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'HOUSE ON FIRE': BILL FOEGE'S ACCOUNT OF SMALLPOX ERADICATION

Friday, 29th of June 2012

• ‘HOUSE ON FIRE’

This book by William Foege ($22.95 in bookstores, $20.38 through Kindle) is the most recent of several accounts of smallpox eradication, complementing those by Donald Hopkins (Princes and Peasants), S. Bhattacharya, (Expunging Variola),  Lawrence Brilliant (The Management of Smallpox Eradication in India) and D. A. Henderson et al. (Smallpox: The Death of a Disease). The W.H.O. account, Smallpox and its Eradication, is now on the Internet at http://whqlibdoc.who.int/smallpox/9241561106.pdf

Dr. Foege explores in detail not only how the winning strategy, surveillance and containment, developed in Nigeria during its civil war, but also how S & C was adopted in the large South Asian programs, sometimes against the opposition of government and WHO medical officers. Here is Foege’s account of a key decision making meeting held in Bihar, northern India in early 1974.

            'One of the field-workers, a young Indian physician, raised his hand. He looked too youngeven to be a medical school graduate, and he was very thin, the epitome of a dedicated field-worker. He did not appear to have the needed gravitas for the moment, and I worried that a mistake was in the making. But the physician stood and, with great deference, addressed the minister. He was shaking as he described himself as just a poor village man. But, he said, when he was growing up, there were things you  could depend on. For example, if a house is on fire in a village, no one wastes time putting water on the other houses, just in case the fire spreads. That is the mass vaccination strategy. Instead, as in the surveillance/containment strategy, they rush to pour water where it will do the most good.

            . . .The Minister hesitated and stared at the group for some time. And then the unimaginable happened. He changed his mind on the spot. . .he said, in a small voice, “I’ll give you one more month.”

            . . .the smallpox problem in Bihar finally began to decline in June 1974. (pp.171-172).'

Foege’s conclusions, pp. 189-192, deserve quoting:

• Spend the time and attention needed systematically to improve the tools as well as the techniques to improve them.
• Coalitions are powerful.
• Trust holds teams together.
• Social will is crucial.
• Social will must be transformed into political will.
• Public health solutions depend on good science, but the implementation of those practices depends on good management.
• Tactical flexibility is crucial.
• Allocate resources where they are needed.
• Effective leadership is crucial.
• Never give up.
• The measure of civilization is how people treat each other.
• Be optimistic.
• Global efforts are possible.
• The objective may be global, but implementation is always local.
• Communications functions as the nervous system of successful coalitions.
• Effective evaluation methods are the key to success.
• Humility does not mean fatalism.

 

AMAZON.COM  REVIEWS OF ‘HOUSE ON FIRE’

Mary Guinan

This review is from: House on Fire: The Fight to Eradicate Smallpox (California/Milbank Books on Health and the Public) (Hardcover)

This is a wonderful account of the final phases of one of the greatest public health accomplishments of the 20th century, the eradication of smallpox. Bill Foege realized during the African campaign that the mass vaccination strategy which was successful in other countries would be unlikely to work in the remaining countries with smallpox. First in Africa and then in India he and others implemented the search (surveillance) and containment strategy based on the mode of spread of the smallpox virus. Using epidemiologic evidence they showed that this method was far superior and advocated for it to be the primary strategy for elimination in Africa and the India. It was a radical change, not embraced by many and vigorously opposed by others. The "Fight" in the title may refer to the political and scientific fight as well as to the arduous work by the multitude of people involved. The background story of how smallpox was feared from earliest history and how the countries of the world came together and planned its elimination is fascinating. The excitement and ingenuity of those involved in the elimination campaign was remarkable. The author credits the success of the program to these workers. Imagine millions of people in every country of the world working for the same goal for decades. What an accomplishment. More sobering are the conclusions and Appendix entitled "A Plan in the Event Smallpox of Bioterrorism" which should be required reading for those in the field. The author pleads for evidence-based decision making. Read the book to find out about the tallest man in the world, how General Washington's knowledge of smallpox helped win the American Revolution and how President's Lincoln's Gettysburg Address may never have been given because of his smallpox infection.

By  Nahad Sadr Azodi

This review is from: House on Fire: The Fight to Eradicate Smallpox (California/Milbank Books on Health and the Public) (Hardcover)

Bill Foege's House on Fire is not only an entertaining account of the Small Pox eradication effort, but also about life, passion and a belief in something bigger than oneself. I enjoyed his personal stories, humor and insight into one of the greatest human achievements. This book served as a motivating reminder for the reasons many of us enter the world of social service, health and development.

