Interview Transcript
This is an interview with David Thompson about his activities in the West
Africa Smallpox Eradication Program. The interview is being conducted at
the Centers for Disease Control and Prevention, on July 14, 2006. This is
during the 40th anniversary celebration of the launching of the Smallpox
Eradication Program. The interviewer is Harrar.
Harrar: Can you tell me where you received your early medical training?
Thompson: I received my medical training at the University of Minnesota
and graduated in 1965.
Harrar: How did that prepare you for your experience with the Smallpox
Eradication Program?
Thompson: I had always been interested in international, global health.
My parents were missionaries in South America. In my senior
year, I received a Smith-Kline fellowship to work in a mission
hospital in Cameroon for 3 months, and it was there that I
became convinced that it was public health that needed the
emphasis, not curative medicine; that was my primary goal from
then on.
Harrar: What was it specifically that led you to that conclusion?
Thompson: I had the sense of a large population of people, a minority of
whom ultimately came to the hospital, were treated, would go
back home, and would keep coming back with the same problems. I
realized that hospital-based care, as good and necessary as it
is, didn't make much of a dent in things like mortality rates,
etc. For me, it was confirmation that I wanted to go back to
Africa, but I wanted to do public health. I had no idea that I
would be involved in smallpox.
Harrar: Can you be specific about the kinds of ailments that people
might be better served by public health versus curative
medicine?
Thompson: Malaria is a big example; all the immunizable diseases;
measles, whooping cough; malnutrition; TB, you name it. I
realized then that I could have a much greater impact personally
by multiplying my few gifts by working through physician
extenders and by focusing on simple but effective community
efforts of a preventive nature. Bill Foege [William H. Foege]
impressed on me the other truth-that when you've got limited
resources, you just prioritize and use those limited resources
to serve the needs of an entire, clearly defined
population/community.
Harrar: Very interesting.
How did you come to be specifically involved with the
Smallpox Eradication Program?
Thompson: I was finishing a rotating internship at Hennepin County
Medical Center in Minneapolis. It was the peak of the Vietnam
War. I wasn't exactly a pacifist, but I was very, very
uncomfortable with the war and didn't want to serve in it. So I
applied to the Public Health Service (PHS). At that time I was
planning on a medical missionary career, and I thought time as a
PHS officer in the Indian Health Service would be good
preparation.
I had a long application process. I was in the midst of a
very busy internship. I had to have a physical exam that
required going up to the Indian Health Service Hospital on the
Cass Lake Indian Reservation. They discovered that I had a fair
amount of dental work that had to be done before my application
could be finalized. That took some time, and I thought I wasn't
going to be accepted. I called all the various branches of the
PHS, and everything seemed to be full. Then all of a sudden one
day I got an airmail special delivery letter asking, "Would you
be interested in going to Africa with CDC?" Nothing else. I
said, "Absolutely," and that was the entree.
Dr. D.A. Henderson [Donald A. Henderson] came up to
Minneapolis and interviewed us at the airport. When he found out
that we were interested in medical missions, he proceeded to
spend the rest of the interview talking about how poorly medical
missions had done in the arena of public health. This was true.
I left the interview very deflated, thinking, "Well, this won't
go anywhere." And then, interestingly enough, we received the
letter of acceptance.
Harrar: What has been the contribution, do you think, of medical
missions to the public health of Africa?
Thompson: Historically, I think they've provided a lot of very good
person-to-person medical care in terms of building hospitals,
clinics, etc. Christian missions were pioneers in establishing
medical and education institutions in the interior parts of many
of these countries. A lot of these early missionaries died in
the process of providing these services. But it was a system
with fixed institutions. People came to these institutions. The
philosophy was, "I'll take care of you if you cross my
threshold," but then the people would go back out into the same
situation, re-contract malaria and all the other diseases that
you find in Africa, and then come back to the hospital. As time
went on, studies showed clearly that most people died outside of
the hospital. Historically Christian missions were slow to enter
the field of public health.
