Interview Transcript
This is an interview with Dr. David J. Sencer, former Director of CDC,
about the West Africa Smallpox Eradication Program in the 1960s. The
interview was conducted on July 7, 2006, at CDC during the 40th anniversary
of the launch of the program. The interviewer was Victoria Harden.
Harden: Dr. Sencer, before we get to smallpox, I'd like to establish
that in 1966 you were the Director of CDC and managed the
overall direction of the West African Smallpox Eradication
Program.
You were born in Grand Rapids, Michigan, on November 10,
1924. Would you describe your childhood and your pre-college
education?
Sencer: I don't remember very much about the early years. My
father died when I was 4, in 1929, just at the beginning of the
Depression, and my mother had to go to work. I was an only child
in an empty house and had to fend for myself. I went to
elementary school in Grand Rapids and started high school there
as well. My mother felt that I needed to be in an environment
where there were more men, however, rather than living just with
a lonely widow. So she encouraged me to apply for a scholarship
to Cranbrook School, a boarding school outside Detroit, and I
was awarded one. My mother had to pay $32 a month, which in 1936
was quite a burden on her, but between that money and the
scholarship, I was able to attend Cranbrook School for 5 years.
I think I received a very good basic education in an environment
which was much more masculine than being home with my mother.
Harden: At that time, did you have any notion of what you wanted to do
for a career?
Sencer: When I was in high school, the things that really
interested me were the sciences: biology, chemistry, geology. I
was more interested in the sciences than I was in the "softer"
things.
Harden: You went to Wesleyan for your college education in the middle
of the war, in 1942. Tell me about going to college at this
time, and how this prepared you for medical school.
Sencer: Actually, that's the beginning of the war, 1942, not the
middle.
Harden: Yes, the beginning, you're correct.
Sencer: My first year was a normal undergraduate year. There was
no pressure to speed up my education, and the draft was not
threatening. I took normal liberal arts courses-English, German,
history, and 1 course in biology.
The next year, however, the pressure began to build. The
military had a variety of programs-the Naval V-12 Program and
the ASTP[Army Specialized Training Program]-through which
college students could actually enroll in the military, be paid
a small stipend as able-bodied seamen or privates, and continue
their college educations with a commitment to become military
officers after graduation. I was in the Naval V-12 Program at
Wesleyan.
By that time, assessing my various interests, I had also
decided that medical school would be the best career route for
me, and I was thinking of getting into biomedical research. We
didn't call it biomedical research at that time, but doing
research in medicine was my goal. Suddenly, however, I found
that I had to accelerate my program. I took organic chemistry
first thing in the morning, followed by inorganic chemistry,
which actually provided the introductory material for organic
chemistry, plus physics. The only things that I could find to
fill out my schedule were 2 courses in German literature. That
year I struggled with a very heavy classroom load and completed
all of my pre-med credits. Although I had not expected it, the
Navy officials at Wesleyan informed me that I had to leave the
undergraduate program because I had completed my pre-med
credits. There were no openings in medical school, however, so I
was sent to naval boot camp.
Harden: Let me interrupt you, just for 1 moment before we go forward.
You said you had determined that you would go into medicine.
Would you explain how you came to that decision? Did anybody
push you in that direction?
Sencer: No, no. There was no role model. That was the way my own
thinking just evolved, considering my various interests.
I went to boot camp and learned close-order drill, how to
evacuate a lifeboat, how to climb a rope, and other things like
that. I became a hospital corpsman, which at that time was known
as a "pharmacist medic." I was at Mare Island Naval Hospital and
then at the Naval Hospital, Camp Pendleton, the Marine Corps
base. My name was on a list to be transferred to the Marine
Corps. During this period, someone asked me if I wanted to go to
medical school. I said, "I have a choice between the Marines and
medical school? I'm a coward. I'll go to medical school."
Initially, I went to a 2-year medical school at the
University of Mississippi, in Oxford. I was in a class of 27
people. After I finished my 2 years there, I transferred to the
University of Michigan for the final 2 years of medical school.
Soon after I got to Ann Arbor, a routine chest x-ray showed that
I had minimal tuberculosis. For a year, I was hospitalized at
the university hospital because effective drugs had not yet been
discovered and so tuberculosis was treated with bed rest. In Ann
Arbor, when they said bed rest, that is what they meant:
bedpans, meals in bed, etc. Once a month they would weigh you.
You would roll out of bed onto a stretcher, and they would weigh
the stretcher and you. After a year of bed rest, you collapsed
on the floor when you tried to stand up because your knees
weren't used to carrying your weight.
Harden: What did you do all that year? Did you read?
Sencer: I read and listened to the radio. I read the New York
Times, Harper's, the Atlantic Monthly, and the Saturday Review
of Literature. The hospital's 1 rule was that you could read
anything you wished as long as it had nothing to do with your
job. I read no medicine, no journals. This was good because it
opened up a whole new variety of things to me. When you have
been in the grind of pre-med and medical school, you don't have
time to think about a world outside of science. I also listened
to the radio. I had an FM radio, and in those days, that was
unusual. I could get the political broadcasts, the Town Meeting
of the Air, and similar things that got me interested in
politics. That year was a life-changing interlude. I won't say I
enjoyed it, but it was probably the best thing that happened to
me. I also learned to knit.
