Interview Transcript
INTERVIEW
Audio File: Stephen Jones Audio File
Transcribed: January 30, 2009
Interviewer: This is an interview with Stephen Jones on July 11th, 2008
at the Centers for Disease Control and Prevention in Atlanta, Georgia
about his role in the smallpox eradication project. With this
interview we're 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 experiences. 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.
For the record could you please state your full name and that you know
you're being recorded.
Interviewee: Full name is T. Stephen Jones and I acknowledge that I'm
being recorded and agreed to that.
Interviewer: Very good. Thanks for coming in today Steve and I guess
[inaudible 01.15] good place to start would be before you ever came to
CDC and I'm curious about have you - did you always want to be a
physician? And so think back to your early days and when you went to
college and if you could talk a little bit about what you wanted to do
when you were getting out of high school?
Interviewee: Well I had a great interest in science and math and at the
time of the Sputnik there was a big U.S. government response including
setting high school students working in engineering companies and I
went to work at the Salvenia Company near Boston and pretty quickly
came to the conclusion I wasn't really interested in engineering. And
I had always been interested by medicine and that just took over my
future planning. So that's how I got into medicine basically.
Interviewer: And then did you intend from the beginning to go into
public health or did you see yourself more as practicing clinical
medicine?
Interviewee: Well when you go to medical school and you - and I was
trained in medical medicine, you're in a world where all the values
are academic medicine and practice. And so I knew relatively little
about public health until I was an intern in nineteen sixty nine at
the Stanford, [inaudible 03.01] Stanford Hospital and had to take into
consideration that as a healthy male doctor I was going to be drafted
into government service and probably spend a year in Vietnam. And at
Stanford there was Dr. Tom Merrigan a very good infectious disease
doc, talked about the communicable disease center as a potential
option and knew about this program called the epidemic intelligence
service. So I applied for EIS and Mike Greg was my interviewer and
although it was a little bit - I applied late and it wasn't clear I
was going to get in. Then I - so I was in the EIS class of nineteen
sixty nine and I was posted to Alaska and had an extraordinary
experience there. But finishing there I wanted to live and work
overseas and I went to Guatemala and worked as a primary care doc for
a year and a half. And was in the process - and was living in Texas
in early nineteen seventy four and intending to probably work for
LARASA as a clinician in south Texas.
And then I received a letter from Lyle Conrad which was sent out I
guess to former EIS officers and others and said that CDC were working
in cooperation with WHO and trying to recruit people who would be
willing to work for three months in India as part of smallpox
eradication efforts. And that was such an extraordinary offer it took
me only a small fraction of a second to make the decision that I
wanted to do that.
Interviewer: And were you still with CDC when you were in Texas or were
you working with the...
Interviewee: No, I had ended my connection to the public health service
when I left Alaska and...
Interviewer: Okay, and EIS.
Interviewee: And EIS, yeah. I was a private citizen.
Interviewer: Okay. And so you got the letter from Lyle Conrad inviting
you to participate in the smallpox eradication program and about then
what was the time frame in terms of how much longer before you - did
you come back to Atlanta then for training or?
Interviewee: No. There was no - there was nothing - I didn't go to
Atlanta. I basically agreed to go and then had, I don't remember what
the interval was between the letter and my departure. I went in early
to mid June. I flew from Texas to the west coast and then from the
west coast to New Delhi and arrived on June fourteenth of -- or
sixteenth I can't remember -- of seventy four at the New Delhi airport
at two or three o'clock in the morning. Was met by Bill Foege.
Interviewer: And then had you ever been to south east Asia before or
India?
Interviewee: I had - because I lived in a developing country namely
Guatemala I sort of assumed I was a seasoned, experienced
international traveler or worker or whatever but I found India to be
totally overwhelming at least initially partly I'm sure because it was
the middle of the hot season and I was substantially jet lagged. But
it was an extraordinary experience and much more challenging then
central America.
Interviewer: Interesting. Where did you - where were you posted in
India?
