Interview Transcript
This is an interview with Dr. Ralph H. "Rafe" Henderson, about his role in
the West African Smallpox Eradication Project of the Centers for Disease
Control. Today is July 7, 2006, and this interview is being conducted as a
part of the 40th anniversary reunion of the launching of the Smallpox
Eradication Project. The interviewer is Victoria Harden.
Harden: Dr. Henderson, I want to begin by setting the stage for who you
were in the smallpox project, and I'd like to start at the
beginning. If I am correct, you were born in New York City, on
March 5, 1937. Would you give me a brief account of your
childhood and education, who your parents were, and whether any
of these early experiences nudged you towards medicine or public
health?
Henderson: Yes. My father was born in Burma, which is the explanation for
my nickname, Rafe. The British soldiers in Burma, who were then
in charge, used Rafe as a nickname for Ralph. My father's name
was also Ralph, and when he named me Ralph, then they called me
Rafe as a nickname. So that explains that. But it also explains
my orientation for international health. My grandparents were
medical missionaries; their grandparents were also medical
missionaries in Jamaica. My uncle was a medical missionary in
China. My father was the black sheep of the family: he went into
publishing with the Reader's Digest.
But my brother and I became physicians. When I was doing
my internship at Boston City Hospital, I was contacted by
somebody from CDC, who told me about the Epidemic Intelligence
Service (EIS). And that, combined with a lot of my other
interests in the international sphere and missionary work-
although my father was not religious and I'm not particularly
either-seemed to be a very good next step for my career in
public health.
Harden: Let's drop back a little bit and ask you to talk about your
years at Harvard. You were at Harvard for both your
undergraduate education and medical school. Was there anybody on
the faculty who was particularly important to your career?
Henderson: Yes, obviously in college, one always has heroes. Mine was a
psychologist named Jerry Bruner [Jerome S. Bruner], who was
dealing with cognitive psychology, and I found that very
interesting. I won't tell you the funny things we did, but in
any case, it was an interesting time at Harvard. I was there
only 3 years because I had spent the year before going to
Harvard as an exchange student for the English-Speaking Union.
So I was in the U.K. for a year, in what was a public school,
before coming to Harvard, so I was only at Harvard for 3 years.
Then I went on to medical school.
In medical school, many of us were very, very influenced
by Professor Thomas Weller, who had worked with Enders [John
Franklin Enders] and Robbins [Frederick C. Robbins] in
developing the polio vaccine and later on the measles vaccine.
Weller was very eloquent about tropical public health and the
challenges and the needs that were going on. As I say, a whole
bunch of us came out from under his tutelage very interested
(well, let's say interested because we were too young to be
career-committed at that point). I think he was a strong
influence.
Harden: You joined CDC immediately after your internship and residency
in Boston City Hospital. Were you one of the folks joining
initially to avoid-pardon me, to discharge-your military
obligation?
Henderson: Well, I think "avoid" is a very good term because I think for
many of us, that was 1965, '64, '65, when the Vietnam War, was
just starting. And how does one want to spend one's military
career? Well, it was certainly a very easy choicevivid one for
us. I would like to think that my own reflexes-both seeing the
difficulties of practicing in a city hospital, where you're
seeing end-stage disease and not being able to do very much
about it, and my interest in international health-made CDC a
choice whether or not there had been a military draft. But it
was clear that that served the best of all purposes as far as I
was concerned. I was not interested in serving in other areas of
the military. I was very interested in serving in what I knew,
at that point, CDC was doing.
Harden: In public health service.
Henderson: Right.
Harden: So in 1965 and '66, you were an EIS Officer. Would you talk a
little bit about your EIS training and assignments?
