AN UNEXPECTED RETURN TO THE CDC
I flash back to 1966. As Paula and I became more comfortable in our new culture as medical missionaries in Nigeria, opportunities for health improvements began to appear. Living in a village allowed us to understand the rhythm of daily life, to understand the risks that villagers confronted daily, and to think about solutions that might be reasonable for that context.
We were, in a sense, living within a bubble, observing the village. Although we did not have electricity, running water, or an indoor bathroom, we coped. During the rainy season, the water supply was adequate. Roof water was caught in a gutter to fill a fifty-five-gallon drum. We dipped water from the drum for baths into a metal tub in the bedroom. We boiled water for drinking. Without electricity, we used a kerosene stove and a kerosene refrigerator to preserve food and to cool boiled water used for drinking and cooking.
During the dry season, we hired a young man to carry water in two five-gallon tins (about eighty pounds) on the back of his bicycle. These he would empty into the fifty-five-gallon drum. As the dry season progressed, the distance traveled to find water increased. By the end of the dry season, two trips a day would be the norm, and water conservation became important.
Screened windows, bed nets, and chloroquine as a malaria prophylactic protected us from the disease that plagued the rest of the village. Bouts of fever were common for both children and adults. A certain degree of immunity to malaria developed in villagers. But this immunity was not absolute. And while it modified the intensity of each bout with malaria, the illness was still debilitating, at best, with deaths common in children and in pregnant women. Malaria prophylaxis for those two groups became very important. Immunizations provided protection against other diseases, and wearing shoes or sandals protected against hookworm.
It became clear to Paula and me that two factors, not shared by villagers, provided us protection for our own child. The first was knowledge that we had acquired. This was potentially transferable to all persons in the village. The other factor was money. If we had been limited to a dollar a day per person, as they were, it would have been enough for food and shelter, but it would have left nothing for vaccines, screens, or the wood required to boil water. Vaccinating the village children, treating malaria, and providing safe water, sanitation, and dietary improvements were all basic needs. But providing them would require ingenuity plus outside resources to launch such projects.
Serendipity once again intervened. The CDC asked me to be a short-term consultant as it initiated the Smallpox Eradication Program in West and Central Africa, part of a global effort to eradicate the disease. Henry Gelfand, an epidemiologist with the smallpox program, was sent to Enugu to talk to me about the possibility. He made it clear that he did not think this was a good idea, but he was carrying out orders. He did not think the CDC needed part-time consultants. I, however, saw this as a great opportunity to become acquainted with the Nigerian public health system, which held promise for our future work. Accepting the request led to a visit back to the CDC in the summer of 1966 to participate in the training program for forty-three CDC personnel about to be assigned to twenty countries in West and Central Africa.
Smallpox in Eastern Nigeria
While we were back in the United States, our second son, Michael, was born in Walla Walla, Washington, the home of my parents. Paula and I and our two boys then prepared for our return to Nigeria. I went ahead to set up a flat for the next year in Enugu. Suddenly, we had running water and electricity. Lawrence Atutu Ochelebe, who had worked with us in the village and then at the medical compound, now joined me in Enugu to establish the flat. (Lawrence was perceptive and loyal. Some months later, he told me that he could not be sure but he thought that a neighbor had managed to tie into our electric line, and we were therefore paying their electricity bill. That night he turned off our main electrical circuit while I watched to see what would happen at the neighbor’s flat. Indeed, the neighbor’s flat went black—as did half a city block!)
Soon Paula arrived with David and Michael, and we settled in. Next, the Thompsons arrived. David Thompson was a physician, trained in pediatrics, and Joan Thompson was a nurse. A second CDC assignee, public health advisor Paul Lichfield, arrived with his wife, Mary.
We entered into six months of hard work. It started with an outbreak investigated on December 4, 1966, the month before the program was to officially start. We had not yet received our major supplies and therefore could not do mass vaccinating in the area as we would ordinarily have done. We were reduced to vaccinating only those people we felt were at immediate risk of exposure—family members, village neighbors, and those who had contacted the persons with smallpox.
