Plan to run the vaccination clinics twenty-four hours a day until everyone has been vaccinated. The procedure is so easy that the number of vaccinators could even be doubled so complete vaccination could be accomplished in two days, if needed.
Keep the vaccine in a central location, if there is concern about storage conditions, with advance plans to ship the vaccine overnight to each of the three thousand counties. Containers for shipping could be available; address labels could be affixed in advance.
This plan, using the lessons learned during the global program, would quickly contain dozens, even hundreds, of simultaneous outbreaks in the United States. Informing the public of the plan would prevent uncontrollable panic.
Figure 16. Instructions given to field-workers for vaccinating with the bifurcated needle
Notes
ONE. A LOATHSOME DISEASE
1. Donald R. Hopkins, Princes and Peasants: Smallpox in History (Chicago: University of Chicago Press, 1983).
2. Donald R. Hopkins, personal communication, December 1979.
3. G. Catlin, O-Kee-Pa, a Religious Ceremony, and Other Customs of the Mandans (1867. Centennial edition, edited by J. C. Ewers, New Haven, CT: Yale University Press, 1967).
4. Elizabeth A. Fenn, Pox Americana: The Great Smallpox Epidemic of 1775–82 (New York: Hill and Wang, 2001).
5. Garry Wills, Lincoln at Gettysburg: The Words That Remade America (New York: Simon and Schuster, 1992).
6. Hopkins, Princes and Peasants.
7. Edward Jenner, An Inquiry into the Causes and Effects of the Variolae Vaccinae, a Disease Discovered in Some of the Western Counties of England, Particularly Gloucestershire, and Known by the Name of the Cowpox (1798. Reprint, Denver, CO: Nolie Mumey, 1940).
8. Jefferson quoted in Hopkins, Princes and Peasants, 310.
TWO. A SUCCESSION OF MENTORS
1. Some years later, Ravenholt’s interest in global fertility control led him to head up the population program at the U.S. Agency for International Development (USAID). For a compilation of Ravenholt’s contributions, see “Adventures in Epidemiology,” January 15, 2009, at www.ravenholt.com.
2. Through the years, the name changed first to Center for Disease Control, then to Centers for Disease Control, and finally to Centers for Disease Control and Prevention. The acronym (CDC) remains unchanged.
3. For more information, see “Epidemic Intelligence Service,” www.cdc.gov/eis/, accessed December 14, 2008.
4. C. W. Dixon, Smallpox (London: J. and A. Churchill Ltd., 1962).
5. W. H. Foege, “Investigation of Suspected Smallpox—New Mexico,” Report to J. D. Millar, March 1963. Archives housed in the Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia (hereafter cited as CDC Files).
6. Jim Curran, K2: The Story of the Savage Mountain (Seattle: The Mountaineers, 1995); Robert H. Bates and Charles S. Houston, Five Miles High: The Story of an Attack on the Second Highest Mountain in the World by the Members of the First American Karakoram Expedition, 2nd ed. (New York: Lyons Press, 2000).
7. T. H. Weller, “Questions of Priority,” New England Journal of Medicine 269 (1963): 673–78.
8. Tom Weller, John Enders, and Fred Robbins had won a Nobel Prize in 1954 for demonstrating that it is possible to grow poliovirus under laboratory conditions, thereby setting the stage for the development of polio vaccine, which was licensed in 1955. Weller remained active and interested in global health for the rest of his life. He died in 2008 at the age of ninety-four.
9. F. Fenner, D. A. Henderson, I. Arita, and Z. Jezek, Smallpox and Its Eradication (Geneva: World Health Organization, 1988), 409.
10. Rei Ravenholt to Sargent Shriver, June 24, 1961. Author’s personal files.
THREE. PRACTICING PUBLIC HEALTH IN NIGERIA
1. Personal communication, June 1965.
2. See, for instance, S. Bhattacharya, M. Harrison, and M. Worboys, Fractured States: Smallpox, Public Health, and Vaccination Policy in British India 1800–1947 (New Delhi: Orient Longman, 2005).
3. Elenore Smith Bowen [Laura Bohannan], Return to Laughter: An Anthropological Novel (Garden City, NY: Doubleday, 1964), 230.
