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41 LESSON 6 COLLECT GOOD DATA Even If You Don’t Yet Know What Important Questions They May Answer Results are obtained by exploiting opportunities. peter drucker Iknew almost nothing about smallpox, but I did know the countryside of what was now Bangladesh. Stan Foster, a colleague on the team, had spent seven years working on smallpox in Nigeria, and he knew everything there was to know about smallpox, but he had no experience in Asia. On the flight to Dacca, we began educating each other. Stan and I had an important job and were given all the support available, but that support was very limited. The minister of health’s nephew was appointed director of Bangladesh ’s Smallpox Eradication Program. He was about my age, had received his medical education in Bangladesh and Lebanon, and spoke fluent English. One of the first things I noticed about him was his love of his title, his authority, and his big desk. The day we arrived was his second day on the job. I suggested that we visit the infectious disease hospital 42 TEN LESSONS IN PUBLIC HEALTH outside Dacca to get some sense of the disease we were dealing with and the state of the epidemic. After we parked in front of the large, isolated building, I discovered that he had no intention of going inside. Nothing I said could persuade him to enter the building. The reason suddenly dawned on me. Bangladesh’s director of smallpox eradication had never been vaccinated against smallpox! This was a bad omen, both regarding the leadership of the program and the local opinion about vaccinations . If the director of the program, a well-trained physician , was still unvaccinated, it was highly unlikely that the many friends and relatives visiting patients in the hospital were vaccinated. A quick survey confirmed that many of the visitors lacked the easily recognized vaccination scar. In essence, the hospital was serving as a central repository and distribution center of infection. Those visiting their loved ones were contracting the disease and spreading it to their families and friends back home. My first useful act was to station guards at the hospital’s door to vaccinate everyone before they entered . The most intense focus of infection at that moment was in Khulna District, a coastal region in the south of the country. It became my task to organize local control efforts. It soon became apparent that we were dealing with two distinct outbreaks : a generalized epidemic moving inexorably through the town of Khulna, the provincial capital, and, some miles away in the countryside, a second epidemic within a densely inhabited refugee camp. These were “reverse” refugees, a group of Urdhu speakers who had come to East Pakistan from Bihar at the time of original partition. They had never assimilated into the local, Bengali culture and were considered by many Bangladeshis to have been collaborators in the West Pakistani occupation. COLLEC T GOOD DATA 43 Epidemic-control programs depend upon zeal and common sense. Common sense told me that the outbreak in Khulna City could be stopped by the new “surveillance and containment” strategy: find new cases and vaccinate all their potential contacts. Obsessed with collecting data, I designed surveillance forms and insisted that the field workers keep careful notes on all cases, family members, and other contacts. These data enabled us to demonstrate, for the first time in a rigorous fashion, that surveillance and containment actually worked. Wherever we initiated vaccination efforts , the epidemic stopped within days. The situation in the towns was bad enough, but the crowded refugee camp was another matter altogether. The people were desperately poor and entirely dependent on relief rations. They lived in thin, small tents that were occupied by often large, over-extended families. The sick and dying were everywhere, and the scene was nothing less than apocalyptic. Because everyone had potential contact with an infected person, the only sensible approach seemed to be to vaccinate everyone. Time was absolutely of the essence. We began, vaccinating more than 2,000 people a day. Within two weeks we had vaccinated 31,000 people, at least 75 percent of the camp’s inhabitants. Unfortunately, not everyone wanted our help; a substantial proportion of the population was suspicious of vaccination . They remained a threat to themselves and to the larger community. We acted on the moment with proselytizing zeal. As others have reported doing under similar circumstances , we coerced the population in ways that might not be condoned...


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