Bill Foege: Another mountain to climb

Bill Foege and the end of smallpox

Meghan Holohan
Published: July, 2006

Bill Foege
Photo by Brian Smale
One day in 1966, the two-way radio in the corner of the medical clinic crackled: “Can you come see if there is a smallpox case in the village?”

William “Bill” Foege, M.D., MPH, jumped into his VW bug and bumped over the dirt plains of eastern Nigeria where he was serving as a medical missionary until he got to the village. Sure enough, it was smallpox.

At the time, public health experts thought the best way to rid the world of this ancient, often-lethal scourge was to vaccinate everybody. But Foege (pronounced “Fay-ghee”) didn’t have enough vaccine for everyone in the village.

As a consultant for the smallpox eradication program operated by the U.S. Communicable Disease Center (now the Centers for Disease Control and Prevention), he also knew blanket vaccination wasn’t foolproof. Sometimes public health workers only went to certain locations like schools to give shots. Sometimes they vaccinated the same students over and over again.

Was there another way?

Foege imagined himself as a smallpox virus. To jump from one person to another generally required close, prolonged contact. But what if the close contacts had already been vaccinated? Could the virus be stopped?

Perhaps, but first he had to find everyone suffering from smallpox.

So Foege, the lanky, gregarious son of a Lutheran minister, called local missionaries via two-way radio (there was no telephone service), and asked them to recruit a network of “runners” to canvas the villages in their areas.

The runners carried photographs showing the small and rubbery smallpox lesions. They asked children too young to do answer anything but the truth, “Have you seen anybody who looks like this?” Small boys and girls proudly pointed to the homes where smallpox sufferers lived.

Foege and his team then moved in to vaccinate their contacts—a technique now known as surveillance and containment or circle vaccination—and village by village, smallpox began to disappear.

“He was charming. He was persistent. He was intelligent. He was analytical,” says long-time friend and colleague William Schaffner, M.D., chair of Preventive Medicine at Vanderbilt University Medical Center. “And so he created this new approach—the find-and-contain through ring immunization, interrupting the chain of transmission strategy of smallpox eradication.

“That’s not laboratory science,” Schaffner continues, “but that conceptual innovation led to the eradication of one of the greatest plagues that mankind has every known. That’s public health.”

Foege (center) testifies during a Senate hearing on Legionnaires' disease held at the CDC in 1977.  Joining him are CDC virologist Walter R. Dowdle, Ph.D., (left) who later served as the agency's deputy director; and David W. Fraser, M.D., a medical epidemiologist who helped identify the outbreak.
Photo courtesy of the U.S Centers for Disease Control and Prevention (CDC)
Forty years ago, when Foege and his young family shared a four-room mud hut, he and his wife Paula made sure their 3-year-old son David wore shoes so he wouldn’t get hookworm. The child had received every conceivable vaccination before he left the United States. They boiled their water and slept under mesh mosquito nets.

Foege realizes that if he’d had to survive on the average Nigerian’s income—less than a dollar a day—he would have spent his money on food instead of vaccinations and mosquito nets.

It’s this knowledge—27 years after smallpox was eradicated from the Earth—that keeps him focused on improving public health worldwide. He can’t get away from it.

“He has a tremendous sense of compassion and humanity, and his vision is based on intellect and experience and his understanding where things fit,” says another longtime colleague, James Curran, M.D., MPH, dean of the Rollins School of Public Health at Emory University and former director of CDC’s AIDS Task Force.

“He has a tireless commitment of improving public health of underserved,” Curran says. “He is one of the very top public health leaders in the world over our lifetime.”

Drawn to Africa

These days Foege, 70, is a senior fellow at the Bill & Melinda Gates Foundation.

He is a member of the scientific board that helped design and implement the Grand Challenges in Global Health initiative, funded largely by the Gates Foundation.

The initiative is exciting, he says, because it gives scientists the freedom to explore areas that traditionally haven’t gotten a lot of funding. “It has the research community looking at global health,” he says.

Foege is familiar with the criticisms leveled against the program, that its technology-based solutions might suck money from less sophisticated public health measures, like basic sanitation projects, and that it fails to account for the broader, cultural and economic factors that contribute to poor health.