4. Ibid., 231–44.
5. William Schneider, “Smallpox in Africa during Colonial Rule,” Medical History 53 (2009).
6. Ibid.
7. Donald R. Hopkins, Princes and Peasants: Smallpox in History (Chicago: University of Chicago Press, 1983).
8. Hausa woman quoted in Schneider, “Smallpox in Africa during Colonial Rule,” 198.
FOUR. FIRE LINE AROUND A VIRUS
1. The program was staffed by over three dozen unique workers. One example is Dr. George Lythcott, a pediatrician who headed up the regional office established by CDC in Lagos, Nigeria. He displayed exceptional interpersonal skills that often made the difference in getting African authorities to agree to the program and to any needed changes. Stories abounded of his fast and intuitive responses, and as an African American he seemed to get an immediate and positive response from Africans at all levels. In one country, when he was unable to see the head of state to get an agreement signed, he reportedly contacted the man’s mistress, who arranged for a meeting and a signature. In West Africa, while he was escorting the surgeon general in a celebration of the 25 millionth smallpox vaccination, a sudden change of plans required an unexpected stop in Togo. George’s visa had expired, but he was not about to be left behind. He had no idea how he was going to get admitted to the country. With the help of one of the French-speaking CDC people, he practiced some phrases to use on the immigration officer, who surely would understand his predicament. At the immigration counter, he was totally surprised to be greeted by a young Togolese woman. Forgetting the French phrases, he adopted a different persona, greeting her with, “Hi, Baby!” He then asked if he could “borrow her Bic,” and in front of her, with her pen, he changed the date on his expired visa. She was suitably charmed, stamped his visa, and once again George successfully made up the rules on the fly.
George would immediately get to know the people in an office, at the airport, or in the field. One time in the departure area at the Lagos airport, having made his usual rounds, he came back to me saying, “They have overbooked by three people. If they call your name for a phone call do not go to the other room.” Minutes later, three names were announced; they had phone calls. Would they please go to the next room and identify themselves? Three people left the room, the door closed, and the airline immediately boarded the rest of us. On another flight, George learned that some first-class seats would be empty. He offered to show me how to travel first class on the condition that I kept my mouth shut and let him do all of the negotiating. We walked to the first-class section and sat down. George made it a point to go to the cockpit just to say to the pilot, “It is good to see you again.” The flight attendant now thought they were friends. Later, she looked at his ticket and said, “I am sorry, this is a coach ticket.” George looked surprised and said, “Certainly you won’t discriminate against me because I don’t have enough money for a first-class ticket.” Thinking he was the pilot’s friend, she let him stay. Looking at my ticket, she started to tell me I couldn’t stay in first class, but George just brushed it off, saying, “He’s with me.”
A few years later, George and I were sent to Calabar after it was captured by the federal troops during the Nigerian Civil War. The embassy had asked us to do a survey of the condition of children in the area. As we were leaving Lagos in a Nigerian military aircraft loaded with fifty-five gallon drums of jet fuel and oxygen tanks, in a lightning storm, George said, “Do you realize traveling on a military plane to a war area means our life insurance is no good?” He continued, “I can’t take this. I’m going to sleep.” Which he did. On arrival in Calabar, a military jeep took us to the commanding officer, who told us where we would sleep and eat, and how we would use a military jeep to do our survey. As we were leaving he asked, “Do you want women for the night?” George, never lo
st for words, said, “Thanks anyway, but my friend here is a preacher.”
2. F. Fenner, D. A Henderson, I. Arita, and Z. Jezek, Smallpox and Its Eradication (Geneva: World Health Organization, 1988), 903.
3. Ibid.
FIVE. EXTINGUISHING SMALLPOX IN A TIME OF WAR
1. Peter Enahoro, How to Be a Nigerian (Santa Rosa, CA: Spectrum Books Ltd., 1998), 21.
2. World Health Organization, Smallpox Eradication—Report of a WHO Scientific Group, Technical Report Series no. 383 (Geneva: WHO, 1968).
3. W. H. Foege, “Epidemiology of Smallpox in West and Central Africa,” Seminar on Smallpox Eradication and Measles Control in Western and Central Africa (Lagos, Nigeria, May 13–20, 1969).
4. Henry M. Gelfand and D. A. Henderson, “A Program for Smallpox Eradication and Measles Control throughout West Africa,” Journal of International Health 2, no. 1 (Fall 1966).
