House on Fire

by William H. Foege

  I found an unexpected ally for my views, as well as a mentor, in Dr. Wolfgang Bulle, medical secretary for the Lutheran Church–Missouri Synod. Bulle had obtained his medical training in Germany during World War II, and he suffered from what seemed to be posttraumatic stress disorder, especially in relationship to his experiences on the Eastern Front as the Soviets moved into Germany. Perhaps out of a need to extirpate the images of those days, he worked for ten years as a surgeon in a mission hospital in South India. An unusually intense workaholic who abhorred wasting time, he seemed to work much of the night reading, underlining, and making notes. Certain there were better ways of addressing the health problems of the developing world than the traditional hospital-based approach, he was willing to try community prevention. With enthusiasm, he posted our family of three—Paula, our three-year-old son, David, and myself—to the Ogoja area of Eastern Nigeria, where a clinic was being set up in the small town of Yahe. Neither Bulle nor I knew exactly what I would be doing. The idea was to go there, learn the language and culture, and see what the needs were. We did have a clear picture of the goal, however: to integrate community-based prevention into a church health program.

  VILLAGE LIFE IN NIGERIA

  In August 1965, Paula, David, and I took the Queen Elizabeth to Southampton, spent ten days at the London School of Hygiene and Tropical Medicine getting advice on leprosy, tuberculosis, and African health conditions, and then sailed from Liverpool to West Africa on an Elder Dempster Line ship, which allowed us some time to acclimate to the temperature and to read up on our new home as we traveled south. We disembarked at Lagos, at that time the capital of Nigeria. Lagos was hot, humid, colorful, noisy—and crowded. People were accustomed to moving in very close quarters, whether on the street, in queues, in taxi cabs, or in the market. My brief experience in India was somewhat of a preparation, but this was all new for Paula and of course David. After several days in Lagos, we traveled to Nigeria’s Eastern Region, stopping for a night in the city of Enugu, the region’s capital. Though much smaller than Lagos, Enugu nevertheless offered shopping and amenities that, on occasion during the coming months, would lure us into making the three-hour drive from our village home ninety miles northeast, over dirt roads that seemed to test our body parts’ ability to remain connected.

  Dr. Bulle had arranged for us to spend our first six months in the village of Okpoma, about fifteen miles from Yahe, so we could learn the local language, Yala, and learn about the culture through daily contact with the villagers. Our home in Okpoma was a mud-walled house with four rooms: a living room, a kitchen, a “master” bedroom, and a bedroom for David. There was no electricity, running water, or indoor bathroom. For washing up, we put a tub on the floor of David’s room and carried in water. In the village, the living room of every home was considered communal. It was not only accepted but expected that village members would enter our living room and sit down to observe and learn about us. This they did daily, so the learning was reciprocal.

  The village was far quieter than the cities, except at night. Every night resounded with drumming. An important chief from our village had died just before our arrival, so drumming occurred nightly for the first several weeks. We quickly became accustomed to the noise and found that it actually provided a soothing background to sleep.

  Map 1. Nigeria, 1966–67

  We had been instructed on how to behave when the current village chief made his first visit, including offering him a glass of palm wine. We also were informed that he much preferred beer. One day soon after we arrived the chief came to the house, sat in our living room, and conversed with us through an interpreter. When we offered him a glass of beer, he was obviously pleased. The custom with palm wine was to sip off the top layer of the liquid, which could contain foreign material and insects, and spit that mouthful out before consuming the wine itself. Following that practice, he sipped the beer’s top layer and, to our surprise, spit it on the living room wall. Our three-year-old son was obviously impressed. That night, before going to bed, he asked for a glass of powdered milk. He took a mouthful and spit it on the wall!