Henderson: Well, it was incredible. In those days, they used to call the
interns "the iron men" because we didn't get salaries, we ate at
the hospital, we often slept at the hospital, we had 1 set of
clothes. But we came to Atlanta and we're presented with a slide
rule; we got a salary; we were treated like important
individuals. It was incredible. Absolutely incredible. And we
had a very exciting 6-week EIS course, training us in shoe-
leather epidemiology. Because of my interest in international
health, I applied to the smallpox unit. I was lucky enough to be
selected. And then, lo and behold, I was sent off, very shortly
after the training, to West Africa as a technical advisor to the
French public health organization in the western part of West
Africa, called the OCCGE [Organization de Coordination et de
Cooperation pour la Lutte contre Grandes Endemies]. That's a
very long name, but part of it, the Grands Endemies, translates
into the "great endemic diseases."
I have to back up a couple of steps to explain why I was
going over there. In about 1963, roughly, the NIH [National
Institutes of Health] conducted a major field trial of measles
vaccine in West Africa, beginning in Upper Volta, as it was
called. And it was an astounding success. They covered most of
Upper Volta in a few months, with mobile teams, and did it very
well. They had high vaccination coverage, and measles pretty
well disappeared.
Now, that was a self-serving exercise, in that we, the
United States, wanted to test the measles vaccine on a large
scale. Here was an area where this could be done, where it was
desperately needed, where kids were dying of this disease, and
you would have had to have a very, very bad vaccine indeed, not
to be ethically justified in doing a combined trial of the
immunization and of the vaccine itself and seeing what impact
you would have on public health. Well, the impact was absolutely
astounding.
One of the reasons that USAID [US Agency for International
Development] was willing to go along with D.A. Henderson [Donald
A. Henderson] and others at CDC in joining a smallpox
eradication program, which USAID wasn't interested in, with the
measles program, which USAID was interested in, was that they
knew that they couldn't do much with the measles program unless
they had some good technical support. USAID had some disastrous
experiences without technical support, before they funded the
full program in '66.
Because the United States had the measles vaccine and no
other nation did, it was perceived that a measles immunization
program allowed the United States an entryway into West Africa,
where the French culture was dominant, one that did not compete
with the French either on educational or economic grounds. But
here was a neutral health ground-very popular concept. All the
countries desperately wanted the measles vaccine because measles
was such a bad disease.
And so I went over as one of the people to help out in the
stages before the full program got going. I was advising OCCGE
in running these mass immunization campaigns with measles
vaccines.
Now, the French were very good at doing mass campaigns;
there was no problem with that. The problem was that they were
not very good at dealing with this funny, electrical jet
injector, which we were using to administer the vaccine. And
they were not very good at dealing with the many, many
difficulties in supply and logistics posed by our USAID and U.S.
Government contributions to the programs. And so, when I
arrived, or at least one of my interviews was with the Ministry
of Health in Upper Volta and with the Chef des Grands Endemies,
the French advisor who was running the Grands Endemies. The
Minister was furious because our 5 Dodge trucks that had been
given to help administer the vaccines were consuming his entire
budget of gasoline for his entire Grands Endemies. And the USAID
deal was, "We give you the trucks, but you run them. You pay for
the gasoline." And of course, that just wiped out the budget for
the Ministry of Health for gas. All of these enormous trucks
were consuming all the gasoline. And so he was not a happy
person.
Harden: Was there any solution to this problem?
Henderson: They did the best they could. They were unhappy, but they did
not do a bad job with the things. One of my problems as
advisor was firing off cables about getting spare parts for the
jet injectors. They kept running out of some tiny points-I
didn't know what they were, but I think that on a regular engine
they'd be called the points. They relate to the electrical
system. Forget it. But that's all I knew. And I knew that they
were burning out, and they couldn't get spare parts. So one of
my jobs as a technical advisor, very technical, was to send
cables back saying, "Send more of these things because they
can't run the injectors." Nor did CDC send enough diluent, so we
were often using Evian, one of the French bottled waters, as
diluent for the measles vaccine.
I was overseas for about 6 months, traveled widely in
those countries. I was treated extremely well by the French
advisors, even though they knew I didn't speak very good French
and they knew a lot more than I did about anything they cared to
ask me about. But they were very gracious, very good about
teaching me and helping me learn about things. I think I saw in
those 6 months enough problems to last me the rest of my life
about what can go wrong with an immunization program and with
other kinds of public health programs that you're running. It
was extremely valuable.
