All of the recent talk about collective intelligence has reminded me of one of the best examples of making use of collective intelligence – an example which occurred without benefit of social media or even the internet. I wrote about the World Health Organization’s (WHO) eradication of smallpox in The Organizational Learning Cycle, presenting it as one of four exemplary organizations. There has probably never been a better illustration of an organization learning from it’s experience; of workers freely sharing their knowledge with each other; and of drawing on the ingenuity and knowledge of frontline workers.
Smallpox is the only major human disease to have ever been eradicated. The goal was established by WHO in 1967 and ten years later the eradication of smallpox had been accomplished. But before its eradication in 1977, every year over 10 million people in Asia and Africa, where the disease was still endemic, were inflicted with smallpox and 20-40% died, with the rest left scarred and many blinded. Once smallpox is contracted, there is no treatment.
Support for a world-wide campaign to eliminate smallpox grew when it became evident that North America, Western Europe, and Japan had all been able to eradicate the disease. More recently the Philippines and much of Latin America were free of smallpox. The decision to take on this enormous task was also influenced by the US military’s recent invention of the jet injector that was capable of handling up to 1000 vaccinations an hour and could be used effectively by untrained workers. Deeming the time had now come, in 1967 the World Health Assembly began an intensive effort that would focus on Africa, Asia, the Indonesian archipelago and Brazil.
By 1967, the start of the campaign, past experience in epidemiology overwhelmingly indicated that the most successful strategy was surveillance and control – a strategy that relied on containment teams quickly moving into areas of outbreaks, insolating infected persons and rapidly vaccinating all those around them. Despite the epidemiological evidence, The WHO chose mass vaccination, a strategy that involved immunizing 80% of the population on the supposition that smallpox would then decline more or less automatically. The choice of mass vaccination over surveillance and control was influenced by a number of factors, 1) the success of a recent test of the jet injector for mass vaccination that was conducted in1963 on the island of Tonga, an isolated and remote location; 2) the push from the national governments of the cooperating counties who saw mass vaccination as a highly visible display of government action, and 3) the large investment that had been made in creating a vaccine infrastructure, including jobs and salaries. So the campaign began with a strategy of mass vaccination.
Donald Henderson led the WHO headquarters team dedicated to smallpox. He had only 150 staff to work with 150,000 fieldworkers, mostly volunteers, in 50 countries. Headquarters had no authority over the fieldworkers yet chose to deal with them as co-researchers. Headquarters treated requests for help from the field with absolute priority providing immediate responses. To diminish the gap between fieldworkers and headquarters, all headquarters staff and regional advisors were expected to spend at least one-third of their time in the field, visiting each country at least once and preferably twice a year.
Within a year of the start of the campaign an outbreak occurred in Nigeria, where 90% of the population had already been vaccinated. Fieldworkers did not have adequate supplies for mass vaccination so they quickly sent for more. But the supplies of vaccine were late in arriving. Working with the limited supplies they had, the fieldworkers sought out smallpox cases and then vaccinated those who were in the immediate geographical area surrounding each case – surveillance and containment. By the time the mass campaign supplies arrived there were no detectable cases in Nigeria – containment had worked where mass vaccination had not.
With the lessons from Nigeria, the WHO smallpox team’s strategy changed to surveillance and containment. In hindsight it was recognized that the Tonga context, an isolated island with a limited population, was very different than countries like Nigeria with contiguous areas and large populations. Even so, the decision to change the strategy was not easily taken given the factors that had influenced the original decision.
Experimenting with surveillance and containment (which fieldworkers called the Bank Robber Theory, as in "go where the money is") fieldworkers discovered they could contain an outbreak when as few as 50% of the population was vaccinated. The process involved discovering new outbreaks before the smallpox had time to spread, then vaccinating the victims families, neighbors, and then the village in an ever-widening circle until no more cases occurred.
The focus on the new strategy meant the need for new practices and policies. Considerable attention was turned to the practice of reporting, a critical element of surveillance and containment. In some countries a reward was offered to the first person in an area who reported an undiscovered outbreak to authorities. The rewards were large, sometimes equivalent to one month’s income for poor villagers. A network was established through radio connections to report outbreaks. A manual was produced detailing the philosophy of surveillance and outlining methods for improving case detection and notification. A major breakthrough in reporting occurred when each local unit began to be visited regularly by a mobile surveillance team that provided instruction and assistance. The fact that someone was actively and visibly concerned with receiving reports and then acted on those reports encouraged increased reporting.
