CHAPTER 9

Apprenticeship

Three Kinds of Souls, Three Prayers:

1) I am a bow in your hands, Lord. Draw me, lest I rot.

2) Do not overdraw me, Lord. I shall break.

3) Overdraw me, Lord, and who cares if I break!

—Nikos Kazantzakis

We have to hurry,” Nicole said, dragging me downstairs to the Monday meeting with the WHO regional director. The “Hurricane on High Heels” bounded down the steps from the fifth floor to the ground floor, her perfectly coifed hair bouncing behind her.

The formal meeting room at WHO was in the officer’s decorous and stately board room, something straight out of an eighteenth-century British men’s club. Some twenty doctors and various UN officials sat in large comfortable leather chairs around a long rectangular teak wood table. The view from the roof showed a dilapidated power station belching smoke in one direction and a sprawling slum of unimaginable poverty and filth in the other. The people in these slums earned their livings rummaging through garbage heaps in search of anything they could burn, sell, or eat.

The day’s agenda was to prepare for the biannual report on the general health status for Southeast Asia. The countries represented were India, Nepal, Bangladesh, Sri Lanka, Burma, Thailand, Indonesia, Maldives, Mongolia, and Bhutan. Nicole and I entered as Dr. V. T. H. Gunaratne, the WHO regional director, a huge six-foot-five-inch Sri Lankan Buddhist, stood and scowled. He was ready to gavel the meeting to order. Nicole hated these meetings and thought they were a waste of time.

I felt too young, too inexperienced, too shaggy to be in that room filled with Asia’s leaders in public health. When I scanned the faces at the table, it looked as if God had organized faces according to skin tone. The Mongolian health minister was first. Next to him was a golden Thai doctor, and on through the faces of Asia—Bangladesh, Japan, Korea, Indonesia, Burma, Taiwan—two African dignitaries, to the European staff members, a pale Englishman next to a tall blond Swede, next to a ruddy-faced Pole who was sitting next to an American. I had never been in a room with such diversity. It looked like a rainbow of humanity, a mystical convergence, a sign that I was in the right place. The room was a real-life example of what it looks like when the saying “we are all in this together” is translated into the practical, with representatives from so many diverse cultures, religions, and races, united in the fight to bring good health to all. That is what the words “World Health Organization” meant to me then.

The meeting began with presentations on the general mortality rate, or crude death rate, of regional member countries. India reported first: “India had fourteen deaths per one thousand population last year compared with twenty-two ten years earlier,” reported the Indian director general.

Smallpox in the World, 1972

“Bangladesh, twenty deaths per one thousand population.”

“Sri Lanka, eight deaths per one thousand,” said the proud Sri Lankan health minister.

Gunaratne turned to the newly appointed Mongolian health minister, who a few days earlier might have been riding the steppes on horseback in traditional Mongolian garb, which he wore proudly during his first official visit to the WHO office, the first trip, in fact, out of Mongolia in his life.

“Mr. Minister, welcome to our Monday reporting meeting. It is our custom that you report various rates in your country. First, please tell us the death rate in Mongolia last year.”

“Dr. Gunaratne,” the health minister said, “the death rate in the People’s Republic of Mongolia is exactly the same as it is in India.”

“Sir, I need a number,” Dr. Gunaratne insisted.

“In Mongolia, Dr. Gunaratne,” the health minister said, “the death rate is exactly the same as it is in the honorable Soviet Union.”

“Sir, I need a number in Mongolia.”

“In Mongolia, Dr. Gunaratne, the death rate is exactly the same as it is in the People’s Republic of China.”

Dr. Gunaratne rose to his full six-and-a-half feet. “Sir, the rules of WHO are clear. You must report the death rate in your country each year so that we can measure your progress.”

The Mongolian minister stood up and said again, “Dr. Gunaratne, the death rate in the People’s Republic of Mongolia is the same as in the People’s Republic of China, or in the honorable Soviet Union, and for that matter it is the same as it is in the wealthy United States of America. We have, in Mongolia, exactly and precisely one death per individual.”

Everybody laughed.

The number didn’t matter. He was expressing Buddha’s First Noble Truth—that the suffering of sickness, old age, and death is inevitable for each one of us.

Like Gunaratne, the health minister was a Buddhist. He was not awed by the formality of the WHO clubroom. In the precarious geographical situation of Mongolia, wedged between the much larger and more powerful Soviet Union and China, he needed to not upset his oversized neighbors by reporting any kind of progress that surpassed them. He played the fool, speaking truth to power and displaying what it was like to inhabit the two worlds I was beginning to bridge, the metaphysical and epidemiological.

That was the only joke I would ever hear in that room. The light moment passed quickly. But I was in the right place, at the right time, the first day of my first real job. I may have been wearing a bad tie and ill-fitting suit, but I felt completely part of the plan and part of the great mystery.

I was giddy with anticipation that first day as a UN employee. I was the youngest expatriate hired by WHO, and certainly the first ever recruited from the Neem Karoli Baba Monkey Temple in the Himalayas. I was an enthusiastic recruit, the apprentice, the mascot, the kid who loved India, spoke Hindi, and thrived in an Indian culture that was not always inviting to Western outsiders.

But I did not know anything about smallpox or the United Nations.