Harden: One of the points that has been made over and over here is that
medical knowledge about smallpox was really only the first step
to eradicating it. The logistical problems, and the personnel
problems, and the diplomatic problems, all of these things were
key to eradicating the disease. So you were seeing this in
advance of the project.
Henderson: Yes, I think that's very true. I think the CDC tradition,
though, is an important one to emphasize. We medical people went
over with public health advisors, who joined us as nonmedical
people, who were there exactly for the management issues. CDC
had had a long tradition of this in the venereal disease control
program, as it was called in the old days, and the advisors then
branched out into tuberculosis and many other programs. There
were always public health advisors who were trying to get the
logistics and the management right. And so I think the CDC
position was, "We've got to have some medical expertise to be
credible, but we really need the management to be sure that we
can be effective." And I think that was really the key to the
success of much of what we did.
We didn't have such great medical knowledge of smallpox,
if I can say that. The program was designed to immunize
everybody in West Africa against smallpox, sort of a 100%
vaccination coverage. And we didn't find out until a couple of
years into the program that we didn't need to do that. That was
one of the really startling breakthroughs in the program-the
ring vaccination strategy of simply immunizing around active
smallpox cases, breaking the cycle of transmission, and not
going all-out to maintain high levels of immunity in all sectors
of the population. We learned that relatively rapidly, I must
say, within a year or so of the program. But it was a major
conceptual breakthrough for us.
Harden: Would you walk me through setting up the regional office in
Lagos? You were the Deputy Director and the epidemiologist. I
know that the Director, Dr. Lythcott [George I. Lythcott], is no
longer alive. So will you tell me about how it was formed and
how it functioned?
Henderson: Well, it's a funny thing. I have very little idea about that. I
knew that there was to be a regional office and that George was
the Director. When I was in West Africa, and the full program
came into being, I was then recruited from my role as an EIS
Officer to join as the Deputy Chief of the regional office.
George had worked in Ghana, and was a senior person, very well
respected. It was perceived that if we were going to have a
regional office, we should have a good regional office. And in
the early days, as I understand it, the idea was that this would
be the first regional office. Then, as the program expanded
worldwide, as we got rid of smallpox in West Africa and then
moved to other regions, there would be other regional offices in
other regions, which were similarly constituted. In any event,
we never did that. Ours turned out to be the only regional
office.
I was there as an epidemiologist, but I was one of the few
people who spoke French. So even though I didn't speak French
very well, my responsibilities were mainly for looking after the
francophone countries. My role as deputy was sort of doing all-
hands work. We had an equipment specialist with us, a very good
health educator, a statistician, and a secretary who was
knowledgeable about local and embassy issues having worked in
West Africa before. And we also had Jim Hicks [James W. Hicks],
our Senior Administrative Officer, who was very effective.
George, as the Director, dealt with all the terrible,
terrible political problems that were really insolvable, and he
managed to solve most of them. Jim Hicks dealt with equally
difficult administrative problems, like who had furniture in
their houses just in Lagos; could we get transport from the
embassy in the early days; what was going on with the financing
of things. He had all sorts of fights with the embassy and the
USAID mission, who didn't really have the resources to give the
support that they were supposed to to our group in the regional
office.
Harden: Now you, as I understand, wrote most of the E-1s, the programs
for each of the countries, in the francophone countries. Is this
correct?
Henderson: I don't remember that. At my age, I'm finding that happens more
and more often. I do know that I spent some time going around
with George Lythcott and Henry Gelfand trying to finalize and
write what we called pro-ags, project agreements.
Harden: Yes, that's what I meant.
Henderson: That's right. I recently got a communication from a colleague
who was working with us in West Africa. He sent me some of the
letters he had sent me then. And he quoted me asking if we could
give some of the cars that had been assigned to us, as advisors,
to our national counterparts? And he said in the letter to me,
"Rafe, you had already anticipated this and put the request in
for these cars. You knew that they would be needed by the
ministry, and that you couldn't justify it just for the
ministry, but you would justify it by giving it to the advisors
who were there, anticipating that they would then be shifted
back." I have no recollection of that at all.
