Interview Transcript
This is an interview with Jean Roy about his experiences in the West
African Smallpox Eradication Program. The interview is being conducted on
July 13, 2006, at the Centers for Disease Control and Prevention. The
interview is a part of the 40th anniversary celebration of the launching of
the project. The interviewer is Victoria Harden.
Harden: Mr. Roy, would you briefly describe for me your childhood, pre-
college education, and talk about influential people-friends,
parents-in your life.
Roy: Yes. I was born in Maine, in 1941, and grew up there, went to
primary school there. And then I went off to Pennsylvania for
high school, at a Catholic school in Scranton. I had read a book
earlier-oh, I must have been 12 years old-The Keys of the
Kingdom. I'm Catholic, but it was about Baptist missionaries in
China. And I was fascinated by life in China, and the Chinese.
And if you know something about Maine, there aren't many
opportunities economically, for jobs, and so on. People either
went into the Foreign Service or became missionaries. Throughout
my life and career overseas, now, I've run into so many Maine
natives who were part of the foreign service, working for USIS
[the US Information Services], or are missionaries.
So that was my background. So I wanted to be a missionary
to China. So I went off to Maryknoll College, a Catholic college
in Glen Ellyn, Illinois. It was associated with Loyola
University in Chicago. I was intending, always, to become a
missionary. By then, China was closed because of the communist
revolution, so I aimed towards Africa. Now the college campus
happened to be on a former golf course, which had been taken
over by the seminary college. And, of course, I was addicted to
golfing. But I made a tragic mistake one day by going golfing
with the sister of a colleague. And as a future Catholic priest,
this was a real no-no. I got called in and disciplined, and
asked, "Why were you out there? Think of what the public will
think, a young seminarian out playing golf with this young lady
on a Sunday afternoon" (which was visitors' day).
And that's when I started to rebel. I thought, "Do I
really want this kind of life?" So I graduated, got a degree in
philosophy, and then said, "What am I going to do for the rest
of my life?" And this brings me to the Peace Corps. After being
in the seminary for 8 years, I still wanted to go overseas. This
was 1963. John Kennedy had just announced the formation of the
Peace Corps. So I sent in my application to Washington, thinking
I would never be accepted, but at the time they liked idealists,
and they liked the seminary background, and I got accepted. I
was assigned to West Cameroon, in West Africa.
Harden: Would you tell me what you did in Cameroon between 1963 and
1966, when you got into the smallpox program?
Roy: Several things, and it all has a relationship with the work
I've done in the last 40 years. 1963, if you recall, was the
year that measles vaccine was licensed in the United States. And
that's the year they did trials in Upper Volta, which is now
Burkina Faso. As a Peace Corps volunteer, I knew nothing about
public health. I knew all about philosophy. I spoke French-I'm
of French Canadian background, so that's where the French
influence came in-and that helped me to get the assignment to
French West Cameroon. West Cameroon is English-speaking, but
there's also a larger section of the country that is French-
speaking. My assignment was actually to start the first Federal
Bilingual Grammar School in the Cameroons.
In 1961, West Cameroon (British Cameroon) was part of
Nigeria until the U.N. referendum when the citizens voted to
leave Nigeria and join East Cameroon, which was of French
colonial descent, French-speaking, and much larger. The Ex-
British Cameroon tribal groups were much closer to the French ex-
colonial Cameroon, and it made sense to vote to join together.
The French government then poured massive amounts of aid
into the British Cameroon, to make it French. British Cameroon,
with 1 million people, was a very small sliver of land between
Nigeria and the Eastern Cameroon section. The British
Cameroonians drove on the British side, they used the common law
code, used the pound sterling. Just a few miles away in the
French section, the French franc and the Napoleonic code of law
were used, and they drove on the American side of the road.
The referendum changed everything in the former British
territory. I was there just when all of this was changing, and
naturally the 3 million francophones dominated the 1 million
anglophones. But the French started something that was very
clever. They were going to make all Cameroonians bilingual. 1963
was the first year of the first bilingual grammar school, a
pilot effort to merge a French lycee with a British grammar
school curriculum. I was the first foreign teacher on the campus
at Man O'War Bay, which is famous for the slaving interceptions.
The British Man O'War used to anchor in the small bay on the
coast of Cameroon and intercept the slaving ships after the
British outlawed slaving. It's a beautiful site, at the foot of
Mount Cameroon. It's a wild, wild place, very much like Hawaii,
with volcanic peninsulas into the ocean. Te setting was that of
a former Outward Bound camp that had been turned into this new
secondary school campus. So there I was, the only person who had
a driver's license, so I got to drive the school's only Land
Rover and serve as Chief Administrator.
