Stanley Music Oral History

Interview Transcript
	   
INTERVIEW
Audio File: Stan Music Audio File
Transcribed: January 29, 2009

Interviewer:     This is an interview with Stan Music on July 11th, 2008 at
      the Centers for Disease Control and Prevention in Atlanta, Georgia
      about his role in the smallpox eradication campaign.  The interviewer
      is Melissa McSwegan.  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 it will be in the public
      domain.

      So for the record could  you please state your full name and that you
      know you are being recorded.


Interviewee:     My name is Stanley Music and I know that I'm being
      recorded.

Interviewer:     Thank you.  To start out with can you talk a bit about how
      your education and upbringing led you to work in the health field?

Interviewee:     Yeah.  My father was an immigrant although he came to this
      country at a very early age.  He was the oldest of five or six
      children and when his father died he was still a teenager and he had
      to quickly abandon any of his hopes at a higher education and start
      earning a living for his family.  As a result of that he always
      encouraged both his sons -- me and my brother -- to become a
      professional man whatever that meant to him but he wanted me to be a
      doctor or a lawyer or something professional and not have the
      financial worries that he had pretty much all of his life.

Interviewer:     And so then once you did - begun working in health how did
      you get involved with the smallpox campaign?

Interviewee:     Well I went to - I got accepted to two medical schools one
      of which was in the same city in which I lived and the other was an
      hour away and would require that I be in residence away from home
      which opportunity I jumped at because I had been to college in the
      same city in which I lived.  So I went to University of Maryland,
      medical school and fell under the influence of professor of medicine
      Ted Woodward who was quite well known in international infectious
      disease circles.  Because I fit his profile of whatever he was looking
      for, during my junior year summer between third year and fourth year
      of medical school he sent me as a research assistant to Pakistan.  And
      I saw an incredible variety of infectious diseases, human rabies,
      smallpox, cholera and a few others that made a deep and lasting
      impression on me and probably set my values for somebody who wanted to
      help make a difference in diseases of poverty in tropical areas and
      generally trying to bring the benefits of twentieth century medicine
      to a population that was living in hundreds of earlier times in
      effect.

Interviewer:     So, when you first began working with the smallpox
      campaign what was your role?

Interviewee:     Oh.  We have skipped an awful lot of history then.  So I
      was very much interested in infectious disease, internal medicine and
      actually specialized in infectious disease but couldn't quite see
      myself as an academic fighting for grants etcetera.  So I followed a
      friend of mine, Mike Greg down to CDC and paid him a visit where he
      was part of the EIS program and editing the MMWR and got very
      interested in a career in the public health service in epidemiology.
      And the following year I applied to the EIS - excuse me - and was
      accepted and because of my Pakistan experience when I was an EIS
      officer and Pakistan and - West Pakistan and East Pakistan had a
      falling out and East Pakistan wanted to become an independent country
      called Bangladesh.  I was part of the team that was sent by CDC to
      work in Bangladesh on a nutrition survey designed to make sure that
      the food that was in the country was given on a priority basis to the
      areas that needed it the most.  That experience in turn led me to
      learn Bengali and that's why Stan Foster was very interested in
      recruiting me to the Bangladesh program because I had been to the
      country before and I spoke enough of the language to get around on my
      own.  So that kind of set the stage for my smallpox involvement.

      I protested mightily when he asked me to join because I had just
      acquired admission and a full federal scholarship to University of
      London to get an MPH equivalent degree.  But he agreed that if I gave
      him two years of smallpox eradication that he would see to it that I
      continued on in my academic studies before joining CDC permanently as
      a staff member and he was good to his word as was I.

Interviewer:     So tell me a little bit about the working relationships
      you had with your counterparts on the ground and what were the
      successes and failures you had with that.

Interviewee:     Well, counterpart was I think in many ways an exaggeration
      because they really had no clue as to what was expected and what was
      going to be done.  We ended up actually setting up a whole parallel
      system of employment.  We used Ministry of Health personnel to be sure
      but by giving them - by basically doubling their salaries and giving
      them access to motorbikes and Land Rovers and other transportation we
      elevated their status and they became very loyal to us.  They became
      reliable surveillance partners who could go out on a schedule and be
      in a village market on a given day at a given time and advertise about
      the smallpox program and get information about whether there was any
      smallpox showing pictures of kids with smallpox and asking if they
      knew of anyone.  But we set up a whole parallel system.  The
      government of Bangladesh was very good at acquiescing to our stated
      and carefully thought out -- most of the times -- needs but they
      really weren't partners in the delivery of the services.  They just
      stood aside and let us do our things mostly.

Interviewer:     What were some of the biggest challenges you faced on the
      work on the ground?