I came at a time in medical mission work when there was
beginning to be a shift towards thinking about a public health
approach, and my involvement with CDC just confirmed that for me
personally. Today, I think they're doing much more in terms of
public health.
Later on I helped to start a totally community-owned and
-oriented public health program in southern Chad, but I also
provided regular medical care in the local government hospital
and in our home.
Harrar: What drew you, in your early life, to think that you might want
to become a medical missionary?
Thompson: I came from the rural Midwest, miniature Scandinavia. My
parents were missionaries; they spent most of their lives in
Bolivia and Ecuador. My father was a minister and a farmer, but
he met all sorts of needs. I remember very well going with him
up to the local village, taking care of people who had been
severely burned. That instilled in me an interest in medicine
that increased with time. I've always had an interest in issues
of justice.
Harrar: And what kinds of injustice have you seen that are most
compelling to you that you wanted to fight?
Thompson: Well, living in this time, injustice is such a huge issue. I
have always been sensitive to the inequities, the imbalances,
the increasing self-centeredness, and isolation that
characterize our Western world, particularly the United States.
My parents always allowed me to see and share in the suffering
of others. They didn't hide this. As a matter of fact, they made
me participate in it.
I remember very well when I was in early grade school. It
was after the war, and my father insisted that we all sit up and
listen to a radio program put on by the Lutheran World
Federation, which then was focusing on the refugee situation in
Germany. These were all very sad stories, and I remember wanting
to go upstairs and hide.
Harrar: And your parents wouldn't allow it?
Thompson: No, no, they wouldn't.
Harrar: I believe that Martin Luther King said that, of all the
inequities there are in the world, the worst inequities are in
health. Could you comment on health inequities?
Thompson: Health inequities. I've spent 16 years of my life working in
Africa, 12 of those in Chad, which is one of the poorest nations
in the world. I had a child die on my dining room table from
pneumonia. He'd been treated in the hospital, and he wasn't
making it, so we took him into our house. My intervention with
the limited resources we had did not work either. I watched so
many children and adults die who didn't need to die.
And then we live in this very affluent country and culture
with slums, a large homeless population, and millions of people
without medical insurance let alone consider the utterly poor of
the "two thirds world'. The United States is way down the list
of industrial countries in terms of its giving to overcome
global poverty. What our government does in this regard is
pitiful.
These inequities can be overwhelming, but they don't need
to be; we simply need to find a place where we can make a
difference. And in my case, very fortunately, I had the
marvelous opportunity to spend 4 years with CDC and the Smallpox
Eradication Program. The 12 years in Chad were a wonderful time,
when I was able to share and to learn, to participate. And,
actually, I wanted to continue on in that work and spend the
rest of my life working in Africa. But other things intervened
and didn't make that possible.
So I struggle with the inequities even here right now. I
work in an inner city, safety-net hospital, taking care of
recent immigrant kids. So inequities are a part of my life.
Harrar: Would you say that the inequities are greater in the developing
world than they are here, or could you just comment on that?
Thompson: They're of a different nature. It's interesting when you work
in the inner city. There are certain strengths in African
culture that aren't there in the inner city. There are ways in
which a culture and the strengths that hold people together-the
collective forces that make people help one another, that give
people cohesiveness and commitment to a group-aren't as present
in the inner city, but in Africa they're very strong. In Africa,
excess of this commitment to community results in tribalism, but
the very positive part of it is this tremendous allegiance to
your clan, to your family, to your extended family. So the
inequities are certainly bigger in Africa and in the
underdeveloped world, but they are mitigated by the cohesiveness
of the community and the concept of the extended family.
Although the levels of poverty etc. in this country are
certainly less, the inequities here are almost harsher and
harder to tolerate because we could do something about it and we
don't. So I think our failings or our guilt-if I can talk about
guilt-is bigger here because it's our own country and our own
people and we could do so much more. That does not take anything
away from the responsibility we need to take to address global
inequities and poverty.
