Jay Friedman Oral History - West Africa

Interview Transcript
	   
This is an interview with Jay Friedman on July 13, 2006, at the Centers for
Disease Control and Prevention in Atlanta, Georgia, about his involvement
with 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 Diane Drew.

Drew: Would you mind giving me a little bit about your background, where
           you grew up, what's your education, that kind of thing?
Friedman:   I was born and raised in New York City, in the borough of
           Queens. I went away to college at the age of 17, to Florida
           State University in Tallahassee, Florida, where I graduated in
           1961.
Drew: And what was your field of study?
Friedman:   I majored in business administration-not that I was so business
           oriented, but I wasn't a great student and thought that was an
           easier path to grey hair. I was the equipment manager of the
           baseball team, which was a championship team. And, as equipment
           manager, I had a full scholarship, which my father loved, which
           is why I stayed at Tallahassee.
                 Following that, I went to law school for a year. But I
           didn't like it very much, and joined the Peace Corps in 1962. I
           spent 2 years in Sierra Leone, West Africa, mostly teaching
           English, math, and motor mechanics-
Drew: That's quite a combination.
Friedman:   -in a vocational high school in the city of Freetown. Motor
           mechanics because I had put my way through college working as a
           mechanic at an Oldsmobile dealership in Long Island, New York.
Drew: How cool.
Friedman:   Learned how to work on cars, which perplexed my father totally.
Drew: That's a very handy skill to have.
Friedman:   Yes. One problem is my knowledge of cars ended when I graduated
           from college in 1961, so I know nothing about newer cars, just
           old ones.
                 Following the Peace Corps, in 1964, I went to American
           University in Washington, D.C., majoring in international
           relations and economics, and, if you like, a minor in French,
           which I learned to speak fluently. I spent 5 months in France to
           that end.
Drew: What part of France?
Friedman:   I was in Paris, then in a small town called Boulogne-sur-Mer,
           which is right on the English Channel. From the high part of the
           town, you could see the White Cliffs of Dover.
Drew: Oh, wow!
Friedman:   We used to go on weekends in France.
Drew: So you were really immersed in France, I'm sure.
Friedman:   Yes. I was living with a family in Boulogne. The husband was a
           fishing-boat captain. And Boulogne is the world's capital for
           mussels. So I had mussels smothered in loads of butter at night
           and gained lots of weight. Thankfully, though I still love
           mussels, I left the French way of cooking behind.
                 I finished at American University with a master's degree
           in 1966, at which time I didn't know exactly what I wanted to
           do. I was approached by the Coast Guard to become a Coast Guard
           officer, which I seriously considered.
                 I had been getting a Peace Corps bulletin for returned
           volunteers, which came every month or so. And at this very
           juncture of my life, the issue that was delivered to my
           apartment in Washington had an advertisement from CDC. They were
           looking for people who had lived in Africa, who could speak
           French, and who could fix a car.
Drew: This sounded like it had your name written right on it.
Friedman:   It just jumped off the page.
Drew: Really.
Friedman:   So it had a phone number in Atlanta. And this was in the days-I
           don't know if you remember these-when making a long-distance
           phone call was a big deal. Quite a big deal.
                 So I dialed the phone number and got a gentleman named Leo
           Morris on the phone. He was the assistant branch chief or the
           assistant chief in the smallpox program. He was coming to
           Washington the next day for some unrelated reason, and we made
           an appointment to meet.
                 We did. He interviewed me, and he hired me on the spot.
Drew: That seemed so fateful.
Friedman:   But I don't think at CDC today, anyone can hire anyone on the
           spot.
Drew: That's true, that's true.
Friedman:   And certainly not anyone without any public health background
           whatsoever, who could merely speak French, fix cars. I don't
           think such qualifications would get you anywhere today.
Drew: But it's the perfect combination.
Friedman:   Right. And Leo said, "You're hired." I don't know what
           bureaucratic shortcut he used, but that certainly was the case.
