“Life accumulates” was a favorite saying of Jim Laney, former president of Emory University. In many ways the strategy that stopped the virus was a logical extension of the firefighting principle I was taught back in the summers of 1956 and 1957. By removing the fuel one step ahead of the virus, we had built a fire line around it.
A BETTER WAY
Dave Thompson, Paul Lichfield, and I had no way of knowing that this new approach was going to work as well as it did, so during the subsequent weeks as the scenario in Ogoja province unfolded, we acquired more vaccine and, with the help of the missionaries, expanded vaccination coverage in the area. However, once the transmission ceased, we realized that these additional vaccinations, while building herd immunity against a future outbreak, did nothing to stop the current outbreak. If smallpox never returned to this area (and it never did), then every additional vaccination was essentially wasted effort—a theft of time and vaccine. Even on this small scale, we were seeing the inefficiency of mass vaccination.
Despite this success, we did not immediately abandon the mass vaccination approach. Indeed, we went ahead and implemented it because that is what we had been sent to do. After Christmas, we began training teams of health workers from the Eastern Nigeria Ministry of Health. We used stopwatches to see how fast they could set up an immunization site, drive in stakes, attach ropes for crowd control, clean the jet injectors, set up one injector for smallpox vaccine and another for measles vaccine, and when all was in order, give the first immunization. The teams became proficient and even competitive in demonstrating their skills.
Once the teams were trained, we ran a vaccination pilot project in Abakaliki, a city located east of Enugu. The project was nearly perfection in execution, community involvement was high, and our evaluations showed that we had vaccinated over 94 percent of the population, an incredible coverage rate at any time but especially impressive as a first effort.
We had barely finished congratulating ourselves when a smallpox outbreak was reported in Abakaliki. We were sure there must be some mistake, but investigation confirmed that it was definitely smallpox. We figured that the outbreak was in a small geographic pocket of people that had somehow been missed. But as the number of cases mounted, we were surprised to find them distributed throughout the city. All of the infected people turned out to be members of a religious group, the Faith Tabernacle Church, that had refused vaccinations based on religious convictions. They comprised a missed pocket but not a geographic pocket.
This experience altered our thinking. Clearly, mass vaccination could protect the vast majority of a population without guaranteeing that smallpox transmission would cease. This reinforced the lesson of the Ogoja outbreak—that there might be a better way.
FIVE Extinguishing Smallpox
in a Time of War
In the first weeks of 1967, Dave Thompson, Paul Lichfield, and I made a choice we could not have predicted. As we designed the eradication project for Nigeria’s Eastern Region, we also researched smallpox reports from past years. We recorded the previous outbreaks by date and place on maps of the region, and as we did, a macro pattern appeared. At the beginning of most high-transmission seasons, smallpox outbreaks were generally more prevalent in the northern part of Eastern Nigeria, suggesting that they migrated in from the Northern Region and gradually moved southward. We wondered initially if we could impede the progression, and thus stop smallpox, by building a fire line of mass vaccinations across the northern part of the region. The results in Abakaliki, however, were compelling and gave us pause, especially as they followed so soon after the dramatic results in Ogoja. We decided that the surveillance/containment approach ought to be tested in a larger area.
With this thought in mind, we talked with Dr. A. Anezanwu, director of the smallpox program for the Eastern Region and our supervisor at the Ministry of Health in Enugu, about putting most of our resources into surveillance and containment, focusing on the northern portion of the region first, with plans to continue south. We would go ahead with some mass vaccination activities because the measles program required that approach. But we could channel much of our effort into finding and containing outbreaks as the mass vaccination approach proceeded. Changing strategies involved risk. If the new strategy failed, the entire Nigerian eradication program could possibly be delayed or even jeopardized. As we discussed the pros and cons, Dr. Anezanwu warmed to the idea of trying something new and radical. He was a member of the Ibo tribe, as were the majority of people in the Eastern Region, and the Ibos have a reputation for entrepreneurship and taking risks. He agreed to try surveillance/containment, though probably not because we were so persuasive. Rather, Eastern Nigeria in early 1967 was the right place and time for decisions that were at odds with federal thinking. It was yet another expression of the rebellion brewing at that time.
