House on Fire (9 page)

Don Millar, who had worked with Henderson to lay the groundwork for the global smallpox program, was put in charge of the Africa program.
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Don brought considerable enthusiasm to whatever task he took on. In his new role as director of the Africa program, Don showed great leadership abilities as he recruited, trained, and dispatched some forty medical and operations officers to West Africa. He also brought a strong respect for evidence to the job. He constantly reviewed what was working and why, reporting his observations weekly in a newsletter called “Friday Afternoon Reflections,” and he was always ready to implement successful new tactics in place of what wasn't working.

Since the days of Jefferson and Jenner, people had thought that smallpox should be eradicable. By the mid-1960s, enough countries had become free of smallpox that it was clear that the vaccine, if applied correctly, could bring about eradication. However, eradication had so far been accomplished only in wealthy countries and in countries with a low level of smallpox or with smallpox workers who were obsessive in pursuing the program. What remained unknown was whether the same goal could be accomplished in poor countries that had high smallpox rates combined with meager health resources and inadequate infrastructures and communications systems.

Some people assumed that it could be done, that it was just a matter of addressing the inherent problems of resource-poor nations. Others maintained that smallpox could never be eradicated, and they offered as proof the fact that similar efforts to eradicate malaria as well as yellow fever had failed. Those who believed eradication was possible would point out the difference: unlike malaria and yellow fever, smallpox is entirely dependent on human organisms in its life cycle. The doubters would respond that no disease had ever before been eradicated, and thus it was surely an impossible goal.

It was in this climate of hope, doubt, and debate that the WHA executive board finally approved a global smallpox eradication project in
February 1966. This decision did not come easily. Back in 1958, the Soviet Union had proposed before the WHA a resolution calling for a global effort to eradicate smallpox. The resolution had passed, but little in the way of substantial efforts had followed. At its May 1965 meeting, the WHA again debated the issue. Many countries, including the USSR and the United States, supported the idea, but there was disagreement over how to budget for the program, and once again the delegates passed a resolution with no plan for action. The following year, in 1966, the WHA finally ratified a funded program for global smallpox eradication, to be completed within ten years, and asked WHO to assume the principal role in organizing and coordinating the effort.
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There were several reasons why the WHO program had a good chance of succeeding. First, key technological advances made it possible to standardize the quality and stability of the smallpox vaccine worldwide. Up to this time, the production of the vaccine had remained almost a cottage industry in many countries. This meant that while the vaccinia virus—somewhat modified over the years from Jenner's original cowpox virus—was a great vaccine, it wasn't consistently great. The potency varied widely. The production process was crude, involving shaving calves, scarifying the exposed skin (scratching or lacerating the skin to make it raw), and painting this raw surface with a substance containing vaccinia virus. The virus would grow on the scarified tissue and then be harvested by raking off the pustular material. The resulting matter was cleaned of extraneous bits of hair and flesh to provide high concentrations of vaccinia virus. It looked as unappetizing as it sounds.

Much of the resulting vaccine was kept in a liquid form that required refrigeration to remain viable—yet high temperatures were the norm in most smallpox-endemic areas. It was possible to launch effective programs with liquid vaccine, as many areas had shown over 160 years, but it was very difficult. Early in the twentieth century a method was developed for freeze-drying vaccines, permitting them to be stored at room temperature for extended periods. However, there remained the problem of how to convert all the vaccinia manufacturers around the world to this new technology.

Early in the eradication program, WHO, under the leadership of D. A.
Henderson, assembled a panel of experts who came up with a global standard for the vaccine and created a detailed manual for its production as well as how to convert to freeze-drying the vaccine. Consultants were sent out to help countries convert to the new system. Reference centers for testing vaccines were established in Canada and the Netherlands. To fill the gap while all areas of the world were catching up, two dozen countries already producing vaccine of satisfactory quality donated vaccine where it was needed. By 1969, all vaccine used in the smallpox-endemic countries met WHO standards, and by 1973 more than 80 percent of the vaccine in use was being produced by the developing countries themselves.

A simplified and improved vaccination technique, in the form of the jet injector, also increased the odds of success for the global eradication effort. Up to the mid-twentieth century, most areas of the world were still using the multiple pressure vaccination technique, in which a vaccinator repeatedly pressed a needle, at an angle, through a drop of vaccine placed on the vaccinee's skin. The needle nicked the skin on the upstroke, created a small injured area where the vaccine could begin multiplying. The procedure is simple but difficult to teach, which meant that take rates varied according to the vaccinator's skill and even for the same vaccinator under different conditions. The method also required cleaning the skin before vaccination, which meant that vaccinators were encumbered with bottles of alcohol, acetone, or soap and cotton swabs.

