Interview Transcript
This is an interview with Dr. Stanley Foster about his activities in the
West Africa Smallpox Eradication Project. The interview is being conducted
at the Centers for Disease Control and Prevention as a part of the 40th
anniversary observance of the launching of the West Africa program. The
date is July 14, 2006, and the interviewer is Victoria Harden.
Harden: Dr. Foster, would you begin by just briefly describing your
childhood and your growing up, and who made you who you are.
Foster: Okay. I grew up in Melrose, Massachusetts. My family was
very religious. My father died when I was 9 years old, and one
of the things that happened soon after that was I met Gordon
Seagrave. He was the famous missionary surgeon whose Burmese
nurses provided the medical care to Stillwell's troops during
World War II. And he became my role model. From that stage on, I
was going to be a doctor. I went to Williams College and then
went on the University of Rochester.
I think the connection to CDC was through D.A. [Donald A.
Henderson], who also graduated from Rochester, as did Deane
Hutchins. At that time, in early '62, they were drafting
doctors, so I decided I'd rather come to CDC than go to the
Army, so I came here. One of the interesting things that sort of
started it off was that with 2 "F" names, Bill Foege [William H.
Foege] and I sat next to each other in the EIS class of '62. I
was assigned to the Indian Health Service in Arizona and carried
out 18 epidemiologic studies. My basic assignment was for
trachoma. At that time, about 20% of the Indian children had
trachoma.
Harden: Had you specialized in infectious diseases or anything in your
medical training?
Foster: Internal medicine was my field. And, as was often the case,
Alex [Alexander Langmuir] would try to seduce officers he wanted
to stay. He sent me to Bolivia to investigate an outbreak of
conjunctivitis in Peace Corps volunteers. I came back to my home
in Phoenix, got to Atlanta at about 3:00 in the morning, and at
6:00 in the morning I was on a plane back to Phoenix and on the
way to the Truk Islands in the South Pacific to investigate an
outbreak of diarrhea with Palmer Beasley.
The assignment was an epidemiologist's paradise because a
boat would only go out to an island once a month. You would know
the entry point, and there would be a health worker there who
would write down the cases and the names. It was a great
epidemic. And the pattern of transmission was that of influenza,
but the disease was diarrhea. We brought back the specimens, and
the lab tested them out. They couldn't come up with an agent. We
tried to write up the article several times, but without an
agent, we couldn't. Twelve years later, when I came back from
Bangladesh in '76, the lab called me and said, "We just found
out what your '64 outbreak was. It was a rotavirus."
Harden: Rotavirus. Ah.
Foster: So we pulled out the article, finished it, and got it
published.
Harden: So you were doing epidemiology up until 1966?
Foster: Well, no, that's not quite true. I did my EIS training
from '62 to '64. Then I left CDC and went back to Rochester for
a year of residency. Then I went to the University of California
in San Francisco and did a fellowship in pulmonary disease. I
probably would have stayed on in San Francisco in pulmonary
disease, but I got the call from D.A., saying, "Do you want to
go to Africa and get rid of smallpox?" My wife and I thought
about it, and we decided after 24 hours that was right. We had 3
kids at the time, and I think one of the things we need to
discuss is wives and kids.
Harden: Yes.
Foster: In terms of the impact of those experiences on the kids.
Three or 4 of my kids' careers developed out of experiences with
smallpox. My oldest son was interested in traditional medicines,
and he now does Internet work in China. My second son, when he
was in the 8th grade in Dhaka, Bangladesh, did a study of
rickshaw drivers and how much of their income they spent on
food. Now he's the chair of the Department of Economics at
Brown. My third son got his start, really, in 1974 in
Bangladesh, when we had tremendous floods and a famine. People
were dying on the streets in front of our house. And he decided
to go into medicine. I had no knowledge of the impact that the
famine had on him until I read his Peace Corps application. And
then I understood that that experience, back in '74, was the
major event that sent him into medicine.
Harden: This is very interesting. You said you came from a religious
family. Were they missionaries or ministers?
Foster: No, my wife's folks are missionaries. They went to
Guatemala on their honeymoon. And her mother was interesting.
She refused to go as a missionary wife. She said she'd only go
as a missionary, and that was back in the '20s. They went down
to Guatemala and learned Spanish. Then they learned Mayan and
put the Mayan writing into a written language. And then they
translated the New Testament. They had a school and a clinic.
