House on Fire

by William H. Foege

  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

  THE PRACTICE OF VARIOLATION

  Africa, like other parts of the Old World, especially India and China, had maintained a tradition of variolation as a tool for limiting, if not preventing, the full impact of smallpox when it struck. Variolation (also called inoculation) is often confused with vaccination. Vaccination refers to the transfer of virus material that is not smallpox but is similar enough to it that the person develops antibodies effective against the smallpox virus. Variolation is the much more ancient practice of transferring material from the pustule of a smallpox patient to the abraded skin of a healthy person. Variolation therefore involves transferring the smallpox virus itself, rather than a surrogate virus. There is still some risk of death. However, the mortality rates with variolation are much lower than when the virus is transmitted naturally, through the respiratory tract—perhaps 1 or 2 percent fatalities from variolation versus 20 to 30 percent from natural infection.

  In most variolation practices, the virus is introduced through the skin. It is believed that in China, however, the intranasal route (insufflation) was used, with powdered scabs that had been stored for some time and that had been obtained from patients with few lesions. Presumably the low number of lesions indicated a less virulent virus and thus a less severe infection in the recipient. The practice may have developed independently in India, China, and Africa, although some believe that it originated in India and spread from there.7

  Certainly one of the enduring mysteries concerning smallpox is how and why variolation developed. An accidental inoculation of the virus through the skin, through an open cut or sore, would not have been noticed in smallpox-endemic areas, so it must have been done consciously and deliberately. A clinical trial of sorts would have been required to detect the difference in mortality rates for those inoculated compared to those who acquired smallpox by natural spread. In any case, variolation was practiced for centuries, right up into the 1960s and the days of the smallpox eradication program. In fact, smallpox eradication workers had to be alert to the possibility of variolation because it was one way of initiating smallpox outbreaks.

  Variolation was apparently practiced in Africa well before colonial rule. A Hausa woman, recalling her childhood in the 1890s, described a method of passing the disease “from arm to arm.” She said, “They used to scratch your arm until the blood came, then they got the fluid from someone who had the smallpox and rubbed it in. It all swelled up and you covered it until you healed. Some children used to die; your way of doing it is better.”8

  During the colonial era, variolation did make its way to Europe and North America. The colorful American clergyman Cotton Mather, possessed of a scientific mind, observed that the black population of Boston had a lower attack rate for smallpox than did the whites. He discovered that slaves had brought the practice of variolation from Africa and were using it to protect themselves. In his enthusiasm, he wrote a tract promoting the practice. Many, however, believed that variolation actually spread the disease (which it could) and that, moreover, it was against God’s will. The practice never took firm root in the New World. In Britain, meanwhile, Lady Montague, wife of the British ambassador to Turkey, reported in 1717 on the Turkish use of variolation; her account interested the royal family enough that they decided to try it—first on criminals and only then on their own children. It became accepted in Britain and was practiced widely.

  In West Africa, variolation was performed by practitioners called fetisheurs. In 1969, while visiting Benin (then called Dahomey) in connection with the eradication program, I spent a day with one practitioner. He looked like a typical village person but was better dressed. He exuded the confidence of a person who knows more than those around him, though without the arrogance often seen in city dwellers who returned to their villages for a visit. He enjoyed talking, and through an interpreter, answered my most probing questions with candor and clarity. Indeed, he reminded me of an attending physician teaching a medical student.

  The fetisheur, it became clear, knew exactly what he was doing. When a person had smallpox, the family would consult him. He would instruct the patient on what he or she needed to do to recover. The fetisheur knew that the mortality rate for smallpox in his area was between 20 and 25 percent; he also knew that most of his patients would therefore recover, regardless of treatment. The fetisheur was rewarded by the family either way. If the patient died, he simply informed the family that the patient had not followed his very specific instructions.

  Fetisheurs, this practitioner explained, used visits to patients as opportunities to collect scabs, which they kept in bottles in a dark place, having discovered that sunlight and heat render the virus impotent. If no smallpox had occurred for some time and a fetisheur needed business, he could seed an outbreak by what amounted to covert variolation. He would grind scabs into a paste, coat thorn branches with the paste, and place these in doorways where they would scratch unsuspecting passersby. Even a single “take” could start a new outbreak.

  In due course, the practitioner introduced me to his two students, who were serving two-year “residencies” to learn the trade. Their knowledge of smallpox and its transmission was impressive. In their efforts to understand and communicate about the cause of the disease, however, the fetisheurs did not use what we in the West would call a scientific approach. Rather, they told patients that they had contracted the disease because they were being punished for some previous offense. When I asked why babies, too young to have committed misdeeds, sometimes contracted the disease, the three men responded almost in unison: the baby was being punished for something the parents had done.

