Interview Transcript
Interview
Dr. David Pratt with Interviewer Elisa Koski
Transcribed: January 2009 | Duration: 0:31:56
Elisa Koski: This an interview with David Pratt on July 11, 2008 at the
Centers for Disease Control and Prevention in Atlanta, Georgia about
his role in the Smallpox Eradication Project. The interviewer is Elisa
Koski.
With this interview, we are hoping to capture for future generations,
the memories of participants and their families involved in
eradicating smallpox. This is an incredibly important and historic
achievement and we want to hear about your experience. I have some
questions to guide you, but please feel free to recount any special
stories or anecdotes that you remember about events or people. The
legal agreement you signed says that you are donating the oral history
to the U.S. Federal Government and that it will be in the public
domain. For the record, could you please state your full name and that
you know you are being recorded.
David Pratt: Sure. My name is David Pratt and I am aware of the fact
that I am being recorded.
Elisa Koski: Thank you so much. Thank you for being here today and
being willing to share your experiences. I'm going to start with a
question about your childhood and how you grew up. Could you briefly
describe for me your childhood and your pre-college education and how
you became interested in Public Health?
David Pratt: Sure. I grew up in a small town in Massachusetts, Newbury
Port, Massachusetts and did my primary grades in Newbury Port and had
nobody really - I shouldn't say nobody, I had two aunts who were
nurses and I think they perhaps had influences. Nobody in my direct
family though, neither my parents, nor my grandparents were involved
in healthcare in any way. So perhaps it was my aunts' influence that
got me interested.
Elisa Koski: How did you become involved with CDC, and particularly the
Smallpox Eradication Program?
David Pratt: Very interesting question. I went to medical school at
Tufts in Boston and while I was a medical student at Tufts there were
people in infectious disease who were Fellows in training in
infectious disease and one Kenny Ratson had actually been an EIS
Officer; and I was a medical student while Ken was a Fellow and in
discussions back and forth about a variety of questions and
interesting topics he shared with me and with the other medical
students what it was like to be an EIS Officer. So I became really
quite interested in that. At the same time at Tufts Medical School,
Jack Geiger and Count Gibson were running a family medicine program
and they were doing some very interesting things with Social Medicine
in Bolivar County, Mississippi and in Housing Projects in South
Boston. So the complete picture of what Public Health could be like
from the social, economic and cultural aspects to the infectious
disease aspects, really increasingly got me interested. So following
my medical school experience with Ken Ratson and Community Medicine, I
applied to become an EIS Officer. Now at that time, we have to
remember that the Vietnam conflict was ongoing and choosing a career
in Public Health was also ethically more comfortable for me at that
point in my life. So it was a wonderful way to serve the country, it
was an exciting area to learn and be a health professional, and it was
an exciting time.
Elisa Koski: Thank you. How did you specifically end up in India, you
mentioned a little bit, prior to this interview as we were being
introduced, that you actually had an option?
David Pratt: Right. When EIS Officers in my cohort came to CDC we had a
choice of what kind of assignment to take. There were assignments here
in Atlanta and there were assignments in the field with State Health
Departments; and I chose to actually take an assignment with the
Hawaii Department of Public Health. That group was doing routine State-
based Public Health, but in addition, we were doing some vaccine
development, specifically an intranasal vaccine with measles. It was
clear for the group of people who came in when I came into the EIS
that there were going to be opportunities, international
opportunities. One was an opportunity in Nigeria, the Biafran famine
was ongoing and huge amounts of migration of Nigerians ethnically
diverse moving across the country and a great deal of hardship and
despair over that, and EIS officers were given an opportunity to go
and actually do assessments, surveillance, measurement around the
famine. The alternative option was Smallpox Eradication. When we came
to CDC the West Africa campaign was largely victorious and a very
clear strategy had been laid out by Henderson and others and so those
two options were available. Ultimately I chose to turn down an offer
to go to Nigeria and accept the offer to go to India in 1974.
Elisa Koski: What influenced that decision, why would you have rather
been in India?
David Pratt: I think two things really. One was the - I think even then
I understood the magnitude of what we were going to try to do. I also
thought that the work in Biafra, though important, and doing the
assessment of the famine, and the impact of famine on the health of
those children was important, I thought it was also desperately sad,
probably tougher going and I thought that the chance to have an
opportunity to play a role in the eradication of a disease was very
significant and exciting and India also interested me a great deal. As
a resident at the University of Michigan, I had a medical student who
talked in very interesting terms about work that he had done in India
and so I was intrigued by his descriptions, I was intrigued by the
challenge and the opportunity and decided that when the call came from
Lyle Conrad here at CDC that it was a good thing to do.