Interviewee: I was posted in Bihar and we had some training in New
Delhi and then we traveled by train from New Delhi to Patna and it was
- this was a coal fired train and I learned about how people who used
to travel in trains in those days became covered with the grimy soot
of the coal burning engine even though we were in first class.
Interviewer: Wow. So were you part of a team in India when you went
over as the smallpox? Were there others that were kind of in your
cohort or?
Interviewee: Yes. There was a group of something on the order of ten
to fifteen people who had all been, I guess had responded to this
letter from Lyle and other reasons and we were in a group that was
trained and we had training from Larry Brilliant and Bill Foege. And
when we got to Patna we had - we went to the field where I saw the
first person I had ever seen with smallpox and Bill Foege was training
us in the basic parts of identifying smallpox and doing the
surveillance and containment activities.
Interviewer: And was that still in the New Delhi area?
Interviewee: No. That was in - that was near Patna. I don't remember
where exactly.
Interviewer: Okay, okay. And then what do you remember about your
early days kind of getting involved with the program, figuring out who
your counterparts were going to be?
Interviewee: Well I - basically we had this couple of days of training
in Patna and then each of us were derived - almost all of us had no
prior experience with smallpox or India. We were - and we had a
driver, a jeep and a paramedical assistance, a PMA who was basically a
translator because most, almost none of us knew any Hindi. And we were
sent off to a district to start working with the civil surgeon and the
district medical officer and the - I'm now forgetting the chief
administrative officer. And I was assigned to Muzaffarpur district
which is one district south of the border with Nepal and at that time
it was a very simple place. Muzaffarpur town had one restaurant and I
stayed in one of these old British empire dock bungalows. And it was
quite an experience to get started there because we were - in the
beginning the expatriates were - the amount of support that we had at
that point was quite limited. It was the PMA, the driver with whom
you always had to have this game of trying to make sure the petrol
wasn't stolen and then making connections with the local officials and
then going out to the basic walks, places where the local medical
officers who were in government service were providing family planning
and curative services to people and finding the smallpox that was
there. And there was plenty of smallpox at that time.
Interviewer: You mentioned making sure that the petrol wasn't stolen.
I know that Bihar has a reputation of being a I think the lawless
state and I'm wondering if it was like that back in the seventies as
well and...
Interviewee: Well it...
Interviewer: ...was it harder than some of the other places in India?
Interviewee: Well the - Bihar's reputation in those days was
particularly as a place that was very conservative and very quote
unquote backward. And when Mrs. Gandhi in an introduction to the
history of smallpox in India and eradication she said something like
smallpox is a disease of underdevelopment. And in India the places
which had better government services and a higher - things worked
better such as all of the south, had basically eradicated smallpox
already. So smallpox had remained in India was in the places which
were more traditional, where there was less economic development,
where there was less education. And so that was Bihar, Uttar Pradesh
and West Bengal were the primary areas where smallpox was and that
contributed to the pattern of where smallpox was at that time.
Interviewer: How did you find out about the smallpox cases that were
out in the field?
Interviewee: Well, one of the things that had been instituted was a
reward system so that people in the general public and health workers
could earn and I don't remember what the level was when we started but
it was quite low, a small amount of a number of rupees for reporting a
case or an outbreak of smallpox once it was confirmed. And so that
was one mechanism and the other was that there was an increasing sense
among people in India that smallpox was a problem that ought to be
dealt with and confronted so there was a - people had a desire to
report the smallpox and also presumably to try and get some help
dealing with it.
Interviewer: What was the reaction of the people who were in the field
in the remote rural areas when you showed up with your few colleagues
to give the immunizations and to investigate the case?