So I switched on the part of me that was a good student and took copious notes through the tedious orientation, a short course in international law, UN history, and the rights and obligations of those who carry a UN passport. Plus a less formal, but equally important briefing about decorum and the high expectations of an international civil servant living in India. To top it off there were explanations on how to fill out WHO expense forms, monthly reports, and travel notes. Not a word yet about smallpox.

It was June 1973 in New Delhi, the rains had not yet begun, the summer heat seemed to build upon itself daily; dust storms made the city almost unbearable. Cows ambled slowly through the dry and dusty streets. Rickshaw peddlers cycled slowly over the steaming asphalt. The shops on Connaught Circus closed during the afternoon when demand for electricity peaked. The wealthy turned up their air conditioners, causing load shedding and brownouts, which made everything move even more slowly.

It was no accident that the British had moved their capital from Delhi to the hill stations of Simla and Nainital during the summer. Delhi was for working; the hills were for living and playing. Girija and I made the opposite move, coming down from the hill station of Nainital several days earlier on a quest neither lofty nor spiritual: we sought what every modern expatriate living in the Indian capital sought—a small apartment with a big air conditioner. We moved temporarily into a room at the Indian International Center, near the fifteenth-century gardens of the Lodi kings of Delhi. At least in those gardens one could find solitude, history, and cooling trees.

Mr. Katri seemed genuinely happy to hand me the new blue UN passport that meant I was really hired. I had a foot-tall stack of papers to sign: emergency next of kin, income tax exemption, retirement fund, rights and duties, and a form detailing what WHO would do if I died overseas. The discussion of what would be done with my body if I died in India was followed by a short ceremony—tea and biscuits—to celebrate my entry into the ranks of UN workers. It was a sweet gesture. Katri and I had been through a lot together—at least a dozen meetings after each trip I made from the ashram to WHO.

I thought about the first person to help me understand why, after World War II, so many people put so much faith in the United Nations. When I was wandering alone in Southeast Asia, after sending Wavy off to New York and to the hospital, I would often consult the I Ching, a Chinese book of divination, for guidance. John Blofeld, a UN diplomat living in Thailand, had written many books on Asian spirituality, including a popular translation of the I Ching. On a whim, while I was passing through Bangkok, I phoned the UN office and asked for John Blofeld. By chance, he was there and answered his phone. I told him about the Hog Farm bus trip and our use of the I Ching, and he invited me to lunch. His office was filled with exquisite Buddhist and Taoist images that rivaled those in any temple. He was the first person I’d ever met who was pursuing a spiritual path while working in what looked like a conventional job in a political organization. I asked him why he stayed at the United Nations instead of devoting all his time to spiritual practice. “Because the UN—nations united—is the best hope for humankind,” he said. When the countries involved in the mass killings of World War I and II looked around at the carnage, they gave up a little bit of sovereignty in forming this organization in order to prevent such genocides from happening again. “And if we fail to see the UN live up to its promise,” Blofeld continued, “it is difficult to envision a world where humans live up to our potential.”

As the adopted new puppy of the WHO smallpox team, I got teased a lot. The younger Indians never stopped singing “Dum Maro Dum” when they saw me. And every time Nicole introduced me to someone new, she added in a conspiratorial stage whisper, “You know, his guru told him to come and work for WHO.”

Invariably a scientist would ask me, “So if your guru told you to tie your shoes with green laces, would you?”

“Yes.”

“Would you jump off the top of the Red Fort if he asked you to?”

“Yes, but he wouldn’t ask me.”

“But what if he did?”

“He wouldn’t ask me to do anything to hurt myself.”

“But if he did ask, would you jump?”

I started off with a sense of humor about this, but like all such taunting, it grew tedious. After all, we had bigger problems.

More than three-quarters of the smallpox deaths and cases in the world were now in the four countries on the subcontinent: Nepal, Bangladesh, Pakistan, and India. As the largest and most complex country on that list, India was the cause for most concern. But because Prime Minister Gandhi was focused almost exclusively on India’s crippling poverty and near-disastrous population explosion—as she should have been—she did not support the transfer of resources from birth control and maternity and child health care to the smallpox eradication program. All across India billboards featured her smiling face with the headline “Two or three, that’s enough,” to encourage family planning. Sometime while I was in India I remember seeing a billboard with a document called the Twenty Point Programme, India’s list of priorities. Building new roads, providing health for all, supporting women’s rights, improving life in slums, and protecting the environment were among them. Although smallpox in India was on the top of the world’s worry list, it was not on India’s list at all.

There was good reason that smallpox eradication remained a global priority. The numbers of people killed during the twentieth century alone is staggering when compared to even the worst tragedies and atrocities of that century. World War I, the deadliest conflict in human history up to that time, was ended by the 1918 Spanish flu pandemic that claimed 50 million lives. World War II, whose conflicts and genocides nearly brought humanity to its knees, took 60 million lives. The Armenian genocide took 1.5 million, and the Cambodian, 4 million lives. Add to those figures the 20 million deaths during the Soviet and communist Chinese revolutions, and the war in the Congo Free State, and you have between 150 and 200 million deaths resulting from all the war, genocide, and disease in the twentieth century alone. That’s roughly two-thirds the population of the United States.

Yet those 200 million deaths amount to less than half of the deaths caused by Variola major, the deadly form of smallpox. Between 1900 and 1980, smallpox killed half a billion people. Try to imagine anything else that could have killed 500 million in such a short period of time. We forget that over the course of humanity’s ten-thousand-year history before vaccination, many human beings came into contact with smallpox, and it killed one of every three who contracted the disease.