They stayed there for 45 years. Every year or 2, my wife and I
go back to that same town. My wife is fluent in the Mam
language. We have a nurse we work with, and she tells us what
she wants us to teach.
Harden: I'm interested in this streak of idealism.
Foster: Oh, you should get a copy of my college caricature. I have
a digitalized copy. It shows me sitting in a pot in Africa, with
the pygmies standing around. "Bless this food to our use" and
"Dr. Stanley, I presume" written at the bottom. I did have a
missionary bent at that point in time.
Harden: I'm seeing a different type of person who has been involved
here at CDC with the smallpox program than what I have seen with
investigators at NIH [the National Institutes of Health] in
terms of the things that motivated them to go into research.
Let's talk about once you were recruited into the program. They
asked you apparently to recruit others, as well. And you
mentioned that the recruitment of this 1 person.
Foster: Andy Agle [Andrew N. Agle].
Harden: . . .was interesting?
Foster: Yes, it was very interesting. Andy was a public health
advisor and a good mechanic. I remember, I met him at a building
in San Francisco. He walked in, and he said, "I saw this
advertisement that you wanted a public health person who spoke
French and was a good mechanic, and I knew you needed me." That
was it.
Harden: Very confident.
Foster: Yes, he was, there was no question about it. Andy turned
out to be one of the best. He worked for a long time in West
Africa; then he was working with smallpox in Afghanistan. He was
getting bored with Afghanistan, and I brought him to Bangladesh.
Then he worked for many years at the Carter Center and was very
close to [President] Jimmy Carter. He did a lot of agricultural
stuff and really worked incredibly well with the Carter Center.
And then he took a job in Nigeria. He died about a year ago.
Harden: Initially, you were the medical officer in Nigeria. Would you
tell me which region you were in, and what you found?
Foster: Well, I was responsible for the whole country. At that
time, Nigeria had 4 regions. the West, the Midwest, the East,
and the North. About half of the population was in the North and
about half in the South. We had Margaret Grigsby and Jim Lewis
in the western region; Warren Jones was in the Midwest; Bill
Foege, Dave Thompson [David M. Thompson], and Paul Lichfield
were in the East; and Deane Hutchins and Vicky Jones [Clara
Jones] were in the North. And it was a very different program in
the North than in the South.
Harden: Would you tell me about that?
Foster: In the North, the traditional leadership was incredibly
strong. I remember the first village I went to, Gwadabaw, in
'66.I got there at 6:00 in the morning, and there were 6,000 men
in a line. We vaccinated the men, and then they went home, and
then the women came out. Well, for the women to come out was a
big social occasion. They really didn't want to go back in.
But I learned something that day, which was very
interesting. It was a big district, and I told the district head
that we should have 3 vaccination sites in his town because it
would take us too long to do it at 1 site. He said, "I forbid
you for doing that." He says, "Everybody has to be vaccinated in
front of me. Nobody will tell me that they were vaccinated if it
had to be in front of me, whereas if there were 3 sites, they
could be tell me they were vaccinated when they weren't. The
Emirs of Sokoto, Katsina, Kaduna, and Kano were very powerful
people. The Emir of Sokoto would ride around in his Mercedes
every night, and if there was no petrol, the Mercedes got pushed
around town. But he was very powerful. So the only thing that
you had to do in the North was to convince the Emir, and he
would call in his district heads, and then everything would
happen. It was easy to get 96%-98% coverage in that region. In
the South, it was much more difficult. The people would not go
200 or 300 yards for vaccination. People were much more
independent in the South. There was not the structure, and it
made it much more difficult to get people to come for
vaccination.
Harden: Why would they not want vaccinations?
Foster: Well, I think if you go historically back, there was a
demand for injections. We believe that occurred secondary to the
yaws program, which gave shots of penicillin to treat yaws. But
it cured venereal diseases and pneumonia and everything else. So
injections were always sought after. In the North, the structure
was such that people would be told to do it and they'd do it. In
the South, you had to really convince them or use enough
publicity to get people to come for vaccination. So it was a
totally different thing.
And the epidemiology of measles was different. In the
North, where the women are in purdah, or where the population
density was relatively low, the median age of measles was about
36 months. In Lagos, where you have mothers carrying their
babies on their backs to market, the median age was around 14
months, and then that was with a population of 600,000. When I
went back in the '80s and '90s to Lagos, which now has a
population of over 10 million and possibly 20 million, the
median age of measles had dropped even further, to around 8
months. Controlling measles was impossible.