The missionaries had nightly radio contact, and we were able to use that means of communication to provide geographic assignments; the next day, the missionaries could send people to every village in their assigned area to find smallpox cases. Within twenty-four hours, we knew which villages already had smallpox, which enabled us to be precise in our vaccination efforts. The outbreak stopped quickly, and we received permission from the medical authorities in Eastern Nigeria to expand the idea of precision vaccination (later called surveillance/containment), rather than mass vaccination, to stop smallpox. But we also needed to institute a program to immunize children from 6 months to 6 years of age for measles. That required a mass approach. We were able to combine the two needs by identifying smallpox outbreaks and, in those areas, attacking smallpox quickly through selective vaccinations, and at the same time, we launched the mass vaccination program for both measles and smallpox in the geographic areas involved. The abrupt movement of teams to Enugu, cited later in the chapter, provides an example of rapid changes in plans to protect against smallpox while still protecting children from measles.
With experience, surveillance improved. To the best of our knowledge, we detected every smallpox outbreak in Eastern Nigeria within the first six months of the campaign. Some were small, a handful of cases, but some were large. One outbreak, in Abakaliki Province, some forty miles from Enugu, included more than 1,000 cases. Temporary shelters were constructed outside of towns and villages, and persons who had previously had smallpox delivered food and provided the interface with those so quarantined.
As recounted in House on Fire (1), we were successful in getting supplies even when the federal government of Nigeria halted shipments to the region. We were working on the last known outbreak in the Eastern Region when we were asked to attend a meeting, in Accra, Ghana, of people assigned from the CDC throughout the twenty-country area. What would later be known as the Nigerian Civil War was building to a flash point, but a check with the American Consulate in Enugu was reassuring: they expected fighting would be delayed for some months as both the federal government and the Biafra military had to recruit and train soldiers as well as purchase supplies. It seemed reasonable to leave for a few days for the meeting in Ghana and then return to continue the program.
Our wives and children had been evacuated two months earlier in anticipation of fighting, but those of us remaining were not overly concerned about leaving, as the consulate thought there would be sufficient warnings that would allow us time to leave before the fighting broke out. However, the large number of roadblocks constituted a barrier to efficient travel, and at times, the stops could be unnerving. Often the people checking vehicles would be teenagers, fueled by beer and wielding AK-47s. The combination was potentially explosive and required a cool, respectful approach on our part.
For the Accra meeting, we prepared materials on our experiences to demonstrate how we had implemented surveillance and containment activities throughout the region. Maps highlighting the locations of outbreaks and vaccination efforts were copied for distribution. The mixture of mass vaccination and surveillance/containment we were practicing was a departure from the instructions given in the training program at the CDC. Indeed, the field manual was clear in warning against being distracted by smallpox outbreaks lest those diversions detract from the orderly plan of mass vaccinations. Jumping from outbreak to outbreak did not appear orderly. Therefore, we attempted to document everything to explain the deviation from the plan.
For example, a Saturday morning meeting in our smallpox headquarters in Enugu had been interrupted by the news that smallpox patients had been admitted to the Enugu General Hospital. We immediately verified the diagnosis and then changed our intended activities for the next week. This seemed anything but orderly. We decided to move vaccination teams both to Enugu and to the area where the smallpox patients had been discovered. We used the rest of the weekend to plot sites for vaccination teams on Monday and developed a schedule for when they would move from site to site. As we vaccinated against smallpox, we also protected all children under age 6 from measles, combining mass vaccination with surveillance/containment.
It was while finding vaccination sites and marking them on my enlarged map of Enugu that I was arrested and spent the remainder of Saturday being questioned by the police. Prison in Nigeria is not a sought-after experience. But interestingly, my concern at the moment was for the time being lost for planning Monday’s activities. I assumed I would be released. From their perspective, with the possibility of civil war discussed daily in the newspaper, having an outsider putting marks on maps was threatening. It was late in the afternoon before they were able to locate the medical person in charge of smallpox eradication in Eastern Nigeria. He came to the police station and was able to secure my release.
The outbreak was contained, as were all other known outbreaks, and we left for the Accra meeting with our teams working on the last known outbreak. We expected to return, document the absence of smallpox in all of Eastern Nigeria, and continue with the mass vaccination program that would protect from smallpox importations and would provide measles protection to children.
Getting to the meeting required taking a small boat across the Niger River and having our passports stamped on both the Biafra side and then the Nigerian side. We hired a taxi to take us to Lagos and then on to Accra. We had been there only a few days when we heard that fighting had broken out on the Biafra borders and that we would not be able to reenter Eastern Nigeria.
Civil War
The civil war in Nigeria brought an abrupt change in many plans. Since I could not return to Enugu, I tried working in Northern Nigeria, expecting that it would be a short period of fighting, and one side or the other would quickly back down. I was totally mistaken about the length of the fighting, which went on until early 1970, over two and a half years of agonizing fighting and civilian starvation.
