22 12 2286 https://www.globalhealthchronicles.org/files/original/08c7c49aad0df2cab4a6bb2c95047808.jpg bb93d5d769875424d1fb491adc0ad51d https://www.globalhealthchronicles.org/files/original/817185efe3d9b4f4fe6938e66252dcac.pdf a2f11c309db619cc07e145849f2cbe0b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> This is an interview with Dr. William Foege about his activities in the West African smallpox eradication project. The interview is being conducted July 13, 2006, at the Centers for Disease Control and Prevention. It is a part of the 40th anniversary celebration of the launching of the West African smallpox eradication project. The interviewer is Victoria Harden. Harden: Dr. Foege, would you briefly describe your childhood and your pre-college education--who influenced you to go to medical school and get interested in public health? Foege: I started out in northeast Iowa, and lived in a small town of 100 people. When my family moved away, the population went down eight percent. I went to a one-room schoolhouse for the first five years. We then moved to Chewelah, Washington, and I thought I was really in a big city. It was about 1500 people. Harden: And why did you move? Foege: My father was a minister, and he got a call to a new church in Chewelah, Washington. We moved for that reason. From there, I went to Colville when he started a new church in Colville, and that's where I graduated from high school. I went from high school to Pacific Lutheran [College], what is now Pacific Lutheran University, in Tacoma, Washington, and became interested in biology, because of a very forceful biology teacher who was a man I've never seen the likes of. Harden: What was his name? Foege: His name was William Strunk. In class, he would walk into the room, lecturing as he walked in. He would go to the board and actually write with both hands simultaneously, putting up phyla and families and classes and genera. He would still be talking as he left the room. I was a lab assistant to him and also worked at his place on weekends, doing yardwork. He played an important part in getting me into science. My older sister, Grace, four years older, had gone to the same school, and she went to medical school. She also was an influence. I was also influenced as a fifteen-year-old when I spent three months in a body cast, unable to turn over or do anything. That was in the days before television, so I was doing a lot of reading. I began reading about Albert Schweitzer, and medicine, and Africa, and all of this became very interesting to me. Harden: Had you had an accident, or...? Foege: I had a problem with my hip that required three months of immobility. The hope was that it would heal correctly, and it did, but the hip was always off a little bit. This period was a time of reflection and reading that I might not have had without that physical problem. In medical school, I began working after school and on Saturdays for a fellow by the name of Ray Ravenholt. Ray Ravenholt had been one of the first EIS officers, Epidemic Intelligence Service officers, at CDC [Centers for Disease Control], and he was always pushing the idea of public health and also the idea that I should think about joining the EIS at CDC. I went off to New York for my internship, and I had been accepted in an internal medicine residency, when I got a call from Don Millar [J. Donald Millar] at CDC. He said they had just received some positions that enabled them to expand the EIS class, and would I be interested? I abandoned my idea of going into internal medicine, and went to CDC in the EIS class of 1962. Harden: Had you always been interested in public health, or was that just a sideline until you got to CDC? Foege: Ray Ravenholt was such a powerful influence on me that I was interested in public health by the time I graduated from medical school. Of course, I didn't see exactly where I was going until Don Millar called with this EIS opening, but then I never looked back. I was extremely pleased at CDC with the EIS program. I was first assigned to Colorado, a state assignment, and while there I did two overseas TDYs [Temporary Duty]. One was to India, in 1963. At an EIS conference, they had announced that the person holding the Peace Corps position in India had taken sick. It was going to take some time to replace him, so they were looking for a volunteer to go as the Peace Corps physician. This I did, and it turned out to be important in so many ways. I saw global health close up. I saw my first cases of smallpox. I made rounds at Holy Family Hospital in New Delhi. I worked for a man by the name of Charlie Houston, who was key in mountaineering. In 1953, he had actually led a group up K2 [Karakoram 2 mountain in Pakistan], and before getting to the top they were stuck in a storm. One person developed deep vein thrombosis in one leg and then developed it in the other leg. Charlie Houston said that they had to get him down, but everyone said, "We can't go down in a storm." Houston said, "It's his only hope." So they attempted to rescue him in a storm, and as they were descending across an ice field at a forty-five degree angle, one person slipped and fell. This person got tangled up in another rope, and then four people were falling. They hit Charlie Houston, who was on a third rope and knocked him unconscious. The four people plus the three on Charlie Houston's rope were all falling, and they were held by a man by the name of Peter Schoening, who, with his ice axe, was able to stop all of them. It's an incredible story, and to make it even more incredible, two months ago I went to the University of Colorado, where they gave Charlie Houston, at age 93, an honorary degree. They had a half-day program giving him an honor. All of the survivors of that 1953 expedition were there, including Bob Bates at age 95, former headmaster at Exeter, and Bob Craig, the youngest of the group, who was now in his late 80s. Charlie Houston was spectacular person to work for. He was able to demonstrate that you can work in a developing country and not get overwhelmed by it. He always got