Interview Transcript
A Miracle Happened There: The West and Central African Smallpox
Eradication Program and Its Impact
Joel G. Breman, MD, DTPH
Fogarty International Center
National Institutes of Health
Histories of the Global Eradication of Smallpox
Wellcome Trust Centre for the History of Medicine
University of London, London
April 25, 2007
A Miracle Happened There: The West and Central African Smallpox
Eradication Program and its Impact
Joel G. Breman, M.D., D.T.P.H.
London, April 25, 2007
Introduction
Thank you Dr. Bhattacharya for inviting me to share my personal
perspectives of the 1966 to 1971 20-country West and Central African
Smallpox Eradication Program. In fact, it was a Smallpox Eradication-
Measles Control Program. The Africans were really more interested in
measles control than in smallpox eradication, but that's another story.
I worked almost 13 years on smallpox. I lived in Guinea from 1967 to
1969 as a medical epidemiologist, also covering Senegal. From 1972 to
1976, I was responsible for smallpox and other disease surveillance in
eight West African francophone countries belonging to the Organisation de
Coordination et de Coopération pour la lutte contre les Grandes Endémies,
the OCCGE, a regional public health and research organization, based in
Burkina Faso. From 1977 to 1980, I was at the Smallpox Eradication Unit,
WHO, Geneva, completing and confirming eradication. In the years at the
end of the global program, I was responsible for poxvirus research,
focusing mainly on human monkeypox, and certification of global
eradication. During all these postings overseas, I was a United States
Centers for Disease Control and Prevention, then the National Communicable
Disease Center or CDC, staff member.
I will focus on my experiences in Guinea to reflect what happened
elsewhere in the program, while granting the great diversity of history,
cultures, politics, and disease ecology in the areas where we worked. I
know I am representing over 50 CDC West and Central African pox-fighters
and more than a thousand African and expatriate health workers, and all
their families - to whom I dedicate this talk and exempt from any errors.
What is a miracle? One definition is "an event in the natural world,
but out of its established order, possible only by the intervention of a
divine power". Certainly, eliminating a disease in less than 5 years that
had been firmly established in West Africa for over a millennium was
miraculous. The "divine power" was the fortuitous convergence of modern
science and technology; the political will of newly emancipated African
countries committed to a better life for their people, including smallpox
eradication; devoted African health workers; a United States Presidential
decision to support WHO and the African program through the U.S. Agency for
International Development; and a group of young, naive, brash, irreverent,
idealistic, and adventurous medical and operational staff from the CDC.
The Background
The history of smallpox shows how long and deeply imbedded this
disease had been in Africa. Smallpox in West and Central sub-Saharan
Africa is a story of at least 1,300 years of continuous disease with 34,000
unbroken chains of human-to-human spread. The disease probably came to
western Africa by camel from Egypt in the 7th century A.D. with the
penetration of Islam west and south. Over the next several hundred years
there were periodic internal wars within and between the great and small
African empires and then exploration and colonization, starting with the
Portuguese in the 16th century followed over the next three centuries by
the Belgians, British, French, Spanish, and Germans. In addition, slave
trading carried smallpox along its routes within Africa, to Europe and the
Americas. Disease flourishes when communities are disrupted by war and
oppression and don't have responsibility for their own well-being. The
miracle of vaccination began late in the 18th century with Jenner's
discovery, but it was only in the early 20th century that a form of dried
vaccine developed by Lucien Camus in France was sent to Guinea and the
Ivory Coast.
During the early-to mid-20th century the great mobile health teams of
the French military, initiated first by Eugene Jamot in the Cameroon to
combat sleeping sickness, showed that diseases could be confronted in a
rural environment, if not defeated. Smallpox vaccinations, using liquid
vaccine prepared on the flanks of cows, became a mainstay of some of these
mobile health team activities. These early vaccines were heat labile and
had miserable potency. While many persons were vaccinated, relatively few
were ever immunized, mainly in the capitals, and with minimal impact on the
disease. Vaccine take rates reported from the Belgian Congo ranged from 9
to 64%, averaging 38% in the 1930s and 1940s. From 1935 to 1944, 26
million vaccinations were given in French West Africa to a population that
was 16 million in 1944. Yet smallpox raged. Epidemiological approaches to
smallpox control were not generally used. Fearing the visible wrath of
smallpox, and having a notion that the disease could be passed between
humans, villagers often constructed "isolation" huts for patients.
Traditional healers were consulted and thrived because little else could be
done.
