House on Fire (2 page)

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.

 

 

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.

This book tells the story of one of those workers, and, like the accounts of any single team member, it is subject to memory defects, biases, and faulty interpretations. One advantage is that I was involved in the eradication effort from the beginning. I did keep rudimentary notes, but errors in my account are probable and I am responsible for them.

My gratitude goes first to the countless workers around the world who achieved smallpox eradication. I am especially grateful for my colleagues in India, including Drs. P. Diesh, M.I.D. Sharma, Mahendra Dutta, and C.K. Rao. There is no way to adequately thank the World Health Organization (WHO) and CDC people I worked with: in New Delhi, especially Drs. Nicole Grasset, Zdeno Jezek, Larry Brilliant, Don Francis, Don Hopkins, Prem Gambhiri, and Harcharn Singh; in Geneva, the WHO staff, led by D.A. Henderson; and in Atlanta and around the world, the CDC workers, especially Dave Sencer, Bill Watson, Stu Kingma, Don Millar, Bill Griggs, Stan Foster, Joan Davenport, Jeff Koplan, Don Eddins, Frances Porcher, Ann Mather, Maudine Ford, and Carol Walters—and at least one hundred others.

Countless colleagues in Nigeria helped make the early days productive. These include Wolfgang Bulle, David Thompson, Paul Lichfield, and the missionaries who helped during the first smallpox outbreak in Ogoja, among them Annie Voigt, Hector Ottemüller, Harold Meissner, and Wally Rasch. The support staff in Lagos included George Lythcott, Rafe Henderson, Jim Hicks, and Stan Foster.

Institutions help provide the structure, the resources, and the ability to develop objectives, coalitions, and programs. I am especially thankful for the support and assistance of the Centers for Disease Control and Prevention, the Carter Center, Emory University, and the Bill and Melinda Gates Foundation. It is an honor to have been involved with any one of the four. To be involved with all of them is beyond any expectations.

Many assisted with the collection of materials and with organizing and writing this book, especially Stu Kingma, M. I. D. Sharma, Frances Porcher, and Ann Mather. I am grateful to Mark Rosenberg for his help and his persistence in urging me to complete the manuscript, and to Sam Verhovek, Don Hopkins, and Dan Fox for their reviews and suggestions. Polly Hogan gave invaluable assistance in turning numbers into graphs, concepts into maps, and ideas into written text.

Ordering the material into a logical sequence with understandable sentences was the special contribution of Carolyn Bond, whose own experience living in India enriched her grasp of the material at hand. At the University of California Press, Lynne Withey, Hannah Love, Jacqueline Volin, and Sue Carter provided valuable ideas and guidance throughout the manuscript preparation process.

I also want to acknowledge countless mentors and friends, some mentioned in the book, and some mentioned, as it were, only in my mind. Truly, the book's coauthor is my wife, Paula. For over fifty years she has played a key part in my engagement in global health interests, and as I wrote these chapters, she not only compensated for my failing eyesight but also shared her acute sense for where the real story lay. When you are writing, it's often difficult to discern the wheat from the chaff; I thank Paula for her unerring instinct about what to leave in, and what to take out—as well as for her excellent suggestion for the book's title. To David, Michael, and Robert, I give heartfelt thanks for your sacrifices over the years.

 

 

 

 

You can smell smallpox before you enter the patient's room, but it's hard to describe. Even medical textbooks fall short when it comes to smells. The odor, probably the result of decaying flesh from pustules, is reminiscent of the smell of a dead animal. On at least two occasions, smell alone alerted me to the presence of smallpox. As I walked down a hospital hallway in India, the dead-animal odor stopped me in my tracks; following the smell, I located a smallpox patient. Another time, as I walked down an alley in an urban slum in Pakistan, the same smell hit me. There are competing smells in such places, but again one smell stood out. Knocking on doors, I found two siblings with smallpox.

Today, thirty years after the last recorded case of smallpox on the planet, I still find myself contemplating alternative tactics for its eradication, including one using smell. What if back then we'd been able to use trained dogs to identify smallpox patients? This would have sped up the
searches in urban alleyways and railway stations, where people often lay on the ground, obscured under blankets.

Those of us working in the worldwide smallpox eradication program in the 1960s and 1970s made countless visits to smallpox patients. Most of these visits were to small, crowded, airless, single-room dwellings with the windows covered. In the dark, we were taken to the patient's bed, and it was possible, with a penlight, to examine the lesions and estimate the stage of the disease. Early on, the pocks would be surprisingly hard and deep. As the disease developed, they would fill with pus and soften, becoming pustules. Once the pustules began to break down, the mixture of pus and blood would stain the patient's bed and clothing. The person in the bed might have been happy and productive the previous week, but now had limited prospects of even seeing another day.

The disease took each of its hosts by surprise. They were not aware that a virus had entered their body and was silently establishing a beachhead by multiplying in the mindless way that viruses do. The virus carried no ill will; it was simply responding to the drive to perpetuate itself. It cannot reproduce on its own; it has to borrow cells from a human being. The borrowed cells put out ever more viruses, which in turn take over other cells.

Having borrowed and destroyed the cells in order to reproduce, the virus shows its gratitude, as it were, by wreaking havoc on its host. After two weeks of multiplication, just when the immune system is organizing a defense, the virus's host for the first time realizes something is wrong—a fever, a headache, perhaps a backache and vomiting. We all experience such symptoms occasionally, so the host doesn't worry. But after another two days, there is no denying the truth. The throat is sore because of lesions on the mucous membranes, and red bumps have appeared on the skin, especially on the face, arms, and legs. Over the next few days, the bumps turn to pustules. A robust immune system and a strong constitution might, at this point, turn the tide against the virus, and the host will recover. Even so, for most survivors, the price is high: pockmarks or even permanent blindness. Many, however, are unable to develop sufficient defenses; they die.

We saw some patients who didn't live long enough to develop pustules. The skin became swollen, the fever was high, and the patient became toxic. The virus completely overwhelmed the immune system.
The patient began to bleed with a hemorrhagic version of the disease that led, mercifully, to an early death.

Once the virus had left the host's body in absolute chaos, it sought out a new host to repeat the process. To me, the process made no sense—what was the purpose? What was the meaning? But the reality of nature seems to be that some species provide no evident benefit to the community of living organisms.

While working in the smallpox eradication program, I visited many villages. In one house I might find a baby, face swollen, eyes closed, breathing hard, with exposed surfaces thick with raised, pus-filled blisters. In such cases I would have to admit that there was nothing to be done. The devastated parents were about to lose the child. The next house might reveal two children lying in the same bed. At first glance they might appear well nourished, though sick with smallpox. However, lifting the blanket would reveal that they were very thin and poorly nourished. Their swollen faces, for just a moment, concealed their starvation.

In another house a young man might be wearing only a loincloth, because he didn't want anything touching his face or limbs, which were covered with lesions. His legs were bloody. He was trying not to move, grimacing in pain when he did. Any touch caused the lesions to bleed. His face was contorted with pain; he wanted only to die.