Harrar: I'm working on a series about health disparities right now in
the United States so I'm just curious whether you see those as
being directly involved with race or with socioeconomic status?
Which is bigger in your own experience?
Thompson: Our history of racism has had a very negative effect on our
society. The result of that has contributed to a loss of
identity and culture that has been very disruptive to family and
community life. There are obvious and severe economic effects as
well. There is a tendency to become callused towards this, to
live in affluence with blinders on so we don't see the sadness
and turmoil that are there. The solution-or at least an
approach, if there is one-is to share, in some tangible way, the
suffering of someone, somewhere (preferably close by) so that we
don't lose sensitivity and become callused, isolated, thinking
only about acquisition, protection, insurance against all
suffering, and the need to live looking eternally young.
Harrar: When you wake up in the morning and think, what's the meaning
of my life, have you found some comfort that you . . .
Thompson: Yes, I do. I wake up in the morning looking forward to the day.
I come from a conservative religious community, Lutheran
background, and right now I'm concerned about reawakening in the
church a sense of biblical justice. The Bible is full of a
prophetic kind of advice and wisdom that is concerned about
taking care of the poor, the widow, the elderly, and the
refugee. I wake up with hope, and I've got a good job that
allows me to do this. We have a large extended family that
reaches around the world. A wonderful part of this has been
having a wife and a family who have been very supportive; they
have been a very key part of this all along. I wouldn't have
been able to do it without Joan.
Harrar: Did you take your family abroad when you worked?
Thompson: Oh, yes. When we went to Nigeria, the Biafran War was brewing,
and our families were evacuated before the first year actually
came to an end. Joan was 8 months' pregnant with our second
child, who was born later in the United States. Then we were
reassigned to Liberia, and our last child was born there. When
we went back to Africa to work with the church, they were all in
grade school; they all graduated from high school in Nigeria
before returning to the United States for college. We raised our
family in Africa. I'm very, very thankful for that.
Harrar: How would you say that has changed their worldview?
Thompson: Their worldview is such that they tend not to see color.
They're similarly interested in living justly, if I can put it
that way, in sharing.
Our daughter has 2 daughters; they live in Billings,
Montana. One of the neatest things they did, when the girls were
probably about 8 and 6 years old, was to get a list from United
Way of families that needed specific things at Christmastime.
They went out and the girls helped shop for all of these things.
Then they actually delivered these things to United Way; that
made a lasting impression.
Harrar: So you have a sense that you were able to pass on to your
children what your parents taught you.
Thompson: Yes. I'm very thankful for what my parents gave me, and I'm
thankful for the lessons we learned together as a family in
Africa. One of the things we did was have our children
participate in our life and activities, even though that
involved interruptions, doing without things, and some degree of
hardship. One night our children, who were in the latter grade
school years at the time and home on vacation from their
boarding school, were chatting. They were talking about parents
who weren't available and weren't around. I kind of got the
sense that they might be talking about me, so I said, "Well,
look, I'm here every day; I'm here at night." And they replied,
"But, Dad, you fall asleep." My work frequently took me out into
the villages on motorbike and that sort of thing. I loved the
work, but it was taxing and our children experienced a father
who was often pulled in many directions and sometimes over-
extended. But I think my children were able to accept and adjust
to that and ultimately were able to share some of the sense of
accomplishment that came from it.
They're all doing similar things in very different arenas
today. Our son and wife are actually going to Liberia to adopt 2
Liberian girls this summer, we hope.
Harrar: How exciting, that's great.
Can you tell me, on a day-to-day basis, what kinds of
things did you do for the smallpox eradication effort? And tell
me about Dr. Foege, too.
Thompson: Yes, I had the good fortune of being assigned to the Eastern
Region of Nigeria with Bill Foege and Paul Litchfield. I don't
know why we were assigned together, but I suspect it might be
the fact that Bill was a missionary at the time on contract to
the smallpox program, and I was interested in medical missions.