Harden: And would you say this had a lot to do with your later interest
in worldwide public health?
Sencer: I think it planted seeds. I did not immediately become an
advocate of anything, but the reading, listening, and thinking
planted seeds and gave me a background in things other than
science and medicine. I went back to medical school and finished
on a part-time basis because they were very cautious in those
days about not over-stressing patients with tuberculosis. I
finished in January 1952 or December 1951. I have the
distinction of being both the first and last in my class. I was
a class of 1, so if I want to brag, I can do it. If I want to
poor-mouth, I can do that, too. I'd met my wife before I went
into the hospital, and after I got out, we got engaged and got
married.
I started my internship in Ann Arbor, a rotating
internship in medicine. I continued with what we called a
residency in those days and call a fellowship nowadays. I had a
residency in internal medicine for about a year and a half. One
day on grand rounds, the Chief of Medicine said to me, "Sencer,
you know the military's looking for you?" I said, "Well, no. I'm
4F." He said, "Not anymore. They say you're 1A, and they want
you. They wrote and asked if you were essential, and I told them
the department would fall apart for exactly 2 minutes if you
left." By this time, we were also expecting a baby, and we were
preparing to move out of our apartment before the baby arrived
because no pets or children were allowed. Here I was, then,
faced with 2 decisions: what to do and where to stay. I
contacted the navy to see if I could re-enlist, but they turned
me down because of my medical history with tuberculosis. The
navy did say that if I were drafted, it would be happy to take
me into its quota. I thought that was a terrible way to do
business.
One night, I was at a concert in Ann Arbor and saw a
friend who was a professor of public health, Cy Axelrod [S.J.
Axelrod]. I told him my problems, and he said, "Join the Public
Health Service (PHS)." I said, "What's that?" He explained and
said that the PHS had a tuberculosis research program that I
might be able to join. I wrote the Public Health Service and
said that I want to join their tuberculosis program. They
responded with the question "Why?" and I answered, "I know why,
what I want to know is when." Finally, in January 1955, I became
a Public Health Service officer in the tuberculosis program.
Harden: Do you think you would have stayed in internal medicine and
gone into private practice had you not come into the PHS to
satisfy your military?
Sencer: We liked Ann Arbor, and I thought that I might just stay
on at the university.
Harden: But instead, you joined the Public Health Service and began to
work in tuberculosis and migrant health.
Sencer: At first, I just sat around in Washington. They did not
seem to know what to do with me. I worked as a code clerk on
some research projects in tuberculosis. Eventually, I was sent
to Idaho to run a survey of the health status of migrant
laborers. When I arrived, I found a little caravan of 2 house
trailers used as examining rooms, a mobile x-ray truck, and a
mobile laboratory. To gather data, we had to drive to labor
camps around the Snake River Valley, so I learned how to drive a
car with a trailer attached. We would go into a labor camp, hook
up the water, and talk with them about coming in for
examinations.
Several things about this assignment changed my whole
attitude about medicine. I began really seeing people who were
disenfranchised. These were people who claimed to be from Eagle
Pass or Farr, Texas, but you knew very well they were from the
other side of the border. They had come to Idaho for 6 months,
but they could not get citizenship during those 6 months, so
they had no rights in Idaho. The farmers weren't interested in
paying them anything more than the minimum wage, and there was
no health insurance. We didn't see much disease in these camps,
actually, because the migrants were a fairly healthy group. They
had to be in order to work in the fields 12 hours a day.
One case we did encounter was that of a young man who had
a tuberculosis of the knee. Idaho had agreed to accept people in
the hospital if they had infectious tuberculosis, but he didn't
have infectious tuberculosis. We were faced with the question,
"How do we get him treatment?" Finally, we decided that the only
way was to bend the rules a bit. We convinced the young man that
he was under 18-he was actually 20-because if he was under 18,
he qualified for Crippled Children's Services, a federally
funded service. By this subterfuge, we were able to get him
treated.
A few days later, we found a 12-year-old girl who had far-
advanced tuberculosis in the hospital in a town we visited. The
hospital administrator called us and said, "Get her out of
here." He obviously did not want to have to treat her any
longer. I went to see her parents, and I said, "Don't visit your
daughter, because if you do, they'll make you take her home."
Instead, we made arrangements to have her transferred to the
tuberculosis hospital about 100 miles away.
To go to the hospital, however, she had to possess 2 pairs
of pajamas and a toothbrush. Well, pajamas, what are they?
Migrant workers did not own them. I said, "Let's see what we can
do." I went to the TB Association, but they would not provide
the money to buy the pajamas. Their attitude seemed to be, "She
doesn't buy Christmas Seals, so we won't help her." I went to
the Latter-Day Saints, as this was a big Mormon area. "She's not
one of ours," they said. I went to the Catholic church, and the
priest said, "They never baptize 'em down there in the valley,"
but he gave me $10 anyway. I gave it back to him. There was a
small community of Quakers outside of town, and I went out and
met with their elders, and they said, come back at 6:00 PM. I
went back at 6:00, and there was a whole pile of clothes. I
thought, "Oh boy, this is an opportunity to talk to them about
problems with the migrants." But they wanted to talk about the
fact they were playing baseball on Sunday in Boise, not the
thorny and politically volatile problem of migrant people.