Harden: There was, at this point, however, some tension between CDC
personnel and USAID as to whom the CDC reported to-whether they
reported to USAID, or reported to CDC through the regional
office . And I think it fell on you to clear the air about
this, if my reading is correct.
Henderson: Boy, I don't remember that either, very much. I do remember
going to a couple of countries; my wife and I were talking about
that. I remember being in Chad, and I was trying to recall, 40
years later, why was I in Chad? And then it occurred to me,
there was something going on with USAID and our staff there that
I apparently was trying to mediate. Again, I don't remember the
details of that. I do remember that there was a general problem
when we from CDC came into the West African countries, and we
felt we were masters of the universe, and there was nobody about
to tell us what to do, certainly neither USAID nor the embassy.
We had a mission. We were going to get our stuff done. And so
that was a general tension that I do recall. I don't remember my
role exactly, and what I did about it.
Harden: You started to tell me about developing the cluster sampling
system and the instruments we adhered to, to do the sampling.
Would you explain, for the record, what cluster sampling is, and
how you developed it?
Henderson: I can, but I would also like to go back at some stage, to lead
up as to why I ever got into that.
Harden: Okay, let's go back. Tell me how you got into cluster sampling.
Henderson: I had come back from India in the spring of 1967, when there
was a smallpox outbreak. We had been expected to eradicate
smallpox in India in a very short period of time. We did not
succeed in doing that. My wife and I came back to CDC, and found
that, in the interim, the Biafran War had broken out. She was
then not allowed to go back to Lagos as a dependent. I would not
go back to Lagos without her, and we arranged a compromise, as
my range of responsibilities was the francophone countries
anyhow. I did a whole series, 6 months or so, of continuous
consultancies, firefighting, and all sorts of stuff in West
Africa.
And then the Biafran War settled down, and we were able to
go back to Lagos. I got back to my regular job, as Deputy Chief
of the regional office. And I promptly got myself into trouble
with headquarters because I kept feeling that the policies that
we were being asked to follow by headquarters were not the best
ones for us in the field and that there was not a very good
understanding of what was needed in the field.
Harden: And when you say headquarters, you mean here in Atlanta?
Henderson: In Atlanta. So I became a very shrill voice, I'm afraid,
demanding and troublesome. And I don't remember whether I was
called back, or whether I had to come back on for another
occasion, but when I did get back here at CDC, I was pretty well
told, "Enough of this nonsense. We need some assessments done.
Go do them." Again, my memory is foggy, and it may be that there
was a lot of help, but I don't remember. What I remember was
going off and saying, "Oh yeah. Okay. We need to do
assessments." And it turned out to be 3 major assessments, one
in northern Nigeria, one in western Nigeria, one in Niger. And I
brought some reports that I'd been looking at recently, and
trying to scratch my head, and yeah, the cluster sample survey
was part of that assessment or evaluation. There were also
aspects of the assessments where we reviewed records,
interviewed people, looked at the health centers, inspected
vaccination teams, and the rest of it. So it was a very
extensive project.
Now on cluster sampling: if you do a random sample, if it
was the Gallup polls that we do in the United States, you can
get away with sampling a relatively tiny fraction of the
population. But you have to do it in a very meticulous, random
manner, so that the individual that you select is not selected
with any bias that you can imagine. This is very intensive, very
expensive, and very difficult to do. A compromise that was
developed by CDC staff, Serfling and Sherman (Robert Serfling
and Ida Sherman of CDC), here in the United States, was a
cluster technique. And that meant that, rather than taking a
single individual and asking questions, you could take a group
of individuals. But if you did that, you had to compensate for
the fact that they were a group and no longer independent. So
one of the group had more similarities to the other members of
the group than if you'd taken a totally different person from a
different area because the cluster was a geographic cluster. So
you would get households that were all together, or members of a
household that were all together-that was the "cluster" part of
the cluster . Rather than sampling as individual people, you
sampled them in groups. I had learned the Serfling-Sherman
technique as an EIS Officer. We had done a sample in Atlanta.