Photo of a child with smallpox taken in 1975 by Stanley Foster, M.D., a member of the CDC's Epidemic Intelligence Service, for the Global Smallpox Eradication Campaign.
Photo courtesy of the U.S Centers for Disease Control and Prevention (CDC)
It can only do so much, he argues. A nonprofit organization, no matter who runs it, cannot fill in for the government, which is ultimately responsible for public health—including the control of potential pandemics like avian flu.

“The Grand Challenges program is looking at the problems that poor people face that aren’t being addressed by the U.N. or other agencies,” he explains.

Standing 6-feet, 7-inches tall, Foege walks with long, determined strides. He walks with purpose. Give Schaffner vignette about height. Around the Gates Foundation, he’s known for his warmth and humor: he addresses everyone by name and asks about his or her families.

“It’s his thoughtfulness that makes him a special leader and mentor,” says Jeffrey Koplan, M.D., MPH, who succeeded Foege as CDC director in 1998 and who currently is vice president for academic health affairs at Emory University’s Woodruff Health Sciences Center.

“I’ve met many people who are concerned about people in the abstract or as amorphous groups,” Koplan says. “Bill cares about every individual he meets, but he also can see the individuals in groups and populations. He cares about those he’s never met and those yet to be born.”

Foege’s journey to the top echelon of global health began as a boy in tiny Colville, Wash., when he first read Albert Schweitzer’s autobiography, The Primeval Forest. He felt drawn to Africa, and to medicine.

While attending medical school at the University of Washington in Seattle, Foege worked at the Seattle-King County Department of Public Health under Reimert Ravenholt, M.D., MPH.

Ravenholt, who later directed the global population program at the U.S. Agency for International Development, “quite deliberately converted me to the joys of global health,” Foege says.

So did the CDC’s Epidemic Intelligence Service, which Foege joined after earning his medical degree in 1961.

The service emerged from a government effort to develop a synthetic anti-malarial drug during World War II. Based in Atlanta, it became the surveillance arm of the fledgling CDC, on the look-out for epidemics and outbreaks of communicable disease.

In the early 1960s, Foege, assigned to the Colorado State Health Department in Denver, got a call from a doctor on a Navajo reservation in Farmingham, New Mexico. “I’ve got a case of smallpox here,” the doctor said.

A Nigerian child, held by his mother, receives a small-pox vaccination during the 1968 World Health Organization Smallpox Eradication Project.
Photo courtesy of the U.S Centers for Disease Control and Prevention (CDC)
Foege, who had never seen a case of the disease, pored over a medical textbook on the way to the reservation. There he found a young boy covered with a rash. None of the lesions looked like smallpox.

So Foege became the medical sleuth—knocking on doors, talking to everyone who had contact with the boy and mapping the boys’ lesions every night. After a few days he had solved the mystery—the boy was recovering from measles and disseminated herpes.

House on fire

Foege’s experiences with the CDC only intensified his desire to go to Africa. So, after earning a master’s degree in public health from Harvard in 1965, he volunteered to serve as a doctor for a hospital operated by the Lutheran Church in Yahe, Nigeria.

In 1967, in the midst of his smallpox eradication efforts, Biafra seceded from Nigeria, prompting civil war.

His family, which by then included 1-year-old Michael, boarded an evacuation plane, leaving Foege and other doctors behind. They thought the war would end in a few days. Instead, they were drawn into a prolonged conflict: Foege saved a colleague from a Biafran soldier who was holding him at gunpoint, and he was detained several times by the rebels before he finally left the country.

He returned to Nigeria in 1968 as part of an international relief effort, and soon he was again organizing smallpox eradication. After the conflict ended in 1970, he and his colleagues were able to show that their efforts had been successful—they had quenched the disease.

In 1973, Foege moved on to India, where smallpox still raged. Within six days of starting a containment trial in four Indian states, he and his team had identified 10,000 new cases of the disease.

The health minister of Bihar Province wasn’t convinced. If circle vaccination was working, why weren’t the numbers going down? He wanted to reinstitute blanket vaccination.

“It was not easy to change perceptions,” Foege recalls. “There was a fear that smallpox would move so fast that we would have to do mass vaccinations to keep it down—but that was not true.”

For three days, he and his coworkers tried to convince the health minister to continue circle vaccination. On the day of their last meeting, desperation filled the room. If the official ordered blanket vaccination, all of their work would be lost.

