Nigeria and West Africa: International Aid and Eradication
"The program which you are working to develop in the 19 African countries is a working model of the fully organized smallpox eradication campaign which we aim to launch on a much wider basis. It will constitute a major part of the entire global program, and, therefore, your task in ensuring its success is of critical importance. If not pioneers in time, you are at any rate pioneers as regards the size and potential importance of the program you are handling." --Dr. Marcolino Candau, Director-General of the World Health Organization (Ogden, 1987, p. 32)
Over the course of the early twentieth century, smallpox vaccination campaigns had reached a point where the disease could be eradicated within a country's borders. Sweden was the first to officially eliminate the disease in 1895 (although Sri Lanka may have done so earlier in the century), Austria followed suit in the 1920s, the Soviet Union and the Philippines joined the club in the '30s, and the United States saw its last cases of smallpox in Texas in 1949. The WHO had previously campaigned for the global eradication of malaria, but the adaptability of disease-spreading mosquitos and malaria itself led some to conclude total eradication of any disease was impossible, and it was thanks to the lobbying of Czechoslovakian epidemiologist Dr. Karel Raška that hopes for the total eradication of smallpox continued to burn on. By the 1960s, new technological innovations made eradication appear more feasible-- deep-freezing could preserve vaccines in tropical climates without refrigeration and jet injectors could vaccinate thousands of people with the labor of only a few trained individuals.
Pan American Health Organization
2019 photo of the headquarters of the Pan American Health Organization
The Centers for Disease Control (CDC) were granted an opportunity to test these new technologies in the field when the Prince of Tonga approached the U.S. for assistance eradicating smallpox in his country. The CDC obliged him and got their first taste of having to manage vaccination in difficult terrain as they struggled (but ultimately succeeded in) reaching people living in the mountains and remote islands of the Pacific country. The CDC gained further experience combatting smallpox when they worked with the Pan American Health Organization (PAHO) to put down an outbreak of smallpox that crossed the border from Brazil to the previously smallpox-free Peru.
While the CDC was planning how to eradicate smallpox in the 1960s, the nations of West Africa were winning their independence from Britain and France. Seeking to prove their credibility as the new rulers and improve the lives of their people, leaders of four of the new West African sent ministers to the U.S. to learn about possible treatment for measles, considered more threatening than smallpox to people in the region. Arrangements were made with Dr. Paul Lambin, the Minister of Health for the Republic of Upper Volta (now Burkina Faso), to promulgate a new measles vaccine in the country and cases of the disease were slashed over the next two years. Other West African nations began contacting the Agency for International Development (AID) to replicate the program in their countries. However, as more countries began lobbying to join the measles program, the CDC internally worried about the efficacy of this plan-- after all, measles eradication may not be possible. After some negotiation with the CDC and other U.S. agencies, AID agreed to supplement the measles control programs with a smallpox eradication campaign, which would have a more permanent effect on West Africa and the world at large.
Fighting smallpox in Niger
Photo taken by Dr. J. D. Millar during the Smallpox Eradication and Measles Control Program in Niger
Owing to its sizable population and central location within West Africa, Nigeria was identified as a critical country to the smallpox eradication campaign. The country's Principal Medical Officer, Dr. Adeniji Ademola, was an enthusiastic supporter of the program and well-respected in Anglophonic West Africa, yet the 1960s was a turbulent time in Nigeria's history. In 1966, a military coup overthrew the government and killed Prime Minister Abubakar Tafawa Balewa, a counter-coup later that year killed the first coup's leader, Johnson Aguiyi-Ironsi, and then a civil war would rage in the country from 1967 to 1970. Dr. George Lythcott, an African-American pediatrician who recently joined the CDC's mission, spent six weeks in Lagos networking before he was able to get an audience with an official who could sign off on the necessary paperwork to begin the mission.
Abubakar Tafawa Balewa
1962 photo of Abubakar Tafawa Balewa, first Prime Minister of Nigeria until his overthrow and murder in 1966.
Ultimately twenty countries were included in the CDC and WHO's campaign to eradicate smallpox in West Africa, and a standard framework known as Eradication Escalation was used to develop a basic vaccination policy in each county. Mass vaccination would remain the central pillar of the anti-smallpox crusade, but epidemiological data indicating that smallpox was a seasonal disease suggested that if physicians aggressively contained the few smallpox outbreaks during the wet season, there would be fewer cases to deal with during the more dangerous dry season. Such a strategy required thorough monitoring and tracking of smallpox cases-- it was best to catch an outbreak early before it grew into an epidemic-- and not infrequently missionaries operating in the area became informants for the CDC and its allies, reporting suspected incidents of smallpox when they saw them. Frontline medics were at first hesitant to implement the Eradication Escalation strategy, believing it to be a ridiculous scheme concocted by administrators, but successes in countries like Sierra Leone, which reached zero smallpox nine months after escalation was implemented, legitimized the practice.
Of course, the circumstances of every country are unqiue, so even as health experts worked from the same Eradication Escalation framework, adjustments had to be made for the special circumstances they found themselves in. For instance, as mentioned above, Nigeria descended into civil war amidst the smallpox vaccination campaign. On May 30, 1967, the predominantly Igbo Eastern Region of Nigeria seceded to form the Republic of Biafra in response to anti-Igbo pogroms in the Northern Region. Remarkably, Nigerian and Biafran health officials continued to collaborate during the civil war, and temporary ceasefires were occasionally arranged to transport vaccines and smallpox patients between the two states. Nevertheless, the national volatility occasionally threatened the campaign, and even foreign officials were subject to suspicion. At least once in both Nigeria and Biafra, American health officials were detained, put under armed guard, and interrogated about their possessions and activities. Looking back on their efforts in Nigeria, the CDC believes their aggressive vaccination campaign in the Biafran city of Enugu before the outbreak of war pacified the last bastion of smallpox in Eastern Nigeria and limited the spread of the disease as refugees fled the region.
Emir of Kaduna, Nigeria receiving a vaccination
The Emir of Kaduna, Nigeria receives a smallpox vaccine in front of a crowd in 1967
Cultural and political differences within a country could also present problems to vaccinators. In Nigeria, the emirs of the largely Hausa and Muslim Northern Region possessed the centralized power and influence to compel citizens to accept vaccination, while Yoruba chiefs in the Western Region had little influence over their independently minded people, who trusted their traditional god of smallpox more than they trusted government agents they suspected were out to introduce some new tax.
Nigeria also demonstrates how total eradication was not always easy to proclaim. At the dawn of 1970, the CDC was preparing to declare smallpox eradicated in West and Central Africa, and a celebration was planned for the end of March when on March 21 a teenage girl in the northern city of Kaduna was reported to have contracted smallpox. Sweeps by Nigerian and international officials turned up pockets of cases that had quietly proliferated under their noses. These final outbreaks were never especially large-- the largest affected sixty people and a few were as small as two cases-- but to ensure that smallpox could never come back, all people who contacted infected smallpox were vaccinated and every rumor of smallpox was investigated. Only in retrospect did Nigerian officials feel secure in declaring that on May 21, 1970, the last diagnosis of smallpox in the country was made.
"Assessment teams, following the vaccinators at seven- to fourteen-day intervals, found coverage rates above 95 percent in Sokoto Province. When these figures were relayed back to Atlanta, they were viewed with great skepticism. Dr. Mike Lane recalls, “We were sure they were doing it wrong or fudging the data.” It was the first time CDC had met the awesome power of absolute traditional rule." (Ogden, p. 52)