Bill Foege [William H. Foege] did a modification of that in The
Gambia early on. I knew about that.
So when I was asked to run these surveys, run these
evaluations, and do a cluster survey as part of that, I further
adapted that survey. To look back on that, it was incredible.
How am I going to do a survey in a huge area of the country?
What kind of a sample do I select? How do I get the records
done? How do I collate them? I taught myself to type; I didn't
know how to. I realized I was going to have to write these long
reports, so I was going to have to type.
I realized I was going to need some way of recording the
data. So I had worked on my own files with McBee cards-strange
animals. I'm just going to hold up one. It's a strange card with
a lot of holes on the sides of it. And you punch a notch in a
hole. Each hole corresponds to something you've written on the
card. So, for example, is this person who you're sampling a male
or a female? Male, 1; female, 2. If they check 1, I punch 1,
which is numbered on the edge of the card. At the end of the
day, I get a hundred cards together, and with a sort of
knitting needle, I run through the hundred cards, at the number
1. And lo and behold, all the cards that have this number
punched fall out, if I shake them vigorously enough. These cards
were fascinating to use-difficult to use, but a godsend because
I could then train teams, who would go out with these cards and
then, while they were in the field, simply mark a number for
each of the data points I had. Then at the end of the day at
their leisure, they would take a paper punch and punch out the
holes that corresponded to what they had found during the
survey. Then I collected all the cards from all the teams at the
end of the survey, went home, and spent a long time shaking
knitting needles and having the cards fall out. And I'm sure
there were a lot of errors involved with the things. But it was
absolutely an incredible exercise, and I can't believe, even to
this day, that I was able to do that, with very short notice, to
go in, to design the cards, to decide on the sample surveys.
But I want to talk a little bit about the actual sample
survey design because that was fascinating. What are you going
to do with a population that is as varied as you have in West
Africa? Yes, you've got some people in cities, but you've got
people in villages. You've got people that don't particularly go
to a village; they're nomads; they're all over the place. And,
again, I'm just impressed with ourselves, myself, in that time.
We designed the sample surveys to try to get if not a valid
sample, at least an idea of these various groups.
So, for example, we could have a sample survey that said,
let's take a valid statistical survey of all the villages in a
catchment area, or a state, or a country, that are under 5,000
population. Perhaps we thought under 5,000 would be a high-risk
group for smallpox. We'd get all the villages. So you select,
say, 30 villages out of those. And then we said, "You get your
sample from that village but then leaving the village, for the
next 10 kilometers, you stop every person you see, and you
interview them-no matter who they are, or what they're doing."
And then we said, "In addition to that, you go to some of the
local markets, and you do a market survey and find out who's
there. And within the market, sometimes you can select
individual groups." We knew there were nomadic tribes, and we
could recognize them because they wore distinctive things. So we
could say, "Survey 10 of the nomads from this area, and 10 from
that area."
In western Nigeria, we had an area of the state that was
very heavily influenced by fetisheurs, by the traditional
healers. And we knew that they had a cult, the Shapona or
smallpox cult, that did not appreciate being vaccinated against
smallpox. They were against vaccination. And we knew that
vaccination coverage was lower in that area than in other areas.
So we did a separate sample of the fetish area and the nonfetish
area.
We did all sorts of tricks to try to probe where we were
weak. It wasn't so much that the sample was going to give us a
wonderful average of what was going on in the country, but my
idea was, let's point the finger at where we think we're doing
least well. Let's find out what's going on there; that's where
we need to make the changes. It was just a fascinating
experience. As I said earlier, the survey was only part of the
full assessments we did. We also looked at records, we
interviewed people, we inspected vaccination teams.
We found faults everywhere. There were problems
everywhere. And that was one of the great lessons that I learned
in my life-despite all the problems that you find every day, and
despite the fact that you think nothing's going well, that isn't
always the case. You can have some success despite it.
The other thing that was impressive looking back now on
this, is that there was no stopping us. I mean, getting a sample
survey, doing these assessments, that's no problem. We'll just
do it. And I think it was the attitude of the entire program. We
had a goal; we were going to do it; nothing was going to stop
us.