           And 2 weeks later, in July 1966, I was here in Atlanta. I flew
           down from Washington and rented an apartment-an apartment, which
           I believe is where this very building, Building 21, is now. If
           you're looking at the buildings, to the right of the building
           they just tore down, there was an apartment house. CDC was much
           smaller then.
Drew: Sure.
Friedman:   And there's still a pine tree growing right there, which was
           right next to my bedroom.
Drew: Oh, how funny.
Friedman:   The tree is still there; nothing else.
Drew: That's funny.
Friedman:   In any case, I was the closest person at CDC to the office. We
           met every day in the auditorium, which has just been torn down.
           And I literally awakened at 10 to 8:00 and would be sitting in
           the place where we had our training course 10 minutes later.
Drew: You had a really easy commute.
Friedman:   I had an easy commute. The apartment became a motel later.
Drew: Didn't CDC take it over and have offices there?
Friedman:   The motel closed, and there were CDC offices there. Through the
           '80s. And it was only in the '80s, I believe, or the early '90s
           that they built Building 21. But, thankfully, did not cut my
           tree down. I have a picture of me in front of it in 1966.
            Anyway, I began at CDC as a trainee in the Smallpox Eradication
           Program in July '66. Leo Morris, the guy who hired me, was my
           boss.
Drew: And you were in the public health advisor series?
Friedman:   Yes. There were 4 of us hired through this Peace Corps
           advertisement: myself, Jean Roy [Jeannel A. Roy], Tony Masso
           [Anthony R. Masso], and Mark Pointe, all of whom are going to be
           present at the reunion.
                 And the others-I think all of them-were public health
           advisors for the VD [Venereal Diseases] program, the VD branch,
           who had been chasing syphilis up and down the streets of New
           York City.
Drew: Yeah, [looking for] the contact persons.
Friedman:   It was felt that their expertise in that regard would be useful
           in smallpox. The 3 other guys and I who were coming from the
           Peace Corps did not have that expertise, but we knew the
           language and other things, fixing cars. Tony was with the Peace
           Corps in South America somewhere. But Mark, Jean, and I had all
           been in Africa and all spoke French.
                 Anyway, we started a training program here in Atlanta,
           which went on for several months. We were taught epidemiology,
           the epidemiology of smallpox in particular, which was very
           simple, actually, in the scheme of things in the world of
           epidemiology; and administration, how the government works.
                 We would be going to 19 countries. The majority of them
           were French-speaking countries, French colonies in West and
           Central Africa.
Drew: And did you know ahead of time which country you were going to go to?
Friedman:   Not at the very outset. When the program began, I think none of
           us knew, although I assumed, having learned French, I'd be going
           to a French country. At some point during the training course,
           which went on for 3 months, we were told. Originally, I was to
           go to Niger, and then, for various reasons-I forget what they
           were-I was told I would be going to Mali.
                 In most countries, we had both a medical officer and what
           were called operations officers, of which I was one. Our jobs
           were to assist the medical officer with the epidemiologic work-
           ups of smallpox outbreaks. More importantly, we were in charge
           of the logistics of the whole enterprise because the people who
           organized the program-D. A. Henderson [Donald A. Henderson], Leo
           Morris, Henry Gelfand, Rafe Henderson [Ralph H. Henderson], and
           others-wisely realized that smallpox was not so much a medical
           problem as a management and logistics problem.
                 The means for fighting smallpox were mostly known, not
           totally. Its epidemiology is very simple. Vaccination is an
           absolute preventive measure for varying periods of time. It's a
           simple disease epidemiologically in the sense that only human
           beings are the reservoir, meaning the virus doesn't lurk in
           water or in insects or in the environment in general. The virus
           is only found in humans, which makes a huge difference. Once you
           interrupt the chain of transmission from human to human, you can
           stop the disease in its tracks, which had been done in much of
           the world by 1966. The major foci, or the focus-I'm not trying
           to impress you-
Drew: Hey, I'm already impressed. It's okay.