Elisa Koski: Can you tell me a little bit about your role when you
arrived in India?
David Pratt: I think as a slight - to step back just a bit - it took a
fair bit of convincing in my own life circumstance, I just had an
infant son born way away from family, so my wife - and this is our
first child, so she was there to take care of a child by herself when
I trotted off to India. We knew communications was very poor,
telephonic communication was virtually non-existent in the areas that
we were going to be in and telegrams were iffy. So I had to really
convince my wife that this was of great enough significance to allow
me to leave her and my son to go and do this. So the context was
socially challenging for me personally, but I thought very important.
So the routing that I took was basically from Hawaii over through
Thailand, from Thailand up to Delhi and then when we got to Delhi we
were met by the WHO people at the regional office in Delhi and began a
briefing. I think it's important to explain, or share, how dramatic
the arrival in India was for us in 1974. The gulf in terms of
economics and in terms of the way the place looked from where we had
come from, that is Hawaii and mainland United States, was incredibly
different. The smells, the sounds, the beggars at every stoplight, the
crush and the throng of millions of people it felt like, was very
different and for a while the truth is, I think we were stunned,
literally stunned and it took us a while to kind of catch up with the
fact that we were in a brand new environment, very different than the
West. So there were going to be lessons to be learned about the
economics, about the sociology, about the psychology of this new
terrain that we were entering. So those first few days were very
challenging I think for all of us.
Elisa Koski: Of course, there was the challenge with your wife and son.
Did you encounter any other challenges when you first arrived,
housing, food and water, anything that you can recall like that?
David Pratt: The WHO team in New Delhi arranged to pick us up at the
airport which is always interesting and hasn't changed too much in
India, getting through the airports; and they brought us to our
hotels. They had things pretty well arranged, the logistics, pretty
well arranged for us. The hotels were certainly comfortable, not
lavish, it wasn't anything we expected and I think they built a very
nice routine, a briefing routine for us in Delhi before we went to the
field. The food of course was very different than what I was used to
in Hawaii, but I always have been sort of an omnivore and interested
in different cuisine, exotic cuisine, so that was fine with me. I was
good with that. I think where it got interesting is when we went by
train across the North of India, a group of us all together, to go to
our duty station which was in Bihar. Now at the time I really didn't
realize that Bihar was among the poorest States of India and that the
poverty that we'd witnessed in Delhi was going to be compounded by the
kind of misery that we would see when we got to the Bihari regions
across the Ganges River to the North. So it got more interesting
rather than less interesting as we went further and further to our
duty stations.
Elisa Koski: Can you describe to me a little bit about what happened
when you arrived in your duty station?
David Pratt: Okay.
Elisa Koski: What was your role? How did you interact with your team?
David Pratt: I was assigned to two areas, two States or two regions
inside Bihar. One was called Sarn; (S-a-r-n), and the other was Siwan
(S-i-w-a-n). The stepping off point for those assignments was in Patna
and you may remember from Lord Jim, the name of the boat in Lord Jim
is the Patna, ill fated boat-Anyway we went to a hotel in Patna, where
we had a further briefing on Bihar and our duty station and then very
interestingly took ferries across the Ganges River. There were some
wonderful lessons about the ferries. It turned out that moving a WHO
jeep across the Ganges River was not as easy as simply pulling up and
buying a ticket. It turned out that if you pulled up and bought a
ticket, everybody went around you and the reason everybody went around
you was because there was another payment being made that was
invisible beyond the ticket, so it's called baksheesh. So if you
didn't understand that if you really wanted to get that ride across
the river, it would be the ticket plus some baksheesh, you would wait
a long time at the ferry dock. So cross the river by ferry and then
got to Chapra which was the area that was my headquarters for those
months that I served in that region.
Elisa Koski: Can you tell me about the smallpox situation when you
arrived?
David Pratt: There were lots of outbreaks going on. I think at the time
in my region, there were 18 or 20 outbreaks that were in the midst of
being dealt with, controlled; contained. A wonderful experience for me
as I reflect on it; was the first day in my region. We went by jeep to
an outbreak at a village, we went into a mud hut in the village and a
woman presented me with her infant covered with smallpox lesions. I
picked the child up as you would to examine anyone; the child was
pretty miserable and had still persistent fever in spite of a fairly
well developed rash, and the thing that really struck me was at that
moment I was betting that my immunization was sufficient to keep me
healthy as I went forward in the program. So it really was a
challenge; you know, how deeply do you believe in immunization, how
profound is your faith, and so it was obviously pretty profound. I
examined the child and on we went. I mean, I am recognizing that the
case fatality rates are 25%. So it was a huge gamble really that
things were going to work. I mean, we all knew the history of the
immunization, that it was robust and successful, but when it's you,
with a child at home, and so forth, and you are beginning an
assignment, you'd rather not get a dreadful illness in the middle of
India.