I'll tell you 1 other anecdote that illustrates that. We
got stuck in western Nigeria during one of these assessments. We
got often stuck in western Nigeria. It was during the rainy
season, and we spent more times pulling ourselves out of mud
holes than anything else. But we were in a rubber plantation,
for reasons I don't understand, but we were doing a survey
there. And it turned out that the vehicle was running down on
hydraulic brake fluid. The brake pedal kept getting weaker and
weaker. And we knew when we left in the morning that we needed
some extra fluid. We had some, but by the middle of the day, it
was getting low, and we were running out. And we finally looked
under the hood and found that the brake line was rubbing against
the engine, and it had cut a little hole in the hydraulic line.
And I said, "Right, okay. I know how to do that from an intern
in Boston City Hospital. Give me some tape, and I'll tape it
up." I taped it up. But each time I did it, because the brake
line has a lot of pressure it just blew the tape away. It didn't
work at all. We were down to our very last little bit of
hydraulic fluid, and I said, "Right. What am I going to do?" And
we got some cotton that we had for first aid. I took some sap
out of a rubber tree, chewed the sap into the cotton to make it
a solid compress, and tied a whole series of very tight suture
knots around the hydraulic line. Amazingly, the thing held 'til
we got back at the end of the day. But that was the attitude:
"This isn't going to stop us. We can fix this. Nothing is going
to stop us." And that happened over and over and over again, to
everybody in the program. It was incredible. And I think it was
one of the things that made the program just such a success.
People would not be stopped.
Harden: Now, do a little analysis here. Was it just because these
particular people were so special? Was it an American thing? Was
it inspiration from above? What do you think made this group?
Obviously, it's a very special group. Do you have any opinions
on this?
Henderson: I hesitate to say it, but I'll say it anyhow. It's not a very
special group. And I think that's the magic of it. Special in
that the challenge was there, yes. Good leadership. Good
support. A strong image of what needed to be done. But by God,
when you do that, and you give people responsibility and things
that they've never met before, most times, most people will rise
to that challenge. And I say that because I then had experiences
later in life, in the World Health Organization (WHO), or other
programs, where we had the same sort of thing. We had specific
goals to achieve and people from many cultures, many different
backgrounds, still rising to that challenge in an extraordinary
way.
And don't forget, as I'm sure that nobody will, that we
were a tiny fraction of those who did the work. Most were the
nationals - the vaccination teams, the staff, the people living
in the endemic villages. So let's be clear that we were helpers
in a project that was done largely by national staff.
Harden: Were there any particular problems in dealing with the national
staff that you recall or were there good relations from start to
finish?
Henderson: I would have to say mixed. I think the relationship got better
as we all got more familiar with the environment and the
cultures with which we were dealing. When we arrived, we, the
CDC people, fresh out of the U.S., were impatient. We didn't
understand why something couldn't be done yesterday; what was
the problem? And of course, the folks we were dealing with-
whether it were the national ministries of health, the French or
English advisors who were there, the other expatriates-they
thought we were nuts when we first arrived. They couldn't
understand why we were having these expectations. Many of the
French thought that the word "eradication" should be eradicated.
They had very little little time for this eradication concept.
And so, yes, there were a lot of tensions with that. But I
would have to say, again, that the experience of the public
health advisors-who had dealt with those kinds of issues in the
United States with state and local health departments and
recalcitrant public officials at all levels and learned to find
ways of getting things done so that everybody went along with it-
these types of situations are where they really shone. We in the
medical officer field were often not so good at that, and I
think we were very well served by having the public health
advisors with us.
Harden: In December 1969, there was an observance of the hundred
millionth vaccination in Niger. Were you involved in that at
all, and do you have any special memories of that event?
