persuade people. Like, he vaccinated himself repeatedly to show it was safe.

But there were times when the push for “zero pox” got the best of him.

Steve Jones: I vaccinated a woman who was not willing to be vaccinated. I had a bifurcated needle and I held onto her arm, and I vaccinated her. And she resisted.

Then the people of the village responded, and it got angry. And I was hit on the head and knocked to the ground.

Céline Gounder: He ended up needing stitches.

Steve Jones: I regret this, and I realized that I did the wrong thing, even if I hadn’t been bonked on the head.

[Music fades out]

Steve Jones: I was passionate and believed that it was a really important goal to achieve, and I made a mistake.

I learned about being overzealous and not treating people with respect.

Céline Gounder: Bhakti Dastane says that she also came away with regrets about resorting to intimidation.

Bhakti Dastane: Definitely using the force was not the proper thing to do, looking back now. But at that time, we were enthusiastic and trying to zero pox and so that a hundred percent vaccination.

[Music starts]

Céline Gounder: During the campaign in India, there were instances of not just coerced vaccination, but of physical force.

Medical historian Sanjoy Bhattacharya is a professor of medical and global health histories at the University of Leeds in the United Kingdom.

He says the Adivasi Indigenous people of India were among the most frequently vaccinated under duress.

Sanjoy Bhattacharya: They were encircled, by often Indian paramilitaries or police forces, and then groups of Indian and overseas workers would go into these villages.

Céline Gounder: A lot like the treatment of Indigenous people in the U.S., the Adivasi have been traditionally marginalized and exploited. Many of them were understandably suspicious of government health and of course vulnerable to coercion.

Sanjoy Bhattacharya: Often kick down doors, often pull people from places they were hiding in and forcibly vaccinate them, literally sit on them and vaccinate them.

[Music out]

Céline Gounder: Today, around 50 years later, Sanjoy has spoken with villagers who still remember.

Sanjoy Bhattacharya: They remember these pink, unfriendly — that is a terminology they use — pink, unfriendly people who would come in, shout at them, and not really engage them at all. I mean, what sort of leadership is that?

Céline Gounder: Sanjoy rejects the idea that strong-arm tactics were somehow OK because of the urgency of the mission.

Sanjoy Bhattacharya: Efficiency? By whose standard? None of us would like to be sat on by a 6-foot-tall and rather heavy man.

Céline Gounder: And, he says, in the long run, force is usually counterproductive, creating a ripple of pushback, which ends up being more costly than leaving people unprotected.

[Music starts under Sanjoy]

Sanjoy Bhattacharya: Any public health goal can be achieved without force. It needs engagement. It needs self-awareness; it needs humility. It needs money and time.

Céline Gounder: Engagement takes time, and it’s built on trust.

When we come back, epidemiologist and researcher Sandhya Kajeepeta will join us to talk about just that.

Sandhya Kajeepeta: I remember in early 2020 seeing news stories of very violent arrests of Black New Yorkers for alleged violations of covid mandates that were extremely vague.

Céline Gounder: That’s after the break.

[Music out]

Céline Gounder: By the end of April 2020, there had been over 18,000 covid deaths in New York City. I was working at a large public hospital in Manhattan — Bellevue.

Remember, at that time, there’s still a lot we didn’t know.

Our best advice was to tell everyone to stay home.

In cities like New York, police were tasked with enforcing these new rules around social distancing and masking.

But the results, they weren’t always good.

[Music begins]

Newscaster: The 33-year-old seen getting thrown to the ground and slapped repeatedly in what started as social distancing enforcement along Avenue D and East Ninth Street.

Newscaster: It is the most recent incident involving the NYPD [New York Police Department] social distancing enforcement that has come under fire.

[Music out]

Céline Gounder: Seeing that footage of Black New Yorkers being arrested really upset me.

And I wondered, was this enforcement doing more harm than good?

I wanted to know. So, I talked about it with social epidemiologist Sandhya Kajeepeta.

She studied how police enforced these rules and how it impacted public health during the first months of the pandemic.

Sandhya Kajeepeta: In my neighborhood in Harlem, I would see huge numbers of police officers issuing citations and making arrests in response to these mandates. But if I went downtown, to the southern part of Central Park, or to the West Village, I would see parks department employees handing out free masks.

