2001 Mary Woodard Lasker Public Service Award

Smallpox eradication implementation

Nature Medicine Essay

This year's Lasker Public Service Award honors a public health physician who pioneered a new technology to eradicate disease and who has been a key figure in getting the fruits of medical research into the public health programs in developed and underdeveloped countries. With gusto and audacity, William Foege has led battles against recalcitrant microbes and tackled mysterious diseases. He played a crucial role in purging smallpox from Earth and has since guided projects aimed at eradicating other devastating infectious diseases. Under his direction, the CDC unraveled the medical enigmas of toxicshock and Reyes syndrome, and issued early warnings about how AIDS spreads. After completing his work for the government, he signed on with several nonprofit groups aimed at improving health worldwide, especially for children. Foege gravitates toward monumental challenges; when he arrives, his drive to solve problems and his relentless optimism allow him to surmount them.

Isolate and conquer

By imagining that he was a virus, Foege beat smallpox at its own game. He outsmarted the lethal microbe by zeroing in on its next potential victims — and inoculating them with a protective vaccine. This triumph provided the blueprint that public health workers used to obliterate smallpox from the planet.

In December of 1966, Foege was running a medical center in West Africa and awaiting a large shipment of smallpox vaccine. As a consultant to the CDC, he was planning a massive immunization campaign. The goal: Inoculate as many people as possible. This strategy was expensive, but conventional public health wisdom said it was the only choice; even with 90 percent coverage, outbreaks still occurred.

But the germ beat the vaccine shipment. One day, Foege got word that smallpox had hit a remote region in Eastern Nigeria. He needed to act immediately to prevent an epidemic, but adequate supplies were months away. He pretended he was the virus and schemed about how to ensure his own propagation. Then he realized the key: Strike susceptible people as quickly as possible. With this insight, he knew he needed to find those individuals — before the virus did. The race was on.

Every day at 7 p.m., the coalition of missionaries that peppered the region tuned in their ham radios to make sure no one had fallen ill or needed anything. That evening, Foege joined them. With maps laid out in front of him, he divided up the area around the outbreak. The next day, each missionary sent runners to the surrounding villages, hoping to locate smallpox cases. By that night's radio call, the group had pinpointed the virus.

Foege's medical team distributed a portion of the precious vaccine to those villages. The shot wouldn't cure people who already were sick or who were well on their way to symptoms. It would, however, protect the next generation of potential victims — individuals who hadn't yet been in contact with the virus or who had been exposed very recently.

But that was only the first step. People who carried the microbe but who still felt healthy would travel to other places and expose a new round of people. To figure out where the virus would show up next, the team analyzed market patterns. Every five days, the area's inhabitants gathered to buy or sell goods at designated locations. Each of these markets served different villages, so Foege's team members could trace routes the virus might take. They identified geographic areas at highest risk and made tactical strikes with the remaining vaccine.

Two weeks later, they knew they had contained the outbreak. By building a moat of resistance around the infected people, Foege had caused transmission to sputter out even though he had vaccinated only 7 to 8 percent of the area's population.

He subsequently used this new strategy — called "surveillance and containment" — to fight smallpox in West Africa. The scheme wiped out the scourge in three years and five months—more than one and a half years quicker than planned and under budget.

After these successes, Foege took the helm of the CDC's smallpox eradication program to combat the disease worldwide. The World Health Organization soon 'borrowed' him to work on the problem in India, where the virus raged uncontrollably. In October of 1973, his team conducted its first surveillance. In May of 1974, Foege sent a telegram to WHO headquarters; it said that in one state alone, the group had discovered 10,600 cases in a single week. By continually improving surveillance and vaccination strategies, they had stamped out the virus completely a year later.

In 1977, the world bid goodbye to naturally transmitted smallpox. By tracking the virus and targeting only people who had likely been exposed, Foege and the method he developed broke the chain of transmission that extended back to the very first human case in the time of Ramses V, about 1000 BC. Foege raised his glass in celebration of this tremendous achievement, but the heady joy had ebbed years earlier. Since his first "surveillance and containment" efforts had succeeded, he knew this success was possible; after that, it was just a matter of follow through. Foege had already moved on to new challenges.

Mysterious medical problems

By that year, he had returned to the United States and begun directing the CDC. In May of 1980, the agency received reports about a disturbing new phenomenon. A rash of previously healthy young women were showing up in emergency rooms in shock — high fevers, racing pulses, and dangerously low blood pressures. Medical intervention saved many of them, but some died. At first, no one could explain this frightening trend.