Smallpox is a horrible disease and terrifying death. Small red bumps, accompanied by a fever, appear on the hands, feet, and face. They spread across the entire body both inside and outside, turning into painful, oozing pustules. They line the esophagus, turning even a sip of water into torture. They form on every organ, inside the colon, the mouth, the vagina, and in many cases the eyes, often leaving—if you are lucky enough to survive—blindness in its wake. Hemorrhagic smallpox, the worst form of the disease, has a cruel predilection for killing pregnant women. The victim will bleed from every orifice. It is fatal every time.

Smallpox might have been the plague of boils visited upon Pharaoh in the book of Exodus, and perhaps the cause of Job’s lesions. Based on an estimate of the percentage of ordinary people with smallpox scars in the Middle East around the time of Jesus, some academics speculate that one-third of Jesus’s twelve disciples had smallpox scars on their faces. As recently as the twentieth century no Indian mother would allow a daughter to marry a man who did not have scars on his face, because they signified that he had survived an infection. If the husband-to-be wasn’t immune before marriage, contracted smallpox later and died, his wife might have to commit suicide, given the old Hindu tradition of sati.

In any effort to rid the world of a disease there is likely to be conflict between global priorities and the national needs of sovereign states. Indian priorities put the country on a collision course with the more than 150 countries that had already eradicated smallpox, making sanctions or even international quarantine a possibility. While Prime Minister Gandhi would have gladly settled for allocating modest resources to control smallpox, she was not willing to divert the massive resources called for by an eradication program, even if the long-term benefit outweighed the short-term costs.

Some skeptics believed that eradicating smallpox would increase the population explosion in India. But data show that though saving children’s lives might increase population in the short term, in the long term, it is the single greatest determinant in population reduction. Parents decide how large their family will be on the basis of how many of their children are likely to survive into adulthood. National vaccination programs help parents opt to have smaller families, leading to lower population growth and fostering a robust society, because if you vaccinate a child, he or she will likely live into adulthood. This is known as the “child survival paradox”—that preventing childhood deaths, after a short lag, leads to an overall reduction in population. In Bangladesh and in parts of the Indian state of Bihar, 50 percent of kids were dying before age five. Parents who lost a sibling while they were themselves children are likely to produce more offspring, giving birth to twice as many children, so that they end up with enough children to work the family farm or contribute to services that might help the family earn a livable wage. As parents see their children survive longer, however, they no longer need to plan for replacement births.

When I first arrived in India, smallpox was still killing hundreds of thousands of Indians in a year. While that seems like an incomprehensible number, it did not seem so large to a planner in the Indian Health Ministry, who also had to consider that diarrhea, malaria, and respiratory disease each killed one million, mostly children, every year.

Add to this the fact that production of the vaccine, manufactured in India under WHO supervision, killed cows, a sacred animal in India, in the process. The vaccine or cowpox virus was implanted onto the belly of a cow and allowed to grow. Then the cow was sacrificed in order to harvest the vaccine. For Hindus, the gentle cow is the symbol of abundance and selfless giving. Killing cows, even in pursuit of a vaccine that could save millions of children, was too much for many Indians to consider.

The moment on May 14, 1796, that Edward Jenner injected the pus from a milkmaid’s cowpox-infected fingers into the skin of his gardener’s son was one of both inspiration and madness. The idea that that this process would someday stop a powerful plague from ravaging humankind seemed impossible. The inspiration for such inconceivable leaps of imagination is a sacred act. There are many such moments in public health—John Snow, the father of epidemiology, made the leap of imagination that connected one contaminated reservoir to the spread of cholera through London in 1854. He was seen as a radical for demanding the city government turn off a famous, trusted water supply, the Broad Street pump. Or when Bill Foege, short on supplies in Africa, realized that “ring containment”—selectively vaccinating those at greatest risk, in closest proximity to an outbreak, would be a more effective strategy for eradicating smallpox than mass vaccination. The very word inspiration means “to inhale the spirit.” We think it means to inhale air, but spiros means spirit. When you die, you exhale spiros, or expire. I think of great moments in science—such as when we figured out that injecting children with a small amount of cowpox immunizes them against smallpox—as being intertwined with great moments of faith. I don’t see how most truly profound scientists could ever believe that the things he or she studies could exist in the absence of intelligent design. At the same time, I find it hard to understand how any person of faith could believe that God can be diminished by the study of this glorious plan and design. Even Einstein himself believed both in an intelligent Creator and the approach of science as a method for unraveling the code of a master planner.

For the next few months, I worked as a clerk on weekdays at WHO. Girija and I would then drive from Delhi to Kainchi on Friday night, have Saturday and Sunday with Maharaji, and return Sunday night in time for me to go back to work on Monday. As a secretary, I had a stable and predictable schedule.

It was the best of all worlds—every day I inhaled reams of information about smallpox, epidemiology, how the Indian government worked, how the UN system worked, what treaties meant, and much more about public health. I typed up letters from Nicole to D.A., made aide memoires or notes to the record for each visit a WHO medical officer made to Burma or Indonesia or Nepal. I worked with the four other secretaries, all local Indians—Malhotre, Malik, Gupta, and Prem Gambhiri—to do the filing and bring supplies up to the SEARO team. I sat in most of the meetings on strategy and got to know the Indian counterparts, especially M. I. D. Sharma and R. N. Basu, who was the assistant director general of health services.