5. CDC, West and Central African Smallpox Eradication/Measles Control Program—Manual of Operations, issued October 1, 1966. The author of the manual is not identified in the manual itself. However, in an interview published as “Smallpox: Dispelling the Myths” (Bulletin of the World Health Organization 86, no. 12, December 2008), D. A. Henderson states that he and others prepared the manual for West and Central Africa; Henderson then modified it for other parts of the world.
6. CDC, West and Central African Smallpox Eradication.
SIX. UNDER THE RULE OF VARIOLA
1. Letter from H. Gelfand to J. D. Millar, May 2, 1969. Author’s personal files.
2. F. Fenner, D. A. Henderson, I. Arita, and Z. Jezek, Smallpox and Its Eradication (Geneva: World Health Organization, 1988).
3. J. Z. Holwell, “An Account of the Manner of Inoculating for Smallpox in the East Indies (AD 1767),” in Indian Science and Technology in the Eighteenth Century: Some Contemporary European Accounts, vol. 1 of Collected Writings of Dharampal (Delhi: Impex, 1971), 143–63.
4. My thanks to Dr. M. I. D. Sharma for his help in assembling the following material on smallpox in India.
5. G. Mukhopadhya, History of Indian Medicine, 2nd ed. (New Delhi: Oriental Books Reprint Corporation, 1974).
6. O. P. Jaggi, Folk Medicine (Delhi: Atma Ram and Sons, 1973).
7. S. Bhattacharya, M. Harrison, and M. Worboys, Fractured States: Smallpox, Public Health and Vaccination Policy in British India 1800–1947 (New Delhi: Orient Longman, 2005), 64.
8. Holwell, “Account of the Manner of Inoculating for Smallpox.”
9. C. W. Dixon,Smallpox (London: J. and A. Churchill Ltd., 1962); K. M. Lal, D. Chand, and G. S. Murty, “Smallpox in Uttar Pradesh (1877–1954),” Journal of the Indian Medical Association 30, no. 4 (1958): 120–26.
10. M. I. D. Sharma, The History of Smallpox in India, unpublished paper, 1980. Author’s personal files.
11. British Medical Journal, Jenner Centenary Number, May 23, 1896.
12. Donald R. Hopkins, Princes and Peasants: Smallpox in History (Chicago: University of Chicago Press, 1983), 74.
13. S. P. James, Smallpox and Vaccination in British India (Calcutta: Thacker, Spink and Co., 1909).
14. Sharma, History of Smallpox in India.
15. R. W. Hunter, A Statistical Account of Bengal (London: Trubner and Co., 1876).
16. S. J. Thompson, The Silent India (Edinburgh: Williams, Blackwood and Sons, 1913).
17. Bhattacharya, Harrison, and Worboys, Fractured States, 35.
18. Ibid., 54.
19. Hopkins, Princes and Peasants, 147–48. S. J. Thompson reports that similar rumors were repeated in Burma as part of an antivaccination campaign. See Thompson, Silent India.
20. Bhattacharya, Harrison, and Worboys, Fractured States.
21. James, Smallpox and Vaccination in British India.
22. Bhattacharya, Harrison, and Worboys, Fractured States, 64.
23. Health Survey and Development Committee, Report (Delhi: Manager of Publications, 1946).
24. R. N. Basu, Z. Jezek, and N. A. Ward, The Eradication of Smallpox from India (Geneva: World Health Organization, 1979).
25. Control of Smallpox and Cholera in India. Report on the Deliberations of the Central Expert Committee of Indian Council of Medical Research on Smallpox and Cholera (New Delhi: Ministry of Health, Government of India, 1959).
26. National Smallpox Eradication Programme in India (New Delhi: Ministry of Health and Family Planning, Government of India, 1966).
27. India’s National Institute of Communicable Diseases is equivalent to the Centers for Disease Control and Prevention in the United States; indeed it was renamed the National Centre for Disease Control at its centennial celebration in July 2009. See K. C. Patnaik and P. N. Kapoor, Statistical Review of Smallpox Problem in India (New Delhi: Central Bureau of Health Intelligence, 1965); H. M. Gelfand, “A Critical Examination of the Indian Smallpox Eradication Program,” American Journal of Public Health and the Nation’s Health 56, no. 10 (1966): 1634–51; S. P. Ramakrishnan and H. M Gelfand, A Guide for the Evaluation of the National Smallpox Eradication Programme at the District Level (New Delhi: Government of India, Ministry of Health, 1964).