up every morning just happy to be working and was never overwhelmed. Harden: I believe that you also were involved as an EIS officer with the group that went to Tonga to evaluate the smallpox vaccine, and the jet injector. Would you talk about that? Foege: The other overseas TDY that I did was to Tonga, a group headed by Ron Roberto [Ronald R. Roberto]. The idea was to see could you dilute smallpox vaccine and use it in a jet injector. Tonga had not done routine vaccinations since 1905, so it provided a virgin population in which you could measure antibodies and so forth, and the Tongans were agreeable to having this study done. We wanted to evaluate the effectiveness of different dilutions of smallpox vaccine--a one-to-ten, one-to- fifty, one-to-one hundred, and so forth. It turned out to be a very good study that demonstrated you could dilute the vaccine one to fifty, and that you would still get uniform take rates. We also demonstrated that the vaccinations could be given with the jet injector, which didn't require special training in technique to have the vaccinations come out the same with every person. It was easy to train a person to use a jet injector. This turned out to be a very important study. Harden: May I ask you to describe how the jet injector worked? Did it actually touch the people's skin, and if so, did you have to sterilize it between uses? I don't understand how you could do thousands a day, if you had to sterilize between every one. Foege: The jet injector nozzle actually did press up against the skin. At that time, people were quite sure that there was no chance of cross-contamination, that the vaccine came out at high pressure, but we've subsequently changed our mind about this, and that's why we don't use jet injectors at this point. But because we believed it completely safe at that time, one could actually do people almost as fast as they could walk by. You set up a rhythm: grab the arm, step on the hydraulic lever, shoot, and the person would continue on. You could do a thousand people an hour, and I remember at one point doing a prison in eastern Nigeria, where they had the inmates lined up, and they were actually pushing them through by hitting them with sticks. I did 600 people in twenty minutes, because it was such a regimented line that you could just grab people and do them so fast. At one point, I recall doing over 11,000 smallpox immunizations in one day. So, yes, you could do this very quickly. Harden: Before we move on in your career, is there anything else that you would like to comment about in your EIS training here at the CDC? Foege: In those days at CDC, anyone in the EIS program saw Alex Langmuir [Alexander Langmuir] as a mentor. He was a very powerful personality. He knew what he was doing, he was inspired and inspiring. And so I'd look back on those days as days where Alex Langmuir was reaffirming how important it was to do public health, and how important it was to do global health. He was interested in everything. Also during that time as an EIS officer, I read an article in the New England Journal of Medicine. It was called AQuestions of Priority,@ written by Tom Weller [Thomas H. Weller]. I had no idea at the time that Tom Weller was a Nobel laureate, but when I read the article, I knew I wanted to know him, because he was saying in the article things that I believed. It was a commencement address to the Harvard Medical School, and he was essentially saying, "You're only going through life once, you might as well try to get it right, and here [at Harvard] you come out with all these skills and this knowledge, and you have to ask how you're going to use it. Think about using it in the parts of the world that can best use these resources. The developing world doesn't have the resources of skills and knowledge, and now that you've gone through, think about using what youve learned in the developing world." Harden: Maybe I can digress here for one philosophical question. The early 1960s were an idealistic time, in a variety of ways, and the idea that to get it right in life you went and served people is a very different idea from getting all you can for yourself. Would you comment on the idealism of your peers in this period? Foege: The early 1960s turned out to be a very nice time to be growing up in the United States. President Kennedy inspired people with the idea of the Peace Corps. People thought about how best to serve their country and how best to serve the world. So when I read an article by a Harvard professor saying the same thing, I decided that I wanted to get to know him. I applied at Harvard, and no place else, and I spent a year with Tom Weller. Harden: As I understand, you did this on your own, rather than having the CDC sending you. You received a Master's of Public Health degree.Foege: That's right. CDC actually offered a career development program to me, which meant that I could have training paid for for a number of years, and then I would pay back a certain number of years. But by this time, I already knew I was going to Africa or someplace else in the developing world, and it didn't seem fair to have CDC pay for my education and then, even if I paid back a certain period of time, leave for another job. So I went to Harvard on my own. I did get a scholarship, but I went on my own, and it turned out to be everything that I had hoped it would be. Tom Weller was an inspiring person. He worked with an inspiring group of people, including Frank Neva [Franklin A. Neva], who was my faculty advisor. Neva is the father-in-law of Peter D. Bell, who became president of CARE, and the father of Karen Bell, who ended up teaching here at Emory University in the School of Public Health. And so it turned out to be a very nice experience. When Tom Weller retired from Harvard, it so happened that I gave the commencement address that year. I got out that New England Journal of Medicine article, and I read the portions that I had found so attractive before, and made the point that you never know what will ripple downstream from what you say or what you write. Well, Tom