Friedman:   Remaining in the world were foci in Brazil and East Africa,
           which was variola minor; an attenuated form of smallpox, and
           variola major, the real smallpox, with a 25% death rate, in West
           and Central Africa, the Indian subcontinent, and Indonesia.
           Almost all other countries had eradicated smallpox through
           vaccination activities. And it was, of course, eradicated in
           countries with the best-and I'm going to use this word loosely-
           management.
Drew: Sure.
Friedman:   So, naturally, in developed countries, they had mass-vaccinated
           enough of the population years before that it never really even
           got a foothold.
            Well, we had it in the United States, I guess, in great amounts
           in the 19th century. In the 20th century, there were just
           sporadic outbreaks. I remember as a child in New York City,
           there was a scare, around 1947, right after the war. I think
           there were a couple of cases of people coming from other
           countries where it was endemic. There were 1 or 2 cases in New
           York City. But the entire city got vaccinated immediately,
           including me. I remember it well as a child.
            I believe the last cases in the United States were in the very
           late '40s, I think in Texas. They might have been imported cases
           from Mexico. I don't remember exactly.
                 In Europe, there was an outbreak in the '70s in Yugoslavia
           of some Muslims. I believe it was involved pilgrims from Mecca
           to Yugoslavia.
                 Most cases outside the endemic areas I named were
           imported, usually traveled from an endemic area. Mecca was a big
           point for the transmission of many communicable diseases because
           masses of people gathered there. But there were other areas
           where smallpox cases would come from.
                 Anyway, I went to the training course, and I was assigned
           to work under a medical officer named Pascal James Imperato,
           known as Pat, who's going to be here also. In fact, he and his
           son are staying at my house. Pat and I went to Mali. I went in
           December of '66 and Pat a month or so later.
                 And the original strategy for eradicating smallpox in West
           Africa was to use mass vaccination of the population with jet
           guns.
Drew: Right.
Friedman:   Now, you've heard of these. They were developed by the military
           to quickly vaccinate the recruits, I guess anyone in the
           military.
Drew: Were these the ones that were powered, that required electricity??
Friedman:   Mali had a measles control program, also directed by CDC
           people, including Rafe Henderson, that began a year or so
           before; it used the military jet guns. And the jet gun consisted
           of a thing that looked like a gun, 2 hoses, and then a pump to
           pump hydraulic fluid into it and charge it, to load it, if you
           like, against a spring. The military once had an electric pump,
           which ran at 110 volts US current. To use the military jet guns
           in West Africa, you had to use a transformer and plug them into
           the wall, or, in this measles campaign, which predated smallpox,
           they had International American trucks with a refrigerator and
           generator mounted on the back. The generator generated 110
           volts, and they could use the electric guns in the field. This
           was all very unwieldy. The trucks would break; the generators
           would break. The electric pumps were very well made, made on a
           military, I believe, cost-plus basis so they were very solid.
           And the guns themselves rarely broke.
Drew: It was all the other things they were connected to?
Friedman:   Yes, the refrigerators, the trucks, even though Internationals
           are very good trucks.
                 They decided, wisely, that the electric guns weren't the
           way to go with smallpox, although we had a number of them in
           Mali. We assigned those to fixed health facilities, where they
           could plug them in the wall and transform them.
Drew: Where people could come to you.
Friedman:   Yes. This was mostly in the capital city.
                 Everywhere else in Mali, and everywhere else in West
           Africa, they used something called the Ped-O-Jet. It was the
           same gun part, upon which you put a bottle of vaccine and a
           needle. But instead of the pump on the ground, the 2 hoses
           coming to it being powered electrically; it was a pedal. The
           operator would step on the pedal-and I'm making a stepping
           motion.
Drew: Yes, right.
Friedman:   I'm telling the recorder that.
Drew: Please note.