Interviewee:     Well, one of the biggest challenges was getting people to
      do what they were supposed to do.  They weren't used to being
      inspected.  They weren't used to being challenged, they weren't used
      to having somebody count the number of vaccines vials and then three
      weeks later come back and ask how many people had been vaccinated and
      then go back and count the vaccine vials again and see if things
      actually jived.  I learnt very early that the Bengali intellect is
      quite well formed and they know for example that there are exceptions
      to every rule.  So when I said you know if you find a smallpox case
      the whole village is quarantined and you vaccinate everyone, but if I
      then did an inspection when they said everyone had been vaccinated,
      they would - I would discover a guy dying of TB or congestive heart
      failure or something lying off in a corner of a hut, and he had been
      exempted from vaccination.  But I said there are no exemptions and
      they said every rule has exemptions and I said okay, thought about for
      a while and then I said, "Okay.  We are now going to vaccinate
      everybody with one exception.  We will vaccinate no dead persons."
      And they laughed but they understood and then I had no problems.  So
      it was a matter of understanding the culture, understanding their
      attitudes and the challenge then of translating my desires into
      something that they could follow and give me results that I was
      looking for.

      Another big challenge was these seasonal fairs that pulled people in
      from many, many miles away.  They were a source of revenue to the
      district commissioners who got a piece of the commercial action but
      when I found that a particular fair was actually a disseminating
      source of smallpox because people who were infectious were coming,
      mingling with people who were still susceptible who then spread out
      and returned to their villages, I had a big problem.  And I had to -
      people who were earning the money threatened me because I was going to
      report this.  In the end I went to Dhaka and informed my superiors
      about it but basically got no support until D.A. arrived from Geneva,
      listened to my tale of woe and did his little magic with the political
      heads of the health department and WHO and then we managed to put
      vaccinators into the fair areas and stop the transmission.  So there
      were challenges all the time.

      Another challenge we had was a lack of petrol in the area that I was
      designed to cover.  So we had Land Rovers and we had jeeps and we had
      motorbikes but we couldn't run them because we didn't have any fuel
      and there was no way to get any fuel.  But we ended up doing something
      quite inspired, quite illegal and quite dangerous.  We found a train
      siding run by the army with cars full of petrol.  We ended up one
      night unpinning the connection to the last car, rolling it a couple of
      miles down the track and siphoning out all the gasoline and finding
      ways to store it and returning the car under the cover of darkness
      back to the train as if nothing had happened only it was now largely
      empty instead of being full.  But we needed the petrol to make our
      surveillance rounds and to keep pressure on this disease to stop it
      from spreading.  So, yes there were challenges every day of many, many
      kinds.

Interviewer:     Tell me a little bit more about life in Bangladesh from a
      cultural perspective.  Not so much just about the work but what was it
      like living in Bangladesh?

Interviewee:     Ha.  It meant when the sun went down the lights went out.
      It meant learning to be patient, it meant learning to enjoy the simple
      things like a home cooked meal. There were a mixture of Muslims and
      Hindus and a few Christians and a few non believers of every variety.
      There were some people of the old ruling class under the days of the
      Maharaja who still lived in crumbling palaces but it was a wonderful
      education and at night there was nothing to do but talk.  There was no
      radio or television or anything although I did have a little portable
      shortwave but the culture was rich, the people were wonderfully
      talkative.  The oral traditions were great and I learnt a lot about
      the people and their culture, their habits, their food, their
      clothing, their rituals and the way that they accepted life.  And
      although they had by my standards a very primitive existence, they
      actually enjoyed their lives I thought to a much greater extent even
      with all the poverty and the disease and the premature mortality and
      the excess morbidity to a greater extent and with more relish than I
      could recall from the United States.

Interviewer:     As you were working with the smallpox campaign, was there
      a particular point where you knew that smallpox could be eradicated
      and would be eradicated?

Interviewee:     Well, actually no.  I had the belief that it could be
      because I understood the epidemiology and nothing in my experience had
      given any reason to believe that my understanding was different than
      reality but every day in Bangladesh ten thousand - that was the birth
      rate - ten thousand new susceptible would be born.  So even if as in
      my dreams we could fly B-52 bombers wing tip to wing tip over the
      country spraying vaccine so that everybody who took a breath would be
      vaccinated, the very next day we would have ten thousand new
      susceptible.  And I knew that just vaccinating, trying to vaccinate
      and keep a population fully vaccinated wasn't going to work.  What we
      needed was an epidemiologically oriented program that Bill Fergie
      designed and clearly when we were working efficiently with good
      surveillance and good follow up, good containment, good ring
      vaccination, good quarantine, we stopped the spread cold and it worked
      every time.  So I knew that once we had it all together it was going
      to happen very quickly and it did.

Interviewer:     Now that you have thirty some years of perspective on this
      campaign is there anything you would have done differently?

Interviewee:     No, I don't think there was actually.  I think it was a
      treasure of an experience, it shaped my life and my career and my
      attitudes, my values.  I thought that smallpox was just the beginning,
      that we would then march on to measles and all the other vaccine
      preventable diseases.  After all we had the surveillance organized, we
      had the trained staff, we had people in place, all we had to do was
      implement it but that was not going to be.  But my generation of CDC
      epidemiologists were always somehow more empowered and more
      aggressively public health oriented than our colleagues who didn't
      have this experience.