People were willing to help a little on an individual basis, but
no one wanted to address the larger problems.
Those problems, however, got me interested in public
health because public health measures provided a way in which
you could do more for large groups of people than what you could
do trying to help 1 individual at a time. I had begun thinking
of a career change into public health when I got a letter
saying, "You're being transferred to Columbus, Georgia, to run
the tuberculosis research station there." This seemed like a
great opportunity to me, so we moved, but it was my wife's first
experience in the South, and Columbus, Georgia, was really
"South" at that time. She was not a bit happy. I, on the other
hand, had a wonderful job.
And the PHS then sent me to the School of Public Health at
Harvard. Getting a Harvard MPH [Master's in Public Health] was
in my view a necessary "union card" for moving forward in a
public health career. I learned very little at Harvard, except
from the other students. What they taught me was much more
important than many of the courses that I took.
After finishing my MPH, I returned to Columbus for a year
and then transferred to Washington, to a job that I thought was
just terrible. Finally, however, I realized that it provided an
excellent opportunity to learn how things really happen in
Washington. I worked in the Bureau Chief's office essentially as
a "gofer," but I learned about the budget process, about
interagency problems, and about how things really transpired at
this level. Then, in 1960, I was transferred to CDC as the
Assistant Chief, and I fell in love with an agency.
Harden: That is what I understand. Elizabeth Etheridge stated in her
history of CDC that you always thought the best job in the world
was to be Director of the CDC.
Sencer: Absolutely.
Harden: So, obviously, your mind had shifted. Your Washington training
served you well in learning how the bureaucracy functioned. Now
walk me through your rise through CDC until we come to the
beginning of the smallpox program.
Sencer: For the first 2 years, I was the Assistant Director. Larry
Smith [Clarence A. Smith] was the Director. To become familiar
with all of the activities of CDC, I obtained copies of all
articles published by the print shop at CDC and scanned them.
During those 2 years, I was intimately involved with
decisions relating to how polio vaccine would be licensed. In
1955, when the Public Health Service licensed the inactivated
vaccine [Salk vaccine], the PHS bought all of the existing
vaccine and distributed it to the states but did not give the
states any money to help organize distribution programs. For the
states, the easiest way to reach children was to give it through
the public schools. The result was a shift in polio cases back
towards what was known as "infantile paralysis." By the 1950s,
polio had become a disease more of older children and young
adults, but after school-aged children began receiving routine
vaccinations, it was the preschool-aged children who became
vulnerable to infection with polio. These tended to be the
children of people living in the inner cities with low incomes,
who could not afford to have pediatricians vaccinate their
children. There were outbreaks of polio in the late '50s and
early '60s in Kansas City, Chicago, and other cities, all
concentrated in the inner cities.
When oral polio vaccine came on the horizon, the Surgeon
General's Public Affairs Officer J. Stuart Hunter suggested
following the same distribution procedure. We at CDC opposed
this. We wrote legislation stipulating that the Public Health
Service would provide vaccines, not just against polio, but also
against all childhood vaccines, to state and local health
departments and that this vaccine could be used for children
under 5 years of age. The legislation also included money for
the states to organize immunization programs. This shifted
federal law from a focus solely on polio to a broader emphasis
on general immunization against childhood diseases, including
diphtheria, tetanus, and whooping cough. This law stood as basic
immunization legislation for a long time. Vaccines against
measles, German measles, and chickenpox were subsequently added
to the law's coverage.
Between 1963 and 1966, I was CDC Deputy Director; Jim
Goddard [James Goddard] was Director. Jim was a wonderful guy.
He was gung-ho, do everything. After about 6 months, however,
Jim decided that he was in the wrong job. He thought he was
better suited to run a small agency that needed to grow or an
agency that was in trouble and needed to be fixed. CDC was
neither. So Jim began looking for another job, and, basically, I
did the day-to-day management of CDC during those years. In
1966, Jim was appointed Commissioner of the Food and Drug
Administration, which was an agency that was in great trouble at
that time and still is.
I became CDC Director in 1966. At the same time, USAID [US
Agency for International Development] transferred the Malaria
Eradication Program, which was in great trouble, to CDC. Malaria
eradication was failing because it was based on premises that
did not work. Suddenly, CDC had the responsibility for a program
that was failing. We also inherited staff in 16 different
countries, and we had to fund them out of the CDC budget. It was
a huge problem. CDC became the biggest employer of people in
Haiti through the program. The whole Malaria Eradication Program
became a direct CDC hire, and we could imagine the staff of the
Malaria Eradication Program 1 day marching down the streets as
part of a political uproar in Haiti. But over time-not in 1966,
but over time-we brought about major changes in the way malaria
was approached around the world. We worked with WHO [the World
Health Organization] to get away from the concept of eradication
and to begin emphasizing control and prevention of deaths in
children.
Later, in 1966, the smallpox program started. Actually, it
goes back before that. Let me reconstruct the history as well as
I can remember it. I will talk about CDC's involvement in
smallpox, not the whole smallpox eradication effort around the
world. During World War II, Alex Langmuir [Alexander Langmuir],
the Director of Epidemiology at CDC, had been very interested in
biological warfare. The Epidemic Intelligence Service (EIS) was
created, in fact, because of the threat of biological warfare
during the Korean War. During Congressional testimony, Dr.
