Interview Transcript
SMALLPOX-MEASLES, THE PRESENT AND THE FUTURE
July 16, 2006
Centers for Disease Control, 40th Smallpox reunion
By
Bill Foege
INTRODUCTION
I totally enjoyed last night and the recounting of stories. But it struck
me that we should do that two nights in a row for two reasons. The first
would be to correct stories. For example, I would not want you to think
that I actually ate Don Hopkin's special cake. What happened was that Don
brought the cake and asked Bill Watson to make sure that no one bothered it
until he could get pictures. I was meeting in the next office with Bill
when he asked if I had seen the cake. I had but I just said I thought I
would take a short break and go look at it. I ran down to the snack shop,
bought a cupcake and was stuffing the cupcake into my mouth as I went back
to Bill's office and I said, "That is great cake!"
The second reason is because of all the reminders that are triggered by
other people's stories. I recalled last night that while living in a flat
in Enugu, our house helper told me he thought the neighbors might have
tapped into our power line. That night we tested the theory by having him
watch their house while I went downstairs and turned off our power switch.
Half a city block descended into darkness!
Singing Happy Birthday for Chris D'Amanda last night reminded me of Ty Cobb
being interviewed on his 70th birthday. They began to reminisce about the
old days. The journalist asked him what he thought his batting average
would be if he would be playing today. Ty Cobb guessed it would be about
.290 to .300, considerably below his life time average. The reporter asked
what would be the major reason. Would it be because of new pitches,
artificial turf, constant traveling, or night games? Ty Cobb answered that
the main reason would be "Because I am 70 years old."
Most of us are in that range and we know it is easier to get older than it
is to get wiser.
The question, as we conclude the session, is a search for wisdom.
WHAT DOES IT ALL MEAN?
Samuel Johnson said we can not tell the precise moment when a friendship
starts but as with a glass of water being filled drop by drop there is one
drop that causes it to overflow. We can not tell the precise moment when
smallpox eradication became inevitable, but the tipping point was sometime
during those magic years that the people in this room roamed Africa. Not
earlier than 1967, because we could not have been sure it was doable. And
not later than 1970 because by then we had shown it could be done and so it
became inevitable.
Of course the African Program protected many from smallpox and measles.
That had a direct impact on those people and those families but continues
to have an impact two generations later on the fact that they even have
descendents.
But the real meaning was even bigger. Dave Sencer once said that smallpox
eradication refreshed public health. That is no small thing.
But it was even bigger than that. It showed that an international health
goal was possible It gave courage to global health workers. It gave
credibility to WHO...a credibility they struggle to maintain but a
credibility they would have been unable to achieve without CDC. Before it
was over CDC would mobilize some 300 CDC people to the smallpox eradication
effort and they were willing to make it a WHO success, not a CDC success.
This is also no small thing.
CDC knew that was happening at the time and it is to the credit of Dave
Sencer, Bill Watson, Don Millar and all the others that they were willing
to spend CDC capital to allow WHO to have this success without ever
demanding anything in return from WHO. It is to the credit of Hafden
Mahler that he recognized what was happening and privately was able to say
thanks but also said that he hoped we would recognize why he could not
publicly acknowledge what CDC was doing. In those cold war days it would
have only caused other difficulties.
It continued a CDC foreign policy started by Dave Sencer that is little
known, and now is lacking at CDC. Dave formed a committee to look at
global health to ask how CDC could make the greatest contribution. The
committee recommended that in the absence of large resources the greatest
contribution would be to place our best managers in positions outside of
CDC, to influence global health policy. The first target would be WHO
Geneva. Over the years that is exactly what CDC did. It detailed great
people to WHO, paid their salaries but let WHO do the supervision. DA
Henderson was on CDC's payroll, as was Rafe Henderson, Mike Merson, Bob
Hogan, Jonathan Mann etc. It established a global relationship with WHO
that was very useful to both the US and the world. WHO was able to have
good people, direct connections to CDC and CDC in turn had direct
information on health globally. Everyone benefited.