Harden: What was the toughest problem you encountered?
Foster: Oh, the Biafran civil war. I had flown to Benin to see
Warren Jones there. I got off the plane, and Biafran hijackers
got on and hijacked the plane. And that plane later was used to
bomb Lagos. It was very interesting: we believe that they were
using the passenger plane as a bomber, defusing the bombs, and
throwing them out the door. We felt that probably the reason
that the plane exploded was because the bomb went off before it
got out the door. Of course, they had to find somebody who was
asleep at their gun to reward for shooting this plane down. That
was tense, and a lot of people were evacuated.
I was talking with Deane Hutchins at lunch. I took the
kids and my wife up to Kaduna because I thought it was safe. The
next day, they bombed the Kaduna airport. But one of the
interesting things at that time, we knew there was no smallpox
in Biafra; but I was really afraid smallpox would get into
Biafra. So I convinced the government that the safest thing for
them to do was to vaccinate a large area around Biafra so that
the smallpox wouldn't get out of Biafra into Nigeria. That way
we kept it out. We also vaccinated a lot of children coming
through the lines. The malnutrition in pockets of Biafra was
just absolutely terrible. I think the war was really the
toughest obstacle. The regional office was shattered by the
bombings in Lagos, and it was not as safe a place as it had been
before that.
Harden: How did you get along with your counterparts?
Foster: Oh, I had the most wonderful counterpart in the world, a
fellow by the name of Yeme Ademola, who had gone to the Harvard
School of Public Health. If you go back into the history of the
smallpox/measles program, USAID [US Agency for International
Development] wanted to do all the countries except Ghana and
Nigeria. And Ademola was one of the ones who achieved its
inclusion in the program He actually went and met with Senator
Kennedy [John F. Kennedy] to push that.
Yeme was just so honest. He looked out for the poor. For
example, he had a cooperative grain bank, where he would buy
produce when the price was low, and then they would sell it when
the price was high. He supported a clinic. He was just an
absolutely wonderful guy, and he also was my neighbor. So he and
my wife would often go out and have tea with Yemi and his
British wife. He also is the subject of the most traumatic part
of my time in Nigeria. I got a call one night about 3:00 in the
morning, Rosa, his wife said that he had been attacked. When I
arrived at the front door, the murderers went out the back door.
He had been macheted across the neck. I went in and tried to
save him, but I couldn't. And at that time, I wasn't thinking of
my wife, who was pregnant. Panicked about me, she started to
abort. It was a horrible day. And then the next day, the police
came and wanted to put me under arrest for Yemi's murder. After
a 6-hour standoff, the American Embassy got me off on account of
my diplomatic status. So that was the single most traumatic
event of my years in Nigeria.
We had an incredibly interesting team. We had Deane
Hutchins and Vicki Jones. My favorite story of Vicki was when
she went out in the field once for 4 or 5 weeks, and she'd
either broken or forgotten her mirror. When she came back to
Kaduna and looked at the mirror, she said, "Something's wrong."
And then she realized it was that her face was white. In other
words, she'd only seen black faces for 6 weeks. But she was
wonderful.
The teams in the North were also just absolutely
extraordinary people. They had a driver there. He would know,
when he went into a village, who you needed to see first, who
you see second, and who you should see third. He had driven for
a political figure before that, and he was just good. The teams
would go, and they could vaccinate with the jet injectors, 8,000-
10,000 a day. The most I ever remember vaccinating in a day was
once in the Midwest: with 4 lines we vaccinated 14,000.
Harden: Wow.
Foster: I think it's important to put in perspective what Henry
Gelfand had learned about India. The Indians had vaccination
numbers greater than the population, but they still had lots of
smallpox. So Henry Gelfand went out there and did an assessment.
And he found the vaccinators were vaccinating the schoolchildren
regularly, so that they could get high numbers of vaccination,
but coverage was very low. So when we went to West Africa, we
were absolutely sure that with high coverage (Rafe [Ralph H.
Henderson] and Don Eddins adapted coverage surveys from the US
immunization survey to Africa) we would stop smallpox. There was
no question about it. And that was our strategy, and we were
absolutely sure that with high coverage with the jet injectors
and coverage surveys-if we got above 90% coverage, or 95% or
even better-we'd stop smallpox.