Justin Andrews, who was the Director of CDC at that time, was
asked about how we planned to address biological warfare. Justin
thought real quickly on his feet, and said that since military
draft obligations could be fulfilled through service in the
Public Health Service, CDC would establish an epidemiology
service of young people who would be trained to recognize
abnormal occurrences and thus be able to provide early warning
against biological warfare. That is how the EIS began.
Alex, of course, had been plotting for such a program, and
he happily seized the opportunity posed by biological warfare to
implement it. For a long time, he had been interested in
smallpox, and he got D.A. Henderson [Donald A. Henderson]
interested as well. In 1962, Don Millar [J. Donald Millar] was
sent to Indonesia as an EIS Officer as part of a malaria
assessment program, and while there, he saw smallpox for the
first time. He became very interested in the disease, and when
he came back, surreptitiously carrying some scabs of smallpox
for the lab, he was put in charge of what was called "smallpox
surveillance" in the Epidemiology Program. He was it. No one
else was involved.
Henderson and Millar began discussing whether smallpox was
a disease that could be eradicated. In contrast to malaria,
which has a mosquito vector and animal hosts as well as human
hosts, smallpox is directly transmitted from person to person
and has no animal reservoir, which makes it possible to
eradicate. We had a good vaccine, which made the disease
susceptible to eradication. The military had invented a jet
injector, which could be used to give rapid vaccinations to
large numbers of people. CDC helped the military modify the jet
injector so that it was possible to give intradermal injections,
since smallpox injections had to be given intradermally.
The intradermal jet injector was tested with smallpox
vaccine in the friendly islands of Tonga. Everybody made cynical
jokes about why they picked Tonga-why not choose a lovely
Pacific island with gorgeous beaches? Our audiovisual group here
at CDC made a beautiful movie of this, called Miracle at Tonga,
with the waves crashing up on the scene. But the actual reason
it was chosen was that Tonga had never had smallpox, and there
had never been any vaccinations, so it was a virgin territory in
which to try out vaccinating people with a jet injector, and it
worked very well.
In 1965, after a couple of years in Geneva, the World
Health Assembly of WHO passed a resolution calling for the
worldwide eradication of smallpox. President Lyndon Johnson also
issued a statement saying the United States would support this
initiative and contribute to the effort.
Harden: Was CDC involved with getting President Johnson to issue that
statement?
Sencer: Yes, but I had nothing to do with it. Alex and D.A.
Henderson worked with Jim Watt [James Watt], who was the
Director of International Health for the Public Health Service.
They also worked the streets of Geneva to get the resolution
passed, and they deserve a lot of credit for this. It involved a
lot of hard, political horse-trading. The Indians were against
it, and representatives from countries that had been burned by
the failed malaria eradication said, "Oh, no, no, no." But D.A.
Henderson had become quite familiar with WHO, and WHO had become
quite familiar with D.A., which I think becomes important as we
go on.
One day in 1965, Jim Goddard was out of town, so I took a
phone from Dr. A.C. Curtis [Arthur Clayton Curtis], who was in
the African Bureau of USAID. He asked if CDC would like to take
on a measles eradication program in West Africa. This call came
at a propitious time. Dr. Harry Meyer at NIH [National
Institutes of Health], in the old Division of Biologic
Standards, was testing out different strains of measles vaccine
in large populations. Measles was a terrible disease in Africa,
with high mortality in children. It was a real killer. Many of
the field trials in which Dr. Meyer was involved were done in
West Africa, and the measles vaccine proved to be a tremendous
success. USAID looked at the results of Meyer's efforts and
decided that it might be a good time for CDC and USAID to expand
the measles vaccine program in West Africa. I told Dr. Curtis
that we were not interested in measles eradication, because
measles eradication was not feasible, but that measles control
might be feasible if we could couple it with smallpox
eradication. If we could do that, CDC would be interested. And
he said, "Sure." It was as simple as that.
Then began the hard work of negotiating agreements with
USAID, writing what they call pro-ags [program agreements or E-
1s], and all sorts of documents that had to be written about
each country, and getting each country's agreement with the
documents. Dr. Henry Gelfand, on CDC staff, spent lots of time
going from country to country, getting country agreements,
getting things signed, trying to recruit people to become part
of the program. All of this was happening in late 1965 and early
1966. Finally, all of the paperwork was done. USAID had agreed
to fund the program. We had a 5-year agreement with USAID for a
program to start on July 1, 1966.
D.A. was a good friend of mine, and of the family, and his
daughter and our oldest daughter were also very close friends.
They were in the same grade in school. His daughter often told
my daughter that they were moving to Geneva in November, but
when I would ask D.A. about this, he would reply, "Oh, no, I'm
not going. I want to stay here and run the CDC program." His
daughter Leigh, however, continued to say, "We're getting ready
to leave in November," and D.A. continued to insist, "Oh, no,
no." But finally, he said that he was moving to the WHO in
Geneva, arguing "I was ordered to do it." Well, you know his
mouth was drooling to take on the WHO program all the time.
When D.A. was transferred to Geneva, Don Millar was
appointed head of the Smallpox Eradication Program. Don had been
studying at the London School of Tropical Medicine for a year.