On the weekends, Maharaji exchanged ideas with me and Girija almost as if he were more consultant or coach than guru. “What are your colleagues like?” Maharaji asked me. “Do they believe in God? Why are they working so hard to stop suffering if they are not doing it for God?”

I told him about how Nicole Grasset was intensely devoted to her work but didn’t talk about God. Bill Foege, an American who had been a missionary doctor in Africa and who helped devise our strategy, was motivated by a deep Christian faith. The Czech epidemiologist Zdeno Jezek was propelled by ideals of what we would call secular humanism. I could barely contain my admiration for these people. “But most of all,” I told Maharaji, “I admire my Indian colleagues who have sacrificed time with family to work alongside us with so much generosity, warmth, and dedication.”

Over the following weekends, Maharaji delighted in talking about the program’s progress. I cannot understand how he knew about the seasonality of the disease, the mythology about the smallpox goddess Shitala Ma, the way smallpox is transmitted by breathing, how the disease clusters in certain Indian communities. But he always reminded us that beyond the science and logistics, behind the personalities of the smallpox warriors and the program management, was the purity of our motivation, which would make us worthy to do God’s work. “Abraham Lincoln was the greatest president,” Maharaji once said, “because he knew that the real president was Christ.” My memories of those weekend conversations remain with me as lodestars for my life.

I spent most of my time at the SEARO office putting together the documents for what would become the Indian Smallpox Campaign. A search of all the municipal areas would begin in August 1973, followed the next few months by a door-to-door search of all houses in the highly endemic areas. After that, monthly searches throughout the country—“All-India Searches”—would begin, during which our teams would visit half a million villages, knocking on 150 million doors, making more than 2 billion house calls over the course of twenty months. But the search could only begin after Prime Minister Gandhi approved the full plan, which we hoped would happen any day.

One of the keys to the plan required pairing a foreign WHO epidemiologist with an Indian doctor counterpart in every single district of the badly infected states. It was easier to recruit Indians than foreign doctors. Dr. Muni Inder Dev Sharma, whose name combined the god Indra and a worldly sage, universally called M.I.D., was a tireless, grandfatherly epidemiologist who had headed the national malaria program. He now led the Indian National Institute of Communicable Diseases (NICD), and he had the idea of bringing back to work the older epidemiologists who had been forced into retirement at age fifty-seven, the age by law that Indians had to retire from civil service. M.I.D. firmly believed that smallpox would be eradicated through the strategy of surveillance and containment, not mass vaccination, and he recruited Indian doctors who had the same mindset. D.A. and Nicole mined their global networks, and Bill Foege, with his years of experience working with smallpox in Africa, exhausted his contacts at the CDC. During the first months of the campaign, we brought in three dozen epidemiologists from more than twenty countries, but primarily from Russia, Czechoslovakia, England, and the United States.

In the weeks leading up to the arrival of these new doctors, who knew a lot about epidemiology but not necessarily much about smallpox or India, I was tasked with developing a curriculum that incorporated the epidemiology and biology training slides that the CDC used to educate smallpox workers in Africa with what I could learn about the culture, customs, and language of India and how they influenced the transmission of smallpox and attitudes toward vaccination. I brought in sociologists, anthropologists, epidemiologists, and cartographers who had worked in India on cholera and malaria to act as faculty for our training programs.

A few epidemiologists dropped out early because of family or health or visa issues. So for the August search of urban areas, we had to stretch the small number of foreign doctors. Several regions had to be combined, which meant one international doctor would have to be responsible for two or three districts. They had twice as many houses to visit, twice as many vaccinators to oversee, twice as many politicians to keep from interfering. Running this lean put the entire operation at some risk.

In late July, just weeks before the massive searches would begin, Nicole got word that one of the Russian epidemiologists, an academic expert on smallpox, had taken ill and would be delayed at least six months. There was no wiggle room left in the plan, so this meant that a city or district would be left uncovered.

Nicole, Bill, and D.A. scrambled to find one more international doctor; WHO sent requests to all the other regions. But none of the other smallpox programs could spare anyone. They were tapped out.

Nicole and Bill met with M.I.D. and R. N. Basu to discuss the problem. They had two weeks to find, train, and deploy another epidemiologist, but they were out of options. As I reflect on it today, they must have been desperate because Nicole asked Bill to give “the kid” a try at fieldwork. They would take me out to an area near Meerut, a city about two hours northwest of Delhi. The next morning, I couldn’t ride my bike fast enough to get to work.

At the time, India was divided into twenty-one states. Most had distinctive cultures, historically tied to one or more of the more than one thousand languages and dialects spoken in India. Our team divided India up on the basis of smallpox concentration. The highest was located in four states we called hyperendemic: Madhya Pradesh had a relatively moderate infection rate, while Bihar and Uttar Pradesh were nearly overrun with smallpox. In between these extremes was the state of West Bengal; its porous border with its heavily infected neighbor, Bangladesh, made it a major cause of concern, so it was also considered hyperendemic. Southern India, which was by and large better educated, was entirely free of the disease.

The first step was to search the urban areas in the four hyperendemic states to ferret out undocumented cases of smallpox. The closest hyperendemic cities to WHO headquarters in Delhi were scattered across the Hindi-speaking state of Uttar Pradesh, cities like Meerut, Lucknow, Kanpur, and Allahabad.

