Neal Ewen Oral History

Interview Transcript
	   
This is an interview with Neal Ewen on July 14, 2006, at the Centers for
Disease Control and Prevention in Atlanta, Georgia, about his involvement
in the West African Smallpox Eradication Project. The interview is being
conducted as part of a reunion marking the 40th anniversary of the launch
of the program. The interviewer is Kata Chillag.

Chillag:    Let me ask you about how you came to do public health as a
career.
Ewen: I graduated from college in 1960 with a B.A. in English. Then I spent
           2 years in the Army. In 1963, I went to a job search through my
           university. One of the people interviewing at that time was a
           CDC rep who was hiring venereal disease [VD] investigators. I
           accepted the position and spent about 3 years in VD prior to
           joining the smallpox program.
Chillag:    How did you make the transition to smallpox?
Ewen: Well, there were a number of people interviewed, and I was one of
           those selected for the program.
Chillag:    So you had an interest in doing . . .
Ewen: I wanted to do it, yes. But this is all self-select. I mean, we all
           wanted it.
Chillag:    What was your role in the smallpox program?
Ewen: I was a Public Health Advisor assigned to Bangui, Central African
           Republic [CAR], where I worked with the local Ministry of Health
           in matters concerning smallpox and measles vaccinations.
Chillag:    And I understand that, unlike many, you were alone, without a
           medical officer. Is that correct?
Ewen: Partially. I had no medical officer in CAR, but there was a medical
           officer based in Chad who covered both Chad and CAR. But,
           obviously, since he lived in Chad, he spent most of his time
           there.
Chillag:    Had you worked internationally prior to smallpox?
Ewen: No. I had no international experience prior to this.
Chillag:    So, what were your expectations of working in CAR?
Ewen: Well, to just learn about different things-the program, obviously,
           but also seeing different cultures and seeing if I could learn
           enough French to survive, which I did.
Chillag:    Did you have prior French training?
Ewen: I had French training in CDC during the summer of 1966.
Chillag:    So, what were your expectations of the work before doing it?
Ewen: Well, we had a pretty good idea of what we would be doing in terms of
           working with teams that were provided with vaccine; with the
           means to administer it, called the Ped-O-Jet; the procedures for
           ordering supplies; and some attempt to account for supplies,
           which we could do, certainly, at the central level. Once the
           supplies were distributed to the field, they were distributed,
           so they had to track it at the field level.
Chillag:    What were the biggest challenges in doing these things?
Ewen: I think traveling over rather difficult nonpaved roads in the country
           took a lot of time and energy. And just getting from 1 place to
           another was a challenge, particularly during the rainy season.
                 As far as the operation of the Ministry of Health teams at
           that time, they more or less closed down in our summer-July,
           August, September-because the heaviest rains came at that time.
Chillag:    So you had to, of course, collaborate with locals and the
           Ministry of Health and then the field. What was that like?
Ewen: It was much different in Chad, CAR, Cameroon, and Gabon, what they
           called the OCEAC [Organization de Coordination pur la Lutte
           contre Endemies d'Afrique Central] countries, and the OCCGE
           [Organization de Coordination et de Cooperation pour la Lutte
           contre Grandes Endemies] countries further west, e.g., Mali,
           Guinea, Ivory Coast.
                 I was attached to the central office. There was a major in
           charge, a military naval captain. He had doctors in 5 sectors in
           the provinces, and they were in charge of their provinces. So I
           didn't have to set up vaccination teams, as some of my
           colleagues did. We provided them the supplies. They had the
           infrastructure, and with a little training in how to administer
           this jet gun, they were ready to go. So we didn't have to worry
           about the supplies and logistics and setting up schedules and
           supervising. That was taken care of for us.
Chillag:    Was the ministry very receptive overall?
Ewen: They had no problem with our being out there. I was fortunate enough
           to be placed in a building in the Ministry of Health office,
           where they could not say even "Good morning" in English, so I
           had to learn French. What happened to practically all the other
           Americans over there is they worked out of the American Embassy,
           and they didn't learn to speak French because they didn't have
           to. But it was forced upon me.
Chillag:    Of your training, skills, and experiences that you had before
           doing this, what were most useful for you?
