(March 12, 1936 - )
Born in Decorah Iowa
Year of Discovery: 1967
The Eradication of Smallpox Through Worldwide Vaccination
A Missionary Discovers a 6% Method
Bill Foege (pronounced FAY-ghee) is an epidemiologist who made a crucial discovery that led to the worldwide eradication of smallpox, one of history's most devastating diseases. He developed and proved the vaccination strategy of surveillance and containment. Prior to his discovery it was thought that 80 to 100% of the world's population would have to be vaccinated against smallpox in order to eradicate it - a daunting, if not impossible, task. His targeted strategy allowed for as little as 6% of a population to be vaccinated, yet still removed the disease from populations, and much more quickly than mass vaccinations.
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.
Lives Saved: Over 122,000,000
Read His Feature Chapter in the Book
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.
Excerpt from Scientists Greater Than Einstein: The Biggest Life Savers of the Twentieth Century
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
"Bill, I think I have some cases of smallpox." It was Hector Ottemiller, a missionary.
"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. When they arrived in Alifokpa, where the road ended, they parked and took the Velosolex motorized bicycles off the car. Off they went into the African savannah for the last twelve kilometers to the village of Ovirpua, to vaccinated those who had contact with those sick with smallpox.
Foege's Vaccination Records
In some locales smallpox vaccination was done using a Ped-O-Jet vaccination gun. 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, it used compressed air to shoot the vaccine into people's arms. With no needle there were no sterilization issues. Foege kept track of 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.
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.
Foege's Life as an Action Hero
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, the soldiers would fake reading the faked documents, and allow them through.
Once Foege was denied vaccine when he was trying to quell an epidemic in the countryside. He drove 70 miles through armed checkpoints, distracted the administrators, slipped into the warehouse and absconded with enough vaccine to bring the epidemic to a halt.
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.
More than once Foege was shot at with machine guns.
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."
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.
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 Six 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.
Ben Franklin Failed to Innoculate his First Child to Smallpox
“In 1736 I lost one of my sons, a fine boy of four years old, by the smallpox taken in the common way. I long regretted bitterly and still regret that I had not given it to him by inoculation. This I mention for the sake of the parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”
Vaccines are Ubiquitous & Omnipresent Throughout Our Lives
It is bizarre that vaccines are controversial, when virtually everyone has had vaccines. The average person born today may get 70+ vaccines in their lifetime.
- There are 31 childhood vaccines (counting booster shots). Over 90% of people have received some of these vaccines.
Virtually everyone constantly benefits from vaccines
- Did you know that all beef, poultry, and pork you eat comes from vaccinated animals?
- And that all horses, dogs, cats, and zoo animals are vaccinated?
- Who wants to live in a world where you can’t pet your friends’ dog because it may not have been vaccinated, and may have rabies?
Quotes by William Foege
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."
On Living in Africa
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
The basics for breaking transmission of the virus were remarkably simple and similar to fighting forest fires.
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.
"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." Foege dutifully provided a list of 81 books to read.
"I saw Bill a couple of months after that," Foege recalled, "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.
From his book, House on Fire: The Fight to Eradicate Smallpox
Perhaps most significant, the smallpox workers were learning and improving every month, while the smallpox virus, for all of its evolutionary success, could not respond with the same agility. It continued in the way of its ancestors, unaware that its strategy for survival, adequate for millennia, would soon no longer suffice.
One had to be an optimist with a feel for numbers to be ecstatic at the same time that Bihar had over 5,000 known smallpox outbreaks and had just reported over 11,600 new cases of smallpox in a single week.
It wasn’t science that threatened to stop us. It wasn’t even nature per se. Rather, it was human nature: the human factors that involve strikes, job security, political concerns, turf. I remembered those words from graduate school: “When you tangle with culture, culture always wins.” As hard as the daily work had been, this was the only time I was discouraged and uncertain about the outcome. I thought we had lost the battle.
