Interview Transcript
Conversation
Dr. William Foege & Dr. William Foege
Transcribed: January 30, 2009 | Duration 0:41:22
A Conversation between Dr Mahendra Dutta & Dr William Foege
Introduction
Today is the 9th of July, 2008. This is a taping as part of the Continuing
Series of all Histories of Smallpox Eradication Program. Today Dr. William
Foege and Dr. Mahendra Dutta are going to have a conversation. Both of them
know that this is being taped and they've signed permission for us to tape
and to use it in appropriate manners.
Dr. William Foege: Okay. Mahendra, 30-plus years ago, we spent so much
time together working on smallpox, but I never asked you, how
did you happen to get into the program? Did you volunteer? Was
this dictated?
Dr.Mahendra Dutta: Yes, I did volunteer. I had returned from my
training in Epidemiology for nearly 9 months back to the office
where I worked with the Director General of Health Services and
the campaign was being mounted and they needed more people to
help in the campaign, and that's how I volunteered.
Dr. William Foege: Ah, ah. So you did volunteer. Now, we've often
talked about the top group of people. You, M.I.D Sharma, C.K
Rao, Pidish, and so forth, an extraordinary team, but how did it
happen that they came together, because I don't think you could
have found a better group of people if you'd searched the world.
How did that happen?
Dr Mahendra Dutta: There was a continuous process of selection. People
at the helm of affairs in the Ministry of Health, technocrats,
were getting involved and those who could not perform they were
quitting also. So ultimately the fittest survived. So that's how
you saw them all together.
Dr. William Foege: Ah! So this was evolution. Okay-Survival of the
fittest. Now there was a person I was very fond of early on in
the program who was running the program in Bihar. I totally
missed the fact that he was extracting funds from us at an
alarming rate. How did you pick that up and how did you handle
it?
Dr Mahendra Dutta: I got involved with the program in February when Dr.
Dish[inaudible name0:02:49] asked me to visit and see how things
are moving there because he was not comfortable.
Dr. William Foege: This was February 1974?
Dr Mahendra Dutta: February 1974, and in this visit, when I reached, I
went to a district, Munger, there is a district by that name,
where I spent a week seeing how things are happening. The
reports we were receiving were that people do not accept
vaccination; and when I went there I was surprised. Every
morning we went to villages, we had a team of 20 people to
vaccinate with us, and one after another village where we went,
people were pleading to get vaccinated; and the stories that we
got were: so many died in this village, people were really
alarmed. They wanted vaccination, then the civil surgeon, the
head of the health administration of the district was hostile to
Dr. Sinha and he narrated me all those stories, how he is
employing over and above the normal staff, some extra workers,
and virtually paying them 1/5th or 1/6th of the money that they
are supposed to get and the remaining is being pocketed. So this
was corroborated by another colleague who had worked with me
earlier who was my other class fellow in the public health
training, and he corroborated that this is actually happening. I
finally met the Health Commissioner at a very personal level in
a club and told him. He said that this is no news to him. So
then everybody knew-so I said then, "What to do." The gentleman
said, "Well! I am not heading the health services. It is a
technocrat there. He has to come. I am a bureaucrat. Then only,
I will step in." It went on like this, till fortunately, let me
say, may be you are aware, in 1974 May, there was a nuclear
explosion in India.
Dr. William Foege: I remember that!
Dr Mahendra Dutta: Pokharan, and after Pokhran, the Newsweek in its
front page carried a report, "Another Explosion in India" and
this was the smallpox explosion in Bihar, when you will
recollect that in our May search, we discovered over 8,500 new
outbreaks with 11,000 cases. So -
Dr. William Foege: In one week, 11,000 cases - if I can just interject
here - The previous Fall, D.A Henderson had asked me, "What's
the largest number of cases you will find in any State in a week
in India?" And we actually took this quite seriously, and we
concluded that it would be less than1,000 cases. So we suggested
that they use 3 digits for their computer programming. D.A-
always suspicious of us; added 4 digits, and then we had to call
and say, we've had 11,000-plus cases in one week, in one State,
and so even the computers were not cooperating anymore. Okay, so
go ahead - then May of 1974...