I actually became the Assistant Principal. This was
September 23, 1963. Within 6 weeks, 35 students came in from the
anglophone sector of the country, and a few weeks later, 35
students from the francophone side. And that was the idea. Every
year for 7 years (it was a 7-year course), 35 students from each
sector joined to learn the other sector's colonial tongue, until
they were well-versed in the other language to be mixed. By
graduation, the students had reached the equivalent of a second
year of university-high school plus 2 years.
Today, there are many bilingual grammar schools, or
lycees, and 3 very large bilingual universities in the Cameroon.
And these young men are now ministers, diplomats, teachers, and
doctors.
The notable thing, though, was that it was September 23,
1963, when John Kennedy sent us off to Africa, and on November
22, that fateful day, I still did not have a short-wave radio. I
was 7 miles from the nearest town and had no bicycle or
motorcycle and still did not have access to the Land Rover. Late
Friday afternoon, I believe, on the 22nd, an African came
running up to me, and he was saying, "Your President, your
President is dead." I had no idea what he was saying. It didn't
register. He didn't know very much, but he must have heard it on
the radio, and all day Saturday I wondered what had happened.
On Sunday, still being a good Catholic, I walked my 7
miles through woods and over 15 bridges to go to the main town
for church, and at the same time I visited the Peace Corps
volunteers at the girls' school in town. I walked into their
house; they were all sitting on the sofa crying, and I said,
"What is going on?" And someone said, "John Kennedy is dead."
Immediately the next day, I took my 4,000 or so West Africa
francs that I had saved and bought a short-wave radio.
But that was the beginning of the Peace Corps. I spent 2
wonderful years, working in an administrative and teaching
capacity, doing all the things to make a school work. But the
special thing that I remember was the vaccine trials, the
measles vaccine trial. Africans were talking about it because
measles had always been the greatest killer of children in
Africa. And this vaccine was like a silver bullet, a magic
bullet.
After the Peace Corps, I returned to the States. I sort of
enjoyed the idea of the bilingualism, and I went off to get a
master's degree in linguistics at Columbia University. That was
1965. I was back in New York City, and I said, "Great, I'm back
in civilization." John Lindsay was the mayor. I was thinking,
"Gee, that'll be great. I'll have newspapers again, I'll have
running water again, I'll have electricity again." What happened
between September '65 and June of '66 in New York City? The
railways, the metro strike. The huge metro strike against
Lindsay. Then came the first ever newspaper strike in New York
City. And for long periods, I said, "This is like Africa." And
then the blackout occurred. The most famous NYC blackout. I was
at Columbia University; I had an exam that night, which I didn't
take. So I said, "Gosh, I came back to the biggest city in the
United States, and it's more like Africa than Africa."
I worked in a halfway house with the Presbyterian Church
to earn my living. So I started with the Baptist Chinese
missionaries, and here I was in New York City, working with the
Presbyterian Church, helping them out. I was just doing their
Sunday bulletins. I was a great typist, and again, doing
administrative sort of things.
The Peace Corps was excellent about helping us find jobs
and careers. And every month, we'd get a "Green Sheet," we
called it. It contained all the job announcements from
universities, foundations, private corporations. At that time,
everybody wanted returned Peace Corps volunteers because they
were thought to be serious, and so on. And 1 month the Green
Sheet had an announcement for this institution called CDC. And I
said, "Gee, that's the Cameroon Development Corporation." The
Cameroon Development Corporation is now called the Commonwealth
Development Corporation, but it was an old British colonial
company, which had large plantations: palm oil, bananas,
pineapples, rubber trees, and many other products in Cameroon.
So I read that the CDC is looking for somebody for Africa with
French-speaking ability, some administrative experience, and
previous experience in Africa. I said, "Boy, this is great." But
then they had all the public health requirements, and I said,
"Oh, this will never work."
I also had another wonderful job offer, after I' received
my master's in linguistics. USIS was starting up English
language schools throughout the world at the time, in 1965.
USAID [US Agency for International Development] gave the
contract to a group; it may have been the Academy for
Educational Development in Washington. But they were hiring a
director of English language schools, English as a second
language, for Leopoldville, in the former Belgian Congo,
Kinshasa. I was accepted to be the director there, so I had a
choice to make. I decided to apply to CDC, and eventually did
get recruited, but perhaps that's where we can start talking
about CDC because it's an incredible saga of how I jumped ship
from linguistics to public health.
Harden: This is fascinating. Is it unusual for CDC to recruit from
outside, and what made them decide to recruit you? What
qualifications did they want?
Roy: Excellent question. It was a lot of luck on my part, a lot of
trust and risk-taking on CDC's part. And I hope it was worth it.