Between 1957 and 1965 all of the West and Central African countries
in the program had gained independence, with Liberia having become
independent in 1847 as a refuge for slaves from the U.S. Freedom gives a
young country the ability to be audacious, to build on others' experience,
to try new things, to make mistakes. It brings idealism and shared passion
to a mission; focused passion gets things done. African communal reliance
expressed as "pan-African nationalism"-practiced for a while in Guinea and
a few like-minded countries--created the milieu to make the eradication
miracle come true more easily. Regrettably, independence and nationalism
by themselves do not alleviate poverty.
Atlanta
I first arrived in Atlanta and then Guinea 40 years ago with my wife
Vicki from a residency in internal medicine. I had essentially no foreign
experience. My French was fragmentary. Fortunately, my medical training
was at Los Angeles County General Hospital, the largest hospital in the
U.S. where we saw mainly indigent patients, many with complex pathology.
The outstanding pediatrics and communicable diseases departments were
headed by Paul Wehrle of the University of Southern California, an alumnus
of the CDC, who recruited me. We were trained in Atlanta in epidemiology
and biostatistics in the Epidemic Intelligence Service course; the
virologic, clinical, epidemiological and control features of smallpox and
measles; and in vaccinology and vaccines. We learned about tropical
diseases, African history, culture, anthropology, geography, and weather
patterns. In 1967, B.B. Waddy from the London School of Hygiene and
Tropical Medicine came and spoke on the British experiences dealing with
the great scourges. One pearl from Waddy that I never forgot was that the
entire economic system of West Africa depends upon people getting paid
promptly at the end of the month. Those going to Francophone countries
studied French for a couple of hours at night after the other courses.
The two month training covered basic repair and maintenance of
vehicles, refrigerators, and vaccination equipment. We learned all about
the Ped-O-Jet vaccine injector, a pneumatic, foot-pedal armed, portable
inoculation gun. CDC teams were trained in the summers of 1966 and 1967
and left in fits and starts depending on how successfully negotiations were
concluded with countries, USAID missions, Embassies, in some instances WHO,
the OCCGE in Bobo-Dioulasso, Burkina Faso (ex-Upper Volta), and the
Organisation de Coordination pour la lutte contre les Endémies en Afrique
Centrale (OCEAC), another francophone health organization based in Yaoundé,
Cameroon. The lightning-illuminated nights in Atlanta in the summer of
1967 were exceedingly hot and humid, a good preparation for life in Africa.
I was amazed at how young and bright the Smallpox Eradication
Program's leaders were in Atlanta. Don Millar, age 33, was the Director.
He was a jovial, brilliant epidemiologist with a syrupy Virginian accent,
wry humor, and skilled in playing guitar and singing folk and bluegrass
anthems. Millar had just returned from training at the London School of
Hygiene and Tropical Medicine. Young Bill Foege, also a CDC alum and
guitarist, was a medical missionary working in eastern Nigeria when the
civil (Biafran) war erupted in mid-1967. Foege returned to the CDC as a
regional smallpox program supervisor and became an important strategist,
rising in later years to become Director.
D.A. Henderson had worked on organizing the West and Central African
program in the mid-1960s and getting President Lyndon Johnson's office to
support the endeavor fully. His epidemiological skills, including doing
landmark studies on influenza, polio, and other diseases, led to his
becoming a protegé of Alexander Langmuir, the famed founder of the CDC
Epidemic Intelligence Service. Henderson was also in his 30s when he went
to Geneva in 1966 to head up the global smallpox eradication program.
Indeed, most of us who worked in the CDC SEP program were in our 20s and
30s. A special comment is needed about the public health advisors, called
operations officers or OOs. One of CDC's main innovations was developing
and assigning talented administrators and managers to health programs.
They managed the crucial organizational, logistics, transport, equipment,
and budgetary domains. Having OOs in Africa was the brainchild of Billy
Griggs and Bill Watson, top CDC managers. All operations officers were
trained in epidemiology and many used these skills well. Several OOs rose
to important positions at the CDC, WHO, Red Cross, The Carter Center, and
elsewhere. Among the many greats, Bob Helmholz in Senegal went on to
become Chief Administrative Officer of the Onchoceriasis Control Programme
in West Africa and the Chief Administrator of the South East Asian Regional
Office of WHO. Jean Roy, former Peace Corps volunteer, directed smallpox
eradication in Benin (ex-Dahomey), child survival programs in the
Democratic Republic of Congo (ex-Zaire), and initiated an innovative
combined malaria and measles control program at the International
Federation of Red Cross and Red Crescent Societies in Geneva.
Guinea Reflections
My time in Guinea could be divided into three overlapping emotional
periods - frustration, isolation, and jubilation. Guinea is slightly
larger than the United Kingdom. In 1969, the country had about 3.75
million people speaking three major local languages, representing the Susu,
Peuhl, and Malinké populations, with French the national language. The
life expectancy of a Guinean newborn in the 1960's was 29 years. The mid-
century birth rate of 62 per 1000 and infant mortality of 216 per 1000 live
births were the highest in the world. The economy was in shambles, the
French having left abruptly when the Sekou Touré-led nation voted not to
remain with the French commonwealth after independence in 1960.