He had gone there because there were people in England who were
very much interested in smallpox and could provide him with
additional experience and training. You will be interviewing Dr.
Millar, I'm sure, and you might want to ask him about his
dissertation at the London School. I'll let him tell the story.
By the fall of 1966, Don had come back from England. He was the
logical one to head up the Smallpox Eradication Program (SEP).
In the early part of 1966, the SEP had been run out of
D.A.'s Epidemiology Program. The people in the Epidemiology
Program were provincial in some ways. They thought that
epidemiologists were the only professionals needed to craft a
solution to any infectious disease problem. A big program like
this, however, requires logistical experts as well as
epidemiologists, so I pressed the Epidemiology Program to add
Public Health Advisors to the staff of the SEP... I pushed hard
to have Billy Griggs appointed as a deputy to D.A. Henderson, to
deal with the nitty-gritty of organizing and paperwork and so
on. As the SEP began staffing up for the West African program,
Billy made sure that there was a person called an "Operations
Officer" with each of the epidemiologist "Medical Officers." The
Operations Officer took care of the logistical things that had
to be done. You'll be talking to many of those.
Harden: As CDC Director, what made you buy into that idea? Did the time
that you had spent with the migrants influence your realization
of how many "operations" details were involved in such a public
health effort?
Sencer: Yes. When I first came to CDC, there was an older man
(he's 9 days older than I am) by the name of Bill Watson
[William C. Watson Jr.]. He had been in the Venereal Disease
(VD) Program for a good number of years, and it had been
transferred to CDC. Larry Smith was the Director of CDC at that
time, and he had previously been the Director of the VD Program.
He knew Bill's capabilities. He had moved Bill out of the VD
Program and appointed him Assistant Executive Officer at CDC.
I got to know Bill very well-he was a close personal
friend as well as a professional colleague. He often told
stories about how the VD investigators worked, and through
listening to him, I began to understand that the logistical
effort was a key part of disease control programs. People who
could get out in the field, knock on doors, talk to people, and
understand how people behaved were essential. The first
assignments given to VD Public Health Advisors usually were in
local health departments. They tracked down contacts of cases of
syphilis and gonorrhea and tried to bring them in for treatment.
After a couple of years of this work, they would become
supervisors, with responsibility for several other people.
Harden: And they weren't physicians.
Sencer: Oh no. They were a group of people who were recruited at
the baccalaureate level. They were not disappointed pre-meds,
but rather people who were interested in people. There were
certain schools at which the PHS traditionally recruited because
the PHS knew that these schools would turn out the sorts of
people that they wanted. The recruits would move up in a
supervisory managerial chain that stood behind the physician in
charge. In a state health department, there would always be a
senior Public Health Advisor behind the physician who was the
state VD Control Officer. The Public Health Advisor pushed,
pushed, pushed. He or she never made a medical decision but
pushed the physician to make the necessary decision and assume
the leadership role. And they learned quickly that this was how
you get things done. You don't have to make the decisions
yourself if you can get somebody else to make the right
decisions.
Harden: That's very interesting.
Sencer: Yes. A history of the Public Health Advisors is being
written. I think they're looking for a publisher.
Harden: You were explaining how the SEP was organized-what types of
people were needed. What did you look for in your staff? What
did they need to be able to run this program successfully?
Sencer: I looked for Billy Griggs to make good personnel
decisions. The physicians had already been pretty much recruited
by D.A. We lost a few real misfits the first year in training.
Many of the physicians who were recruited were EIS Officers.
Stan Foster [Stanley O. Foster], for example, had been an EIS
Officer. He had left CDC and was back in residency training.
D.A. called him and said, "You want to go to Africa?" And Stan
said, "Sure," and he came back to CDC. Rafe Henderson [Ralph H.
Henderson], who had been appointed to be the regional
epidemiologist on the ground in West Africa, had been at CDC for
quite some time. He had been on some of the early trips to West
Africa. Rafe had very good sense about people, too.
I put my trust in the people who were running the program.
I knew Billy Griggs made good decisions; I knew Don Millar made
good decisions; I knew D.A. was charismatic and a great
stimulator. He was not the best manager, but while he was here,
he developed some excellent management techniques. I knew what
was going on, but I did not micromanage. My philosophy is to
hire good people to run something, and then you let them run it.
Harden: When did you make your first trip to Africa?
Sencer: In the smallpox program? I think my first trip was for the
25 millionth vaccination event. They had a big celebration in
Ghana, in 1968, to mark the 25 millionth vaccination that was
given. This was a great public relations opportunity for the
Smallpox Eradication Program. USAID thought it was wonderful.
Many ambassadors were there. Jim Lewis, who you'll be
interviewing later, was the Operations Officer in Ghana. He made
most of the arrangements for this great to-do. It was out in the
country, about 90 miles north of Accra. There were tribal chiefs
in uniform, with umbrellas and gold robes and dancing, and so
on. Events like this were called durbars. I remember that the
American Ambassador shook his head, saying, "I've been to a 12-
chief durbar, but this is the first time I've ever been to an 18-
chief durbar." The Surgeon General was there, and he gave the 25
millionth vaccination to a screaming little girl.