Bill and I packed up a jeep with supplies and picked up a paramedical assistant to help administer vaccinations, as well as a junior doctor from the Indian Health Ministry. Prem Gambhiri, an administrative assistant who doubled as a driver for Bill, took the wheel. We were off on my first trip into the field.

The Meerut district medical officer, a native of Uttar Pradesh, briefed us on the smallpox situation. He showed us hand-drawn maps which indicated that the southwestern side of the district was smallpox-free, though he suspected that the entire northeastern area, especially near Muzaffarnagar and just across the river from the Bijnor district, was infected. I watched Bill take in the information, reviewing maps, case reports, and graphs related to the historical incidence of smallpox in the district. He paid special attention to the bus and train routes that connected Meerut with Delhi to the southwest and the heavily infected areas of the state of Uttar Pradesh to the north and east.

Bill and the district medical officer spoke in English but the medical officer struck up a bilingual counterpoint with our paramedical assistant and the Indian doctor we’d brought with us. In English, the medical officer said, “All cases are being reported.” But in Hindi he confided his fears that people were carrying smallpox back and forth between adjacent districts, traveling for work or visiting family and friends. In English, he said, “How thrilling that smallpox will be eradicated. This is such a great undertaking by WHO.” But in Hindi, he expressed his opinion: “I don’t believe smallpox will ever be eradicated. There is no incentive for families with sick children to come into the medical system and be reported, nor are there incentives for public health officials to report new cases. You can’t do anything once you have smallpox, and if the case is reported, everyone in the area gets quarantined. They can’t work and they lose their salaries.” Continuing in Hindi, he reported that vaccination programs had been inconsistent and certain communities—Muslims, leather tanners, and migrant workers, especially those employed in brick kilns—had dangerously low vaccination coverage rates. “WHO,” he said in Hindi, “is pugal [crazy] to think that smallpox can ever be eradicated in India.” Then he turned to Bill and said in English, “I am so optimistic about the program. Vaccination levels have much improved.”

“Bill,” I said, as soon as the medical officer was out of earshot, “he’s telling us two different stories.” Bill listened and said nothing except, “Let’s go to an infected village.” He needed to see for himself which version of the story was true. It wasn’t the first time he’d dealt with skeptical local medical officers.

Bill knew the Variola virus better than anyone else in the world, though his experience tracking and eradicating it had been almost exclusively in Africa, where the population is spread out; villages there are small and far apart from one another. India was different: densely populated, culturally complex, religiously diverse. The district magistrate and the civil surgeon joined us and suggested we head for a village just across the river from a reported smallpox outbreak in Bijnor. We organized ourselves into three jeeps—the civil surgeon drove with Bill; I went with the district magistrate, Ramesh Agrawal,^† and two Indian doctors.

A scion of a local merchant family, Agrawal spoke English more properly than I did, but when he realized I spoke Hindi, he seemed to enjoy speaking with me in his native language. I told him about my time on the ashram and about Maharaji’s prediction. He was very surprised by this. “Neem Karoli Baba said smallpox would be eradicated? Really?” I was happy that people in Meerut seemed to know Maharaji. The respect for “Blanket Baba,” as Agrawal called Maharaji, established an intimacy between him and me, like long-lost relatives finding each other. It changed the course of our conversation and he became an ally. “If you want to really smoke out all the hidden cases of smallpox,” Agrawal told me, “you need a big parade, lots of elephants and drums. And a reward. Make the news come to you, and turn the kids who report a case into heroes. Nobody will report smallpox cases unless they get some personal or family benefit.”

We reached the village, which was more like a small town of nearly one thousand inhabitants. On the outskirts, skinny migrant laborers carried baskets of yellow or red clay to the brick kilns, returning with large stacks of twenty or more bricks balanced on their heads. The furnaces had tall smokestacks, perhaps two or three stories high, which belched dark smoke that hung in the air, burning our eyes and tasting like cinder. Surrounding the houses were thirsty fields of vegetables and flowers, which were about two hundred yards from the brick kilns. The houses were concentrated in two distinct clusters or mohallas, one mostly Hindu and the other mostly Muslim.

Our small parade wound through the narrow, twisting dirt paths, led by the civil surgeon and district magistrate, then followed by the district medical officer and on down the hierarchy. We went first to the headman’s house, who joined us while we walked, stopping to look at vaccination scars on the forearms of the children we saw. We looked into the schools and talked to shopkeepers. We visited the local market. We did not see any children with smallpox, but we knew they were there. Somewhere.

Agrawal was right; because there was no incentive to report smallpox, and because of the fear of quarantine, people were not reporting cases, and they rarely notified WHO or any other health official about outbreaks. Smallpox was unique in Indian culture as well. It wasn’t considered a simple disease like cholera or polio. People believed that someone who got smallpox had been visited by Shitala Ma, the cooling mother. No Indian would consider offending her by bringing outsiders into the home while the goddess was visiting.

This turned out to be a huge obstacle; if smallpox was divine, much of the population would feel it neither could be nor should be stopped by doctors. Like most educated Indians, M.I.D. and R. N. Basu were embarrassed by this deeply entrenched superstition. And there were other obstacles. Some Muslims thought the smallpox vaccine was a Hindu conspiracy to reduce the Muslim population in India; they believed they were being injected with something that would make Muslim men sterile. Finally, although most smallpox vaccinations had very few side effects, some batches of the vaccine—usually those donated by the Soviet Union, which were more highly concentrated—caused red, swollen, and sore arms and crusted lesions with big scars at the vaccination site, usually on the forearm. Some people even got ill and could not work for a while.