Ewen: Well, I was used to the VD program of going door-to-door and meeting
           people and talking to them. They were not always the most
           cooperative of patients or clients or whatever you want to call
           them, so I had that personal-skills experience, which I think
           may have helped a little bit. And I was in a position where I
           didn't have to try to motivate the workers. That was the job of
           the ministry. And they were pretty much motivated. They wanted
           to keep their jobs because jobs were scarce in all of those
           countries.
Chillag:    Well, I just wonder about this because I worked quite a bit
           internationally, and one of the biggest challenges was getting
           stuff, procurement. So I'm wondering if there were any
           particular challenges related to that.
Ewen: There were no problems for me with procurement. I think with every
           program in West Africa, we had no difficulty getting supplies
           sent from America. We'd communicate with CDC for so many doses
           of vaccine with a time schedule. CDC would notify the
           manufacturer. We'd get information when the material was coming
           in, by what flight. (I think there may have been some surface
           delivery, but I don't think so. I think everything was delivered
           by commercial air.) So, no, procurement was not a problem It was
           just "I need this," and it was taken care of. Competitive
           pricing was also not a problem. Somebody else did that.
Chillag:    Nice. So, what do you wish you had known beforehand that you
           didn't know?
Ewen: I hadn't ever thought about that. I don't think I can answer your
           question.
Chillag:    Okay. Well, if something comes up . . .
Ewen: I learned a lot. It wasn't something I expected, so to speak.
Chillag:    Yes. So what were some key things that you learned?
Ewen: Well, one, of course, I learned the French language, which has not
           served me well in this country but served me well there. And I
           guess one  thing I learned is that I wish I had gone on to learn
           Spanish, but I didn't.
                 The other thing, I learned was that I was very much a
           white expat [expatriate] in a black country. They had their
           customs, their cultures, and some of them were quite strong. And
           I never tried to challenge any of the beliefs. I accepted what
           people told me. I had difficulty sometimes separating truth from
           fiction. I think most of the time I got the truth, but their
           beliefs were so far from my own cultural beliefs that it was
           hard to accept some of the things they believe as truth.
                 To give you an example, they think differently, we think
           differently. Neither one of us is wrong. We're simply different
           cultures. So that is one of the things I learned. And that's
           been very good. It's given me a better outlook on the world and
           the problems that go on in our lifestyle.
Chillag:    Tell me about your living conditions.
Ewen: Oh, we had very nice housing. We were under what I call the embassy
           umbrella. It provided us housing and took care of our electrical
           problems, our plumbing problems, things of that nature. The only
           thing we had to pay for were our personal house servants; I had
           1one in CAR and two later, in Upper Volta. And you paid them
           their salary, and that was the extent of the fixed expenses
           except that you had to buy your own food. But for that, they
           allowed you a post allowance and they allowed you a post
           differential, and the two are different. But that helped relieve
           some of the cost of the food, in particular.
Chillag:    So you were alone? You weren't with a family?
Ewen: I was single when I went to CAR. I was married when I went to Upper
           Volta.
Chillag:    And how was bringing your wife to Upper Volta?
Ewen: She seemed to like it okay. I mean, she was pretty much like the
           other American women, a stay-at-home mother. She did briefly
           work for  agency in New York that was trying to gather all kinds
           of public printed literature from different countries, and she
           would go to the different ministries saying, "What do you have
           that's public but is free?" Sometimes she would  pay for it and
           she was paid f by New York, and in the process made some
           contacts herself. That kept her busy for about a year. So she
           seemed to enjoy it.
Chillag:    You talked about traveling on the bad roads. Did you travel a
           lot regionally or within the country?
Ewen: I was always within the country. We had this central office in
           Bangui, the capital, and there were 5 provincial capitals, if
           you will. I traveled to them, but always by truck.
                 One time I was talking to a colleague about how I would to
           drive these horrendous distances. He said, "Why don't you take a
           plane?" I said, "There are no private airlines in CAR." The only
           airline we could use was to make arrangements with an American
           who happened to have a pilot's license, or to borrow the
           presidential plane, the President of country, by the way. No
           internal flights. I drove.
Chillag:    Did you have one of those infamous Dodge trucks?
Ewen: I was the only program in the country that did not have a Dodge
           truck. One of the good things an otherwise incompetent
           administrator did was to insist on International Harvester,
           which was a wise move on his part because in Bangui, there was
           an International Harvester dealer. He was selling trucks similar
           to mine with many of the same parts. So if I was lacking
           something in spare parts, I'd go down and buy them from him.