Four or 5 major events led to a change in that strategy.
The first was that when we first arrived in Nigeria, there was a
smallpox outbreak in eastern Nigeria, in Ogoja, where Bill Foege
had been a missionary. They had a limited amount of vaccine. But
by focusing the vaccine on the infected area, they stopped the
outbreak. The second important thing was a series of spot maps
that Bill Foege drew. Each year the smallpox would come from the
North, and there'd be a few outbreaks on the northern border and
in the East. Then the outbreaks would increase in number and
frequency, so you could just see it spread southward. And
although Bill doesn't remember this, I remember Bill sitting on
the steps, looking at these monthly maps and seeing how the
smallpox spread. And he raised the question, "If we stop these
first few outbreaks, will we stop them all?" The third major
event in the shift in strategy occurred in Abakaliki. (There's a
nice paper about this by Dave Thompson and Bill.) They'd done a
coverage survey, and Abakaliki had over 90% coverage. Then all
of a sudden they had an outbreak of smallpox. The outbreak
occurred in a religious group that had refused vaccination; I
think it was called Faith Tabernacle. Smallpox even though the
coverage in that area was 90%; the small group of unvaccinated
people was able to sustain an outbreak. The fourth factor was
the shape of the epidemic curve-a low in September-October and
epidemic in the early spring. Bill figured it out that every
chain of transmission in the fall caused 74 cases in the spring.
He realized that the peak time for surveillance was when the
chains of transmission were fewest. So, in my opinion, those
were the major events that shifted the strategy from mass
vaccination and surveys to surveillance/containment. And that
was certainly a major shift.
And I think, although the disease eradication programs
were different, when you compare smallpox to malaria, malaria
was a centrally directed program, and they never really
responded to the signs of drug resistance, and insect
resistance, and the program failed. Smallpox was different. The
program was driven by data collected in the field. We learned
from our failures and changed strategies to address them.
When I teach on lessons learned from smallpox/measles, one
of the major things is learning from our mistakes, being willing
to learn from our mistakes. My favorite story on this is about
Sabour. He was one of my team leaders in Bangladesh. At this
time, India was free of smallpox, but we were still having
trouble. And I went up to see Sabour in Mymensingh, near the
Indian border. If we did everything right, once we found an
affected village, there should be no cases after 14 days-after 1
incubation period. So I asked Sabour, "How many outbreaks do you
have?" And he said, "Sixteen." And I asked him, "How many had
gone more than 14 days." And he said, "Eleven." Well, this was a
disaster. The people could've walked those cases across to
India, where the reward was big, and made a lot of money. And so
I said to Sabour, "What are you doing?" His response was, "I'm
doing everything the book says. I'm putting the patient in the
house; I'm putting a guard at the front door and the back door.
I have an extra guard at night to keep the guards awake. I am
making a list of visitors, vaccinating them, and putting them
under surveillance. I'm vaccinating everybody in the household.
I'm vaccinating everybody in a half-mile. And I'm searching
every place in 5 miles." And then, across a cup of tea, an
incredible smile. And Sabour said, "And today I found out why.
I'm going in, and I'm asking for a list of visitors. They are
not giving me the names of relatives who came to visit because
they don't consider relatives as visitors. And so we added a
list of relatives to the procedure and solved the problem."
I think that this story illustrates one of the main points
to get at, that a lot of us at CDC who are in leadership
positions got a lot of credit for smallpox eradication, but it's
these people who worked 28 days a month in the field, month in
and month out for 5 years, some of them, who were the real
heroes of smallpox.
The other lesson to get out of this story was the
importance of giving workers at the field level the indicators
to assess their own performance. When they didn't meet them,
they asked why and come up with a solution.
There's 1 other similar story from India, which is really
important. At a critical time in the program in India, things
were going to hell in a basket in Bihar, and the numbers were
going up. And the Minister said, "I'm sorry, no more
surveillance/containment. We're going back to mass vaccination."