Infrastructure was fragmentary-the only major paved road went out to
Kindia, about 150 km east from the capital, Conakry, and there were few
road-worthy vehicles. There was one doctor per 160,000 persons in rural
areas, where over 90% of the people lived. Most Guinean doctors were
called "médecins Africans", a pejorative term used by many expatriates for
a high level physician's assistant who received special training, usually
in Dakar. Very little medical equipment was present and drugs were always
in short supply. Who else was in Guinea when I arrived? - the communists
and socialists. Few western countries wanted to offend the French so the
Soviets, Czechs, Yugoslavs, North Koreans, mainland Chinese and Cubans
came. The Chinese and Cubans were in several regions throughout the
country and, while the iron curtain was still down, we often met and
occasionally dined together at a regional governor's house. I took special
satisfaction when the foreigners were ordered to be vaccinated by regional
authorities. After one long trip, I found the infectious diseases and
smallpox isolation ward at the main hospital in Conakry had been turned
into an acupuncture unit run by the "red" Chinese. Fortunately, by then
smallpox was in full retreat.
Early, my bureaucratic masters at the CDC were aggravating -
insensitive, and unresponsive. They immediately began demanding reports on
accomplishments, projected program activities and budgets even though we
had barely arrived. Shipments of vaccines, refrigerators, and other
materials did not arrive when scheduled or arrived without prior
notification. The worst, by far, was not receiving the vehicles, the legs
of the program, until the second year of field activities. On top of this,
the Guineans initially appeared indifferent and suspicious of us
neocolonialists from the west.
The reason the Guinea program began in 1967, rather than 1966, was the
absolute need to get a written agreement for me, Don Malberg, and later
Russ Charter, the operations officers, to travel anywhere in the country
unimpeded. No other foreigners had this special laissez-passer. Henry
Gelfand of the CDC gets the credit for this negotiating coup. Henry and
George Lythcott, who headed the program's regional office in Lagos, pounded
out these crucial agreements country-by-country and with other partners,
including those at U.S.A.I.D. in Washington, D.C. Henry and George and
others involved deserve special battle ribbons for this unheralded task.
While we used the U.S. Embassy telecommunication system,
communications were miserable. I received one telephone call from Atlanta
in almost two years and I had to go to the main post office to get it. The
few phones in the country were unreliable and I never had one. Mail often
took months, particularly for my medical journals which came by ship every
3 months - if the ships were allowed to dock in the Conakry harbor.
Transport in the field was by foot, vehicle, boat and the Russian Antonov
or Ilyushin airplanes. These planes were used by Air Guinée and noted for
their abrupt take offs and descents and thick fog and ice producing air
conditioning systems. Messengers were the usual mode of contact.
Throughout the entire time I was in Guinea, I was anxious - worried if the
equipment and vehicles would arrive in time, if the team members would be
vaccinating according to schedule, if the roads would be open and passable,
and--most concerning--if smallpox was becoming uprooted. I was also
anxious about the well-being of Vicki, who was not yet used to my long
periods away without communication. In time, she accommodated, worked at
the U.S. Embassy as a nurse, and traveled some with me. And, she too fell
in love with the kind and welcoming Guineans and with Africa.
Guinea had the second highest rate of smallpox in the world in 1967,
after Sierra Leone directly to the south. Most of our smallpox was along
this border, and Sierra Leone had widespread disease. We tried to
coordinate our vaccination efforts with Don Hopkins and Jim Thornton of the
CDC and E.C. Cummings, the national Sierra Leonean program Director, based
in Freetown. After a two week training period, starting in late 1967
during Ramadan, we began moving east along the Guinean southern endemic
border. Our goal was 80% coverage, based on the dictum, incorrect in my
experience, that this level of "herd immunity" would stifle epidemics and
eliminate disease. Indeed, reliance on mass vaccination, forwarded
initially by WHO and the CDC as the major tactic was discarded within one
year of my arrival. Mass vaccination was replaced by the "escalation
eradication" strategy based on disease epidemiology and containment. This
strategy was presented by Bill Foege at our regional program meeting in
June 1968 in Abidjan. He has credited the idea to a Royal Commission on
Vaccination report of 1896. Using seasonal occurrence of outbreaks to
direct control efforts made immediate sense to me and others. As smallpox
was a dry season disease, the fewest outbreaks and cases occurred during
the heaviest summer rains. Working smart, not only hard was a good mantra
for any task-even though it was clear that we would be slogging through the
mud.
