Interview Transcript
This is an interview with Dr. William Foege about his activities in the
West African smallpox eradication project. The interview is being
conducted July 13, 2006, at the Centers for Disease Control and Prevention.
It is a part of the 40th anniversary celebration of the launching of the
West African smallpox eradication project. The interviewer is Victoria
Harden.
Harden: Dr. Foege, would you briefly describe your childhood and your
pre-college education--who influenced you to go to medical
school and get interested in public health?
Foege: I started out in northeast Iowa, and lived in a small town
of 100 people. When my family moved away, the population went
down eight percent. I went to a one-room schoolhouse for the
first five years. We then moved to Chewelah, Washington, and I
thought I was really in a big city. It was about 1500 people.
Harden: And why did you move?
Foege: My father was a minister, and he got a call to a new
church in Chewelah, Washington. We moved for that reason. From
there, I went to Colville when he started a new church in
Colville, and that's where I graduated from high school. I went
from high school to Pacific Lutheran [College], what is now
Pacific Lutheran University, in Tacoma, Washington, and became
interested in biology, because of a very forceful biology
teacher who was a man I've never seen the likes of.
Harden: What was his name?
Foege: His name was William Strunk. In class, he would walk into
the room, lecturing as he walked in. He would go to the board
and actually write with both hands simultaneously, putting up
phyla and families and classes and genera. He would still be
talking as he left the room. I was a lab assistant to him and
also worked at his place on weekends, doing yardwork. He played
an important part in getting me into science. My older sister,
Grace, four years older, had gone to the same school, and she
went to medical school. She also was an influence. I was also
influenced as a fifteen-year-old when I spent three months in a
body cast, unable to turn over or do anything. That was in the
days before television, so I was doing a lot of reading. I
began reading about Albert Schweitzer, and medicine, and Africa,
and all of this became very interesting to me.
Harden: Had you had an accident, or...?
Foege: I had a problem with my hip that required three months of
immobility. The hope was that it would heal correctly, and it
did, but the hip was always off a little bit. This period was a
time of reflection and reading that I might not have had without
that physical problem.
In medical school, I began working after school and on
Saturdays for a fellow by the name of Ray Ravenholt. Ray
Ravenholt had been one of the first EIS officers, Epidemic
Intelligence Service officers, at CDC [Centers for Disease
Control], and he was always pushing the idea of public health
and also the idea that I should think about joining the EIS at
CDC. I went off to New York for my internship, and I had been
accepted in an internal medicine residency, when I got a call
from Don Millar [J. Donald Millar] at CDC. He said they had
just received some positions that enabled them to expand the EIS
class, and would I be interested? I abandoned my idea of going
into internal medicine, and went to CDC in the EIS class of
1962.
Harden: Had you always been interested in public health, or was that
just a sideline until you got to CDC?
Foege: Ray Ravenholt was such a powerful influence on me that I
was interested in public health by the time I graduated from
medical school. Of course, I didn't see exactly where I was
going until Don Millar called with this EIS opening, but then I
never looked back. I was extremely pleased at CDC with the EIS
program.
I was first assigned to Colorado, a state assignment, and
while there I did two overseas TDYs [Temporary Duty]. One was
to India, in 1963. At an EIS conference, they had announced
that the person holding the Peace Corps position in India had
taken sick. It was going to take some time to replace him, so
they were looking for a volunteer to go as the Peace Corps
physician. This I did, and it turned out to be important in so
many ways. I saw global health close up. I saw my first cases
of smallpox. I made rounds at Holy Family Hospital in New
Delhi.
I worked for a man by the name of Charlie Houston, who was
key in mountaineering. In 1953, he had actually led a group up
K2 [Karakoram 2 mountain in Pakistan], and before getting to the
top they were stuck in a storm. One person developed deep vein
thrombosis in one leg and then developed it in the other leg.
Charlie Houston said that they had to get him down, but everyone
said, "We can't go down in a storm." Houston said, "It's his
only hope." So they attempted to rescue him in a storm, and as
they were descending across an ice field at a forty-five degree
angle, one person slipped and fell. This person got tangled up
in another rope, and then four people were falling. They hit
Charlie Houston, who was on a third rope and knocked him
unconscious. The four people plus the three on Charlie
Houston's rope were all falling, and they were held by a man by
the name of Peter Schoening, who, with his ice axe, was able to
stop all of them. It's an incredible story, and to make it even
more incredible, two months ago I went to the University of
Colorado, where they gave Charlie Houston, at age 93, an
honorary degree. They had a half-day program giving him an
honor. All of the survivors of that 1953 expedition were there,
including Bob Bates at age 95, former headmaster at Exeter, and
Bob Craig, the youngest of the group, who was now in his late
80s. Charlie Houston was spectacular person to work for. He
was able to demonstrate that you can work in a developing
country and not get overwhelmed by it. He always got up every
morning just happy to be working and was never overwhelmed.
Harden: I believe that you also were involved as an EIS officer with
the group that went to Tonga to evaluate the smallpox vaccine,
and the jet injector. Would you talk about that?
Foege: The other overseas TDY that I did was to Tonga, a group
headed by Ron Roberto [Ronald R. Roberto]. The idea was to see
could you dilute smallpox vaccine and use it in a jet injector.
Tonga had not done routine vaccinations since 1905, so it
provided a virgin population in which you could measure
antibodies and so forth, and the Tongans were agreeable to
having this study done. We wanted to evaluate the effectiveness
of different dilutions of smallpox vaccine--a one-to-ten, one-to-
fifty, one-to-one hundred, and so forth. It turned out to be a
very good study that demonstrated you could dilute the vaccine
one to fifty, and that you would still get uniform take rates.