Friedman:   And it would charge the gun, and the bottle of vaccine, of
           course, would be on the top. And then you pulled a trigger, and
           the vaccine would be injected forcibly into the skin of the
           vaccinee.
                 We had 2 types of nozzles on the guns. One was for
           intradermal smallpox injections, right on the top of the skin,
           and one for the measles vaccine, which was intramuscular, where
           it would go straight in as if it were a needle. Smallpox, you
           just deposit the vaccine on the surface of the skin and then
           prick the skin, normally with a needle. And this nozzle on the
           jet performed that function.
                 Unfortunately, the Ped-O-Jets were not made for the
           military. They were made for CDC by a firm in New York, and I
           don't think they were up to the same quality level. The guns
           would break-not so much break, as their internal valves and
           springs would wear out or get stuck. The nozzles would clog, for
           which we had special wires to ream them out. And especially the
           pedal, the pedal pump. I think they were made of aluminum with
           Teflon O-rings acting as piston rings. And this aluminum, being
           a soft metal, would wear out very quickly. Being an ex-mechanic,
           I had to fix them all the time, although I trained Malians to
           work on them, which is not very difficult.
                 And we spent a lot of time fixing these Ped-O-Jets. In
           fact, in Mali, we had 1 guy, a vaccinator, assigned full-time to
           work on Ped-O-Jets that were being used out in the field. So we
           had to transport them back to the capital to have this guy work
           on them. The simple repairs could be done in the field. But any
           time the pedal pump broke, you had to send it in. You had to re-
           machine the whole piston when that happened.
Drew: Sure. Was this whole process of doing the foot stroke on the pedal
           and shooting the gun difficult to coordinate?
Friedman:   Yes. That's a good question. In the French-speaking countries,
           we were very fortunate. The French had set up decades before
           something called a Service des Grandes Endemies (SGE), which in
           English is the Endemic Disease Service. It consisted of  mobile
           teams of male equivalents of registered nurses, which in French
           are called Infirmier d'Etat, which is literally "state nurse,"
           but it really means registered nurse. These are very high-level
           people with excellent training.
                 These groups of Africans would go in the bush, as we
           called it in Africa, on vehicles, sometimes walking or on horses
           or whatever, and attend to the public health needs of the
           population on a scheduled basis.
Drew: Making rounds in different areas?
Friedman:   Yes. And it was run as a military service. The workers in it
           had ranks, and they were, by and large, headed by French
           military doctors with military ranks. And under them were-it
           sounds very racist today-what they called in French Medecin
           Africain, which means African doctor. These were Africans
           trained in the university in Dakar, Senegal, to be medical
           doctors, but on a lower level. Shall we put it this way: they
           received less training than a medical doctor in France. So the
           heads of the Endemic Disease Service were usually the French
           medical doctors, and sometimes the French medical officers were
           in charge of actual teams. But, more frequently, they had what
           they called these African doctors, who, in my opinion, were
           superb people in the field. They really knew medicine on a field
           level. But, in fact, when you were sick, you didn't go see one
           of them. And they really had good training.
Drew: Well, it sounds very systematic, too.
Friedman:   It was very systematic. And they had a load of military
           [unclear].  Below them were the nurses, the Infirmier d'Etat,
           the male nurses. And below them were other ranks, vaccinators
           and so forth.
            Everyone had a rank. And these teams were, as I say, run in the
           military way. A team would line up in the morning in front of
           the Medicin Africain, or the senior guy on the team, to show
           their fingernails and show that they had cleaned them the night
           before. Etc. etc. It sounds colonial and semi-racist, but it
           worked. They actually eradicated sleeping sickness.
Drew: Great!
Friedman:   The formal name of sleeping sickness is trypanosomiasis, and
           the Africans used to call it the trypano service, service de
           trypano. And over the years-I think this began after World War I-
           they added other conditions and other diseases to the service,
           among which was treating lepers. They had lepers who would wait,
           for example, under a certain tree every month to get a drug
           called, I believe, Lomidin, if I'm not mistaken. I may have the
           names of the drugs wrong. So the guys on the teams would refer
           to them as "my lepers."
