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Illustrations by Joe Cepeda

WorldWarWON (continued)

The regional directors interpreted the initiatives of the World Health Assembly as being primarily advisory. Some they accepted, some they ignored, and some they modified to suit their own and the region’s particular needs and agendas.

Given the director-general’s openly expressed skepticism about smallpox eradication, it was not surprising that there was little support for smallpox eradication in the regions. Two regional directors were passively or openly hostile to the program; one largely ignored it; and one actively opposed it. Fortunately, the one who most strongly opposed the eradication program was replaced through election by a strong supporter a year after we began.

The regional offices added a dysfunctional layer of bureaucracy for communications with country program directors and WHO advisers. Recall that at the time of the program, there were no e-mail facilities, no mobile phones, and no fax machines. Telex and ordinary telephone calls were expensive (and not always technically possible). Personal contact and correspondence by mail were our only reliable routes for communication. WHO policy required, however, that all correspondence with countries had to pass through the regional offices. But this was more than simply a routing of memos. For example, if I wanted to communicate with a smallpox program adviser in Uganda, my letter had to go first to the African Regional Office whose office was in Brazzaville, Republic of the Congo. It would be read by one of the staff, who might eventually prepare a draft forwarding memo for the regional director’s signature—a deceptively simple procedure that often required several rewrites and could take weeks. The recipient, the WHO country representative, would then consult with our WHO smallpox eradication adviser. A reply followed this track in reverse.

This bureaucratic tangle ensured that four to five months might elapse between the time I sent a simple query and received a reply—if one came at all. Eventually I resolved the problem by simply sending original copies of memos to the regional office, as directed, and carbon copies directly to the recipient. However, this added another wrinkle because the WHO mail pouch did not carry personal mail and the copies were so regarded. Regular postal service worked reasonably well, although it often cost me 100 to 150 francs a month to send my documents. It was worth it.

The direct system of communication sometimes created its own problems: once we received a telex from Uganda asking that 2 million doses of vaccine be sent urgently. We sent the vaccine by air the following morning. Five months later, the regional office wrote to report an urgent request from Uganda for 2 million doses of vaccine. We did not know whether this was a new request or the one we had dealt with five months previously. (It was the latter.) The policy of quietly short-circuiting the regional office, when necessary, continued for years and, surprisingly, was never questioned, if indeed the regional directors ever learned about the practice.

Indonesia—A Remarkable Achievement with Few Resources

The program began in July 1968 in Java, one of the world’s most densely populated areas. Thirteen “advance teams” were established. Each had a vehicle and was headed by an Indonesian medical officer who had been given a month’s special training. WHO supplemented the medical officer salaries so they could serve full time. The teams’ primary functions were to work with local authorities to promote the vaccination program, to provide some sort of supervision to vaccinators, and to try to establish the regular reporting of cases to the national smallpox program headquarters. At first these activities seemed to have little effect on smallpox incidence. However, as the importance of surveillance containment became apparent, the teams in two of Java’s three provinces cut back on all routine vaccination and undertook special searches in order to find and contain cases.

It was during this period that the first use was made of schoolchildren and teachers to report outbreaks, and the idea of the WHO Smallpox Recognition Card came into being. As the number of smallpox cases declined to low levels in a province, the teams moved on to more heavily afflicted areas. It was a surprise to find that despite the density of population, the spread of smallpox remained concentrated geographically. Long-distance spread to more distant areas was infrequent.

In Indonesia, the reported numbers of cases of smallpox for 1967 and 1968—13,000 and 17,000, respectively—depicted a problem that was much less serious than the program staff had anticipated. [Dr. Jacobus] Keja, then serving as the SEARO regional adviser for smallpox, decided in 1968 to undertake a population-wide survey of facial smallpox scars. From this he could develop an estimate of the actual numbers of cases that had occurred during 1967. He found that the true number was more likely to have been at least 100,000 cases. The minister of health was profoundly skeptical and asked that his own Indonesian statisticians review the data and reach their own conclusions.They concluded that the true number of cases was actually even higher, more likely 200,000 to 500,000 cases. Interest in the program at the highest levels of government soared, and additional Indonesian government resources were quickly made available.

The development of a surveillance system was one of the more remarkable achievements in Indonesia. It became fully effective in early 1970. The architect was an Indonesian medical officer, Dr. A. Karyadi. He standardized reporting forms and established a goal of receiving all reports within two weeks from provinces and within three weeks from the outer islands. This required imagination and innovation.The postal service was limited in its geographic scope and was unreliable at best. But creative methods were found—enlisting bus drivers, military personnel, special messengers, and businessmen as couriers. By September, Karyadi reported that 95 percent of the weekly reports were being received from all reporting sites on two of the main islands. This contrasted to the situation only a year before, in which only half of the units had reported—with delays of twenty-one weeks. In May 1970, he began issuing a weekly surveillance report, much as [statisticianepidemiologist] Leo Morris had done in Brazil.

As the advance teams experienced increasing success, routine vaccination efforts declined, case searches increased in number and intensity, and additional vaccinators were enlisted to help in containment vaccination. What appeared to be the last cases in Indonesia were discovered in December 1971—little more than three years after the program had begun. Four weeks passed without cases, and then 45 cases were notified from a sub-district only 17 miles (twenty-eight kilometers) from the capital. Special teams began a rapid search and vaccination effort, but 160 cases were discovered before the last occurred in late January 1972.

The success of the Indonesian program, given the obstacles and paucity of resources, was a remarkable achievement. International support was minimal, amounting to only $1.3 million (little more than one cent per person); it included 24 vehicles, 430 motorcycles, and 3,100 bicycles. Several of the exceptional senior staff were eventually recruited to serve as WHO advisory staff in other countries. One of them, the Indonesian program director, [Dr. Petrus] Koswara, forty-three years of age, was the only WHO staff member to die while working in the program. He succumbed to a heart attack in 1974 in Ethiopia.

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  • Joan Levin

    Chicago 03/27/2010 01:17:14 PM

    Sadly the important pioneering role of Dr. Karel Raska was overlooked in this article. You may read Dr. Alex Langmuir's appreciation of Dr. Raska and Dr. Henderson's addendum originally printed in 17 Intl. J. Epid. 491 (1988) at

  • Joan Levin

    Chicago 03/27/2010 01:25:33 PM

    Sadly the pioneering role of Dr. Karel Raska was overlooked in this article. Interested readers may learn more about this in Dr. Alex Langmuir's Appreciation and the Addendum by Dr. D. A. Henderson published in 17 Int. J. Epid. 491 (1988) and found online at .

  • JustinBeersons

    USA 04/13/2011 06:07:08 AM

    Hi - I am definitely glad to discover this. cool job!

  • zeroxtrpo

    england 05/04/2011 10:50:23 PM

    Wow this information is great! Thanks this has helped me a lot! I'm sure your posts are one of the best out there! Always so accurate!

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