              And so I did have the International truck, the equivalent of
           the Dodge truck.
Chillag:    But with a dealer.
Ewen: Yes. Oh, that was good. I had a dealer available. It worked well.
Chillag:    You've touched on some of them, but what do you think was the
           biggest challenge about the work?
Ewen: I don't know if this was a challenge, but retrospectively, I was cut
           off from a lot of things that were going on at CDC in other
           areas because you just weren't around to talk about them and
           hear about them, and-except for official publications-read about
           them. So that was an outcome. t was not looked upon as a
           challenge at the time, but I realized it was a shortcoming, if
           you will.
Chillag:    And it affected your work there?
Ewen: No, it didn't affect my work there, no. As I say, I made that
           judgment later on.
            As for other challenges. . . I think I mentioned the fact that
           it was tough to travel, and learning the French language.
Chillag:    Well, to step back and look at the program as a whole, if you
           were in charge, were there any changes you would make about how
           it was run or done?
Ewen: We didn't have a problem with smallpox in CAR. We did with measles.
           Cameroon, next door, did have some smallpox, but it didn't get
           across the border. The French had done a pretty good job of mass
           vaccination. And the population in the country was sparse so
           that cut down the means of transmission in a crowded country
           like Nigeria or Senegal.
                 No, I don't think I felt that I needed to see any changes
           from my point of view. I'm guessing there were a lot of people
           in Nigeria who probably have a different outlook on that. Of
           course, that was a tough country to run. But not where I was.
Chillag:    What were the biggest rewards for you of the work?
Ewen:       Oh, a sense of freedom, a sense of adventure, the fact of
           learning another language and seeing the cultures.
                 Although tangential, I found out that I'm very much a
           white expat. I would never do well as a permanent member of any
           other societies, nor, I think, could I live in Europe very
           comfortably. Some people make that transition, but I don't think
           I could. I would always feel as an outsider.
Chillag:    Why do you think that is?
Ewen: I think it's my personality.
Chillag:    Interesting.
Ewen: I like to be there, but with a defined period of time when I can make
           decision whether I want to stay there.
Chillag:    I understand. At what point did you think smallpox could
           actually be eradicated?
Ewen: Well, when I left the program in 1970, they were still doing a lot of
           work in Nigeria. But we did have reports showing progress, a
           decline in the number of cases. And everything I read and heard
           saying "We're going to get it" rang true. I realized they were
           going to be able to eliminate smallpox in Africa.
                 Later on, the World Health Organization took on a big
           initiative in Far Eastern Asia, and some of our CDC people
           worked there, some for very short tours. But smallpox had to be
           eradicated. I was a little more skeptical about that, but they
           got it done.
Chillag:    And how does it feel to have been part of that?
Ewen: Oh, very good. It was a good group I worked with. That was the main
           thing about the group that I was with.
                 I mentioned this to a couple of people today or yesterday,
           that during that summer of '66, we were all there-[ages] 25, 28,
           to early 30s-willing to go, wanting to go, and during the course
           of the summer, something happened to the group. And I realized
           later on what happened: we developed that magical, ineffable
           quality called esprit de corps. You don't teach that. It has to
           happen. And I think, by and large, it happened with our group.
Chillag:    And did you maintain contact over the years?
Ewen: Oh, yes, with several people.
Chillag:    Has your experience affected any choices or other things that
           you've done in your career after that?
Ewen: No, I don't think so. Oh, when I came back the second time from Upper
           Volta, I moved into family planning for CDC, assigned to a state
           health department in Albany, New York, for 10 years. Then I took
           my last 10 years, also in family planning, at CDC headquarters.
           But I don't think my work in smallpox affected me either
           positively or adversely. Well, it may have been positive in the
           sense that I have been successful in coping with different
           situations, so that may have been a side benefit. I'm not aware
           of it.
Chillag:    Is there anything that you think is important to people to know
           for posterity about the smallpox eradication and your
           experience?
Ewen: Not from my own experience, no.
Chillag:    In general?
Ewen: Well, I think some of the comments that people made and emailed
           preparing for this would probably sum up my thoughts, too, about
           epidemiology and various principles that have developed out of
           what they did.
Chillag:    Well, thank you very much. It's been a pleasure.
Ewen: Okay. Thank you.
                                    # # #