I. For me, it was. CDC had recruited, I think, something like 60
staff people to go to the West and Central Africa
Smallpox/Measles Program, which USAID was funding in 1965. The
idea was to send epidemiologists and Public Health Advisors
paired together-the Public Health Advisor as an Operations
Officer, to make things work-what I used to say (and Public
Health Advisors didn't like it), the manpower part-and the
epidemiologist for the brainpower part. However, to be fair to
my colleagues, we had brainpower as well. But it was a great
combination of having the epidemiologist and the Public Health
Advisor.
So they'd already recruited the epidemiologist for the
country that I eventually was assigned to, which was Dahomey,
now called Benin. It's just west of Nigeria, and east of Togo,
sandwiched in between Togo and Nigeria. It is just a sliver of a
country, with, at the time, 1.5 million people. Not very large.
But the first Public Health Advisor that CDC recruited had a
heart attack. So he had to decline. So D.A. Henderson [Donald A.
Henderson] and Leo Morris and Billy Griggs, who were all trying
to put a staff together for West Africa, went on to their second
candidate, who accepted the job. He was a traditional, well-
trained Public Health Advisor, a VD [venereal disease] type, as
we called them back then. And he was raring to go, but his wife
says, "Oh, I'm not going to Africa, I can't move the family,"
and so he declined.
At that point, there were very few or no Public Health
Advisors who had been trained, and who had come up through the
ranks at CDC from the '50s, available to go to Dahomey, and
that's when CDC, Leo Morris, and D.A. Henderson reached outside,
and they eventually hired 3 Public Health Advisors from outside:
me, Mark LaPointe, and Jay Friedman, all 3, ex-Peace Corps
volunteers. All 3 of us had French experience. All 3 of us had
teaching or administrative experience. None of us had public
health experience. So that was the risk, I think, and the trust.
So anyway, they sent Leo Morris out to New York City to
interview me. He came to the halfway house at the Presbyterian
Church where I was working, on 36th Street, and we had an
interview, then we went to the bar and had a beer. I remember
saying, "Oh, I'll never get this job."
Meanwhile, I had heard that CDC had commissioned officers.
And again, what was happening in 1965? Vietnam. And you saw my
career path to that date: I had been deferred because of the
seminary. I'd been deferred from the draft because of the Peace
Corps. I'd been deferred again because I came back to get a
master's degree at Columbia. And I had an 81-year-old lady in
Augusta, Maine, who was my draft board representative, who had
been after me for about 12 years. And I thought, "How am I going
to get around this?"
While I was in New York, I visited an ex-colleague from
Peace Corps Cameroon, who was an urban planner living in an
apartment in Greenwich Village, and he said, "I'm doing my
Vietnam duty." I said, "What?" He says, "Yes, I'm a commissioned
officer. I don't wear a uniform. I go to work every day. He was
a sort of a sanitation engineer, urban planner, and he fit right
in to the category for the Commissioned Corps." So I said, "Boy,
that's a fantastic way to do your Vietnam service." And then I
found out that CDC had this Commissioned Corps, and I thought
that perhaps I should put my money on CDC rather than the
Leopoldville, Kinshasa, linguistic directorship. But meanwhile,
just to protect myself, I took the Army Officer's Candidate
test, and also qualified. I said, "If I'm going to Vietnam, I'm
not going as a grunt, I'm going as an officer." Those were my 3
options at the time: the CDC, the Congo, the army.
Leo Morris came, interviewed me, and D.A. Henderson sent a
letter later saying, "We'd love you to join us, we'd like to
assign you to Dahomey." I had visited Dahomey in 1964, when I
was a volunteer, so I knew exactly where I was going, beautiful
little place. So on July 6, 1966, I came to CDC. I was sworn in,
along with Jay Friedman and Mark LaPointe. All 3 of us came on
July 5, started auditing the EIS course, and started doing all
the training to get ready for the smallpox/measles program.
Harden: Did you know anything about Dodge trucks when you got here?
Roy: No, that was great. We learned all about jet injectors, the
vaccination guns, and Dodge trucks, with training down at the
Chrysler Corporation down near the airport. We went together
with Bill Foege [William H. Foege], Rafe Henderson [Ralph H.
Henderson].
It was just amazing. I was 25 years old, and it was my
first time in the South. I lived in a rooming house across from
what is now the Rollins School of Public Health. "Ma Moates" had
a typical clapboard house, a porch, just right out of any novel
of the South of the '20s, '30s or '40s. Matter of fact, we had
rocking chairs on the porch where Gordon Robbins and I spent
many evenings. The Moates chewed tobacco, and each had spittoons
in their living room; they both chewed tobacco. It had no air-
conditioning, of course. So it was so humid that the ceiling
over my bed fell on me while I was sleeping. Here, I was a Maine
boy who had been to Africa, but arrived in Atlanta and found a
whole new culture, way of life. I never dreamed that I'd spend
the rest of my life based out of Atlanta.