We also demonstrated that the vaccinations could be given with
the jet injector, which didn't require special training in
technique to have the vaccinations come out the same with every
person. It was easy to train a person to use a jet injector.
This turned out to be a very important study.
Harden: May I ask you to describe how the jet injector worked? Did it
actually touch the people's skin, and if so, did you have to
sterilize it between uses? I don't understand how you could do
thousands a day, if you had to sterilize between every one.
Foege: The jet injector nozzle actually did press up against the
skin. At that time, people were quite sure that there was no
chance of cross-contamination, that the vaccine came out at high
pressure, but we've subsequently changed our mind about this,
and that's why we don't use jet injectors at this point. But
because we believed it completely safe at that time, one could
actually do people almost as fast as they could walk by. You
set up a rhythm: grab the arm, step on the hydraulic lever,
shoot, and the person would continue on. You could do a
thousand people an hour, and I remember at one point doing a
prison in eastern Nigeria, where they had the inmates lined up,
and they were actually pushing them through by hitting them with
sticks. I did 600 people in twenty minutes, because it was such
a regimented line that you could just grab people and do them so
fast. At one point, I recall doing over 11,000 smallpox
immunizations in one day. So, yes, you could do this very
quickly.
Harden: Before we move on in your career, is there anything else that
you would like to comment about in your EIS training here at the
CDC?
Foege: In those days at CDC, anyone in the EIS program saw Alex
Langmuir [Alexander Langmuir] as a mentor. He was a very
powerful personality. He knew what he was doing, he was
inspired and inspiring. And so I'd look back on those days as
days where Alex Langmuir was reaffirming how important it was to
do public health, and how important it was to do global health.
He was interested in everything.
Also during that time as an EIS officer, I read an article
in the New England Journal of Medicine. It was called
AQuestions of Priority,@ written by Tom Weller [Thomas H.
Weller]. I had no idea at the time that Tom Weller was a Nobel
laureate, but when I read the article, I knew I wanted to know
him, because he was saying in the article things that I
believed. It was a commencement address to the Harvard Medical
School, and he was essentially saying,
"You're only going through life once, you might as well
try to get it right, and here [at Harvard] you come out
with all these skills and this knowledge, and you have to
ask how you're going to use it. Think about using it in
the parts of the world that can best use these resources.
The developing world doesn't have the resources of skills
and knowledge, and now that you've gone through, think
about using what youve learned in the developing world."
Harden: Maybe I can digress here for one philosophical question. The
early 1960s were an idealistic time, in a variety of ways, and
the idea that to get it right in life you went and served people
is a very different idea from getting all you can for yourself.
Would you comment on the idealism of your peers in this period?
Foege: The early 1960s turned out to be a very nice time to be
growing up in the United States. President Kennedy inspired
people with the idea of the Peace Corps. People thought about
how best to serve their country and how best to serve the world.
So when I read an article by a Harvard professor saying the
same thing, I decided that I wanted to get to know him. I
applied at Harvard, and no place else, and I spent a year with
Tom Weller.
Harden: As I understand, you did this on your own, rather than having
the CDC sending you. You received a Master's of Public Health
degree.Foege: That's right. CDC actually offered a
career development program to me, which meant that I could have
training paid for for a number of years, and then I would pay
back a certain number of years. But by this time, I already
knew I was going to Africa or someplace else in the developing
world, and it didn't seem fair to have CDC pay for my education
and then, even if I paid back a certain period of time, leave
for another job. So I went to Harvard on my own. I did get a
scholarship, but I went on my own, and it turned out to be
everything that I had hoped it would be. Tom Weller was an
inspiring person. He worked with an inspiring group of people,
including Frank Neva [Franklin A. Neva], who was my faculty
advisor. Neva is the father-in-law of Peter D. Bell, who became
president of CARE, and the father of Karen Bell, who ended up
teaching here at Emory University in the School of Public
Health. And so it turned out to be a very nice experience.
When Tom Weller retired from Harvard, it so happened that I gave
the commencement address that year. I got out that New England
Journal of Medicine article, and I read the portions that I had
found so attractive before, and made the point that you never
know what will ripple downstream from what you say or what you
write. Well, Tom Weller got a standing ovation in the middle of
my commencement address, and it completed a circle. I've
remained in contact with Tom Weller, who's in his 90s, just as I
have with Charlie Houston and some of my other mentors.
Harden: When you finished your training at Harvard, you joined a
medical missionary program in the Lutheran church. Apparently
it took a bit of effort to convince them to let you do a public
health mission, as opposed to a primary care mission. Would you
talk a bit about that, and what you finally set up?
Foege: Let me mention one more thing about Harvard before going
to that. In one of Tom Weller's classes, we had to do an
independent project and present it. I happened to do a project
on the feasibility of smallpox eradication in the world. I had
no idea that I would ever be involved in this, but I found it an
intriguing topic. There was a person in this group, Yeme
Ademola, who was the head of preventive medicine for Nigeria.
He had taken a year off to get a master's degree at Harvard, so
Yeme and his wife Rosa were there, and he was part of that
class. After graduation, Yeme Ademola came down to CDC, and
talked to people about his interest in smallpox eradication in
Nigeria. This is a small aside.
After graduation from Harvard, I went to Nigeria to work
for a church group. I knew that most of the hospital beds in
Africa were provided by church groups, so they had a big
influence on health in Africa. But almost all of them were
involved in clinics and hospitals, not in community work. It's
easy to see why that would happen, because church programs had
found that medicine was a great proselytizing tool. People in
hospitals and clinics felt real gratitude, and so medicine
turned out to be a form of recruitment. I always felt that was
wrong, I felt that churches should be working in Africa or other
places because of what they believed, not because of what they
were trying to get other people to believe.