Weller got a standing ovation in the middle of my commencement address, and it completed a circle. I've remained in contact with Tom Weller, who's in his 90s, just as I have with Charlie Houston and some of my other mentors. Harden: When you finished your training at Harvard, you joined a medical missionary program in the Lutheran church. Apparently it took a bit of effort to convince them to let you do a public health mission, as opposed to a primary care mission. Would you talk a bit about that, and what you finally set up? Foege: Let me mention one more thing about Harvard before going to that. In one of Tom Weller's classes, we had to do an independent project and present it. I happened to do a project on the feasibility of smallpox eradication in the world. I had no idea that I would ever be involved in this, but I found it an intriguing topic. There was a person in this group, Yeme Ademola, who was the head of preventive medicine for Nigeria. He had taken a year off to get a master's degree at Harvard, so Yeme and his wife Rosa were there, and he was part of that class. After graduation, Yeme Ademola came down to CDC, and talked to people about his interest in smallpox eradication in Nigeria. This is a small aside. After graduation from Harvard, I went to Nigeria to work for a church group. I knew that most of the hospital beds in Africa were provided by church groups, so they had a big influence on health in Africa. But almost all of them were involved in clinics and hospitals, not in community work. It's easy to see why that would happen, because church programs had found that medicine was a great proselytizing tool. People in hospitals and clinics felt real gratitude, and so medicine turned out to be a form of recruitment. I always felt that was wrong, I felt that churches should be working in Africa or other places because of what they believed, not because of what they were trying to get other people to believe. I wondered what would happen if you could get this force looking at community medicine instead of hospital medicine. Community medicine takes a far different approach to things. In the end, it made no difference that I actually went to Africa to try to make that change. There were other things happening at the same time that would cause church groups to shift to community medicine. The World Council of Churches had a Christian medical commission, and there was a fellow by the name of McGilvray [James C. McGilvray] who headed that up. He believed in community medicine. He was so influential that, in a period of years, he got medical mission programs to change in three fundamental ways. Number one, he got them to understand they had to work under governments. Colonialism was over, and they had to work under sovereign governments. Number two, he got them to work together. They had been very competitive in the past. In many countries there would be one person who was the coordinator for all Protestant work, and another one who was the coordinator for all Catholic work. McGilvray's influence resulted in--at least, in a few countries--those two sitting in the same office. This was an incredible change. Number three, he got them interested in community medicine. So I could have saved my time. I didn't prove anything by going over. It was happening anyway. But I did go over, and I was trying to promote community medicine. I would probably have spent decades working on this, except that when the war in Nigeria came, it went through our medical compound within the first weeks. Harden: Would you back up and tell me exactly where you were, what was happening, and what you were doing when the war came? Foege: I graduated from Harvard in 1965, and that summer, we left for Nigeria. We went to a medical center in the eastern part of Nigeria. In those days, Nigeria did not have states. It had only four regions. The north, the east, the west, and the midwest. We were in the eastern region. This was the region that was dominated by Ibos, who would later form the Republic of Biafra. We were in a minority area of the east, in a place called Ogoja province, up near the Cameroon border. In this area, there was a medical center at a place called Yahe. It was a crossroads town, and that's where we went. We spent the first six months living in a village in order to learn the local language. It was an eye-opener, because it was a village with no electricity, no running water, and no indoor bathrooms, that sort of thing. We had an opportunity to see what life was like in a village. We had a three-year-old son at the time. Harden: So you were married, with children, at this point? Foege: Yes. I had a wife, Paula, who will be the next interviewee, and a three-year-old son, David, and we had the naive notion that we would actually know what it was like to live in a village. There's actually no way to know that, because we could leave any time. The people living there couldn't leave. Living there was a form of bondage that I don't think it's possible for us to understand. But we were trying to. We lived in the village for six months and then moved to the medical compound. While we were at the medical compound, CDC asked if I would spend time as a consultant for the smallpox eradication program. Harden: This was before or after the revolution? Foege: This was before the war broke out. We had been in Nigeria for almost a year at the time that Henry Gelfand came to Enugu to ask me if I would be a consultant. Our medical center was ninety miles from Enugu, the capital of the eastern region, but we agreed that for a period of one or two years, I would work as a consultant on smallpox eradication, and I would go back to the medical center on weekends. I would try to do both things, ninety miles apart. In 1966, Paula and I returned to CDC to take the summer course for the people who were first going out to Africa on the smallpox eradication work. This is the group now meeting for a reunion. It turned out to be a very nice time for us to be back, because my wife was pregnant, and she delivered our second child, a boy, in