Most resistance to reporting was born of a fatalistic attitude. There was no cure for smallpox, nothing to make a child or spouse more comfortable: “It’s in God’s hands whether they recover or die, so why tell anyone?” Indian medical officers were in a bind as well—if they reported cases, they risked the wrath of their superiors. Those honest and brave enough to report actual numbers of cases might be punished twice: once for reporting a hidden case and subsequently for providing inadequate vaccination coverage that allowed cases to develop.

“Larry,” Bill said to me, “let’s see if we find any hidden cases. I used to play a little game when I was in Africa. Let’s try it here. Ask the village headman to tell all the children that the tallest man in the world has come to visit.” Bill is six-feet-seven-inches tall, and in that village he was the tallest man in the world. I added one tiny exaggeration and told the headman that the tallest and most famous white man was in the village. The headman further embellished and shouted in Hindi like a carnival barker, “Come see the tallest white monkey in the world!”

A few kids came running. We played with them and checked their arms for recent inoculation scars. We vaccinated those without them. The headman embellished his call: “A long, tall, white guy has come from halfway around the world! Come and see!” Now a flood of boys and girls surrounded us. They had never seen a white man of any kind, tall or short. To draw out their friends, they starting calling out, “Englishmen!” or “White monkeys here!” Bill inspected their palms, then studied their faces and the boys’ chests. About a half dozen had either scabs from healing cases or early cases, with fluid-filled vesicles that looked like slightly raised bumps. This doesn’t look as bad as I feared, I thought. Bill knew, however, that the active, serious cases were hidden and asked me to talk to the kids in Hindi. They spoke a rural version of Bhojpuri, a Hindi dialect, and laughed at my proper urban Hindustani. One older mother said I sounded like a British army officer. Everyone laughed. A twelve-year-old boy with a few scabs on his palms offered to take us to his home. He said his one-year-old sister had died from smallpox and his younger brother and another younger sister were very sick.

When we arrived, two long neem branches were arranged in a cross blocking the front door, and a tulsi plant was on display in front of the house—symbols warning that the goddess of smallpox was visiting. The boy’s father stood in the doorway, hoping to keep us out, but the civil surgeon insisted that we enter. Once we reached the threshold the father was required by custom to treat us as guests, but he was not required to take us to the back of the house where the women and children were segregated behind a curtain, observing purdah. But at the civil surgeon’s insistence, they took us to the back room.

There, two children were crying, a boy and a girl, their faces covered with smallpox lesions. The boy had pox around his eyes that were beginning to crust, the swelling forcing his eyes to be closed. Their mother was sobbing. The children were in the eighth or ninth day of the rash, when the disease peaks, and they were both very sick. The youngest girl was lying on a bamboo mat, weak, listless, silent. The angry pustules covering her face looked like they were about to burst. Her eyes also were swollen shut. She was barely conscious, her breathing raspy and labored. Never in my clinical practice nor in medical school had I seen a child so sick, so tormented. I examined her hands; her palms were covered with pox, even her fingertips and the webbing between her fingers. I could only guess how dense the lesions were inside this poor child’s body. I took a deep breath as the emergency room doctor in me kicked into high gear. This is hell! They need intravenous fluids, anti-inflammatory drugs, antiviral treatment. Strong pain meds. Now!

“Bill,” I shouted, too loudly in the quiet room, “we’ll lose this girl. She probably has pneumonia on top of everything else, and her lesions are getting infected. She needs serious attention or she will die. Who do we call? How do we get her to the hospital?”

My agitation was making everyone uncomfortable, especially the family and the Indian doctors.

“Larry, slow down,” Bill said. “We’ve all been in the place you are in right now. We all wanted to call the ambulance the first time we saw smallpox at this stage of the disease. But there is no ambulance. There is no treatment.”

Bill motioned me toward the door. “Because there is nothing anyone can do,” he said when we got outside, “people all over the world attribute smallpox to a goddess or supernatural force. They have smallpox goddesses in Nigeria and Japan too. The only thing we can do, and the only thing we must do, is prevent another child from getting this disease. That means we have to find every case, because once there is one case, there will be a second, a third, and a fourth. We must not let that happen. We must put a ring of immunity around every active case to stop it from spreading. The first step is to control our own emotions. Then we have to keep finding cases in this village, search door-to-door in adjacent ones, and we have to keep vaccinating until there are zero unvaccinated people within a mile or so of this house. So let’s get to work.”

We were applying the innovation Bill had developed when he was running out of vaccine in Nigeria in the mid-1960s during an epidemic. The conventional approach to eradicating a disease had been mass vaccination—vaccinating every single person. The supplies Bill had were insufficient to meet the demand, so he decided to focus on the area around the active cases and vaccinate first those in the immediate vicinity, creating a ring of containment, later known as ring containment, around them. Requiring early detection and early response in a way that mass vaccination does not, it seems like common sense now, but at that time, it was a radically new idea.

