Scrubbed and gowned, I entered the patient’s room. It was only a few steps from the door to the bed, hardly enough time to consider every diagnostic possibility, but my comfort in understanding the differential diagnosis crumbled in those few steps. I saw a very sick, lethargic, feverish baby. Her young mother hovered nervously as I examined the girl. The lesions, primarily on her extremities, were round, single-chambered, and well circumscribed, yet they were not typical of either smallpox or chickenpox. After sending specimens off to the CDC, I phoned Henderson and Millar in Atlanta to review the findings. Since we did not yet know what was going on, we had to treat the situation as “possible smallpox” until the laboratory results were returned.
If this was smallpox, it was a very big public health event. The last case of smallpox in the United States, in 1949, was the result of an importation of the disease to New York. Many still remembered the hundreds of people in lines snaking around city blocks waiting to get vaccinated. The working definition of an “outbreak” is “an unusual occurrence” of a disease. The definition is thus situational, different for different diseases, and even different for the same disease depending on geography. For many infectious diseases, dozens or even hundreds of cases might be required for it to be called an outbreak. For smallpox in the United States, a single case would qualify as an outbreak.
The state and local health departments in New Mexico made staff and vehicles available, and we launched an immediate effort to do several things simultaneously. First, we needed to track the child’s contact with other people for the previous three weeks, even secondary contacts, and determine their histories of recent illness. Second, we had to learn about outsiders who might have come to the area and about trips by local persons to other parts of the world, even in the absence of evidence of direct contact with the child. An undetected case of smallpox, or even two generations of the disease, could have occurred between the introduced case and the current case. Third, we had to identify every person who had been in contact with the child who could be at risk if this proved to be smallpox. Finally, we needed to begin a vaccination program immediately for everyone with potential contact with the child to prevent secondary cases. Vaccination even days after exposure can still prevent the disease or modify its severity.
After initiating these efforts, I spent the remainder of the first full day on the Navajo reservation, reconstructing time lines, questioning people, and vaccinating contacts. That night I learned that the initial laboratory report results were compatible with smallpox. The seriousness of the situation was increasing. Late that night I read a local newspaper interview with a former medical missionary who had worked in Asia and was familiar with smallpox. He had seen the hospitalized child and thought her symptoms were typical of smallpox.
Dr. Nordstrom, the child’s pediatrician, had me stay at his house, so concerned was he that I have nothing else to worry about. The next morning, on the drive to the hospital, he took a long, scenic route, saying that he did so every morning to get “centered” before meeting the problems of the day. It struck me as an important mental health prescription for anyone, and especially for people in his line of work.
Over the next several days we established that tourists from Asia had recently come to Farmington, but they had no connection, even indirectly, with the child. Men from the reservation had been to Mexico, but none reported exposure to anyone with a rash disease.
Control procedures were superb. Every possible contact was found and vaccinated, and the child remained in isolation. She was improving clinically, and her mother began to relax. On the third day, two pieces of information ended the control efforts. We had mapped the lesions daily; now, new lesions had developed that were not typical of smallpox. Smallpox starts with red bumps, progresses to vesicles (blisters), then to pustules, and finally to scabs. The progression is consistent in any one area of the body, though it may be at different stages in different areas. Now we were seeing new bumps in areas that had already progressed through blisters and scabbing. Then came the definitive CDC laboratory report: the first report had been erroneous. It wasn’t smallpox; it was herpes virus.
What made the case so confusing? The child, in addition to having pneumonia, severe thrush, and enteritis, was recovering from measles, which had left a base rash on top of which were superimposed lesions of disseminated herpes. The child recovered well, the physician and the investigators breathed a sigh of relief, and life returned to normal. But it was a peripheral brush with what could have been a deadly disease.5
One month later, in April, I returned to Atlanta for the annual EIS conference, during which current officers had the opportunity to present cases to their peers and the CDC staff. The report of the smallpox scare naturally generated high interest. Many former officers found the weeklong gatherings so stimulating that they would attend the conference on their own time and money just to hear about the latest investigations. The camaraderie among EIS officers tends to be lifelong. An annual publication updated information on the location of current and former EIS officers, and officers would often seek each other out in institutions or overseas locations.
At this meeting it was announced that the physician who served the Peace Corps volunteers in India had to leave his post unexpectedly because of illness, and the Peace Corps was looking for a shortterm replacement while they recruited his successor. The duties would include traveling throughout India to provide medical care for Peace Corps volunteers and arranging for ongoing care by local practitioners. Because of my interest in global health, I decided to volunteer. After interviews in Washington, D.C., I was accepted for the position, and after many briefings, I departed in May 1963 for a three-month tour of duty in India.