I was asked by the Nigerian national smallpox program to evaluate what was happening in Sokoto Province. I soon departed in one of the program’s Dodge trucks with camping equipment and information on where I would find the teams. On the first night in the field, I had just completed erecting a tent and was cooking dinner when a police vehicle appeared. The policeman came up to me and handed me a piece of paper with my name on it. “Is this you?” he asked. I said it was, and he said, “You are under arrest.” He would give me no information regarding the charges or what was wrong. I was put in the back of the police vehicle with armed guards on each side. We headed back for Kaduna.
On the way, the group decided to stop at a rest house for beer. They left me sitting alone in the back of the vehicle. That is when I noticed there was a pistol on the front seat. Was this a trap? I decided not to move, and on their return, they showed no surprise at finding me still sitting there. This was much more nerve-racking than the arrest in Enugu. The reason for the arrest was not clear, and I was sitting between beer-drinking armed guards, barreling down an African highway … a perfect storm of risk factors.
In Kaduna, I was questioned about the purpose of my trip and put under house arrest. It soon became clear that the real problem was that I had been working in the Eastern Region, now fighting Nigeria as Biafra. What information was I trying to get, and did I still have contacts in Biafra? The rest of Nigeria was now at war with the Eastern Region and therefore anyone who had worked in the Eastern Region was regarded with suspicion. Questioning continued the next day and to my surprise included questions on the names of family members and their locations. The decision was made that I could be released, but only if I left Nigeria. This I did, but I was able to travel back to Nigeria many times over the next few years without this arrest coming to light.
When I returned to Atlanta in the fall of 1967, the CDC offered to put me on contract until I could return to the medical center in Yahe, Nigeria, to continue my work with the church health program. I accepted and worked for Dr. Don Millar on smallpox eradication. Under Don’s direction, physician Mike Lane, public health advisor Jim Hicks, and I divided responsibilities for overseeing the CDC program; my area included Nigeria, Ghana, Liberia, and The Gambia.
One of my obsessions was to expand the idea of surveillance/containment to other areas of West Africa and to figure out how best to implement that approach. Program agreements had been signed with each country. A basic tenet of these agreements was that there would be an attack phase of mass vaccination to be completed in three years. All ages would be vaccinated against smallpox and children under 6 against measles. A paper by Henry Gelfand and D. A. Henderson, who had been assigned from the CDC to head up the WHO program in Geneva, had indicated that the mass vaccination cycle might be followed by a second mass vaccination campaign, if indicated. In each country, an attempt would be made to improve the reporting system—to understand the size of the smallpox problem and its distribution but also to serve as the basis for concentrating resources to implement containment of outbreaks as the mass campaign brought down the incidence of smallpox.
Complicating the development of a new smallpox strategy was, of course, the second component of the program, measles control. Measles was a horrendous disease in West and Central Africa, feared by parents and health officers. At the time the smallpox/measles program started, the measles virus was the single most lethal agent in the world. It accounted for at least 3 million deaths a year; some thought the numbers were even higher. It killed more people than tuberculosis. Any change in the smallpox approach had to do justice to measles control. Africa was correct in wanting a program for measles. The United States Agency for International Development (USAID) also was interested and valued this part of the program above smallpox. Indeed, for the entire length of the program, the CDC called the program the Smallpox Eradication / Measles Control Program; USAID called it the Measles Control / Smallpox Eradication Program.
The name was not the important thing. The important thing was that the two agencies had so much trouble working together on common objectives. The lack of trust seemed unbridgeable. The CDC was concerned that USAID was trying to use the program for political purposes, while USAID thought the CDC was diverting resources from the program to other CDC activities.
On one occasion, a USAID employee spent a week at the CDC to understand the program and to improve coordination between the two agencies. When I invited him home for dinner on Monday night of that week, it became apparent that he had a drinking problem. He became convinced of my sincerity over dinner and that, combined with the loss of his inhibitions, led him to ask, “Do you have any idea why I am really here?” I did not.
“I have been asked to find if you are diverting USAID funds to other areas of CDC,” he said. He then described himself as the right person to do this since as USAID country director in a South American country, he had kept two sets of books in order to divert funds. This incident was symptomatic of the problems we encountered to the very end of the program.