The Guinean health workers were the most dedicated, hard-working,
self-sacrificing, field-wise, and innovative group I have encountered. The
hard-earned agreements with U.S.A.I.D. mandated that African Governments
were responsible for all salaries and lodging of their staff, even in the
field. This was a mistake. Because of the absolute poverty of the
government and the Ministry of Health, there was no field allotment of any
type. The teams slept and ate in the villages where they were working.
Their meager salaries were delivered to them or their families erratically.
Alécaut Bangoura, my counterpart, Chef, Service National des Grandes
Endémies (Chief of the Preventive Medicine Services), made the decision to
have the all-male teams stay in the field virtually without a break the
entire vaccination year, from December 1967 through June 1968, and after
the heavy rains, from September 1968 through June 1969. He said that they
would not come back to work if given time off between regions. He was
right, but several personal problems surfaced: marital separation and
divorce; delinquency among school-age children; and impotence upon
returning home were just a few of the laments. Yet, the team members loved
the adventure. They had the rare opportunity to see their beautiful
country and meet and serve their people. They also understood the
treacherous toll that smallpox and measles had taken on Guineans and were
proud that they were doing something about it. The teams were invariably
welcomed warmly in the villages, often with singing, dancing, and patriotic
manifestations. These benefits muted the hardship.
I'm not sure the Guineans were expecting the organizational surprises
that I urged and that came early. First, despite not having many
roadworthy vehicles nor a large contingent of "volunteer" nurse workers, we
immediately took one vehicle and driver for the independent evaluation
team. One of our best and most respected vaccination team leaders,
Kourouma Famba, an "agent technique de la santé", a highly skilled chief
nurse, was trained in cluster sampling survey methods to determine smallpox
and measles vaccine coverage. Shortly after the vaccination teams passed
through a region and city, Famba's team visited a representative number of
villages and people, asking who had and had not been vaccinated by age and
sex; he looked at arms to read primary and secondary vaccination reactions,
and recorded "take rates" to assure smallpox vaccine potency and good
technique. Concurrent, statistically valid program evaluations and close
supervision were not traditions in African health programs. Second,
because of lack of transport we combined the Field Supervisor's role with
that of an advance information team. Joseph Kourouma, a demanding leader,
was superb at solving field problems; he met regional and local authorities
and publicized when and where the vaccination teams would be arriving in
each village or assembly point with written notice of date, time, place,
and exactly what would be done. He also arranged the teams' regional
reception and lodging. Using the well-organized Guinean political and
administrative machinery assured outstanding cooperation throughout the
country. Third, six months after the program began, we designated another
team with a vehicle for the crucial smallpox detection and containment
activities headed by Sékou Bangoura. When extra transport was available we
could perform mop-up vaccinations in villages and towns with low coverage;
for this we often left vaccine and instructions for regional health
workers.
I mentioned that we didn't have vehicles when we began. The U.S.
Embassy donated a few road unworthy Willy Wagoneers and older trucks from a
previous measles vaccination campaign. The Guineans came up with a Russian
dump truck and a Land Rover. Our car park and maintenance areas were the
UNICEF "garage", a sparsely supplied lot with several auto and truck
carcasses used for spare parts, and the U.S. Embassy motor pool. We were
truly a shaggy-looking army when we started. We didn't have much motor oil
either, and had to go to Sierra Leone to buy it. Gasoline was not easy to
get and we sometimes purchased this on the black market, what Guineans
called "le marché americain". The only blistering argument I had with Dr.
Alécaut was when I saw one of our vehicles rolling down the street in a
parade, filled with young political revolutionaries during one of the
hastily called national holidays. About the same time, another program
vehicle was being used by Alécaut personally. When I insisted on regaining
the needed transport at our private confrontation, Alécaut blasted me very
sternly. "Monsieur le Docteur - personne dans le programme est
indispensable". No one here is indispensable, meaning I could leave if I
didn't like the way things were done. For a while, I thought I might be
kicked out of Guinea as yet another counter-revolutionary. Within two
weeks both vehicles were returned to the program. Bangoura Alécaut became
a lifelong friend.
The wisest comment about transport in Africa came from Pierre Ziegler
- a legendary Frenchman who had spent 16 years as Chef des Grandes Endémies
in Chad. Ziegler was later Chief of the WHO smallpox program in the
Democratic Republic of Congo (ex-Zaire) and first Director of the West
African Onchocerciasis Control Programme. He wrote, for every vehicle in
the field you should have one in reserve along with an ample supply of
spare parts. This could be applied to refrigerators, vaccine cold boxes,
and Ped-O-Jet Injectors. For many years, while based in Burkina Faso, I
carried spare axles and two spare tires in my one weary Land Rover.
