House on Fire
CALIFORNIA/MILBANK BOOKS ON HEALTH AND THE PUBLIC
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Public Health Law and Ethics: A Reader, edited by Lawrence O. Gostin (revised and updated second edition, 2010)
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State of Immunity: The Politics of Vaccination in Twentieth-Century America, by James Colgrove
Low Income, Social Growth, and Good Health: A History of Twelve Countries, by James C. Riley
Searching Eyes: Privacy, the State, and Disease Surveillance in America, by Amy L. Fairchild, Ronald Bayer, and James Colgrove
The Health Care Revolution: From Medical Monopoly to Market Competition, by Carl F. Ameringer
Real Collaboration: What It Takes for Global Health to Succeed, by Mark L. Rosenberg, Elisabeth S. Hayes, Margaret H. McIntyre, and Nancy Neill
House on Fire: The Fight to Eradicate Smallpox, by William H. Foege
Inside National Health Reform, by John E. McDonough
House on Fire
THE FIGHT
TO ERADICATE SMALLPOX
WILLIAM H. FOEGE
University of California Press
BERKELEY LOS ANGELES LONDON
Milbank Memorial Fund
NEW YORK
The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan analysis, study, research, and communication on significant issues in health policy. In the Fund’s own publications, in reports, films, or books it publishes with other organizations, and in articles it commissions for publication by other organizations, the Fund endeavors to maintain the highest standards for accuracy and fairness. Statements by individual authors, however, do not necessarily reflect opinions or factual determinations of the Fund. For more information, visit www.milbank.org.
University of California Press, one of the most distinguished university presses in the United States, enriches lives around the world by advancing scholarship in the humanities, social sciences, and natural sciences. Its activities are supported by the UC Press Foundation and by philanthropic contributions from individuals and institutions. For more information, visit www.ucpress.edu.
University of California Press
Berkeley and Los Angeles, California
University of California Press, Ltd.
London, England
© 2011 by The Regents of the University of California
Library of Congress Cataloging-in-Publication Data
Foege, William H., 1936–.
House on fire: the fight to eradicate smallpox / William H. Foege.
p. cm — (California/Milbank books on health and the public; 21) Includes bibliographical references and index.
ISBN 978-0-520-26836-4 (cloth: alk. paper)
1. Smallpox. I. Milbank Memorial Fund. II. Title. III. Series: California/Milbank books on health and the public; 21.
[DNLM: 1. Smallpox—epidemiology—Africa—Personal Narratives.
2. Smallpox—epidemiology—India—Personal Narratives. 3. History, 20th Century—Africa—Personal Narratives. 4. History, 20th Century—India—Personal Narratives. 5. International Cooperation—Africa—Personal Narratives. 6. International Cooperation—India—Personal Narratives. 7. Smallpox—history—Africa—Personal Narratives. 8. Smallpox—history—India—Personal Narratives. WC 585]
RA644.S6F64 2011
614.5'21—dc22
2010041703
Manufactured in the United States of America
20 19 18 17 16 15 14 13 12 11
10 9 8 7 6 5 4 3 2 1
This book is printed on Cascades Enviro 100, a 100% post consumer waste, recycled, de-inked fiber. FSC recycled certified and processed chlorine free. It is acid free, Ecologo certified, and manufactured by BioGas energy.
To my wife, Paula, for making this work even possible; to Patty Stonesifer, for the support that made it possible to write the account; and to the legions, from WHO/Geneva to households around the world, who made smallpox eradication a reality
If a house is on fire, no one wastes time putting water on nearby houses just in case the fire spreads. They rush to pour water where it will do the most good—on the burning house. The same strategy turned out to be effective in eradicating smallpox.
