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Authors: William H. Foege

House on Fire

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House on Fire

  1. The Corporate Practice of Medicine: Competition and Innovation in Health Care,
    by James C. Robinson
  2. Experiencing Politics: A Legislator's Stories of Government and Health Care
    , by John E. McDonough
  3. Public Health Law: Power, Duty, Restraint
    , by Lawrence O. Gostin (revised and expanded second edition, 2008)
  4. Public Health Law and Ethics: A Reader
    , edited by Lawrence O. Gostin (revised and updated second edition, 2010)
  5. Big Doctoring in America: Profiles in Primary Care
    , by Fitzhugh Mullan, M.D.
  6. Deceit and Denial: The Deadly Politics of Industrial Pollution,
    by Gerald Markowitz and David Rosner
  7. Death Is That Man Taking Names: Intersections of American Medicine, Law, and Culture,
    by Robert A. Burt
  8. When Walking Fails: Mobility Problems of Adults with Chronic Conditions,
    by Lisa I. Iezzoni
  9. What Price Better Health? Hazards of the Research Imperative,
    by Daniel Callahan
  10. Sick to Death and Not Going to Take It Anymore! Reforming Health Care for the Last Years of Life,
    by Joanne Lynn
  11. The Employee Retirement Income Security Act of 1974: A Political History,
    by James A. Wooten
  12. Evidence-Based Medicine and the Search for a Science of Clinical Care,
    by Jeanne Daly
  13. Disease and Democracy: The Industrialized World Faces AIDS,
    by Peter Baldwin
  14. Medicare Matters: What Geriatric Medicine Can Teach American Health Care,
    by Christine K. Cassel
  15. Are We Ready? Public Health since 9/11
    , by David Rosner and Gerald Markowitz
  16. State of Immunity: The Politics of Vaccination in Twentieth-Century America
    , by James Colgrove
  17. Low Income, Social Growth, and Good Health: A History of Twelve Countries,
    by James C. Riley
  18. Searching Eyes: Privacy, the State, and Disease Surveillance in America
    , by Amy L. Fairchild, Ronald Bayer, and James Colgrove
  19. The Health Care Revolution: From Medical Monopoly to Market Competition,
    by Carl F. Ameringer
  20. Real Collaboration: What It Takes for Global Health to Succeed,
    by Mark L. Rosenberg, Elisabeth S. Hayes, Margaret H. McIntyre, and Nancy Neill
  21. House on Fire: The Fight to Eradicate Smallpox,
    by William H. Foege
  22. Inside National Health Reform,
    by John E. McDonough
House on Fire






University of California Press

Milbank Memorial Fund



The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan analysis, study, research, and communication on significant issues in health policy. In the Fund's own publications, in reports, films, or books it publishes with other organizations, and in articles it commissions for publication by other organizations, the Fund endeavors to maintain the highest standards for accuracy and fairness. Statements by individual authors, however, do not necessarily reflect opinions or factual determinations of the Fund. For more information, visit

University of California Press, one of the most distinguished university presses in the United States, enriches lives around the world by advancing scholarship in the humanities, social sciences, and natural sciences. Its activities are supported by the UC Press Foundation and by philanthropic contributions from individuals and institutions. For more information, visit

University of California Press
Berkeley and Los Angeles, California

University of California Press, Ltd.
London, England

© 2011 by The Regents of the University of California

Library of Congress Cataloging-in-Publication Data

Foege, William H., 1936–.

    House on fire: the fight to eradicate smallpox / William H. Foege.

       p. cm — (California/Milbank books on health and the public; 21) Includes bibliographical references and index.

978-0-520-26836-4 (cloth: alk. paper)

    1. Smallpox. I. Milbank Memorial Fund. II. Title. III. Series: California/Milbank books on health and the public; 21.

    [DNLM: 1. Smallpox—epidemiology—Africa—Personal Narratives.

2. Smallpox—epidemiology—India—Personal Narratives. 3. History, 20th Century—Africa—Personal Narratives. 4. History, 20th Century—India—Personal Narratives. 5. International Cooperation—Africa—Personal Narratives. 6. International Cooperation—India—Personal Narratives. 7. Smallpox—history—Africa—Personal Narratives. 8. Smallpox—history—India—Personal Narratives. WC 585]

644.S6F64 2011




Manufactured in the United States of America

20  19  18  17  16  15  14  13  12  11
10  9  8   7  6  5  4    3   2    1

This book is printed on Cascades Enviro 100, a 100% post consumer waste, recycled, de-inked fiber. FSC recycled certified and processed chlorine free. It is acid free, Ecologo certified, and manufactured by BioGas energy.