Contrast that to the current dysfunctional situation. In April, 2004, a
letter from Bill Steiger in HHS informed WHO that a request for a person
from CDC, even for meetings, had to go through Wash DC and they would
decide, in Washington, the person who would be detailed. Washington DC
obviously does not understand global health and CDC in turn acquiesced. So
politics now trumps science at CDC in a way that I thought had been fixed
for all time by the success of the African program and the early CDC
contributions to WHO. The façade of civilization is very thin.
But the meaning of the African program goes beyond smallpox eradication,
WHO credibility and a working relationship with WHO.
THE CURRENT OUTLOOK FOR GLOBAL HEALTH shows the enduring effect of the West
and Central African program 40 years ago.
Everything has now changed.
1. There is a New understanding of what global health is.
a. Altruism has always been an ingredient but now there is a
palpable understanding that we are All in this together
b. There is an understanding that health is a crucial factor in
Development and macro economists such as Jeff Sachs and
Amartya Sen make the case for us.
c. Immigration concerns even become involved. If one looks at
Norway 125 years ago it is clear why there was massive human
migration to the US. That doesn't happen today because
Norway became a land of opportunity. The ultimate answer to
immigration from other parts of the world is to make them
places of opportunity and health is part of the equation.
d. You will recall that we always had to make the case for how
the US would benefit. I looked recently at a proposal we
made to Clayton Curtis for an expansion of smallpox and
measles and it is riddled with justifications on what it
would mean for the US. That has all changed. Last fall, at
the global health summit, Bill Gates was being interviewed
along with President Clinton, and he was asked why should the
average American, with a mortgage and car payments be
concerned about global health. Gates answered, "Because it
is the right thing to do." We can make the case for
development, improved markets, American benefits...but we
don't need to. It is the right thing to do.
Add to this new understanding, better...
2. Tools
a. I don't need to spend much time reviewing the new vaccines,
Hepatitis B, more stable measles vaccine, H. flu, and now
Rotovirus and Human Papilloma virus vaccines. We now have
two anti-cancer vaccines that will make a difference in the
developing world.
b. We have drugs that are so safe they can be used on a mass
basis. We think of AIDS drugs but we also have Mectizan,
Albendazole, Praziquantal, Zithromax all making a profound
difference in global health and unavailable when we went out.
c. That is just the beginning. We will see over the next
decades new drugs, new vaccines and new diagnostics that will
finally start to close the gap in health. As Bill Gates
predicts, over the next 20 years we will have understood and
made inroads on the top 20 infectious disease problems of the
developing world.
3. Resources - Warren Buffet's gift is just the latest example of the
huge increase in resources. When we went out, global health was
always resource poor and that is changing in the last 5 years.
4. Interest - Not just the core group anymore but researchers,
economists, NGO's by the thousands. And even politicians with
little understanding of the world are now giving money to global
health. It is an unusual time.
THE PROGRAM 40 YEARS AGO IS PART of what made this all possible.
We didn't actually know we could eradicate smallpox and at the same time we
never doubted it would work. We were optimists. The trouble with being an
optimist is people assume you don't know what is going on. But we did.
In the words of Harlan Cleveland, what characterizes global health people
is "unwarranted optimism."
Julie Richmond, former Surgeon General, said smallpox was eradicated
because CDC sent out people too young to know it couldn't be done.
I grew up with the saying that some things have to be seen to be believed
but we proved, in Africa the opposite, that some things have to be believed
to be seen.
So the implications of the West African program are still being realized.
They get greater every year and they follow the instructions of Leonard
Scheele, Surgeon General from 1948 to 1956, who said, "The world cannot be
allowed to exist half healthy and half sick."
THERE ARE OTHER LESSONS
. NOT ONLY ARE GLOBAL APPROACHES POSSIBLE IN HEALTH, WE WERE PIONEERS
IN HEALTH GLOBALISM.
