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Bill Foege - Smallpox:
Smallpox was an exceptional killer, even though by the time the smallpox eradication effort began Jenner and others had been vaccinating for some 170 years and the U.S. was smallpox-free. The figure is an estimate generated from 1967-2008 based on the percentage of the world population at risk, using WHO reports of over 2 million deaths per year prior to introducing the global eradication program (smallpox was endemic in 33 countries at this time). This is quite a conservative estimate.
--Amy R. Pearce, PhD
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(March 12, 1936 - )
Foege was a Lutheran missionary doctor in Nigeria in 1966 when the United Nations planned the campaign to try to eradicate smallpox. He was recruited, and drew upon his previous work fighting forest fires, and his training in epidemiology, to formulate the surveillance and containment strategy. Living a life far removed from stereotypical science, he was instrumental in proving the concept in Eastern Nigeria just before the Biafran War. When war came, he turned to relief efforts. He went on clandestine missions to obtain medical aid, came under fire by machine guns, and was arrested by both sides. This is hardly what people expect when thinking of a medical career!
After proving the strategy in Eastern Nigeria, Foege returned to the United States to work at the CDC (Centers for Disease Control and Prevention). While there, he promoted his vaccination strategy and it was used throughout Western Africa to quickly eliminate the disease. He then went to India to help implement the strategy there. India's large and diverse population made eradication seem impossible. Running the effort in the worst smallpox states in India, he again precipitated and experienced many adventures, and again his strategy was quickly successful.
In 1977, President Carter appointed Foege to head the CDC. While there, he oversaw the response to Toxic Shock syndrome, the risk of children getting Reye's syndrome when taking aspirin, and the start of the AIDS epidemic. He guided the CDC into becoming involved in all forms of human health, not only infectious disease. Later he became the director of the Carter Center, set up by former President Jimmy Carter, and was a consultant to the Gates Foundation, when Bill and Melinda Gates were starting their efforts to improve global health. He is currently a Senior Fellow at both places.
by Billy Woodward, Lexington, KY
Table of Contents
Key Experiment or Research
Quotes by William Foege
Quotes About Foege
Excerpt from Scientists Greater than Einstein
The Science Behind the Discovery
Science Discovery Timeline
Recommended Books About the Science
Books by William Foege
Books About Foege
Major Academic Papers
Links to Science and Related Information on the Subject
Click the image to view Bill Foege's Lasker Foundation interview
When confronted with a vaccine shortage, Foege drew upon an analogy to make his discovery. Foege said, "The basics for breaking transmission of the virus were remarkably simple and similar to fighting forest fires." Foege had spent his college summers fighting fires in the Colville and Wallowa National Forests in the Pacific Northwest. His trainers had pounded into him and his fellow firefighters the principle that a fire can't burn without oxygen or fuel. He drew upon that analogy. During forest fires, dirt was shoveled on flames to block oxygen, and firefighters built a perimeter of scraped dirt around fires to block access to fuel. In the Ovirpua outbreak, Foege realized that susceptible people were the fuel of smallpox, and he realized that if they could vaccinate only those people that might provide fuel, the virus might be snuffed out. They could also scrape away a perimeter of fuel around the islands of smallpox by vaccinating ahead of where the virus might go, leaving it nowhere to spread.
A Seven Percent Solution
Foege was known to his colleagues as a "deep thinker" with an insatiable appetite for research. The Ovirpua success led Foege on a quest to better understand how smallpox is transmitted. He performed epidemiological studies in Eastern Nigeria and found that smallpox was not as contagious as scientists had thought. It seemed to spread slowly, not rapidly. Foege realized that "the tenacity of the virus in continuing to infect new generations within a household was confused with high transmissibility." He mapped its historical presence. Most villages did not experience the disease for decades at a time. In fact, only about 1% of villages had anyone infected with the disease at any one time. This meant it existed as islands in populations, not as contiguous and connected strings of people. This confirmed that the disease could be surrounded by vaccinated people, leaving it nowhere to go. He also found that smallpox was seasonal, beginning in the north each year and proceeding south, ebbing and flowing with the seasons. At the low point, September had only 4% of the smallpox cases in the year. He realized that this was most likely due to the social interaction patterns of people. In the planting season, people stayed home and worked. After harvest they came together to trade and celebrate. The best time to attack the disease would be when its occurrence was low.
Foege went to the Nigerian vaccination coordinator for Eastern Nigeria, Dr. Anezanwu, with his new strategy. Dr. Anezanwu accepted his argument and the first use of the new strategy occurred in Eastern Nigeria in 1967. Foege, along with Dave Thompson and Paul Lichfield, coordinated efforts with the local government and health care workers and eradicated the disease in five months. Rather than vaccinating 100% of the population, they vaccinated only 7%. It was a huge advance. Next, the strategy was used in other countries in Western Africa. Each country eradicated the disease within one year. This proved the strategy worked, so it came to be used in campaigns throughout the world.
Edward Jenner. In 1796, Jenner performed experiments that demonstrated that getting cowpox - a mild form of poxvirus common in cattle - immunized a person against smallpox. Jenner extracted cowpox and named it vaccinia ("vacca" being Latin for cow). Jenner's cowpox virus was passed down all the way to Foege, mutating along the way into a slightly different virus, but still making whoever received it immune to its killer cousin - the smallpox virus.
Leslie Collier. Getting smallpox vaccine into many parts of the world was difficult, since it had to be refrigerated. The answer was freeze-dried vaccine, which had been developed in the 1920s. Unfortunately, freeze-dried vaccine was often contaminated by bacteria. Phenol had been added to it, which destroyed the bacteria, but often damaged the virus making up the vaccine as well. Leslie Collier, of the Lister Institute in England, solved this problem in the 1950s by developing a stable unrefrigerated vaccine. He added peptone, a soluble half-digested protein, which prevented damage to the virus. The resulting freeze-dried vaccine could remain stable for years at temperatures of up to 113 degrees F. The dry powder was suspended in a 40 percent solution of liquid glycerin when it was time to be used.
