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House on Fire

House on Fire: The Fight to Eradicate Smallpox

Copyright Date: 2011
Edition: 1
Pages: 240
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  • Book Info
    House on Fire
    Book Description:

    A story of courage and risk-taking,House on Firetells how smallpox, a disease that killed, blinded, and scarred millions over centuries of human history, was completely eradicated in a spectacular triumph of medicine and public health. Part autobiography, part mystery, the story is told by a man who was one of the architects of a radical vaccination scheme that became a key strategy in ending the horrible disease when it was finally contained in India. In House on Fire, William H. Foege describes his own experiences in public health and details the remarkable program that involved people from countries around the world in pursuit of a single objective-eliminating smallpox forever. Rich with the details of everyday life, as well as a few adventures,House on Firegives an intimate sense of what it is like to work on the ground in some of the world's most impoverished countries-and tells what it is like to contribute to programs that really do change the world.

    eISBN: 978-0-520-94889-1
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-viii)
  2. Table of Contents
    (pp. ix-x)
  3. List of Illustrations
    (pp. xi-xii)
  4. Foreword
    (pp. xiii-xiv)

    The Milbank Memorial Fund is an endowed operating foundation that works to improve health by helping decision makers in the public and private sectors acquire and use the best available evidence to inform policy for health care and population health. The Fund has engaged in nonpartisan analysis, study, research, and communication since its inception in 1905.

    House on Fire: The Fight to Eradicate Smallpox, by William H. Foege, is the twenty-first book in the series California/Milbank Books on Health and the Public. The publishing partnership between the Fund and the University of California Press encourages the synthesis and communication of...

  5. Foreword
    (pp. xv-xviii)

    The eradication of smallpox from the entire world has been justly described as one of the most remarkable achievements in the history of medicine and public health. In India—a country one-third the size of the United States but with three times the population, with 638,365 villages and thirty-five cities with a million-plus population—the campaign to eradicate smallpox involved the most acute and challenging difficulties encountered anywhere in the entire smallpox eradication effort. The story of Indiaʹs successful eradication program can be told fully only by those who were on the team that brought about this achievement, and this...

  6. Preface
    (pp. xix-xxii)

    • ONE A Loathsome Disease
      (pp. 3-11)

      You can smell smallpox before you enter the patientʹs room, but itʹs hard to describe. Even medical textbooks fall short when it comes to smells. The odor, probably the result of decaying flesh from pustules, is reminiscent of the smell of a dead animal. On at least two occasions, smell alone alerted me to the presence of smallpox. As I walked down a hospital hallway in India, the dead-animal odor stopped me in my tracks; following the smell, I located a smallpox patient. Another time, as I walked down an alley in an urban slum in Pakistan, the same smell...

    • TWO A Succession of Mentors
      (pp. 12-27)

      My participation in the smallpox eradication program was the result of my engagement with a host of mentors, some of whom I encountered only in books. Family, friends, and teachers also had a tremendous influence on me, the earliest, of course, being family.

      My father was a Lutheran minister who was raised on a farm in Iowa. Growing up with four sisters and a brother in a series of parsonages provided me with an unvarnished, down-to-earth beginning in life. The houses always seemed too small. Each paycheck was cashed, and the money was distributed into Band-Aid cans marked for groceries,...

    • THREE Practicing Public Health in Nigeria
      (pp. 28-42)

      The possibility of eradicating smallpox interested me, but since medical school, I had held a different vision of what my career would be. I wanted to do public health work in medical missions in developing countries.

      It had always disturbed me that church groups did so much medical work in developing countries yet took so little responsibility for disease prevention. Mission boards rarely encouraged it, even though prevention is the most efficient use of limited resources. This of course made them little different from health care delivery systems in the United States. A June 1965 response I received from the...

    • FOUR Fire Line around a Virus
      (pp. 43-59)

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

      The shift from village to town offered a...

    • FIVE Extinguishing Smallpox in a Time of War
      (pp. 60-80)

      In the first weeks of 1967, Dave Thompson, Paul Lichfield, and I made a choice we could not have predicted. As we designed the eradication project for Nigeriaʹs Eastern Region, we also researched smallpox reports from past years. We recorded the previous outbreaks by date and place on maps of the region, and as we did, a macro pattern appeared. At the beginning of most high-transmission seasons, smallpox outbreaks were generally more prevalent in the northern part of Eastern Nigeria, suggesting that they migrated in from the Northern Region and gradually moved southward. We wondered initially if we could impede...