September. It all worked out that we came back here, and she had the baby in Walla Walla, Washington, where my folks were living, and I attended the summer course and then met up with her. Now, an interesting aside. It takes a while to get a passport for a baby, to get a baby added to a passport. I even contemplated taking a picture of any baby and getting this on the passport before ours was born, so that we could move more quickly. I did not take that route, showing more sanity than usual. We waited, and I returned to Nigeria. Paula came over with the two children when the baby was about six weeks old. Harden: These are the small logistical problems, personal logistical problems that people rarely think about. Foege: Sometimes they turn out to be overwhelming. When I knew that I would be coming to the US for the summer course at CDC, I bought tickets for my wife and for David. CDC would send the ticket for me. We got to Lagos, ready to board the flight, but my ticket had not arrived from CDC. I talked with the Pan-Am manager, and he said, "You're in luck, because the plane is late by twenty-four hours. We have more time to try to get the ticket." But it was July fourth. That meant nothing in Nigeria, but it meant we couldn't get anything out of CDC. And so the next day, we went right down to the line with tickets for them but no ticket for me. About an hour and a half before flight time, the manager called me in, and he said, "We haven't heard anything. But I'll tell you what I'll do. If you write out a check for the amount of the ticket, I'll put it in my desk drawer, and so I'm covered if I get audited." I told him, "I can't do that. I don't have that amount of money in my account." We were at an impasse, but an hour before flight time, he said, "I'll tell you what I'm going to do, and I've never done this before. I'm going to give you a ticket." And he said, "I'm going to have to write out the check if I get audited." He gave me a ticket, and we got in line. But the airline representatives said, "This ticket was for yesterday." I said, "Of course it was. The plane was supposed to be here yesterday." Then I had to go back to the Pan-Am agent and say, "They won't take this ticket." He was exasperated by that time, but he got us through. We got on the plane finally, and at last I felt that we could relax. I actually said to my wife, "Isn't it going to be nice to get back to the States, where things work?" We got to New York. It was hot, it was at night, and we were twenty-four hours late, so, of course, everyone had to have new connections. My wife and son had a new connection, but I didn't, because I didn't actually have a ticket. This caused a problem. Pan Am said that they would put everyone up overnight and that we would all get out in the morning. We stood in the heat, and even though we were coming from Nigeria, it struck me how hot it was in New York. We were waiting for the bus to take us to the motel, the traveler's motel. There was a Pan-Am man there in a suit and a tie. He was very efficient. He picked me out and asked me to give them a hand. And then he picked out another person, and I realized he picked us for our size. He took us outside and said, "The battery's dead on the bus. Would you help push it to get the bus started?" And we did. We pushed it fast enough to get the motor to turn over, and the engine caught. Then he called for men to board first. I wondered why he did this, but the men, like sheep, got onto the bus. It turned out that the back of the bus was very hot. He was saving the front of the bus for the women and children. I heard him say to the bus driver, "Remember to stop at the first service station and put in three quarts of oil." I thought, "Three quarts of oil. This is a real problem." The bus driver let out the clutch and killed the motor. Everyone was told to stay on the bus, as hot as it was. The Pan-Am man said that another bus was coming to push this one to get it started, and that's what happened. And again he said to the bus driver, "Remember, three quarts of oil." We went down the highway, and it must have been eleven or eleven-thirty at night by then. He pulled off into a service station and sat there for a moment. Then he turned around and said, "You know, folks, if I stop the engine to put in oil, we're not going to get it started again." And so off he went onto the highway, and soon the motor froze up. There we were, on the side of the road, with the motor frozen, and he told everybody to get off the bus because it was too hot to stay on. He made a phone call, and pretty soon this Pan-Am agent comes screaming up in a car, and by this time he had his tie off and his jacket off and he was starting to look disheveled. He said, "Don't worry, we have some cars and another small bus coming." When the cars and the small bus came, he told the women and children to get in the cars, and the men to get in the bus. All the women and children did as they were told, except my wife, who stayed with me. She said, "The way things are going tonight, I may never see my husband again, so I'm not moving." Finally, we got on the bus and we get to the motel. But to have said, AWon't it be nice to get back where things work?