Under Foege's direction, the CDC identified a risk factor for so-called "toxic shock syndrome" — a new type of tampon, which provided an unusually fertile breeding ground for a toxin-producing bacterium. The manufacturer yanked the tampons from the market, and incidence of the illness plunged.

New medical riddles continually popped up to challenge Foege. In the early 1980s several studies reported cases of Reyes syndrome — a childhood illness characterized by liver failure, trouble staying alert, and coma — associated with flu or chicken pox and aspirin. Preliminary evidence connected the disease with the aspirin rather than the infections, but the numbers weren't high enough to nail down the potential link.

Foege struggled about how to proceed. Children were dying, but he couldn't pin the blame on aspirin. He asked the American Academy of Pediatrics and others for advice. On one hand, he had a responsibility to tell the public what the studies were showing; on the other hand, he didn't want to alarm parents if the painkiller posed no hazard. Furthermore, aspirin manufacturers got wind of Foege's discussions and put enormous pressure on him not to release the results. He received phone calls at home; people told him that the CDC enjoyed a good reputation and it would be too bad if he ruined it. The manufacturers also claimed to have new information that would quash the connection with aspirin — but they never produced convincing data.

Although the studies weren't air tight, Foege decided that the public should know what the CDC knew. He released the information. Subsequently, the agency started a study with enough people to produce clear-cut results — but they aborted it early because preliminary data established that the syndrome was related to aspirin.

AIDS followed. Even before scientists had isolated the virus, his agency devised guidelines about how to foil transmission, based on epidemiological observations: Avoid high-risk sexual practices and transfusions with blood products.

Foege extended the CDC's reach beyond infectious disease. He brought accidental injuries, homicides, and suicide as well as chronic diseases into the purview of the agency. By including these phenomena, he expanded the CDC's mission to include a wider swath of public health issues.

New hats, new bugs

After his tenure with the CDC ended in 1984, Foege began directing both the Carter Center and a United Nations Task Force for Child Survival. Under his leadership, the Carter Center has spearheaded efforts to obliterate river blindness. It has deployed a drug that destroys the immature form of the river blindness parasite to endemic regions of Africa and Central America. The medicine is reaching 25 million people a year; it not only is saving them from blindness, but is allowing them to reopen fertile lands next to streams that had been abandoned because of the high incidence of disease. Foege has also targeted Guinea worm — a water-born parasite that grows to lengths of two or three feet within its victims. This parasite is about to disappear from the world, largely because of the Carter Center's activities.

In the last several years, Foege has worked with the Bill and Melinda Gates Foundation as a consultant to help the organization meet its objectives. This organization is striving to deliver vaccines to all children of the world, develop new vaccines against AIDS, tuberculosis, and malaria, and come up with tools to thwart diseases such as sleeping sickness that don't lend themselves to vaccination. These efforts are affording children born in poor countries new possibilities of reaching adulthood, a potential not imagined a few years ago.

With his vision and inspiring leadership, William Foege is championing the fight against forgotten diseases in the developing world. He continues to usher the planet toward his goal — a state of global health equity.

by Evelyn Strauss

Award presentation by Daniel Koshland, Jr.

William Foege, this year's awardee of the Mary Lasker Award for Public Service, is long on wisdom, long on inventiveness, and long in the length of his legs. As you will hear from what I say, all of these measures of longitude are significant in his award.

William Foege was Director of the Center for Disease Control when he set out with a few others to eradicate smallpox from the world. Later the CDC under his direction unraveled the medical enigmas of toxic shock and Reyes syndrome and issued early warnings about the spread of AIDS. When the Merck Company decided to make its drug against river blindness available free in Africa, they said they would do so if William Foege were responsible for administrating the program. It was done so well that other companies followed suit and offered their drugs, also free, to underdeveloped and impoverished countries.

A small glimpse of Dr. Foege and the enthusiasm he generates among coworkers, public officials, and natives in Africa can be seen in a couple of events in his life. When he embarked on his campaign to eradicate smallpox, he could generate crowds to come to see him in African villages by getting his cohorts to announce that the tallest man in the world was coming to their village on next Tuesday. When he did arrive he used the publicity to explain about vaccines and get the natives to be willing to be immunized.