Paul Litchfield, our Operations Officer, had also been a Mormon
missionary. I considered myself extremely fortunate to be part
of this team!
We arrived in Enugu in the fall of that year, and very
soon there was a major smallpox epidemic that produced over a
thousand cases. The epidemic was centered in the area where Bill
had worked before with the mission; consequently, he knew key
people and understood the area. One of the missionaries was
particularly helpful; he supplied us with motorbikes and we went
hunting smallpox. For weeks, we (Paul Lichfield [Paul R.
Lichfield], Bill, and I) spent most of the week out in the
countryside trying to track down smallpox and organizing an
official vaccination campaign. Then we'd come back on weekends
and crash. It was tough on our families, specifically my wife
and Paul's wife, who had never been overseas. For me, it was
kind of a lark. I was having fun.
While the smallpox epidemic was raging in Ogoja Province,
pressure was being applied to conduct a vaccination campaign in
Enugu, the capital city. We temporarily moved our activities to
Enugu. One day, Bill, Paul, and I were going around Enugu with a
big map, looking for logical gathering sites to vaccinate
people.
People started gathering around, and pretty soon policemen
appeared; we were arrested and brought to the police station. In
the context of all the fears and stories circulating about the
atrocities etc. that preceded the war, our maps and activities
looked suspicious. The police called the Ministry of Health, and
Dr. Anazonwu, our counterpart, came down and said, "Fine, no
problem." We were immediately released.
Towards the end of the Ogoja epidemic, we began hearing
about hidden smallpox cases among people in a big town who
belonged to a group called the Faith Tabernacle. This religious
group refused immunization and vaccination. They were hiding
these cases because they feared having vaccination forced on
them and because the patients themselves would be sent to the
huge isolation camp that the Ministry of Health had set up out
in the bush. With the help of one of the health inspectors, I
was able to investigate the epidemic and identified 4 distinct
generations of smallpox that were being transmitted in this
submerged and interrelated community without spreading to the
rest of the community. Unfortunately, the conditions leading up
to the Biafran War started heating up and we had to be
evacuated. So, really, my memories of smallpox and the program
in Nigeria are limited to the above
Harrar: And your own faith, experience with faith, was that helpful to
you in getting this group to open up to . . .
Thompson: No.
Harrar: No?
Thompson: No, no, no.
Harrar: That did not apply?
Thompson: That didn't apply.
Harrar: What other cultural obstacles did you encounter?
Thompson: Fear of vaccination was the biggest thing along with the fear
of being sent to the isolation camp if you were diagnosed with
smallpox.
For the most part, the obstacles weren't all that great.
The obstacles were more mechanical, just getting teams into the
field, keeping them going, keeping them supplied. I think
ultimately the people appreciated and cooperated.
The Ministries of Health weren't all that excited
initially about smallpox eradication. They wanted measles
immunization, and we had to combine measles immunization with
smallpox to get to the smallpox program accepted.
I encountered a lot more cultural issues in my later work
than I did in smallpox.
Harrar: How about politics, either here in the United States or in the
countries where you were working? Any comment on that?
Thompson: I can't comment very much on politics.
Our time in Nigeria was so brief that our relationships
were limited to one small sector of the Ministry of Health. Of
course the fears of genocide and the tensions that led up to the
Eastern Region's withdrawal from the federal government and the
civil war were increasingly occupying people's attention and
those did get in the way.
In Liberia the times were stable; the physician in charge
of infectious disease and our immediate supervisor was a very
wise and gracious ex-Haitian who did all the political
interference. So we didn't have any political issues that I can
recall.
Harrar: Okay. You were starting to say that there were more cultural
and political things when you worked in other places (in Chad
more than in Liberia).