I wondered what would happen if you could get this force
looking at community medicine instead of hospital medicine.
Community medicine takes a far different approach to things. In
the end, it made no difference that I actually went to Africa to
try to make that change. There were other things happening at
the same time that would cause church groups to shift to
community medicine. The World Council of Churches had a
Christian medical commission, and there was a fellow by the name
of McGilvray [James C. McGilvray] who headed that up. He
believed in community medicine. He was so influential that, in
a period of years, he got medical mission programs to change in
three fundamental ways. Number one, he got them to understand
they had to work under governments. Colonialism was over, and
they had to work under sovereign governments. Number two, he
got them to work together. They had been very competitive in
the past. In many countries there would be one person who was
the coordinator for all Protestant work, and another one who was
the coordinator for all Catholic work. McGilvray's influence
resulted in--at least, in a few countries--those two sitting in
the same office. This was an incredible change. Number three,
he got them interested in community medicine. So I could have
saved my time. I didn't prove anything by going over. It was
happening anyway. But I did go over, and I was trying to
promote community medicine. I would probably have spent decades
working on this, except that when the war in Nigeria came, it
went through our medical compound within the first weeks.
Harden: Would you back up and tell me exactly where you were, what was
happening, and what you were doing when the war came?
Foege: I graduated from Harvard in 1965, and that summer, we left
for Nigeria. We went to a medical center in the eastern part of
Nigeria. In those days, Nigeria did not have states. It had
only four regions. The north, the east, the west, and the
midwest. We were in the eastern region. This was the region
that was dominated by Ibos, who would later form the Republic of
Biafra. We were in a minority area of the east, in a place
called Ogoja province, up near the Cameroon border. In this
area, there was a medical center at a place called Yahe. It was
a crossroads town, and that's where we went. We spent the first
six months living in a village in order to learn the local
language. It was an eye-opener, because it was a village with
no electricity, no running water, and no indoor bathrooms, that
sort of thing. We had an opportunity to see what life was like
in a village. We had a three-year-old son at the time.
Harden: So you were married, with children, at this point?
Foege: Yes. I had a wife, Paula, who will be the next
interviewee, and a three-year-old son, David, and we had the
naive notion that we would actually know what it was like to
live in a village. There's actually no way to know that,
because we could leave any time. The people living there
couldn't leave. Living there was a form of bondage that I don't
think it's possible for us to understand. But we were trying
to. We lived in the village for six months and then moved to
the medical compound. While we were at the medical compound,
CDC asked if I would spend time as a consultant for the smallpox
eradication program.
Harden: This was before or after the revolution?
Foege: This was before the war broke out. We had been in Nigeria
for almost a year at the time that Henry Gelfand came to Enugu
to ask me if I would be a consultant. Our medical center was
ninety miles from Enugu, the capital of the eastern region, but
we agreed that for a period of one or two years, I would work as
a consultant on smallpox eradication, and I would go back to the
medical center on weekends. I would try to do both things,
ninety miles apart. In 1966, Paula and I returned to CDC to
take the summer course for the people who were first going out
to Africa on the smallpox eradication work. This is the group
now meeting for a reunion. It turned out to be a very nice time
for us to be back, because my wife was pregnant, and she
delivered our second child, a boy, in September. It all worked
out that we came back here, and she had the baby in Walla Walla,
Washington, where my folks were living, and I attended the
summer course and then met up with her.
Now, an interesting aside. It takes a while to get a
passport for a baby, to get a baby added to a passport. I even
contemplated taking a picture of any baby and getting this on
the passport before ours was born, so that we could move more
quickly. I did not take that route, showing more sanity than
usual. We waited, and I returned to Nigeria. Paula came over
with the two children when the baby was about six weeks old.
Harden: These are the small logistical problems, personal logistical
problems that people rarely think about.
Foege: Sometimes they turn out to be overwhelming. When I knew
that I would be coming to the US for the summer course at CDC, I
bought tickets for my wife and for David. CDC would send the
ticket for me. We got to Lagos, ready to board the flight, but
my ticket had not arrived from CDC. I talked with the Pan-Am
manager, and he said, "You're in luck, because the plane is
late by twenty-four hours. We have more time to try to get the
ticket." But it was July fourth. That meant nothing in
Nigeria, but it meant we couldn't get anything out of CDC. And
so the next day, we went right down to the line with tickets for
them but no ticket for me. About an hour and a half before
flight time, the manager called me in, and he said, "We haven't
heard anything. But I'll tell you what I'll do. If you write
out a check for the amount of the ticket, I'll put it in my desk
drawer, and so I'm covered if I get audited." I told him, "I
can't do that. I don't have that amount of money in my
account." We were at an impasse, but an hour before flight
time, he said, "I'll tell you what I'm going to do, and I've
never done this before. I'm going to give you a ticket." And
he said, "I'm going to have to write out the check if I get
audited." He gave me a ticket, and we got in line. But the
airline representatives said, "This ticket was for yesterday."
I said, "Of course it was. The plane was supposed to be here
yesterday." Then I had to go back to the Pan-Am agent and say,
"They won't take this ticket." He was exasperated by that time,
but he got us through. We got on the plane finally, and at last
I felt that we could relax. I actually said to my wife, "Isn't
it going to be nice to get back to the States, where things
work?"