SEEING SMALLPOX IN INDIA
As is true for so many travelers to India, my first few hours in the country were overwhelming. My flight landed at 3 A.M. in New Delhi. May is a very hot month in North India, and my initial reaction as I walked down the steps from the plane was disorientation: it could not possibly be this hot in the middle of the night. But it was. As I left the baggage area I stepped out into a virtual sea of people, many pressing in to be the one to take my suitcase and briefcase, escort me to a vehicle, and deliver me to my next destination. With experience one becomes accustomed to this scene, but the first time is entirely confusing. Just in time, I saw a sign with my name on it held by the Peace Corps driver assigned to meet me. We drove to the hotel through predawn streets already crowded with people. By the time I checked in at my hotel, I had experienced two of the constants in India: heat and crowding.
Yet this was only a hint of what was to come. Summer temperatures that year reached 50 degrees Centigrade (122 degrees Fahrenheit). I saw asphalt roadways so soft that they retained the footprints of people crossing the street. A walk through Old Delhi’s markets was an immersion in real crowding. Yet what I expected to be a totally overwhelming experience turned out to be surprising as I saw how people could be cheerful, resourceful, and productive in situations that would have left most Westerners demoralized and unable to function.
During this assignment I worked under the supervision of Dr. Charlie Houston and found in him yet another important mentor. He was a cardiologist by training and a mountain climber and social activist by avocation. He worked over the years trying to develop an artificial heart, and he became a world authority on high-altitude physiology. Houston was an example of undaunted courage and had long been famous in mountain-climbing circles for his role in an attempt, in 1953, to rescue a sick climber from K-2, the second-highest mountain on earth, during a storm.6 He faced each day with the cheerful confidence that he could make a difference, and the challenges of doing health work in a developing country never seemed to dampen his enthusiasm.
Houston made sure that in addition to taking care of Peace Corps volunteers, I made rounds at hospitals so I could begin to understand the health problems facing India. This was my first opportunity to see smallpox patients. The experience w
as life changing. Textbook descriptions miss the often catatonic appearance of patients attempting to avoid movement, the smell of rotting pustules that permeates the room, and the social and psychological isolation imposed by the disease. I had seen polio patients in iron lungs who could see their families only through a window and with the help of a mirror. Smallpox separated patients from their loved ones, too, but in a different way. Pustules mixed with pus and blood might cover the face. The smell was overpowering. Visitors recoiled, and even hospital staff tried to avoid touching the patient.
And, since smallpox patients were getting no specific treatment, being in the hospital offered no medical advantage to them. It merely ensured quarantine. Even if patients recovered, they would likely have lifetime facial scars, in which case the social separation in the hospital was simply a harbinger of their future life. I left India with the conclusion that although many diseases and conditions are tragic, smallpox was in a class by itself for the misery it inflicted on both individuals and society.
A RESEARCH PROJECT IN TONGA
Nine months after returning to the United States from India, I said yes to another foreign assignment. D. A. Henderson asked me to go to Tonga as part of a CDC research team. The CDC had incorporated a new vaccination technology, the jet injector, into its programs, and the Tonga study was meant to determine if the smallpox vaccine could be effectively diluted for use in the jet injector, and if so, what the optimal dilution would be. Tonga had not had smallpox or a smallpox vaccination program since the early 1900s; therefore, it provided a virgin population in terms of smallpox antibodies. The plan was to use different dilutions of vaccine on different population groups, compare the results, and determine the optimal dilution.
The CDC research team arrived on the island of Tonga on Easter weekend of 1964. Dr. Ron Roberto was the team leader for a group that included Drs. Peter Greenwald and Pierce Gardner, as well as Vachel Blair, a movie photographer who would be making a documentary of the project titled Miracle in Tonga. The final leg of the trip was in a small plane from Nandi, Fiji, to Nuku’alofa, Tonga. We landed on a grass airstrip in a classic South Sea island paradise.
However, the sense of being in paradise was almost immediately shattered. We learned on arrival that a major earthquake had occurred in Alaska, and there was concern about a tidal wave spreading throughout the Pacific and ultimately coming to Tonga. The main island is quite flat, and the guesthouse where our team was supposed to stay was on the north end of the island. Our hosts decided that we should be driven to the south end of the island, for safety’s sake.
As we settled into our temporary lodgings, we set up a schedule of two-hour shifts so that one person would remain awake listening to the radio, which was broadcasting emergency reports through the night in Tongan and English. About 2 A.M., the radio announcer reported that a tidal wave this far south had not materialized, so the station was going off the air until morning, as usual. The person listening decided to turn off the radio, let everyone continue sleeping, and explain what had happened in the morning. At 5 A.M., another member of the group woke up, turned on the radio, and found only static. Assuming the tidal wave had hit and knocked out the radio station, he woke the team as well as the people in the surrounding houses to alert them to the arrival of the (thankfully nonexistent) tidal wave. It was an exciting beginning to our stay.
The vaccine dilution testing project went well. We learned how to use and fix jet injectors, and by comparing various dilutions with a standard vaccination group we decided on a 50:1 dilution as optimal. The results of the study were very useful a few years later when the West and Central African smallpox eradication program used the jet injector to deliver measles vaccine to children and smallpox vaccine to the entire population. With this useful tool, tens of millions of injections were given within a few short years.