Bill spent the whole weekend with the Minister, trying to
convince him to continue surveillance/containment. But the
Minister said he couldn't take the political pressure and he had
decided that the only solution was to mass-vaccinate. At the
Monday meeting, the Health Minister of Bihar got up and said,
"I'm sorry, WHO [the World Health Organization] has recommended
we continue to do this, but I can't stand the political heat any
more, so we're going back to mass vaccination." In the back of
the room, a hand raised. And a man got up and said, "Mister
Minister, I am a poor country doctor. But when we have a house
on fire in our village, we direct the water at that house and
not the whole village." And the Minister said, "You have 1 more
month." And fortunately over that month things got better, and
so they continued surveillance/containment. Both of these
examples illustrate the really major contributions that poorly
paid and unrecognized field workers made. They really deserve a
great deal of credit for what went on and the success achieved.
Harden: But don't you think it was also remarkable that the bureaucracy
and the people at headquarters were flexible enough to ask for
and act on that kind of information? Many times you get
bureaucracies that think they know best, no matter what's coming
in. I think the synergy was quite remarkable.
Foster: Yes. Well, I think that's the main difference between
smallpox and malaria. When we introduced the reward for
reporting smallpox in Bangladesh, I introduced a single reward.
But after about 6 months, only 35% of the public knew about the
reward. And then all of a sudden, I discovered my mistake. None
of the health workers were telling the public because they
didn't want the public to claim the money. So we doubled the
reward to pay both the health worker and the public, and within
4 or 5 months, 80% of the country knew about the reward.
Harden: So getting the word out, and knowing how the culture operates,
also played a huge role.
Foster: The Bangladeshi field staff used to say that working for
the smallpox program was the best form of family planning (they
were never home) because at least their wives didn't get
pregnant. As you look at the evolution of
surveillance/containment in West Africa to the rest of the
world, it's a steady thing. .Probably the best place it was
demonstrated was in Sierra Leone. Don Hopkins didn't have enough
material to do the whole country. So on 1 side he did mass
vaccination, the other he did surveillance/containment. Smallpox
stopped in the southeastern area but continued on in the mass
vaccination area. That proved surveillance/containment worked.
Secondly, the legacy of surveillance/containment out of West
Africa clearly was key to the success of global eradication of
smallpox. Had it not been developed, it is unlikely that we
would have ever stopped smallpox, in Asia especially.
Harden: What about the role of the bifurcated needle? In my mind, West
Africa was the jet injector and Asia was the bifurcated needle.
Foster: This is not quite true. When we shifted from mass
vaccination to surveillance/containment, the bifurcated needle
became the preferred route of immunization. The bifurcated
needle was developed to vaccinate chickens. It had 2 main
advantages. It increased the amount of vaccine available 100-
fold. It only took 1/100 the vaccine required by the multiple
pressure method, where a drop was put on the skin and the site
was scarified by pressing a needle parallel to the skin 15
times. The bifurcated needle take rates were 99% effective
versus the traditional method's effectivity of 90%-98%.
In Bangladesh, the bifurcated needle totally transformed
containment. We could train a villager to use the bifurcated
needle in 10-15 minutes. This brought ownership of containment
to the village and quicker, more effective, control. It also
solved the problem of getting health workers to spend nights in
the infected villages, a major problem in the early stages in
containment in Asia. Once you were hiring vaccinators to
vaccinate their village, the barrier of the stranger was
removed, and accommodations in the infected village were
possible and acceptable.
I think we go should back just a little bit, to 1945.
After World War II, smallpox was endemic in most countries of
the world, especially in tropical areas, where the liquid
vaccine was unstable in the heat. So the development of the
freeze-dried vaccine (you could carry it in your pocket, it
didn't require refrigeration, and you could mix it up for the
day and it would be good) was a big thing.
New topic relevant to West African program but not to smallpox
And then the initial development of measles vaccine, the
Edmonston B measles vaccine, it could only be given with gamma
globulin. And the vaccine was not, at that time, licensed. It
had been tested in about 20,000 kids. At just about that time, 4
Ministers of Health visited the States and NIH. Harry Meyer
happened to talk to them, and one of them got very excited. The
Minister of Health of Upper Volta said measles was killing 20%
of the children in Africa and Meyer should come to Upper Volta
(now Burkino Faso) to test the vaccine there. So the first year,
Harry went to Upper Volta and tested the vaccine. The vaccine
proved its safety and efficacy without gamma globulin: that was
a major step forward. The demand was such that the next year
they vaccinated 700,000 in Burkina Faso. It was a tremendous
success medically and politically.