Harden: The summer of 1966, then, when you got here, you were sworn in,
but were you a commissioned officer yet? What about your lady at
the draft board in Maine?
Roy: No, it took quite a while. I was sworn in as a civil servant
and started the training. About 2 weeks later, July 10 or July
14, I received another letter from my draft board saying that in
October I would get my final notice and I would have to report
to Fort Dix. So I went to D.A. Henderson and said, "D.A., look
at this. All this work you've done. I'm your number-3 candidate
for this job. The first one had a heart attack, second one
didn't want to go, and now I may not be able to go."
Then I said, "But I hear you have the Commissioned Corps
at CDC." And D.A. says, "Yes." And I said, "Well, do you think I
could, you know, be accepted?" To which he says, "No, it's for
doctors, dentists, nurses, statisticians, epidemiologists that
have PhDs. If we do it for you-[Vietnam was getting other boys
as well, and CDC was filled with Public Health Advisors of draft
age]-we'd have to do it for everybody at CDC."
So I resigned in July at the only time that Delta went on
a massive 2-week strike, in the summer of '66. No Delta flights
out of Atlanta. And I was supposed to leave. But then D.A. says,
"You know, if you get commissioned, that's fine. But we can't do
it for you. Do you know anybody in Washington?" I said, "Yeah, I
know Ed." And he says, "Which Ed?" I said, "Ed Muskie [Senator
Edmund Muskie. He's from my hometown, Waterville, Maine, and he
knows my mother, knows the family, was a neighbor." And D.A.
says, "Well, when you go back. . ."
I was going back by Greyhound bus, so it took me a day and
a half back then to get to Washington. I went to Ed Muskie's
office and saw his secretary, Virginia, and told her the story.
She said, "Ed's not here; he's meeting with Bill." And I said,
"Bill who?" And she said, "Bill Stewart [William H. Stewart]. I
didn't know who Bill Stewart was. And she says, "But let me give
him a call." So she called, and told him that I was from
Waterville, who I was, what I'd done, Peace Corps, blah blah,
and smallpox eradication in Africa, and Ed told Bill, and Bill
says, "Gee, that sounds good. Tell him to go over to the
Commissioned Corps office, to fill out the form."
So, great. I went over there and started to fill out the
form. Which medical school did you go to? Doesn't apply. Which
dental school? Doesn't apply. Which nursing school? Doesn't
apply. Well, do you have a degree in chemistry? Engineering?
Nyet, nyet, nyet. I signed it, dated it, and submitted it.
Just before leaving Washington, I called D.A.-it was about
4:00 in the afternoon. I told D.A. that I'd seen Ed Muskie and
this fellow Bill Stewart. He says, "Who did you say?" And I
said, "Bill Stewart." He says, "Holy smokes." (D.A. is always
saying "Holy smokes!") He reminded me "That's the Surgeon
General." And I said, Oh, I guess, well I knew Ed Muskie was the
sponsor of the Clean Air bill, the very first Clean Air bill, in
1965. And Ed was speaking with Bill when his secretary called
about my situation. So I told D.A. that I filled out the form,
but, I didn't think it's going to go anywhere.
I then took the bus, went up to Maine, another 2 days on
the bus. And then after about 3 days in Maine, D.A. called me.
"Jean, do you want to come back to Atlanta? We think it's going
to work." So I took the bus all the way back, 3 long days,
because there were no flights. I came back and continued the
program. I did all the training, the Dodge trucks, the jet
injector, the French training, the statistics, and listened to
all of the fantastic speakers from London, people who had been
to Africa, the public health workers who had been working on
sleeping sickness, and leprosy, and other diseases. They were
just the greats of public health. They're all dead now, I'm
sure. But just inspiring. That whole summer was just like a
graduate Peace Corps training Program. My Peace Corps training
had been 3 years before at Ohio University for 3 months, but
this was just an upscale version of that training, which was
absolutely fantastic. And here I was, a very timid, shy fellow
from Maine. Although I'd traveled all over the world, I was
still very timid and shy, but extremely impressed with CDC and
what went on that summer.
In September, everybody started going off to their
assignments. The critical thing that everybody needed to have
was a security clearance. You couldn't move until the whole
family had security clearance because you were going with the US
government. And 1 or 2 didn't get security clearance. After all
the training, they had to pack up their children and then go
back home and start a life again, where they'd left off before.