Aaron Ismach. Working for the U.S. military, he developed the Ped-O-Jet gun. Before the gun, smallpox vaccine was scratched into a person's arm using a needle or a rotary lancet. This meant it was rarely precisely administered, so it often failed to cause an immune reaction. The jet injector Ismach developed provided vaccine success rates of close to 100%, and was used throughout the Western Africa campaign.
Benjamin Rubin. In 1961, Benjamin Rubin, a researcher for Wyeth Laboratories, had the ingenious idea of turning a sewing needle upside down and cutting into its eye, leaving two sharp prongs. The prongs were just far enough apart to hold the exact amount of liquid vaccine needed for a vaccination, due to capillary action. The bifurcated needle, as it became known, also had carefully shaped prongs that prevented it from being stabbed too deeply beneath the skin. Virtually anyone could be trained to pick it up, dip it into a solution of vaccine, then insert the vaccine under the skin of another person. With its success rate of close to 100%, the bifurcated needle was the perfectly engineered solution for worldwide vaccination in any environment, since it was completely mobile, inexpensive, and could be used with no instructions. Most vaccinators carried up to 100 of the needles, which they sterilized each night by boiling them, so that they could be reused the next day. The bifurcated needle was used in much of Asia.
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Discovery: Method to eradicate Smallpox:
Bill Foege: Developed the strategy of vaccination named surveillance and containment that provided fast removal of smallpox from all populations with as little as 7% of a population vaccinated.
"Being at CDC as director, I always said was like having test week in medical school every week."
Foege's work as a doctor at the Lutheran medical clinic in Nigeria reinforced what he had learned in India: "That most people in the world do not present with a single problem. Whatever brings them to the hospital or clinic is with a background of malnutrition, roundworms, hookworms and a half-dozen other conditions."
In 1965, Foege and his family lived in a rural African village, in a hut without running water or electricity. As they began to acclimate to African village life, Foege realized their lives would never be equal with those of true villagers. He said, "In one sense it was an opportunity to know something about what it's like to live in a village in Africa. On the other hand, I've always said we could never truly feel that because we could leave anytime we wanted to - anytime it got to be too much. We were able to, during the dry season, hire a young man on a bicycle who could go to the water hole five miles away and get water and bring it back and put it in a 55 gallon drum for us. So we were able to do things that a villager couldn't and I've said that the big lesson for me was - number one, that here we were living in third world conditions and yet our son was living with first world risks, and the reason being - we could apply all the knowledge we had on immunizations, on screening the windows, on boiling the water, and so forth - but, number two, if you had limited me to a dollar a day I would have to have spent that on food and shelter and could not have done these other things - could not have afforded vaccines or even firewood to boil drinking water and so this combination of knowledge applied and poverty - those are the two things that separated us."
On Surveillance and Containment
"In retrospect it seems clear - we didn't know how to eradicate smallpox when we started. But this was not a negative. It was a characteristic of all unsolved problems. We are always faced with making sufficient decisions based on insufficient information. If we had waited until all the answers were available, the work on smallpox eradication would never have started - selecting the target helped develop the appropriate tools and strategy."
"The basics for breaking transmission of the virus were remarkably simple and similar to fighting forest fires."
"After that first search, there was a lot of discouragement and some people thought we should stop the searches. I kept arguing, the reason we found so much is, this is the most efficient surveillance system we've ever tried and the last thing you want to do is stop using it. Let's just wallow and get behind but let's keep looking and that's what we did."
"Those of us in WHO started traveling by train and finding ourselves in the overnight compartments with our Indian counterparts and this turns out to be so different than going in for a weekly meeting in someone's office. Pretty soon, a trust level had developed where we actually were discussing the crucial things - even the sensitive things."
Foege ordered 60 more epidemiological officers (a total of 236 from 30 countries were eventually used). It was intense -- eighteen hour days, seven days a week. Foege says, "We were having a monthly meeting in each state that was of high incidence. We were having people come back from the field for a day, reporting on what they were doing, and we were trying to learn as fast as we could and keep making tactical changes every month so that we were fine tuning this just as rapidly as we possibly could. Then, each month, we tried to pretend that we were on top of it and each month it kept getting worse."
"I think the story is so incredible in India and the thing that turned it around is what you would always like to see in a coalition but don't often see, which is that people suppress their own egos and you get a coalition of people who really work as an absolute team. I don't think the Indian government would have ever have made a major decision without those of us who were now assigned through WHO agreeing, and we would never from WHO, have made a decision without the Indians agreeing. It was simply a unit working together."
"The philosophy behind science is to discover truth. The philosophy behind medicine is to use that truth for the benefit of your patient. The philosophy behind public health is social justice. That's the important point. Public health programs are attempts at social justice."
"What is it that is better than science? Better than science is science with heart, science with ethics, science with equity, science with justice."
On Bill Gates
In the late 1990s Foege was asked to join the Gates Foundation as an advisor. He was used to such requests, saying, "Do you know how many times before I have heard those sorts of things? Rich people say that all the time."
Gates seemed sincere, so from 1999-2001, Foege served as Senior Medical Advisor for the Bill and Melinda Gates Foundation. One of Bill and Melinda Gates' first requests was for a reading list. Foege provided a list of 81 books to read and says, "I saw Bill a couple of months after that and I asked, 'How are you doing on those books?' And he said, 'Well, I have been so damn busy I have read only nineteen of them.' I didn't know whether to believe him, so I asked, 'Which was your favorite?' He didn't hesitate for a second. 'That 1993 World Bank report was just super,' he told me. 'I read it twice.'" Still skeptical, Foege pressed him on what he had learned from it. Gate's answer proved he wasn't just another rich guy with a momentary interest in doing a good deed. "Not only had he devoured the World Bank report," Foege says. "But on his own he had found the weaknesses. Incredible." With the help of Warren Buffett, the Gates Foundation has received donations of more than 38 billion dollars to be used for global health, education, and development. Foege now says, "I think a hundred years from now, when the history of global health is put into some perspective it's going to be clear that the tipping point was about 2000. It'll be due to Bill & Melinda Gates. They've changed everything."
