The Peace Corps’ Contributions to the Global Smallpox Eradication Program About the Office of Strategic Information, Research, and Planning (OSIRP) It is the mission of OSIRP to advance evidence-based management at the Peace Corps by guiding agency strategic planning; monitoring and evaluating agency-level performance and programs; conducting research to generate new insights in the fields of international development, cultural exchange, and Volunteer service; enhancing the stewardship and governance of agency data; and helping to shape agency engagement on high-level, governmentwide initiatives. Front Cover: Peace Corps Volunteers Robert Steinglass and Doug Arbuckle administering the smallpox vaccine in Mille, Ethiopia, in 1974. Photo: Steinglass, personal collection. ii Dedication This report is dedicated to the memory of Dr. Donald Ainslie “D. A.” Henderson (September 7, 1928—August 19, 2016), a seminal figure in the field of smallpox eradication. The Peace Corps is deeply appreciative of having had the opportunity to correspond with Dr. Henderson about the contributions of Peace Corps Volunteers and returned Volunteers within the context of the global eradication program. His charismatic leadership, tireless energy, and unflagging devotion to this program inspired countless public health workers around the world, including many of the returned Peace Corps Volunteers interviewed for this report. iii Acknowledgments In 1806, approximately 10 years after Dr. Edward Jenner conducted the first documented experiment with smallpox vaccination, laying the foundations of modern medicine, President Thomas Jefferson wrote to the English physician and scientist. Jefferson acknowledged the importance of this discovery, extending “a portion of the tribute of gratitude due to you from the whole human family. Medicine has never before produced any single improvement of such utility. Future nations will know by history only that the loathsome small-pox has existed and by you has been extirpated.”1 “Future nations will The prediction that future generations would know of smallpox know by history only through history alone has indeed come true. Yet when the Peace that the loathsome Corps was founded by President John F. Kennedy more than 150 small-pox has existed years after Jefferson wrote those words to Dr. Jenner, smallpox still and by you has been existed in dozens of countries and continued to cause millions of extirpated.” deaths every year.2 For much of the 20th century, even countries like the United States, which had successfully eliminated the disease – Pres. Thomas Jefferson within its borders, were still susceptible to periodic outbreaks from to Dr. Edward Jenner imported cases. One such incident in New York City in 1947 began with a single infected visitor from Mexico. The outbreak was quickly contained so that there were only 12 new patients and two deaths, but that success came at the enormous cost of vaccinating 6 million people.3 In the late 1960s and 1970s, Peace Corps Volunteers and returned Peace Corps Volunteers (RPCVs) played a role in bringing the final chapter in the global story of smallpox eradication to a close. This report is dedicated to capturing their stories, which so vividly bring to life President Kennedy’s vision of what the Peace Corps could be and what its mission might achieve in the context of global partnerships. In the words of the Peace Corps’ founding Director, Sargent Shriver, “The Peace Corps represents some, if not all, of the best virtues in this society. It stands for everything that America has ever stood for. It stands for everything we believe in and hope to achieve in the world.”4 1 “From Thomas Jefferson to George C. Jenner, 14 May 1806,” National Archives. 2 Jonathan Roy, Smallpox Zero, Introduction. 3 D. A. Henderson, Smallpox, 19. 4 Sargent Shriver, speech at the 35th Anniversary of the Peace Corps, March 1, 1996. iv Peace Corps Director Carrie Hessler-Radelet provided the initial impetus for this research project. Karen Van Roekel, chief of strategic planning and data management in the Peace Corps’ Office of Strategic Information, Research, and Planning (OSIRP), served as lead investigator for this study and author of this report. The other Peace Corps staff who contributed to developing the study plan and conducting interviews included Shelley Smith, chief of programming and training in the Office of Global Health and HIV (OGHH); Melissa Silverman, former director of Communications; Danielle Porreca, former program specialist in OSIRP; Travis Johnson, former program specialist in OGHH; and Jessy Libbing, former administrative assistant in the Director’s Office. Samuel Ludwig, writer-editor in OSIRP, served as co-author of the Conclusions and as the senior editor for this