Thompson: Generally speaking, working cross-culturally in Sub-Saharan
Africa is difficult. There were often old historical distrusts
and animosities. However, the area we were working in Chad had
primarily one ethnic group; they had a long tradition of strong
leadership and that was very helpful in organizing a community
program. They had, in effect, a king; they were used to working
together and that contributed significantly to the ultimate
success of the program. In Chad, my work involved setting up a
very simple healthcare system using lay volunteers, young
farmers, whom we trained. They were able to treat malaria,
prevent dehydration with oral rehydration, take care of simple
wounds, and give a treatment for intestinal parasites as well as
educate by example. An immunization program in participating
villages was carried out with the cooperation of the local
government hospital. We were there 12 years. After about 6
years, I turned responsibility over to a Chadian nurse and
worked as his advisor for an additional 6 years before leaving
permanently. We chose the leadership carefully.That and the
cultural cohesiveness helped them not only to continue on their
own, but also to thrive.
There were relatively few cultural barriers with the Chad
program. It was the cultural strengths of the community itself
that made our work possible. I think we would have encountered a
lot more barriers if we had started to expand this program
beyond this limited population, to work interculturally.
Harrar: How important do you think a primary healthcare system is to
solving a global problem like smallpox or polio eradication?
Thompson: It's part of the answer. The eradication of smallpox was a
special case; it was basically achieved by applying massive,
regional programs of a vertical nature. These regions of the
world had minimal primary care resources, but that did not
prevent them from mounting special mobile campaigns with the
help of well-targeted and effective outside technical and
financial assistance. The eradication of polio would prove to be
much more difficult and more dependent on primary care
resources. Even when I was with smallpox, I started thinking
about how the eradication effort could be used to build primary
healthcare at the local level. One thing the smallpox
eradication effort did accomplish in respect to primary
healthcare was the practical epidemiologic and managerial
expertise it left behind in each country. The development of
successful primary healthcare systems is highly dependent on
operating from a firm public health/epidemiologic base! However,
I didn't get a chance to apply what I learned in the smallpox
program until I returned to Africa in 1975 under the auspices of
our church. The goal then became to create a simple, self-
sustaining, primary healthcare system with immunization as a
core feature.
There are several unique healthcare systems operating in
countries like Chad. The primary and most obvious is the
government system, which is very centralized, poorly managed,
and poorly supplied, for obvious reasons. Chad is one of the
poorest countries in the world with very little infrastructure.
(The main clinic building in Léré dated from the pre-World War I
German colony era.) Another system, which I call the emerging or
chaotic system, is the sale of almost anything in the
marketplace. In addition, many families have a little box of
medicines they received from their city relatives. And finally
you've got the traditional healthcare system that includes
herbalists, bonesetters, diviners, etc.
Unfortunately, with the passage of time and the
availability of miracle medicines (antimalarials and
antibiotics), an attitude arose in the popular mind that the
individual is not really capable or responsible for his/her
healthcare; an expert/outside agent provides that. The people
lost their ability or confidence to care for themselves that
they had, even though much of that care may have been
problematic. So the long-term answer is to build a primary
healthcare system that restores self-confidence along with local
responsibility and control.
Large vertical programs have their place, and smallpox was
probably the best example of a successful one. But I think as we
move on from that, there has to be more emphasis on creating
locally owned, locally driven, primary healthcare systems that
nonetheless work within the system, subject to the local
authorities. Good technical expertise and public health
principles need to be coupled with local decision making as part
of a more global national effort. This is what our program in
Chad was all about, but we accomplished only the first step by
establishing a program in a single cultural community. The next
and harder step will be to grow related programs in other areas
and cultures.
Harrar: You mentioned that the local people you trained were
volunteers, and I know there's a long history of community-based
volunteers in many parts of Africa.
Thompson: Right.
Harrar: At the same time, I hear people like Jim Kim and Paul Farmer
saying they think healthcare workers should be paid. You know,
why should we ask the poorest people in the world to volunteer?
Could you comment on that for a moment?