On Death - Foege's Humor
On the question of how he would want to die, Foege said, "I've thought about it many times. And I've decided these are the characteristics of my death. First I want my death to be meaningful. Second, I'd like it to be a time of my choosing...so I can plan to say my goodbyes and put my affairs in order. Finally, if possible I'd like it to be quick and painless. I'd like to be executed."
2009 Speech in India
By May 1974, with 8 months of experience and expansion of surveillance and containment as the primary approach to smallpox eradication, the program became so efficient that a virus that had eluded the best efforts of vaccination programs for 170 years was subdued in the blink of an eye. Why? Because, in biological terms the coalition evolved faster than the virus could evolve!
On the Eradication Effort
"Except for my father, two men have helped to shape who I am. One of them was Admiral Hyman Rickover... and the other one was Bill Foege. Much more significant than changing my life, he has changed the life of millions of people around the world."
"He conceived the idea that smallpox....could be eradicated by a novel method of surveillance and containment. It sounds so simple now. Like many great scientific insights, now through the retrospective-scope, now it sounds obvious. But it was a real breakthrough, one of the great conceptual breakthroughs in public health."
-Larry Brilliant, Executive Director, Google.org (and a major contributor in the eradication effort in India).
"Dr. Foege's impact on the world's health has been extraordinary. In terms of lives saved and freed from disease, he has changed the world as we know it."
"In 1972 the technique (of surveillance and containment) was formulated in a scientific paper that Foege, Millar and Lane published in the American Journal of Epidemiology. Titled "Selective Epidemiologic Control in Smallpox Eradication," it was perhaps one of the most important documents in the campaign against the disease since Jenner. It laid out the case for a complete reversal in techniques."
"If the United Nations, through its World Health Organization, never does anything else than eradicate smallpox - it has to be called a success."
"I could not be the ex-president that I am and do the things that I do were it not for Bill Foege."
About the Dark Days in India, before Surveillance and Containment Kicked In
"I was under great stress and strain," says Basu, an Indian who worked at the health ministry about Surveillance and Containment. "Whenever they asked me, ‘What is the progress of the program?' I used to tell them the number of cases that month. It was always higher than the previous month. And they used to laugh at me and make sarcastic remarks: ‘Dr. Basu says that progress is satisfactory because more of our people are dying.'"
CDC Deputy Director Bill Watson recalls, "It really dismayed people. There was a lot of second guessing. The pressure was on to do it the old way (mass vaccination) - this new system isn't working."
Foege Was Influenced by Albert Schweitzer
At fifteen, an injury put Foege in a body cast for three months. Immobile, he could do nothing but read. He read the books of Albert Schweitzer and imagined a life in the jungles of Africa. One Schweitzer quote in particular remained with him: "No one has the right to take for granted his own advantages over others in health, in talents, in ability, in success, in a happy childhood or congenial home conditions. One must pay a price for all these boons. What one owes in return is a special responsibility for other lives."
Foege Was Mentored by Another Lifesaving Scientist - Thomas Weller
When Foege was in the Epidemic Intelligence Service at the CDC he worked in both India and Tonga. While there, he read a commencement speech by Thomas Weller, another lifesaving scientist (who worked with John Enders in revolutionizing virology). In the speech, Weller seemed to speak directly to Foege, who paraphrases it frequently: "you're only going through life once - you might as well try to do it right and if you're getting all this training, skills, knowledge, and so forth - you should ask where could it do the most good." Foege immediately applied to Harvard, and nowhere else. He got in and, mentored by Weller, received a Masters in Public Health degree. He came out as an epidemiologist, and even more of an idealist, believing more strongly than ever in global health.
Some were Skeptical of a "Missionary Guy"
The CDC sent Henry Gelfand, a prominent public health physician, to Africa to lay the groundwork for the smallpox eradication campaign. West Africa had the highest rates of smallpox on earth, so would need strong direction. Gelfand was prodded to look up a tall, clean-cut, practical joker who those at the CDC thought would be perfect as an advisor. Gelfand was skeptical of a "missionary guy," but reluctantly agreed to meet Foege, if only to placate the home office. It didn't take him long to be won over by Foege, for he was highly intelligent, had wonderful people skills, and was full of energy.
A Different Africa
Foege on Africa in the 1960's: "Africa was a heady place - everyone had the sense that they were on the way up - they had shaken off the suppressors - the European powers - and they would now show the world what they would do. Everyone felt good and almost giddy about the future."
Foege's Vaccination Records
Like many epidemiologists, Foege liked to count and measure. When he was in the Epidemic Intelligence Service, he worked on mass vaccination trials in Tonga. These were done using the newly invented Ped-O-Jet vaccination gun. It was the size of a 9-mm Luger, with a bottle of vaccine attached to the top, and an air hose that fell from the gun to a foot pedal. The foot pedal compressed air that was used to shoot the vaccine into people's arms. With no needle there were no sterilization issues and the gun could be used over and over again. Using it later in Africa, Foege obtained his personal records. His quick fire vaccination record came the time he set up his vaccination kit in a prison in the Abakaliki area of Nigeria. Long lines of expressionless men shuffled through the sand, prodded by sticks to keep them moving. Foege vaccinated 600 men in just a bit over 20 minutes. Foege's one-day record, set on one very long day in Enugu in 1967, was 11,000 people vaccinated.
Get Your Juju On
During one of Foege's trips down a dirt road the driver was confronted with a roadblock. When he slammed on the brakes, nothing happened. He jerked the vehicle off the road and they ran into a tree. They got out and checked - everyone was OK. The land owner rushed over, irate that the vehicle had offended his juju -- his sacred tree - and demanded compensation. Juju refers to a magical spirit bound to a specific object. Foege calmly informed him that he had it completely backwards. The tree had damaged his juju, his sacred vehicle, and it was he that was due compensation. Eventually they called it even and Foege raced on to the smallpox outbreak.