After the event, while we were there, we had more
meetings. USAID had also recruited a reporter from the New York
Times,. Fred Friendly's son. They had the military attaché's DC3
from the embassy in Dakar. The next day we flew for breakfast
from Dakar to Abidjan, had breakfast at the airport with the
Minister of Health and the ambassador; flew to Monrovia,
Liberia, for lunch with the Minister of Health and the
ambassador; and to Freetown, Sierra Leone, for dinner. We refer
to that as "breakfast in Abidjan." All of this was good public
relations. It showed that the Surgeon General of the Public
Health Service was with us-that is, that we had support from the
top. It reinforced at USAID, too, the importance that we gave to
the program because we were able to get the Surgeon General to
participate.
From Sierra Leone, we flew to Bamako, in Mali. The pilot
had never been there. He flew east until he found the Niger
River, and then he followed the river up to Bamako. Mali, at
that time, was a Marxist country, with mostly Chinese activity
there. It was Chinese construction, Chinese this, Chinese that,
Chinese all over the place. We spent some time in Bamako, then
flew out to a market town, and then took the Dodge trucks out to
the Dogon Territory. This was located at the "end of nowhere,"
out with cliffs that fall off into the sub-Saharan plateau. The
Dogons are the people who had the big, big masks. They had
dancing and thousands and thousands of people getting
vaccinated. It was very colorful. There was a missionary there,
with whom we stayed. He had been in the mission field for 40
years. Ten years out, 2 years back, 10 years out, 2 years back.
We slept under the stars, where there were no artificial lights.
It was a wonderful experience. The next day we flew to Timbuktu
and then went on through Niger, Togo, Dahomey, and back to
Lagos, and home. That was my first major trip to Africa during
the Smallpox Eradication Program.
Harden: Tell me more about how you ran CDC as Director at this time.
Sencer: Even in those days, I was known for "walking around." I
wanted to know what was happening, so I walked around to see
things. I would ask questions, and it scared people sometimes.
There was 1 person I recall, into whose office I seemed to walk
every time he was reading his paperback instead of working.
Finally, he didn't even put it in his desk drawer when I came
in.
Harden: Could you say a little more about the bureaucratic relationship
of the Smallpox Eradication Program to the Department of Health
and Human Services, to the Public Health Service, to the
National Institute of Allergy and Infectious Diseases at NIH,
and any other federal agencies?
Sencer: The West African program was self-contained as far as
budget and management were concerned. We had our money from
USAID. Billy Griggs handled most of the dealings with USAID
concerning paperwork. At the front office level, we did not have
too many problems with USAID. The collaboration was something
that we knew about on a day-to-day basis, but it was not
something that gave us problems. We had good leadership, and our
philosophy was to get good people and let them do the work.
Harden: What was the toughest problem that you faced?
Sencer: During the African program? You know, most of the
problems, Billy handled. Ask him about that because the toughest
problems were paperwork and things like that. Our real problems
with smallpox began after the African program. The 1 thing that
the African program did was to demonstrate that mass vaccination
was not the way to go in smallpox eradication. You'll get Bill
[William H. Foege] to tell this story himself, but early in the
program, Bill was working as a medical missionary in eastern
Nigeria. He was volunteering as the smallpox epidemiologist for
that area. He did not have enough money to buy enough vaccine
for the mass vaccination program, so he began looking at spot-
maps of how smallpox was moving from village to village and how
long it took to move from village to village. He said, "If we
could prevent smallpox from moving from 1 village to the next,
maybe we could break the chain of transmission." He developed a
scheme of getting village leaders to tell them when there was a
smallpox case. He and his team would then go in and vaccinate
the people in that village and around it-the contacts of those
with smallpox-to contain the disease. And suddenly, smallpox in
his area began disappearing. He hit it at the low point in
transmission, so he was able to get to all of the foci of
smallpox, and smallpox disappeared from his area.
This strategy was presented in a variety of ways to others
in the program. Finally, it became possible to see if it would
work on a large scale. In Sierra Leone, Don Hopkins [Donald R.
Hopkins] was the Medical Officer and Jim Thornton was the
Operations Officer. Sierra Leone had the highest rates of
smallpox in Africa and was as backward as they come. Don and Jim
knocked out smallpox in months. This impressive demonstration
caused Foege's strategy to be adopted for the whole West African
program.
Harden: What mechanism did you use to tell everybody, "We're changing
the way we're doing the Smallpox Eradication Program?" And what
convinced you that Dr. Foege's approach was the way to go?
Sencer: This was a scientific study. They needed to show
convincing data that the strategy worked, and they did. I didn't
have anything to do with it other than to say, "Yes, you've got
the data to support your argument. We will do it that way."
Harden: But I understand the World Health Organization's approach to
smallpox eradication did not change so rapidly, even in light of
these data.
Sencer: Yes. WHO was reluctant to accept this. They had been
selling the concept of mass vaccination, and they were reluctant
to begin talking about a new approach. They had sold countries
on mass vaccination, and to change strategies would require that
they go back and re-educate them. After the West African Program
was completed, D.A. finally accepted that this was the way to
go, and it was after the African program that the hard work in
smallpox eradication began. That is another story, of India and
Bangladesh and so on.
Harden: Once you had achieved zero pox in West Africa and had finished
the program, CDC no longer received funding from USAID. You did
not want to let the program completely die, however, because you
wanted to continue surveillance activities, as I recall. At that
point, you appointed Bill Foege to be head of the Smallpox
Eradication Program. Would you talk about the follow-up from CDC
to the West African program?
