House on Fire (7 page)

We had read about the arrival of the first rains, which usually occurs in March, but to experience the relief they brought was something else again. The water poured down in torrents. People left their houses and gathered in the rain, dancing and rejoicing. The rains signaled the end of the dry season and promised new crops, cooler temperatures, and the end of the long trips for water.

To practice community health in another culture requires an understanding and appreciation of that culture. But it's also arrogant to assume you can truly understand it. Paula and I had daily lessons in Yala from an American who had settled in the area six months before us and who was the first foreigner to analyze the language. We learned to prepare local foods with pounded yams and cassava, and to bargain in the markets, which were held according to the local five-day calendar. The calendar had existed for as long as anyone could remember, and was still used alongside the seven-day weekly calendar introduced by the British.

As much as we learned, the differences between the villagers' experience and ours always remained starkly evident. For one thing, we could leave any time we wanted. For another, we had access to basic health
knowledge and the money to be able to apply it, while the villagers did not. To cite just one example, we arrived in the village at the end of a whooping cough epidemic. The characteristic coughs, or whoops, which often go on for weeks, persisted throughout the village at night during our early weeks in the village, making clear the price paid for not having routine childhood immunizations. We were able to provide our child not only with immunizations but also with prophylaxis against malaria, screened windows to protect against mosquitoes, bed nets, and safe water. The villagers could not do this for their children. They did not have access to such basic health practices. They had to spend the little money they had, the equivalent of $1 per day, on food and shelter.

While village life in Africa offered a predictable rhythm and the benefits of community, I was also struck by its limitations. People with wealth and education in a country like the United States can read about a new idea in the
New York Times
in the morning and be applying it in the afternoon. Those without education or money, whether in the United States or in Africa, cannot. Lacking the resources to change their future, they fall prey to a certain fatalism. Through the years I have come to see fatalism, the assumption that you can't really change your future, as one of the great challenges in global public health.

Another lesson I have learned over time is to respect culture as a powerful force; when you tangle with it, culture always wins. Thus, it's essential to approach any culture and its customs with respect. An early demonstration of the power of culture occurred one evening in Okpoma. Some neighbors were visiting us in our courtyard. One of the women had been stung by a scorpion—a very painful condition but usually not fatal for adults. I offered her the usual medical treatment, an injection of a local anesthetic. She refused and instead wanted to see the local healer. We walked to his house and watched as he spit into the dirt to make a paste and applied it to her sting. From the standpoint of Western medicine, this treatment could have brought no immediate medical benefit, yet she immediately stopped crying and moaning. It was a dramatic example of the power of belief in the effectiveness of a traditional cultural practice.

While contact with other expatriates was limited, I did find a mentor in Nigeria—another former EIS officer, Dr. Herman Gray, who was doing missionary work. Paula, David, and I spent a weekend with him. Besides sharing many observations about diseases and their treatment under African conditions, Gray gave us a primer on snake bites. He had a collection of preserved snakes that he used as a reference to identify the dead snakes that people brought to him when they sought treatment for snake bite. The people's well-justified fear of snakes made it even more astounding that they could find the courage to walk barefoot on paths after dark. We saw this fear demonstrated when our house-helper, Lawrence Atutu Ochelebe, on finding a snake in our house, beat not only the snake but also the broom into an unrecognizable pulp.

Figure 2.
David Foege and village children, Nigeria, 1965

After six months, Paula, David, and I moved to the medical compound at Yahe, and I began working in the clinic. In Yahe we still lacked electricity
but did gain the luxuries of running water and a bathroom. Here I joined three nurses in running clinics while putting my new language skills to use. In rural Africa, where separate languages coexisted in small geographic areas, learning one local language was only a beginning. At the clinic we might see patients from more than twenty different language groups in the course of a week. Sometimes three interpreters were required to communicate with a single patient, increasing the opportunity for errors of interpretation.

The combination of pathogens we would see in a single child was often a source of dismay. A young girl might appear at the clinic with a case of measles, but an examination would then disclose that she was also malnourished. She might also have malaria parasites circulating in her blood, microfilaria from onchocerciasis coursing through her body, blood in her urine because of schistosomiasis, and hookworms, roundworms, and whipworms in her intestine. Most of these problems could have been avoided by simple measures, such as wearing shoes, using bed nets, and drinking safe water.

By March 1966, my family and I had settled into the work of the clinic and life in Yahe. I was making plans for the community work that was most needed—improving water supplies, improving childhood nutrition, and setting up immunization programs—when an unexpected letter arrived from the CDC. In February, the World Health Assembly (WHA) executive board had approved a global smallpox eradication effort, a plan that was sure to be passed at the WHA's annual meeting in May. The program would be administered by WHO with the assistance of the CDC. Could I be available as a consultant for setting up the program in the Eastern Region of Nigeria?