The Devastation of Smallpox
Throughout Africa, villagers sometimes built temporary abodes outside of their village to house people who were sick with smallpox. Past victims were responsible for care and feeding, since it was commonly known that smallpox survivors developed immunity. One week Foege saw 1,000 cases of smallpox. In a temporary abode, Foege saw hundreds at all stages of the disease. The smell of rotting flesh was pungent and sickly sweet. Foege, like the others, had to force himself not to be overwhelmed. Rafe Henderson, an officer working in another area, recalls: "To see a bad case, the reaction is one of horror, of wanting to withdraw. The person is just covered with blood and scabs and the eyes are closed and puffy. Breathing is hard. Your fear is not only that you can do nothing for him, but also your reaction is, ‘Oh, my God! Could I get this?'" They had all been vaccinated, and had to trust the science behind it, or go home. To some, the work was unbearable, and they did leave.
Some villagers coped in another way. They worshipped smallpox cults, known as Sakpata or Soponna. For them, smallpox was a visit from an unhappy god. Fetisheurs of the cult sometimes erected shrines, and some priests received the possessions of those who died, as well as practiced variolation - the inoculation of people with the smallpox virus, itself. Smallpox cults existed in India as well.
Every Outbreak Attacked
When smallpox hit Enugu, the capital, a decision had to be made. All the trained teams were busy vaccinating further east. Should they pull teams out of the rural areas to treat Enugu or finish the jobs they were doing? David Thompson remembers the argument and Foege's position: "He wanted to pull the teams out of Ogoja to vaccinate Enugu, which I was reluctant to do. But we did just that." Foege insisted on vaccinating around every outbreak. If a cinder escapes from a forest fire, it must be chased down before it can start another big fire.
Back in Enugu, the three smallpox advisors drove around the city, deciding where to set up vaccination centers. As they stopped and laid out the maps, the locals gathered around, suspicious of what the three foreigners were doing (this was during the lead up to the Biafran Civil War). Foege says, "Suddenly I was surrounded by police. I was so intent on what I was doing, I didn't even see them pulling up." Foege and the others were arrested and held for five hours before Dr. Anezanwu, the Nigerian Director of Smallpox Eradication for Eastern Nigeria, showed up to get them released. It wasn't the only time Foege was arrested. He joked that the evidence proved he was politically neutral, for he was arrested by both sides.
Armed Teenage Roadblocks
As spring arrived, the Biafran Civil War was imminent. It pitted the Ibo tribe of Eastern Nigeria against the national government in Western Nigeria. Foege and the other smallpox advisors evacuated their families, returning to do their jobs alone. Roadblocks became common, often manned by teenagers with machine guns. Sometimes they were stopped and searched every few miles. They learned that official-looking papers helped expedite their passage, so they began creating their own documents. Many of those who manned the roadblocks were illiterate, so when presented with papers containing apparently official stamps, an officer would often fake literacy to the soldiers who had brought in the foreigners and allow them through. They continued to use surveillance and containment and the vaccinations went forward.
A Strange Mission for a Missionary
In 1967, the test of Foege's surveillance and containment strategy was in full force throughout Eastern Nigeria. They ran out of vaccine and turned to the national government for more supplies. The national government, located in Western Nigeria, was in full dispute with Eastern Nigeria in what would turn out to be the Biafran War. They refused the east any more vaccine supplies. As told for the first time in the book, Scientists Greater than Einstein, Foege would not accept defeat when lives were on the line. Read about his daring solution in the book.
The Tallest Man in the World
In one village in Nigeria, Foege asked a chief how he could get people to come to be vaccinated. The chief told Foege not to worry and set drummers to drumming. Over the next hours, a huge crowd began to appear. Foege asked the chief how he got them all to come. The chief laughed and said everyone came to see the "the tallest man in the world." Soon children were prancing around the six foot seven Foege, happy to be vaccinated.
Anecdotes from India
When they started a big surveillance and containment push in India, the reports of smallpox cases coming in were overwhelming. Foege says, "When we did our first big search in India in October 1973, I had actually been promoting the idea of a reward for finding smallpox. October was supposed to be a low month for smallpox and so I thought this would be the ideal time to do a reward - when we have the fewest cases that we're going to have. In six days time, our search in four states found ten thousand new cases of smallpox that no one knew existed. If we had given a reward, the bank would have been broken. I am so pleased that the Indians just absolutely refused to consider it."
The Role of Psychology
One of the big lessons they learned in India was psychological. "To start with," Foege says, "it seems to make sense, that the searchers should have vaccine and when they find a case immediately vaccinate around them. We found out that doesn't work. The reason is - if you already bias a searcher that they have to do more work if they find a case than if they don't find a case - you're asking them not to find a case. You actually have to divide the work load. Searchers only search and report on cases and then containment teams go in."
The Atomic Age
In May of 1974, there were 11,600 new cases in one week in one Indian state, resulting in 4,000 deaths. In the state of Bihar alone, there were 8,664 infected villages. It was the same month India detonated its first atomic bomb, and plenty of pundits noted the irony that they could smash the atom, but could not smash smallpox.
A Last Ditch Save
The surveillance and containment effort came dangerously close to imploding. At one meeting, a minister of health insisted on giving up on surveillance and containment and going back to mass vaccinations. An Indian doctor stood up and said he had grown up in a poor village: "When there was a fire, the villagers poured water on the burning hut, not on all the houses." The Minister relented and gave them one more month.
Foege's creation of the strategy of surveillance and containment became manifest when he was suddenly confronted with a smallpox outbreak:
Sunday morning, December 4th, 1966 was sunny and warm. The fronds of the African oil palm trees were still except when a grey parrot, a mimicry bird, lighted on a branch, searching around for fruit. People walked back from church, their children running ahead. Foege was in the missionary clinic when he was called to the radio.
