There are several reasons why the world had to wait 170 years after Jenner’s work for smallpox to be eradicated. First, it was not until the 1960s that a vaccine was developed that could be produced in the countries where smallpox was endemic. Second, better vaccination techniques were developed, specifically, the jet injector, which was used in Africa and elsewhere around the world, and the bifurcated needle, which was tested in field trials and used widely, especially in India and Bangladesh. Third, the new world order that emerged after World War II, including the development of the United Nations and WHO, made a global initiative possible. Fourth, enough people believed that eradication was possible. It took a new passion to proclaim that a disease that had plagued humanity for so long was not a fixed entity in the human landscape.
Finally, there was a crucial shift in vaccination strategy, from mass vaccination as the primary strategy to a highly focused form of surveillance and containment that turned out to be ideal for interrupting the progress of the smallpox virus. Surveillance and containment was envisioned from the beginning as the logical next step after mass vaccination had reduced the level of smallpox transmission; but it was found that surveillance and containment could be used as the primary strategy, speeding up the eradication effort. It was applied first in Nigeria in 1966 and 1967, then in other parts of West and Central Africa, and eventually elsewhere. It was refined six years later in the most intense smallpox area of the world: Bangladesh and the northern Indian states of Uttar Pradesh and Bihar. The chapters that follow track the story of this development.
TWO A Succession of Mentors
My participation in the smallpox eradication program was the result of my engagement with a host of mentors, some of whom I encountered only in books. Family, friends, and teachers also had a tremendous influence on me, the earliest, of course, being family.
My father was a Lutheran minister who was raised on a farm in Iowa. Growing up with four sisters and a brother in a series of parsonages provided me with an unvarnished, down-to-earth beginning in life. The houses always seemed too small. Each paycheck was cashed, and the money was distributed into Band-Aid cans marked for groceries, clothes, gas, and so on. My mother made many of the family’s shirts and dresses, and clothes were handed down from one sibling to the next. A large garden, chickens, and one or two milk cows provided a major portion of the family diet. We canned food for the winter. The town’s grocer—in Eldorado, Iowa (population one hundred)—always treated the family to a pint of ice cream when the grocery bill was paid at the end of each month.
When my family moved away from Eldorado, the town’s population diminished by 8 percent. My father had received a call to a new church in Chewelah, Washington, a town of fifteen hundred people sixty miles north of Spokane. At the time, I thought Chewelah was a really big city. It was only when we moved twenty miles farther north, to Colville, that I realized what a big city was: Colville’s population topped four thousand. There, my father started a new church.
Wherever we lived, my brother, four sisters, and I always had chores to do, and older siblings were responsible for supervising younger siblings. We were all expected to work hard but also to have fun, and we enjoyed much laughter and warmth. Games were a constant, even though some of the more conservative church members frowned upon such worldly frivolities. When the doorbell rang, playing cards would disappear in a flash, magically reappearing as soon as the visitor left. Our house was always intensely busy but well organized, and at the end of the day we children fell asleep to the comforting sounds of our mother playing hymns or classical music on the piano or violin, after which she often worked on correspondence courses.
My mother was not only well organized and interested in everything; she was also quite resourceful. Soon after my parents married in 1928, their Model T broke down a mile from home. Having grown up on a farm, my father was comfortable with mechanical repairs, and he set to work, asking my mother if she would walk home to fetch the pliers he needed to finish the job. His bride readily agreed but, having been raised in a city, she had no idea what pliers were and was too embarrassed to say so. By the time she arrived home she had a plan: she looked up “pliers” in the Sears catalog.
On another occasion, an ice storm brought below-freezing temperatures and took down the power lines. My father was away at a conference, and the hundreds of baby chicks in the chicken house, where lightbulbs warmed the interior to springlike temperatures, were at risk. My mother spread newspaper on the kitchen floor, closed the kitchen doors, let the chicks loose in the kitchen, and used the gas cooking stove to heat the room until the electricity was restored. The chicks survived. For a person who believed that cleanliness was next to godliness and who knew the smells of a chicken coop, this was an impressive approach to problem solving.
My father never let go of the work ethic he had learned growing up. He was always busy, calling on church members, visiting the sick in hospitals, or working in his study on his sermons and Sunday school lessons. He also tended the garden and the cows, helped with canning and house maintenance, and drove us children to music lessons or to work. He seemed content with his life choices, though when he was in his nineties he told me that he regretted that as a boy, he had never learned how to play, and that as a father, he had not played with us more when we were young.