Henderson: That was in Ghana, and I have some memories of it. I wasn't
involved with the organization of the event, thank goodness,
because it was a massive affair. But I do remember going and
giving an interview to the Ghanaian newspaper about things. The
report of the interview in the press talked about our work in
eradicating rabies or malaria, or something totally not having
anything to do with what I had said or what the program was
about. One of the reasons I was doing that interview was that, I
think the Minister of Health and George, the Director of the
program, were off doing the hundred millionth observance, and
they needed somebody to satisfy the local news media who could
speak about the program. So my role was a very minor one. But it
was a grand affair.
Harden: If you were going to do the program all over again, would you
change anything about the way it was run?
Henderson: Given that it worked, I think not.
Harden: How did the smallpox eradication program change your life and
career, or did it?
Henderson: Oh, very much. When I came to CDC, my idea was to work in
public health for a while, go back to internal medicine, and
maybe get a joint accreditation in public health and internal
medicine, as many of my colleagues were doing. But when I got to
West Africa and had a little bit of experience there, 2 things
happened. One, I was addicted to public health. Two, I knew I
had to go back and get some management training. So I applied to
the Director of CDC, Dave Sencer, and asked him for a career
development extension to go back and get a degree in public
health at Harvard Medical School. And I said, "I know Harvard. I
will look during that first year at the School of Public Health
and I will find some management training I can do during the
second year." I was sitting in Lagos, so I couldn't tell
Sencer exactly what that second year was about, but I said it
would be management. And, in fact, I tried to get into the
Harvard business school, but they had a very rigid program that
I thought was very unhelpful. The Kennedy School was just
starting a program of Master of Public Policy. They wouldn't let
me into it because they said I was too old. I think I was 28 or
29. I insisted that I was just the right person and talked my
way into it. So that was my second year of training. So it did
change my life in a radical way.
Harden: What impact do you think the program had? What impression did
it leave in Africa about the United States, about CDC? Do you
think it had an impact on the end?
Henderson: I think it was good. I mean, it may have been astounding. When
you're working down in the guts of an organization, one doesn't
see the perspective of what others have about the whole range of
things. I don't think we left a bad impression, by any means.
But that was nothing I was aware of, or got feedback on.
Harden: You said your wife was traveling with you. What impact did the
smallpox eradication effort have on your marriage, in terms of
anything? Traveling?
Henderson: Well, we were unusual. We had just gotten married. My wife is a
pharmacist, and we didn't have kids. And I thought that she
could be extremely helpful in what I was doing. Sample surveys
are not difficult to do. Keeping the records, drawing maps,
things of that sort, she does very well, and so we worked as a
team. And we continued to travel wherever we could as a team,
together. Now, she wasn't paid by anybody. I paid for whatever
travel was going on, but we worked together all the time. And in
fact, when I think about it now, it set an unusual precedent. We
kept running into problems later in life, when she would sit in
on staff meetings, or go to meetings with other organizations,
and they would say, "What's your wife doing here?" Well, there
would be administrative assistants, other people who would not
be contributing from a professional perspective but would be
sitting and listening in. But the fact that she was a wife
alienated a lot of people. Eventually, she began introducing
herself as my personal assistant. That seemed to work a lot
better. But it had a very strong bonding affect on our marriage
and lasted throughout our professional lives and through the
present..
Harden: Before we stop, is there anything else about the Smallpox
Eradication Program that you think of, that we should discuss?
Henderson: I think that one of the extraordinarily important legacies was
the group of people. Now, I have just told you that the group of
people was not extraordinary, that they were ordinary people.
But having gone through that experience, many of them continued
on working together as colleagues throughout their careers. And
the smallpox program in West Africa morphed into the larger
global program, with many of our staff from West Africa joining
the global smallpox eradication program and having major roles
in that.
After spending some time at Harvard and back at CDC, I
went back to WHO in 1977. I had left West Africa in '69. So
almost a decade later, I came back to international health at
the recommendation of Dave Sencer, to go and replace D.A.
Henderson at WHO and to run what was then a new program, the
Expanded Program on Immunization, which was a child of the
smallpox program.