Sencer: When we reached zero pox in West Africa, Bill came back to
CDC. Don was still in charge of the CDC smallpox program for a
while. Then the International Red Cross called and said that
they were concerned about the famine in West Africa, which
occurred as a result of the Nigerian War. The Red Cross asked if
Bill Foege-they asked for him by name-would come and do
surveillance of how bad the famine was. Bill went, even though
his wife was very reluctant to have him go because she knew if
he went, he might not come back soon because he would want to
stay and see things through. He went out and developed a
surveillance technique for the famine, and we began feeding CDC
people in, to maintain the surveillance activities and to
identify where the famine was at its worst, so that relief
activities could get to those places. This was being done with
CDC money at this point, but we had little authority to pay for
famine management in African countries. We were able to do it
under the guise of protecting the United States from the
possibility of the recrudescence of smallpox. Some of the travel
was being paid for by USAID, but CDC was paying all the
salaries.
Then the State Department began getting worried about what
was happening in Biafra, the secessionist state. State asked if
we would send somebody in to do a rapid assessment. Karl Western
[Karl A. Western], who had been at CDC for a good number of
years, agreed to go. He was taken out to 1 of the islands off of
Nigeria and flown in at night to Biafra. We had no official
presence in Biafra. Karl did a magnificent job of showing that
the famine in Biafra was the worst famine that had occurred
since the potato famine in Holland after the war, but that it
was localized. He also showed that 1 organization's relief
activity would set up in a village, and then other
organizations' relief activities would come in in competition.
You'd get the Lutherans, you'd get the Catholics, you'd get the
Worldfam, Oxfam, and so on. This meant that some villages were
getting all of the aid, but the major part of the country was
not getting any. Aid was flowing to places where it was easy to
get to but not out in the bush.
As a result of Western's work, I got a call 1 night from
Jesse Steinfeld, the Surgeon General. He said, "You and Western
get to town, right now." On a snowy January night, we went to
Washington, to the White House. We went into the Situation Room,
and who should show up but Henry Kissinger. Suddenly, we were
briefing Henry Kissinger on famine in Biafra. At that time,
Kissinger was the National Security Advisor. In typical
Kissinger fashion, he was playing USAID, which was arguing that
there was no problem in Biafra, against the State Department,
which was arguing that there was a serious problem in Biafra. He
was enjoying the bureaucratic struggle. He didn't give a hoot
about famine. It was the bureaucratic struggle. Kissinger later
became Secretary of State.
We also briefed the State Department person who was going
to Congress the next day. One of the major signs of malnutrition
is edema of the legs, which is caused by protein deficiency.
Assessing edema in a population was a quick way of determining
how bad the famine was. This Assistant Secretary of State kept
calling it "endema," and we kept saying, "No sir, it's 'edema.'"
"Oh, yes," he would say. He got to Congress, however, and in his
testimony, it was "Endema, endema, endema."
Harden: I want to drop back into the smallpox program and ask if there
is any other event of significance that springs to your mind
like the 25 millionth vaccination event you described?
Sencer: We went to a village, Ede, in Nigeria, for the observance
of the 10 millionth vaccination in Nigeria. When we got there,
there was the Timi, who was the chief of the village. He was
wearing a leopard-skin cap and robes, and when he went out into
the town square, everybody gathered around. He stood up and gave
the most erudite history of smallpox in Nigeria, back into the
early days of colonialism. It was beautiful.
Afterwards, we went in to his house and saw a plaque on the
wall that said, "Honorary Kentucky Colonel," and another plaque
that said, "Honorary Alumnus of Western Michigan University."
Surprised, I asked him to tell me about those plaques. He said,
"I'm an expert in the talking drums, and the State Department
takes me to the United States to give lectures on the talking
drums. In return, Kentucky made me an honorary colonel, and
Western Michigan made me an honorary alumnus."
We asked, "What are talking drums?" He said, "The drums
talk. They don't talk in code, they talk in Yoruba. Would you
like a demonstration? I always keep a drummer out in the
courtyard across from my house in the morning, so he can tell me
what's going on in the village on the drums." He then asked his
drummer to demonstrate the drums. One of the USAID people said,
"Have that man across the way come in and bow to the Timi and
throw the cat out." So the drummer pounded away, and this guy
came running across, bowed to the Timi, picked the cat up, and
threw it out.
I said, "Hmm, put-up job." He said, "All right, you tell
him what to say with the drums." I was smoking in those days. I
said, "Tell the man to come and take a cigarette out of my
pocket and light it. He pounded the drums, and this guy came in,
counted 1, 2, 3, 4, to me, reached into my pocket, took out a
cigarette, put it in my mouth, reached into his robes, and
pulled out a lighter. He said, "You know, it's true. We speak in
syllables. The drum has a head that you can squeeze the side of,
and it changes the sound, the tone, but it has trouble with
English words.
Don Millar said, "How would it say 'Dr. Millar?'" He said,
"Oh, that's Yoruba. Do-ki-tar-mil-lar." And that drum began
going, "Do-ki-tar-mil-lar, do-ki-tar-mil-lar." You could hear
it. Bill Foege-he was known as the tallest man in Africa-said
that when he was coming to a village, the drums would pound out,
"The tallest man in Africa is coming." Learning about the
talking drums was a wonderful experience.