Dr MahendraDutta: Yeah, then the stage came that the government of
India and the State Government, they all got really startled
because a lot of journalists who had come to Rajasthan to cover
the nuclear explosion, they moved into Bihar and started
reporting. Now at that point of time, we were asked by the
Health Commissioner there who was the chief bureaucrat in the
Health Service. Earlier he took the stand that the Technical
Head should come to me but now he himself went to the political
head and told him that this is the problem that they want the
Program Manager Dr. Sinha to be moved out; and then he was - a
substitute was selected by consensus. He was a very good person.
Everybody felt that he was going to deliver, and he moved in and
then things moved. So after that, we had very fast track
movements on the program.
Dr. William Foege: I want to come back to this, but this has always
been an example to me of an outsider not able to see what was
actually happening and an insider understanding immediately what
was happening. What else did I miss?
Dr Mahendra Dutta: Well, you didn't miss much because even in this
case, I recall you were believing that smallpox will definitely
go sooner or later. I wanted it to be sooner.
Dr. William Foege: Yes,
Dr Mahendra Dutta: That's about the only difference of you.
Dr. William Foege: So the reporters came to India, they did their
reporting on the nuclear test and now looking for other stories,
suddenly this becomes a very good story. Smallpox is out of
control and they have no background to know that this is partly
due to the improvement of the program and surveillance was
improving and there were a lot of people now on the problem, but
it caused Parliament to make life miserable for you because
everyday they were asking for explanations; and how important
was that in diverting people from smallpox eradication to
answering Parliament?
Dr Mahendra Dutta: Well, the group of workers who were handling at the
National level for the Parliament was only being fed by the
peripheral workers. We were not disturbed much in the field. In
fact, we were helped by this lot of reporters coming in and
giving the stories. It was a helpful thing because the
Government at that time asked us to request whatever we needed
more and we increased our efforts far more then.
Dr. William Foege: What was Karan Singh's, the Minister of Health, what
was his approach to all of that bad news?
Dr Mahendra Dutta: Oh! He was the real support. He recognized that the
disease is being tackled in other States and it was only the
problem of inactivity in Bihar, that's why they were lagging
behind. So he himself visited later in Bihar and emphasized that
we put in more efforts and things were already showing up, and
very soon things will be completed. In fact, we recollect that
he all along was a big moral support.
Dr. William Foege: So, at the very top, you had all the support you
needed. If you go down a layer, to the Director General of
Health Services, to Dr. J.B Srivastav, what was his role at this
time?
Dr Mahendra Dutta: Unfortunately he belonged to the group of
unbelievers. There were people, I believe in every country, who
did not believe that Smallpox can be eradicated vis-à-vis the
others. He belonged to the other group and he was always
pessimistic about our claims of eradicating it very soon. So all
I recollect is that I had a very good liaison with him and he,
several times, enquired of me, "Is it real what you are
reporting-so good a progress in so short a time?" So that was
the main thing he would always accept when I say so and I
recollect when later we were so close to the endpoint and we
were going in for announcing a reward for a case. The minister
was to make that announcement on July 1, 1974. He was asking,
"Isn't it too early to make such an announcement?" And I said,
"Well the amount of money and effort we are putting in each day,
I shall be so happy that if I can have all the remaining few
hundred cases discovered by this reward and it will save a lot
of money and time." It was a matter of chance that not a single
case was found and we didn't have to pay a single reward but Dr.
Srivastav had apparently not been at the most peripheral level,
in the field level; that is why he couldn't appreciate how
thoroughly the things were happening.
Dr. William Foege: How powerful was his pessimism in influencing the
Minister of Health of Bihar when they wanted to change back to
mass vaccination.
Dr Mahendra Dutta: He came to Patna on the asking of the Minister of
Health and addressed the civil surgeons and at this meeting he
pleaded that the ultimate solution of the problem would be
covering backlog of mass primary vaccinations; children who have
never been vaccinated. Unfortunately, the minister took it very
seriously and wrote to Dr. Karan Singh, the Indian Minister for
Health that your Director General has requested that we should
cover the backlog of primary vaccinations, children who have
never been vaccinated. He asked for money; vaccine and
bifurcated needles for vaccination to harness a new
organization, the block level health staff to complete it.
