Hunting for cases of Smallpox in Rural Highlands of Gondar: A Personal Experience

At the start of the Global Smallpox Eradication Program (SEP) in 1966, Ethiopia was one of 33 countries where the disease was considered endemic. Before the establishment of the SEP of Ethiopia in 1971, an estimated 50,000 cases were reported annually from the 99 Awrajas (out of 102) of the country. The disease affected both genders and all ages with overall mortality rate of about 1.5%. The incidence rate among children under 5 years of age was highest, with those below 12 months suffering the most.

In early 1970s, Ethiopia had a total of only 340 doctors for the whole country. Thus, expatriates needed to contribute in the eradication of the devastating viral infection. About 191 health professionals from 13 countriesaround the world had participated as WHO staff in the SEP of Ethiopia. The majority (105) were from the United States of America followed by Japanese nationals numbering 27. Canadians (24), Europeans (such as from the UK, France and Italy), other Asians (Iranians, Indonesians, Indians), Brazilians, Egyptians as well as professionals from the then Union of the Soviet Socialist Republic also participated in the SEP of Ethiopia. 

Professor Eisaku Kimura was one of three doctors from the far eastern islandof Japan. He was sent to Ethiopia (1973-75)by the Overseas Technical Cooperation Agency (now JICA) to work under the WHO for theSEP of Ethiopia. He played a particular role in finding out endemic foci and conduct vaccination to prevent the spread of the smallpox in the then Begemdir Province. His main field was in different villages of the Semen Awraja including the Tsegede Plateau and remote places extending to the Tekeze River as well as to Humera. 

By early to mid-1970s, about 2 million of the 28 million Ethiopians lived in the then Gondar region, one of 14 administrative regions. It had 7 Awrajas: Wogera, Semen, Libo, Gayint, Debretabor, Chilga and Gondar Awrajas.

Professor Eisaku Kimura is aphysician and at present theprofessor at the Department of Molecular Protozoology, Research Institute for Microbial Diseases, Osaka University. He was born on October 9, 1946 in Akita prefecture, Northern Japan.He received his undergraduate degree from Niigata University in 1972 to become a medical doctor. Between 1976 and 1987, he was a research fellowin medicine as well asin parasitology at the Institute of Tropical Medicine, Nagasaki University, where he also became Doctor of Medical Sciences.

By 1974, Gondar, Gojam, Shewa and Wello reported about 75% of smallpox cases of Ethiopia. With all hard work, most other endemic countries but Ethiopia had already interrupted the transmission of smallpox by 1975. Particularly, the isolated parts of Gondar, Gojam and Hararge, in both the mountains and in the Ogaden desert were the most difficult places where cases were concentrated. Difficulty of transportation and war in Ethiopia were some of the reasons.

The Semen Awraja included the Semen mountain range containing 18 peaks all above 4000 meters. Involving local villagers in the search and containment of infective cases of smallpox was particularly challenging. As perthe tradition, extended family groups lived in distant villages. Transportation was either on foot or on mule-back along footpaths due to the paucity of good roads.Donkeys were used to carry vaccine, tent, blanket, etc.

Water may come from unsanitary sources thus making helminthiasis and dysentery a danger to residents as well as to expatriate staff involved in the SEP. Because of the remoteness of the place, injera as food was sometimes a luxury! 

“Walking 10 hours a day is surely tough. Luckily, I could overcome this because I used to do rock climbing and other difficult exercisesas a member of the mountaineering club at medical school. However, I suffered from several serious diseases: In Ras Dashan Mountain,I had dysentery with tenesmus and fever, which appeared suddenly and I deteriorated quickly. Two-day long walk to reach AdiArkai crossing a mountain torrent turbid by upstream rains so many times was really a frantic and life-threatening escape from Semen Mountains. Despite this and other hard experiences, I cannot remember I felt any mental hardship in continuing the work…Smallpox was my duty. Infectious hepatitis was the final and decisive blow to me. My consciousness was blurred when I was carried to the Gondar Med College, where I was hospitalized for several weeks, and then judged ineligible to continue the work.

Despite the challenges of relentless geography and security issues, his team effected the surveillance of cases by visiting villages and schools. Also, local markets, which are held at different days of the week and visited by people from far areas, were utilized as the important source of outbreak information.

In the final stage of the eradication program,patient isolation was enforced by the posting of a 24-hour-a-day guard. All residents in an infected village were registered, vaccinated and checked for successful `takes`.Families of patients were compensated with small payments for any loss of earnings caused by their required isolation. This hard work resulted in thegradual significant decrement of the number of cases from this part of the country, especially as of June 1975.

The last cases from Gondar were detected in February 1976 from the thenEstieworeda of Debretabor located in the Blue Nile River gorge. The source of the infection in this area was thought to be a wandering musician and his three infected children, who traveled from Gojam region. Vaccination, containment and the rugged, sparsely populated mountainous nature of the area helped prevent the spread of the infection after the identification of the foci.

The last known case of smallpox for Ethiopia was registered in August 1976, from Bale region. Nevertheless, a `special` surveillance program was continued for problematic areas such as Gondar, Eritrea and some parts of Southern Ethiopia. No case of confirmed smallpox wasidentified though some cases of fever and rash were ultimately diagnosed as chickenpox or measles. As of April 14, 1978, no cases of smallpox were reported to WHO from anywhere in the world since the last case reported from Somalia in October, 1977.

Professor Dr. Kimura has been involved in a number of other overseas activities. His role as a WHO consultant in the filariasis control programs in American Samoa, China, Fiji, Kenya, Thailand and Micronesia are examples. He also participated in the control of schistosomiasis in Laos and Kenya. Currently, Prof Kimura is with Osaka University. He is a well-recognized academician with several publications! He is also amember of research group in Uganda developing a malaria vaccine. At the same time, he assists young doctors logistically.At the moment, he is conductingepidemiological surveys on filariasis in rural Uganda. University of Gondar acknowledges his work in the SEP of Ethiopia! His contribution during the difficult times of our fellow citizens is very much appreciated!

 References

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