We got to New York. It was hot, it was at night, and we
were twenty-four hours late, so, of course, everyone had to have
new connections. My wife and son had a new connection, but I
didn't, because I didn't actually have a ticket. This caused a
problem. Pan Am said that they would put everyone up overnight
and that we would all get out in the morning. We stood in the
heat, and even though we were coming from Nigeria, it struck me
how hot it was in New York. We were waiting for the bus to
take us to the motel, the traveler's motel. There was a Pan-Am
man there in a suit and a tie. He was very efficient. He
picked me out and asked me to give them a hand. And then he
picked out another person, and I realized he picked us for our
size. He took us outside and said, "The battery's dead on the
bus. Would you help push it to get the bus started?" And we
did. We pushed it fast enough to get the motor to turn over,
and the engine caught. Then he called for men to board first.
I wondered why he did this, but the men, like sheep, got onto
the bus. It turned out that the back of the bus was very hot.
He was saving the front of the bus for the women and children.
I heard him say to the bus driver, "Remember to stop at
the first service station and put in three quarts of oil." I
thought, "Three quarts of oil. This is a real problem." The
bus driver let out the clutch and killed the motor. Everyone
was told to stay on the bus, as hot as it was. The Pan-Am man
said that another bus was coming to push this one to get it
started, and that's what happened. And again he said to the bus
driver, "Remember, three quarts of oil." We went down the
highway, and it must have been eleven or eleven-thirty at night
by then. He pulled off into a service station and sat there for
a moment. Then he turned around and said, "You know, folks, if
I stop the engine to put in oil, we're not going to get it
started again." And so off he went onto the highway, and soon
the motor froze up. There we were, on the side of the road,
with the motor frozen, and he told everybody to get off the bus
because it was too hot to stay on. He made a phone call, and
pretty soon this Pan-Am agent comes screaming up in a car, and
by this time he had his tie off and his jacket off and he was
starting to look disheveled. He said, "Don't worry, we have
some cars and another small bus coming." When the cars and the
small bus came, he told the women and children to get in the
cars, and the men to get in the bus. All the women and children
did as they were told, except my wife, who stayed with me. She
said, "The way things are going tonight, I may never see my
husband again, so I'm not moving." Finally, we got on the bus
and we get to the motel. But to have said, AWon't it be nice to
get back where things work?@ and then run into this, it was
ironic.
Harden: Would you now walk me through the events in the Nigerian war
that forced you to end the mission program and moved you into
CDC?
Foege: In the last part of 1966, and the early part of 1967,
there was a lot of tension in Nigeria. The east kept
threatening to form its own country. In retrospect, I suppose
oil was behind this, but we didn't quite understand it at the
time. We continued working. In late 1966, two very important
things relating to smallpox happened during my time in eastern
Nigeria. One was a mass vaccination program we did in a place
called Abakaliki. We were very successful, getting about ninety-
three percent of the population vaccinated. We were pleased by
this kind of coverage, only to see an outbreak of smallpox a few
weeks later in Abakaliki. We didn't think that this should have
happened, because we believed in the idea of herd immunity.
What was different about the outbreak was that it occurred in a
religious group, Faith Tabernacle Church. All of the cases were
in the Faith Tabernacle Church. The members of this church had
refused vaccination. The source of the outbreak had probably
come from another Faith Tabernacle member outside of Abakaliki.
The point is that we found that no level of vaccination in a
population was so high that you could exclude the possibility of
smallpox. That's one thing that happened.
Harden: You said that your independent project at Harvard was to come
up with a smallpox vaccination strategy. Had your strategy for
that project been mass vaccination?
Foege: Everyone in those days was thinking in terms of mass
vaccination, and that's what I was thinking of when I was at
Harvard, that if you got to a certain level of vaccination, you
would make it so difficult for smallpox to be transmitted that
it would just die away. That's what we thought, but the
experience in Abakaliki proved otherwise.
The second thing that happened occurred on December 4,
1966. It was a Sunday. I got a radio message from Hector
Ottomueller, a missionary, who asked if I could come to look at
what he thought might be smallpox. We went to the area, which
was probably six, seven miles off of a road. We used Solex
bicycles, French bicycles with a small motor on the front. They
were so light that when you came to a creek, you could actually
walk across on a log holding the bicycle in one hand. They were
a very efficient method of transport. Sure enough, these were
smallpox cases. It was so early in the program, we didn't have
much in the way of supplies, and then I learned we wouldn't get
any more supplies. We were faced with the question of how to
use our small amount of smallpox vaccine most effectively under
these conditions.
That night, we went to a missionary's house to take
advantage of the fact that they got on the radio with each other
at 7:00 pm each night to be sure no one was having a medical
emergency. With maps in front of me, I was able to give each
missionary a geographic area, and ask if they could send runners
to every village in that area to find out if there were any
smallpox cases in any of the villages. Twenty-four hours later,
we got back on the radio to see what they had found. That night
we knew exactly where smallpox was. Our strategy was to use
most of the vaccine in the villages where we knew that smallpox
existed. Second, we tried to out-figure the smallpox virus. I
mean, we literally asked ourselves, "If we were a smallpox virus
bent on immortality, what would we do?" The answer was to find
susceptible hosts in order to continue growing. So we figured
out where people were likely to go because of market patterns
and family patterns. We chose three areas that we thought were
susceptible, and we used the rest of our vaccine to vaccinate
those three areas. That used up all of our vaccine. We didn't
know it, but in two of the areas, smallpox was already
incubating, but by the time the first clinical cases appeared,
those areas had been vaccinated. And so smallpox went no place.
By three or four weeks later, the outbreak had stopped. And we
had vaccinated such a small proportion of the population!
There was this contrast between the situation in
Abakaliki, with a very high percentage of coverage and still a
smallpox outbreak, and that in Ogoga province, with very poor
coverage, but with an outbreak that was halted. We began to
wonder if this new strategy might be worth trying in larger
areas. We talked to the Ministry of Health. It was a very
crucial time, because war was being talked about every day. The
Ministry of Health said that in the eastern region, they were
willing to change the whole strategy against smallpox. We could
put all of our attention on finding smallpox and containing each
outbreak. Five months later, when war fever was at a peak, we
were working on the last known outbreak in that entire region of
twelve million people. In five months, we'd cleared out every
outbreak. We were working on the last outbreak when war broke
out.