Interviewee: Well, you know the smallpox had been in India for a long
time and was such a part of everyday life that there was in fact a
deity Sheetla Maha, was smallpox and sort of infectious diseases that
involved a rash but more smallpox than anything else. And that was -
so there was some belief that smallpox was a blessing or came from
deities but on a day to day basis when you - when we would go to a
place where there was smallpox, a village where there was one or more
cases of smallpox, people were very cooperative and we did a process
of finding cases. We had a set of forms for listing cases and then in
the beginning doing only a relatively small number of houses, the
nearest houses to the home where the or the home or homes where the
people lived who had smallpox, enumerating all the people that lived
in those houses and vaccinating everyone and keeping track of the
evolution of their smallpox vaccinations and finding out where people
had - the cases had traveled and giving notifications to other areas
that might be affected because someone had traveled to another place.
It was a fairly easy to operate system.
Interviewer: Do any of your trips back to the villages stand out as
exceptional, remarkable, perhaps unique in what you encountered there
or the reception of the people to you?
Interviewee: Well it was - in the beginning it was all unique and
exceptional and extraordinary because here I was, we were dealing with
this classic killer. And I guess that the ravages of smallpox and
what it could do to people and how it killed people and in particular
this form known as flat smallpox where there was just a confluent rash
so that people were just all pox, rash. And there was a way that you
could particularly with a person who had flat smallpox there was a
certain odor that you could smell that you could identify and you
could almost make a diagnosis of smallpox based on that. But it was -
the devastation to people and families of smallpox was extraordinary
and it contributed to my feeling that smallpox was an unmitigated
evil. There was no apparent good side to smallpox that I ever could
find so it was a worthy adversary.
Interviewer: How did they react to use of the jet gun in the little
towns, any problems?
Interviewee: Now you - I'll help you know the proper history. By then
nobody used jet guns. We just used the famous bifurcated needle and
so smallpox being historically present in India and a huge problem
there people were very familiar with vaccination and vaccination had
been done by a variety of methods. So vaccination itself was not
really a problem. I mean there was some - there are many schools or
ways of medical care including ayurvedic and homeopathic in India.
And the people, the practitioners of those types of medicine at times
had opposed vaccination for one reason or another. And I can remember
having some sort of a debate with a homeopathic doctors about smallpox
vaccination. But there were always people - there was always a small
number of people who refused to be vaccinated and one of the rules of
the expatriates was to help convince people that they ought to be
vaccinated.
Interviewer: To follow up on one of the comments you made, one of your
roles was to convince people that they needed the vaccine. How did
you go about doing that?
Interviewee: And I was going to extend on that. It became a - it was
clearly something that as an expatriate, as somebody from obviously
outside of India that the expatriates had a particular possibility of
being influential with people that were declining to be vaccinated.
And I remember I had many, many, many conversations with people who
were declining to be vaccinated. And I remember in particular at
least once and I'm sure it was many times, a sign of respect was to
touch someone's feet or shoes and I did that multiple times in trying
to convince people to be vaccinated. And another thing that you did
was to vaccinate yourself so I in the process of a few months in India
was - I was - I had vaccinated myself hundreds of times as a way to
show people that it was a trivial thing to be vaccinated, a minor
process. So those are some of the things.
Interviewer: How did your relationship with the translator? Do you -
it sounds like you always went in the field to the villages with your
translator.
Interviewee: Yeah.
Interviewer: And how did that develop over time?
Interviewee: Well, it - many people - obviously because of the history
of India as being part of the British Empire there were many, many
people who spoke good English and in particular the government
servants and medical officers and all were fluent in English. So it
was possible to function a lot without a translator but it was also
essential to have somebody who could help you with Hindi. In the end
I got to be moderately competent with Hindi and perhaps over estimated
my ability to communicate and understand. And it was an important
relationship. Your PMA was - the degree to which the PMA was
interested, aggressive, concerned, involved was a big deal, while if
you had a more passive PMA then expatriate was much less effective
obviously. So it was a very important relationship and...
Interviewer: When you went out in the fields, excuse me, when you went
out in the field did you go for several days at a time from village to
village or were these more long days in the field and then back to
your headquarters in the evenings?