A second glance at his ingenuity was his response to an outbreak of smallpox in East Nigeria when they were closing in on its eradication. The conventional wisdom was that the entire population would have to be immunized right away or all was lost. But he didn't have enough vaccine or people to do that. So he quickly collected his helpers — the volunteers and missionaries who had hand radios and contacts with villages — to locate the villages where the outbreaks occurred and quickly immunize everyone who had contact. Moreover, he knew that other villagers who felt healthy and visited other localities would spread the infection, so he interviewed the villagers, found the neighboring markets and schools and quickly immunized the people in those one-day's-walk-away villages. This policy — called surveillance and containment — not only saved the day but became the strategy for the rest of Africa that brought the eradication of the scourge of smallpox more than one and a half years earlier than planned and under the budget allocated.

Dr. Foege later became an adviser to the WHO and had to maneuver his programs for eradication and free drugs to the underprivileged past bureaucrats of many nations, including our own, which requires someone long on wisdom but also long on patience.

Dr. Foege showed his ability to be long on courage when he had to resist in the early days considerable pressure from advocates of aspirin that his identification of it with Reyes Syndrome would have adverse consequences for those who used aspirin for other therapies.

The Mary Lasker Public Service Award is designed to honor those who have been effective in generating support for research or spreading the benefits of research to the wider expanses of society. In a luncheon of this sort with so many distinguished leaders, it is difficult to think of a quick summary of all Dr. Foege's accomplishments that doesn't sound banal, so I will simply fall back on an old cliché that you will see is relevant, even among all these leaders: he is a giant.

William H. Foege

Acceptance remarks, 2001 Lasker Awards Ceremony

Nature Medicine Essay

In 1965, I stopped at the London School of Tropical Medicine on my way to live in Africa. Of the many people I talked to, as I desperately tried to understand the health conditions I faced in Africa, was a Dr. Cochrane who had retired as medical director of Vellore Medical School in India and who had authored the definitive textbook on leprosy. Having asked a simple question on leprosy, I was trapped for the next three days at his house reviewing leprosy slides since he felt he would be a failure if I left London knowing as little as I did. It was the week that I discovered that the compulsion to teach far surpasses the compulsion to learn.

And so, I feel the compulsion to pass on six lessons I have learned, each building on the previous one, to illustrate my gratitude to the Lasker Foundation.

First, Pope Clement IV asked Roger Bacon, in the 13th century, to summarize science. Two conclusions from Bacon were that science lacked a moral compass and that the Church was not providing it. If Roger Bacon would return today he would still be puzzled by a society that worships science but hasn't figured out how to provide a moral compass.

Second, Roger Bacon had great vision, predicting automobiles and airplanes, but he could not have anticipated the joy of science in 2001, where many are engaged and many benefit. To work in the field of science is a gift, a privilege, an unqualified joy… but with some strings attached. I tell students they should love science… absolutely love it… but, they should not worship it.

Third, Einstein emphasized that the right to search for truth implies a duty to not conceal any part of what one has recognized to be true. We are urged to deal in whole truths.

Fourth, Primo Levi, author of Survival at Auschwitz and The Periodic Table, took an additional step by saying that the right to have truth is tied to the responsibility not only to acknowledge the whole truth, but even beyond that, to use it. He said the person who knows how to reduce torment, but doesn't, becomes the tormentor.

Fifth, this obligation, to not become the tormentor, is global. As Einstein said, "Nationalism is an infantile disease." He called it the measles of mankind. And so the whole truth involves an obligation to use our science for the benefit of everyone, wherever they live. So what is it that is better than science? Better than science is science with heart, science with ethics, science with equity, science with justice.

Sixth, not one of us can do much alone. The power is in the accumulation of every last one of us, bound together in shared goals, adding our paltry daily allowance until the contributions of millions of people in research and academics finally develops a vaccine. And where additional millions construct the structure of industry, providing glassware, needles and syringes, airplanes, vehicles, bills of lading and a thousand other details. And millions more provide the health education, the education system, the vaccinators and the organizers to give the vaccine.

Col. Thomas Allen sent the 5th Wisconsin company into battle during the Civil War saying, when you hear the signal, march double time towards the Confederates and halt only when you hear the signal. And then he added, "You will never hear the signal to halt."

Global health is the sum total of the science and the successful application of that science. It requires the effort of optimists because we will never hear the signal to stop.

And so I say thanks for recognizing, not me, but the global application of health sciences. For recognizing the coalitions that make it possible… from bench scientists to field workers… the millions working anonymously… the optimists in millions of communities. On their behalf, thank you very much.