My parents placed a high value on education. As children, all six of us were expected to take piano lessons and learn to play one other musical instrument, and it was assumed that we would go to college. Both at home and at our one-room school, there was little emphasis on science. Two of the first people to stir my interest in science were Shirley and Jim Kohlstedt. The Kohlstedts were just out of college, starting their own drugstore in Colville, living above the store. They later told me they hadn’t really needed another employee, especially a thirteen-year-old who had just moved to town, but they were moved to sympathy by my apparent handicap. Having broken my leg during a basketball game, I had on a long leg cast, which was hidden by my trousers. When the cast was removed some weeks later and I walked into the store without a limp, they realized their mistake, but retained me as an employee anyway.
The Kohlstedts gave me a hands-on introduction to the world of science. Drugs altered the outcomes of disease, the metric system was an alternate way of measuring the world, and precision rather than opinion dictated how prescriptions were filled. Under their supervision, I filled prescriptions, demonstrating by oral test that I knew what each drug was intended to do. Soon I was also babysitting for their children and sharing in their family activities. I would come to realize that the best mentors not only have qualities one wants to emulate but also take a personal interest that often leads to involvement with their families and a relationship that continues through the years.
Tony Steiger, a frequent visitor at the drugstore soda counter, would become for me the epitome of a scientist. He was not a physically imposing man, but he was possessed of a keen intelligence and wide-ranging curiosity. He worked as an assayer, analyzing ore samples brought in by miners, but his interests went far beyond his work. He encouraged my budding interest in science, introducing me to the mysteries of logarithms. He taught me at night, in his home, and after each lesson I would experience the heady feeling that I knew a little more of a new and rarefied language.
When I was fifteen, I spent three months imprisoned in a body cast to treat a separation of the head of my femur. This was before the days of television in our town, which meant that I spent long hours reading, both for school and for pleasure. Albert Schweitzer’s Out of My Life and Thought provided a glimpse into as foreign a world as I could imagine and left a lasting curiosity about other lands and peoples, the conditions of their lives and their health. I was hooked. I had earlier developed an interest in psychiatry as the result of reading a single novel about a colorful psychiatrist, but tropical medicine now became a competing interest. While in high school, I began subscribing to publications in both fields.
Fo
r two summers I worked for the U.S. Forest Service in Washington State and Oregon, and was regularly diverted to fight fires. The principles were simple and drilled into us repeatedly: separate the fuel from the flames, and the fire stops. Usually this meant building a fire line that went right down to soil so the flames could not cross it. At least two people would be sent to a fire, even a small one. We planned our approach with aerial maps and then carried in food and drinking water, basic firefighting tools, and lightweight sleeping bags made of paper. Water was almost never available to douse the fire. Our basic tool was a Pulaski, a combination ax and mattock that made it possible to cut down trees, chop logs in two, and dig a fire trench all with the same tool. Working in shifts, we would contain the fire as quickly as possible, hike back to the vehicle, report in, and be directed to the next fire. We might keep going for several days and nights in a row. During my second summer of firefighting, I graduated to chainsaw operator, with the task of determining the fire line’s placement and cutting and removing logs that crossed the line. A series of Pulaski-wielding line builders would follow in leapfrog fashion, building the fire line as fast as the chainsaw operator could walk. Teamwork was essential—another valuable lesson I learned early in life.
TOWARD A CAREER IN EPIDEMIOLOGY
In 1953, I entered Pacific Lutheran University in Tacoma, Washington, as a biology major, which brought me into the sphere of influence of Bill Strunk, a charismatic biologist. He was tall with a full head of white, wavy hair that made me think of Einstein. He engendered great loyalty from young, impressionable, and eager students. A formidable instructor, he would walk from his office and down the corridor, his lecture already under way, to the classroom, where he would walk up to the blackboard and, without a pause, begin writing out phyla, families, classes, and genera with both hands simultaneously—an ability I have never again encountered. Strunk was my advisor when I applied to medical school at the University of Washington. A true scientist, if he was to recommend a student, he required the student to take a series of tests, including IQ tests, psychological tests, and tests of reasoning ability. If the student passed, Strunk became an active part of the process, mentoring the student right through admission and then maintaining contact over the years.
Before beginning my senior year at Pacific Lutheran, a classmate and I decided to arrive a week early to attend freshman orientation, so we could meet the new freshman girls before the other upperclassmen had a chance to. The plan worked better than I could have imagined. On Thursday evening of that week, as we sat outside the cafeteria after dinner, my friend offered me a challenge: “I will bet you a quarter you can’t get a date with the next girl out of the door.” A minute later, the door opened and out into the refreshing September evening walked Paula Ristad, a freshman from Palo Alto, California. She did not make it easy for me to win the bet. Having met me briefly at a freshman party earlier that week, she pegged me as a freshman. My attempt to impress her by saying I was a senior backfired. She concluded that I was both a freshman and a liar. My tenacity, however, eventually paid off. I started medical school at the University of Washington in 1957; Paula and I were married in December 1958. After our marriage, Paula transferred to the University of Washington to complete her degree in education.