Harden: What else did you learn about Africa in the program?
Sencer: What did I learn about Africa? Oh, my goodness. In those
days, it was a wonderful, wonderful part of the world. There was
a lot of concern about improvement, but they were not as highly
politicized as they are now. You would get outside the capital
city and find wonderful people who were shaking off colonialism.
One of the things about the West African program is that
there were 2 very distinct parts of Africa in which we worked:
francophone Africa and anglophone Africa. Each had a very
different medical system. The French were much better organized
than the English. When colonial government ended, the English
just picked up and left. The French left things behind and left
some Frenchmen behind, too. They pretty much controlled the
currency, and communications, and so on.
Harden: Let me change the question slightly. What did Africa learn
about the United States and CDC?
Sencer: Thank you for asking. One day in 1969 in the World Health
Assembly, the Minister of Health of Mali, which had been a
Chinese-Marxist country, made a speech. This man said, "I want
to thank the United States for giving us assistance in our
smallpox eradication program, but not so much for the vaccine or
the machinery or the Jeeps but for the people that the United
States sent to help us." That, to me, was the crowning glory of
the program. The Africans recognized that it was people rather
than things that the United States gave to Africa. We had sent
to Africa young guys and gals who had had no experience in
diplomacy, who had no experience with politics and so on, and
they went out, altruistic and wanting to get a job done. "We've
got a job, let's go do it, we can't do it ourselves, and we've
got to get the people in Africa to do it. We'll be there to
stand behind them and push. We'll give them the tools, we'll
give them the know-how, but they've got to do it." And they did
it.
Harden: I have just a few more questions. In the middle of the West
African project, some people recommended that smallpox
vaccinations be stopped in the United States, and this became a
hot topic of discussion at CDC. Would you comment on that?
Sencer: Actually, it was a little after the West African program,
because it was in 1972 that we really came to the belief that we
could safely stop smallpox vaccinations. By then, enough
eradication had been achieved, not only in Africa but in other
parts of the world, to minimize the threat to the United States.
The risk of importation was so slight that the risks of
continuing vaccination with the predictable adverse reactions
that occur with smallpox vaccine far exceeded it. As usual, we
had a meeting of our immunization advisory committee to go over
all of this.
We met on a Saturday morning. I had invited the Medical
Officer of Health of Great Britain, George Godber, with whom I
had seen recently, to come to our meeting. George was a
fascinating person. He was the architect of the National Health
Service in England. Ruddy-faced, white hair, monocle. He had
lost this eye, and he said, "Why spend money on 2 lenses? I only
need one." He kept a handkerchief up in his sleeve to pull out
and wipe his eye. He was a real character but highly articulate.
He wrote and spoke beautifully. At that meeting, we struggled
mightily with the wording of our recommendation on smallpox
vaccination. George finally said, "Dave, excuse me, this is your
country. But it is my language." He clarified the wording for
us.
Harden: If you were going to start the program over again, would you
change anything about how it was run?
Sencer: No.
Harden: Not a thing?
Sencer: Not a thing-as long as I could have the same people.
Harden: How did the program change your career at CDC? What impact did
it have?
Sencer: It changed CDC, and since I was part of CDC, it changed my
career. What it did was push CDC into international health, into
global health. It was the first time that we had responsibility
for a large international program from its inception. We had
inherited the malaria program, but the West African Smallpox
Eradication Program was totally a CDC operation. This was the
beginning of CDC's global involvement that continues to this
day, not just of ideas and equipment, but of people. In Dakka,
at the old cholera lab; we started the field epidemiology
training programs in different countries. It just goes on and on
and on. I think that individuals grow with the organization. You
don't pull the organization. The organization pulls you.
Harden: Since your role in the smallpox program was here at
headquarters in Atlanta, did it have any impact on your family?
Sencer: Not as much as it might have, although I did a lot more
traveling after the program began. I was not a traveling
salesman, just home on the weekends, but I did have to travel a
lot. It became worse with traveling to Washington, but I think
my family were envious of my going to Geneva for 2 or 3 weeks
every year for the World Health Assembly meeting, and things
like that. But I don't think it had any great impact on the
family.
Harden: But all 3 of your children are in the field of health in 1 way
or another. Am I right?
Sencer: Yes. Our oldest daughter, Susan, is a pediatric
oncologist. Our middle daughter, Ann, is a nurse practitioner in
oncology, and our son, Stephen, is Deputy General Council at
Emory, but he handles a lot of the research and intellectual
property sorts of things there.
Harden: Before we stop, is there anything else that you would like to
add?
Sencer: I'm tired.
Harden: Thank you very much for speaking with me. I think this gets us
off to a wonderful start for these recollections.
David Sencer Oral History
David Sencer interviewed by
Victoria Harden
July 6, 2006
Dr. David Sencer served as Director of CDC from 1966-1977. Dr. Sencer describes how his career brought him to CDC and the early days of getting the Smallpox Eradication Program started. He discusses his philosophy of management, his trips to Africa, shifting the smallpox program to Asia, and the legacy that CDC and the smallpox program left in Africa.
The Centers for Disease Control and Prevention produced this government publication. Use of this public domain resource is unrestricted.