  It was September when we arrived, shortly before the rainy season yielded to the dry season. As the dry season progressed, we came to appreciate the sheer luxury of year-round water available at the tap at home in the States. The village’s name, “Okpoma,” means “place of the salt.” The ground contained so much salt that it provided a commercial industry for local inhabitants. However, the well water was too saline for consumption. Water catchments were used during the rainy season. In the dry season, the villagers would walk to streams and water holes to get drinking water. As the hot, dry weather continued and nearby water sources dried up, they had to travel longer and longer distances on foot to access larger water sources. This work most often fell to the women.

  Life was not easy for any of the villagers; however, the women worked incredibly hard, while the men could often be seen resting. During the dry season, the women’s day would start early with a three- to five-mile walk to a water source; the women would return with heavy pots of water balanced on their heads. Two morning water trips were followed by work in the yam fields, and finally a trip late in the day for firewood to prepare the evening meal.

  We gradually learned how to bargain. A market was held every fifth day in our village, and markets were held in other villages on a preordained circuit during the other four days. Markets would provide the usual local foods, clothing, flashlights, kerosene, matches, and so on. As part of the market, or on separate days, there would be opportunities to buy fresh beef. Small herds of cattle would be driven from northern Nigeria by young men and boys, usually from the Fulani tribe, and a local entrepreneur would buy a cow and butcher it for sale. The price was 2 shillings (0.28 cents) a pound, regardless of cut, and the entire animal would be sold within hours. Because of the long walks experienced by the cattle, the meat, no matter which cut, was sufficiently tough that it required cooking in a pressure cooker. For most other things, bargaining was required. Initially, after thinking a fair deal had been concluded, we would find that we had endangered the local economy by paying far too much.

  At our house, we hired a young man to bicycle to the closest water source during the dry season with two ten-gallon tins tied on his bike rack. When full, the two tins weighed about 160 pounds. By the end of the dry season, when the water trips were long, he could make no more than two daily trips, but this provided adequate water for our small household. Boiling the drinking water on the propane stove took hours every day. The boiled water was stored in bottles in a kerosene refrigerator, which also put out heat, increasing the temperature in the house to even more uncomfortable levels. In late November the annual harmattan, the breeze from the north, arrived—a welcome event because it cooled off the temperatures even though it brought sand and dust from the Sahara Desert, dimming the sun and leaving everything dark and gritty. A dusted table would be covered with another layer of dust within an hour. Mosquito nets on the beds—necessary to reduce the chance of catching malaria—kept out not only mosquitoes and rodents but also any welcome breeze that might have come through the room at night. During the hottest months we sometimes sat up for hours at night to avoid getting into a stifling bed.

  We had read about the arrival of the first rains, which usually occurs in March, but to experience the relief they brought was something else again. The water poured down in torrents. People left their houses and gathered in the rain, dancing and rejoicing. The rains signaled the end of the dry season and promised new crops, cooler temperatures, and the end of the long trips for water.

  To practice community health in another culture requires an understanding and appreciation of that culture. But it’s also arrogant to assume you can truly understand it. Paula and I had daily lessons in Yala from an American who had settled in the area six months before us and who was the first foreigner to analyze the language. We learned to prepare local foods with pounded yams and cassava, and to barg
ain in the markets, which were held according to the local five-day calendar. The calendar had existed for as long as anyone could remember, and was still used alongside the seven-day weekly calendar introduced by the British.

  As much as we learned, the differences between the villagers’ experience and ours always remained starkly evident. For one thing, we could leave any time we wanted. For another, we had access to basic health knowledge and the money to be able to apply it, while the villagers did not. To cite just one example, we arrived in the village at the end of a whooping cough epidemic. The characteristic coughs, or whoops, which often go on for weeks, persisted throughout the village at night during our early weeks in the village, making clear the price paid for not having routine childhood immunizations. We were able to provide our child not only with immunizations but also with prophylaxis against malaria, screened windows to protect against mosquitoes, bed nets, and safe water. The villagers could not do this for their children. They did not have access to such basic health practices. They had to spend the little money they had, the equivalent of $1 per day, on food and shelter.