@ and then run into this, it was ironic. Harden: Would you now walk me through the events in the Nigerian war that forced you to end the mission program and moved you into CDC? Foege: In the last part of 1966, and the early part of 1967, there was a lot of tension in Nigeria. The east kept threatening to form its own country. In retrospect, I suppose oil was behind this, but we didn't quite understand it at the time. We continued working. In late 1966, two very important things relating to smallpox happened during my time in eastern Nigeria. One was a mass vaccination program we did in a place called Abakaliki. We were very successful, getting about ninety- three percent of the population vaccinated. We were pleased by this kind of coverage, only to see an outbreak of smallpox a few weeks later in Abakaliki. We didn't think that this should have happened, because we believed in the idea of herd immunity. What was different about the outbreak was that it occurred in a religious group, Faith Tabernacle Church. All of the cases were in the Faith Tabernacle Church. The members of this church had refused vaccination. The source of the outbreak had probably come from another Faith Tabernacle member outside of Abakaliki. The point is that we found that no level of vaccination in a population was so high that you could exclude the possibility of smallpox. That's one thing that happened. Harden: You said that your independent project at Harvard was to come up with a smallpox vaccination strategy. Had your strategy for that project been mass vaccination? Foege: Everyone in those days was thinking in terms of mass vaccination, and that's what I was thinking of when I was at Harvard, that if you got to a certain level of vaccination, you would make it so difficult for smallpox to be transmitted that it would just die away. That's what we thought, but the experience in Abakaliki proved otherwise. The second thing that happened occurred on December 4, 1966. It was a Sunday. I got a radio message from Hector Ottomueller, a missionary, who asked if I could come to look at what he thought might be smallpox. We went to the area, which was probably six, seven miles off of a road. We used Solex bicycles, French bicycles with a small motor on the front. They were so light that when you came to a creek, you could actually walk across on a log holding the bicycle in one hand. They were a very efficient method of transport. Sure enough, these were smallpox cases. It was so early in the program, we didn't have much in the way of supplies, and then I learned we wouldn't get any more supplies. We were faced with the question of how to use our small amount of smallpox vaccine most effectively under these conditions. That night, we went to a missionary's house to take advantage of the fact that they got on the radio with each other at 7:00 pm each night to be sure no one was having a medical emergency. With maps in front of me, I was able to give each missionary a geographic area, and ask if they could send runners to every village in that area to find out if there were any smallpox cases in any of the villages. Twenty-four hours later, we got back on the radio to see what they had found. That night we knew exactly where smallpox was. Our strategy was to use most of the vaccine in the villages where we knew that smallpox existed. Second, we tried to out-figure the smallpox virus. I mean, we literally asked ourselves, "If we were a smallpox virus bent on immortality, what would we do?" The answer was to find susceptible hosts in order to continue growing. So we figured out where people were likely to go because of market patterns and family patterns. We chose three areas that we thought were susceptible, and we used the rest of our vaccine to vaccinate those three areas. That used up all of our vaccine. We didn't know it, but in two of the areas, smallpox was already incubating, but by the time the first clinical cases appeared, those areas had been vaccinated. And so smallpox went no place. By three or four weeks later, the outbreak had stopped. And we had vaccinated such a small proportion of the population! There was this contrast between the situation in Abakaliki, with a very high percentage of coverage and still a smallpox outbreak, and that in Ogoga province, with very poor coverage, but with an outbreak that was halted. We began to wonder if this new strategy might be worth trying in larger areas. We talked to the Ministry of Health. It was a very crucial time, because war was being talked about every day. The Ministry of Health said that in the eastern region, they were willing to change the whole strategy against smallpox. We could put all of our attention on finding smallpox and containing each outbreak. Five months later, when war fever was at a peak, we were working on the last known outbreak in that entire region of twelve million people. In five months, we'd cleared out every outbreak. We were working on the last outbreak when war broke out. Now I didn't know that war was going to break out at that moment. The smallpox program had planned a meeting in Accra, Ghana, for the first of July, 1967. I went to the American consulate in Enugu and asked, "What's the chance that there will be fighting in the next weeks?" And they said, "Not a chance. Neither side is strong enough at this point to actually initiate anything." But the border had already been closed between the east, which called itself Biafra, and the rest of Nigeria, and six weeks earlier, we had sent our wives and children out. We had gone to Port Harcourt, where our wives and children got on planes. They were DC-6s, I can still recall. It took forever for them to get off the runway, because every seat had an adult and a child. Harden: And where did the planes go? Foege: From Port Harcourt to Lagos. Port Harcourt was in the east, but they had received permission for people to fly out. When the smallpox meeting was about to start in Accra, Ghana, I determined from the consulate that we would not have to worry about fighting in the short term. We crossed the Niger River in canoes. They were slightly big canoes. There was no formal border between the two regions. And yet, we got our passports stamped on each side, by people who were pretending that this was all legitimate. We got taxis from the other side of the river to Lagos, and from there we got to Accra. We were in Accra at this meeting when the fighting broke out. The American consulate had it all wrong, and we couldn't get back. We did not know for months whether that last outbreak had actually been contained or not. It turns out that it was contained. There was never any smallpox in the area of fighting during the Nigerian-Biafran civil war. That turned out to be a real blessing. But think of how close we came. There was a window of opportunity because of our December experience with the small outbreak. We had asked if we could try this strategy on a larger area, and in five