    • SIX Under the Rule of Variola
      (pp. 83-104)

      As the new decade began, the win column in the global effort to eradicate smallpox started to lengthen. In January 1971, nine months after the last smallpox case in West and Central Africa, Brazil reported its final case. Three months later, Indonesia became free of smallpox. By the end of the year, only nine countries still had continuous smallpox transmission. In July 1972, Afghanistan became smallpox free.

      Yet even as the number of countries with smallpox was declining, progress was disappointing in the four smallpox-endemic countries of South Asia: Bangladesh, India, Nepal, and Pakistan. In India, a new mass vaccination...

    • SEVEN Unwarranted Optimism
      (pp. 105-122)

      By the end of the summer of 1973, my family and I had settled into a new life in New Delhi. Everything was an adventure at first—money, school, shopping, the making of friends, and we adjusted once more to the heat and humidity of the tropics. I began work with the WHO smallpox team headed by Dr. Nicole Grasset at the SEARO office, which was in charge of the smallpox program for all of South and Southeast Asia. There was never any question, however, that our main focus was on India. We worked closely with health officials in the...

    • EIGHT A Gorgeous Coalition
      (pp. 123-144)

      Mahatma Gandhi once said: ʺInterdependence is and ought to be as much the ideal of man as self-sufficiency. Man is a social being.ʺ Whatever people set out to accomplish requires teamwork. Every team does not work together efficiently or effectively. The vast team that came together to eradicate smallpox in India achieved both.

      By 1973, smallpox eradication had become such a priority in India that the best possible people in Indiaʹs Ministry of Health were assigned to it. Such a statement may be fashionable, even diplomatic; in this case, it was also true. In addition, over six hundred high-level supervisory...

    • NINE Rising Numbers, Refining Strategy
      (pp. 145-162)

      The first four months of 1974 were whipsaw months. The seasonal low point for smallpox transmission had passed, and transmission was now naturally increasing. At the same time, the searches were becoming more efficient. While this efficiency was a source of great pride for the smallpox workers, especially the search teams, it also meant that the reported smallpox numbers rose dramatically.

      Boring to some, the numbers were fascinating to the smallpox leadership team. Many evenings after dinner I would say good-bye to my family and head to the New Delhi station to catch the overnight train to Lucknow or Patna....

    • TEN Water on a Burning House
      (pp. 163-172)

      As the month of May began, a hot month in Bihar even by Indian standards, the number of smallpox outbreaks skyrocketed along with the temperature. The sixth search (April 29–May 4) had revealed 2,622 new outbreaks, the highest one-week total we would see. This brought the pending outbreak total to 4,921. The pending figure would have been even higher except that containment teams were by now so efficient that they were removing over 800 outbreaks per week from the pending list. More important, the number of new outbreaks was only slightly greater than the findings one search earlier, while...

    • ELEVEN Smallpox Zero
      (pp. 173-187)

      The arrival of a new vision just when people think they have worked to the maximum gives them new energy, allowing them to push beyond their previous limit. In early August 1974, the smallpox leadership team sent out to the field-workers in Bihar a graph showing the decrease in outbreaks reported in June. The same graph was distributed to all smallpox workers in India on August 26 as part of the seventh SEARO surveillance report. The whole team could see that their work had now paid off: we were on the downhill slope.

      The turnaround in Uttar Pradesh happened at...

  9. Conclusion
    (pp. 188-192)

    The smallpox program justified its own existence by the results it produced: lives set free, misery prevented, and resources made available for other activities. The program also offers lessons that are applicable to similar public health projects.¹

    Smallpox eradication did not happen by accident. Stephen Hawking, in his bookA Brief History of Time, says the history of science is the gradual realization that things do not happen in an arbitrary fashion. This is a cause-and-effect world, and smallpox disappeared because of a plan, conceived and implemented on purpose, by people. Humanity does not have to live in a world...

  10. Postscript
    (pp. 193-194)

    Over the years, on every return to India, I have searched the faces of people on the street, looking for pockmarks. Soon I could find no pockmarked face under the age of ten, then twenty, and now, no pockmarks are to be found on people under the age of thirty-five....

  11. APPENDIX: A Plan in the Event of Smallpox Bioterrorism
    (pp. 195-198)
  12. Notes
    (pp. 199-208)
  13. Glossary
    (pp. 209-212)
  14. Index
    (pp. 213-218)