Then the United States expanded to the other countries in
OCCGE [Organization de Coordination et de Cooperation pour la
Lutte Contre Grandes Endemies] and that was when CDC first
became involved. Probably the best story about that concerns
Larry Altman [Lawrence K. Altman]. Larry's now a science writer
for the New York Times. He was sent out to Mali to address
problems with the measles program there. One day he sent back a
cable to Washington that said, "The trucks don't keep the
vaccine cold." And a cable came back from Washington, "Park in
the shade." And so Larry sent a cable back, "Send trees."
The measles program was a smashing success medically and
politically. You had 3 parallel channels. You had the smallpox
channel going on at CDC; you had Harry Meyer, who had proved the
safety and effectiveness of given multiple vaccines at the same
time. And then USAID and measles. USAID for some reason thought
they could vaccinate a fourth of the children the first year, a
fourth the second, a fourth the third, a fourth the last, and
they would be done. That was totally wrong. I was talking to
Dave Sencer about a phone call he got from A.C. Curtis from
USAID, who called him and said, "What about a measles
eradication program," and Dave said, "No, it can't be done.
Measles is only control, Smallpox is eradication. Why don't we
marry smallpox and measles?" Without measles, there would have
been no West African Smallpox Eradication measles Control
Program, no global program, and probably no eradication of
smallpox. The WHO 1,000-page history of smallpox has several
flaws, the major one being the order of chapters. They placed
the West African chapter after India and Bangladesh. Bangladesh
and India built on the lessons learned in West Africa and
succeeded because of it
While the marriage of smallpox and measles was key to
smallpox eradication, the effects on measles were short-lived
because of the lack of infrastructure to maintain vaccination.
Successful control of measles has only been achieved in the last
5 years with a new strategy. It should be recognized that Jean
Roy, the Operations Officer in Benin, has been a key player in
this success in bringing the League of Red Cross Societies into
play-resources from the wealthier countries and Red Cross
volunteers on the ground to mobilize the public.
It should also be said that the marriage of smallpox and
measles was a major barrier between USAID and CDC. USAID felt
they had been been conned. This was really the basis of a lot of
the angst between USAID and CDC because essentially USAID paid
the whole bill.
And I was talking to D.A. last night on the phone, trying
to clarify a few pieces of history, which is always difficult
with D.A. When the United States first agreed to do smallpox,
there was a briefing of the US delegation to the WHO Assembly.
Even the secretary of HHS [Department of Health and Human
Services; then, it was Health Education and Welfare] was not
aware of the plan. So then the announcement went out at the
assembly, from President Lyndon Johnson, that the United States
would support a smallpox eradication program in West Africa.
Later, the smallpox/measles marriage took place. Clearly, Dave
Sencer was a key actor in this. D.A. told me last night-which I
didn't know-that that press release about smallpox was written
by Bill Moyers. That was the international Year of Cooperation,
or something like that. And smallpox eradication and the US
contribution fit this like a glove from 3 perspectives: science,
development, and politics.
Harden: You have mentioned the 2 women who were professionals the West
African Program. Neither of them is here for the reunion, but
could you talk about who they were and how exceptional they
were?
Foster: Yes. Two very different people. Vicki Jones, young, free
spirit, guitar-playing, and Margaret Grigsby, an older, African-
American woman professor at Howard, very prim and proper. I
remember we had some issues insuring that there was a proper
latrine arrangement for her when she went to the field. And it
was difficult in the area that Margaret was in, in terms of
getting cooperation. Margaret was great. She had her heart and
soul in the program and bonded well with her African colleagues.
I do remember the first outbreak I went to in the western
region. They had isolated the smallpox patients in a cocoa farm,
and the only people who were allowed to go there were those who
had the scars of smallpox. This is very, very interesting. On
the other hand, you have the smallpox cult, Shapona cult, where
if you didn't want to get smallpox, you paid the priest. If you
got smallpox and didn't want to die, you paid the priest. And if
you died, the priest got all of your worldly possessions. So
they couldn't lose.
There are historical accounts, in the 1800s, of priests
actually infecting people who didn't pay up by putting smallpox
scabs on sticks going into houses. Actually, I remember the last
African outbreak I visited, in Togo. A couple of the traditional
healers were there trying to pick scabs. Fortunately, the scars
were from a vaccinial modified case, so it was not likely that
there was much virus left.
Harden: What did Africa teach you about yourself and about public
health?