months we had cleared out smallpox from the entire region. Because of that, smallpox turned out not to be a factor in the war. Harden: So you knew by then that this method of "surveillance/ontainment" or "eradication escalation"--whatever term we are going to use--was a more effective way to eradicate smallpox. And at this point, when you were asked to come back into CDC, you must have had to sell this idea to people. Tell me about whom you had to sell it to, and what you did to sell it. Foege: At the end of the meeting in Ghana, I wasn't quite sure what to do, since the east was now closed because of the war. I went back to Lagos, and it was decided that I would work in northern Nigeria for a while. I also need to step back just a few weeks, or a few months, to say that on one morning, in Enugu, a Saturday morning, we went in to work and found that there were cases of smallpox in the hospital in Enugu. And suddenly we knew we had to do something in Enugu itself and spent the rest of that day planning for doing vaccination in Enugu. That afternoon, I went out in a VW bug, and mapped out the places in Enugu where you had enough room that you could actually have people lined up to do vaccinations. I was not thinking of anything except smallpox at that point. But suddenly, I was surrounded by police. Someone had reported that there I was with maps, and of course that looked suspicious, so I was arrested. It took hours before they would allow me to make a phone call. I wanted to call my wife, so that she would know why I wasn't coming home for dinner. They would not let me do that. But they eventually let me call my counterpart, Dr. Anazanwu, in the Ministry of Health, and he came down and got me bailed out. I tell this just to make the point that I had been arrested by the Biafrans. When I went to work in northern Nigeria, I was in Sokoto province, which is up in the northwest part of Nigeria. I had just set up a tent for the night, and was getting ready to cook dinner, when a pickup drove up and police officers got out. A man came up to me, gave me a piece of paper, and asked me,"Is this you?" And there was my name on the paper. And I said, "yes." And he said, "You're under arrest." He would not communicate anything more. He would not say why I was under arrest, but I had to put everything together and get into the back of the pickup. And we started the long trip back. At one point, they stopped at a guest house in order to go in and drink beer. They left me alone, sitting in the back seat of that pickup, with a pistol on the front seat. I knew I didn't want to move at all, which I didn't. They came back, and we continued to ride. In Kaduna I was put under house arrest, and after several days, they said that they would allow me to leave the country, if I would never return. I left and flew out to Ghana. But a few weeks later, I was asked to go back to Lagos by the regional office of the smallpox eradication program. I knew how poorly official records were kept, so I went back, and there was never any problem. The point I am making is that I was arrested by both sides, which showed my neutrality. When I went back to CDC, I expected that the war was going to be finished within weeks. That was my thinking, and when I returned to CDC, I came back as a contract employee for what I thought would be a period of weeks or months. I began working on the idea of using surveillance/containment throughout West and Central Africa. That's what I worked on--selling the idea. Some people were sold immediately. I mean, I think of Don Hopkins [Donald R. Hopkins] going to Sierra Leone, which had the highest rates of smallpox in the world. Sierra Leone at that time had poor communications and transportation. He started out from the beginning, doing surveillance/containment. He never bothered with mass vaccination, and surveillance/containment worked, well. Other people were more reluctant, and I can understand that. We had sold most of the governments on universal vaccination. Eastern Nigeria had been easy to convert. They saw the logic, but it was not that easy every place. But gradually, place after place did do this, and the bottom line was, we were able to eradicate smallpox in five years. In country after country, smallpox disappeared. I'm quite sure that in any geographic area where they converted to surveillance/containment, twelve months later, it was smallpox free. Nigeria had its last cases in May of 1970, and the whole twenty-country West African area had smallpox disappear in three years and five months, a year and seven months before the target, and under budget. Harden: What I'm hearing from you is that each group working in the field had to choose to adopt this approach, that there was no top-down direction from Atlanta. I thought that an order might have come from headquarters in Atlanta, instructing everybody to stop doing mass vaccination and start doing surveillance/containment. That was not the way it happened? Foege: It's hard to make that kind of change when countries are autonomous and they have their own programs, and they've not been sold on a new approach. Don Millar was an immediate convert to surveillance/containment, and he was in charge of the entire West Central African program. Mike Lane had a fiefdom, a region that he was in charge of, and he was an immediate convert. So, right from the beginning, we were talking this out. With each meeting, it was possible to demonstrate that surveillance/containment was working in particular areas, and so gradually, everyone did come on board. But it took a little while. Nonetheless, to have smallpox disappear in three years and five months--it didn't take long. Harden: So the program agreements that were initially signed with each country had described mass vaccinations, and in shifting to surveillance/containment, you had to "sell" each individual country, correct? Foege: That's right. And to me, the amazing thing is not that it took some period of time. The amazing thing is how fast we changed strategy. I mean, we just turned things upside-down, and it happened