Interviewee: Well, headquarters didn't really exist in those days. We
had - I had a room in a dock bungalow which was basically a - if I
remember it was a single living space with a bathroom and that was all
the office we had. It was very low key and not very well supported in
the beginning and as I stayed in Muzaffarpur for probably something on
the order of five months and then gradually we got additional
resources and we had more staff, more vehicles. We had local young
medical officers from India who joined in and medical officers from
other parts of India and so it became a much more elaborate operation
and a much bigger team as those resources were added and they made a
big difference. And so I couldn't tell you exactly when we ended
smallpox in Muzaffarpur nor exact - we had - when I arrived it was -
there were probably a hundred outbreaks and within four or five months
it was essentially taken care of part of which was the weather and the
fact that we got into the poor transmission season. But the
surveillance and case finding and then containment activity was a very
effective tool for slowing and then stopping the spread of smallpox.
And what happened is as the number of outbreaks dropped the amount of
work that we did with each outbreak could be increased substantially
and to some extent that was measured by how many houses we would
include in the containment activity. So in the beginning it was a
relatively small number of ten or fifteen or twenty and as we got more
resources as there were fewer outbreaks it became fifty, a hundred,
hundreds of houses.
Interviewer: That you would go out and vaccinate at the reporting of
one case?
Interviewee: We would put a number on and then the houses and household
would receive a number and there was a regular thing in which we put
the number of people in the household written on the side and the
vaccination status of how many of them had - cause you had to - you
vaccinated and then you went back to see that - you had a vaccination
take and monitored that. So that was part of the containment
activity.
Interviewer: How long after did you return then?
Interviewee: Well, it would be - depending on what was going on you
might stay in the local area if you have the time and there were other
dock bungalows and other places that you could stay around the
district. But when you have a hundred outbreaks you can't visit them,
each of them for very long and the typical way that we worked at that
time as we were in the field for probably twenty five days out of the
month. And then we went to Patna for a couple of days of state level
meetings in which we reported on our progress and heard from our
colleagues about what was going on and had people like Mahindra Dhata
or M. I. D. Sharma from the Indian health side and Bill Foege and
Larry Brilliant and others from the WHO side inspire us not that we
needed much inspiration.
Interviewer: So were you pretty much working seven days a week when you
were out in the field?
Interviewee: When you're living in the country side in India
particularly in nineteen seventy four, there was nothing. There were
- I suppose there was some cinema but there was nothing to do and one
of the things that always struck me about smallpox is it was an awful
disease and it caused tremendous suffering. And so there was a kind
of a feedback loop of encouragement or inspiration and so that -
because as you could see that if you worked hard then you could reduce
the number of cases of smallpox and if you worked even harder you
could do that sooner. And then as you got the number of smallpox
cases went down then you were sort of getting to the point where you
were going to have local control, local eradication and you knew that
that was part of a grander plan of eradicating smallpox in Bihar and
in India and in the world. And so you had a feedback loop to keep you
working harder and harder and harder or at least continue to be
putting in tremendous amounts of effort because you were working
toward an extraordinary goal of taking this killer disease and getting
rid of it, 100% gone. It wasn't a - you didn't have to work - you
didn't have to suffer for small gains. You could...
Interviewer: Like you could see your - the results of what you were
doing?
Interviewee: You could see the results and you also knew that if you
and everybody else worked hard that you were going to definitively get
rid of smallpox. It wasn't something that was done by half or where
you settled for a partial victory. We were headed to a 100%
eradication which is an extraordinary achievement and in part why
smallpox for me was the most - was the peak of my personal - my life
and my professional experience. I mean it was an extraordinary one
for that part of it and for a number of other things.
Interviewer: Right. So you had mentioned that you saw this drastic
decline in the smallpox cases in India and I think earlier you
mentioned you also spent time then in Bangladesh. Is that about the
time then - were you transferred or did you ask to go to Bangladesh or
how did that happen?
Interviewee: I actually - David Sensor was in India and I'm afraid I
can't give the - this was I believe January of nineteen seventy five.