Contents
List of Illustrations
Foreword by Carmen Hooker Odom and Samuel L. Milbank
Foreword by David J. Sencer
Preface
PART ONE AFRICA: IDENTIFYING THE KEY STRATEGY
1. A Loathsome Disease
2. A Succession of Mentors
3. Practicing Public Health in Nigeria
4. Fire Line around a Virus
5. Extinguishing Smallpox in a Time of War
PART TWO INDIA: MEETING THE CHALLENGE OF ERADICATION
6. Under the Rule of Variola
7. Unwarranted Optimism
8. A Gorgeous Coalition
9. Rising Numbers, Refining Strategy
10. Water on a Burning House
11. Smallpox Zero
Conclusion
Postscript
Appendix: A Plan in the Event of Smallpox Bioterrorism
Notes
Glossary
Index
Illustrations
FIGURES
1. Statue of Edward Jenner vaccinating a child
2. David Foege and village children, Nigeria, 1965
3. Rotary lancet, a vaccination device used in India until the early 1970s
4. Ped-O-Jet, the delivery instrument for millions of vaccinations in Africa in the 1960s
5. First smallpox patient seen in Ogoja, Nigeria, outbreak, 1966
6. Patient outside infectious disease hut near Abakaliki, Nigeria, 1967
7. The first cadre of smallpox warriors, Ghana, 1967
8. A village smallpox goddess
9. The bifurcated needle
10. Search team member in India seeking information on smallpox using a recognition card
11. Smallpox reports from weeks 34 to 47 in Uttar Pradesh and Bihar, India, 1973
12. Average number of new and contained outbreaks per week, Bihar, India, January to April 1974
13. Average number of new and contained outbreaks per week, Bihar, India, January to May 1974
14. Graph distributed to field-workers showing the turning point, when outbreaks began to decrease in India, 1974
15. Total outbreaks per week in India,
January 1974 to May 1975
16. Instructions given to field-workers for vaccinating with the bifurcated needle
TABLE
1. Smallpox deaths in well-vaccinated British India, 1868–1907
MAPS
1. Nigeria, 1966–67
2. Northern India
3. New smallpox outbreaks in Bihar, India: 1974 and 1975 compared
Foreword
CARMEN HOOKER ODOM, President, Milbank Memorial Fund
SAMUEL L. MILBANK, Chairman, Milbank Memorial Fund
The Milbank Memorial Fund is an endowed operating foundation that works to improve health by helping decision makers in the public and private sectors acquire and use the best available evidence to inform policy for health care and population health. The Fund has engaged in nonpartisan analysis, study, research, and communication since its inception in 1905.
House on Fire: The Fight to Eradicate Smallpox, by William H. Foege, is the twenty-first book in the series California/Milbank Books on Health and the Public. The publishing partnership between the Fund and the University of California Press encourages the synthesis and communication of findings from research and experience that could contribute to more effective health policy.
With an insider’s knowledge of the worldwide smallpox eradication program in the 1960s and 1970s, Foege, a physician, relates the strategies used to eradicate smallpox in Africa and India and the challenges encountered along the way. He reveals the reasons behind the success of this program: a shared global objective; conception, implementation, and management of a clear plan tailored to a specific disease in terms of its context, range, and vulnerabilities; evaluation of the tools and techniques used and their subsequent modification; a willingness at all levels, from the local citizenry and government to country officials and global institutions, to communicate and work together to achieve the end goal; tenacity; and optimism.
As Foege notes, the smallpox eradication program shows that “humanity does not have to live in a world of plagues, disastrous governments, conflict, and uncontrolled health risks. The coordinated action of a group of dedicated people can plan for and bring about a better future. The fact of smallpox eradication remains a constant reminder that we should settle for nothing less.”
This book should be useful to policymakers, foundations, and nongovernmental service organizations as well as to professionals in global health as they work together to confront the shared global risk of emerging and reemerging infectious diseases.
Foreword
DAVID J. SENCER
The eradication of smallpox from the entire world has been justly described as one of the most remarkable achievements in the history of medicine and public health. In India—a country one-third the size of the United States but with three times the population, with 638,365 villages and thirty-five cities with a million-plus population—the campaign to eradicate smallpox involved the most acute and challenging difficulties encountered anywhere in the entire smallpox eradication effort. The story of India’s successful eradication program can be told fully only by those who were on the team that brought about this achievement, and this book is written by one of the team’s two pivotal participants. It is so much richer because this participant happens to have one of the most impressive memories in the world, and he has used his own extensive notes and references from others involved in the campaign.
The other pivotal participant, Dr. M. I. D. Sharma, was the director of the smallpox eradication program for the Government of India during the years when this final effort was mounted and brought to a successful conclusion in 1975. He also served concurrently as the director of India’s National Institute of Communicable Diseases. His unflagging commitment to eradication, the excellence of his leadership, and his skillful use of the human, fiscal, and material resources—committed from all over the world—in the Indian eradication effort constituted a central and indispensable element in the success of this program.
Dr. William Foege, as a Centers for Disease Control and Prevention (CDC) epidemiologist assigned to the Southeast Asia Regional Office of the World Health Organization (WHO), worked on the eradication effort throughout the Indian subcontinent. The methodology of surveillance and containment, an alternative to mass vaccination refined in the 1960s in Africa, enabled the Indian and multinational team to successfully eradicate smallpox in India. Dr. Foege’s tenacious advocacy of the containment approach, together with his meticulous monitoring of the continually changing status of the Indian eradication effort and his adjustment of strategy and resources in response to altered circumstances, was an essential ingredient of this success.