TESTING A RADICAL APPROACH IN A REBELLIOUS LAND
What no one knew was that we had only six months to test the new approach. War was looming between the Eastern Region and the rest of Nigeria. When we consulted political officers about how soon the fighting would start, they were somewhat reassuring: both sides needed time to secure weapons, train soldiers, and actually begin military actions; meanwhile, there were hopes for a settlement that would forestall war.
The political situation affected the smallpox effort directly. For one thing, it increased the risks involved in travel. The fear of war meant heightened security and numerous local roadblocks. On some trips, our car was stopped and searched every few miles. The roadblocks were often maintained by citizen soldiers or two or three teenagers who mixed guns, alcohol, and bravado. They had to be taken seriously at all times. Sometimes travel was facilitated by showing an official letter that stated our purpose and asked all security personnel to speed our travel for the sake of stopping smallpox. This might not work if the guards lacked sufficient literacy, but the reverse was also true: someone wanting to fake literacy would feign reading an official-looking letter and give orders to allow us to proceed. We soon learned to construct our own letters, putting enough stamps on them so they conveyed importance.
One missionary was questioned at a roadblock about the labeling machine in the trunk of her car. She explained its use and then demonstrated it by asking one guard for his name, which she spelled out on a label. She presented the label to the very happy young man, and of course the other two guards requested the same and she obliged. Several miles beyond the roadblock she became aware of an unusual rattling noise, so she stopped the car and opened the trunk. Three AK-47s were piled in the trunk, left by the guards as they walked off admiring their name tags. When she appeared again at the roadblock, the young men were visibly relieved; with their weapons returned, their supervisor wouldn’t discover that they had been disarmed.
On one occasion when I was traveling, the driver discovered just as we approached a roadblock that the brakes were not working, nor was the emergency brake. No one would even consider running a roadblock, so the driver jerked the steering wheel to the right, our van hit the ditch hard, proceeded up the other side, knocked down a small tree, and came to rest against a mud hut. A crowd began to gather around us, and soon the area chief arrived. Once he had sized up the predicament, he spoke through an interpreter, telling a story in the powerful oratorical style prized in Africa. The story went on for some time, but the bottom line was that our truck had hit a sacred juju tree. This had offended the juju gods and would require the sacrifice of a chicken, which cost 10 shillings, and he expected me to pay. My initial emotion was relief. Ten shillings was a small price to pay, and we could be on our way.
However, something perverse invaded my thinking, and before I had thought it through, I began to respond. I had every intention of paying the 10 shillings. I also knew from experience that the chief was very likely taking advantage of the situation—the tree was probably not a juju tree, but as a visitor I had no option but to pay. I explained that in my culture, the van had some of the characteristics of a
juju god, and the truck was offended that the tree was in its way. I would now have to sacrifice a goat, which cost 20 shillings. I pulled 10 shillings from my pocket and asked who would receive my 10 shillings and who would give me the 20 shillings. The silence was so heavy that I immediately knew I had made a big mistake. But then one man broke the silence with a laugh. It was contagious and soon everyone was laughing. No money changed hands, everyone joked about who was the biggest storyteller, and we were off in low gear to find a place to fix our broken brake line.
ACQUIRING CRUCIAL SUPPLIES
The political tensions at times forced us to take risks just to accomplish our job. The Nigerian federal health authorities now questioned everything being done in the Eastern Region, including the rapid start of its smallpox program. This was evident at a meeting called in Lagos in early 1967 to discuss health education for Nigeria’s smallpox eradication program. The meeting was disintegrating into a full-blown attack on the posters, methods, and plans in the Eastern Region, when a young professor from the University of Ibaden, Dr. Adetokunbo Lucas, commented that a prime objective of health education is to get the attention of people in order to transmit a message, and that the Eastern Nigeria materials had just attracted more attention than materials from any other region. That simple observation by a person of distinction from a non–Eastern Nigeria tribe brought the meeting back to its purpose. Lucas would go on to have a distinguished career, with posts at WHO, the Carnegie Corporation, and Harvard University.