"Truth Be Told", Guinean Worries
I never felt confident that smallpox was gone from Guinea until
shortly before I left in June 1969. Outbreaks were reported in multiple
regions before we vaccinated, during vaccination and, most discouragingly,
after we vaccinated and had investigated and contained outbreaks. The
outbreak areas were among the most difficult to reach. Faranah region, the
birthplace of the President, had smallpox in several villages near
international markets along the Sierra Leone border. Local health
authorities there flat-out fabricated mop-up vaccination records after low
coverage during the initial campaign. Another large outbreak surfaced in a
very difficult to reach isolated Atlantic coastal island off the coast of
Kamsar, Boké, where there was a large bauxite deposit. And, in Forécariah,
in southwest Guinea there were multiple importations from Sierra Leone.
Some of these importations started smoldering outbreaks despite vaccination
coverage of close to 90 percent. Over 210,000 vaccinations were given over
14 months in this one region having a censused population of 95,000.
Nevertheless, by late December 1968, one year after we began field work,
the onset of illness in the last smallpox patient began in Forécariah.
Regretably, the investigation was delayed to early January 1969 so the
record shows that Guinea still had smallpox in 1969. Were we smallpox
free?
In April or May of 1969, after 4 or 5 months of no cases, I was given
a telegram late in the afternoon from the Ministry of Health stating that
smallpox was present in Mamou city - 300 km from Conakry. Arriving with a
team that night we went immediately to the house of the director of public
health. I showed him the telegram. He said yes, he had sent the telegram
to Conakry; yes there had been smallpox in the hospital when he sent the
cable; yes, the month and day were the same...but the telegram had been
sent one year earlier! It had remained buried on someone's desk in the
health ministry. I was still unconvinced even though the director verified
the old date on the cable, so we all went to the hospital. By lantern we
saw a patient with severe but typical chickenpox and took specimens. After
viewing every patient in the hospital and reviewing outpatient and
inpatient record books for the past year, I was convinced. There was no
smallpox in Mamou. Two months later I left Guinea as scheduled, in
jubilation.
Program Pearls
What did we learn in Guinea, clinically and epidemiologically?
1. Smallpox was easy to diagnose during an epidemic, often difficult at
other times. I saw the spectrum of disease, from patients with the
fulminant, flat, lethal form to those with a few lesions. Severe
chickenpox and allergic reactions are diagnostic conundrums,
particularly when the patient appears to be the only case.
2. The disease affected smaller communities and was not explosive. While
smallpox was horrific, feared and disfiguring, it affected relatively
few people in rural communities and spread slowly. Close, face-to-
face contact with an infected patient was virtually always needed for
transmission.
3. Surveillance and response were the major keys to eradication. I am
convinced that identifying outbreaks promptly, first during the low
transmission season in 1968 and later at any time, was the reason we
had such rapid success. Smallpox, then suspected smallpox, became a
public health emergency in everyone's eyes. With this attitude and
responsive action, smallpox melted.
4. Once outbreaks were reported or found, we investigated them
compulsively. Our contact tracing covered places and persons that
cases had visited within three weeks before and three weeks after they
became ill. This assured that we knew all possible sources of disease
acquisition and dissemination. These places and persons were
investigated and vaccinated. If they were in neighboring regions or
countries the authorities were notified. Repeat visits to outbreaks
identified more patients and assured complete containment. Sometimes
patients were kept hidden because of severe illness or shame so house-
to-house searches were necessary.
5. We collected specimens. Again, severe chickenpox can resemble
smallpox. Monkeypox, seen in later years in western and central
African countries, looks exactly like smallpox clinically and doesn't
spread avidly between humans. You never know for sure until the
laboratory confirms the diagnosis. A table showing many specimens
collected with negative smallpox virus results and the alternate
diagnoses is the best ending for a report on eradication. Skeptics-
and there are many during eradication programs--will accept laboratory
results more than other explanations.
6. One key to success was using good, freeze-dried, stable vaccine.
"Cold was gold". Creation and maintenance of the cold chain was
especially challenging, particularly in Upper Guinea where the
temperature could go well over 40° C and electricity was absent to
unreliable. The portable kerosene refrigerators were essential as
were ice chests packed with "chiens froids" ("cold dogs"), and
thermoses for field use. Measles vaccine was especially fragile and
teams were urged to open the 10 or 50 dose vials when they had a
suitable number of persons to vaccinate.
7. "Herd immunity" is an oversold concept and not applicable unless you
have a fully isolated herd. This is never the case in Africa.