Elisa Koski: Of Course. Can you describe to me a little bit about the
progression of your assignment there, from your first day onward; how
did things move forward?
David Pratt: From that day, seeing that outbreak that very first day,
it was right at the tail end of the monsoon, humidity was very high,
day time temperatures were routinely 40 degree Celsius, 104 - 105
degrees, and taking notes, which I tend to be a compulsive note taker;
was very challenging because perspiration would run down your arm onto
a pencil right on to your notepad or onto your notebook. So I had to
find clever ways to do note taking that wouldn't saturate my books,
and so on and so forth. So it was very, very warm, very dusty; when
the monsoon ended the dust began. But it was still raining during the
time that we first arrived. The Indian Public Health people said that
searching, trying to search through the monsoon was nuts and yet the
people we relieved had done it and had done it successfully. So we had
in some ways bucked the standard wisdom about it and had gotten off on
a really good foot.
So I was turned over to a region that was well done, well maintained.
I stayed in a place that was called the Circuit House. The Circuit
House - they were they were also called Dak Bungalows. They were
locations where the British mail people went when they delivered the
mail around the country. It was basically a squat toilet, there was a
shower that was heated by a tank on the ceiling, a little desk, no
screens on the doors, we had bed nets that we used and I had monkeys
as my neighbors who would come in on my porch and actually come in my
room if I wasn't very careful. So I had good neighbors and the
accommodations were decent, in the day it got very hot, but at night
it cooled successfully; and I didn't realize, but my colleagues, my
Indian colleagues assured me that the mosquito nets served a dual
purpose, not only would it keep the malarial mosquitoes from biting me
at night, but it was also good as a preventive measure against Cobras
and Kraits and Russell's Vipers which were snakes that potentially
could bite you in the night because you were warm. So they would sense
your warmth and come up on your bed. So I had no problem with that,
but my Indian colleagues frequently slept on the cement floor in our
building covered with their dhotis and mosquitoes would bite right
through the cotton. It was extraordinary to see the situation that
they were in at night.
So the living situation was in the Circuit House or Dak Bungalow. In
the morning I had a chowkidar, the servant of the bungalow; he would
bring tea to me from a tea stall down the road and one morning I had
my tea delivered by this little man and my Indian Epidemiologist
counterpart saw this occur and was horrified, because it turned out
that the man who delivered the tea to me was an untouchable and that's
unacceptable. They were unclean so to bring me food was sort of
revolting[indiscernible0:17:11] and being outside the caste system
there was no issue for me but there was like a little confab and they
discussed it and explained that really you shouldn't do that. I
continued to have tea from the chowkidar the day after that, it just
wasn't an issue with me, but it was my first banging into the whole
issue of caste was right there in the Circuit House that day.
Elisa Koski: Okay. How close were your field assignments to the Circuit
House? Were you were working right in the surrounding villages or did
you have to travel a lot?
David Pratt: No, there was a fair amount of travel. We had jeeps and
drivers and on an average day, we would probably work 8 or 10 hours
driving and you would go from outbreak to outbreak, District Health
Officer - you would visit with the District Magistrate, you would meet
with the various people who were critical to you being able to get the
project done. So there was a great deal of traveling around. We all
had drivers and I have to say that the Indian, Dr. Chakravarty who was
my counterpart in Chapra was an extraordinary guy, very bright and
could accomplish things that clearly I could not accomplish. He spoke
the language; he knew how to influence in very effective ways, so he
was critical. I would begin the morning by going to his home and his
wife would serve me another cup of tea, we would lay out the day and
then we would just simply start going; and routinely we'd leave his
house probably at 10:00 o'clock and not return until 8:00 or 9:00
o'clock at night - that evening. He never stopped for lunch, I don't
know what the guy ate, but he never stopped for lunch, so we just kept
going. Sometimes we'd stop actually on the road and our driver would
buy in the market cow dung, these dried patties of cow dung, light
them on fire and then buy cucumbers and cook cucumbers in their skin
and we would eat those as kind of a snack, a break on the road with
tea. So extraordinary things, and cow dung was routinely used as fuel.
In the mornings in the villages you could smell the cow dung burning
as people began to make tea and food for breakfast.
Elisa Koski: Very, very interesting. How were you received when you
arrived in these villages?
