House on Fire (6 page)

In the fall of 1964,
I
left my job as an EIS officer with the CDC to begin an academic year in the Tropical Public Health Department at Harvard, of which Weller was chair. During that year of study I had the opportunity to spend considerable time with Weller, a Nobel Prize–winning scientist.
⁸
I had gone to Harvard to study global health, not smallpox, but when it came time to choose a topic to present in Weller's spring semester seminar class, I decided to write a paper on the possibility of eradicating smallpox globally. At the time, I had no way of knowing that I would be involved in exactly such a venture by the following year.

The paper was a purely academic exploration of what might be involved. In India I had seen the absolute misery of smallpox patients. In Tonga I had seen that the jet injector offered a standardized vaccination method that could be used widely with reliable take rates (a “take” is a successful vaccination as evidenced by the appearance of a sore, crater, or blister at the vaccination site several days after the vaccination). The smallpox vaccine was good; it lasted ten years or more, and it was inexpensive. Moreover, the smallpox virus's life cycle did not involve a nonhuman host, which would have complicated the strategy (yellow fever eradication had failed when it was found that nonhuman primates also harbored the virus). And because of the disease's obvious symptoms, surveillance (tracking a disease) was relatively easy. Finally, people—including government officials—feared the disease and were therefore likely to cooperate. Citizens would likely participate, and governments would likely fund the program. I used the word
eradicate
in my presentation quite deliberately both because I believed in the possibility of eradication and because many people didn't. Some believed that eradication was impossible because of the failed attempts at eradicating both yellow fever and malaria. Others assumed that emptying a viral niche was impossible—even though species extinction occurs all the time.

My presentation sparked an intense debate. Weller's own questioning unnerved me at first. He probed from various angles, exposing the weakness of my arguments by using the failed attempts at malaria eradication
as his lever. Later, one of his staff members told me that Weller would never deliberately embarrass a student and that his intense questioning was meant to explore ideas he thought had merit.

A classmate, Dr. Yemi Ademola, head of preventive medicine for Nigeria, continued the discussion with me for weeks after the seminar. He became so interested in the possibility of a smallpox eradication program in Nigeria that he eventually traveled to Atlanta to discuss its possibilities with D. A. Henderson and Alex Langmuir. They had already been working with WHO officials to secure a commitment from the World Health Assembly to adopt the global goal of smallpox eradication.
⁹

Indeed, other people had been thinking along similar lines for some time. Several years before smallpox eradication was discussed at the CDC and WHO, Charlie Houston had suggested a program to eliminate smallpox from India by using Peace Corps volunteers to head up mobile vaccination teams. His plan was rejected at the time in Washington, D.C. Rei Ravenholt had a similar idea and wrote to Sargent Shriver, head of the Peace Corps, on June 24, 1961, suggesting that the Peace Corps launch a smallpox eradication program using Peace Corps volunteers to train vaccination teams, all supervised by medical officers. Ravenholt notes in his letter that there is “no technological obstacle to its rapid eradication.”
¹⁰
A movement toward smallpox eradication seemed to be building from many directions.

 

 

 

 

The possibility of eradicating smallpox interested me, but since medical school, I had held a different vision of what my career would be. I wanted to do public health work in medical missions in developing countries.

It had always disturbed me that church groups did so much medical work in developing countries yet took so little responsibility for disease prevention. Mission boards rarely encouraged it, even though prevention is the most efficient use of limited resources. This of course made them little different from health care delivery systems in the United States. A June 1965 response I received from the Board of Foreign Missions of the United Lutheran Church of America was typical: “Our medical personnel are unable to do much in preventive medicine on a community scale. Understaffing and time limit what they can do in this area.” The board had missed the point.
¹
One
possible explanation for this stance is that medical work had become such a useful proselytizing tool. Clinics and hospitals attract people and can leave them feeling indebted after they have received help. I always felt that was wrong. Churches should be working because of what they believe, not because of what they are trying to get other people to believe.

Prevention, on the other hand, often goes unappreciated. When people do not realize they might otherwise be susceptible to a disease, they feel no urge to thank someone for a vaccination or other preventive measure, much less adopt that person's religious beliefs. People rarely reflect on the fact that they have not had to deal with smallpox, tuberculosis, whooping cough, diphtheria, rabies, or other controlled maladies in their lifetimes. Yet this is not by chance. Every disease encounter missed is the result of deliberate actions taken by unknown benefactors in the past. It is one of the clear attractions of work in public health: the public health practitioner can remain anonymous.

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.

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.