And I remember riding on a train with him and I believe with Bill
Foege and there was a discussion about - at that point it was clear
that India was headed for success and the program in Bangladesh was in
deep trouble in terms of having many outbreaks of smallpox. And I was
one of the first people to go from the India program to the Bangladesh
program as part of the beginning process of helping the Bangladesh
program transform itself into what was the sort of India model I guess
you would say.
Interviewer: Were there differences in the composition of the teams or
what were the differences?
Interviewee: Well they - I believe this is the case and I'm - this is
my impression. India, the India program was a transformed approach, a
new approach because earlier in Asia in Pakistan and Afghanistan and
other parts of and I think also in the Africa programs although I'm
less clear about that, the model was a relatively small number of
expatriates who were WHO employee, full time WHO employees, perhaps a
dozen or so. And in India what had happened is that there was - it
was such a large scale problem that the program model that evolved was
the one that I sort of described where first you bring in some
significant number of expatriates for short time work and then you
amass resources and you have lots more money and government commitment
and you provide lots and lots of vehicles. You provide - you pay for
more local staff, you recruit the young Indian medical officers so
that you have a huge, in the end you have a huge operation that was a
sort of - I mean it was a parallel organization to the government and
the local government, the government in India and the local government
in the states and districts where you worked with a specific purpose.
In the Bangladesh program was one where they were working with the
old model and they were I think hoping that they would be able to show
that the program in India was sort of overkill and that they could
achieve smallpox eradication with a relatively small intimate group if
you will of expatriates and WHO employees. And I believe that they
had been offered resources but felt that they didn't need them.
Interviewer: Did you have local counterparts in Bangladesh as well?
Interviewee: Oh yeah.
Interviewer: And was it - I'm sure a car and a driver and a translator.
Interviewee: Yup.
Interviewer: Others in addition?
Interviewee: That was the pattern everywhere and the - in Bangladesh we
had a - there was a different sort of type of expatriate. There were
more people with young volunteers who were not medical officers and
who came from a wider array of countries. There was more Americans in
the India program and we had a lot of - substantial number of people
from the U.K. and elsewhere. One of the aspects or the fascinating
things of smallpox eradication work in India and Bangladesh was the
fact that there was these many nations, people coming together from
around the world whether it was the Soviet Union or France or the
United Kingdom or the United States or Czechoslovakia or Poland or
whatever working together in a team. So that was one of the
extraordinary parts of working on smallpox eradication.
Interviewer: Steve as we come to a close about this and you had
mentioned a little bit about this before about how working in the
smallpox eradication program really had a huge impact on your life and
how you think about public health. Could you talk just a little bit
about that before we close?
Interviewee: Sure. I mentioned this aspect of smallpox eradication as
this extraordinary in the sense of there was really nothing like the
experience you could have of working on a killer that had existed for
centuries and centuries and centuries and by your hard labor
contributing to getting rid of a plague in the generic sense of it.
And that - that's a life experience and I also in that process of work
spent or got to know a lot more people from the CDC. And when I
finished in Bangladesh in the summer of seventy six it was quite a
challenging thing to think about coming back to the United States and
changing from this sort of single focused monomania working on
smallpox eradication to coming back to a quote unquote real world.
And part of what I did was to gain time to get perspective by getting
a masters in public health but I was just committed to work on public
health. I was intoxicated by the experience and it was clearly
something where you could have a huge impact. And my connections -
the first work that I did after school of public health was to work on
- with the immunization program in the Pan American Health
Organization. And then I came back to CDC while working with that
program and I was totally committed to public health and had no
interest in clinical medicine whatsoever anymore.
Interviewer: Thank you. It sounds like - I appreciate you being part
of this oral history project and...
Interviewee: It's a pleasure.
Interviewer: ...just sharing your experience working with the smallpox
program in both of those countries, around India and Bangladesh. It
just sounds like it's had a tremendous impact and I know that you went
on to have a very long and productive career in public health before
retiring from CDC. So thank you again.
Interviewee: Thank you.
Stephen Jones Oral History 2008
July 11, 2008
Steve Jones describes his experiences in the smallpx eradication program in India and Bangladesh