Early on the WHO smallpox team recognized the need to constantly learn from fieldworkers’ experience and adapt and change based on that learning. Although policies were established centrally, control resided at the local level. Fieldworkers were able to alter their practices to fit local culture. For example, in some locations where tattooing was used to ward off witchcraft, the vaccination scar became a part of that custom; in others midwives were used to encourage vaccination, in yet others the radio was a major tool.
Fieldworkers thought of themselves as researchers as well as workers, systematically recording their practices and tracking data. They religiously made those practices and data available to other fieldworkers. Every 2-3 weeks a summary was made of new approaches and distributed to fieldworkers. The variation in practice and the emphasis on collecting and sharing findings allowed the WHO smallpox team to innovate and learn continuously.
One of the changes fieldworkers brought about by their collection of data was the method of vaccination. Initially the WHO used the newly developed jet injector. But over time fieldworkers realized that speed was not a factor when staff were going from house to house, or waiting at local watering holes. The jet injector proved to have maintenance problems, breaking down in the field with no way to repair it. Through the influence of fieldworkers, the bifurcated needle, a simple device that had two prongs with a wire between them on which a drop of vaccine could be suspended, replaced it. The bifurcated needle was inexpensive to make and could be flamed with a match over 200 times without dulling – so was more field-worthy.
Even longstanding techniques were questioned and changed. Headquarters learned from field reports that the time-honored technique of swabbing the vaccination site made no difference in bacterial infection – so supplies that were costly both to purchase and then transport could be eliminated. They learned, again from field reports, that adult women rarely contracted small pox, so the time consuming task of vaccinating them could be eliminated.
It would have advantaged the WHO to track the number of vaccinations given and the number of areas free of small pox. But they chose instead to track trends in the incidence of smallpox. Those data were frequently embarrassing both to the WHO and to the cooperating countries – yet it allowed the WHO smallpox team to learn in a way that could not have been possible from data that was more sensitive to public relations. Negative as well as positive results were widely publicized.
Looking back at the effort from 1999, Donald Henderson, who led the smallpox team, said, “… research initiatives were encouraged at every level. This occurred despite the opposition of senior WHO leadership who insisted that the tools were in hand and the epidemiology was sufficiently well understood and that better management was all that was necessary to eradicate smallpox. Research initiatives included the development of new vaccination devices to replace traditional lancets; field studies, which revealed the epidemiology of the disease to be different from that described in the textbooks and, in consequence, the need for modification of basic operations; the discovery that the duration of vaccine efficacy was far longer than that normally stated, making revaccination much less important; operational research, which facilitated more efficient vaccine delivery and case detection; and studies which demonstrated conclusively that there was no animal reservoir. The principle was to ask again and again, how could this programme be made to operate more efficiently, more effectively. And, indeed, without the fruits of these research efforts, it is highly unlikely that eradication would have succeeded.”1
The story of the WHO’s success is a story of learning from experience, both successes and failures. Among them:
• The initial strategy of the WHO smallpox team did not succeed and they were able to shift strategies in mid-stream
• The initial technology proved difficult, and although the jet injector was one of the reasons the project had originally seemed feasible, they switched to the simpler solution of the bi-furcated needle
• Field workers considered themselves co-researchers, creating testable hypotheses in the field and reporting the results
• Field workers had authority to experiment, adapting their practice to local situations
• Data collected in the field about both practices and results were systematically distributed
• Everything was open to question – even long standing practices like swabbing the vaccination site
• All headquarters staff spent one third of their time in the field to reduce the gap between themselves and fieldworkers
• Policies promoted the collection of accurate rather than politically correct data
We Need More Examples of Collective Intelligence
We need more examples like this story to really understand what collective intelligence means. I’d appreciate it if you would suggest organizations you know of that provide other good examples. Add them to the comments so we can all see them, and I’ll write about any here that I can dig out enough information on.
1. Henderson, D. “Eradication: Lessons from the past.”
2. Hopkins, J.W. (1998).The eradication of smallpox: organizational learning and innovation in international health administration. The Journal of Developing Areas 22, 321-322.
3. The World Health Organization Smallpox Eradication Programme