Our team of doctors in the village in Meerut district spread out, going to every house and vaccinating everyone within a mile or two. That day, Bill and I found two dozen children sick with smallpox. None had been reported. The team did more than eight hundred vaccinations to contain the spread of the disease. As we were leaving, another team of vaccinators arrived to relieve us, fanning out across the river to Bijnor, where we had deduced that the first case—the “index case”—had originated. A worker in the adjacent brick kiln had come to Meerut in search of higher wages. He developed smallpox and took it home with him.

As word got out that doctors were in the village, a few mothers braved ignoring purdah and ran up to us, thrusting dying or dead babies into our arms—“Save my child!”—but this time, and many others to come, their children could not be helped. Some children scratched out their eyes because they hurt so much. They had lesions in their bowels and lungs; they couldn’t breathe.

There is no ambulance. There is no treatment.

When it was time to get back into the jeep and head for Delhi, I was exhausted, despondent, and more than ready to leave. Maharaji had said I would be giving vaccinations in villages. Now I was doing it, but it was not making me feel good or proud. I felt helpless as a doctor.

“If you want to be a public health doctor,” Bill told me on the way home, “you have to change the way you get satisfaction. It’s different from clinical medicine. You won’t see immediate results. You won’t have parents thanking you for bringing down the fever of their child. No one will name their child after you or say, ‘Larry, you saved my family.’ Here, your satisfaction comes quietly, alone, late at night when you are analyzing numbers. You won’t be able to watch the curve of a child’s fever on a hospital chart go down and feel good about yourself. You have to look at charts and graphs of hundreds of anonymous cases, watching the epidemic curve instead. Even when you succeed in stopping an epidemic, you may be the only one who knows what you did. The public doesn’t often reward prevention—you won’t be a hero. But if you’re willing to dedicate yourself to getting outcomes that you alone may see, take quiet satisfaction in the scale of what public health accomplishes, and not worry about personal recognition, then public health and epidemiology will be the source of great happiness.”

This was the medical equivalent of nish kam karma yoga, Maharaji’s custom-tailored path for me.

Riding home next to Bill, he told me about how he had started as a Lutheran missionary doctor motivated by his belief in a just and merciful God. He told me more about other diseases he had seen in Africa, about this worm and that bug, some of which he had contracted himself. I began to get an inkling of what a great soul this student of Albert Schweitzer was when he told me that one of the Lutheran hospitals where he worked in Africa was forcing Muslim children to change their names to Christian names. They had refused to treat a “Mohammed” until he became a “Paul.” Bill’s response was to resign publicly and explain that he wanted to work only with real Christian hospitals; what that hospital had done was not Christian.

At that time, all I could think about was the question of how he, or anyone, could reconcile the existence of a kind and just and merciful God with the suffering of those children we had seen that day. I’ve spent the rest of my life trying to square that circle. I had found another mentor and would soon become one of Bill’s hundreds of apprentices.

When I got home late that night, Girija could see that I was shaken. She said I had a vacant look in my eyes. I would see the same look in the eyes of my colleagues—Indian, American, Czech, and Russian—when they saw their first cases of smallpox, saw piles of small bodies being prepared for cremation or discarded from want of anyone left alive to claim them, heard the wailing of grieving parents, and faced the look of betrayal in the eyes of those parents when the bearers of the WHO insignia had nothing to give, no hope to offer except to work to prevent this horror from ever scarring another child’s face or taking another life.

It was the same in every village with active smallpox: examining and counting each of the dead and dying children; seeing the look on a mother’s face as her eighteen-year-old pregnant daughter bled to death from hemorrhagic smallpox; seeing the trust in the face of little children stricken with the disease as they looked to their helpless mothers and fathers for any kind of hope, only to find none at all. I had never experienced death on such a massive scale.

I felt the urgent need to emerge from the red hot fire pit of the epidemic victorious over the demon of smallpox, the battle finished and won. We were an army: hundreds of doctors and nurses and hundreds of thousands of fieldworkers in dozens of countries. Those I got to know best were D. A. Henderson, Nicole Grasset, Zdeno Jezek, Bill Foege, M. I. D. Sharma, and Mahendra Dutta. While Shitala Ma continued to rage and kill and maim, our soldiers were ready to engage, held back only by Prime Minister Indira Gandhi, who had not yet agreed to the battle, and the complicated thicket of international politics.

Finally, after pressure from the international community, word came that Indira Gandhi’s government would allow the full contingent of international doctors to join their Indian colleagues in an all-India National Smallpox Eradication Campaign. D.A. flew into Delhi and called a meeting of Government of India officials. They created a Central Team of WHO medical officers (Nicole Grasset, Bill Foege, Zdeno Jezek, and me), along with counterparts from the Government of India (M.I.D., Mahendra Dutta, Mahendra Singh, R. N. Basu, C. K. Rao, and R. R. Arora), that would lead the three-phase Intensified Smallpox Campaign. I was to be the youngest member of the Central Team.

August 1973 would see the urban searches for smallpox during the monsoon, when smallpox was typically at its lowest because flooding reduced travel from village to village. In September, during phase 2, we would begin house-to-house searches of the hyperendemic states of West Bengal, Bihar, Uttar Pradesh, and Madhya Pradesh. During the third and final phase, we would conduct the monthly All-India Searches until there was no more smallpox, followed by an extra twenty-four months of surveillance and searches to make absolutely sure nothing was missed.

