House on Fire:  The Fight to Eradicate Smallpox is a memoir written by William H. Foege, the physician best known for developing the strategy of ring-vaccination in the eradication of smallpox.  Concisely put by New Scientist, his book is “a mixture of memoir, dry public health guide, and riveting tale of an all-consuming mission.”   

Though a brief read, House on Fire is comprehensive on each of these fronts.  Foege walks us through his life, starting first with his upbringing in Washington state and ending with his role in India as part of the smallpox eradication team there.  Notably, the book’s narrative ends before Foege’s tenure as CDC Director in the late 1970s and early 1980s, focusing explicitly on his involvement in combating smallpox.  Using his career in public health as a framework, he details how he became involved in global health and how each deployment around the world, whether for the CDC, WHO, or Peace Corps, added to his understanding of contagious disease and of how to better approach smallpox containment.  Ever the epidemiologist, Foege does not shy away from including graphs and charts to emphasize his points, especially as they relate to public health data collection.  He takes the reader behind the scenes of conferences, regular meetings, and everyday discussions to show the collaboration necessary for global health work, the planning needed, and the good-natured humor and guile it often requires.  At times, his interactions seem like a who’s who of American public health:  throughout his career, he works with D.A. Henderson, Alexander Langmuir, David Sencer (who also writes the book’s foreword), and Don Francis.  

Outside of his own history, Foege acknowledges that in order to understand smallpox and to understand the mission of eradication it is necessary to understand the disease’s complex history.  He begins the book with the history of smallpox and details the development of the vaccine from its crude precursor, variolation, to Edward Jenner’s early version derived from cowpox.  As he progresses through his story, he notes important historical moments in the battle against smallpox:  the development of the jet injector and bifurcated needle as ways to better administer the vaccine, the elimination of the virus first from countries and then whole continents, and, most poignantly, the final cases of smallpox ever recorded.  

Though the book necessitates some level of public health knowledge, or at least a comfort with viral disease and baseline public health interventions, it consolidates its role as a basic public health guide at the appendix.  In the last pages, Foege reflects on what to do if there were ever a bioterror attack with smallpox, complete with a diagram on how to administer the smallpox vaccine.  


 House on Fire starts with this epigraph:  

  “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.”  

The reader doesn’t immediately realize the full gravity of the epigraph until later; it is in fact the reason Foege wrote the book - as a comprehensive argument for his use of the strategy of ring vaccination.   Ring vaccination, a method that Foege developed in West Africa in the 1960s when faced with scant vaccine resources, focuses on identifying outbreaks of disease and immunizing anyone who may come into contact with individuals infected in that outbreak - much like dousing a burning house and extinguishing any embers in its perimeter.  A controversial approach at the time (as mass vaccination - where everyone in the community is vaccinated - was the strategy du jour), Foege became its ardent proponent, especially in areas where vaccine supplies and administrators were limited. Though the title is suggested to him by his wife, the analogy to a fire seems to come from an anecdote Foege shares about a conference in which the fate of his ring vaccination strategy in India hung in the balance.  During this conference, Foege and his team needed to make a provocative argument for ring vaccination as a strategy to contain smallpox and needed the health minister to support their decision.  The minister was set on continuing to pursue mass vaccination until a young physician spoke out to make the analogy - explaining that the only way to change the tide of outbreaks is if “they rush to pour water where it will do the most good - on the burning house.”  

Verging on an obsession, Foege and his team’s devotion to public health and putting out this “burning house” runs through the narrative.  Each stage of his work, from continent to continent and assignment to assignment, emphasizes this goal - even before it is stated as a policy objective. Foege’s pervasive devotion to the cause is best exemplified in the book’s postscript, evidence that smallpox eradication continues to be on his mind, even years after the fact:  

“Over the years, on every return to India, I have searched the faces of people on the street,
looking for pockmarks.  Soon I could find no pockmarked face under the age of ten,
then twenty, and now, no pockmarks are to be found on people under the age of thirty-five.”  

Looking forward nearly fifty years, and given the current COVID-19 pandemic, the idea of an infectious disease fading into collective memory is seductive and desperately needed.  And yet, with such a respiratory virus in the daily news, Foege’s descriptions of combating smallpox seem both foreign and exceedingly familiar to us in 2020. 

It is familiar in that armchair epidemiology has become a national pastime.  The discussion of R0 and how viruses propagate through a population seem commonplace, and the role of strong public health intervention is obvious.  Yet, it is foreign in that variola major and minor, the viruses of smallpox, were so much of what SARS-CoV-2 seems not to be:  they led to clinically identifiable disease (via visible pox and with no asymptomatic carriers), did not have any known or possible animal reservoirs, had a fearsome mortality rate, and, if survived, created “lifelong” immunity.  Each of these aspects allowed smallpox to be better tracked, combated, and eradicated.  

Foege also experienced a different stage of vaccine development than we have; the smallpox vaccine had been developed, tested, and refined by the time he utilized it.  Rather, it was the matter of its administration and how to create and maintain local supply of vaccine that required progress.  During his career in the field, he saw the development of the jet injector and bifurcated needle, innovations which allowed many to be vaccinated efficiently and effectively with a vaccine that could trace its origins to the 18th century.  

Notably absent from Foege’s recollections were the use of personalized protective equipment (PPE).  Where so much of the public discourse of COVID-19 has been about the use of masks, the access to N-95s, and proper donning and doffing of equipment, PPE is not at all discussed in House on Fire.  One assumes this is because each individual who worked in the field had been vaccinated against smallpox (or been infected) and developed immunity before being deployed.  

Ultimately, what we see in Foege’s writing is that public health is not one field:  it is a team-sport that combines science, global and domestic policy, and culture in service of social justice.


University of California Press

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