  The disappearance of smallpox from West Africa was bad for business, and the fetisheurs did not give up their smallpox enterprise without a fight. Multiple fetisheurs visited the last smallpox patient in Benin in order to harvest scabs, but they were unable to propagate the virus, and smallpox disappeared despite their best efforts. Adapting to market changes, some began to consult on cases of chickenpox, with a high success rate for recovery.

  FOUR Fire Line around a Virus

  As planned, my family and I traveled to Atlanta at the beginning of July 1966. I participated in the CDC training course and in October returned to Nigeria. Paula, with four-year-old David and our newborn, Michael, followed a few weeks later. This time we settled in Enugu, Eastern Nigeria’s capital. We rented a second-floor flat that had both running water and electricity, which after Okpoma and Yahe seemed like luxuries. I w
ould work with the smallpox program during the week and commute back to Yahe some weekends to work at the clinic.

  The shift from village to town offered a new perspective on the culture of Africa. Villages operate by unwritten rules understood by all, and the people are generally friendly and helpful. While the rhythm of life is hard, it is also soothing. The village is also safe. I could be gone overnight and not have to worry about my family. Indeed, the villagers provided a night watchman for our house, demonstrating that they would look out for us. Urban living offers amenities—it was a heady experience to buy food in a store or go to a British-style club for a swim after work—yet it is also faster, more crowded, and less socially cohesive. Those who move to the cities can lose touch with the rules of village life and even lose their way entirely. Later during our stay, a burglar entered through our second-floor window and took cameras and valuables, including money from the pocket of trousers hanging next to our occupied bed.

  In a poor urban setting like Enugu, everyone is scrambling daily for some small advantage. Several weeks into our stay in Enugu, Lawrence Atutu Ochelebe, who had moved with us from Yahe and was both clever and fiercely loyal, told me that he thought a neighbor might have tapped into our electrical line. While this might be seen as stealing, in very poor societies successfully tapping into an electrical line can also be admired as a small victory. Nonetheless, it was unacceptable. Lawrence and I decided to test his hypothesis by having him turn off our main electrical input line after sunset while I watched the neighbors’ lights. I was surprised to watch multiple flats go dark!

  Similarly, one Saturday night as Paula and I returned to our flat after attending a movie, I noticed one of the smallpox trucks—unmistakable white Dodge crew cabs with large backseats and pickup beds—stopped at an intersection and loaded high with household effects. I knew that all three of our vehicles should have been in the Ministry of Health garage. The driver was making extra money by using it as a moving van. On Monday morning, at the end of the weekly staff meeting, I mentioned that I would like the driver who had been out with one of the trucks at 10 P.M. on Saturday night to stay behind. All three drivers stayed behind! We reviewed the rules, but people in need are under such pressure to find creative ways to get by that it is very difficult to totally stop such activities.

  In late November of 1966, the CDC assignees—David Thompson, accompanied by his wife, Joan, and Paul Lichfield, with his wife, Mary—joined Paula and me in Enugu. David, Paul, and I were assigned to work with the regional Ministry of Health to eradicate smallpox from the Eastern Region, an area of 12 million people. We immediately began making plans to train teams and fan them out across the region to vaccinate the entire population area by area.

  We were helped by two aspects of the culture. First, the people in the region, and in West Africa generally, placed high value on injections. In recent years AIDS has changed that attitude, but in the 1960s injections were regarded with such favor that there was a large underground movement of illicit injection programs. At the medical center at Yahe, I discovered while treating a large abscess in a patient’s buttock that he had recently received an injection from the medical center’s carpenter, who was taking supplies from our pharmacy and running a thriving injection practice at night. The popularity of injections may have originated with the first village-to-village programs in the late 1940s, which sought out people with yaws and treated them with penicillin injections. The effect of the penicillin was dramatic; the unsightly chronic sores healed quickly. The injection, rather than the penicillin, was credited as powerful.

  Second, community leaders—schoolteachers, local health workers, and political or religious leaders—provided valuable assistance in setting up vaccination sites and educating the public. People feared smallpox and for the most part understood that we were offering vaccinations to prevent it. I have no doubt, though, that many were vaccinated not because our information convinced them but because they trusted their leaders, who supported the vaccination effort.

  As an example, sometime in 1967 after the vaccination program was well under way, I stopped in a village to set up a time for vaccinations. Through an interpreter I told the chief I could make sure his village was protected against smallpox if he could persuade them to be vaccinated. He agreed, and I asked when he would like to do it. He surprised me by saying, “Let’s do it right now.” “But,” I protested, “people are out working in the fields at the moment. I would be happy to return late in the day.” He insisted he could get them to return for something this important, and he spoke to an assistant, who began beating a talking drum.