Now I didn't know that war was going to break out at that
moment. The smallpox program had planned a meeting in Accra,
Ghana, for the first of July, 1967. I went to the American
consulate in Enugu and asked, "What's the chance that there will
be fighting in the next weeks?" And they said, "Not a chance.
Neither side is strong enough at this point to actually initiate
anything." But the border had already been closed between the
east, which called itself Biafra, and the rest of Nigeria, and
six weeks earlier, we had sent our wives and children out. We
had gone to Port Harcourt, where our wives and children got on
planes. They were DC-6s, I can still recall. It took forever
for them to get off the runway, because every seat had an adult
and a child.
Harden: And where did the planes go?
Foege: From Port Harcourt to Lagos. Port Harcourt was in the
east, but they had received permission for people to fly out.
When the smallpox meeting was about to start in Accra,
Ghana, I determined from the consulate that we would not have to
worry about fighting in the short term. We crossed the Niger
River in canoes. They were slightly big canoes. There was no
formal border between the two regions. And yet, we got our
passports stamped on each side, by people who were pretending
that this was all legitimate. We got taxis from the other side
of the river to Lagos, and from there we got to Accra. We were
in Accra at this meeting when the fighting broke out. The
American consulate had it all wrong, and we couldn't get back.
We did not know for months whether that last outbreak had
actually been contained or not. It turns out that it was
contained. There was never any smallpox in the area of fighting
during the Nigerian-Biafran civil war. That turned out to be a
real blessing. But think of how close we came. There was a
window of opportunity because of our December experience with
the small outbreak. We had asked if we could try this strategy
on a larger area, and in five months we had cleared out smallpox
from the entire region. Because of that, smallpox turned out
not to be a factor in the war.
Harden: So you knew by then that this method of
"surveillance/ontainment" or "eradication escalation"--whatever
term we are going to use--was a more effective way to eradicate
smallpox. And at this point, when you were asked to come back
into CDC, you must have had to sell this idea to people. Tell
me about whom you had to sell it to, and what you did to sell
it.
Foege: At the end of the meeting in Ghana, I wasn't quite sure
what to do, since the east was now closed because of the war. I
went back to Lagos, and it was decided that I would work in
northern Nigeria for a while. I also need to step back just a
few weeks, or a few months, to say that on one morning, in
Enugu, a Saturday morning, we went in to work and found that
there were cases of smallpox in the hospital in Enugu. And
suddenly we knew we had to do something in Enugu itself and
spent the rest of that day planning for doing vaccination in
Enugu. That afternoon, I went out in a VW bug, and mapped out
the places in Enugu where you had enough room that you could
actually have people lined up to do vaccinations. I was not
thinking of anything except smallpox at that point. But
suddenly, I was surrounded by police. Someone had reported that
there I was with maps, and of course that looked suspicious, so
I was arrested. It took hours before they would allow me to
make a phone call. I wanted to call my wife, so that she would
know why I wasn't coming home for dinner. They would not let me
do that. But they eventually let me call my counterpart, Dr.
Anazanwu, in the Ministry of Health, and he came down and got me
bailed out. I tell this just to make the point that I had been
arrested by the Biafrans.
When I went to work in northern Nigeria, I was in Sokoto
province, which is up in the northwest part of Nigeria. I had
just set up a tent for the night, and was getting ready to cook
dinner, when a pickup drove up and police officers got out. A
man came up to me, gave me a piece of paper, and asked me,"Is
this you?" And there was my name on the paper. And I said,
"yes." And he said, "You're under arrest." He would not
communicate anything more. He would not say why I was under
arrest, but I had to put everything together and get into the
back of the pickup. And we started the long trip back. At one
point, they stopped at a guest house in order to go in and drink
beer. They left me alone, sitting in the back seat of that
pickup, with a pistol on the front seat. I knew I didn't want
to move at all, which I didn't. They came back, and we
continued to ride. In Kaduna I was put under house arrest, and
after several days, they said that they would allow me to leave
the country, if I would never return. I left and flew out to
Ghana. But a few weeks later, I was asked to go back to Lagos
by the regional office of the smallpox eradication program. I
knew how poorly official records were kept, so I went back, and
there was never any problem. The point I am making is that I
was arrested by both sides, which showed my neutrality.
When I went back to CDC, I expected that the war was going
to be finished within weeks. That was my thinking, and when I
returned to CDC, I came back as a contract employee for what I
thought would be a period of weeks or months. I began working
on the idea of using surveillance/containment throughout West
and Central Africa. That's what I worked on--selling the idea.
Some people were sold immediately. I mean, I think of Don
Hopkins [Donald R. Hopkins] going to Sierra Leone, which had the
highest rates of smallpox in the world. Sierra Leone at that
time had poor communications and transportation. He started out
from the beginning, doing surveillance/containment. He never
bothered with mass vaccination, and surveillance/containment
worked, well. Other people were more reluctant, and I can
understand that. We had sold most of the governments on
universal vaccination. Eastern Nigeria had been easy to
convert. They saw the logic, but it was not that easy every
place. But gradually, place after place did do this, and the
bottom line was, we were able to eradicate smallpox in five
years. In country after country, smallpox disappeared. I'm
quite sure that in any geographic area where they converted to
surveillance/containment, twelve months later, it was smallpox
free. Nigeria had its last cases in May of 1970, and the whole
twenty-country West African area had smallpox disappear in three
years and five months, a year and seven months before the
target, and under budget.