Thompson: How are you going to pay for primary healthcare, and where do
you start? One way is to pay them. Well, where are you going to
get the money? These are subsistence farmers. The system that
the villages agreed upon was that they would give each volunteer
2 sacks of corn and I think 4 liters of cooking oil a year, plus
some work in their fields. They didn't receive any money for the
care they rendered. The medicines given to patients were sold at
cost. This way they established a revolving fund that enabled
them to buy new medicines. The reimbursement of the health
workers, however, was always a problem, and it was tempting to
dip into the health post funds. But how else are you going to
start? In this case, most of the health workers were motivated
by their Christian faith to be of service to their community
without expecting anything in return. (The villagers, the great
majority of whom were animist, selected the workers. There were
absolutely no requirements as to church membership or religion.)
The other way is to pay for them from abroad, and then
you're creating dependency. One of the rules we started out with
was that we were going to use available technologies and
available resources so that when I, as the white physician left,
people couldn't say, "Well, I can't do this because he had
this." So I limited my work resources. For instance, I rode a
mobylette or a 100-cc motorbike, rather than a car. In similar
ways I attempted to do my work in such a way so that the Chadian
nurse who I trained and mentored could follow in my footsteps.
Ultimately, primary healthcare is linked to economic
development. I always foresaw the next stage as not more
healthcare, but economic development and local industry, doing
something with agriculture so that people had more money. More
resources would then be available to invest in the next stage of
health development. Government is always a wasteful, albeit
necessary, manager of resources. We need to foster development
in a progressive, step-by-step manner with recurring cycles of
very simple primary healthcare as we did in Léré, then economic
development, then another level of healthcare, and so on, all
based on developing sustainable local economies. The healthcare
and economic cycles could of course go on simultaneously, but it
is important that they be coordinated and go at a speed that is
manageable by the local community. Unfortunately, we weren't
able to see the next stage of economic development, but from
reports, that seems to be happening currently. The program that
I began is still going and actually expanding. But I wonder
whether it can survive in the long term because of the economics
and because they're just one local organization. They're limited
to a sub-prefecture, 100,000 people. My dream was to take this
model, build in adjacent areas, and then let it spread by
itself. Hopefully, this may take place someday. I don't know.
Harrar: What you said sounded very much like the Tau leadership. Have
you read about that, that I go into the village and I talk to
the people about what they need?
Thompson: Yes.
Harrar: I knew that I had succeeded if, when I left, the people said,
"We can do this ourselves." It's a very powerful idea.
Thompson: Yes. There's a story that I believe came out of Guatemala. A
hospital in a rural area had difficulty in expanding their very
good public health programs to villages in the near by
mountains; the hospital wasn't having any effect on this group.
Finally, in desperation, they sent someone up there with the
question: "What are your problems?"
"Oh," they said, "our chickens are dying."
So they sent staff up to find out what the problem was
with the chickens, solved it, and that was the entrée. If I had
to do this all over again, I would have done a lot more of that.
I came in with good ideas and said, "This is the primary
healthcare model we're going to start with," and as time would
tell, the better way would have been to simply to come and say,
"Okay, how do we do this, and what are your needs?" So I made
mistakes.
Harrar: But that's how you learn. Right?
Thompson: That's how you learn. That's right.
Harrar: So were you trained by the West Africans, or the East Africans?
Thompson: West Africans.
Harrar: Do you see lessons from the Smallpox Eradication Program that
can be applied today to public health, other public health
problems?
Thompson: The model of the smallpox program was really simple, had very
clear goals and objectives, and it used non-physicians
extensively. I think the physicians were a necessary element,
but the role of the Operations Officers was equally important.
It was the people behind the scenes and the PHS Operations
Officers who kept the vehicles running, who made sure there were
adequate vaccine supplies, who kept the cold chains intact, who
did a lot of the team teaching, supervision and mentoring. That
was the real secret.