He walked into the radio room, picked up the microphone and spoke into it. A second later, static, then
"Describe them for me, Hector."
"They've been sick, and now round lesions have appeared on their face."
"I better come check it out."
Foege told Paula he had to go, put his medical gear in a leather shoulder bag, tucked himself into the mission's VW Beetle, and drove northeast through Ogoja Province. As the kilometers fell away, Sunday afternoon scenes of rural African villages passed - women carrying vegetables on their heads, children dancing. He passed Nfom, Okpudu, and Okuku before meeting up with Hector and his colleagues. Hector was savvy. He had everything they needed ready, knew exactly where they were going, and would have personal contacts all along the way. He handed Foege bikes he had borrowed, which they fastened on the outside of the car. When they arrived in Alifokpa, where the road ended, they parked. It was twelve kilometers to the village of Ovirpua, where the smallpox cases were, so they unloaded the Velosolex bikes. Made by a French firm, they had a small engine that turned a ceramic roller on the front wheels.
Off they went into the African savannah.
By the time Foege got to Africa in 1965 the big game was gone. Older missionaries could remember elephants and lions and rhinos, but for Foege they were restricted to national parks and reserves. But he could pursue his hobby. Bill Foege is an expert on Arachnology, the study of spiders.
Edward Jenner named the cowpox virus he used to vaccinate people vaccinia, "vacca" being Latin for cow, in the late 1700s. But that isn't where the name vaccine came from. In the 1880s, when Pasteur began developing the concept of vaccination further with experiments on anthrax and rabies, he decided to name the whole concept vaccine, to honor Jenner and his great discovery.
Smallpox is a poxvirus - one of a family of related diseases named after the creatures most likely to contract them - camelpox, raccoonpox, mousepox, monkeypox....
Smallpox is one of the largest viruses known. Sometimes shaped like a dumbbell when viewed with an electron microscope, it is a virus composed of DNA.
Both George Washington and Andrew Jackson survived smallpox. Benjamin Franklin's son, Francis, fondly known as Franky, died of smallpox at the age of four.
Abraham Lincoln was coming down with smallpox when he delivered the Gettysburg Address. He wasn't seen for weeks afterward, while he recovered.
Smallpox destroyed the Incas, the Aztecs, and many American Indian nations, killing as many as 95 percent of their populations. In late 18th century Europe, it killed about 400,000 people a year.
Pocahontas is thought to have died from smallpox.
The last outbreak of smallpox in the United States occurred in Texas in 1949 with 8 cases and 1 death.
The last person in the world to have Variola major was a two-year old girl, Rahima Banu, born in 1973. She lived in Kralia on Bhola Island, Bangladesh. School children throughout the world were shown pictures of kids with smallpox in class and asked to turn in smallpox cases. Rahima's case was reported by an eight-year old girl, Bilkisunnessa, who received a reward of 250 taka. Rahima survived.
The last person infected by smallpox in the wild was Ali Maow Maalin, a Somalian cook. On October 26, 1977 he was diagnosed with Variola minor smallpox. He survived, but the virus was dead.
Janet Parker, a medical photographer, was the last person to die from smallpox. She worked in the Anatomy department of Birmingham University in England. Smallpox was housed in a research laboratory on the floor below her office. In 1980 the virus escaped and infected her. The tragedy led to the suicide of Professor Henry Bedson, the Head of Microbiology department who headed the lab. The last to survive smallpox was Janet Parker's mother, who was infected by her daughter.
Now the only smallpox known to exist in the world is stored in the high-security facilities at the Centers for Disease Control and Prevention in Atlanta, Georgia, and at the Institute for Viral Preparations in Moscow. There is controversy over rather samples should be destroyed or kept for future research.
While there is danger of smallpox being stolen and used as a bioterrorist weapon, computer models of such a threat confirm Foege's surveillance and containment strategy. It is thought that any such use could be quickly halted by vaccinating in rings around an outbreak.
Basic Science Primer on Smallpox
Smallpox is a virus, a tiny protein structure that holds DNA or RNA, which hijacks human cells to survive and reproduce. There are no drugs that kill smallpox so, as with most viruses, the best attack involves prevention by vaccination. Vaccines trick the human immune system into producing antibodies that attack specific viruses, if they should invade the human body. The smallpox vaccine uses cowpox, a cousin virus that is similar enough to smallpox to elicit an immune response. Before Foege's revolutionary discovery, a 1964 World Health Organization advisory committee concluded that vaccinating 80 percent of a population would fail to eradicate smallpox. It recommended mass vaccination of 100% of each population.
There are several clinical forms of smallpox:
-Variola major is the common form, and the big killer. It slays 30 percent of its victims, blinds 10 percent of the survivors, and scars almost everyone.
-Variola minor occurs less often, and is less fatal (less than 1% die), but scars many of its victims.
-Purpura variolosa aka haemorrhagic-type is a subtype of variola major and is 100% fatal.
-Malignant or flat-type is another subtype of variola major and also is usually fatal.
The smallpox virus, which sometimes looks like a dumbbell under an electron microscope, is one of the largest and most complicated DNA viruses known.
The Nature of Parasitic Pathogens
Viruses exist only by infecting a host cell and hijacking its nutrients and energy. As such, they are parasites. Parasitic pathogens (some bacteria exist only in hosts as well) evolve clever tactics to survive. If a germ kills its host too rapidly, it will not have any place to live. It is therefore to the germ's benefit to allow a host to survive long enough for it to multiply, and then jump to another host. When syphilis first appeared in Europe in the 1490s, it killed its victims within months. But over time, it evolved into a pathogen that took decades to kill. Some predict HIV will weaken and kill more slowly as time goes by, in order to optimize its survival. Smallpox likely evolved to cause a long illness in order to aid its survival. Smallpox exists for up to two weeks in a human body with no symptoms, and then for another three or four weeks, when the human is sick. Because it can reside in individuals over such a long period, it does not need to infect a large portion of the population at any one time. To survive, it only needs to pass itself on to two or three other people, and can do so quite slowly.
