William H Foege House On Fire Summary

Review of William H. Foege’s House On Fire: The Fight to Eradicate Smallpox
Rahul Truter
“Future nations will know by history only that the loathsome smallpox has existed and by you extirpated”. This quote comes from Thomas Jefferson to Edward Jenner, he founder of the smallpox vaccine. It would only be 100 years later that Jefferson would see his dream fulfilled, but not without struggle. In House on Fire, author William H. Foege shares his first hand view of the lengths that society needed to go through to rid the world of the disease that had plagued it for so long. The story of the fight against smallpox extends long before our efforts for global eradication and is a representation of how society deals with widespread disease. House on

Fire is a comprehensive, realistic presentation on how society has dealt with widespread disease.
Foege’s first-hand experience with smallpox eradication makes the reader think carefully about the different questions society asks when presented with an outbreak. This question, among many, usually comes up “How do we defend ourselves”? “How do we make sure that the virus does not infect me?” The idea of going out of the way to ensure an outbreak is contained is not a brand new idea. Long before the WHO and CDC, society was already thinking of ways to contain a harmful outbreak. Foege explores this idea when going into the history of India. He recounts smallpox was actually a part of India’s culture for hundreds of years, even working its way into the people’s religion. In fact the first vaccination efforts were conducted through the religious practice of “variolation” at the time. This act was carried out by a group of Brahmins at the time, they believed that if they were able to help the lower class people they themselves wouldn’t be at the risk of infection. A similar idea to the scenario that Foege was in at the time, if smallpox was eradicated from countries with low economic status then there would not be any more risk of outbreaks. When studying an emerging disease it is important to highlight how long a society has dealt with the disease. The length a disease has affected a society provides important answers as to how to approach the disease and ultimately how to fight it.
Besides the question of “How do we defend ourselves?” The question of “What do we do?” is also poignant. Foege separates his experience with smallpox eradication into two parts “Identifying the Key Strategy” (West Africa) and “Meeting the Challenge of Eradication” (India). Foege’s experience in West Africa is a key representation of the steps that must be taken to answer the question “What do we do?” There is a reason that it took so long to eradicate smallpox from the globe, while the creation of new technology for vaccine delivery was a problem, a large reason was that there was no set plan for vaccine distribution. Foege introduces us to the idea that even though we have a vaccine that works, we must have plan to go with it. Mass vaccinations against the virus are go to ideas when faced with a problem as large as smallpox. However, the Foege and his team realized later on in the West Africa campaign the futility in mass vaccinations and the importance of the “Surveillance and Containment” method. When applied to the eradication effort in India the method worked wonders with case numbers dropping rapidly, rather than remaining constant or even increasing, as they did with the mass vaccination campaign. By using his examples of changing vaccination methods Foege conveys to the reader how important it is to have a set plan for vaccination for any emerging disease. On a class centered on emerging diseases it is important to highlight the steps taken to address the disease.
A very important question Foege makes us ask is “What potential problems do we face?” During the West Africa eradication effort Foege highlighted the several potential issues that he faced.

An emerging diseases class must also anticipate what the potential issues are that may halt the eradication process. An example of a problem is when Foege had to figure out what to do when faced with a low supply of the vaccine. There were two main choices, try and target the places where the outbreak occurred, or dilute the vaccine and give it to everyone. Each had their own downside however. If Foege and his team targeted the wrong places then the virus would still spread and inevitably infect everyone in the area and wreak havoc on the region since all of the vaccine would be gone. The other option had an equally catastrophic down side. If the vaccine was too diluted and did not take then the virus could become active and those inoculated would most likely become infected with vaccine-borne smallpox. To make a long story short, the first option was chosen and actually lead to the “Surveillance and Containment” method. This method entailed surveying the population for anyone who could have the outbreak and then making sure to contain any potential outbreak from occurring. This idea of identifying the problems that are being faced and weighing the options against each other is an important concept to understand in an emerging diseases class. In an eradication effort Foege lets us know

that no matter how hard a team works people will die, it is inevitable. Foege teaches the reader to evaluate success not on the number of lives saved, but on the number of lives you potentially protect.
Foege does an excellent job at teaching the reader the key points faced when faced against an emerging disease.

However, Foege does so in a very unsystematic way. Foege separated his experience into two separate stories, “Identifying the Key Strategy” (West Africa) and “Meeting the Challenge of Eradication” (India). While it was important to identify how the “Surveillance and Containment” procedure was developed Foege did not highlight how the procedure was still perfected in the “Meeting the Challenge of Eradication”. To the reader this came across as confusing since it was thought that the procedure used going into India. In fact this procedure’s use had to be defended when questioned by Ambassador Moynihan. Coincedentally through the defending of the idea “Surveillance and Containment” the books namesake was founded. Foege makes frequent references to the benefits of the method while not actually stating that this was the method that was going to be

used.
House On Fire is an excellent read for any student planning on taking a course in emerging diseases. The experiences that Foege shared, highlights the main points of what students must look for when trying to understand any widespread disease. Foege removes the veil of a dry statistical approach to understanding the eradication effort and provides a first-hand account of the tough choices that needed to be made. He provokes the reader to ask questions about smallpox and the factors affecting eradication with any disease. Foege’s use of personal narrative should encourage anyone who would want to pursue work with emerging diseases in a field setting. I strongly recommend this book to any student wishing to have a more concrete understanding about how emerging diseases truly affect us.