Drew: Because they'd meet with the same people on a regular basis?
Friedman:   Yes. The leper had to wait by a tree, by a bush, or on the side
           of the road, or a certain spot every month. The team would pass
           and give him his drugs. And they managed to control leprosy.
                 I remember going with some of these guys in the field, and
           you'd see some leper walking down the road. He'd say, "That's
           one of my lepers!" They knew them personally.
                 They treated leprosy. They started vaccinating against
           yellow fever, with BCG against tuberculosis, which was never
           used in the United States. They'd treat malaria patients.
                 When I got there, we wedded our resources-our trucks, our
           jet guns, and our smallpox and measles vaccine-to the Endemic
           Disease Service.
Drew: You kind of integrated into that existing system?
Friedman:   Exactly. And at one time, they were doing 5 vaccinations at
           once. They were looking for malaria, leprosy, sleeping sickness.
           Of course, there was smallpox, measles, BCG, yellow fever . . .
           What was the fifth one? I don't know.  There was a fifth one.
            They'd go into a village. They'd announce that they were
           coming. They'd send a runner or something. They'd say, "We're
           coming next week," or whatever.
           Believe it or not, the team would arrive in the village, and the
           villagers would be lined up by age and sex.
Drew: Wow!
Friedman:   I mean, this was fabulous! The head of the team would climb on
           the top of a truck and make sure everybody was lined up. They'd
           go to the whole village. I've seen this; it's almost
           unbelievable.
                 And the villagers were lined up by age and sex because
           each cohort of people and each age group got different vaccines
           and different treatments. If the teams were looking for sleeping
           sickness, they'd feel under the chin for swollen glands or
           something. (I think that was for sleeping sickness. These are
           other diseases I didn't know much about.)
            And these guys dealt with everything. They'd feel everybody.
           They'd palpate under the chin and they'd feel for sleeping
           sickness and leprosy.
                 We had a vaccinator arranged on each side of every person,
           and they'd get different vaccinations in each arm.
Drew: And the indigenous people apparently were very cooperative and
           willing?
Friedman:   Yes. And this operation was run like the military. The village
           chiefs were, of course, [unclear], and they loved us, and the
           people loved us.
                 Anyway, that's how we did our smallpox vaccinations in
           Mali, and it worked very well.
                 And the chief of one of these teams was a very senior guy.
           He'd climb on the top of the truck and start barking orders, and
           they'd actually obey them.
                 Anyway, Pat Imperato, the doctor I worked with in Mali,
           was an anthropologist also. He had actually written books on
           African culture and stuff.
                 Mali was very complicated because there were nomadic
           peoples in the country in what was called the delta of the Niger
           River, which is a big swamp area. It's not a delta at the mouth
           of the river at the sea; it's a delta in the middle of Mali, in
           the desert area, where the river would just spread out into a
           big swamp 100 miles across and then re-form as a river 100 miles
           later. There were nomadic cattle keepers in this area. And one
           of the major challenges we had was how to vaccinate those
           people.
                 So Pat, the doctor I worked under, studied them and
           figured out that they moved with their cattle in different ways
           and in different directions.
Drew: There was some pattern?
Friedman:   Yes, there was a pattern to their movements.
Drew: It wasn't just like a random kind of thing.
Friedman:   No, not at all. In fact, he did this along with Malian
           colleagues who knew all this. Pat sort of systematized their
           movements, on paper, and figured out how to position these
           vaccination teams in order to get these people when they were
           accessible. I think at certain times of the year they gathered
           in larger groups when the river got dry, which would be in April
           and May, just before the rainy season began. They'd sort of come
           together in a much smaller area in large numbers, where the
           remaining water in the river was present, where the cattle could
           graze and water. So Pat figured out that's the time of year when
           they should vaccinate the nomads.