Susceptible populations are constantly arriving; the birth rate is
high, and five to 10 percent of the resident population is always on
the move - we gave about 5% of all vaccinations at "barrages
sanitaires" or road blocks - and periodic waves of in- and out-
migration are a given.
Here are the operational lessons I took from Guinea.
1. Disease eradication is best approached as a military campaign. This
requires understanding the enemy, bold assaults, micro-planning,
meticulous logistical support, and divining the changing environment.
Above all, clarity of objectives and a feasible, flexible operational
plan need to be shared openly with staff and all partners involved in
the program. Everyone needs to know what is expected of them and how
to do it.
2. Mobile teams and direct village contact are essential for disease
eradication. While village assembly points were sometimes used, these
were never more than 5 km from any village. If we would have used the
sparse health units exclusively the program would have failed.
3. Keep your promises. For this, you will earn respect, devotion from
your co-workers, and a superior performance. Show up when you said
you would. Pay the workers when you said you would. Deliver the
vehicles when you said you would. Underpromising and audacious
actions often lead to overachieving.
4. Train, train, retrain. Workers at every level want to improve their
skills. If you can't do it properly yourself, the field workers won't
do it properly. This applies to giving a vaccination, doing an
investigation, repairing a Ped-O-Jet injector, or maintaining a
vehicle.
5. Sleep in the field with the teams. Nothing raises the morale of your
troops more than sharing the hardships and joys of battle. One's
presence shows the community you are interested in them and their
culture. You will see and learn more about diseases and their
environment from overnight or extended village visits than by
returning home each night or from perfunctory visits to a capital
city. You will also save gasoline.
6. Communicate to those doing the work in the field frequently and
frankly. Field workers are the heroes of eradication. Program
workers at every level are motivated more by professional satisfaction
- seeing how they are doing compared to other teams, other districts,
other regions, other countries - than by anything else. Everyone
wants to be the first to eliminate a disease. No one wants to be
last. A brief, illustrated surveillance bulletin is a great
motivator. Name names. In Guinea we had one such bulletin: Sierra
Leone called theirs The Eradicator.
7. Don't ask, don't tell. Just before the second year of operations a
group of unfamiliar faces appeared in our brief retraining session.
Dr. Alécaut asked if we could afford to give them some vaccine for
"northwest Guinea". Of course, the answer was yes. Only later did I
find that they were with the liberation movement in Guinea Bissau, a
country that won their independence from Portugal in 1973. I was once
asked by a diplomat to record all military movements I observed within
the country and report them to him. My answer was no: our
surveillance was very different from his surveillance.
The West and Central African Program
Expanding my thoughts to the West and Central African Program, I have
several observations. What was learned? Most importantly, the salient
experiences and lessons from 1966 to 1971 were adapted successfully to the
remaining smallpox endemic countries after 1971 by tens of thousands of
national and global staff.
1. Smallpox could be eliminated from a very large region without 80%
coverage. The program area was about the size of the continental U.S.
and had 120 million persons in the late 1960s. Nigeria had well over
half of the population and the eleventh highest incidence of smallpox
in the world in 1967; we could have used more field staff in this
country. The "escalation eradication" strategy, later called
"surveillance-containment", concentrating on rings of priority
contacts, works. Working smart and hard will always trump working
hard without thinking.
2. Try new technologies. The Ped-O-Jet injector was costly and hard to
maintain for some countries, but it really worked in West Africa after
being tested successfully by the CDC in Tonga and Brazil in the early
1960s. In Guinea, each vaccination team gave about 2,000 smallpox
vaccinations per workday over two years. The bifurcated needle was
not used in the West and Central African program early, but replaced
all other vaccination devices throughout the world by the early 1970s
because of its simplicity and need for only a drop of vaccine.
3. Dispel myths. Smallpox was not an explosive disease anywhere; it
spread slowly taking relatively few victims in its wake. Work by Tom
Mack and others in Pakistan in the mid-1960s, by David Thompson and
Bill Foege in the famous Abakaliki, Nigeria, outbreak, and others in
several countries proved this important point. Traditional healers,
while influential, did not impede vaccination in Togo, Benin, and
Western Nigeria where native medicine and "fetisheurs" reigned. The
smallpox god Shopona in Nigeria was defeated rather than appeased.
Several of us from the program were able to obtain copies of Shopona
at our regional meeting in Lagos in 1969 thanks to Ralph "Rafe"
Henderson who was the regional office epidemiologist and interested in
cultural beliefs about vaccination.
4. Research is critical for all public health programs. Descriptive
epidemiology defined disease patterns - population vulnerabilities,
locations, age, and periods of transmission. Laboratory
differentiation of the orthopoxviruses (smallpox, vaccinia, and
monkeypox), and of herpes-varicella virus (chickenpox) was critical.