Very disappointing. So we were all very nervous. I'd gotten
security clearance from the Peace Corps, so I was a little
optimistic, and I hadn't done anything strange, hadn't been
burning flags or draft cards, like everybody else was doing. So
September comes around and everybody went off to Africa.
October 1, I got my draft notice. "Please report to Fort
Dix October 17." And I went up to D.A. again, "D.A., here's my
draft notice. This is it. And I'm still not commissioned." Three
or 4 days later I was commissioned. Meanwhile, just for
protection, Mark LaPointe, who's also from Maine and had a very
similar background as myself with the same old lady on the draft
board in Augusta, was commissioned as well. We did it at the
same time. Jay Friedman was from New York City and he was not
commissioned. He was not being hounded and did not need the
commissioning, and so he did not get it. But both Mark LaPointe
and I stayed 3 years in Africa as commissioned officers,
fulfilled our military duty. I was sworn in, again, and then
sent the draft notice back and signed it, Lieutenant JG. And
that was the end of the story.
On December 15, I went off to Dahomey, which had the
second-highest incidence of smallpox in the world at that time.
Harden: And you were commissioned at...
Roy: At CDC for service to the Smallpox Program in Dahomey.
Harden: So your commission of the Public Health Service was as?
Roy: As a Public Health Advisor, literally. Or do you mean the
commission title?
Harden: Yes. Normally it's Assistant Surgeon, or Sanitary Engineer,
or...
Roy: It was Assistant Surgeon, more precisely, Junior Assistant
Surgeon General.
Harden: Some title they had made up that would fit. Okay.
Roy: I don't recall. I was elated to have any title. The pay was not
great, but the experience and the opportunity were fantastic.
Harden: Tell me a bit about Dahomey, and what you found in terms of
smallpox, and describe the people.
Roy: Dahomey was a very small country, a sliver of a country, maybe
300 miles long, and 60 miles wide, 1.5 million people. And of
course, I was 25 years old, and I'm thinking I'm going to have
to vaccinate, with the Ministry of Health teams, all 1.5 million
people. I was overwhelmed. Because that was the strategy: start
at the coast, go up north, and vaccinate all the tribes, all the
people, the cities, the towns, and villages. At the time, as I
said, Dahomey had the second-highest incidence of smallpox in
the world.
Harden: And why was that?
Roy: A lot of it was because of the fetisheurs. These are the
medicine men. The people are of Fon origin. The Fon people are
connected to the Yoruba people. And Yoruba is a tribe in western
Nigeria. So the Yoruba Fon people are related. They practice
voudoun, and the word voudoun comes from the Fon Yoruba
language. The Haitians and Brazilians use that word because the
slaves came from that area and brought the language. So the
voudoun is very big in Benin, even today.
In their mythology, there are 2 very important gods. The
god of earth is one, and his power is called sakpata, which is
smallpox. The other god is Shango, and the African-Americans
talk a lot about Shango here in Atlanta, I've heard. Shango is
the god of the heavens, the sky; its power is lightning. But
sakpata is the power of the fetisheurs, who are sort of the
religious representatives of the gods. They were responsible for
purification and cleansing smallpox-infected people in villages.
This was how they made their living. So, when smallpox broke
out, the people normally went to their native medicine men, the
fetisheurs, to find a solution.
Smallpox was the scourge, of course, of the world, and of
Africa, and Dahomey. During my lifetime, I saw hundreds and
hundreds and hundreds of cases of smallpox. This horrible
disfigurement. And the smell. I think everybody will tell you
when you walked into a house with a smallpox patient, right away
you knew it was smallpox, and not chickenpox or some other
disease. The smell was very, very strong. And of course, total
disfigurement, and pustules, and so on.
But the fetisheurs would hide the smallpox patients
because the villages paid them to heal them. So the only time we
heard about smallpox is when it totally got out of hand. The
fetisheurs did not have a vaccine. They did variolation. They
would take scabs from some of the patients. They would dry them,
grind them up, and blow them in the air. And so they would
actually infect people. So they wanted to perpetuate smallpox.
And we were there to stop it. So you see, we had a common enemy,
and it was very clear, very, very soon, that this was a major
cultural barrier to the eradication of smallpox.
And that's when we started doing anthropological studies.
Gordon Robbins, who was a health educator at our regional office
in Lagos, which was an hour away, came and studied the
situation. How do we deal with it? Sort of how we dealt with
chickenpox.
