House on Fire (5 page)

They told me that on Tuesday afternoon, March 19, 1963, a Dr. Frank Nordstrom, a pediatrician from Farmington, had called the CDC to report that a ten-month-old Navajo girl from a reservation, now hospitalized in Farmington, had a puzzling, vesicular rash. Nordstrom knew a great deal about rashes in children, but this one was different. He was concerned that it might be smallpox.

Millar and Henderson suggested that in the hours before my flight to Farmington I acquire
Smallpox,
a textbook written by C. W. Dixon.
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The University of Colorado Medical School library had the book, but it was checked out to a student. First, I had to find the student. Second, I had to convince him that my need was greater than his—no mean feat, as he was writing a paper. I succeeded in talking him out of the book and then read key sections of it at the airport and during the flight. As the plane came to a stop on the Farmington airport tarmac that evening, I felt relatively comfortable with my knowledge about the clinical differences between smallpox and other diseases, especially chickenpox. I was unnerved when I saw the car waiting at the foot of the airplane stairs.
The local health department staff whisked me to the hospital, where a group was waiting for the diagnosis by the out-of-town expert—a twenty-seven-year-old EIS officer who had never seen a case of smallpox.

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.
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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.

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.
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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 was 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.

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.

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.
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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.