Interviewer:     What are the most important lessons that you learned from
      smallpox that you then applied to other areas of your career after the
      campaign finished?

Interviewee:     Well, to a certain degree smallpox was about breaking the
      rules or interpreting the rules with flexibility bordering on breaking
      the rules because nobody sitting back at a desk could figure out what
      was really going on in the field.  If you went to the field you
      learned about the fairs that were spreading smallpox, you learned
      about the people not being vaccinated because they had some other
      illness and etcetera.  So smallpox taught me to break the rules if I
      was going to be successful, if I was going to be carrying out the
      disease reduction, following through on the results of an
      investigation.  But you can't operate that way in the civilized world
      and in modern European or in America.  So I had to change the way that
      Bangladesh had taught me and learn how to be patient, learn how to
      educate, learn how to involve the public and not be the kind of
      imperialistic dictator that solved the smallpox problem but was not
      going to cut the mustard in the real world after that.

Interviewer:     And how did the overall experience impact your life?

Interviewee:     Well it made me a public health believer because I had a
      monster success under my belt.  They gave me a quarter of Bangladesh,
      twenty five million people then, five districts, a suitcase full of
      money and some vaccine and some bifurcated needles and said go do it.
      And I had a driver and we did it.  It was amazing and it filled me
      with a desire to have a full public health career and to carry out
      those initial dreams that I had when I was but a medical student
      wanting to bring those people up to the twentieth century in terms of
      their morbidity, mortality and infant child mortality experience.

Interviewer:     Did you continue working in infectious diseases?

Interviewee:     Well I continued working in epidemiology but I came back
      to CDC and worked with Lyle Conrad in supervising EIS officers that
      were assigned to state and local health departments.  I kept my hand
      in international consultation and did a few WHO and USAID
      consultancies.  I used the time to understand a lot about other
      countries and eventually was recruited to the global EIS by Phil
      Brockman and then when he retired I was named his successor and I put
      programs in Thailand, Indonesia, Mexico, Saudi Arabia, Taiwan,
      Philippines, Peru, Italy and Australia.  And said no to a couple of
      very big countries to the disappointment of my boss because those
      countries weren't ready and they weren't going to participate but that
      was India and Egypt which have since changed and there are now
      cooperative programs with those countries.  But I used that, that was
      - that helped define me.

Interviewer:     Can you tell us one - one of the most memorable moments
      you have of your time in Bangladesh?  Something that happened, an
      event that happened, something that you remember and think back on.

Interviewee:     Yeah, I think I can.  I don't think that there are very
      many people who know this story.  There was a famine in Bangladesh at
      that time, at least in my area.  There was a - they had two or three
      rice crops a year depending on how much water there was and the
      physical geography of individual areas.  And a rice crop had failed so
      there was quite a bit of [inaudible 24.14] starvation and it was
      getting hard to hire people because the wages that we were authorized
      to pay wouldn't give them enough money to buy the food that they
      needed so we weren't really competitive.  And then the new rice crop
      which was not failing was about to come in and here they got a living
      wage plus they could put handfuls of rice in their pants pockets and
      they could earn a lot more, in essence take home take a lot more than
      they could working for me.  And working for me meant being guards,
      vaccinating around infected villages.  Well I couldn't live with the
      idea that we could identify villages and then not protect them and not
      vaccinating those villages and not break the chain of transmission.
      And I sat down with one of my subordinates an Egyptian physician, Ali
      Salim [inaudible 25.32], wonderful man, and we sat up at night and
      thought about our dilemma and how we were going to resolve it.

      We had radioed back to Dhaka and they told us the price that we pay
      for each guard was fixed. I don't remember how much it was, fifteen
      taka a day or something like that but we couldn't pay anymore and we
      needed to pay more.  And I said, "Look you're leaving me in an awkward
      position.  I've got infected villages.  I can't quarantine them, I
      can't vaccinate any of them.  I don't have enough people."  "Those are
      the rules."  Okay.  So Ali and I sat down and decided we were going to
      invent villages and were going to invent outbreaks, and we were going
      to invent workers and we did and we paid them the right wage on paper.
       And we encumbered then a lot of need for money which we then divided
      up among the real workers and paid them enough to keep them working
      for us and not harvesting the rice.  So yes, I can tell you that and
      probably other stories as well about what we had to do to stop
      smallpox.

Interviewer:     Wow.

Interviewee:     Yes.

Interviewer:     Well, is there anything else that you would like to add or
      any other stories that you think?

Interviewee:     I think I've probably gotten myself in enough hot water
      you know.

Interviewer:     Like do you really want that story [inaudible 27.18]?  No.
       Well, thank you very much.  I appreciate your time in sharing your
      experience with us.  It all looks very interesting so thank you.

Interviewee:     Okay.