                 The word for their movements in French was called
           transhumains [sp.], trans humans. I'm sure there's an English
           equivalent word, but I don't know what it is. I've never talked
           about this topic in English. But Pat was studying that. In any
           case, we vaccinated the area.
Drew: And did you have the same degree of cooperation?
Friedman:   Probably a bit less among these nomads. Not living in villages-
Drew: And kind of not having the structure of like a chief per se-
Friedman:   Exactly. That's an excellent question. I didn't even think of
           that. Not living in villages, they were much less easily ordered
           about, if you like. In fact, you couldn't order them about. They
           did their own thing with their cattle. And that was the
           challenge. And so the normal tactics used in villages had to be
           modified.
                 I would suggest you alert the interviewer who's going to
           work with Pat to ask him about vaccinating the nomads in the
           Niger delta. He's a very serious anthropologist. He's written
           books about this. He'll talk your ear off about it.
            All right. So we finished vaccinating Mali.
                 By this time, I had been there 2 years. It was September
           or October of 1968, and I was transferred to Gabon in Central
           Africa, which is around and below the [unclear] of Africa. It's
           a totally different country from Mali, which was semi-desert
           with many logistical problems.
                 I'd spent a lot of time in Mali working on trucks, fixing
           them, and fixing jet guns, and doing a little bit of
           epidemiology on smallpox outbreak investigation. We did have a
           couple of smallpox outbreaks.
                 When I went to Gabon, there was no smallpox, and my job
           was very different. First of all, there was no American medical
           officer there. I was on my own. I was working under a French
           military medical officer named Jean Claude Jeel [phonetic].  I
           was sort of his advisor on smallpox and measles vaccinations.
                 There, I got involved in surveillance, looking for
           smallpox. I also did maintenance for the jet guns and the
           trucks, although the French in Gabon and my predecessor in
           Gabon, Mark LaPointe, had set up an ongoing training course
           whereby the French and the Gabonese trained people on jet guns,
           so I didn't have a lot to do with jet guns. And I didn't have a
           lot to do with trucks. In Gabon, which was a much more
           economically advanced country than Mali, there were lots of
           garages in various towns, and it was possible to get things
           repaired. We didn't have to have our own mechanics, as we did in
           Mali, working on the trucks. If a truck broke, you'd move it to
           a garage and they'd fix it.
                 I learned a lot about surveillance, but I didn't have a
           lot to do, really. I mean, besides surveillance, there wasn't
           much. Plus, in May of '69, we achieved an interruption of the
           transmission of smallpox in West Africa, and I arrived in Gabon
           in late '68. So there was really less of a threat of smallpox
           transmission anywhere in West Africa. We were still looking for
           cases.
                 I stayed in Gabon from late '68 until April of 1970. So I
           wasn't there all that long, 18 months.
                 And then 2 things happened. Personally, I got married to
           my first wife, Lindsey Craper. She's British and was a professor
           at a university in Ghana. We met at a party given by George
           Lythcott, who was our CDC regional smallpox director. George
           lived in Lagos, Nigeria, where I went for a meeting in May of
           '69. Lindsey was a friend of George and his wife Jeannie.
           Lindsey was at the party, too, visiting Lagos from Ghana. So
           anyway, Lindsey and I met at this party. And, to make a long
           story short, a year or so later, we got married.
                 Interestingly enough, Jean Roy told me, the Jean and Betty
           Roy told me - you have to confirm it with him - that they met at
           the same party.
Drew: Oh, how funny!
Friedman:   You'd better confirm it with him.  But I believe . . .
Drew: Was it a New Year's Eve party, by any chance?
Friedman:   It was in May of '69, when we had a big meeting in Lagos.
Drew: Yeah, so it wouldn't have been New Year's Eve.
Friedman:   No, because we had achieved . . .
Drew: Because I may be mistaken.  I was thinking that Betty told me that
           they met at a New Year's Eve party.
Friedman:   A New Year's Eve party.