David Pratt: Interesting. I am 5'6" tall and they would say the big
saab. "The big saab is here," which I always thought was hysterical or
they would say, "The American saab is here in the village." So it was
a respectful term - the fact that an American would come that far to
Bihar to work on this issue was felt to be extraordinary by the
Indians. So in many ways there was a great deal of respect. It was
beneficial as well that I was outside the caste system because I was
allowed to make mistakes and gaffes that an Indian couldn't make, and
I could perhaps ask for things that an Indian couldn't ask for and get
away with it. So I was well received, respectfully received, and I
tried to work carefully with the people, the Indian health
professionals that were with us-it was intriguing, when we were there
- when my group was in India, Daniel Patrick Moynihan was the
Ambassador to India and he indirectly told the American EIS Officers
who were deployed in the field never to speak to the press. Only allow
the Indians to speak to the press and don't make any derogatory
comments at all. So we were well schooled and well prepped about what
not to do, what not to say in the country. So we really counted on our
Indian colleagues and counterparts to do a great deal of the PR and
the outreach and the commentary that Ambassador Moynihan really
prohibited us from doing.
Elisa Koski: You mentioned earlier that you were perhaps more socially
free to have some indiscretions or make some mistakes that Indian
people would not have been allowed. Can you describe any particular
instances where you ran into a problem or where those mistakes weren't
accepted?
David Pratt: Yeah. There were times when people would flatly refuse you
because you didn't quite look right and I remember specifically one
outbreak, a woman became very upset when I personally asked to be able
to immunize her, and I think I was bucking probably the male-female
divide, Eastern-Western divide, so that was an instance where it was
very clear that I was not welcome in that circumstance. But that was
the minority. The thing that was interesting, another key learning for
me in the villages, is the villages were frequently broken up into
tolas [0:22:07] or sections. There was often a Hindu section, there
would be a Muslim section and then there would be a section for
tribals [0:22:12]; and it was always humorous to me that when you
spoke to the different leaders of the different tolas, they would make
derogatory comments about their counterparts, and it frequently went
something like this. "Oh, you will never get them to be immunized,
they don't know anything. They are sort of ignorant." It was
intriguing how each of them made similar commentary of the others, but
at the end of the day they all allowed us to immunize them; and the
strategy was frankly to invite the village headman to be the first
recipient of vaccine when we were doing containment. So if the opinion
leader in the village would allow you to immunize him, then all things
seemed to flow from that. So if he got it done, well everybody would
line up behind him and we would be able to do a good job.
Elisa Koski: Of course. I would like to talk a little about how your
entire experience in India really influenced your life and impacted
your career in public health subsequently?
David Pratt: You have to realize that this was sort of like winning the
grand slam in tennis at 29 years of age. Where do you go from here?
You know, it was an extraordinary event and as the years went on and
the true eradication was proclaimed, and so on and so forth, it became
even more spectacular in my career. So what do you do? What is your
follow on act? It's like a first novel, if it's a success, it's a huge
challenge. I think that I took a lot of important lessons from the
Smallpox Eradication Program. The first one is that sometimes naiveté
is a wonderful asset. You know, we really didn't know how
extraordinary what we were going to do was, and we went at it anyway
assuming that it could be done. So I think that was of importance, the
naiveté; and the other thing that goes with it is a comment that Colin
Powell makes and he says that - General Powell's comment is that,
"Optimism is the most important force multiplier" and I tried to
remain - the optimism that I brought to the table I thought was
powerful in allowing us to get my region - and by way by the time I
left my region we were smallpox free. All the outbreaks had been
contained and I left an absolute pristine area, I should say the
Indians and I as their assistant, left a pristine area, and I was
always outwardly very optimistic although as I read my diaries, I read
that there were times when I was very pessimistic that we would get
the job done. But ultimately when I spoke to our searchers and spoke
to students and spoke to people in the villages, I was always kept
that very optimistic view. That's one.
I think a second big one is the fact that it is sometimes really
simple stuff that makes a huge difference. For instance, the
logistics, knowing where to get gasoline, knowing how to keep your
jeep serviced so when you had to go to an outbreak you could keep
going. Having sufficient Rupees to pay the people who search, just
really nuts and bolts of good management were critical to succeeding
in India and in the rest of my career they have been critical elements
as well. Simplicity too; I think part of our success in the Smallpox
Eradication Program had to do with the fact that we were using proven
technology for the vaccine, we were using a strategy and the tactics
to deploy that strategy that had been proven in West Africa and
basically what we did was execute, execute, execute. Just this kind of
diligence of doing it every day, following the book, compulsively
filling in all the things that we needed to get the job done. Atul
Gawande who was a writer, an American health writer, talks about the
power of diligence and improving quality in care.