Harden: What I'm hearing from you is that each group working in the
field had to choose to adopt this approach, that there was no
top-down direction from Atlanta. I thought that an order might
have come from headquarters in Atlanta, instructing everybody to
stop doing mass vaccination and start doing
surveillance/containment. That was not the way it happened?
Foege: It's hard to make that kind of change when countries are
autonomous and they have their own programs, and they've not
been sold on a new approach. Don Millar was an immediate
convert to surveillance/containment, and he was in charge of the
entire West Central African program. Mike Lane had a fiefdom, a
region that he was in charge of, and he was an immediate
convert. So, right from the beginning, we were talking this
out. With each meeting, it was possible to demonstrate that
surveillance/containment was working in particular areas, and so
gradually, everyone did come on board. But it took a little
while. Nonetheless, to have smallpox disappear in three years
and five months--it didn't take long.
Harden: So the program agreements that were initially signed with each
country had described mass vaccinations, and in shifting to
surveillance/containment, you had to "sell" each individual
country, correct?
Foege: That's right. And to me, the amazing thing is not that it
took some period of time. The amazing thing is how fast we
changed strategy. I mean, we just turned things upside-down,
and it happened in twenty countries.
Harden: To me, as a historian, the fascinating thing is how that
flexibility was embraced. So many times change is not embraced
when somebody has a new idea and can demonstrate that it works,
because people are so invested in the old idea.
Foege: It also shows the value of having young people involved in
the project. Julie Richmond [Julius Richmond], the former
Surgeon General, once said that the reason smallpox eradication
worked is that the people involved were so young they didn't
know it couldn't work. And you know, that's probably true.
People were very flexible. And when you think of the number of
people that went from CDC into West Africa, most of them had
never had experience in West Africa. And yet, they adapted
fast. I think, when you look at the group as a whole, what
characterizes them is that they were problem solvers. Everyone
has mixed motives, of course. It's hard to know exactly what
motivates people. Today I am often asked, "What is Bill Gates's
motivation? And I say, "How do I know? I don't even know my
own motivation, it's such a mixture of things." The people
involved in smallpox eradication had a lot of interest in doing
new things, and exploring, and so forth. But the thing that
characterized them all was that they were problem solvers. You
couldn't give them a problem that was so difficult they didn't
want to try to solve it. And so, they were very adaptable.
When a new idea came out, they quickly used it.
Harden: In the middle of the West African smallpox eradication effort,
there was a recommendation that smallpox vaccines be stopped in
the United States. Were you involved in these discussions?
Foege: I was involved during those years. In 1971, we really did
attempt to stop smallpox vaccination in the United States. It
took a lot of courage to support that, because there was still
smallpox in Africa, Pakistan, India, and Bangladesh--lots of
places. But but by then Mike Lane and John Neff and other
people had done the calculations that showed what the risk was
of the vaccine. The United States had a risk of smallpox coming
in from another country, but we concluded that the risk of
importation was less than that of the vaccine itself. Part of
the reason is geography. Europe acted as a filter for smallpox
cases. People coming from Africa or from India or Pakistan,
often went to Europe first, and then to the United States, so
Europe continued to have outbreaks, and we didn't. We
calculated the risk of smallpox coming to the United States.
For instance, if you look at ships, because of the time it takes
to get here, and so forth, we were able to calculate the risk of
smallpox coming to the United States by ship was about one
importation in 600 years. It is far greater than that for
airplanes, but it gives you an idea that it was possible to
calculate the risk based on the incidence in a country, how many
people go from that country to the United States, what
percentage of them are probably not adequately protected, and so
forth. The recommendation to stop giving smallpox vaccinations
in the United States came out in 1971. It took quite a while
before it was actually followed by everyone.
As a part of that recommendation, we also developed a plan
for what to do if there was an importation. Some of us went to
the states-we got to all of the states--to train their public
health officials as to what would be needed if a smallpox case
was imported. We used what was called the CASE manual. "CASE"
stood for Comprehensive Action for a Smallpox Emergency. Inside
the front cover of that notebook was a big chart that you unfold
and put up on the wall. It showed every step that you had to
take. And every step had a place in the notebook that gave the
details. Our point in designing this manual was that people did
not have to study this ahead of time. They just needed to know
that it was available to tell them what steps to take if they
thought they had a case of smallpox. This was very important so
that no one would panic if a case appeared. The chart in the
CASE manual was very clear. I think we did a good job of
educating the state health officers, the counties and so forth,
on what to do in case of a smallpox outbreak.
Harden: Is there is anything else about the West African program you
would like to talk about?
Foege: I think we've covered the main things. The only other
things I had were stories of various kinds, but I don't think
they're as important as the big picture.
Harden: I'd like to hear those stories!
Foege: The program itself, as you can imagine, was very
difficult. Communications were bad, transportation was
difficult, it was often hard to get food. It was not an easy
time to be in an area in which civil war was about to break out.
There were many tensions. There were roadblocks where teenage
boys with guns were drinking beer and making decisions. This
was difficult.
Harden: Were you afraid?
Foege: You always had to be a little bit afraid of a teenage boy
with a gun who's drunk. They do irrational things. So, yes,
you never wanted to talk back. There are many stories from that
time. Once at these roadblocks, they looked into the trunk of
one woman's car and saw that she had a labeling machine. A
labeling machine looks a little bit like a pistol, but not much
like one, but they were curious to know what this device was.
She explained that it would make their name, and then she showed
them. They spelled out their names, and she made a label for
each of them. When they cleared her to proceed, she continued
down the road but heard a rattling in the trunk of the car. She
stopped to look and found three guns in the trunk. Each boy had
taken his label and walked off with it, leaving his gun. She
immediately drove back to return the guns, and of course, the
boys were very nervous, thinking a commanding officer was going
to come by and see that they didn't have their guns.