Much has been said about the humanitarian benefits derived from the eradication of smallpox, and the importance of these benefits to all the nations of the world cannot be disputed. But another benefit of almost equal weight in the minds of many public health professionals was the demonstration that the Indian government and its people could apply principles of sound management and deliver a program that stretched from the remotest village to the most populous urban centers of their country. Supervision, delegation, evaluation, performance appraisal, and accountability—all commonplace terms in the business schools of the world—acquired operational reality in this vast undertaking. The concepts and practices of sound management became a reality in the work of more than 250,000 workers throughout the nation.
The health and well-being of people throughout the world have been enhanced by the dedication of these Indian smallpox eradication workers, by the responsiveness of the hundreds of millions of Indian people who accepted vaccination and actively collaborated in the reporting of disease and suspected cases, and by the hundreds of health workers from other nations who, with their Indian counterparts, devoted the best of their skills and capacities to this effort. All of us, and those who will follow us, are indebted to these workers and to their leaders, particularly to the late Dr. Sharma and those who collaborated so closely and effectively with him in this last major battle of the war against smallpox.
The author of this volume was in a delicate position in India. Dr. Foege was recognized by the Indian leadership as a representative of WHO and the CDC, but his precise role and scope of responsibilities in the eradication effort were not crisply defined. He had to persuade the authorities to make necessary changes and to recognize that eradication was achievable only if the CDC continued to provide the resources needed. Dr. Foege demonstrated to all levels of the Indian bureaucracy qualities of leadership that often go unrecognized. For one thing, he was willing to do whatever it took for the effort to continue. It was not unusual for him to place himself in physical jeopardy for the sake of the program. For example, he would carry millions of rupees in his briefcase to make sure that payrolls were met. Some people believe that leadership means being out in front, being visible; Dr. Foege demonstrated that great leaders can lead from behind the scenes, giving others the credit and recognition.
The publisher and a number of colleagues urged Dr. Foege to place himself more visibly in the narrative. But the publisher does not know Dr. Foege. As director of the CDC, I was one of his supervisors while he was working on smallpox eradication in India, and I have known him for more than forty years. He tells stories not about what he has done, but about what others have done. Dr. Foege called me from India about six months before the last case of smallpox was contained. I urged him to remain there and asked whether he realized that in a few months, the last case of smallpox in India would be eradicated and that there would be a huge celebration for one of the most extraordinary events in the history of global health. He responded, “I realize that this is going to happen, but if I remain in India, too much attention would be directed toward the external support that India received, and it is very important that recognition be given to the accomplishments of the hundreds of thousands of Indians who really did the work.” He said to me, “This is why I am coming home.” And against my suggestion, he packed up, and he and his family came home.
This principle of “ego suppression” continued to guide Dr. Foege as he returned to the United States and pursued his lifelong career goal of working as the director of the CDC, as the founder of the Task Force for Child Survival, as the executive director of the Carter Center, and as a senior advisor to the Bill and Melinda Gates Foundation, all in the pursuit of global health equity. The world’s debt to William Foege is enormous.
Preface
We lose our histories far too fast. In the dozens of public health efforts in which I have been involved throughout my career, the histories have rarely been written soon enough. Within years, sometimes within months, people’s accounts begin to differ. Often the participants simply do not keep journals or record their notes. In an effort to capture the history of the smallpox eradication effort forty years after the fact, the participants at the 2006 reunion of the first smallpox workers sent by the Centers for Disease Control and Prevention (CDC) in Atlanta to West and Central Africa in the mid-1960s were invited to record oral histories. Many commented that they had forgotten details, and their accounts were incomplete. Based on this experience, the CDC decided to collect oral histories from the people involved in the 2010 H1N1 influenza phenomenon right away, in 2010. This is a wise practice, for much that might benefit future generations can be learned from eyewitness accounts of important events.
Thousands of people participated in the global smallpox eradication effort in the 1960s and 1970s, and each one has a story to tell. Their stories might vary, yet the people involved shared common attributes. They were optimists; they actually thought they could change the future—and they did. They were risk takers; there was no shortage of people telling them that the effort was futile and they were hurting their career chances—this proved untrue. They were problem solvers; they had little idea of what they were facing, and they took on the problems in order and in stride. They also knew how to mix hard work and fun. Working under sometimes grueling conditions in hot and humid village regions worldwide, with few amenities, these field-workers gathered periodically for meetings where humor and the shared sense of being part of something important carried the day.
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