CAN SMALLPOX BE ERADICATED?
Earlier in 1964, before going to Tonga, I had read an article in the New England Journal of Medicine that prompted me to decide, on the spot, that I wanted to study with the author, Dr. Tom Weller.7 Weller had presented the Journal article the previous year as the commencement address to the Harvard Medical School. He expressed a vision of global health that I wanted to explore. He was saying to those young graduates: now that you have developed these medical skills and the knowledge that goes with them, think about using them in the parts of the world that need them the most.
In the fall of 1964, I left my job as an EIS officer with the CDC to begin an academic year in the Tropical Public Health Department at Harvard, of which Weller was chair. During that year of study I had the opportunity to spend considerable time with Weller, a Nobel Prize–winning scientist.8 I had gone to Harvard to study global health, not smallpox, but when it came time to choose a topic to present in Weller’s spring semester seminar class, I decided to write a paper on the possibility of eradicating smallpox globally. At the time, I had no way of knowing that I would be involved in exactly such a venture by the following year.
The paper was a purely academic exploration of what might be involved. In India I had seen the absolute misery of smallpox patients. In Tonga I had seen that the jet injector offered a standardized vaccination method that could be used widely with reliable take rates (a “take” is a successful vaccination as evidenced by the appearance of a sore, crater, or blister at the vaccination site several days after the vaccination). The smallpox vaccine was good; it lasted ten years or more, and it was inexpensive. Moreover, the smallpox virus’s life cycle did not involve a nonhuman host, which would have complicated the strategy (yellow fever eradication had failed when it was found that nonhuman primates also harbored the virus). And because of the disease’s obvious symptoms, surveillance (tracking a disease) was relatively easy. Finally, people—including government officials—feared the disease and were therefore likely to cooperate. Citizens would likely participate, and governments would likely fund the program. I used the word eradicate in my presentation quite deliberately both because I believed in the possibility of eradication and because many people didn’t. Some believed that eradication was impossible because of the failed attempts at eradicating both yellow fever and malaria. Others assumed that emptying a viral niche was impossible—even though species extinction occurs all the time.
My presentation sparked an intense debate. Weller’s own questioning unnerved me at first. He probed from various angles, exposing the weakness of my arguments by using the failed attempts at malaria eradication as his lever. Later, one of his staff members told me that Weller would never deliberately embarrass a student and that his intense questioning was meant to explore ideas he thought had merit.
A classmate, Dr. Yemi Ademola, head of preventive medicine for Nigeria, continued the discussion with me for weeks after the seminar. He became so interested in the possibility of a smallpox eradication program in Nigeria that he eventually traveled to Atlanta to discuss its possibilities with D. A. Henderson and Alex Langmuir. They had already been working with WHO officials to secure a commitment from the World Health Assembly to adopt the global goal of smallpox eradication.9
Indeed, other people had been thinking along similar lines for some time. Several years before smallpox eradication was discussed at the CDC and WHO, Charlie Houston had suggested a program to eliminate smallpox from India by using Peace Corps volunteers to head up mobile vaccination teams. His plan was rejected at the time in Washington, D.C. Rei Ravenholt had a similar idea and wrote to Sargent Shriver, head of the Peace Corps, on June 24, 1961, suggesting that the Peace Corps launch a smallpox eradication program using Peace Corps volunteers to train vaccination teams, all supervised by medical officers. Ravenholt notes in his letter that there is “no technological obstacle to its rapid eradication.”10 A movement toward smallpox eradication seemed to be building from many directions.
THREE Practicing Public Health in Nigeria
The possibility of eradicating smallpox interested me, but since medical school, I had
held a different vision of what my career would be. I wanted to do public health work in medical missions in developing countries.
It had always disturbed me that church groups did so much medical work in developing countries yet took so little responsibility for disease prevention. Mission boards rarely encouraged it, even though prevention is the most efficient use of limited resources. This of course made them little different from health care delivery systems in the United States. A June 1965 response I received from the Board of Foreign Missions of the United Lutheran Church of America was typical: “Our medical personnel are unable to do much in preventive medicine on a community scale. Understaffing and time limit what they can do in this area.” The board had missed the point.1 One possible explanation for this stance is that medical work had become such a useful proselytizing tool. Clinics and hospitals attract people and can leave them feeling indebted after they have received help. I always felt that was wrong. Churches should be working because of what they believe, not because of what they are trying to get other people to believe.
Prevention, on the other hand, often goes unappreciated. When people do not realize they might otherwise be susceptible to a disease, they feel no urge to thank someone for a vaccination or other preventive measure, much less adopt that person’s religious beliefs. People rarely reflect on the fact that they have not had to deal with smallpox, tuberculosis, whooping cough, diphtheria, rabies, or other controlled maladies in their lifetimes. Yet this is not by chance. Every disease encounter missed is the result of deliberate actions taken by unknown benefactors in the past. It is one of the clear attractions of work in public health: the public health practitioner can remain anonymous.
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