Even in the smallpox days, we were looking at how to use other
vaccines with smallpox vaccine, how to do combined
immunizations. So a lot of the science had already been done by
us in West Africa, plus other colleagues elsewhere that were
working on the same issue. When smallpox success seemed assured
in 1974, the Expanded Program on Immunization was adopted by
WHO. The idea was to take what we knew about the smallpox
experience, providing immunizations for a disease, and do a
childhood immunization program. The program faltered for a
couple of years, and I was called in both because the program
was faltering and D.A. who everyone assumed would take over the
program decided to leave WHO. There was a desire on the part of
the U.S. to have a CDC US person replace D.A. and I went back to
do that.
Now, when I went back, a lot of the "mafia" I worked with
were the smallpox mafia-both the smallpox mafia that we had in
West Africa and the larger mafia that was then created when the
global program was created because the global smallpox program
was just phasing out. So suddenly I had a whole large staff of
people who had that same motivation, who had that same
perspective, coming into my program now, into the Expanded
Program on Immunization. They continued on to do polio
eradication, the diarrheal disease program, a whole slew of
very, very important public health initiatives. And that came, I
think, directly from this initiative in West Africa, the
smallpox group, then going to the larger, international group,
and then the international group coalescing around several
extremely important public health programs.
Harden: Do you think there will be another disease we can eradicate?
Henderson: Well, we're certainly trying with polio.
Harden: And having some very difficult problems, I think, and
discussions about whether it will be done.
Henderson: Yes. It's a very interesting quandary in public health because
you don't know, when you're beginning, if you're going to
succeed. If you knew that, it wouldn't be a problem. You'd just
get it done. We didn't know when we did smallpox in the
beginning that we would succeed. In fact, we had to change the
program radically in order to succeed. The same is happening
with polio-major, major technical breakthroughs, change your
philosophy, change of the way we approach things-learning as we
go, and having a lot of problems on the way. But that's the way
you make progress in science. That's the way you get better.
Now, there may come a day when we say, "Okay, enough is enough.
We've got to call it quits." But until that very end, I think
it's absolutely well worth giving it the best shot that we can.
Malaria was a situation where we tried and tried, and then it
became increasingly apparent that this was not going to work. We
didn't have the science. We didn't have the technical skills or
the technical equipment to do the job. We had to change the goal
of the program. That's not happened with polio, yet. We have a
lot of good irons in the fire, and I don't think we should be
anywhere near giving up at this time.
But there will also be interest in eradicating measles; there
will be interest in eradicating other diseases. When I did the
Expanded Program on Immunization, coming in in '77, people in
WHO said, "OK Rafe, we know who you are. You're one of these
eradication people. You are just interested in the short term."
And I said, "Not on your life. I'm not interested in
eradication. I'm interested in long-term childhood
immunization."
But I was interested in eradication. And I came back to that in
the late 1980s, when our routine immunization had more or less
done what it could do. It was reaching levels that were not too
bad but were also not too good. And at that point, we adopted
polio eradication, not only because we thought we were ready for
it but also because the polio eradication effort was 1 thing
that stiffened us up in the other efforts. Because we were
dealing with a specific disease, that helped us do the rest of
the things, gave us more enthusiasm for doing those other
things, as well. And I do think that the occasional disease-
specific initiative, whether it's eradication or radical control
of a disease, can help strengthen a larger health initiative, or
set of initiatives, and will remain a useful public health
strategy as long as we have both the combination of large,
integrated services that we're doing and some specific things
that are within those integrated services. I think that
combination remains extraordinarily important in public health
and probably in other enterprises as well.
Harden: Thank you so much for speaking with me. I think we've got some
fine footage here. I am delighted about the details on the
cluster sampling system. Nobody else has provided anything on
that for me, so I'm very pleased to have that.
Henderson: Good.
###
Ralph (Rafe) Henderson Oral History
Ralph Henderson interviewed by
Victoria Harden
July 7, 2006
Dr. Henderson was Deputy Director of the West African Smallpox Progam, stationed in Lagos in the Regional Office. He was responsible for the on the ground epidemiologic aspects of the program and developed methods of evaluation that have served in a multitude of other programs. He was subsequently assigned to WHO to initiate and direct the Expanded Immunization Programme, and was an Assistant Director General of WHO.
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