All of the countries were coming out of the colonial
period with a certain legacy of hierarchy and beaurocracy. For
instance, when it was proposed that I go to Liberia, there was a
reluctance to accept me as an epidemiologist because I was just
a recent graduate. I'd just finished an internship; I didn't
have a public health degree at the time. There were a number of
people like this. There was a tendency to believe you needed
degrees and experience. One thing this program showed was that
if you had professional staff with the basic medical background
who were adaptable, teachable, creative, hardworking, and well
supported, you could do almost anything. (The brief training
provided by CDC before we left for Africa, that included the
summer EIS course, was superb.) A good understanding of basic
epidemiology was also critical. The proof of this is in the
results of the program.
Harrar: Can you elaborate on the epidemiology aspect of it? What were
the challenges and the keys to that?
Thompson: The epidemiologic keys pretty much came from Bill Foege and the
principles behind his notion of eradication-escalation. First of
all there are almost no cases of smallpox infection that are not
quickly and easily recognizable. So the first step was to
achieve a high level of herd immunity and a low incidence of
smallpox by means of mass vaccination campaigns. Random sample
vaccination scar surveys were then carried out to insure that
the vaccination take-rates or immunity (as measured by a recent
vaccination scar) were indeed adequate. The next step was to
have a good surveillance system in place so that any suspected
case of smallpox was reported and aggressively investigated.
When cases were identified, the final tactic was to do ring
immunization in the community around the case and look even more
aggressively for other cases. It was simple and brilliant.
I think CDC did a marvelous job of putting resources
behind this program so that we didn't run into mechanical
roadblocks like lack of well-functioning equipment. One of the
major problems was that the 4-wheel-drive vehicles were breaking
down, but the needed axles were going to Vietnam, and so they
had to scrounge and make do. But they always came up with
solutions. The administrative backstopping by the Atlanta and
Lagos staffs, and their ability to work things out with USAID
[US Agency for International Development] and WHO [the World
Health Organization], for instance, were extremely important.
Finally the CDC staff on the ground in the individual countries
and their partners were resourceful and became adept at finding
local solutions.
Harrar: So, how did you personally feel about being part of this
program? In your own life and career, would you rate it right up
there, or . . .
Thompson: Oh, man. My involvement in the smallpox program was a mountain
peak that I, in many respects, felt I didn't deserve; I consider
myself extremely fortunate to have been a part of this. The
opportunity to work with Bill Foege and to keep up that
friendship down through the years has been stimulating and
wonderful. All you have to do in public health circles is drop
the word, "I was with smallpox," and you've got recognition.
Harrar: Are there any funny, heartwarming, or terribly important
stories to you that you'd like to lay down on tape?
Thompson: Everybody knows Bill Foege; he's great! He has a fabulous
memory and is one of the best story tellers around. He is
extremely competitive, and once had a contest with an office
mate as to how early they could get to work. Bill won that hands
down!
A secretary found him reading an airline schedule book and
asked, "What are you doing?" Bill responded in all seriousness
that he was memorizing the schedule. A bit suspicious, she asked
him what the connections were between 2 specific cities. As luck
would have it, he had been looking at exactly that specific
connection and rapidly gave her the correct data. She was very
impressed. Bill remained silent.
Later Bill told a story of when he was in India with the
smallpox program. He traveled frequently on the trains and made
friends, as he was wont to do, with the conductors and staff. A
staff member was leaving the country and Bill volunteered to
take a large crate of personal effects with him to the coast. He
got the train officials to agree to carry the crate without
charge or papers. Arriving at the destination, the crate was
unloaded, and Bill was heading out of the station. Some customs
officials stopped him and asked for the papers on the crate.
Realizing he was in a jam, he acted as if he couldn't understand
and began talking in German. I believe he even began reciting
the Lord's Prayer when his limited German ran out. His ruse was
at the point of being discovered when the officials were
interrupted by more serious problems and disappeared.