Smallpox is a virus that enters the body through a person's nose or mouth from virulent droplets in a person's cough or sneeze. A week, possibly two, passes with no symptoms, when the virus is incubating in a person's cells. The disease progression is as follows:
- The body begins to ache.
In Africa, the mortality rate was typically 20 to 25 percent; in India 30-35%.
Smallpox is one of the most deadly diseases in human history. Smallpox destroyed the Incas, the Aztecs, and many American Indian nations, killing as much as 95 percent of their populations. It raged through Europe in the late 1700s, killing about 400,000 people a year. It was common in the United States as well up until the twentieth century. Outside of Europe and the United States, smallpox continued to kill even in the twentieth century. In fact, from 1900 to 1970 it killed more people than all the wars and genocides combined. It is thought to have killed more than 300 million people while war killed about 188 million people (war deaths include both combat and noncombat deaths, genocides and political pogroms that starve people).
Countries that had eradicated smallpox by vaccination went to great lengths to prevent it from recurring. In the 1960s, the United States spent about $150 million a year to keep it out of the country, utilizing methods such as screening anyone entering the country.
In 1963, the virus was still striking an estimated ten to fifteen million people a year in 43 countries, killing two million of them. It was endemic -- meaning it was constantly occurring -- in 33 countries.
Statistics about Smallpox
In 1963, 10 to 15 million people a year experienced smallpox - over 2 million died.
In Western Africa the mortality rate to children under the age of one was 29%.
In Western Africa the mortality rate to adults over the age of 45 was 32%.
Overall, in Africa the mortality rate was 20 to 25 percent.
In India the mortality rate was 30-35%.
In 1967, when the WHO launched the plan to eradicate smallpox, 60% of the world's population was threatened with getting smallpox. Smallpox occurred in 43 countries. It was endemic -- meaning it was constantly present in the population -- in 33 countries.
The Smallpox Eradication Effort
When Stalin was in power, he removed much of the Soviet Union's participation in the United Nations. After his death in the 1950s, the Soviet Union once again began participating in United Nations' programs. In a dramatic representation of their sincerity, they suggested a plan to eradicate smallpox from the world. Such a grandiose plan wasn't immediately accepted, but it began to be studied. A 1964 World Health Organization advisory committee concluded that vaccinating 80 percent of a population would fail to eradicate smallpox. It recommended 100% vaccination - in other words, mass vaccination.
Considering the fact that hundreds of thousands of babies are born throughout the world each day, that many countries are hostile to outside international agreements, and that many people are nomadic and others don't believe in vaccinations, many scientists and policy makers argued that vaccinating everyone was an impossibility. The famous microbiologist René Dubos wrote at the time: "Eradication of microbial disease is a ‘will-o-the-wisp;' pursuing it leads into a morass of hazy biological concepts and half truths."
But in the 1960s some scientists argued that smallpox could be eradicated. Because it infects no other species - only humans - if for a single two-month period no one on earth caught smallpox, then the disease would either kill or run its course in whatever humans were already infected, and that would be it - the virus would cease to exist. This had happened in North America and Western Europe, so why could it not happen in the whole world? The key in the smallpox-free areas had been mass vaccination. So many people had received vaccinations that the virus had no one to spread to - so poof, it was gone. Virologists called this herd immunity. If the whole herd of humanity were immunized, the virus would die.
It took a decade for the United Nations to gain the financial cooperation of the rest of the world. Eventually both Russia and the United States agreed to provide funding. So in May, 1966, the Nineteenth World Health Assembly voted to institute a worldwide smallpox eradication campaign. The United States Agency for International Development (USAID) concentrated on the twenty countries of Western Africa. They provided commodities, vaccine, jet vaccine injectors, and vehicles, with the CDC coordinating the efforts. Each country's ministries of health provided manpower.
It was into this paradigm of mass vaccination of the whole world, that Foege stepped when he joined the effort.
Foege in Africa
In 1965, Foege went to Eastern Nigeria to be a missionary doctor at a Lutheran clinic with his wife, Paula, and their small son, David. They initially lived in a typical African village in a mud hut without running water or electricity, with the goal to learn Yala - an unwritten tonal language of the region. It was a most friendly village. The village held that one's living room was open to the public, so the Foeges had many visitors. The next year the United Nations planned a smallpox eradication campaign, and Foege was recruited to join the effort. Foege began working weekdays in Enugu, Nigeria, with the local government, planning a campaign to vaccinate everyone in Eastern Nigeria. At the time, mass vaccination of virtually 100% of the population was thought to be the only way to eradicate smallpox. On weekends Foege returned to the missionary clinic to work.
Foege's Discovery Required Proof
Science is based on inductive logic - the examination of detailed data to find general principles. Epidemiologists take vast arrays of information about a disease and its presentation in people, and seek out patterns in that information. When Foege had his idea of a new strategy for vaccinating people, he realized that he didn't have adequate data about smallpox. He says, "In retrospect it seems clear - we didn't know how to eradicate smallpox when we started. But this was not a negative. It was a characteristic of all unsolved problems. We are always faced with making sufficient decisions based on insufficient information. If we had waited until all the answers were available, the work on smallpox eradication would never have started - selecting the target helped develop the appropriate tools and strategy."
One principle of using inductive logic is to seek out more data. Old data may be wrong or may leave out important variables. In science a good method of using inductive logic can be stated succinctly as - look, learn, iterate...look, learn, iterate. Foege identified some incorrect assumptions about smallpox. It was not as contagious as thought and it spread slowly, not quickly. He also discovered some new variables. It was seasonal and it moved geographically based on social patterns.