To my wife, Paula, for making this work even possible; to Patty Stonesifer, for the support that made it possible to write the account; and to the legions, from WHO/Geneva to households around the world, who made smallpox eradication a reality

If a house is on fire, no one wastes time putting water on nearby houses just in case the fire spreads. They rush to pour water where it will do the most good—on the burning house. The same strategy turned out to be effective in eradicating smallpox.




List of Illustrations

Foreword by Carmen Hooker Odom and Samuel L. Milbank

Foreword by David J. Sencer



  1.  A Loathsome Disease

  2.  A Succession of Mentors

  3.  Practicing Public Health in Nigeria

  4.  Fire Line around a Virus

  5.  Extinguishing Smallpox in a Time of War


  6.  Under the Rule of Variola

  7.  Unwarranted Optimism

  8.  A Gorgeous Coalition

  9.  Rising Numbers, Refining Strategy

10.  Water on a Burning House

11.  Smallpox Zero




Appendix: A Plan in the Event of Smallpox Bioterrorism








  1. Statue of Edward Jenner vaccinating a child

  2. David Foege and village children, Nigeria, 1965

  3. Rotary lancet, a vaccination device used in India until the early 1970s

  4. Ped-O-Jet, the delivery instrument for millions of vaccinations in Africa in the 1960s

  5. First smallpox patient seen in Ogoja, Nigeria, outbreak, 1966

  6. Patient outside infectious disease hut near Abakaliki, Nigeria, 1967

  7. The first cadre of smallpox warriors, Ghana, 1967

  8. A village smallpox goddess

  9. The bifurcated needle

10. Search team member in India seeking information on smallpox using a recognition card

11. Smallpox reports from weeks 34 to 47 in Uttar Pradesh and Bihar, India, 1973

12. Average number of new and contained outbreaks per week, Bihar, India, January to April 1974

13. Average number of new and contained outbreaks per week, Bihar, India, January to May 1974

14. Graph distributed to field-workers showing the turning point, when outbreaks began to decrease in India, 1974

15. Total outbreaks per week in India, January 1974 to May 1975

16. Instructions given to field-workers for vaccinating with the bifurcated needle



1. Smallpox deaths in well-vaccinated British India, 1868–1907



1. Nigeria, 1966–67

2. Northern India

3. New smallpox outbreaks in Bihar, India: 1974 and 1975 compared


President, Milbank Memorial Fund
Chairman, Milbank Memorial Fund





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 findings from research and experience that could contribute to more effective health policy.

With an insider's knowledge of the worldwide smallpox eradication program in the 1960s and 1970s, Foege, a physician, relates the strategies used to eradicate smallpox in Africa and India and the challenges
encountered along the way. He reveals the reasons behind the success of this program: a shared global objective; conception, implementation, and management of a clear plan tailored to a specific disease in terms of its context, range, and vulnerabilities; evaluation of the tools and techniques used and their subsequent modification; a willingness at all levels, from the local citizenry and government to country officials and global institutions, to communicate and work together to achieve the end goal; tenacity; and optimism.

As Foege notes, the smallpox eradication program shows that “humanity does not have to live in a world of plagues, disastrous governments, conflict, and uncontrolled health risks. The coordinated action of a group of dedicated people can plan for and bring about a better future. The fact of smallpox eradication remains a constant reminder that we should settle for nothing less.”

This book should be useful to policymakers, foundations, and nongovernmental service organizations as well as to professionals in global health as they work together to confront the shared global risk of emerging and reemerging infectious diseases.







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 India's successful eradication program can be told fully only by those who were on the team that brought about this achievement, and this book is written by one of the team's two pivotal participants. It is so much richer because this participant happens to have one of the most impressive memories in the world, and he has used his own extensive notes and references from others involved in the campaign.

The other pivotal participant, Dr. M. I. D. Sharma, was the director of the smallpox eradication program for the Government of India during
the years when this final effort was mounted and brought to a successful conclusion in 1975. He also served concurrently as the director of India's National Institute of Communicable Diseases. His unflagging commitment to eradication, the excellence of his leadership, and his skillful use of the human, fiscal, and material resources—committed from all over the world—in the Indian eradication effort constituted a central and indispensable element in the success of this program.

Dr. William Foege, as a Centers for Disease Control and Prevention (CDC) epidemiologist assigned to the Southeast Asia Regional Office of the World Health Organization (WHO), worked on the eradication effort throughout the Indian subcontinent. The methodology of surveillance and containment, an alternative to mass vaccination refined in the 1960s in Africa, enabled the Indian and multinational team to successfully eradicate smallpox in India. Dr. Foege's tenacious advocacy of the containment approach, together with his meticulous monitoring of the continually changing status of the Indian eradication effort and his adjustment of strategy and resources in response to altered circumstances, was an essential ingredient of this success.

BOOK: House on Fire
12.28Mb size Format: txt, pdf, ePub

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