Drew: But I may be mistaken.
Friedman:   I may be mistaken.  One of us is mistaken.
Drew: Yeah, hey.
Friedman:   Anyhow, I think Betty knows.
Drew: It still sounds like a nice situation.
Friedman:   Betty knows.  If Betty said it was New Year's Eve . . .  Maybe
           it was at George's house for a different party.
Drew: Yeah, yeah.
Friedman:   So, anyway, Lindsey and I got married, and my term in Gabon
           ended, and it was decided there was no need for any further CDC
           operations overseas in Gabon.
                 But Nigeria had been the site of the last outbreaks of
           smallpox. It was a very large, very populous country, and it was
           felt we should really do much more intensive surveillance in
           Nigeria. Nigeria had just reorganized itself politically, the
           entire country. Instead of large regions, there were now states-
           I think there were 11 or 15 or something like that. And they
           wanted an operations officer in each one of the states to be in
           charge of the surveillance efforts and continue with mass
           vaccinations (although, at the time, we were switching away from
           mass vaccination).
Drew: And Nigeria was colonized by the British?
Friedman:   Yes. It was an English-speaking country. But my first
           assignment, Gabon, was French-speaking, of course. Nigeria is my
           first English-speaking country.
Drew: My son says that the health care systems left behind by the
           respective colonial powers were somewhat different in terms of
           how well or maybe not so well they worked.
Friedman:   Exactly, very different political and health structure in
           Nigeria from the French, ex-French colonies like Mali and Gabon.
                 Anyway, I was assigned to Kano state in northern Nigeria.
           It's at the very northernmost part of Nigeria. So my new wife
           Lindsey and I moved to Kano, where I was assigned to what was
           called the Epidemiology Unit in the Ministry of Health of this
           state of Kano. My boss was the chief medical officer of the
           ministry, Dr. Patel; he was Indian.
                 Northern Nigeria is an interesting area.  The people are
           Hausa-that's the name of the ethnic group; it is a very large
           ethnic group. And the Hausa language was spoken all over that
           part of Africa, even among people who were not Hausa ethnically.
           It's a much simpler language than the languages further south in
           Africa in that it's Hamitic. It's more like Indo-European
           languages. So foreigners tend to learn it to a greater or lesser
           extent. My wife, Lindsey, learned it perfectly. Her field is
           linguistics. I learned it a bit, enough to talk to villagers.
                 In any case, our job was continuing mass vaccination,
           although, as I started to say, we were switching to what was
           called the surveillance-containment approach to eradicating
           smallpox. Instead of vaccinating everyone, we'd merely do
           surveillance for smallpox outbreaks. When we found an outbreak,
           we'd do what was called ring vaccination around the outbreak
           area, including the immediate contacts of each case. Eventually,
           this strategy was adopted for the rest of the world, especially
           in the Indian subcontinent. And that was the strategy that
           eradicated smallpox.
            In densely populated countries, including northern Nigeria,
           mass vaccination really couldn't work. It really couldn't get
           everybody, get enough of a herd immunity whereby by the disease
           transmission would be interrupted, especially in India. You
           could never mass vaccinate there.
                 So, in any case, we started doing surveillance-containment
           in Kano state and continued vaccinating, continued looking for
           cases. We never found any.
                 All the while, we were doing vaccinations against measles
           also. The problem with measles was the vaccine. It was much less
           heat stable than the smallpox vaccine. The measles vaccine had
           to be kept frozen. With the smallpox vaccine, we learned that
           (although officially it was supposed to be kept cold) because it
           was freeze-dried and very heat-stable, you didn't have to keep
           it cold. It stayed potent. You couldn't have it out in the sun,
           but as long as you kept it covered, it would stay potent for a
           long time. But with measles vaccine, in spite of our best
           efforts, I'm certain that there were occasions where we were
           vaccinating with impotent vaccine because the cold chain, with
           the fridges and little cooler boxes that the vaccinators carried
           to keep the measles vaccine frozen, just broke down.