The Most Common Inductive Logic Fallacy - Anecdotal Evidence
When Foege thought up his new containment strategy, he understood that just as deductive logic has logical fallacies we are all familiar with, such as contradiction, inductive logic also has its fallacies. The most common one is basing conclusions on anecdotal evidence-one or two isolated incidents.
Anecdotal Evidence and Vaccines
This is a common fallacy of groups opposing vaccination. Vaccines did not spring up as perfect preventative medicines. Many early vaccines were flawed and caused a small amount of sickness and even death. Even in the U.S. in the 1960s, the smallpox vaccine killed a handful of people every year. The question a parent must face is: should their child get vaccinated when there is a one in several million chance of dying from vaccines? Based on the anecdotal evidence of those few occurrences, some parents refuse vaccinations. Others recognize that those odds, while real, must be compared to the chance of sickness and death from the diseases vaccines protect against, which can kill at a substantially higher rate. Nationwide, the few deaths that occur due to vaccines pale in comparison to the number of deaths the vaccines prevent. This is an example of how statistics have come to be so important in science. Statistics allow us to measure risk based on data sets that are imperfect or incomplete, as so many of life's data sets are.
Foege's Proof of Surveillance and Containment came in the other Western African Nations
The epidemiologist in Foege understood that his new strategy of surveillance and containment had just this logical weakness. No credible scientist would buy into this new strategy based on one incident in a small rural province of Nigeria. Foege had to prove it throughout Western Africa to demonstrate that it worked. He did prove, it in other countries, and only then did scientists throughout the world accept his discovery as truth.
Surveillance and Containment in Colossal India
Even with Foege's African success, some believed it would not work in India where the scale of the problem was immense:
-A population of 600 million - 50 times greater than that of eastern Nigeria.
-A largely urban population, with different dynamics than rural Nigeria.
-Over a half million villages.
-70,000 infants born every day.
Mass vaccination had been tried in India in the early 1960s without success. But the first year or two of trying surveillance and containment did not seem to work either. Frustrated from afar, Foege could not sit and watch his strategy fail. He packed up his bags and moved to New Delhi.
At first, smallpox actually seemed to increase while using his targeted methodology. That caused many scientists and government ministers to want to revert to mass vaccinations. Foege held to his belief in surveillance and containment. He realized that no one had ever tried to count the actual numbers of smallpox cases throughout India. Once a comprehensive count was started, it would inevitably count a lot more cases than the government had publicized as existing. After nine months the number of smallpox cases began to decline. Slowly at first, but then quickly the number of cases fell. After two years, the number reached zero.
The Eradication of Smallpox is One of the Greatest Accomplishments in Human History
Next, surveillance and containment vaccination was used in Bangladesh and then in Somalia. With quick success the number of smallpox cases shrunk. The last case of naturally occurring smallpox in the world was recorded in Somalia on October 26, 1977. Ali Maow Maalin, a 23 year-old man, recovered - but the virus was dead. Now eradicated from the earth for over thirty years, more than 122 million lives have been saved who would otherwise have died (that's the population of California, Texas, New York, Florida, Illinois, and Pennsylvania combined).
Timeline Of Smallpox Eradication
1796 - Edward Jenner proved that getting cowpox - a mild form of poxvirus common in cattle - immunized a person against smallpox. Vaccines were born.
Key Administrators in the Eradication Effort
Bill Foege is a modest man who constantly tries to divert credit to others. But, press him about his own personal satisfaction for the role he played. Then sit quietly and listen to the poetic image he conveys.
"I've been going to India now for 40 years," Foege says. Speaking of when he first went, he says, "I was very conscious of how many people on the streets had pockmarks." A decade later when he was running all over the country trying to eradicate smallpox, he still saw the pockmarks on people's faces. Then ten more years passed and he returned to New Delhi. Vividly he remembers standing on the street and watching the people pass by. India is a country of people - people are everywhere. As he watched children go by - some laughing, others quietly serious - not a single one had a pockmarked face. Then later still, in the 1990s, he returned to New Delhi, and again stood on a street and watched the masses of humanity pass - now not a single person under the age of twenty had the pockmark scars. Just recently he was there again, standing on the streets, looking at the faces - no one under the age of thirty had pockmarks. "I think to myself," he says, "This is a change that almost everyone walking down the street is unaware of. There is just no memory. Isn't that great? It's fun to see and I still get pleasure out of seeing the tangible results."
Excerpted from Scientists Greater Than Einstein: The Biggest Life Savers of the Twentieth Century (purchase it in the online store)
Foege was born in on March 12, 1936, in Decorah, Iowa. One of seven children, his father was a Lutheran minister. His uncle, Henry Foege, was a pioneer Lutheran missionary to Papua New Guinea. The family moved to Chewelah, Washington when he was 10 years of age. When he was 15 he had an accident that left him in a full body cast for three months. All he could do was read. He became inspired by Albert Schweitzer and would later follow him to Africa.
Foege's Other Career Contributions
At the Centers for Disease Control
President Carter appointed Foege to head the CDC in 1977. Foege headed the organization for six years, during which time he increased the Center's international activities and extended its emphasis from infectious diseases to all forms of death, including accidents, homicides, suicides, and chronic diseases.
Foege says, "Being at CDC as Director, I always said was like having test week in medical school every week. The amount of information that kept coming in was overwhelming."
He oversaw numerous high profile investigations.
In 1980, toxic shock syndrome was identified as a rising problem. Resulting from a bacterial toxin, it was rare, but could be fatal. The CDC determined that its increase corresponded with super absorbent tampons, of which a new one from Proctor & Gamble seemed especially risky. Proctor and Gamble stopped distribution of the tampon.