Lacking the resources to change their future, people fall prey to a certain fatalism. Through the years I have come to see fatalism, the assumption that you can’t really change your future, as one of the great challenges in global public health.
The tall Foege with his wife
Quotes about Foege
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."
- President Jimmy Carter, 2006
"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."
- John Brauman, home secretary of the National Academy of Sciences, upon awarding Foege the Public Welfare Medal.
"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."
- Joel Shurkin, The Invisible Fire
"If the United Nations, through its World Health Organization, never does anything else than eradicate smallpox - it has to be called a success."
- Billy Woodward
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 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.
The Progression of the Disease
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.
- Sometimes vomiting occurs.
- A high fever of 101 to 104 degrees F. occurs.
- At this time sick people often think they have the flu.
- A rash with small red dots develops inside the mouth and on the tongue. The sores grow and break up, spreading the virus further into the mouth.
- This is the most contagious phase.
- The fever subsides and the person often thinks they are getting better.
- The rash spreads to the face, then down the arms and legs, and onto the hands and feet.
- By the third day of the rash, the red dots start rising.
- Now people hope they have chickenpox. But soon the fever returns.
- The bumps turn into pustules - sharply raised with a small indentation like a belly button in the middle, firm and round.
- To the touch, it feels as though BB pellets lay inside the pustules.
- It isn't chickenpox.
- The next two weeks are horrible. If the pustules are confluent (running together), survival chances are diminished.
- In addition to the fever, the pustules remain, slowly scabbing over.
- The patient is contagious until the pustules are gone.
- If the patient lives, most of the scabs fall off the third week, leaving pock marks - scars for life.
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.
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.
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.
On December 4, 1966, Foege received a radio call from another missionary, saying he suspected a man in the small village of Ovirpua had smallpox. Foege investigated with colleagues and was confronted with a smallpox outbreak. Adequate supplies of vaccine were not yet available, so Foege and his colleagues vaccinated in rings around the outbreak, and in three villages they thought it might spread to due to family connections, and a regional marketplace where locals gathered. Their plan worked. There were a total of only 35 cases of smallpox in the region and then the disease died out. The riveting story of Foege's experiences in Africa is told in the book Scientists Greater Than Einstein: The Biggest Life Savers of the Twentieth Century (for sale in our store).
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.
- 2,641 cities.
- 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.
The problem in India was how to make it work in urban areas. "In a big city," Foege says, "same as in a country area, we would do a six-day search every month in smallpox endemic areas. In the city it meant going house by house looking for cases of smallpox. Cities actually turn out to be harder than villages even though transportation is easier. People are much more anonymous in the city. You might not know whether a neighbor has smallpox. In a village, they will know, but in a city they might not know and they might not tell you even if they do know. So cities are harder; it takes more concentrated work, but it was the same principle of going house by house once a month trying to find where smallpox existed at that moment because that's where the virus was at that moment."
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).
Foege Reflects on the The Eradication of Smallpox
"I've been going to India now for 40 years," Early on he says, "I was very conscious of how many people on the streets had pockmarks." Survivors of smallpox usually are left with pockmarked faces. 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. 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."
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.
1880s - Louis Pasteur named the concept of immunization with a weakened or different germ - vaccine.
1953 - Leslie Collier developed a robust freeze-dried vaccine that could be used anywhere in the world.
1960 - Aaron Ismach developed the Ped-O-Jet vaccine gun that could be used over and over for mass vaccinations with nearly 100% take rates.
1961 - Benjamin Rubin developed the bifurcated needle that could be used by anyone to give vaccinations anywhere.
1966 - United Nations, through its World Health Organization, set up the campaign to eradicate smallpox.
1967 - Bill Foege discovered and proved the vaccination strategy of surveillance and containment that could eradicate smallpox from a population by vaccinating as little as 7% of the population.