Jim Nakano, John Noble, and members of the great CDC laboratory team
were essential for confirming the diagnoses and assuring that
eradication was achieved. John Obijeski and Joe Esposito of CDC made
major contributions to understanding poxvirus genetics and evolution.
A global poxvirus laboratory network focusing on diagnosis and
research in support of the eradication program was established by WHO.
Jim Nakano, Chief of the WHO Poxvirus Collaborating Center, along
with Svetlana Marennikova, Chief of the Moscow WHO Poxvirus
Collaborating Center, were leaders in this important endeavor -
particularly as monkeypox raised its head in the early 1970s from
several West and Central African countries, most notably the
Democratic Republic of Congo Tens of thousands of specimens were
tested by the CDC and Moscow laboratories during global certification
activities throughout the 1970s and during the 1980s when monkeypox
research and surveillance continued.
5. Be prepared to lose a few battles. Learn from adversity. Who from
the program could have foretold or altered the course of the Nigerian
civil war, from 1967 to 1970? Perhaps, someone could have predicted
that CDC and WHO efforts to establish high quality, high volume
smallpox vaccine production factories in Yaba, Nigeria and Kindia,
Guinea, would not succeed because of problems with egg supplies,
sterile water, electricity, refrigeration and anything that required
moving parts. Yet, it was important to transfer technology and
improvise locally. While we were required to use U.S.-made Dodge
trucks, they were vastly inferior to the Land Rover and other brands.
In later years the Toyota Land Cruiser equaled the Land Rover in
reliability and these vehicles could be obtained with managerial
creativity.
6. Listen, listen, listen. Observe carefully. Understand and adapt to
local ways. Pascal "Pat" Imperato of the CDC, Ousmane Sow, and
colleagues working in Mali documented potentially dangerous, but
ineffective variolation practices and how best to deliver health
services to nomads. Don Hopkins, E.C. Cummings, and colleagues in
Sierra Leone described the importance of funerals for spreading
disease, with contamination occurring during ceremonial washing of the
corpse by bereaved family members.
7. Transfer and adapt what you learn to other countries and organizations
and learn from them. Each country improved on what had been done
earlier. People get things done but organizations have cachet,
networks, and resources. The CDC leadership was fully committed to
smallpox eradication. David Sencer assigned staff to countries, WHO,
OCCGE, OCEAC and other agencies until the job was finished. In late
1976, I was asked by Bill Foege and Sencer to join the Smallpox
Eradication Unit at WHO when DA Henderson left. When I reminded Dave
that he had urged me to take a domestic post if I wanted to stay with
CDC, he instantly replied - "I consider Geneva a domestic assignment".
8. Without strong leadership the mission will fail. What do we expect in
leaders? One who is clear in communicating the mission, objectives,
strategies and tactics; has good judgment; is honest and forthright;
is receptive to contrarian views; has creativity in introducing ideas;
is adept in choosing good lieutenants and delegating authority and
responsibility; promotes allegiance to and from field staff; and
provides incentives. A great leader manages by objective and by
example. My view of a successful management scheme is an inverted
triangle with the troops on top supported by a hierarchy of leaders.
The finest leader I have known is D.A. Henderson, who, in addition to
having the above-mentioned qualities, responded to every letter he
received from field staff within 48 hours and to longer documents
including manuscripts usually within two weeks; he also understood the
importance of logistical support. David Sencer, former Director of
the CDC, managed by walking around the campus and into offices and
laboratories to stimulate and encourage staff; Sencer sent his very
best people for extended periods into the field to battle smallpox
including his Deputy, Bill Watson, the Chief Administrative Officer,
who served in India. Bangoura Alécaut inspired respect by insisting
on the maximum work performance from each of the teams. He had great
national pride, but knew and compensated for the shortfalls in Guinea.
He knew what each local, national and international partner could and
couldn't do - making everyone a winner. All three leaders were
decisive, accessible around the clock, chose the right people for the
right job, and knew how to get money by hook or crook. Another
observation: good leaders know the importance of hospitality, social
mixing, inclusiveness, and humor to gain trust and allegiance. In
sum, a leader must tell the story clearly, be devoted and responsive
to field staff, have knowledge of the task, good judgment, make good
appointments, and be resourceful and shameless in attracting
resources. Henderson said many times that every good idea used to
eradicate smallpox came from the field, not from headquarters. There
never were more than four to six smallpox unit medical or
administrative officers at WHO headquarters - even when thousands of
searchers were combing endemic areas. And most of the time the WHO
headquarters staff were in the field. In the late 1970s, our smallpox
headquarters staff ate C-rations in the WHO dining room to commiserate
with the field teams in Somalia to whom we sent these pre-packaged
meals.