Drew: Sure.
Friedman:   We did control measles in certain countries. Gambia was 1
           example. But in other areas, we had greater or lesser success
           with measles control. It was never thought we'd eradicate it,
           although they did in Gambia for a while.
                 In any case, I spent 2 years in Kano, which were
           delightful. I was newly married. It was a very large and well-
           developed city with an international airport, direct flights to
           London and elsewhere in Europe.
                 I joined a British club, which I thought I'd never do,
           learned to play squash; I really had a nice time in Kano. I
           mean, I worked very hard, but the state of Kano was very heavily
           populated, and the area was rather small. So I rarely had to
           spend the night out in the bush as I did before.
Drew: You could do what you needed to do on certain day trips?
Friedman:   Exactly. And so I slept at home most nights. And my older
           daughter, Laraba, was born. Laraba is a Hausa name for girls
           born on Wednesday, which we had chosen from the pantheon of
           girls' names-7 of them, one for each day of the week; well,
           there's more also-before we knew, of course, what day she was
           going to be born on. It was a 6:1 bet. She was, in fact, born on
           Sunday, but .she still wound up being named Laraba.
Drew: A very pretty name.
Friedman:   Which is the name she retains to this day, of course. She is
           now 35 and living in London.
                 What else happened in Kano? We had a very congenial work
           experience there. The epidemiology unit that I worked with was
           headed up by a man named Al-Haji Mohamed Kozoray, he and I
           became quite good friends. We worked together well. Everything
           was nice in Kano. I liked it.
Drew: And so your eldest child basically was a toddler in Kano.
Friedman:   She was an infant. She was actually born in the U.K because my
           wife was English, as I mentioned. Laraba came to Kano in
           northern Nigeria at the age of 2 weeks. And we stayed there
           until April of '72, which was the end of my West African
           sojourn.
                 I went on to do smallpox eradication in Nepal, which is
           not the topic at hand. So I guess I ought to end right here.
Drew: Well, it's a shame because I'd love to hear that story too.
Friedman:   Oh, really? I'd be glad to tell you that one. Any other
           questions?
Drew: Well, are there any other things that you can think of about your
           experiences that you'd like to share?
Friedman:   The only thing I could say about my experience is that it
           introduced me to public health. As I said at the outset, it was
           not my field at all, unlike the other operations officers who
           had come from the VD branch.
                 Eventually, after living in Nepal and then the
           Philippines, where I was in the Expanded Program on
           Immunizations, I came back to CDC in 1978. I joined the Division
           of Reproductive Health and spent 25 years working on
           contraceptive-prevalence surveys, largely in foreign countries.
           But towards the end of the 25 years, I was also working on
           behavioral risk-factor surveys on Native American reservations.
           We had monies from the Indian Health Service to run surveys on
           Indian reservations similar to those I had done in foreign
           countries on contraception. We looked at behavioral risk
           factors. As you know about Native Americans, smoking, diabetes,
           and other conditions related to behavior are important.
                 So I would say my last 5 years at CDC, before I retired in
           2003, were spent working on Indian Health Service stuff,
           surveys; and they paid half my salary. So I had a rather diverse
           career.
Drew: It sounds really interesting and rewarding.
Friedman:   I think so. And I think I was lucky. As a public health
           advisor, I was never pushed up into administration like so many
           people were. I remained in science my entire career. I never had
           to supervise anyone really, which I found much more enjoyable
           than working in administration, which is not my cup of tea.
            So I had a very rewarding career. I always liked going to work
           in the morning. Never in my wildest dreams, before coming to
           work at CDC in July of '66, would I have thought I'd work in
           anything having to do with health, public health, epidemiology,
           survey data analysis, and everything else I did here. So I
           really had a very rewarding career at CDC.
Drew: That's great. And that's very interesting to hear about, and I really
           appreciate it.
Friedman:   You're welcome.
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