What can smallpox teach us about how we’ve managed COVID-19?

For many global health decision-makers, COVID-19 has come to symbolize a failure to apply lessons from past experiences with infectious diseases and raised pressing new questions to be addressed ahead of the next pandemic.

I had the honor of being involved in the campaign to eradicate smallpox, a devastating disease whose historical names – pox, speckled monster and red plague – hint more clearly at the pain and suffering it caused hundreds of millions of people over centuries.

After a decades-long fight to prevent transmission and inoculate people the world over, the last known case of Variola major was diagnosed in a three-year-old Bangladeshi girl named Rahima Banu, and the last case of Variola minor in October 1977, in Somalia. The World Health Organization, which estimates the disease killed 300 million people in the 20th century alone, declared in 1980 that it was the first – and so far only – human disease to be eradicated globally.

In light of COVID-19, it may be helpful to reflect on some of the lessons we learned during our campaign against smallpox to help address the current pandemic and better prepare for the next one.

1. Develop rigorous surveillance systems and relentlessly seek the truth

While conducting our smallpox eradication work, we constantly referenced a slogan from the American Management Association: “You get what you inspect, not what you expect.” It is important to continuously inspect and evaluate and, to do so, involve as many people as possible.

In India, we enlisted tens of thousands of watch guards to monitor the homes of people who had been infected and vaccinate visitors. We also enlisted thousands of contact tracers. As we built our team, we discovered that contact tracers preferred being called “disease detectives,” which conveyed a greater sense of prestige. We also motivated our team of contact tracers by constantly sharing our findings with the people who have provided the information. If people see the data is being used for good and are asked for their input, they are much more likely to continue sharing information and assist with the eradication effort.

Amid COVID-19, some have argued we should not conduct contact tracing until the number of new cases decreases significantly and the pandemic is “manageable.” However, our experience in India, which has a dauntingly large population, showed it can be done. In May 1973, we were discovering 1,500 new cases of smallpox a day just in Bihar state, which meant 1,500 new contact tracing events, including locating and vaccinating the contacts, and isolating those with symptoms until a we could make a diagnosis – all without computers or smart phones.

An excuse given now [for not conducting contract tracing] is that people won’t answer unknown callers on their phones. However, if people were told they would be receiving a call from a healthcare professional to inform them whether or not their test was positive and to discuss who else to test, and if they received a text message in advance giving the name of that healthcare professional, I believe many people would be eager to participate in contact tracing.

2. Data transparency and public trust are vitally important

To conduct proper surveillance and contact tracing, there must be a high level of trust between the people conducting the program and the public – a level of trust that does not exist today.

Our “disease detectives” had to stress to the public that no one would face repercussions for providing name of contacts. We also used incentives and offered rewards to report cases of smallpox – we started with 10 rupees, then 50 and 100 – and finally up to US$1,000 per case identified. A survey at the time showed that more people in India knew they could receive a reward for identifying someone with smallpox than knew the name of the prime minister, which indicated we had successfully communicated our message.

There has been a great deal of trust lost during this pandemic, including in both politicians and public health officials, some of whom have crossed the line between being public servants to becoming private servants. We must absolutely restore trust in the public health system and our pandemic response efforts. One way to do so is to enlist people who are already trusted by the public.

3. The importance of iteration

During our smallpox campaign, we did not have all the answers – nor do we this time. In India, we constantly adjusted our approaches, even up until the last month. Our Indian surveillance system required about four months to get right, while our contact tracing system needed six months. We are still early in the COVID-19 pandemic and it does not benefit us when our political or public health leaders act or communicate as if we have all the answers. We need to be honest about the fact that as the pandemic unfolds and evolves, our response will too.

4. Public health leaders and practitioners must learn from one another and share experiences

Despite the fact that many nations that have different political and governmental structures, health systems, and levels of economic development, they often still have similar pandemic surveillance and response programs and systems. This creates an opportunity to share experiences and learn from each other.

During smallpox, for example, we found that some healthy competition between Indian states was helpful to spurring progress. We would periodically have meetings between the different states, which were eager to demonstrate their progress and new approaches. We also held similar regional meetings in New Delhi involving Pakistan and Bangladesh so public health leaders could share their strategies and progress.

To this end, one of the most important things we learned in India was also the value of human connection in fighting a pandemic. Allow me to share an anecdote: one day, I was about to get on a plane in Patna and noticed the pilot was drinking beer, so I resolved to start taking the train. On these 12-hour train rides, I often found myself deep in conversation with my Indian counterparts and these conversations became far more important than weekly, hour-long meetings. Now, with meetings being conducted by teleconferencing, we should nevertheless take the time to develop personal relationships that are the key to productive partnerships.