Because Dr. Srivastav said he is not against the firefighting
efforts that are being carried out. So Dr. Srivastav's comments
were sought about the statement that he made and I recollect
that Dr. Srivastav was uncomfortable how to respond to it and he
asked me, I had to go back from Patna and I said there is an
anomaly. They too are saying the same thing; that first we bring
the disease to zero level and thereafter we can concentrate on
the backlog of primary vaccinations which we never needed there,
probably; and it was completed without the backlog. Nobody
needed it.
Dr. William Foege: Now you talked about the believers and the
unbelievers. Do you recall the day you became a believer?
Dr Mahendra Dutta: I recall the day when the non-believers were
shunted out. I was responsible myself. Several of my Indian
colleagues who came to work in Bihar with me in the initial
discussions, they belonged to that thinking, though they were
working and I pleaded with them, if you don't believe, probably,
morally, you should not agree to do it. Couple of them did go
back instantly, because unless you have a conviction that you
can achieve, then you are not doing it.
Dr. William Foege: The National Institute of Communicable Diseases put
a lot of effort into this program. Did they take great pride at
it when it succeeded; and did it make a difference in the way
the Government of India supported NICD.
Dr Mahendra Dutta: Oh! Tremendously; I believe they are surviving on
the laurels of achievement of smallpox even today. That's the
biggest thing they did. Of course, they did a couple of other
good things after that but smallpox is a feather in their cap.
Dr. William Foege: There were very many foreign workers and often
times coming for three months and then leaving, and that's the
most difficult, to get people acclimated in 3 months to get some
productive work out of them and then have them leave. What were,
from your point of view, the biggest problems of having these
foreign workers in India?
Dr Mahendra Dutta: Well, I recollect when they landed in Patna, they
volunteered, many of them came through CDC, and when they
arrived in Patna, they were very enthusiastic in performing. At
the same time, probably, they have never worked in a developing
country before. So they were also apprehensive. What we did was
that upon their arrival, besides the technical briefing, a
sociologist was made to speak with them; and this session
attracted them the most. They had so many things to ask the
sociologist. Probably, this was the longest session in the
briefing in Patna, three to four hours, and they were told about
the communities in India, how they operate and how they live
together. So that helped them to know quickly, in the filed, how
to perform. I recollect that the work to be done was so much
that many of them did long extended hours of the day in the
field. From morning till late evening, and we were always
telling them that in the summer months, you should not be out in
the peak hours in the noon but they were defying it also in the
enthusiasm that they must complete the work before they leave.
Fortunately, some of them, and they were good, those some of
them; they asked for extending their period of stay so that
before they leave they could see things happening and I
recollect at least, a couple of them, Steve Jones and David
Hyman; they were later on moved to Bangladesh but they stayed
for about five months in India. So that was their enthusiasm to
show the results. The small mistake that happened in the
beginning, a couple of them arrived with their better-halves and
they couldn't perform because field conditions in India were not
so conducive for their wives to stay alone; and they did not
perform well in the field, and subsequently we had to advice
that anybody coming here must come without their spouse.
Dr. William Foege: So you worked them so hard maybe 90 days was as long
as they could actually take. We wore them out. Have you ever
thought pf what were the biggest mistakes that were made in the
program. If you were doing it all over again, what would you
avoid doing?
Dr Mahendra Dutta: I don't see back, anything wrong, the only thing
that for this short program, as I said, it lasted hardly an year
or so, and there were other programs that suffered because
everybody was occupied with this program, but we had to pursue
with those programs. I recollect that Family Planning was our
biggest competitor as a program, and time and again, the people
in the family planning were disturbed but we had to tell them
that ours was going to last a few more months, and later on we
can join with you in the program.
Dr. William Foege: That brings up the question; if the National
Institute of Communicable Diseases took great pride in this, did
Family Planning take pride in the contribution they made-because
it was an enormous contribution?
Dr Mahendra Dutta: Well, maybe that was only after April or sometime in
1975 that the Family Planning was given a top priority during
the emergency era in India. Before that, they had certain target
approach and that's why they were more eager to perform and let
not their workers be diverted to help in smallpox. Because in
the smallpox, we involved every month, for a week all health
workers for the search and that's what was disturbing them but
seeing the results, they also agreed that we are doing some job
and let it be finished.