Foster: We were young; we were bright; but we were not bright
enough to say we couldn't do it. I mean, that was really
important. In other words, there was never a sense that we
couldn't succeed. It was a totally different story in
Bangladesh. But we learned as we went along. We had pretty good
government response and fairly credible civil service. At least,
we were paying per diems and that sort of thing, kept people
working. It was a well-oiled machine. I mean, we had something
like 80 Dodge trucks in Nigeria. We had lots of spare parts. I
think the last one I saw running was in the late '80s.
Harden: What kind of impact do you think the whole West African program
had on the global eradication program?
Foster: Had West Africa not succeeded, it's doubtful that the
global program would have succeeded. I have no question in my
mind that it laid the foundation, and one of the great
injustices in the smallpox book is that the West Africa chapter
is put after India and Bangladesh. This is extremely unfortunate
and historically incorrect because a lot of the lessons learned
out of West Africa laid the foundation for what went on in Asia,
and Ethiopia, and Somalia.
Harden: Indeed. Is there anything you would change if you were running
the program all over again?
Foster: What we did then, we couldn't do now.
Harden: Say again?
Foster: What we did then, we couldn't do now.
Harden: Why?
Foster: I mean, it was pretty much an expatriate-run operation-
money-driven, technology-driven. We did not have the proper
amount of deference to local culture and societies and
governments.
Harden: I wondered about that.
Foster: It was pretty much a technology-driven program. It was
marvelous in terms of the teams we had. Some of the Operations
Officers, Dave Bassett for one, George Stroh for another. George
was driving from Jos down to the South when his motor mounts
broke, and his motor fell out of his engine. He put the motor
back in and drove home. I mean, just that kind of ability, to
react in the field. So that was important.
In Asia, several things were key. One was that the monthly
meetings were incredibly important. People came in, they gave
their reports, they shared the successes, they shared their
failures, they got drunk, they sobered up, they got their money,
they went back to the field. And most of them spent 25-28 days
in the field. And as I look at CDC people going in the field
now, they don't do that much any more.
Harden: Are there any final things that you want to say?
Foster: The challenges of West Africa were nothing compared to
what it was in Bangladesh, especially in the floods of 1974,
when the 2 remaining areas of infection were totally flooded out
and people went into motion. We went from 89 infected villages
in October of '74, to 1,500 the following May. We were all
depressed. We lost it. A wonderful guy, Rangaraj, was my deputy;
he was the first Indian physician parachutist. He had fought
with Stillwell in Burma. And every morning, he would say, "It's
going to be all right. Hang in there." Every day, he was like
that. There was no rationale for that. Later on, when I was
working in Somalia, I had a beer with Rangaraj 1 night, and I
said, "Ranga, how could you have been so optimistic?" He said,
"I didn't think you had a chance in hell in winning, but when I
fought with Stillwell in World War II, I learned that if you
ever thought you'd be dead the next day, you would be dead." So
it was his military training and his optimism that enabled us to
keep going, during incredibly difficult times. When I walk into
an HIV/AIDS village today, I feel Ranga's hands on my shoulder.
"Hang in there it will be all right."
Harden: And eventually, to win.
Foster: Yeah, and eventually to win. And Ranga was incredibly
important. And there were lots of people like that. In
Bangladesh, we had 22 nationalities on our staff, and they were
they best. I mean, they were family. We were all 1 family. The
monthly meetings were key. Then surveillance got incredibly
better, and we were able to track things. And we used money. We
paid $25,000 in rewards starting at $2.50 per report of an
infected village and increasing to $50 as the number of infected
villages in Bangladesh decreased. And we learned. For example,
when we started in Bangladesh, we were having trouble with
containment until we started hiring people from the village. The
reason we were failing was because health workers had no place
to stay in the villages. Once you started hiring villagers to do
the work, you had a place for your health workers to stay. And
so there was a tremendous lesson.
Stanley Foster Oral History
Stanley Foster interviewed by
Victoria Harden
July 14, 2006
Dr, Stanley Foster traces his early years and interest in international health. Describes his recruitment into the EIS and subsequent assignment to Lagos, Nigeria as the Epidemiologist for Nigeria in the Smallpox Eradication Program. Following that he was assigned to Bangladesh's smallpox program and then became the Project Director for the Combating Childhood Communicable Diseases (CCCD) project at CDC.
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