The CDC followed up by sending Dr. Henry Gelfand to Enugu to meet with me, explore my interest, and talk over the details of a contract. Henry was one of a handful of public health people assigned to work with the new smallpox eradication program at the CDC. The program
was initially headed by D.A. Henderson; Don Millar took over when Henderson moved to WHO to head up its global program. Henry made it clear that he was skeptical about having an outside consultant on the team, who might have dual loyalties. He would have preferred a fulltime CDC employee. I, on the other hand, was enthusiastic about being a consultant. I would be able to continue to do public health in Africa and pursue my interest in smallpox. I also saw the program's possible long-term benefits for developing immunization programs in Eastern Nigeria. An additional incentive was the news that an EIS colleague, Dr. Stan Foster, would be in charge of the CDC workers in Nigeria. During the EIS course at the CDC in 1962, because of alphabetical seating, Stan and I sat next to each other, and that was the beginning of a lifelong friendship. The Fosters were at home anywhere. Stan would prove tireless in his dedication to the concept of global health, first in Nigeria and years later in Bangladesh.

I accepted the invitation to attend the July training session for the first smallpox teams at the CDC in Atlanta. Because of my immediate experience in Nigeria, I was asked to lecture to the trainees on health conditions in West Africa. The timing of the trip to Atlanta was perfect for my family. Paula was now pregnant with our second son, Michael, and he could be delivered in the United States.

I assumed that consulting for the smallpox program in Eastern Nigeria would be a temporary diversion in a career dedicated to public health in Africa. In fact, it turned out to be a decisive shift in direction for my entire life's work.

During my six months in Okpoma and subsequent months in Yahe, I had not seen any smallpox cases, but I knew that smallpox was a muchfeared phenomenon in the area. In rural Africa smallpox was typically not a constant threat in a particular geographic area. Rather, it was a recurrent visitor, returning to an area after five, ten, or even twenty or more years, depending on the population and its degree of contact
with other areas. While smallpox is tenacious in finding susceptible new victims and devastating in its effect, it is not as contagious as some infectious diseases. Although described as “a highly contagious viral disease” in some recent books, smallpox is in fact far less contagious than influenza or measles.
²
Household secondary attack rates for measles can be as high as 80 percent—that is, if a single person contracts measles, 80 percent of susceptible people in that person's household will become ill one generation later. For smallpox, the secondary attack rate might only be 30 percent. In Africa, measles outbreaks would often be recorded in a village every second or third year; transmission was so great that only a few susceptible children were needed to insure transmission. But a village might go decades between outbreaks of smallpox.

Smallpox transmission was typically lower during the rainy season, when humidity was higher and people traveled less. As travel increased again after the monsoons, the virus would also be on the move again through its human vectors. A village's residents would conclude, after some years without a smallpox case, that smallpox was a problem of the past, only to have the virus arrive with a visitor, vendor, traveler, or returning resident. The resulting outbreak would become the consuming event of the village as the virus slowly, over weeks and months, infected much of the cohort born since its last visit, plus some older villagers who had somehow escaped infection during the last outbreak.

The outbreak would totally destroy the rhythm of life, interfering with farming and commerce as the youngest parents were infected, often from their children, and as families buried the dead. The anthropologist Laura Bohannan, who was living with the Tiv people of Northern Nigeria when smallpox devastated the tranquil scene, described the outbreak in her novel
Return to Laughter.
The local people, she notes, called smallpox “water,” and she soon came to understand the meaning. “By now I thought of smallpox as water,” she writes, “as a treacherous hungry sea beating steadily against crumbling dikes. . . . At the first advance of the water, the countryside had seethed and boiled with the movement of people fleeing before it.”
³

She describes the resulting terror, death, and hate: “Fear crept shadowlike over their faces; it jerked at their gestures, sharpened their voices
and sapped their hearts. . . . It marked us all and left the sign for others to read.” She continues, “People held by the tenderest bond of love and affection could, when plague struck, leave each other to die in lonely terror. It must be thus when empires fall, and a whole society goes crashing into ruin. The fear that tears father from child, brother from brother, husband from wife. Where there is no law but nightmare. . . . But there is one thing greater than terror: fatigue. . . . There is nothing left in our minds, our hearts or nerves or bodies to show that we lived.”
⁴
In the West, she says, the closest experience is the horror of war.

As the epidemic waned, the survivors realized they would carry the physical scars—pockmarks on the face, or even blindness—for life; in many cases, these vestiges of the disease interfered with marriage and social relationships. The outbreak became part of the village oral history, discussed less frequently and with less passion as months and years passed, until once again the collective memory dimmed and the village let down its guard. The interval between outbreaks might shorten because of increased population density, but this did not change the cycle of a village's thinking. The villagers would gradually forget about smallpox as time passed, only to face the shock of it again when it returned.

A recent review of smallpox in Africa helps clarify this ebb and flow of smallpox as recorded by the colonial powers in Africa in the late nineteenth and early twentieth centuries.
⁵
England, France, Portugal, and Belgium, after taking control of large areas of Africa following the Berlin Conference of 1884–85, introduced health services as part of developing their empires. One of the few tools they had to offer was smallpox vaccine, and they kept records on vaccinations given and known smallpox cases.

From 1928 to 1960, between fifteen and thirty thousand cases of smallpox were reported per year in Africa. However, given the paucity of clinics and hospitals and the unreliability of reporting, the true number was probably ten to one hundred times higher. Health officials welcomed the years of decline and blamed the subsequent increases on people's reluctance be vaccinated, on importations from other countries, or on variolation.
⁶