1977 - 23-year-old Ali Maow Maalin of Somalia is the last person to catch smallpox in the wild. He survived.
William Foege's Career Timeline
1936 - Born in Decorah, Iowa. One of seven children, his father was a Lutheran minister.
1951 - Spent three months in a full body cast. All he could do was read. Became inspired by Albert Schweitzer.
1957 - Bachelor of Arts (BA), Pacific Lutheran University.
1958 - Married Paula.
1961 - Medical Diploma (MD), University of Washington.
1963 - Epidemic Intelligence Service - spent time with the Peace Corps in India.
1964 - Epidemic Intelligence Service - worked on Ped-O-Jet gun and mass vaccination trials in Tonga.
1965 - Masters of Public Health (MPH), Harvard University.
1965 - Lutheran Medical Missionary - Immanuel Medical Center, Yahe, Nigeria.
1966 - Joined the CDC's smallpox eradication campaign; continued working weekends at the mission clinic.
1966 - December 4, confronted with a smallpox outbreak in Ovirpua, Nigeria.
1966 - December, without adequate vaccine, first use of surveillance and containment vaccination strategy.
1966 - December, researched the variables that affect smallpox transmission in Nigeria.
1967 - Proved surveillance and containment strategy by eradicating smallpox in Eastern Nigeria in five months.
1967 - Provided aid during the Biafran Civil War.
1968 - Worked at the CDC in Atlanta, Ga.
1968-1969 Western Africa - The strategy was proven to eradicate within one year in 19 other countries.
1973 - Foege asks to be assigned to the Smallpox Eradication Campaign in India.
1974 - Foege heads the campaign of surveillance and containment in Uttar Pradesh and Bihar, the two states with the highest rates of smallpox in India.
1974 - May, number of smallpox cases reported reaches its apex.
1974 - May, the minister of health gives the campaign one more month or he will pull the plug.
1974 - June, first drop in number of smallpox cases reported.
1975 - January, 1,010 smallpox cases reported for all of India.
1975 - February, 212 smallpox cases reported for all of India.
1975 - May, last case of smallpox in India found.
1977 - October 26, last case of smallpox on earth found in Somalia. 23 year-old Ali Maow Maalin survived, but the virus did not.
1977 - President Carter appointed Foege Director of the CDC.
1983 - Foege leaves the CDC, having increased its international activities and emphasized all forms of death as worthy of CDC research.
1984 - Foege and colleagues formed the Task Force for Child Survival, which greatly expanded immunization programs worldwide.
1986 - Named executive director of The Carter Center.
2001 - Lasker Award - the Mary Woodward Lasker Award for Public Service.
2006 - University of Washington - The William H. Foege Building dedicated.
2008 - Bill & Melinda Gates Foundation - Senior Fellow.
Books by William Foege
House on Fire - The Fight to Eradicate Smallpox, 2011
ScienceHeores.com Review - A wonderful book with lots of personal anecdotes about the campaign to eradicate smallpox both in Africa & India
1996 - Calderone Prize Columbia University
2001 - Wittenberg Award
2001 - Lasker Award - the Mary Woodward Lasker Award for Public Service
2002 - William H. Foege Fellowships in Global Health - endowed by the Bill & Melinda Gates Foundation with $5 million be housed in the Rollins School of Public Health at Emory University.
2005 - National Academy of Science (NAS) Public Welfare Medal
2006 - University of Washington - The William H. Foege Building: a genome and bioengineering sciences facility on the University of Washington campus, dedicated on March 8, 2006. It is funded by a $70 million Gates Foundation grant, and by The Whitaker Foundation, David C. Auth, PhD, PE, and the Washington Research Foundation.
Key Administrators of the Smallpox Eradication Campaign
Links to Information on Foege
William Foege's Wikipedia Page
Rollins School of Public Health
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.
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.
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.
History and Epidemiology of Global Smallpox Eradication. Centers for Disease Control and Prevention.