You worried about the roadblocks. As the wives were
leaving from Port Harcourt, one of our people had gotten a
little upset with a guard who asked them once more to open their
suitcases. He said, "We've already opened it." Of course, the
guard did not like his response. Next thing, he had him in a
room, with a guard and a gun. Then this person realized that he
had the key to his wife's suitcase. The other guards continued
to ask her to open it, but she couldn't because he had the key.
He asked the guard, "Couldn't I just go out and give her the
key?" The guard said, "No." So he said, "What would you do if
I just stood up and walked over and gave her the key?" The
guard said, "I'd shoot you." My friend stood up, and the guy
cocked the gun. And my friend sat down again. Then he asked me
to come in, and I talked to the guard and asked if I could give
the key to my friend's wife, and the guard let me do that. But
because of this confrontation, my friend was never even able to
say goodbye to his wife. So you just did not want to fool
around with people.
One day, I was in a big, green International van, and we
were driving down the road and saw a checkpoint up ahead. The
driver-there were just the two of us in the car--started putting
on the brakes, but the brakes had gone out. He tried to pull
the emergency brake, but it did not work, either. The last
thing he was going to do was go through that barrier, and so he
went off the road, into a ditch. We bounced around, hit a tree,
and ended up against a building. Suddenly, we were surrounded
by people. This is a common thing in Africa. You think you're
out in deserted land, but as soon as something happens, you're
surrounded by people. It took a while for me to realize what
was happening. The local chief came, and he was a real orator.
He began telling me what we had just done. He said that that
tree we hit was a juju tree, and that we had offended it by
knocking it down with our vehicle, and so he would have to do a
sacrifice. He would sacrifice a chicken. This chicken would
cost ten shillings. When he was all done, and it took him a
long time to get to that point, I breathed a sigh of relief,
because I hadn't known what was coming. Ten shillings--that
was nothing. But then something perverse took over in my mind,
and I began talking back in the same way that he did, telling
him that I understood all of this, and that, yes, we had our own
kind of customs where I came from. Where I came from, this
vehicle was considered to be a juju god, and it had been very
offended to have that tree there in its way, and that I would
have to sacrifice a goat, which would cost twenty shillings.
And then I pulled out ten shillings, and asked, "To whom do I
give the ten shillings, and who will be giving me the twenty
shillings?" There was such a silence that I feared I had made a
mistake. It was just deathly quiet. And then, one man started
laughing. And with that, a few others laughed, and pretty soon
everyone was laughing, they saw the joke. No money changed
hands, and we got out of there.
Harden: I would also like to ask you: When you have lived like this in
Africa, how you readjust to living in suburban U.S., with all
the fast food, with all the affluence?
Foege: It's an interesting experience to live overseas, and many
people find it a great experience, because they have servants
and they get privileges that they wouldn't have in the States.
We didn't quite have that experience, having started out in a
village, where living was very difficult, and much of your day
was consumed in just boiling water. We didn't have electricity,
so we couldn't even have a fan to help deal with the heat.
Despite these difficulties, it was hard to come back.
Everything seems too easy to you when you return. But there was
a good part of this change. When we were using many CDC people
in India on ninety-day TDY projects, I got a letter from Don
Millar, who was providing a lot of the people. He said, "I
don't know if they're helping you at all with smallpox
eradication, but keep asking for them, because they come back
different people. They have now experienced what it's like to
have real problems. They don't put up with a lot of the things
in the United States that cause problems. They just steamroll
over them." So there are good points and bad points about
coming back to the U.S. Living overseas is a broadening
experience, and I think it's so important for people to have
that experience. They come back with some difficulty, but they
come back with a different perspective of how fortunate they
have been.
Harden: When zero pox was achieved in West Africa, the outside funds
for the CDC efforts pretty much dried up, but Dave Sencer [David
J. Sencer] was unwilling to let the program die. He appointed
you to be head, and sent you out to insure that the worldwide
effort was going to be successful. Can you tell me about this
transition, and what actions you took?
Foege: There were two things that happened after smallpox
disappeared in West Africa. First, we must remember that this
was always a smallpox and measles program. Measles was a major
cause of death in West Africa, and it's interesting that USAID,
the funders for the program, always referred to this as the
measles/smallpox program. The CDC always referred to it as
smallpox/measles, not because smallpox was more important than
measles, but because it was part of a global effort, and
eradication was uppermost in our minds. We believed that if we
were not able to achieve eradication in West Africa, the global
effort would most likely not succeed. At the end, we assumed
that USAID would see the benefit of continuing the measles part
of this, because measles deaths had been greatly reduced,
hospital beds that had been taken up by measles cases had now
been freed up for other patients. We had no idea at that time
that they were being freed up for AIDS cases in the future, but
that's what happened. I was very surprised and shocked when
USAID made a decision to stop the measles part of the program.
It was very shortsighted to get West Africa accustomed to having
measles vaccine available to reduce this terrible plague, and
then to say, "We're going to stop the program. Now you're on
your own." We tried very hard to get the measles program either
continued or at least tapered off over sufficient period of
time.
Harden: Who made this decision?
Foege: It was a decision, as far as I can tell, of one person at
USAID, who was new, who didn't have an emotional commitment to
the measles vaccine program and who wanted to do his own things.
That made it extremely difficult, and as hard as we argued, we
could not persuade him. I actually wrote a letter for Dave
Sencer's signature to go to the head of USAID, which hopefully
would put some pressure on them to continue the program. It
went to someone in USAID, who sent it to me for a response. And
that's when I realized how much fun government could be, that
you could write your own letter and respond to it, also.