Also in 1980, the CDC started examining four or five studies that showed a correlation, but not statistical proof, that aspirin taken by children with viruses such as flu or chickenpox could lead to Reye's syndrome. It was rare, but devastating. 40% died and many of the rest had brain damage. In 1981, Foege wanted to put a warning on aspirin bottles. When the aspirin manufacturers found out the CDC was going to publish its concerns jointly with the FDA, they put immense pressure on them not to publish. The FDA backed down, but Foege and the CDC went ahead and published. The manufacturers went to Foege's boss and to the Secretary of HHS, Richard Schweiker, but both backed Foege. Then they went to the Reagan White House. The Reagan administration told the CDC to stop talking about the problem and do another study.
Foege says, "It didn't matter. We'd already published it. It was now in the public domain. So I think that's one of the things I feel best about - that we did not bow to political pressure and we were able to get the scientific truth out." Later studies confirmed the syndrome and warnings began appearing on aspirin bottles in 1986.
In 1981, AIDS appeared. The Reagan Administration was cutting the funds and personnel of the public health service, but Foege managed to funnel funds to the problem by forming a task force on Kaposi's Sarcoma and Opportunistic Infections. The CDC issued early warnings about the disease. But it was hard to get both the government's and people's attention. Foege says, "People preferred that this wasn't happening. They thought, ‘It can't be as bad as people say it is.' I've found that there is an incubation period for ideas as well as for viruses."
Foege was too independent for the politicians, so he moved on.
At the Carter Center
In 1986, Foege became the executive director of The Carter Center. Founded by former President Jimmy Carter, The Carter Center is partnered with Emory University with a mission "guided by a fundamental commitment to human rights and the alleviation of human suffering; it seeks to prevent and resolve conflicts, enhance freedom and democracy, and improve health." It has been active in working on improving agriculture in Africa, as well as numerous other endeavors.
In 1984, Foege and several colleagues formed the Task Force for Child Survival, a working group for the World Health Organization, UNICEF, The World Bank, the United Nations Development Program, and the Rockefeller Foundation. Its success in accelerating childhood immunization led to an expansion of its mandate in 1991 to include other issues that diminish the quality of life for children.
From 1997-2001, Foege was a Presidential Distinguished Professor of International Health at Emory University, Rollins School of Public Health.
Emory University - Emeritus Professor
1957 - Bachelor of Arts (BA), Pacific Lutheran University
Wife - Paula
Timeline of Bill Foege's Life
1936 - Born in Decorah, Iowa. One of seven children, his father was a Lutheran minister.
The conclusions were summarized in a 1971 article in the American Journal of Epidemiology (94:311-315) authored by Foege, J.D. Millar and J.M. Lane entitled Selective Epidemiologic Control In Smallpox Eradication.
Shurkin, Joel N. 1979. The Invisible Fire, the Story of Mankind's Victory Over the Ancient Scourge of Smallpox. New York: G. Putnam's Sons.
Woodward, Billy, Shurkin, Joel and Gordon, Debra. Scientists Greater than Einstein: The Biggest Lifesavers of the Twentith Century. Linden Publishing, 2009.
Foege has received numerous awards, some of the most notable being:
Foege, WH. Millar, JD. Lane, JM. 1971. Selective Epidemiologic Control In Smallpox Eradication. American Journal of Epidemiology. 94(4):311-315.
Foege, WH. Millar, JD. Henderson, DA. 1975. Smallpox Eradication in West and Central Africa. Bulletin of the World Health Organization. 52:209-222.
Foege has written more than 125 scientific articles.
Links to Science and Related Information on Smallpox
René Dubos. 1980. Man Adapting. New Haven: Yale University Press.
Falola, Toyin. 2001. Culture and Customs of Nigeria. Westport: Greenwood Press.
Foege, WH, Foster, SO. Goldstein, JA. 1971. Current Status of Global Smallpox Eradication. American Journal of Epidemiology. 93(4):223-233.
Foege, WH. Millar, JD. Lane, JM. 1971. Selective Epidemiologic Control In Smallpox Eradication. American Journal of Epidemiology. 94(4):311-315.
Foege, WH. Millar, JD. Henderson, DA. 1975. Smallpox Eradication in West and Central Africa. Bulletin of the World Health Organization. 52:209-222.
Foege, WH. 1998. Commentary: Smallpox Eradication in West and Central Africa Revisited. Bulletin of the World Health Organization. 76(3):233-235.
Foege, WH. 2003. The Wonder That is Global Health. Nature Medicine.
Foege, WH. 2008. February 25 phone interview.
Foege, WH. 2008. The Anatomy of Smallpox Eradication in India: Personal Narrative. Unpublished manuscript.
Foege, W. Acceptance remarks - The 2001 Public Service Award.
Glynn, I. Glynn, J. 2004. The Life and Death of Smallpox. New York: Cambridge University Press.
Griffin, T. The Man Who Helped Banish Smallpox from the Earth is the 1994 Alumnus of the Year. www.washington.edu/alumni/columns/top10/calling_the_shots.html
Loftus, MJ. 2002.Health for All. Emory Magazine.
McCarthy, C. 1986. A Man With a Conscience Combines Medicine and Service Around the World. The Washington Post. June 18.
Millar, JD. Foege, WH. 1969. Status of Eradication of Smallpox (and Control of Measles) in West and Central Africa. Journal of Infectious Diseases. 120(6):725-732.
Rosenfield, A. 2001. An Interview with William Foege.
Schweitzer, A. Teaching Reverence for Life. http://www.salsa.net/peace/conv/8weekconv1-6.html
Shurkin, Joel N. 1979. The Invisible Fire, the Story of Mankind's Victory Over the Ancient Scourge of Smallpox. New York: G. Putnam's Sons.
Spector, M. 2005. What Money Can Buy. The New Yorker. October 24.
Stolberg, Sheryl Gay. 2001. A Nation Challenged; Public Health. New York Times.
Thompson, D. 2008. March email interview with David Thompson.
Tucker, JB. 200. Scourge: The Once and Future Threat of Smallpox. New York: Grove Press.
2004. Smallpox Disease Overview. CDC. http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp
History and Epidemiology of Global Smallpox Eradication. Centers for Disease Control and Prevention.