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Epidemiologist Without Borders

As Stan Foster retires from full-time professorship, the impact of this smallpox eradication pioneer and global health teacher extraordinaire goes on and on

By Rhonda Mullen

Never one to shy away from a fashion statement, Stan Foster 82MPH swept into the Rollins Auditorium wearing a golden cap and ceremonial African robe shot through with gold threads worthy of the occasion. The global health professor worked his way through the room, shaking hands with the many friends who gathered at Rollins in April for his last lecture, marking his retirement at age 80. Here were many of the giants of public health with whom Foster had worked on smallpox eradication in Nigeria, Bangladesh, and Somalia, along with students, past and present, whom he had inspired. 

On the front row was Dorothy "Dottie" Foster, Stan's wife and collaborator of 57 years. Theirs has been a life of service, answering needs in communities in partnership with others. Their commitment was obvious as Foster took his audience on a PowerPoint tour of his 50-year career in public health. But those who heard his last lecture already knew that his impact reached far beyond the borders of the school. 

Lagos, Nigeria, 1966-1970

When Foster was finishing a residency in pulmonary diseases at the University of California, San Francisco, a call came from the CDC. Would Foster like to go to Africa and get rid of smallpox? And could he decide by tomorrow? 

Foster had joined the Epidemic Intelligence Service (EIS) at the CDC in 1962 and completed a two-year assignment that took him to Arizona to work with the Indian Health Service on trachoma, which affected 25% of schoolchildren. He investigated other infectious diseases, including a severe outbreak of diarrhea affecting all age groups in the Truk Islands in the South Pacific. Twelve years later, the Truk epidemic was identified as rotavirus.

The Nigeria assignment was tailor-made for Foster. By 1966, the smallpox burden had reached 20 million cases and 3 million deaths worldwide. But hope grew, thanks to an increased supply of a new freeze-dried heat stable vaccine, the introduction of bifurcated needles, and use of jet injectors. On one memorable day, Foster and his colleagues vaccinated 14,000 people who queued in four lines. Surveillance and containment replaced mass vaccination as the African and global smallpox eradication strategy. 

As the USAID CDC team leader for smallpox eradication and measles control in Nigeria, Foster was often out in the field, where 65 Nigerian teams supported by eight CDC colleagues were hard at work. The Foster home in Lagos served as a respite for exhausted team members. 

"Our lives were smallpox," remembers Dottie Foster. "Every single meal, we talked smallpox. We even had smallpox scabs in the refrigerator, waiting to be transferred back to the CDC."

They also immersed themselves in the fabric of their community. "Dad always has believed in the power of individuals and wanted us to be connected with the community," says his son, Andrew, now director of the Population Studies and Training Center at Brown University.

Dottie, for example, jumped in to help a local midwife support a displaced community. She managed to find a local supplier for powdered milk for the children, convince a local chief to donate land for a nursery school, apply for a grant from USAID for building materials, and recruit young people from Crossroads Africa (a forerunner of the Peace Corps) to build the school.

Along with successes came some scary moments. A late-night phone call from the wife of a Nigerian health official brought Stan quickly to her husband's aid. He found his friend bleeding profusely from a machete cut across the neck, and although he tried to save him, the injury was too severe.

The next day, armed policemen showed up at the Foster house to arrest Stan for the murder. Six hours of a terrifying standoff passed before the American Embassy was able to intervene. For several years, Foster was persona non grata in Nigeria.

Dhaka, Bangladesh, 1972-1976

His next assignment to Bangladesh brought a new set of challenges. Civil war had destroyed the nation's infrastructure. Only 10% of 80,000 smallpox cases were reported in 1972. Hindus and Muslims believed that the pox was sacred. Gradually, the smallpox team of Bangladeshi and WHO staff expanded, though they faced increased transmission during the dry and wet seasons.

Political unrest challenged program operations. When fighting broke out in the Fosters' neighborhood, Dottie gathered their children to "play house" in a closet to keep them safe and unafraid.

Among those dispatched by the CDC for field work in Bangladesh was Jeffrey Koplan, who lived with the Fosters for three months. (Koplan served as director of the CDC from 1998 to 2002 and today is vice president of global health at Emory.) He learned Bengali with Dottie Foster at the kitchen table, and from Stan Foster, he gained the practical skills that he would use the rest of his life.