But the immediate difficulty was how to combine the needs of the measles program, which required a mass vaccination program in every geographic area, with the flexibility required for smallpox surveillance/containment, which required the ability to concentrate on the areas with smallpox outbreaks. The solutions were found in various ways. In some countries, such as Dahomey (now Benin), a separate group of twelve health workers on motorcycles concentrated on smallpox outbreaks, while the rest of the staff worked on a smallpox/measles mass vaccination program. In other countries, smallpox workers were diverted as needed for outbreak control but worked also on mass programs. In all countries, the areas of smallpox were circumscribed; therefore, they were not spread evenly throughout the country. This meant that smallpox vaccination numbers continued to climb because of mass vaccination, even if most of the vaccinations were conducted in areas where there was no smallpox. Those vaccinations had no impact on the disease. This was confusing to those not familiar with the program, and at least one statistician at Yale, looking at total numbers of vaccinations, rather than the geographic distribution of those vaccinations, later interpreted the reduction of smallpox to mass vaccination rather than to targeted activities.
In most areas, the experiences of early adopters, that is, those who focused on containment of all smallpox outbreaks, helped to improve on smallpox-eradication activities. For example, it became clear that the smallpox virus had adapted to thousands of years of evolution. It did the virus little good to spread rapidly, exhausting susceptible people in a single generation. Rather, it spread in a slow and deliberate fashion through a household and through a village. This allowed the virus to linger for an extended period, increasing the chance of exposing a visitor, who could take the virus elsewhere. This unique pattern of smallpox provided the opportunity to identify an outbreak and break chains of transmission.
Strike at the Right Moment
It was also clear that smallpox was a seasonal disease and would decrease during the rainy season when human contact and activities decreased because of the difficulty of transportation. (There was also perhaps an inhibiting effect of high humidity on the transmissibility of the virus during the rainy season.) These were the times when mass vaccination was most difficult. However, it was possible to increase the efficiency of the program by increasing the smallpox efforts at that time. Small teams on bicycles or walking could still access remote areas. We emphasized that a chain of transmission broken during this low period of transmission would prevent hundreds of cases over the next year, while a chain of transmission broken during high transmission, while useful, would prevent far fewer new cases over the next year. Approached in this manner, it becomes clear that as difficult as it was to work in the rainy season, a small number of workers could be far more efficient than the usual approach. It is a lesson for all of public health. While the best decisions are based on the best science, the best results are based on the best management, and this was a good management practice. In various ways, it was possible to combine surveillance/containment directed at smallpox while also doing mass vaccination for both diseases.
With EIS officers taking the lead, we studied every country in the African program. Some countries’ programs, such as Sierra Leone’s, under the leadership of Don Hopkins, emphasized surveillance/containment from the beginning and made dramatic progress.
Smallpox Eliminated from West Africa
The original plan was to eradicate smallpox in the twenty countries in five years. It went even faster than planned. The last case in the twenty-country area was reported from Nigeria in May 1970, three years and five months after the program began. The objective was reached a year and a half early and under budget.
The last sentence hides an incredible amount of work by dozens of CDC people stationed in Africa, dozens remaining in Atlanta, thousands of Africans, and an unseen coalition who produced vaccines and supplies, shipped them, stored them, and got them to the right place at the right time. The complexity of that web and the chain of events that finally gets a vaccine into a person are beyond comprehension. No wonder Harland Cleveland once characterized global health workers as people with unwarranted optimism.
Just as significant for the local population was the rapid reduction in measles. Children went from a 7 percent risk of dying from this disease to an environment that increased their chances of reaching adulthood. It was a great and optimistic time. Unfortunately, USAID changed its priorities when a new person became the administrator for the program, and the measles program was brought to an abrupt end—before ministries of health could institutionalize measles immunization in their budgets and ministry programs. Years later, USAID, to its credit, again funded measles programs in Africa, but continuity was lost, and Africans suffered between the two efforts.
USAID has done such important work over the decades, but the fact that it is embedded in the State Department is a flaw because political concerns will always factor into its selection of priorities. When there is a health problem in the United States, the chain of command is clear, and, ultimately, the secretary of the Department of Health and Human Services (HHS) is held responsible. By contrast, a health problem outside our borders leads to confusion. It takes time to determine whether the problem will be handled by the secretary of HHS, USAID, the secretary of state, the National Security Agency, an ambassador, the Red Cross, or all of them. Having all health problems centralized as the responsibility of one person, the secretary of HHS, would reduce this confusion. This change would also ensure that the health priorities of US citizens would benefit from the perspective of global events and that global decisions would benefit from knowledge of domestic approaches. The Ebola outbreak of 2014 again demonstrates the problems inherent in not having a single person, the secretary of HHS, charged with the responsibility of coordinating the US response.