in twenty countries. Harden: To me, as a historian, the fascinating thing is how that flexibility was embraced. So many times change is not embraced when somebody has a new idea and can demonstrate that it works, because people are so invested in the old idea. Foege: It also shows the value of having young people involved in the project. Julie Richmond [Julius Richmond], the former Surgeon General, once said that the reason smallpox eradication worked is that the people involved were so young they didn't know it couldn't work. And you know, that's probably true. People were very flexible. And when you think of the number of people that went from CDC into West Africa, most of them had never had experience in West Africa. And yet, they adapted fast. I think, when you look at the group as a whole, what characterizes them is that they were problem solvers. Everyone has mixed motives, of course. It's hard to know exactly what motivates people. Today I am often asked, "What is Bill Gates's motivation? And I say, "How do I know? I don't even know my own motivation, it's such a mixture of things." The people involved in smallpox eradication had a lot of interest in doing new things, and exploring, and so forth. But the thing that characterized them all was that they were problem solvers. You couldn't give them a problem that was so difficult they didn't want to try to solve it. And so, they were very adaptable. When a new idea came out, they quickly used it. Harden: In the middle of the West African smallpox eradication effort, there was a recommendation that smallpox vaccines be stopped in the United States. Were you involved in these discussions? Foege: I was involved during those years. In 1971, we really did attempt to stop smallpox vaccination in the United States. It took a lot of courage to support that, because there was still smallpox in Africa, Pakistan, India, and Bangladesh--lots of places. But but by then Mike Lane and John Neff and other people had done the calculations that showed what the risk was of the vaccine. The United States had a risk of smallpox coming in from another country, but we concluded that the risk of importation was less than that of the vaccine itself. Part of the reason is geography. Europe acted as a filter for smallpox cases. People coming from Africa or from India or Pakistan, often went to Europe first, and then to the United States, so Europe continued to have outbreaks, and we didn't. We calculated the risk of smallpox coming to the United States. For instance, if you look at ships, because of the time it takes to get here, and so forth, we were able to calculate the risk of smallpox coming to the United States by ship was about one importation in 600 years. It is far greater than that for airplanes, but it gives you an idea that it was possible to calculate the risk based on the incidence in a country, how many people go from that country to the United States, what percentage of them are probably not adequately protected, and so forth. The recommendation to stop giving smallpox vaccinations in the United States came out in 1971. It took quite a while before it was actually followed by everyone. As a part of that recommendation, we also developed a plan for what to do if there was an importation. Some of us went to the states-we got to all of the states--to train their public health officials as to what would be needed if a smallpox case was imported. We used what was called the CASE manual. "CASE" stood for Comprehensive Action for a Smallpox Emergency. Inside the front cover of that notebook was a big chart that you unfold and put up on the wall. It showed every step that you had to take. And every step had a place in the notebook that gave the details. Our point in designing this manual was that people did not have to study this ahead of time. They just needed to know that it was available to tell them what steps to take if they thought they had a case of smallpox. This was very important so that no one would panic if a case appeared. The chart in the CASE manual was very clear. I think we did a good job of educating the state health officers, the counties and so forth, on what to do in case of a smallpox outbreak. Harden: Is there is anything else about the West African program you would like to talk about? Foege: I think we've covered the main things. The only other things I had were stories of various kinds, but I don't think they're as important as the big picture. Harden: I'd like to hear those stories! Foege: The program itself, as you can imagine, was very difficult. Communications were bad, transportation was difficult, it was often hard to get food. It was not an easy time to be in an area in which civil war was about to break out. There were many tensions. There were roadblocks where teenage boys with guns were drinking beer and making decisions. This was difficult. Harden: Were you afraid? Foege: You always had to be a little bit afraid of a teenage boy with a gun who's drunk. They do irrational things. So, yes, you never wanted to talk back. There are many stories from that time. Once at these roadblocks, they looked into the trunk of one woman's car and saw that she had a labeling machine. A labeling machine looks a little bit like a pistol, but not much like one, but they were curious to know what this device was. She explained that it would make their name, and then she showed them. They spelled out their names, and she made a label for each of them. When they cleared her to proceed, she continued down the road but heard a rattling in the trunk of the car. She stopped to look and found three guns in the trunk. Each boy had taken his label and walked off with it, leaving his gun. She immediately drove back to return the guns, and of course, the boys were very nervous, thinking a commanding officer was going to come by and see that they didn't have their guns. You worried about the roadblocks. As the wives were leaving from Port Harcourt, one of our people had gotten a little upset with a guard who asked them once more to open their suitcases. He said, "We've