The searches were accompanied by systematic vaccination of the most at-risk communities, coupled with epidemiological investigations of where the outbreak began and how it spread around the country. Infected people who traveled away from the source of an outbreak would be restricted from further travel; subject to vaccination, isolation, and quarantine; and, if absolutely necessary, vaccination against their will as permitted under Indian law.

To monitor areas of most concern, separate and independent teams conducted random sample assessments to ensure that searches, vaccinations, and containment went according to plan.

In early August the WHO epidemiologists were divided up and dispersed to help local authorities conduct the urban search in Delhi, Patna, Bhopal, and Calcutta. Though not yet a fully certified fieldworker, I had spent a few months on my own in Meerut, so I was sent to Calcutta to gather information for Nicole on how search preparations were going.

In the aftermath of floods, food shortages, and the 1971 civil war between West and East Pakistan, which resulted in the creation of Bangladesh, refugees had overwhelmed Calcutta. Marxists, Maoists, and conservative religious parties struggled for control, and pavement dwellers, homeless, and destitute migrants were everywhere.

One morning, just outside the door of the Fairlawn Hotel on Sudder Street, where many expatriates stayed, I saw an Indian man in his mid-thirties. He had probably left his village in Andhra Pradesh or Orissa or Tamil Nadu lured by the promise of opportunity in Calcutta. And like many people from the country, he had not found a way to make city life work for him. So now he begged for food and a few paisa to hold him over until he could find work. He lived on the pavement with his family, a woman and two babies. Like one hundred thousand others, they lived every aspect of their lives on the street, sharing a thin blanket, eating and shitting and giving birth, rearing their children, loving and dying.

During the week I was there, I walked past this man every day on my way out of the Fairlawn. I always made sure to give him a few paisa coins or a rupee note or two. One day he seemed more lethargic than usual; for a moment I thought I saw papules on his face and palms. When I got to the meeting of the municipal smallpox search committee, I asked the municipal health doctor to send a team to check him out. When I arrived back at the hotel that night, the young man and his family were gone; I could only hope they were moved to the infectious disease hospital. I did not then know that these hospitals in Calcutta were infamous for transmitting more smallpox than they contained. The municipal search would reveal that thousands of the pavement dwellers were infected with smallpox.

I remember telling God, You are a lousy manager, or you’re cruel, or you’re not all-powerful. I could not reconcile a God who was omnipotent, benevolent, and compassionate with this kind of suffering. I couldn’t fathom what sin could be big enough that someone deserved this kind of retribution on top of all their other suffering. Especially the little children. Some of them were taken to Mother Teresa’s hospital, which I visited to see how people infected with smallpox were cared for there. Everything was so clean there compared with other Calcutta hospitals. I thought, At least here the last thing they see before they die is a loving face.

While I was in Calcutta, I took the one-hour taxi ride a couple of times each week to the Ramakrishna ashram, where Ramakrishna’s student Vivekananda studied before he left the country to bring Vedanta to the United States in the 1890s. I sat where Ramakrishna had sat and witnessed the graceful flight of two white egrets, perhaps like those Ramakrishna had watched when he was transported by their beauty into a mystical state, maybe nirvana.

On the way to the ashram one day, I was reading Plato’s Phaedo about Socrates’s death. Socrates had not committed a violent crime—he was sentenced to death for refusing to support and serve what he viewed as a corrupt government. He was killed, as some wry commentators observed, for the crime of declining to serve on committees. I had been fascinated in college by how the best of men could have been put to death by the most enlightened of governments. And I was also interested in how calmly he accepted the draught of hemlock, drinking it right away rather than waiting and talking more about his ideas of the soul, death, and the afterlife with the grieving students who were with him.

Even at the end, Socrates, the wisest man of his age, had not entirely figured out the meaning of life. I found that oddly comforting as I thought of the little girl I had seen in Meerut, the first of so many I would encounter suffering at death’s door. If Socrates could not figure it all out, I should not put more pressure on myself to understand life and an often agonizing death. Socrates himself died with the Great Puzzle unsolved, and this thought brought me some respite from my angry conversation with God.

When I arrived home the next day in Delhi, Girija said, “Something funny happened yesterday with Maharaji. I was with him and a few other Indian devotees at the Barmans’ house. He must think I look like I’m from Greece.”

“Why Greece?” I asked.

“I was sitting there listening to the conversation when he turned to me out of nowhere, and said ‘Socrates!’ And then he looked at me, pointed his finger upwards the way he does, said ‘Socrates!’ again, and giggled. I don’t know what he was thinking.”

At the moment I was reading the story of Socrates’s death, Girija was sitting in front of Maharaji, one thousand miles away from Calcutta, along with the devotee and politician Shankar Dayal Sharma. Maharaji was berating him: “You’re doing nothing, you’re corrupt, and you should be doing social service to the poor. Girija’s husband is in Calcutta trying to help the sick and the poor. I sent him to work on smallpox eradication, which will be God’s gift to mankind. What are you corrupt politicians doing?”

Girija said, “And that’s when he turned to me and said, ‘Socrates!’”

We didn’t know how he even knew the name. He could read only Hindi. He didn’t know much English, let alone Greek.

When other people tell stories about the inexplicable things their gurus thought or did, I confess that my old skepticism returns. I don’t think they are lying or making it up, but I can’t help but think, I am truthful, but they are exaggerating what their gurus did or said. Reading minds was business as usual for Maharaji. It was nothing special. Changing hearts, which is so much more difficult, was his true specialty.