  While village life in Africa offered a predictable rhythm and the benefits of community, I was also struck by its limitations. People with wealth and education in a country like the United States can read about a new idea in the New York Times in the morning and be applying it in the afternoon. Those without education or money, whether in the United States or in Africa, cannot. Lacking the resources to change their future, they fall prey to a certain fatalism. Through the years I have come to see fatalism, the assumption that you can’t really change your future, as one of the great challenges in global public health.

  Another lesson I have learned over time is to respect culture as a powerful force; when you tangle with it, culture always wins. Thus, it’s essential to approach any culture and its customs with respect. An early demonstration of the power of culture occurred one evening in Okpoma. Some neighbors were visiting us in our courtyard. One of the women had been stung by a scorpion—a very painful condition but usually not fatal for adults. I offered her the usual medical treatment, an injection of a local anesthetic. She refused and instead wanted to see the local healer. We walked to his house and watched as he spit into the dirt to make a paste and applied it to her sting. From the standpoint of Western medicine, this treatment could have brought no immediate medical benefit, yet she immediately stopped crying and moaning. It was a dramatic example of the power of belief in the effectiveness of a traditional cultural practice.

  While contact with other expatriates was limited, I did find a mentor in Nigeria—another former EIS officer, Dr. Herman Gray, who was doing missionary work. Paula, David, and I spent a weekend with him. Besides sharing many observations about diseases and their treatment under African conditions, Gray gave us a primer on snake bites. He had a collection of preserved snakes that he used as a reference to identify the dead snakes that people brought to him when they sought treatment for snake bite. The people’s well-justified fear of snakes made it even more astounding that they could find the courage to walk barefoot on paths after dark. We saw this fear demonstrated when our house-helper, Lawrence Atutu Ochelebe, on finding a snake in our house, beat not only the snake but also the broom into an unrecognizable pulp.

  Figure 2. David Foege and village children, Nigeria, 1965

  After six months, Paula, David, and I moved to the medical compound at Yahe, and I began working in the clinic. In Yahe we still lacked electricity but did gain the luxuries of running water and a bathroom. Here I joined three nurses in running clinics while putting my new language skills to use. In rural Africa, where separate languages coexisted in small geographic areas, learning one local language was only a beginning. At the clinic we might see patients from more than twenty different language groups in the course of a week. Sometimes three interpreters were required to communicate with a single patient, increasing the opportunity for errors of interpretation.

  The combination of pathogens we would see in a single child was often a source of dismay. A young girl might appear at the clinic with a case of measles, but an examination would then disclose that she was also malnourished. She might also have malaria parasites circulating in her blood, microfilaria from onchocerciasis coursing through her body, blood in her urine because of schistosomiasis, and hookworms, roundworms, and whipworms in her intestine. Most of these problems could have been avoided by simple measures, such as wearing shoes, using bed nets, and drinking safe water.

  AN INVITATION FROM THE CDC

  By March 1966, my family and I had settled into the work of the clinic and life in Yahe. I was making plans for the community work that was most needed—improving water supplies, improving childhood nutrition, and setting up immunization programs—when an unexpected letter arrived from the CDC. In February, the World Health Assembly (WHA) executive board had approved a global smallpox eradication effort, a plan that was sure to be passed at the WHA’s annual meeting in May. The program would be administered by WHO with the assistance of the CDC. Could I be available as a consultant for setting up the program in the Eastern Region of Nigeria?

