In Memoriam: William Foege and the Nigerian experiment that helped end smallpox

When historians talk about the eradication of smallpox, they often start with Geneva, Washington, or New Delhi. But the turning point came earlier, and further south,  in Nigeria, in the late 1960s, where a young American epidemiologist made a practical decision that reshaped global health.

William H. Foege, who died on January 24 at the age of 89, was not yet a giant of public health when he arrived in northern Nigeria. He was a field doctor facing a familiar problem in post-independence Africa: too little money, too few vaccines, and a disease that moved faster than governments.

Smallpox was still endemic across large parts of Nigeria at the time. The vaccine existed, but vaccinating entire populations in a vast country with weak logistics and poor cold-chain infrastructure was unrealistic. Many eradication efforts before him had stalled precisely because they tried to do too much with too little.

Foege’s insight was disarmingly simple. Instead of vaccinating everyone, vaccinate strategically. Identify each new case, trace its contacts, and immunise only those at risk around it. Contain the outbreak in tight “rings”.

It was a logistical hack born out of Nigerian realities.

The approach worked. Vaccine use dropped sharply, surveillance improved, and outbreaks burned out faster than expected. What began as an improvisation in Nigeria soon became doctrine. Ring vaccination was adopted across West Africa, then India, and eventually formalised by the World Health Organization as the backbone of the global smallpox eradication programme.

In 1980, smallpox became the first infectious disease ever eradicated. The intellectual architecture of that victory was built, in large part, in Nigeria.

Those who worked with Foege often emphasise that he never framed this as a solo achievement. Nigeria mattered not just as a testing ground, but as a collaborator. Local health workers tracked cases, negotiated access to resistant communities, and adapted protocols in ways foreign experts could not. Foege understood early what many global health programmes still struggle to accept: that solutions imposed from above rarely survive contact with reality.

That humility followed him throughout his career.

After returning to the United States, Foege went on to lead the US Centers for Disease Control and Prevention under President Jimmy Carter, later helping to establish institutions that now dominate global health architecture, including the Carter Center, the Task Force for Global Health and, indirectly, Gavi, the Vaccine Alliance. But even as his influence expanded, Nigeria remained central to how he explained public health success.

In speeches and writing, he repeatedly returned to the lesson he learned there: that eradication is not about heroic medicine, but about systems, surveillance, trust, incentives, and local ownership.

Bill Gates, who later described Foege as a mentor, recalled that Foege had been imprisoned twice in Nigeria during the smallpox campaign,  a detail he mentioned not for drama, but to underline the political and human friction involved in real-world health work. It was not enough to have the right science; one had to navigate fear, suspicion and bureaucracy.

That sensibility shaped Foege’s later thinking on HIV, neglected tropical diseases and child health. It also shaped his scepticism toward technocratic fixes divorced from social context — a position that feels newly relevant as global health funding tightens and geopolitics intrudes more forcefully into disease control.

When Barack Obama awarded Foege the Presidential Medal of Freedom in 2012, the citation celebrated his global impact. But his most consequential contribution remains a Nigerian one: the proof that scarcity can sharpen innovation rather than defeat it.

For younger global health professionals, including those who co-authored his final book Change Is Possible, Foege was less interested in reliving victories than in extracting patterns. What worked in Nigeria? Why did collaboration matter more than control? How could success be replicated without erasing local agency?

In today’s world, where eradication targets are being missed, trust in institutions is eroding, and funding is increasingly politicised,  those questions matter more than ever.

William Foege did not eradicate smallpox alone. But without the insight he developed in Nigeria, the world might still be living with it.

That is his quiet legacy: not just a disease ended, but a method,  born in Africa, that taught global health how to think.

Obidike Okafor is an award winning, seasoned journalist and content consultant. Obidike has left his mark on the global stage, writing for prestigious publications in Nigeria, the UK, South Africa, Kenya, Germany, and Senegal. He also has experience as an editor, research analyst and podcaster.

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