Well, it was sure true with smallpox, diligence really paid off. Which
reminds me of a point where things were not looking so good, in early
October in fact, it was October 5, 1974, I know from my diaries-we
went to meet with Bill Foege - Dr. Foege in Patna, and we were
explaining how it was going and the answer was: "Not so great" and we
were really working hard. I mean: we were doing 10 and 12-hour days,
lots of driving around and very bumpy roads, the infrastructure in
India was tricky, and we met with Bill and he said, "Not good enough,
you are going to have to do more." So we were saying - Jason
Weisenfeld[inaudible name0:26:57] and l were working in the region
together, and we'd say, "Phew, okay we can do it Bill, but we are not
sure how much more." So we went back and tried to think; how do we do
this in a fashion that is more efficient, more effective as well as
putting in more hours. That was extraordinary. So I think those were
the real key takeaways, simple things logistics, good management,
proven technology and diligence. Just doing it, recording it,
measuring the heck out of it and continuing to execute every day.
Elisa Koski: How about in your personal life, I mean you mentioned that
prior to going you were quite torn of leaving your wife and son at
such a critical time and those obviously had to play into some of your
future decisions as well? How did this experience in India indicate
your personal decision to continue on in Public Health?
David Pratt: Yeah. That's a great question. Actually I didn't continue
in Public Health until much later. Well, I'll explain. I was invited
to move from India to Bangladesh and then ultimately it would be a
move from Bangladesh to East Africa where the smallpox was finally
eradicated, Jason Weisenfeld and so forth, his team; and it was pretty
clear that I was not going to be able to continue with the effort.
Several reasons: I had an infant son at home; I had a commitment to
continue my training in internal medicine. My father had had a heart
attack, my mother-in-law died while I was deployed in India. I mean it
was social catastrophe. So it really probably took me 24 months before
everything was kind of right in the world, in my little world back
home after I got back. So I made a conscious decision at that point to
do something that was going to be less travel and more like
traditional clinical medicine. I continued to drift towards Public
Health in spite of that and ultimately did a number of activities in
clinical care that drew upon the public health model to allow me to
get the good vibrations back again about public health, and then
ultimately when I retired from being a medical director with a large
Fortune 500 company, now I have gone back - actually go back fulltime
into Public Health, which is a wonderful place to be.
Elisa Koski: Excellent. In conclusion, I'd just like to offer you the
opportunity to share anything that we perhaps didn't cover, that I
didn't touch on, anything very poignant about your time in India,
people, places that you would like to add.
David Pratt: Yeah. A couple of things: Number one is that I was a grunt
in a huge campaign and it was my wonderful opportunity to be at the
right place at the right time with wonderful leadership, Indian,
International, American-It was a tremendous experience for me to work
with D.A. Henderson and with Bill Foege, Mike Lane, Nicole Grasse, and
a gentleman named Yallaporka[inaudible 0:30:02], who was an Indian
expert, a smallpox expert. So it was a privilege, first of all, to do
that work. I played a minor role in a great pageant of strategy and
tactics and so forth, and I am grateful for that. Another thing that
was very clear is that it was the Indians who did the job in India. We
frequently, I think, perhaps take more credit - the EIS types, but at
the end of the day; the day by day, grind them out, hard, hard work
was done by the Indians and we need to salute them for the
extraordinary job that they did. Bright, bright people very hard
working, deeply committed and it was an honor to work beside them and
with them. I think that the Public Health model that I learnt in the
Smallpox Eradication Program of assessing a situation, trying to
decide how do you do the greatest good with the smallest number of
resources, in the shortest period of time, served me again and again
and again, whether it was organizing programs for farmers in Upstate
New York or whether it was thinking about field engineers deployed by
General Electric in Nigeria, the same thinking that I learned and was
underscored in the India Smallpox Campaign served me again and again.
So it was a wonderful learning experience for a young man, it laid a
foundation, an infrastructure for a career that has been very
rewarding, and I look back on it fondly as both formative and
instructive for the rest of my life.
Elisa Koski: Excellent. Thank you so much for being willing to share
your experiences with us and for speaking with me today. I wish you
the best in your future endeavors and as you continue on with your
medical training.
David Pratt: Thank you, it was my pleasure.
[End of audio - 0:31:53]
David Pratt Oral History
David Pratt interviewed by
Elisa Koski
July 11, 2008
David Pratt was an epidemiologist assigned to Bihar State in India.