When I first arrived in December 1966 in Dahomey, I'd
heard there was a massive outbreak of smallpox in the prison in
the town of Ouidah, an old slaving town with a fort, and a big
prison. So my driver took me there. I said, "Ah, I'm going to
see my first cases of smallpox." I went into the men's prison,
and they were all covered with pustules and vesicles. I quickly
came back and told my epidemiologist, Bernard Challenor, who is
deceased now, but he was a young, Barbadian-origin doctor-
epidemiologist. I said, "Bernie, Bernie, there's a tremendous
outbreak of smallpox in the prison." So he got into his vehicle,
goes to the prison, comes back smoking a cigar, and says, "Oh,
Jean, you've got a lot to learn about differential diagnosis.
That's chickenpox."
And that was the answer for the fetisheurs, and that's
what ultimately happened. To make a long story short, over 2 or
3 years, as we gradually contained smallpox in Dahomey, in spite
of and with the fury of the fetisheurs because we were taking
away their business, they started focusing on chickenpox. And to
this day, I'm told, chickenpox is what they're now declaring as
the power, or the anger, of the gods, who punish you by giving
you, not smallpox now, but chickenpox. And I bet you they still
call it sakpata. There are still fetisheurs, there is still
voudoun, highly practiced in Benin today, but I think that's one
of the reasons why.
Our surveillance was very, very bad, and as D.A. said,
surveillance was the key to any disease eradication scheme. I
wasn't a real great-I'm not even a good-epidemiologist. Thank
God, that's why I had Bernie, and Rafe Henderson, and Mike Lane
[J. Michael Lane], who would come to Dahomey and give the
support I needed. But even with the French colonial approach to
public health, which we used, the Service des Grands Endemies-
very effective health personnel providing curative and
preventive services throughout French West Africa, and which
controlled yellow fever, leprosy, and the other major diseases,
through their roving mobile teams. These ex-French colonial
teams would go off for 3 months -with tents, cooks, you know,
all the luxuries of home-with the French Medical Director,
leading all the African nurses, who were very well supervised.
They loved it; there was an esprit de corps, teamwork. After 3
months, they'd come back, rest a month, and go off. And at the
end of a year or 2, they would have covered the whole country.
It was a good outreach service.
We used the same approach with smallpox, using those same
teams that had sort of gone defunct because the French stopped
supporting the colonial public health services when these
countries gained their independence in 1960 and 1961. When I
arrived in Dahomey, I found all these nurses, male health
workers, laboratory technicians, who were ready to go out on
tour, as they say, for 6 weeks, l month, 3 months. They were
ready. They loved it. That was their work, and they were helping
people. But for 2 years previously, they had done nothing.
So when I arrived there and set up an office, I found 15
of these teams. And I had 15 Dodge trucks that arrived at port
and started setting them up. And at age 25, this was an awesome
responsibility. But I think all the previous experience in
Cameroon and the Peace Corps really helped me. Great support
from the American embassy. USAID was not so supportive, but they
weren't too keen on the smallpox part, but they were keen on the
measles part of the campaign. So I just replicated the training
I had received at CDC in June, July, August, September. Then in
December, January, February of '66-'67, we trained all these
nurses, and then organized them so that we did the mobile teams
again. Again, they would go out for a month, come back and rest
for 2 weeks.
Their mission was to use the jet guns and to vaccinate
everybody from the coast, to the north, up to the desert. And of
course, we'd done about a third of the country, so about 400,000
vaccinations, and we thought that was great. Today (2006), we
are doing a million vaccinations a week now in Africa; in Kenya
we did 14 million 2 years ago. But 400,000 back then seemed
incredible. And everyone was doing that in all the countries in
West Africa.
But Bill Foege noted back then, "How come we still have
smallpox where we vaccinated everybody?" It's because we weren't
looking for cases. Our surveillance was not good. Just by
vaccinating the masses, we were missing the people who didn't
want to get vaccinated. The fetisheurs were hiding them. The
fetisheurs were against us, and they were telling the population
not to get vaccinated. So these were the reservoirs for
smallpox.
So Foege saw this, Rafe Henderson saw this, and that's
when we started the strategy of search and destroy, using
Vietnam language. Eradication-escalation. But again, we had this
esprit de corps. Rafe Henderson came to Dahomey and said, "Let
us try something." He said he wanted 12 motorbikes, 12
vaccinators, who he trained to identify smallpox, to go out and
look at suspected cases. So this was the start of a very intense
surveillance program. Rafe came and lived for almost 3 months in
Dahomey. We got him an apartment. And I gave him free rein. I
said, "Rafe, I don't understand this search and destroy stuff,
eradication-escalation. Go for it."
So I gave him a free hand, and I kept on running the
regular operation, the systematic, rational, ancient method,
which I hope is a lesson learned. Malaria eradication failed in
the 50s because it was too systematic, too military, too rigid,
not flexible, and every country did the same thing. That's
stupid. You must be constantly changing, adapting. I think Bill
Foege and Rafe did.