. Global Health is actually more about management than it is about
science and a key ingredient is PROBLEM SOLVING. That is why
Public Health Advisors became key, first in Africa and then in
Asia. That is one ability shared by this entire group. You were
all problem solvers.
. The other attribute was TENACITY. Tenacity won't always bring
success. But it is the only thing that will. I often tell
students about Mae West who once described a suitor as so tenacious
he was the kind of man a woman would have to marry to get rid of.
That is the kind of tenacity this group showed.
. We learned there is no substitute for involvement on the ground.
We went, not knowing what we were doing and by being on the ground
we figured it out.
. But also, there is No substitute for headquarters support -- This
is a story of continuity from central level to the field. It would
be wrong to credit the field staff for smallpox disappearing from
West and Central Africa. Don Millar and Billy Griggs plus an
entire support staff enabled the field.
. But, as we heard last night and this morning, the real hero was
Dave Sencer. Dave always found a way to provide people, equipment,
support in creative ways. I used to think, but never said,
"Creative indictable ways." It is time that he becomes a sung hero
of smallpox eradication instead of the unsung hero. I have often
said that he never turned down a single request made...to a point
that it made me very careful when in India to ask for things
because I knew we would get them. Of course Dave is right that it
took the whole CDC but the director sets the tone and those were
years of dedication and high morale.
. Two months ago I took part in a program at the University of
Colorado to honor one of my mentors. Charlie Houston, at the age
of 93, had just received an honorary degree. He had led the team
attempting K2 in 1953. Their attempt to rescue a sick climber in a
storm has become the stuff of legends in the climbing world and
here were the survivors. Charlie at 93, Bob Bates, age 95, former
headmaster at Exeter, Bob Craig the youngest in his late 80's. It
was an inspiring story of six men, tumbling down a 45 degree slope
in a storm to certain death, arrested in their slide by Peter
Schoening who watched the rope get thinner and thinner, but it
held. And they made the point that in truth that Peter Schoening
wasn't holding them alone. The rope actually extended to hundreds
of support people and ultimately all the way home. That is the way
the African program was and we recognize and thank the long chain
of support that always found yet one more way to respond to the
needs of the field.
Finally, the program has led to an entire new day in global health but it
also established for all time that eradication is a goal worthy of our
efforts because
. It frees our grandchildren of a burden and as far as we can see
into the future.
. Eradication pushes the limits of our science and social
organization.
. Eradication is an investment in the future rather than a debt left
for the future. This is true also for polio and Dave Newberry's
point is correct. If you think it is hard to get support for 12
years of eradication efforts think of the difficulty of getting a
hundred years of support for control efforts.
Last year our then 7-year-old grandson surprised me from the back seat of
the car when he asked, "What's the most important thing people could do to
make the world better?"
When we were young we rode in the front seat. Now children sit in
restraints in the back seat and it is a different dynamic. We think of
ourselves as marching into the future. The ancient Greeks saw themselves
as backing into the future since they couldn't see it. I thought to
myself, this is a Greek story, with my future figuratively and literally
behind me, surprising me with glimpses in the rear view mirror and
provocative questions about the future I can not see.
Forty years ago this group, from the back seat surprised the world with a
message of joy saying the world can be better and you can back into it with
new confidence.
Finally, Gregory Berns in SATISFACTION: THE SCIENCE OF FINDING TRUE
FULFILLMENT writes that "Happiness and pleasure are passive emotions that
come from things that happen to you. But satisfaction is a positive
emotion you experience because of things you make happen yourself."
I hope you all take great satisfaction in recalling how you made this
happen. Recall it often because a happy memory never wears out.
The work of this group 40 years ago continues to refresh the global health
community. Thanks you.
"Summation of West African Program" by Bill Foege
Bill Foege
July 15, 2006
Bill Foege shares anecdotes from his time in West Africa, and reflects on the search for wisdom from the experience of smallpox eradication and the emerging field of global health.