  People began streaming into this large village, and with a jet injector I vaccinated several thousand in a few hours. Afterward, I sat down with the chief and remarked on his ability to get the entire village to respond so quickly. I asked him about the talking drum. Through it, had he communicated a set signal to return to the village, or had he sent a more specific message? He assured me it was a specific message. I asked him what he had said, and he replied, “I told them to come to the market if they wanted to see the tallest man in the world.” At six feet seven inches, I don’t actually qualify, but it was enough to get the desired result.

  Intrigued by the talking drums, I later had the opportunity to test their precision. I was sitting with a drummer in a village, and two men, one wearing a green shirt and the other wearing a blue shirt, were standing at a distance too far away to hear us talking. I asked the drummer to direct the man wearing the blue shirt to ask the man wearing the green shirt if he could borrow the pen clipped to his shirt pocket. The drummer began drumming, and the instructions were carried out exactly.

  THE WHO SMALLPOX ERADICATION PROGRAM

  The eradication effort in Eastern Nigeria was one small part of a program the CDC had agreed to administer for the WHO. D. A. Henderson, who had earned a stellar reputation at the CDC for his work in developing disease surveillance programs, had been influential in the development of WHO’s smallpox eradication program. Once the program was approved, Henderson was detailed from CDC to the WHO headquarters in Geneva to supervise the global effort. Henderson’s assignment turned out to be crucial for smallpox eradication. Not only was he skillful in negotiating global agreements and alliances, but his origins at CDC meant a steady influx of CDC people, as well as CDC investment, in the global program over the next decade.

  The CDC was charged with interrupting smallpox transmission in twenty designated countries of West and Central Africa within five years, with funding provided by the U.S. Agency for International Development (USAID). This area of Africa, geographically larger than the United States, was considered at the time to be the toughest smallpox region in the world. It had the highest smallpox rates (number of cases per thousand population) in the world, according to WHO figures, as well as the poorest health infrastructure, transportation, and communication facilities. Since measles was the single most lethal agent in Africa in the 1960s, the program targeted measles as well. Measles vaccines had entered the armamentarium of public health in the developed countries, and USAID now offered the vaccine to West and Central Africa. Children between six months and six years of age were to receive measles vaccine, while the entire population would receive smallpox vaccine.

  Don Millar, who had worked with Henderson to lay the groundwork for the global smallpox program, was put in charge of the Africa program.1 Don brought considerable enthusiasm to whatever task he took on. In his new role as director of the Africa program, Don showed great leadership abilities as he recruited, trained, and dispatched some forty medical and operations officers to West Africa. He also brought a strong respect for evidence to the job. He constantly reviewed what was working and why, reporting his observations weekly in a newsletter called “Friday Afternoon Reflections,” and he was always ready to implement successful new tactics in place of what wasn’t working.

  Since the days of Jefferson and Jenner, people had thought that smallpox should be eradicable.
By the mid-1960s, enough countries had become free of smallpox that it was clear that the vaccine, if applied correctly, could bring about eradication. However, eradication had so far been accomplished only in wealthy countries and in countries with a low level of smallpox or with smallpox workers who were obsessive in pursuing the program. What remained unknown was whether the same goal could be accomplished in poor countries that had high smallpox rates combined with meager health resources and inadequate infrastructures and communications systems.

  Some people assumed that it could be done, that it was just a matter of addressing the inherent problems of resource-poor nations. Others maintained that smallpox could never be eradicated, and they offered as proof the fact that similar efforts to eradicate malaria as well as yellow fever had failed. Those who believed eradication was possible would point out the difference: unlike malaria and yellow fever, smallpox is entirely dependent on human organisms in its life cycle. The doubters would respond that no disease had ever before been eradicated, and thus it was surely an impossible goal.

  It was in this climate of hope, doubt, and debate that the WHA executive board finally approved a global smallpox eradication project in February 1966. This decision did not come easily. Back in 1958, the Soviet Union had proposed before the WHA a resolution calling for a global effort to eradicate smallpox. The resolution had passed, but little in the way of substantial efforts had followed. At its May 1965 meeting, the WHA again debated the issue. Many countries, including the USSR and the United States, supported the idea, but there was disagreement over how to budget for the program, and once again the delegates passed a resolution with no plan for action. The following year, in 1966, the WHA finally ratified a funded program for global smallpox eradication, to be completed within ten years, and asked WHO to assume the principal role in organizing and coordinating the effort.2