28. World Health Organization, “An Assessment of the National Smallpox Eradication Programme,” restricted report (Geneva: WHO, 1968).
29. The jet injector was awkward to transport, required setting up and taking down at each stop, and was expensive to purchase and maintain. In May 1967, a team headed by Dr. Ralph (Rafe) Henderson tried unsuccessfully to introduce jet injectors into India. Rafe Henderson was working in the smallpox regional office in Lagos, Nigeria, and his team included Drs. Lyle Conrad and Gordon Reid from the CDC. As the team set up to demonstrate the usefulness of the jet injector by using it on Indian health officials, they discovered they had no saline diluent with them. They substituted sterile water, which can be used as a diluent with no reduction in vaccination take rates. Unlike the diluent, however, sterile water causes significant stinging at the injection site. The CDC team successfully demonstrated how easy it was to use the jet injector, but the painful stinging left the health officials unconvinced. The team worked in both urban and rural areas to combat smallpox outbreaks, but left India frustrated because the jet injector was not widely accepted. Years afterward, Henderson learned that initially there were high expectations that the introduction of jet injectors in India might lead to smallpox eradication in a period of weeks (Ralph Henderson, personal communication, March 2010). In West Africa years later, smallpox workers would always ship vaccine and diluent together, even if sending diluent by air was costly, in order to avoid the pain caused by using sterile water to dilute the vaccine.
30. Shortly after obtaining the patent, Wyeth waived royalties on any bifurcated needles produced under WHO auspices. This act of corporate philanthropy in global health (later known as pharmacophilanthropy) was a defining moment for the smallpox eradication effort. Pharmaceutical companies would later increase their contributions to global health dramatically. Merck, for example, provided hundreds of millions of treatments of Mectizan to prevent river blindness, and GlaxoSmithKline provided Albendazole for the global lymphatic filiarises program. Merck teamed up with the Gates Foundation to bring twentyfirstcentury science to Botswana, demonstrating the ability to rapidly treat HIV infections and to reduce HIV positivity in newborns by over 90 percent. Unfortunately, the public has been inadequately versed about pharmaceutical companies’ recent attempts to assist in the improvement of global health. Wyeth provided early leadership.
31. S. Bhattacharya, Expunging Variola—The Control and Eradication of Smallpox in India, 1947–1977 (New Delhi: Orient Longman, 2006), 147.
32. Ibid.
SEVEN. UNWARRANTED OPTIMISM
1. This fact was poorly understood in the debates surrounding the attempt to vaccinate U.S. citizens in 2002. Public health officials and others who had not participated in the smallpox eradication program insisted that surveillance and containment procedures could not work in the United States. Immunity levels, they argued
, were extremely low on account of the cessation of routine smallpox vaccinations in the early 1970s. Given the realities of population density, however, surveillance and containment would have been less difficult in the United States than in most of the situations encountered in Bihar in 1974 because of fewer susceptible people per square mile.
2. Henry Gelfand once theorized that the sex trade probably created the ultimate transmission problem with smallpox, since prostitutes could still work early in their illness, before they realized they were sick. Indeed, some outbreak investigations supported his theory.
3. Minister of health’s speech from author’s personal files.
EIGHT. A GORGEOUS COALITION
1. Larry Brilliant and his wife, Girija, went on to have stellar careers in public health and the business world. They were key to developing the Seva Foundation, which focused on remediating blindness in the subcontinent. Larry later wrote a book, The Management of Smallpox Eradication in India (Ann Arbor: University of Michigan Press, 1985). His work culminated in his leadership of the Google philanthropy effort.
2. A. R. Rao, Smallpox (Bombay: Kothari Book Depot, 1972).
3. Personal communication, Don Francis, January 16, 2009.
4. S. Bhattacharya, Expunging Variola: The Control and Eradication of Smallpox in India, 1947–1977 (New Delhi: Orient Longman, 2006).
5. The CDC West and Central Africa program attempted to augment the archives by securing oral histories from the participants who returned for the forty-year reunion of smallpox warriors in 2006, held in Atlanta. This effort was so productive that oral histories were also obtained from people working in Asia who met in Atlanta in 2008, and an archive has been established at Emory University. For more details, see http://globalhealthchronicles.org/smallpox.
NINE. RISING NUMBERS, REFINING STRATEGY
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