That was the genius of those early days of smallpox:
figuring out that mass vaccination is not the answer. Sure, for
some diseases like measles that are highly contagious, you want
herd immunity, and so on. But in this instance, it was search
and destroy. So Rafe had his 12 motorbikes, his 12 vaccinator-
the "dirty dozen," as we called them, and he had a great time.
He had his Land Rover, and he would follow them, supervise them.
They went off, and they would probably go to 12 different sites
and report back whether there was smallpox or not. If it was
smallpox, they would go right back and start the containment,
vaccinating everybody in and out of the village, not let people
out or let people in, and make sure that everybody was
vaccinated. By doing this strategy, within 3 or 4 months,
smallpox just started going down tremendously. And then, it was
a secondary goal to vaccinate everybody. It was good policy to
give vaccination to everybody because, again, for 4 or 5 years,
we conducted surveillance, regional surveillance for smallpox to
be sure that there was no appearance of hidden cases. So it was
good to have as many people vaccinated. But the key to
eradication was the search and destroy, the containment, and the
flexibility to adapt to new diseases, new approaches, and not
use the old ways.
I'm very active in vaccination and public health in Africa
today. And every time I see young people wanting to do things I
did, I say, "No. That is totally wrong. Do not. You might have
learned this as an MPH student, but no. What is the situation?
Everyone and everything is different; it must be customized."
Harden: Well, and one of the most important things that I have gleaned
is that, not only figuring this out, but the importance of the
logistical support of getting out into the villages, having
those trucks and having them work, finding housing for these
people. That it was certainly much more than a medical problem.
Can you talk about that a bit?
Roy: Absolutely. These are logistics problems. They're management
problems. They're operational problems. This is very
controversial, and not really fair to our medical colleagues,
but a lot of the problems in public health today are because
we've used a medicalized approach. Let's take HIV, for instance.
I give this talk-I give it to old ladies, to governing boards of
the British Red Cross, Belgian Red Cross, because I'm with the
Red Cross in Europe, and I shock them. I say, "Do you really
think that doctors and nurses in hospitals and laboratories can
stop HIV? They can't." And remember now, I'm with the Red Cross,
so I'm talking about civil society. I say, "The people in the
villages are going to stop the HIV. Because to really stop HIV,
you have to be in the bedroom. Are the doctors, nurses,
hospitals, medical centers in the bedroom?" And then somebody, a
Belgian HIV activist said, "No, it's behind the bus stop, too."
And I said, "Well, are the doctors behind the bus stop, too,
where you go for a quickie?"
Smallpox was eradicated in Bangladesh and India because we
removed the task from the medical community. We allowed
thousands and thousands of ordinary people, with the magic of a
bifurcated needle, to do the vaccinating. And you can learn that
in 5 minutes. Tens of thousands of ordinary people, using
bifurcated needles, eradicated smallpox. We must beware that
what we think is a medical, a public health, problem, is really
a people problem. You must change behavior. In my talks, I go
through the helmets, the seat belts, the condoms. Those things
have nothing to do with doctors and medical schools and
hospitals. It is people behavior.
Harden: But it's an awful lot to do with culture, and religion, and
values.
Roy: Exactly. Major lesson learned. I use the Kano experience for
polio. There was a major outbreak of polio in Kano, Nigeria, and
they've now exported their polio cases all over Africa, to
countries that had not had polio for 10 years. And what was the
problem there? I'm told that they perceive the vaccine to be an
"American vaccine" (but it isn't; it's made in Indonesia) "to
sterilize the Muslim girls so they wouldn't have babies." But
actually, the vaccine is made by Muslims, in Indonesia, to
vaccinate against polio. And of course I agree that in Nigeria
maybe it was a political problem as well. But, this was not a
medical public health problem. It was a communication problem.
And had we spent, in the last 40 years, USAID funding, public
health funds, on people rather than on consultants and white
elephants of hospitals, I think we'd be further ahead today. In
Kano, we should have spent our polio eradication money on
schools, mosques, churches, people, Boy Scouts, Girl Scouts, and
the Red Cross. As I say, people. If people know that the vaccine
is good, they'll get vaccinated. Like measles: they know measles
kills. But they don't see a lot of polio. Now they are, however,
because they stopped vaccinating for 3 years, and there's a
resurgence. And that has cost hundreds of millions of dollars.
But just to get back to a point of the importance of
people in public health, the polio-eradication effort would not
have occurred if it had been left only to the medical
institutions and the public health agencies. It was Rotary
International, the ordinary business people out of Evanston,
Illinois, with the help of CDC by assigning a CDCer there,
because they said, we're not a health agency. They had raised
$50 million in 1982. I was there at the Evanston headquarters in
1986, when Rotary was ready to give up. "We can't continue
raising money for polio eradication because we're not a medical
health institution." No problem. We'll give you somebody. And
they went on to raise $600 million.
