B : Programme Development
Kul Bhushan: Bull Dev Prev TB 1964, 9, 12-18.

"It was March 1949, BCG Campaign was just being born in India. My initiation into BCG vaccination work, also then took place. Training was given by experts of International Tuberculosis Campaign. I was not alone. There were others with me doctors, health visitors, clerks and peons. Some were declared unfit. After training, each doctor was made in charge of a team consisting of two health visitors, a clerk and a peon. We were allotted different areas for work. Our field of activity included schools, factories, police force etc. We had to visit each place of work thrice: first for the 1 TU tuberculin test, second exactly three days later for reading of 1 TU test and giving 10 TU test and third for vaccination etc. after another interval of 3 4 days. School Work3 : BCG work in the school was very slow and the coverages low the main reason consent from the parents. One year later an old head master (who had taught me) asked many a searching questions. He insisted on going through the literature. On our next meeting he asked me, 'Do you really want to vaccinate the children'? To an enthusiastic affirmative reply from me, he said 'Then, scrap the consent forms. They arouse unnecessary suspicion. I am convinced that the work you are engaged in is good'. I readily agreed and never used them again. Output of work improved. Soon the consent forms in my state were a thing of the past and gradually in other states too. Thanks to the venerable old head master-an unknown, unsung, hero of BCG Mass Campaign launched : In 1951 we were asked whether BCG vaccination could be extended to general population groups in rural and urban areas. The strength of a team was raised to six technicians. Maps and census books were obtained, vehicles and more vaccination equipment were procured, more cards were printed, the district and tehsil administrations were contacted, the programme was chalked out and the mass BCG campaign was launched. Changing Beliefs, Attitudes : In a group of villages no work was possible. We were at a loss to know the reason. At last we started to persuade a temperamental old woman in one of the villages. After some resistance she blurted out that a health worker had told them that some persons had become dumb and deaf after BCG vaccination. We contacted the person concerned. She had also heard about it from somebody. The information was not reliable. After discussions she was convinced. She went to all those villages; she made speeches in favour of BCG vaccination; convinced the people and informed us about it. Need for Publicity : We soon realised the need for more publicity. Public address equipment was hired, gramophone records were purchased. Later UNICEF provided the public address equipment, and cinema projectors were also supplied. The expenses were reduced. The publicity was thus built into the programme for the first time in a health programme in India. The output further improved. As the publicity for BCG increased, the publicity against it also increased. BCG was given the name of 'Birth Control Germs', and likewise many other names. Any intercurrent disease, or an accidental occurrence short of bone fractures, was attributed to BCG. Quiet perseverance and investigations into complaints by the workers, helped BCG to go on, to make strides. Hard Work : Entire teams were engaged from early hours of the day till late in the night. The duties were divided. Planning was rationalised. The first BCG manual was born. The organisational, operational and technical pattern of Mass BCG Campaign was established. The strain was less. Till 1952, two tuberculin tests before vaccination remained in vogue. After some trials by World Health Organisation, single tuberculin test was introduced. Absentees occurring at one stage, at least, were avoided. People were spared one prick. Vaccinations increased. BCG Conferences & Mass Campaign : Periodical conferences of all State BCG Officers were held. Exchange of experiences, difficulties encountered and methods to solve them were discussed. Mass Campaigns by combined effort of teams from few selected states were arranged in some large cities. Everybody put in his best. Success was tremendous. BCG workers fraternised into a close knit community. Some workers exchanged ideas by correspondence. All these efforts helped the Campaign.