The federal authorities nevertheless decided it was time to rein in Eastern Nigeria’s smallpox effort. Explaining that the country must work in a unified way, the federal government cut off smallpox supplies to the Eastern Region—until the other regions had caught up. We were now faced with the serious matter of inadequate supplies—even for a new strategy that was based on a shortage of supplies. Such difficulties were not just bothersome; they threatened the very existence of the program. Moreover, lives were at risk if we had no means to stop existing outbreaks.
In March 1967, as supplies were running short, I drove to Lagos one day with another CDC team member and a plan. We needed some jet injector parts. Requesting these was not likely to be a problem since they were maintenance items, not supplies. In the meantime, we could learn how the warehouse system worked and get to know the warehouse security people. As it turned out, during our visit, one of us kept the security person engaged in trying to find specific items while the other person was free to quietly and furtively acquire essential supplies. We loaded the white Dodge pickup with vaccine, diluent, cold boxes, cold packs, jet injector parts, and anything else we thought we would need to continue the campaign. We now had a truck full of the items that the Nigerian federal government had denied us—and we were scared.
A more direct approach might have been to bribe a security person. But including one additional person in the plan might have caused it to unravel, and there would be no second chance. Indeed, we decided not to even inform the CDC supervisor in Lagos, in case his work would be compromised if it ever came to light that he was aware of our activity. While I always suspected that he was aware of and understood the importance of our actions, the approach of simply taking what we needed is still sufficiently distasteful that in the forty years since then I have never discussed the event with him.
By midmorning my colleague and I were on our way back to Enugu, and we were more than nervous. We didn’t even stop for food, as we imagined that shortages had been discovered by now and a posse had been formed to bring us to justice. Every vehicle approaching from behind was a source of fear.
In truth, no one even noticed. Months later, our supervisor mentioned some difficulty the federal smallpox program was having with its inventory. If this was an attempt to get us to open up, it did not work. I continued to believe that he supported our effort by keeping quiet.
We made it to the Onitsha Bridge, still several hours from Enugu, just as it was getting dark. The Onitsha was the only bridge across the Niger River for the entire western border of the Eastern Region. If we couldn’t cross there, we would have to drive more than one hundred miles north to take a ferry across the river.
We found the bridge blocked with bulldozers and trucks. The people of the Eastern Region were worried about a federal invasion from the west. We drove up to the bridge’s entrance and asked the guards if we could speak with the commanding officer. They referred us to their superior, and up the chain of command we went, finally getting to a person with the authority required. We explained our situation and that we needed to get back to Enugu in time to refrigerate the vaccines. The commander asked his men to move the vehicles enough so we could pass, and we were able to wind our way through the roadblock and continue on to Enugu, arriving after midnight.
Hindsight brings clarity. In retrospect, obtaining those supplies from the warehouse in Lagos looms as one of the essential actions in a decade of events leading to smallpox eradication worldwide. In the extended chain of events from success in surveillance/containment in Ogoja province to the interruption of smallpox transmission with the help of this strategy in Africa, India, and elsewhere, perhaps no link in the chain was as precarious as proving that surveillance/containment could work as the primary strategy for an entire region. This happened in Eastern Nigeria, thanks to adequate supplies.