In medical school, it was my good fortune to meet Rei Ravenholt, an epidemiologist who continued the chain of larger-than-life, charismatic people who influenced me. He had a booming voice and take-charge attitude that attracted students but also got him into disputes with peers. I was present the day he won a bet with some cancer researchers who had organized a study specifically to disprove Ravenholt’s assertion that cancer is simply an extension of Darwin’s law of evolution.1 The study failed to disprove the assertion, and Ravenholt won the bet.
Besides teaching at the medical school, Ravenholt was also the Seattle–King County epidemiologist. Along with other medical students, I worked for him at the county health department after school, on Saturdays, and for several summers. Under Ravenholt’s influence, public health became my primary interest, alongside my existing interest in tropical medicine, while my old interest in psychiatry faded. Public health and tropical medicine together pointed me in the direction of the relatively new field of global health, which is public health on a worldwide scale. At the time, global health was poorly defined, but I found it compelling.
Public health looks at illness and other risk factors in aggregate populations and comes up with wholesale solutions, such as changing the environment through water improvement or changing the resistance of the population to a certain disease through a mass immunization campaign. Its philosophical base is social justice, and its scientific base is epidemiology.
The first department of epidemiology in this country was established at Johns Hopkins School of Hygiene and Public Health in 1919. Wade Hampton Frost, who had received high praise for his studies on the 1918 influenza epidemic, was detailed by the U.S. Public Health Service to Johns Hopkins as the first resident lecturer. He later became a professor of epidemiology. Frost was a pioneer in epidemiology, originating the concept of the “index case,” or first known case in an outbreak. Once the first case in an outbreak is identified, epidemiologists can work backward to determine the source of infection for that case and therefore for the entire outbreak.
Dr. Alex Langmuir, a graduate of Johns Hopkins, once summed up epidemiology as the selection of a numerator and a denominator to get a rate, and the gathering of enough information to interpret that rate. Clinical medicine concentrates on numerators, on the portion of society suffering from illness and seeking cure. Epidemiology addresses both numerators and denominators as it studies the distribution of illness or other conditions in the population as a whole.
In 1949, Langmuir began working at what was then called the Communicable Disease Center (CDC) in Atlanta, Georgia.2 There, he developed the Epidemic Intelligence Service (EIS).3 The original purpose of the EIS was to defend against possible biological warfare. The immediate source of the fear of biological attack was the unfounded belief that Korean hemorrhagic fever, which plagued both sides during the Korean War, had been intentionally introduced by the Chinese. (True to the Cold War spirit, the director of a viral research program in China told me in 1978 that his program had been started in response to the belief that the United States had intentionally brought Korean hemorrhagic fever into Korea.)
The practical training of the EIS epidemiologists for biological warfare can’t wait for the real thing, so they focus on the everyday problems of public health in the United States and worldwide. The program helped to strengthen epidemiology as an integral part of public health practice. Langmuir had great confidence both in his own abilities and in the power of epidemiology to provide insight into how to prevent public health problems.
In 1962, after completing medical school and then an internship in New York, I joined the EIS training program at the CDC. Originally, I had intended to do an internal medicine residency in order to broaden my clinical background. Again, a mentor would influence the course of my life. Rei Ravenholt, visiting us in New York, was passionate about promoting epidemiology as a career specialty. He had been one of the first EIS officers, and he recommended that I apply to the EIS. I did, and was accepted. Instead of doing the residency, I headed for Atlanta.
THE THREAT OF SMALLPOX IN NEW MEXICO
In 1962, I became an EIS officer—a medical detective—and was stationed in Colorado. Paula and I made the drive from Atlanta to Denver during the final weeks of her pregnancy with our first son, David. She began having what threatened to be labor pains during the three-day trip. Our first stop in Denver was to make an appointment with an obstetrician at the Fitzsimmons Army Hospital, and the second stop was to get a motel room. We were still living in the motel when the real labor pains started and David was born. He spent his first week sleeping in a dresser drawer in the motel.
The assignment was exciting from the beginning. Within a month I had worked
on a case of imported malaria, an outbreak of typhoid traced to a typhoid carrier in the southern part of the state, the introduction of the new Sabin oral polio vaccine, and several outbreaks of hepatitis. Seven months into my new position, I got a call from Drs. Don Millar and D. A. Henderson at the CDC. There was a suspected case of smallpox in Farmington, and they wanted me to check it out.
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.4 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.
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