Impact
The success of the West and Central African program was the impetus
for success in the rest of the world. If countries with the toughest field
conditions, the fewest resources, and the highest disease incidences could
succeed, hotbeds of disease in countries in the Indian subcontinent and
eastern and central Africa could conquer smallpox and prove that they had
done it. Over the next four years, from 1971 to 1975, David Sencer
assigned over 250 of his staff for periods from three months to several
years to work in smallpox-endemic countries. They worked with national and
international colleagues to eradicate the disease and to confirm
eradication during the difficult documentation and certification phase
which lasted to 1980. CDC poxfighters usually were WHO consultants and
worked as international civil servants. They joined an international
fraternity of co-workers with high esprit from dozens of countries. They
succeeded in bringing modern knowledge of epidemiology, surveillance,
containment, ring vaccination, communications, logistics, teamwork, and
good management to Afghanistan, Bangladesh, Nepal, India, Ethiopia, and
Somalia and to WHO offices in Geneva and New Delhi. In the field, their
allegiance was always to the goal in the countries and organizations where
they were assigned. Every major innovation that was discovered or
rediscovered in West and Central Africa was used elsewhere, refined
locally, tested, and transferred again.
West and Central African countries were not forgotten. CDC staff
joined francophone regional health organizations in Burkina Faso (OCCGE)
and Cameroon (OCEAC) to strengthen surveillance and do research in vaccine-
preventable diseases, cholera, and monkeypox. In 1972, I started my work
on malaria in Bobo-Dioulasso at the Centre Muraz, OCCGE. In the early
1970s, Neal Ewen, who had been the OO in the Central African Republic
smallpox-measles program, began a CDC-Burkina Faso collaborative rural
disease and demographic project working with the Peace Corps.
Inspired by success with smallpox eradication, WHO began the Expanded
Programme of Immunization about 1975, and its early Director was Rafe
Henderson, who later became an Assistant Director General. He was widely
known for refining the vaccination coverage scheme developed by Robert
Serfling and Ida Sherman of the CDC and adapting it to Africa. This
popular coverage survey approach remains in use. Many others from the CDC
have had major influences in global public health. Among these are: Don
Hopkins, now at the Carter Center, Atlanta, who is the father of the Guinea
Worm Eradication Program - a debilitating parasitic disease poised to be
the second one eradicated. Pat Imperato became the Commissioner for Health
of New York City and Chairman of the Department of Preventive Medicine and
Community Health, State University of New York, in Brooklyn. Pat is a
renowned authority on West African art and culture. Stanley Foster,
Professor, Rollins School of Public Health, Emory University, was the CDC-
assigned leader of the Nigerian and Bangladesh smallpox programs, and
worked among smallpox-infected nomads in Somalia. He had done important
facial pock mark surveys showing that 1-5% of smallpox patients were
reported to health authorities before the global campaign. Foster and
Andrew "Andy" Agle were architects of a major African child survival
program in the 1980s and 1990, managed and implemented by the CDC and
financed by U.S.A.I.D. Agle had fought smallpox in Togo as an OO and in
Afghanistan, and Bangladesh. Many Africans who worked on the program rose
to positions of prominence, usually in preventive medicine and in their
Ministries of Health. Bangoura Alécaut, my Guinean counterpart, became
Ambassador to Congo, Brazzaville, and other central African countries. One
of the youngest nurses in the Guinean program, Sidimé Banian, graduated
from the new medical school in Conakry almost two decades after I first met
him.
Perhaps, the most important contributions of the eradication program
are two intangibles - pride and credibility. The pride resides in tens of
thousands of health workers for achieving what many thought impossible.
Smallpox eradication has given increased credibility to those health
workers, their countries, and to national and international organizations
participating in the program - and changed the minds of those lacking
confidence in international cooperation and United Nations agencies.
While smallpox eradication is a miraculous achievement, I'm one who
believes the good old days are yet to come. Today, April 25, is World
Malaria Day and I am wearing my malaria tie to remind us of the need to
conquer this great African and global peril. In closing, my prediction is
that the miracle of malaria eradication and that of other great scourges
will someday be described from this stage. Thank you.
_____________
I thank David Sencer for encouraging me to tell this story and my
adventurous and lovingly supportive wife Vicki and children, Matthew and
Johanna, for living it with me. A set of PowerPoint graphics accompanies
this presentation. jbreman@nih.gov
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"A Miracle Happened There: The West and Central African Smallpox Eradication Program and Its Impact" by Joel Breman
April 25, 2007
Paper presented to the Histories of the Global Eradication of Smallpox, Wellcome Trust Centre for the History of Medicine, at the University of London in London on April 25, 2007.
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