Now, measles elimination is occurring in Africa as we
speak. Shamefully it is 32 years after measles vaccine was
introduced in Africa by the measles program. Africa is now
starting to use measles vaccine in a big way. And that's because
of the American Red Cross. We started in 2001. And of course,
the cases have just gone down tremendously, a 60% drop globally
and a 75% drop in Africa. Because measles was the biggest
killer. It no longer is today.
But it was Rotary, a civil society for polio eradication.
It was the American Red Cross, a civil society, for measles
elimination in Africa. Not a health institution. If we do an
analysis of the really successful public health programs in the
last 40 years, you will see that the most important common
denominator was the people who are victims themselves. You must
involve them, and I think it's a lesson learned for the future.
Harden: So let's get back to smallpox. One question: if you were going
to do the program over again, would you change anything?
Roy: No. We had some assumptions to begin with, but we were very
flexible. I think it was a brilliant group. I've had 40 years. I
started with the Bill Foeges, Stan Fosters, Don Millars, D.A.
Hendersons. I mean, how many people in this world have had that
privilege? Especially somebody who didn't know any public health
was not qualified at all for a job like this by standard rules.
Today, if I tried to get into CDC with the qualifications I had
back then, I would never get my foot in the door. You'd need an
MPH and PhD, if not an MD, and so on. But I think they took
risks; they had a lot of trust. They worked with the African
governments. While our mission was with smallpox eradication,
the African governments wanted measles vaccine. And again, ask
the people what they want, and measles vaccine, which we thought
was going to destroy the smallpox part of it, actually enhanced
it because many more people were dying of measles than of
smallpox. But smallpox was a threat to the Western world, to the
Soviet Union, and so on. And so the world wanted smallpox
eradicated, and sure, there were a few countries in Africa that
had smallpox, so they were a major global threat. But measles
was killing millions and millions of children under age 5, every
year in Africa.
But listening to the people, taking risks, being flexible,
constantly changing, and learning, those were the keys. And I
think the legacies of smallpox are tremendous. You would not
have had measles control in the United States. We all came back,
in '69 to '71, to the United States. Even as public health
advisors, not epidemiologists, we knew a heck of a lot about
surveillance. We knew about containment, and so we started
closing down schools with measles in the United States.
In '72, '73, I ended up in upstate New York with Alan
Hinman, who was an EIS Officer then. And we started closing down
schools, doing search and destroy, containment vaccinations. So
I think we all brought back to the United States real tools,
learning lessons that were applied, that helped control measles
in the United States. Ciro de Quadros, a former smallpox
eradicator, went on to PAHO [the Pan American Health
Organization], and became a major player in polio eradication in
the Americas. PAHO associated measles vaccination with polio
vaccinations after noting that their surveillance of AFP (acute
flaccid paralysis) for polio revealed a lot of measles. And then
the Guinea Worm eradication program, with Don Hopkins [Donald R.
Hopkins], another former smallpox warrior, who came back to The
Carter Center. I mean, the legacies, the spinoffs from the
smallpox/measles program are incredible. Rafe Henderson with the
global EPI [Expanded Program on Immunization] at WHO in GENEVA
is a great global contribution. I guess it was 1976 or 1977 when
Rafe went to the World Health Organization (WHO) in Geneva, and
he expanded immunization. People in Europe ask, "Why the
Expanded Program on Immunization?" And I laugh, because I'm the
only one in Europe that was part of the smallpox group. And I
say, "Oh, that's the expansion of the smallpox/measles."
And this is another lesson, and I'm sure Rafe has talked
about it. All of it is about management. Good management. And I
hope D.A. gets interviewed, and he says this, and I'll say it
for him. D.A. was of course head of smallpox at WHO in Geneva
for many, many years. And on the day he left, he had a press
conference, and they asked him, "D.A., now that you've
eradicated smallpox, what's the next disease to be eradicated?"
And he said, "Bad management."
Harden: Let me just say, thank you very much for speaking with me.
Roy: Good.
Jean Roy Oral History
Jeannel Roy interviewed by
Victoria Harden
July 13, 2006
Jean Roy served as a Public Health Advisor in Dahomey, now known as Benin, which had the second highest incidence of smallpox in the world at that time. Jean describes early lessons learned from his work in the Peace Corps in Cameroon and how it led him to a job with the Smallpox Eradication Program at CDC. Jean talks about the role of fetisheurs and smallpox gods in Benin and getting the program started there, as well as the importance of logistics, management, and local context. "All of it is about management. Good management."