Céline Gounder: I definitely saw that too. Like, just walking to work at Bellevue Hospital, I’d see groups of people picnicking in Madison Square Park — unmasked.

But I never saw the NYPD breaking up those gatherings. That was in a predominantly white neighborhood in midtown Manhattan.

So, Sandhya, when you looked at summons and arrest data, how were the police enforcing those rules?

Sandhya Kajeepeta: We found ultimately that neighborhoods in New York City with a higher percentage of Black residents also had a higher rate of pandemic policing.

Céline Gounder: From your work we see that the enforcement of covid mitigation measures and mandates was unfair, but what about the public health results? Did these measures help curb infections?

Sandhya Kajeepeta: There’s this really clear irony of trying to promote social distancing by instead increasing forced physical interactions between police and community members. And if people were held in jail because of a covid mandate violation, then they faced an even higher risk of covid infection, because the city’s jail was among the country’s top hot spots for coronavirus infections at this time.

It seems very clear that this approach was antithetical to public health broadly and to curbing the spread of the virus.

Céline Gounder: Yeah, and on top of that, it made people more skeptical about the pandemic safety measures we were recommending.

Sandhya Kajeepeta: Yeah, I think there’s certainly a growing body of evidence documenting how police and criminal legal systems more broadly can erode trust in public institutions.

Thinking about the covid pandemic, when I was seeing news coverage of police officers violently arresting and placing their knee on the neck of a Black man in New York, just for allegedly talking to someone too closely, or seeing footage of police forcing a Black woman to the ground in front of her child for allegedly wearing her mask improperly — that’s going to make me question whether public institutions really have our best interests in mind.

I think anyone can see that and recognize that violence and punishment is not getting us to the goal of safeguarding public health and is quite clearly putting people at risk.

Céline Gounder: There will be more epidemics and pandemics in our lifetimes. What would you like to see done differently when we see the next infectious disease outbreak?

Sandhya Kajeepeta: I think the mandates themselves are such a powerful and important message to send to people, that, you know, we’re all working together, we all have an individual responsibility to control the spread of the virus.

But I think when it was announced that police would be used to enforce these mandates, many people in New York City could very quickly predict what would happen, because we’ve seen this racialized pattern of policing be replicated time and time again.

[“Epidemic” theme music begins]

Trust in public institutions is such an important part of encouraging and motivating behavior change. But police enforcement can often have the opposite effect, of eroding that trust.

Céline Gounder: Next time on “Epidemic” …

Tim Miner: 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.

Céline Gounder: “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 Jenny Gold, Zach Dyer, Taylor Cook, and me.

Our translator and local reporting partner in India was Swagata Yadavar.

Taunya English is our managing editor.

Oona Tempest is our graphics and photo editor.

The show was engineered by Justin Gerrish.

We had extra support from Viki Merrick.

Music in this episode is from the Blue Dot Sessions and Soundstripe. We’re powered and distributed by Simplecast.

This episode featured news clips from ABC7 New York and NBC 4 New York.

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 health care, health policy, and public health news.

I’m Dr. Céline Gounder. Thanks for listening to “Epidemic.”

[”Epidemic” theme fades out]

Credits
Taunya English Managing Editor @TaunyaEnglish Taunya is senior editor for broadcast innovation with KFF Health News, where she leads enterprise audio projects. Zach Dyer Senior Producer @zkdyer Zach is senior producer for audio with KFF Health News, where he supervises all levels of podcast production. Taylor Cook Associate Producer @taylormcook7 Taylor is associate audio producer for Season 2 of Epidemic. She researches, writes, and fact-checks scripts for the podcast. Oona Tempest Photo Editing, Design, Logo Art @oonatempest Oona is a digital producer and illustrator with KFF Health News. She researched, sourced, and curated the images for the season.
Additional Newsroom Support

Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chief Chris Lee, senior communications officer

Additional Reporting Support

Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh

Epidemic is a co-production of KFF Health News and Just Human Productions.

To hear other KFF Health News podcasts, click here. Subscribe to Epidemic on Apple Podcasts, Spotify, Google, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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