The second thing that we did was to look at the rest of
the world with an eye to smallpox eradication. We were very
concerned about India. India turned out to have more intense
smallpox than what we encountered in Africa, although we didn't
realize it at the time. India had had smallpox eradication
efforts for decades, going back to the early 1800s. But
somehow, they never quite worked in India. After discussing
this with Dave Sencer, we made a decision that I would go to
India for reconnaissance, to see whether it was possible to do a
smallpox eradication project there. In August and September of
1973, I went to India and spent time with their Ministry of
Health people and with people in the regional office for WHO
[World Health Organization]. The result was that India turned
out to be the site of our next smallpox eradication venture.
India was, in many ways, so much more difficult than
anything we had faced in Africa. The peak of smallpox in India
was in May of 1974, when we had the highest rates that India had
seen for decades. They were much higher than anything we had
suspected we would have. In the fall of 1973, D.A. Henderson
[Donald A. Henderson] asked me, "What's the largest number of
cases that you can expect in any week in any one state next year
in India?" We did some calculations and decided it would be
about 300 to 400. He said, "Just to be sure, we're going to
program our computers with four digits, and not with three. I
recall in May of 1974, having to call him and say that in Bihar,
India, in one week, we had over 11,000 new cases of smallpox. I
mean, it was just overwhelming. But we went from that high in
May of 1974, to zero for the entire country of India in twelve
months.
Harden: Using the same surveillance/containment method?
Foege: Using the same surveillance/containment, which many people
did not think would work in India, because of the population
density, and the high incidence of smallpox. And yet, smallpox
was eradicated in twelve months' time, once we got geared up to
have really good surveillance. I'm talking about surveillance
that was so good that every three months, we would visit every
house in India, looking for smallpox in a six-day period of
time. In six days, 100 million homes would be visited to see if
there was anyone with smallpox. And this was before computers.
The logistics of trying to get people to 100 million homes in
six days, and then finding, on evaluation, that over ninety
percent of those homes had actually been visited, demonstrated
the effectiveness of the Indian bureaucracy once they commit to
something.
Harden: That's very interesting. So you were working with the Indians,
then, and they were going into the homes. That requires huge
manpower and management resources.
Foege: It required, in those six days' time, to mobilize lots and
lots of the health workers, to take them off of other things for
six days. It also meant hiring a lot of day laborers in order
to get the work force to do this. For me, the interesting thing
was that we did not have the government of India and WHO and
other groups officially involved. We worked so closely
together, and I think part of the reason we were able to do that
is, that we started traveling by train together. This meant
being together overnight in a compartment, which gave us the
opportunity to talk in a way that we never would have by going
into someone's office for an hour's meeting. I mean, we were
really in this together.
Harden: What impact did your years in Africa and India, and the
smallpox program in general, have on your family?
Foege: I think the family saw our time in Africa and India as
interesting times. I mean, our children often look back on
India as something they really enjoyed doing. For birthdays,
the person with the birthday gets to choose where we go for
dinner, and inevitably, they want to go to an Indian restaurant.
That's the way they feel about India. I took one of my sons
back to India when he was 18, when I attended a professional
meeting there. It was in Udhampur, and we decided, rather than
fly down from New Delhi, that we would "experience" India again.
We hired a car and a driver and began the thirteen-hour trip.
This was in July, when it is very hot in India. I recall, two
hours into the trip, saying to myself, "This was a mistake." It
was so hot. And of course the windows had to be open, because
we didn't have air conditioning. Diesel fumes from the exhaust
and dust came in, and I looked over at my son, who had sweat
rolling off his face, and I asked, "Michael, how are you doing?"
He looked at me, and he said, "You'll crack before I do." I
mean, they just enjoyed India. And it's given every one of them
a feeling about the world that I like to see. They are
concerned about the developing world, they're concerned about
the inequities that one sees in this country, and between this
country and other countries. It's something that I attribute to
their having lived in other areas.
Harden: Did any of them follow you into a medical career, or public
service, or public health?
Foege: Two of them are teachers, and I consider this to be even
more difficult than doing public health work, because you don't
get compensated well for your work as a teacher. What we pay
teachers is a crime. The third one went into anthropology. All
of them have this feeling of concern about needing to help and
understand other people.
Harden: Before we stop, is there anything else that you would like to
add?
Foege: I see war around the world. We have over a hundred
conflicts going on at any one time. But if you're not actually
in the area, it's just a news story. I think of what it was
like during the Nigerian Civil War, the kind of devastation, and
people starving. People actually starved during that war. I
went back to work in the relief action. I went into one town
where you actually had to step over dead children as you walked
down the street. This is not the way the world should be, and
yet we don't seem to learn. How do you actually get people to
make eye contact, to engage with this sort of thing? For
example, what's happening in Iraq right now shouldn't be
happening at all. How do you get people to understand that this
is absolutely the wrong way for us to be living?
Harden: Thank you for a very fine interview.
Bill Foege Oral History
Bill Foege interviewed by
Victoria Harden
July 13, 2006
Dr. Wlliiam Foege served in the smallpox program in Nigeria, first as a missionary and then a staff member. The highlight of his oral history is the description of the origin and utilization of the surveillance/containment management of outbreaks. He also discusses experiences during the Biafran conflict and other anecdotes. Bill subsequently was assigned by CDC to assist the WHO in its work with the Government of India reorienting the approach to eradication in that country. He was Director of CDC from 1977-83 and is currently a Senior Fellow at the Bill and Melinda Gates Foundation.
The Centers for Disease Control and Prevention produced this government publication. Use of this public domain resource is unrestricted.