Dr. William Foege: You mention that it was in truth a very short
program, at the time it seemed to go on forever. But it only
took us three months to sort of come up with the system, another
four months to perfect the system and then, India went from the
highest rates in May of 1974 to zero twelve months later. No
place else in the world was the change so fast, so dramatic,
it's amazing in retrospect to even look at that. But then you
went on from India to work in Ethiopia. Compare the two
programs.
Dr Mahendra Dutta: Things were very different in Indian program. We did
not have the difficult terrain working conditions in the field.
In Ethiopia, the communications in the field was so difficult,
and here I recollect when at the end phases, every case
occurring in Bihar, I personally went to that village, I could
reach in less than 24 hours. But this could not happen over
there. They needed a much prolonged sustained effort, and I was
part of it that was done from moving from one district to
another so that you make one area free. There, the people also
do not move so much as they do in India; because here in the
Indian program, fortunately, when our efforts were at the peak
that was the lean season for transmission. The disease was
expected to come down with the onset of monsoons but our efforts
were peaking up further. So that's how we could come over so
soon. Because around October-November, when the rains cease and
people started moving about again, we were left with very few
cases; 150 odd villages where the disease was present, and I
recollect later in July, we had some junior teams, mobile teams,
we stationed a team in every outbreak and these young doctors
who were coming as medical interns, they performed so well
because they were all trained, they were all relied upon, they
were amazed at what kind of faith we were placing upon them.
I recollect those who were bearded Sikh gentlemen, when I met
them in the field, they removed their beard; I have no time to
wash every day; and those who didn't have the beard, they were
having beard, I have no time to shave everyday. So those young
people changed the whole complex. Then we introduced the
strategy of guarding the case which was paying dividend that the
case would not be allowed to spread the disease to another
place, around the clock, 8 hour shifts, watch guards were
placed, watch guard supervisor was placed. The family was
compensated that they can't go out for work. So therefore we
will pay rent for the house where our guards will stay; so all
these strategies helped in achieving a very fast disappearance
of the disease.
Dr. William Foege: Its nice, 33 years after the last case, to hear you
talk about it and still have the enthusiasm that you had 33
years ago. What is it though that you would like to tell to
young public health workers that you've learned from this
experience that you hope you can pass on.
Dr Mahendra Dutta: All I could say in brief was that in public health,
community approach, your conviction, your devotion and team
effort, that's what matters the most. The entire team of workers
national, international, higher, lower level functionaries, they
all worked like a very close team; and that's what I can believe
public health team-effort approach-is pride.
Dr. William Foege: I agree with you. I think that's the lesson of
smallpox in India; that the team worked as a unit. It was a
coalition in truth, and people lost their national identities...
Dr Mahendra Dutta: Absolutely, absolutely.
Dr. William Foege: ...their personal identities and it seems as though
we made decisions based on everyone agreeing, I can't remember
that we ever took a vote or had really strong disagreements. So
it seems to me that it was a coalition that was quite unique.
Now, I worry that we have lost the words now of people like
M.I.D Sharma. You talked to him a great deal after smallpox
eradication and I don't know if you have any message that you
would like to pass on from MID Sharma or Dr. Pidish, or some of
the other people who we don't have a chance to question.
Dr Mahendra Dutta: I was meeting them till/[while] they were alive, and
my only understanding was that they felt that the success story
of smallpox eradication was also an achievement which gave them
satisfaction in their life, and the only thing which I felt they
wanted the young generation to follow or emulate what they saw
was, the same thing as I said earlier, that devoted efforts,
team efforts always mattered in community health work.
Dr. William Foege: Years later, I had lunch with Dr. Pidish and he said
something similar, that it was quite different to be on an
Indian team than to be on an international team working on an
Indian problem, and he said to me at that time that, "If you
come back to India, I will come out of retirement," we will do
this again.
Dr Mahendra Dutta: I would say the same. Working with you was a real
pleasure.
Dr. William Foege: Thank you. How did you get into public health
though?
Dr Mahendra Dutta: That was a very different story. My father was a
Public Health Physician.