publication. He received support from Laura Pirocanac in the Office of Overseas Programming and Training Support (OPATS); Lien Galloway in the Office of the General Counsel; and Michael Johnson, Bernard Chang, and Alex Snyder in the Office of Communications. Kristy Schlenker and Chris Praley (OSIRP staff) and Qing Feng (former OSIRP intern) provided support on the review of administrative data and the development of maps for this report. Jane Debruijn provided graphic design and layout services. Dr. Cathryn L. Thorup, director of OSIRP and the agency’s performance improvement officer, provided encouragement and support for this project from its inception through to its completion, and offered substantive comments throughout the manuscript review process. The Peace Corps wishes to thank Dr. Stan Foster, whose early career in the Epidemic Intelligence Service (EIS) at the Centers for Disease Control and Prevention (CDC) included caring for Peace Corps/ Bolivia Volunteers. Dr. Foster worked at CDC for 30 years focusing on smallpox eradication and monkeypox surveillance and in its Combating Childhood Communicable Disease Project (CCCD). For 20 years following his retirement from CDC, he was a professor at the Rollins School of Public Health at Emory University. The Peace Corps also thanks the late Dr. D. A. Henderson, to whom this report is dedicated. Dr. Henderson served as chief of disease surveillance programs at CDC from 1960 to 1965 and chief of the Smallpox Eradication Programme in the World Health Organization (WHO) from 1966 to 1977. He was awarded the National Medal of Science in 1986 and the Presidential Medal of Freedom in 2002. Both men graciously offered their insights for this report, helping to frame the contributions of Peace Corps Volunteers and returned Volunteers within the context of the global eradication program. v For many of these Most importantly, the Peace Corps thanks the many RPCVs who men and women, reached back more than 40 years in time to reconstruct the stories of their story was one their service in support of this enormous human achievement. They of pioneering work in shared their stories through interviews with the Peace Corps, oral the farthest corners histories documented by CDC and Emory University in the Global of remote lands to Health Chronicles online, and correspondence with the author. For eradicate a disease many of these men and women, their story was one of pioneering that had killed millions work in the farthest corners of remote lands. They chose to take on of people and left this challenge to serve the cause of peace and development. They millions of others chose to work tirelessly in a major global program to eradicate a permanently scarred disease that had killed millions of people and left millions more or blinded. permanently scarred or blinded. The esprit de corps that united the men and women who worked to eradicate smallpox led them to coin the phrase, “Order of the Bifurcated Needle,” in honor of the technology used in the final years of the program. As Dr. Mirta Roses-Periago, then-director of the Pan American Health Organization (PAHO), said in 2010 in her closing address for the 30th anniversary of the global eradication of smallpox, Sixty million people should be with us here today. They should be giving a thunderous standing ovation to Dr. D. A. Henderson and all the members of the Order of the Bifurcated Needle for saving their lives over these 30 intervening years since the defeat of that horrible scourge of humanity, smallpox. – Dr. Mirta Roses-Periago ("Smallpox Eradication After 30 Years," D1) vi “In 1966, the global burden of smallpox was estimated at 10 million cases and 2 million deaths per year. Global smallpox eradication, achieved in October 1977, required country-specific partnerships of national and international resources. As described in this report, Peace Corps and returned Peace Corps Volunteers contributed significantly to national eradication programs in more than 20 countries. In three of these limited resource countries (Afghanistan, Ethiopia, and Zaire), Peace Corps Volunteers and their national partners made major and perhaps critical contributions to the achievement of smallpox eradication. Peace Corps scopes of work varied in these three countries. In Afghanistan, female Peace Corps teams were key to overcoming female cultural resistance to vaccination. In Ethiopia, where the government reported 722 smallpox cases, Peace Corps-Ethiopian national teams identified 26,000 smallpox cases in the first year. In Zaire, where the rural health system was barely functional, Peace Corps-Zaire teams were essential in establishing an effective surveillance and containment system. This report captures in a unique way the logistic, epidemiologic,