Book Review

The story of one man’s mission to eliminate smallpox

By Suzanne Koven
June 13, 2011

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If you’re over 40 you need only glance at the small scar on your upper arm to see a reminder of one of the greatest achievements in human history: the total eradication of smallpox. While vaccines have existed since the late 18th century and the last case of smallpox occurred in the United States in 1949, the goal of eliminating smallpox globally was not set by the World Health Organization until 1966. The successful fulfillment of this mission required the recruitment of thousands of local workers in villages and cities on every continent and was often threatened by poor infrastructure, political upheaval, and war.

No one is more qualified to tell the story of this remarkable effort than William H. Foege, the American epidemiologist who planned and led it. He has done so exhaustively and with astonishing humility in “House on Fire: The Fight to Eradicate Smallpox.’’ Many books about smallpox, including “The Greatest Killer: Smallpox in History’’ by Foege’s colleague Donald R. Hopkins, have taken a long view of the disease, tracking the devastation it caused through millennia. Foege took a different and more personal approach, focusing more on his experiences in the 1960s and 1970s during the height of the campaign against the illness. After a brief introduction to the smallpox virus, Foege’s book, in fact, reads as much like a memoir of his career as it does a medical history.

Smallpox, or variola, existed at least since the time of the ancient Egyptians. Evidence of the disease’s characteristic pustules have been found in Egypt’s mummified kings. There was no cure and, over the centuries, millions were killed or maimed by the disease, up to half a billion in the 20th century alone. For millennia, an early form of immunization called variolation, in which a powder formed by grinding the scabs of smallpox victims was inhaled or rubbed into abraded skin, was practiced in India and China. Sometimes variolation conferred immunity, but sometimes it simply caused new outbreaks of smallpox. In 1796, Edward Jenner famously noted the clear skin of English milkmaids who had been exposed to cowpox or vaccinia (vacca means “cow’’ in Latin), a virus similar to smallpox. He demonstrated that inoculation with vaccinia could prevent smallpox and, to this day, all kinds of inoculations are called “vaccines’’ in his honor.

Until the mid 1960s, mass vaccination with vaccinia was considered the best strategy for combating smallpox. But “herd immunity,’’ the idea that if a majority of the population were vaccinated the unvaccinated minority would be safe, had not effectively controlled the spread of smallpox, especially in Africa and India. Foege and his colleagues at the Centers for Disease Control (of which he later became director) tried a new approach called “surveillance and containment.’’ In this labor-intensive method, field workers would identify individuals infected with smallpox, quarantine their homes, and vaccinate those with whom they might have come into contact. Foege, accompanied by his wife and small children, spent years in Africa and the Indian subcontinent guiding this painstaking process. Finally, in 1972 smallpox vaccination was no longer routinely recommended and, in 1978, the last known smallpox case on earth was recorded. There still exist small laboratory stocks of the virus and, chillingly, Foege includes in an appendix instructions for managing a bioterrorism attack in case these are ever weaponized.

Perhaps inspired by the current popularity of memoir, Foege tells the story of the eradication of smallpox in the context of his own life and work. We learn of his impoverished childhood in Iowa, of the local druggist who nurtured his interest in medicine, and of the adventures of the young Foege family as they traveled the world in pursuit of smallpox. Foege’s emphasis on the personal does enliven the myriad statistics he presents. But he seems a reluctant memoirist, uncomfortable with the spotlight, and as a consequence, the story gets bogged down, at times, by Foege’s need to mention (and compliment) every colleague with whom he ever collaborated.

Still, though Foege is anything but self-congratulatory, it is impossible to read “House on Fire’’ without admiring him and feeling grateful for the gift he gave to mankind.

Suzanne Koven is a primary care internist at Massachusetts General Hospital and writes the monthly “In Practice’’ column for the Globe. She can be reached at


The Fight to Eradicate Smallpox

By William H. Foege

University of California, 240 pp., $29.95