Dr. William Foege: I know, the Rockefeller Foundation sponsored him.
Dr Mahendra Dutta: Yes, he was a Rockefeller Fellow and right from when
I graduated from the medical school, I made the choice that I am
going to study in the School of Public Health. I didn't waste
any time. Very next year, I joined the School of Public Health.
Dr. William Foege: Where?
Dr Mahendra Dutta: In Calcutta in India, and then pursued the career
through married[inaudible0:28:34] life, and I have no regrets.
Dr. William Foege: And what did you do after smallpox eradication?
Dr Mahendra Dutta: Oh! After smallpox I worked with the Municipal
Corporation of the City of Delhi. I was their Chief Health
Officer for a few years.
Dr. William Foege: Your father had done the same thing?
Dr Mahendra Dutta: Oh, he'd done the same thing too, and then I was the
Chief Epidemiologist of the NICD for a three-year period, and
finally I was the Deputy Director General for the public health
work in the Ministry of Health, and looking back I feel very
happy that I worked in these positions and got a satisfaction.
Dr. William Foege: But there is something genetic here also. Talk about
your son.
Dr Mahendra Dutta: Oh, he chose it himself, that he wants to also be a
Public Health Physician. He came to the U.S. He was a bit
disgusted about the policies of reservation for certain backward
classes, and he said that he may not get the opportunity in
India to work in the specific field where he wishes to work, and
he will choose to go to public health work and go to U.S. for
training. So I said, "If you wish to go, its up to you." So he
is working here.
Dr. William Foege: Three weeks ago, I was at my final meeting at the
Rockefeller Foundation and I was asked to speak to the staff,
and I said: when people ask me what the Rockefeller Foundation
has done, I resist talking about the Green Revolution, or the
Yellow Fever Vaccine, or the Hookworm Program; I said-I talk
about the scholarships that they gave to people around the
world, and I talked about your father getting one of those to
study public health and that for three generations, this
investment by the Rockefeller Foundation has continued to pay
off. I mean, it's just a wonderful story.
Dr Mahendra Dutta: Very nice of you to say that. My father has left
behind his writings of life and he feels the same, that I
received the training in public through the Rockefeller Program
and I owed a lot to repay it, and I have repaid it because my
son followed the same, my grandson followed the same. So that's
the same way he thought.
Dr. William Foege: In India, how do we improve the number of people
going into public health? You've done it. You've found it to be
a very enjoyable satisfying profession. How do we increase the
number of people doing this?
Dr Mahendra Dutta: It has been a dilemma for all the years but I don't
know how, but things appear to be going haywire now. More and
more people are interested in public health. It's a big change
happening in recent years, and I recollect that four years ago,
a Foundation with the collaboration from the Harvard University
was established to raise Public Health Schools in India -
establish new Schools of Public. Medical Research Council also
following the same example, they are also supporting
establishment of new schools of public health; and the young
doctors are also getting more interested in pursuing Public
Health as careers. Unfortunately, so far the Governmental System
doesn't create more opportunities or caters for public health
people. But I am sure there are two ways of doing it. One is
that you train the people and there will be careers coming up,
the other way is you create careers and then you find shortage
and then people will be trained. So apparently we are going the
other way round. People will get trained and opportunities will
be created to meet those demands. Already several programs,
National [inaudible0:33:06] Programs have started creating posts
for public health physicians at district levels and lower. So
that approach probably is going to be there.
Dr. William Foege: I think we are seeing a renaissance of global health
interest in recent years and I am just pleased that we both
lived long enough to see what's going to be a great change in
the future.
Dr Mahendra Dutta: I wish too.
Dr. William Foege: Are there stories or things that you want to say
about the Smallpox Eradication Program because, you know, we may
never get an opportunity like this again to talk about it. Are
there things that you want to make sure that people hear?
Dr Mahendra Dutta: We have said a lot but the only thing I'll add will
be that in achieving success, besides technical things, there is
also an element of administrative tact, I would call it; whether
you say diplomacy in the modified terms but we, people in public
health, should use this more often and after all you have to
work with your own team, and also this is the team in our
system: there is a bureaucracy, there is a political leadership.
So you have to work along with them and carry them with you.