Experiences in Assessment Team

In 1955, I joined the All India BCG Assessment Team. I saw dedicated workers - busy for 18 hours a day. I came across instances of nervous breakdowns due to overwork and due to frustration. I have known one who slept 16 hours a day and divided the remaining eight hours, judiciously into bits of two hours each between dressing, getting ready for the day's work, sipping tea, meeting friends and taking well earned rest and food! I cannot forget the technician whose woolen suits served as mobile refrigerator for the vaccine; those who walked eight to ten miles a day to cover houses in hilly areas testing small two - digit figures; the silent workers and the boastful ones. The thought of the officer who dared the drivers to lubricate the piston rings daily in their vehicles amuses one besides another who would not sanction casual leave to the staff on basis of telegrams, because they did not bear stamp mark of the station of their origin! It is a pleasure to recall some of ever smiling radiant faces and I shudder at the thought of those who would not smile for any consideration. All types of people go to make the world and also the BCG Campaign! I had to travel a lot, had the opportunity to see the campaigns in different states. Visits to some states were a thrilling experience. Campaigns ran smoothly where they were organised in conformity with the manuals laid down by the Central BCG Organisation. It was a pleasure to see systematic coverage of areas, in some of the States. In a district 2 or 3 teams were posted. Teams divided the areas allotted to them into sectors and covered each sector starting from periphery. No area, no village was left. The testing and vaccination coverages were good. In a few other States I was disappointed to see teams transferred from one district to another, leaving vast areas uncovered. As if this was not enough, some easily accessible or less difficult areas were covered over and over again. Towering successes were followed by great falls where campaigns were built around personalities rather than on sound organisation. I learnt a lesson not to be carried away by such fleeting shows. The unfortunate countrywide press controversy on BCG, raging then, did not effect working of a well organised campaign. Impact of Administration on Work : It was seen that where reasonable powers for day to day administration were delegated to team leaders the work went on with clockwise regularity. I was impressed by success of campaign in states where staff was satisfied, where relationship between officers and staff was more on human than on dry official levels, where deserving staff could hope for promotions coming their way and where they were paid well. I saw campaigns where staff was drawn from other public health or medical sections transferred to BCG as a punishment for not doing well in their parent sections. They spread the contagion, spoiled the finer workers and made a mess of the campaign. Technique of Field Work, Supervision : Practice of making field staff work continuously for 24 days and compensating the Sundays and holidays by one free week in a month, in some states, facilitated the work and kept the staff satisfied. During the free week the vehicles were repaired, the supplies replenished, the payments were collected and the staff was enabled to look after the personal and family matters. Why should the work not be satisfactory? In other States for every holiday, the work was not possible for two days, the strain on vehicles was extensive, the breakdowns were frequent, supplies were not sent in time, the work was suspended, staff went on leave frequently, leave was naturally not granted easily and they felt frustrated; the results were obvious. I saw a few states where supervisors did not move out of their headquarters for months. Some of them were satisfied if supply lines were maintained. They did not realise that the field organisation had failed; timings of work were not kept and sterilisation was indifferent. They insisted on high outputs, quality of work being no consideration. But in States where supervision was frequent and regular and supervisors knew their job well, the standard of work was well maintained. The outputs were realistic. Problems of field work and difficulties of staff were understood and remedies found. The staff remained satisfied.

Supervision : to a few meant only checking the stock books, attendance registers and others. Some restricted it to inspecting the concurrent technical and publicity performance in the field. Only very few included examination of procedures of advance desk and field planning, cleanliness of equipment, sterilisation, preservation of biologicals both at camp and field, advance publicity, public relations work done by team leaders and technicians, the working of transport and public address equipment etc. Years rolled by. Many old faces were missed. In some states untrained and unbriefed supervisory staff led to overall deterioration of the campaign. Generalisations are dangerous as in some states matters improved with change of hands. The campaign were revitalised. Publicity Problem : While in my native state of Punjab, I used to look at the states having full fledged staff and organisation for publicity, with envy. But in some states it was a tragic situation. I felt that integrated publicity organisations in my state was a boon in disguise. In some of the have not states, every member of the team played the publicity game. Peons, drivers, technicians, clerks, team leaders and supervisors, all did their bit while in some states even with well provided publicity organisation such things did not happen. The work was the proof of desired effects of good publicity.

House-to-house Vaccination : In 1962, after the introduction of District Tuberculosis Programme (DTP), a house to house pattern of BCG Campaign was evolved. It offered new opportunities to revitalise the aging BCG Campaign. It promised comparatively stabler life to BCG Technicians. The intervention was timely as every one connected with BCG Campaign had realised its potential pitfalls. Human honesty and supervision did work for quite sometime. But, when the demand for the figures increased and the supervision decreased, fragile human honesty slowly gave way, with too obvious a result. In this short period I have seen that in states in which Mass BCG Campaign did not run well, the house-to-house campaign is also meeting similar fate. Sound organisation and supervision are hallmarks for success of the BCG work whatever be its pattern. I am hopeful that integration of BCG work with the DTP, may provide more efficient and frequent supervision. Prevention will then go hand in hand with cure."