Our counterpart in eastern Nigeria, Dr. Anazonwou, could never
pronounce Dr. Foege's name, and he always called him Dr. Fog,
which is kind of humorous considering who he is.
But I had other goals and after 4 years with smallpox, it
was time to move on. We wanted to return to Africa as medical
missionaries, but for some reason, those doors didn't open up
right away. We went to Baltimore, where I received an MPH
[Masters in Public Health] in international health. Since
pediatrics seemed be the best clinical preparation, we returned
to Minnesota, where I finished a residency in pediatrics at the
University of Minnesota. By that time things were ready, and we
returned to Africa.
Harrar: And what do you see now as the biggest challenge in pediatric
health for the children of the world and the children here in
the United States?
Thompson: It's interesting. The challenges for pediatrics in the United
States are to provide access for all, to decrease the cost of
medical care, to recognize the fact that a lot of the services
we as physicians provide are not truly effective in terms of
improving health and that a number of these services can be
better provided by non-physicians. Our well-child checks (WCCs)
are an example. There are good data to show that WCCs are a very
ineffective use of resources. One of the things that I try to
encourage our trainees to do is to think: how can we live and
work in this environment in such a way that we use fewer
resources so that we can devote more resources to kids in the
underdeveloped part of the world?
Harrar: And what do those children need?
Thompson: Oh, boy. Well, the children in the rest of the world need
peace, first of all, and that's a major failure on our part.
They need local resources. They need training. They need
opportunities for training. Probably one the hardest experiences
for us was to see bright young kids who would have to take their
exams multiple times or bribe an instructor in order to get
their baccalaureate and graduate from the lycée. The corruption
in the system was such that passing marks were frequently not
enough to get a diploma. And then there was so little
appropriate employment available once they did graduate. Not too
surprisingly, we need education, job opportunities, and local
development, so we don't have brain drain or brain loss (from
lack of opportunity and use).
I always liked the bumper sticker that says, "Think
globally; act locally." Right now, probably the biggest
hindrance is our tremendous affluence and this political climate
that we've created today, which is not only getting in the way
today, but also will for decades.
Harrar: What do you see to be the problems the way people are today?
Thompson: 9/11 created an attitude of paranoia. As Americans, we weren't
used to being attacked on our home ground. We've always been
very cocky and self-assured. We could live in an isolated
fashion without really suffering too much. But 9/11 kind of blew
that all away. Unfortunately the reaction was to become even
more insulated, self-protective, and defensive.
There is a glaring gap between the "haves" and the "have-
nots" in the United States. An example from the healthcare field-
and this has gotten a lot of press in Minnesota, the home of the
whole HMO [health maintenance organization] idea-the CEO of
United Health Group, a large HMO, received a total compensation
of $124.8 million in 2004. Then look at the poverty rates and
the rates of the uninsured! We live increasingly in an
environment where we are repeatedly being invited to become more
self-interested, self-protected, suspicious, and reactive to
anything that looks contrary to our interests wherever that
might be. Then we get involved in this war in Iraq. It is going
to be very hard to recover from this and to move on.
Harrar: Do you see some hope in other sorts of small things that are
going on?
Thompson: Oh, yes. There's lots of hope. The smallpox program created
tremendous hope. And I think the program that we started in Chad
does too. They've not only continued but have grown under total
local leadership and financing. And we've seen our children grow
up and do good things. Then you come back to a place like CDC
and run into all these people and see what people are doing.
Yes, there are a lot of good things going on. There is plenty
of hope
!Harrar: Okay. Well, we thank you so much. That was really interesting.
# # #
David Thompson Oral History
David Thompson interviewed by
Linda Harrar
July 13, 2006
Dr. David Thompson was an epidemiologist in the Smallpox Eradication Program (SEP) in West Africa. He recounts experiences in Eastern Nigeria and Liberia. Following his service in SEP he returned to Africa to start a primary health care program in Chad. That program became self-sustaining and gradually the governance was turned over to the village.