Koplan also saw firsthand how to lead. "Stan Foster has zero ego and is selfless in what he does," he says. Within two years, the eradication team had reduced the number of infected villages to 89. Foster predicted eradication by the end of 1974, but then came the worst floods in Bangladeshi history. By the next spring, smallpox had infected 1,410 villages. 

As used in India, Foster introduced a reward for reporting a new smallpox case. Six months later, only 35% of the public knew about the reward. Only then did his team discover their mistake. Health workers were keeping the reward quiet to keep the public from claiming the money. Foster had a fix for that: he doubled the reward to pay both the health worker and the public. Within five months, 80% of 60 million Bangladeshis knew about the reward. That, coupled with eradication teams who searched 1,200 houses every six days, turned back transmission of the disease. 

On November 14, 1975, WHO announced the eradication of variola major, the severe form of smallpox. But then came the report of another case. Three-year-old Rahima Banu, found under a burlap sack and covered with painful pox, was vaccinated in 1975. Hers marked the last case of variola major in the world, and luckily she survived. 

Atlanta, 1994-2013

Stan Foster entered the MPH program at Emory in 1976, but it took him six years to finish his degree. He kept getting called back to the Middle East and to Africa, where he led CDC efforts to combat childhood communicable diseases in 13 countries. 

In 1994, Foster returned to the RSPH to put down roots as a faculty member. He since has shared three decades of field experience with students, whom he prefers to call "learners." 

His classes have been popular. He regularly showed up dressed in character to deliver a lecture. His stories are legend. But behind those entertaining stories were valuable lessons.

"Stan's stories get people thinking," says Aisha Stewart 13MPH. Like dozens of other students, Stewart decided to attend the RSPH because of Foster's recruiting. When she attended Visit Emory, the annual spring event for prospective students, he took out an index card from a stack that he had made that contained excerpts from her CV and personal statement. "I was astonished at the personal attention," Stewart says. "I didn't find that anywhere else, so I decided to come to Rollins."

Given his stories, openness, and availability, Foster became a favorite teacher, receiving the Public Health Professor of the Year award from the RSPH in 1996 and the Emory Williams Teaching Award from the university in 2010.

Of the courses that he has taught, Foster's favorite is "Strategies," which the students dubbed "Tragedies." The class worked in small groups, each led by a teaching assistant, to take on a different health issue in Ethiopia drawn from 10 data sets. On topics ranging from family planning to sanitation, each learner developed a plan and budget to address the challenge. 

Another hallmark Foster class is "Community Transformations," which he will continue to coteach for learners from Emory and the refugee community in Clarkston, Georgia. The goal of the course—to strengthen communities to identify and solve their own problems—emphasizes Foster's trademark style of working in partnership with communities.

"He hates the idea of top down," says Micah Hahn 08MPH, who participated in the class. "He taught us that we are not here to tell anyone what to do."

Sautee, Georgia, the present

Among those lined up to make a comment at the end of Foster's last lecture was the man who sat beside him on the first day of their EIS class in 1962. William Foege, who would go on to lead the worldwide smallpox eradication campaign, knows the Fosters well. "Stan and Dottie epitomize the phrase from the book Cutting for Stone," Foege said. "Home is not where you are from. It is where you are needed." 

Home these days for the Fosters is a cabin in Sautee, Georgia, that overlooks a portion of the Appalachian Trail. Their presence here continues to draw public health stewards, colleagues, students, and fellows from around the world to enjoy the Foster hospitality.

Just weeks after retiring from the RSPH, Stan and Dottie returned to the Guatemalan village where she was born, as they have done for dozens of years, to conduct training and workshops with the native Mam women. The collaboration has spawned more than 300 microfinance projects.

The Fosters' impact has been far and wide, says Jean Roy, whom Stan mentored at CDC. "He's a giant in public health. I believe that along with D.A. Henderson and Bill Foege, he's one of the top three epidemiologists ever."

One of the biggest measures of Foster's career is that smallpox is eradicated from the earth. And there are Foster's learners, many of whom stay in regular touch. As Rebecca Vander Meulen 03MPH writes from Mozambique, "Stan helps people dream about what could be, and challenges them to make it happen."

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