Dr. William Foege: I hope to make that point at our reunion that behind
every public health decision, there is a political decision...
Dr Mahendra Dutta: True.
Dr. William Foege: ...and that we end up trying to educate politicians
but it's a very labor-intensive sort of thing to do because the
politicians keep turning over; that they have a limited time in
office and that I now miss no opportunity to try to get public
health people to go into politics. It seems to be a shortcut,
more efficient, if we can get more public health people to
actually become politicians.
Dr Mahendra Dutta: I wish it happens in my country too. At the moment,
we are facing a dilemma because more and more politicians are
coming from another group, the group which is rather not
desirable but they are the people who flout laws and more and
more of them are entering into politics. A separate stream has
come. Formerly, most politicians were coming over from
categories like rich people, business people, like accepted
heads of the communities. Now some bad elements have started
infiltrating into politics.
Dr. William Foege: We are years ahead of you.
Dr Mahendra Dutta: It is worrying, not me, but it is worrying the
Indian Government itself; how to get rid of these elements in
the politics. Anyway, it's not for me to too much comment on
that.
Dr. William Foege: But that seems to be a chronic problem in many
countries. Let me ask you one final question and that is, the
remarkable contribution made by TATA for the Smallpox
Eradication Program where you had a private corporation agree to
work under Government rules and to use the same approaches and
so forth. It now has happened with other corporations, MURK with
what they have done with River Blindness and Glaxo Smith-Kline
with lymphatic psoriasis and so forth, but that was a very early
example of what TATA did. Has this continued? Do you have
private, public collaboration in health programs from that TATA
experience?
Dr Mahendra Dutta: All I would say is that per force, we had to go for
that collaboration because the Southern Bihar lacked adequate
infrastructure of health from the Government side and TATA has
had a very good infrastructure in that region. They have their
[inaudible0:37:35] and coal fields and factories all over-
spread. Therefore we approached them and they readily agreed
because they were working with the people there where it was
benefitting. I have seen that now it has become a Governmental
Policy in recent years to accept that kind of - because the
medical care itself is going to the private sector more and
more; and government is only obliged to deliver public health
service to the community; the preventive medical care, and in
these efforts, they know that we cannot invest so much, so they
are seeking collaborations from non-governmental agencies
including the private sector.
Dr. William Foege: Well, this has been great fun to get together again
after - we have done it before, but till now at 33 years to talk
a little bit about this, and I will say this on Saturday, but I
want to be sure that it gets recorded now. How wonderful it was
to work with you, what a hard field worker you are, that you
never shied away from doing anything that needed to be done in
the field, and you were just the epitome of deliberate
approaches to solving problems, rather than getting excited when
things went wrong, you would sit down and ask how do we solve
this problem and so it was great to work with you then, and it's
great to hear you reminiscence now.
Dr Mahendra Dutta: I am also pleased that I'd worked with you, and in
fact I learnt also a lot of things, but basically, as I said,
our team-approach was the most successful approach.
Dr. William Foege: Great-good. Thank you.
Question from Audience: May I ask one question? Did he play jokes on you?
Dr Mahendra Dutta: He played rings because whenever he had nothing -
rather, he had something in his brain lurking to solve, he would
have a set of rings how to unfold them. But I don't think Bill
was that kind of person. He was a serious person. The best thing
I recollect is he was a very good assessor. He could assess how
people are performing and that's what we got from him; his
personal assessment of people who were coordinating, who could
survive.
Dr. William Foege: But the ring story reminds me of an absolutely true
story; where we were going to a meeting where another person had
absolutely different ideas than I did, and I knew that because
we discussed it quite often; and it was a 2-day meeting. It was
early in the first meeting when I took off my puzzle ring and
let it fall apart, and I just said, "Oh could you put this back
together? He had had a puzzle ring as a child and he said sure.
He spent the next six hours on this puzzle ring. He even missed
the discussion of the issue that I was worried about where he
would bring up the other side. We were passed on other things
before he realized that the puzzle ring had kept him occupied.
***
Thank both of you.
[End of audio]
A Conversation between Mahendra Dutta and Bill Foege
July 10, 2008
A conversation between two of the key people in the smallpox eradication program in India.
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