By Godfrey P. Oakley, Jr. (Atlanta)

This review is from: House on Fire: The Fight to Eradicate Smallpox (California/Milbank Books on Health and the Public) (Hardcover)

I am fortunate enough to know Bill Foege, to have worked for him at the CDC, to be mentored by his example, and to enjoy many lectures he has given. He is simply one of the great people of our time. Although I went to Nigeria for 3 months in 1969 to work on smallpox immunizations and worked at the CDC for 30 years (in birth defects), there was much about the smallpox eradication story I did not know. I found this book so exciting that it was difficult to put down. I think that all who work in public health will enjoy this book. New students in public health should be inspired by and learn from reading this story of public health action that made such and important difference for mankind. I suspect many a layman or woman will also enjoy this wonderful, readable book.

I draw attention to one of Foege's important messages. If you seek to improve a human condition, it is important to know that you have an intervention that works and that you can tell whether or not the intervention has improved the outcome. It is not just enough to throw good will and money at the problem. As Foege says: "this is a cause-and-effect world, and smallpox disappeared because of a plan, conceivewd and implemented on purpose by people."

On a lighter note, I enjoyed his saying never hire a pessimist. If you need one for a while, contract for one.

By Martin A. Kalis (Atlanta, GA United States) - See all my reviews

This review is from: House on Fire: The Fight to Eradicate Smallpox (California/Milbank Books on Health and the Public) (Hardcover)

I read Dr. Bill Foege's "House on Fire: The Fight to Eradicate Smallpox" as a follow up to Dr. D.A. Henderson's "Smallpox: The Death of a Disease"... and I must say that I could not put this work down! Even though "House on Fire" focuses on the same topic as Dr. Henderson's book, it offers a different perspective based on the author's work and experiences in Nigeria and India. Dr. Foege's work is required reading for all public health professionals and highly recommended for anyone wanting to make the world a better place through science, compassion, and humanism. The book's Conclusion is particularly compelling. In order to really appreciate the Conclusion, one must read the entire work. I highly recommend this intriguing and fascinating book!

By  Melinda - See all my reviews

This review is from: House on Fire: The Fight to Eradicate Smallpox (California/Milbank Books on Health and the Public) (Hardcover)

This reads great as a medical mystery, a memoir, contemporary history or a process analysis. It is an unpretentious first person account of the eradication of Smallpox. If you need to be reminded how much impact one person can have and how far that impact can extend this book will do it for you. I got it because I was interested in the writer and the subject but have since asked a colleague who is working with me to implement and evaluate a pretty good size project (HUGE for me; NOTHING on the scale of this book.) because Foege is so eloquent about the reasoning behind his approach, experimentation, incorporation of new information, developing buy-in, training and implementation, changing in response to evaluation and measuring outcomes.

By  G.X. Larson (Southeastern Michigan)

This review is from: House on Fire: The Fight to Eradicate Smallpox (California/Milbank Books on Health and the Public) (Hardcover)

This book is about the last days of smallpox. Author William Foege played a central role in the fight against smallpox in Nigeria and India. While it is never stated that Foege invented the method, he was among the first epidemiologists in Nigeria to notice that surveillance and containment is a better strategy than mass immunization in eradicating a disease. Mass immunization tries to immunize an entire population, but can be uneconomical (both in monetary and practical terms). Imagine a grid, for example a Minesweeper grid: mass immunization tries to immunize all of the cells on the board. This can be ineffective: where do you start the immunizations?, at the bottom, center? Moreover, immunizing a few rows of the board (population) will not stop a random cell (located away from the immunized cells) from being infected. This infected cell will then of course spread to others.

Surveillance and containment actively seek out those random, infected cells and cut off their access to other cells. Foege and others used this method in Nigeria and in India. India, as one can imagine, was a difficult fight. Its population was (and still is) huge and dense, which meant fighting smallpox was difficult. Foege credits the containment method -- along with other factors such as the nature of world politics (post-war, with a strong US-led international community) and of course passionate humanitarian workers -- with finally defeating the disease. The way I imagine it -- to use another "fire" analogy -- small pox was alike a fireworks show. At the end of the show, the time depicted in this book, fewer and fewer fireworks were being sent off, each individual explosion being less and less powerful. Finally, all that was left was the peaceful night sky.


For another writers' view on the experience of smallpox eradication in India, go to
http://www.childsurvival.net/?content=com_articles&artid=464