Another method still used in some countries, including India, was the rotary lancet. This brutal instrument consisted of a quarter-inch-diameter wheel with tines attached to a long axle. The wheel was placed on the vaccinee's skin and the axle was rotated by the vaccinator's fingers, causing cuts as the tines rotated through a drop of vaccine, giving the vaccine access to underlying tissue. The result, once the vaccine took and the lesion healed, was a large vaccination scar. Many vaccinators would do two or three vaccinations on the vaccinee's forearm or upper arm to increase the chances that one would take. In fact, if the vaccine was not potent, none of the attempts would provide a take; if it was potent, the person was likely to end up with more than one hot, angry vaccination lesion developing at the same time.

Figure 3.
Rotary lancet, a vaccination device used in India until the early 1970s. CDC/Bruce Weniger; James Gathany

In 1960, Aaron Ismach, working with the U.S. Army, had developed a foot-operated jet injector, called the Ped-O-Jet, that was an efficient work of art. It consisted of a hydraulic foot pedal that, with a single step, depressed a piston releasing just enough pressure for one vaccination. The vaccinator placed the pistol-like portion of the jet injector against the vaccinee's skin and pulled the trigger, releasing a plunger that delivered the vaccine intradermally, between the layers of the skin. No needle was involved. A 50 cc bottle attached to the injector could provide five hundred doses of 0.1 cc smallpox vaccine.

The jet injector's tidy and reliable delivery of a packet of virus allowed for uniform take rates (approaching 100 percent) even with different vaccinators. The technique was simple and quickly learned, and because there was so little wastage, the Ped-O-Jet was economical. The 1964 Tonga study I had participated in had determined an effective dilution rate for the vaccine, which meant additional savings.

Figure 4.
Ped-O-Jet, the delivery instrument for millions of vaccinations in Africa in the 1960s. CDC/Susan Lindsley

The Ped-O-Jet, introduced into the West Africa program in late 1966, made it possible to vaccinate one thousand people in an hour. On one occasion, while vaccinating in a large prison where the prisoners moved past the injector in a highly disciplined way, we were able to deliver six hundred vaccinations in less than thirty minutes. During one very long day in Enugu, I did 11,600 vaccinations.

The Ped-O-Jet's speed offered little advantage if vaccinators moved
house to house. Instead, arrangements were made with a village ahead of time, and on the designated day, the vaccinators would arrive and set up the site. People often milled around the site watching the procedure before committing to participate. Even after their own vaccination, they would stay around to watch others go through the line, pressing in to the point where we could no longer move people past the injector. Crowd control was essential. If the site was under a tree, we delineated the route people should take with ropes wrapped around three-foot metal stakes. If it was in a church or school, the vaccinator would be positioned immediately inside the doorway so only one person at a time could pass by.

In addition to these technological advances, the new world order that had emerged after World War II, particularly the development of the United Nations and WHO, made it practical to consider and carry out global objectives. The idea of a global perspective was not new. The Greek historian Polybius understood two thousand years ago that nothing happens in isolation. He said the world must be seen as an organic whole, and he provided examples of events in Africa impacting Athens. By the mid-twentieth century, a global view could truly include the entire world. The UN and WHO made it possible, for the first time in history, to select a global health objective, organize to reach that objective, and apply the greatest resources to the largest problems.

A global perspective is essential to dealing with infectious diseases, since diseases have no regard for national boundaries. And, it turns out, what's good for the global community is good for the individual country. For the United States, which had been smallpox-free since 1949, the investment in global smallpox eradication amounted to just onequarter of the annual expense of vaccinating U.S. children and maintaining a program to check the vaccination status of people coming into the country.

A less tangible yet no less important ingredient in smallpox eradication was simply the belief that it could be done. In fact, in retrospect, the belief that it could be done seems like the most important factor in the global eradication effort. The technology and the infrastructure were necessary, but the planning and hard work required to use them to full effect rested on the faith that eradication was possible. We all know the
adage that some things have to be seen to be believed. In fact, the opposite is often true: some things have to be believed to be seen.

The fact of smallpox was so ingrained in human experience that we had our work cut out for us to convince people that eradication was not a wishful fantasy. The shift from doubt to belief was not unlike a religious conversion; it involved not just facts, but emotion, too. A person suddenly transformed by the vision of what was possible could not be stopped. One dramatic example was Dr. George Glokpur, head of the smallpox eradication program for Togo. In 1967, he attended a three-week course on smallpox eradication held at the CDC in Atlanta. After the first week, he decided to go home. By then, he was convinced he could do it and did not want to wait an additional two weeks before getting started.

As more geographic areas became free of smallpox, it became easier to transmit this belief. Like a communicable disease, the belief in smallpox eradication was infectious, with an incubation period, various degrees of susceptibility, and an increasing rate of spread that finally infected many who came in its path. Once this condition was shared by a critical mass of people, no barrier was insurmountable.

Even though we were setting out to do something never accomplished before, we believed, from the beginning, that eradication of this disease was possible. What we did not know was that we yet lacked a key ingredient: a more effective primary strategy. This final element was fortuitously discovered at the very outset of the program.