Then a young Indian doctor stood up. “Mr. Minister,” he said. “I’m just a village man, but when I was growing up and a house was on fire we’d put the water on that house, not the others.”

Suddenly, the minister understood and agreed to give Foege one more month.

Members of a refugee relief team sent to Eastern Nigeria during the Biafran war in 1968 include Foege (center, with pipe) and nurse practitioner Annie Voigt, CPNP, MPH (right).
Photo courtesy of the U.S Centers for Disease Control and Prevention (CDC)
One month led to two months then three, and soon Foege and his team didn’t need to worry about the future of their plan. The health minister never mentioned stopping it again.

In May 1974, the number of smallpox cases had peaked; 12 months later, there were no more cases of smallpox in India. In 1979, the World Health Organization declared that smallpox had been eradicated.

“He is an extraordinarily positive person who always sees the opportunity of doing something. He is rarely pessimistic,” Koplan says. “He can usually see a victory and snatch it from despair.”

“Bill was one of the two storied heroes of smallpox eradication,” Schaffner adds. The other, Donald A. Henderson, M.D., MPH., went on to direct the World Health Organization’s smallpox eradication effort.

“There were huge successes already using strategy ‘A’ (universal vaccination),” Schaffner continues. “But for the endgame, strategy ‘B’—the Foege strategy—was the one that worked, and he and Henderson share a claim for orchestrating the global eradication of smallpox.”

A good challenge

Foege succeeded David Sencer, M.D., MPH, as CDC director in 1977. During his tenure he broadened the agency’s international activities to deal with health crises like deadly hemorrhagic fever—Ebola—in Central Africa, and oversaw the high-profile investigation of toxic shock syndrome in the United States.

Then, in 1981, young gay men and IV drug users started dying from a rare pneumonia. By the end of 1982, even before the virus that causes AIDS was identified, Foege, Curran and their CDC colleagues had determined that the disease could be spread through blood and body secretions.

In 1984, after President Ronald Reagan appointed James Mason, M.D., as the new CDC director, Foege and several colleagues formed the Task Force for Child Survival and Development, a collaboration of the World Health Organization, UNICEF, the World Bank, the United Nations Development Program and the Rockefeller Foundation.

Foege served as executive director of the task force, which aimed for nothing less than universal immunization of children. During his six-year term, the proportion of children around the world who received basic vaccinations quadrupled—from 20 percent to almost 80 percent.

Former President Jimmy Carter later recruited Foege to become executive director of the Carter Center and its Global 2000 program, which, among other projects, sought to eliminate “river blindness,” a parasitic disease that is a major cause of blindness in Africa.

About seven years ago, Foege was teaching international health in Emory University when he was asked to advise the Gates Foundation’s Global Health program.

Before taking the job, Foege drove to Plains, Ga., to talk with Jimmy and Rosalind Carter. He had remained close to them, and he wanted to see what they thought.

“I never entertained the idea that a rich person would be interested in public health,” Foege recalls. “I never thought it would be the richest man in the world or that he would be emotionally invested in public health.”

He did know there was enthusiasm and energy at the Gates Foundation, and that there was real potential to transform global health. The Carters agreed.

Foege has received a sheaf of awards for his achievements: among them the World Health Organization's Health for All Medal; the Mary Woodard Lasker Award for Public Support of Medical Research and Health Sciences; and the Public Welfare Medal from the National Academy of Sciences.

Photo by Brian Smale
Foege rarely mentions them. That’s not why he did the work. That’s not what inspires him.

And then there’s always one more mountain to climb.

In 1997, at the age of 61 and three years after receiving a hip replacement, Foege tackled a life-long goal, to climb 19,500-foot-tall Mount Kilimanjaro in Tanzania.

Accompanied by Paula and their three adult sons, he trudged slowly upward until—about 1,000 feet from the summit—they stopped to pitch their tents. That night as the water particles from their labored breathing formed ice crystals on the top of the tent, Paula turned to her husband. “You’d better be having a good time,” she said.

Foege smiled. Of course he was having a good time.

Years later this is one of his fondest memories. Yes, it was freezing and hard to breathe, but it also was a good challenge, the kind of challenge that can truly be savored by a man who helped defeat smallpox.

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