WAR LOOMS
Through the first half of 1967, the smallpox team in Eastern Nigeria identified every outbreak of smallpox in the region and contained each one in turn. We were now confirming, through what amounted to additional fieldtesting, that the theory of vaccinating only those who were at immediate risk of exposure was sound. However, the strategy was new, and we were still unsure about how large an area of vaccination was required to contain an outbreak, so we tended to err on the side of excess. When smallpox cases were admitted to the Enugu hospital, we opted for a rapid mass vaccination program for the entire city. We believed that even in this situation the surveillance/containment approach, with the identification and vaccination of all contacts, would have been enough to stop transmission. But lack of experience made us cautious.
We learned of the hospital cases on a Saturday and immediately made plans to have vaccination teams in place to begin the urban campaign in less than forty-eight hours. I traveled through the city that afternoon, looking for vacant lots where we could set up vaccination posts and marking them on a large-scale map of the city. I became totally engrossed in the process of balancing the location of vacant lots with easy access for people and minimal disruption of the usual activities while envisioning how the teams would move, how long they would remain at each vaccination site, and the number of people required per team. I hadn’t thought about the fact that what I was doing might appear suspicious. Suddenly I was surrounded by armed police and placed under arrest. I learned that day that egress is more difficult than access when it comes to jails. Six hours later, the police finally allowed me to contact the Ministry of Health, and my Nigerian counterpart came to the jail to secure my release.
Throughout the early months of 1967, as we were successfully containing outbreaks, belligerent talk filled the newspapers. The Eastern Region threatened to leave Nigeria to form a new country, and the federal government promised military action if such an attempt was made. Tensions increased following the killing of Ibos in Northern Nigeria, and refugees began to flow into the Eastern Region. Amid the charges and countercharges, many groups tried to start peace talks even as both sides desperately tried to improve their military capability. Paula and I decided that in the event of violence in Enugu, we and our two children would stay in our upstairs flat. We had enough canned food on hand to feed us for several weeks. We agreed that at the first sign of trouble, we would fill our bathtub with water for drinking and cooking in case municipal water supplies were interrupted.
One Saturday in March, it was announced repeatedly on the radio that military maneuvers would be conducted at midnight and the streets should be vacated. Th
e announcements were not in English, and in any event we were not listening to the radio, so we were unaware of the exercise. At midnight, shortly after I had fallen asleep, Paula woke me to say the lights of the city were out and it was very quiet. The city going black could have been because of a power failure. The city going quiet was an entirely different matter. I had just read Peter Enahoro’s book How to Be a Nigerian, in which he quips: “On the sixth day, He created the Nigerian and there was peace. But on the seventh day while God rested, the Nigerian invented noise.”1 Paula said, “I don’t like this. Fill the bathtub with water.” I replied, “Don’t be silly. Go to sleep.” A minute later, the first practice mortar shells were launched and we heard machine gun firing. I filled the bathtub with water.
In April, the U.S. Embassy issued the instruction that American women and children had to evacuate from Eastern Nigeria because of the heightened threat of military action. Evacuation flights out of Port Harcourt had been arranged for a Sunday. Missionary families streamed into Enugu on their way to Port Harcourt. On the Friday evening before, I was presented with a large stack of yellow vaccination booklets by the missionary families who had helped during the outbreak in Ogoja the previous December. They had all been vaccinated too, but updating their international vaccination certificates had not seemed a priority at the time. Now they would require proof of vaccination for entry into the United States. This was routine and seemed to pose no special problem. Dr. Anezanwu had a vaccination stamp to certify the vaccinations.
The following morning, Saturday, I took the fifty or so certificates to the Ministry of Health to be stamped, only to learn that Dr. Anezanwu was traveling and would not be back until Monday. I knew where he kept the stamp because the smallpox team members had used it on previous occasions with his permission, so I entered his office by a back door. To my complete surprise, I found his desk locked. Waiting until he returned on Monday was clearly not an option. With some chagrin, I managed to get the drawer open with a pocket knife, but in the process I accidentally broke the lock. I decided that on Monday I would simply explain what had happened and why and have the lock repaired. I stamped the certificates and returned them to those who would be traveling the next day.
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