  The CDC followed up by sending Dr. Henry Gelfand to Enugu to meet with me, explore my interest, and talk over the details of a contract. Henry was one of a handful of public health people assigned to work with the new smallpox eradication program at the CDC. The program was initially headed by D.A. Henderson; Don Millar took over when Henderson moved to WHO to head up its global program. Henry made it clear that he was skeptical about having an outside consultant on the team, who might have dual loyalties. He would have preferred a fulltime CDC employee. I, on the other hand, was enthusiastic about being a consultant. I would be able to continue to do public health in Africa and pursue my interest in smallpox. I also saw the program’s possible long-term benefits for developing immunization programs in Eastern Nigeria. An additional incentive was the news that an EIS colleague, Dr. Stan Foster, would be in charge of the CDC workers in Nigeria. During the EIS course at the CDC in 1962, because of alphabetical seating, Stan and I sat next to each other, and that was the beginning of a lifelong friendship. The Fosters were at home anywhere. Stan would prove tireless in his dedication to the concept of global health, first in Nigeria and years later in Bangladesh.

  I accepted the invitation to attend the July training session for the first smallpox teams at the CDC in Atlanta. Because of my immediate experience in Nigeria, I was asked to lecture to the trainees on health conditions in West Africa. The timing of the trip to Atlanta was perfect for my family. Paula was now pregnant with our second son, Michael, and he could be delivered in the United States.

  I assumed that consulting for the smallpox program in Eastern Nigeria would be a temporary diversion in a career dedicated to public health in Africa. In fact, it turned out to be a decisive shift in direction for my entire life’s work.

  THE EBB AND FLOW OF SMALLPOX

  During my six months in Okpoma and subsequent months in Yahe, I had not seen any smallpox cases, but I knew that smallpox was a muchfeared phenomenon in the area. In rural Africa smallpox was typically not a constant threat in a particular geographic area. Rather, it was a recurrent visitor, returning to an area after five, ten, or even twenty or more years, depending on the population and its degree of contact with other areas. While smallpox is tenacious in finding susceptible new victims and devastating in its effect, it is not as contagious as some infectious diseases. Although described as “a highly contagious viral disease” in some recent books, smallpox is in fact far less contagious than influenza or measles.2 Household secondary attack rates for measles can be as high as 80 percent—that is, if a single person contracts measles, 80 percent of susceptible people in that person’s household will become ill one generation later. For smallpox, the secondary attack rate might only be 30 percent. In Africa, measles outbreaks would often be recorded in a village every second or third year; transmission was so great that only a few susceptible chi
ldren were needed to insure transmission. But a village might go decades between outbreaks of smallpox.

  Smallpox transmission was typically lower during the rainy season, when humidity was higher and people traveled less. As travel increased again after the monsoons, the virus would also be on the move again through its human vectors. A village’s residents would conclude, after some years without a smallpox case, that smallpox was a problem of the past, only to have the virus arrive with a visitor, vendor, traveler, or returning resident. The resulting outbreak would become the consuming event of the village as the virus slowly, over weeks and months, infected much of the cohort born since its last visit, plus some older villagers who had somehow escaped infection during the last outbreak.

  The outbreak would totally destroy the rhythm of life, interfering with farming and commerce as the youngest parents were infected, often from their children, and as families buried the dead. The anthropologist Laura Bohannan, who was living with the Tiv people of Northern Nigeria when smallpox devastated the tranquil scene, described the outbreak in her novel Return to Laughter. The local people, she notes, called smallpox “water,” and she soon came to understand the meaning. “By now I thought of smallpox as water,” she writes, “as a treacherous hungry sea beating steadily against crumbling dikes. . . . At the first advance of the water, the countryside had seethed and boiled with the movement of people fleeing before it.”3

  She describes the resulting terror, death, and hate: “Fear crept shadowlike over their faces; it jerked at their gestures, sharpened their voices and sapped their hearts. . . . It marked us all and left the sign for others to read.” She continues, “People held by the tenderest bond of love and affection could, when plague struck, leave each other to die in lonely terror. It must be thus when empires fall, and a whole society goes crashing into ruin. The fear that tears father from child, brother from brother, husband from wife. Where there is no law but nightmare. . . . But there is one thing greater than terror: fatigue. . . . There is nothing left in our minds, our hearts or nerves or bodies to show that we lived.”4 In the West, she says, the closest experience is the horror of war.