already opened it." Of course, the guard did not like his response. Next thing, he had him in a room, with a guard and a gun. Then this person realized that he had the key to his wife's suitcase. The other guards continued to ask her to open it, but she couldn't because he had the key. He asked the guard, "Couldn't I just go out and give her the key?" The guard said, "No." So he said, "What would you do if I just stood up and walked over and gave her the key?" The guard said, "I'd shoot you." My friend stood up, and the guy cocked the gun. And my friend sat down again. Then he asked me to come in, and I talked to the guard and asked if I could give the key to my friend's wife, and the guard let me do that. But because of this confrontation, my friend was never even able to say goodbye to his wife. So you just did not want to fool around with people. One day, I was in a big, green International van, and we were driving down the road and saw a checkpoint up ahead. The driver-there were just the two of us in the car--started putting on the brakes, but the brakes had gone out. He tried to pull the emergency brake, but it did not work, either. The last thing he was going to do was go through that barrier, and so he went off the road, into a ditch. We bounced around, hit a tree, and ended up against a building. Suddenly, we were surrounded by people. This is a common thing in Africa. You think you're out in deserted land, but as soon as something happens, you're surrounded by people. It took a while for me to realize what was happening. The local chief came, and he was a real orator. He began telling me what we had just done. He said that that tree we hit was a juju tree, and that we had offended it by knocking it down with our vehicle, and so he would have to do a sacrifice. He would sacrifice a chicken. This chicken would cost ten shillings. When he was all done, and it took him a long time to get to that point, I breathed a sigh of relief, because I hadn't known what was coming. Ten shillings--that was nothing. But then something perverse took over in my mind, and I began talking back in the same way that he did, telling him that I understood all of this, and that, yes, we had our own kind of customs where I came from. Where I came from, this vehicle was considered to be a juju god, and it had been very offended to have that tree there in its way, and that I would have to sacrifice a goat, which would cost twenty shillings. And then I pulled out ten shillings, and asked, "To whom do I give the ten shillings, and who will be giving me the twenty shillings?" There was such a silence that I feared I had made a mistake. It was just deathly quiet. And then, one man started laughing. And with that, a few others laughed, and pretty soon everyone was laughing, they saw the joke. No money changed hands, and we got out of there. Harden: I would also like to ask you: When you have lived like this in Africa, how you readjust to living in suburban U.S., with all the fast food, with all the affluence? Foege: It's an interesting experience to live overseas, and many people find it a great experience, because they have servants and they get privileges that they wouldn't have in the States. We didn't quite have that experience, having started out in a village, where living was very difficult, and much of your day was consumed in just boiling water. We didn't have electricity, so we couldn't even have a fan to help deal with the heat. Despite these difficulties, it was hard to come back. Everything seems too easy to you when you return. But there was a good part of this change. When we were using many CDC people in India on ninety-day TDY projects, I got a letter from Don Millar, who was providing a lot of the people. He said, "I don't know if they're helping you at all with smallpox eradication, but keep asking for them, because they come back different people. They have now experienced what it's like to have real problems. They don't put up with a lot of the things in the United States that cause problems. They just steamroll over them." So there are good points and bad points about coming back to the U.S. Living overseas is a broadening experience, and I think it's so important for people to have that experience. They come back with some difficulty, but they come back with a different perspective of how fortunate they have been. Harden: When zero pox was achieved in West Africa, the outside funds for the CDC efforts pretty much dried up, but Dave Sencer [David J. Sencer] was unwilling to let the program die. He appointed you to be head, and sent you out to insure that the worldwide effort was going to be successful. Can you tell me about this transition, and what actions you took? Foege: There were two things that happened after smallpox disappeared in West Africa. First, we must remember that this was always a smallpox and measles program. Measles was a major cause of death in West Africa, and it's interesting that USAID, the funders for the program, always referred to this as the measles/smallpox program. The CDC always referred to it as smallpox/measles, not because smallpox was more important than measles, but because it was part of a global effort, and eradication was uppermost in our minds. We believed that if we were not able to achieve eradication in West Africa, the global effort would most likely not succeed. At the end, we assumed that USAID would see the benefit of continuing the measles part of this, because measles deaths had been greatly reduced, hospital beds that had been taken up by measles cases had now been freed up for other patients. We had no idea at that time that they were being freed up for AIDS cases in the future, but that's what happened. I was very surprised and shocked when USAID made a decision to stop the measles part of the program. It was very shortsighted to get West Africa accustomed to having measles vaccine available to reduce this terrible plague, and then to say, "We're going to stop the program. Now you're on your own." We tried very hard to get the measles program either continued or at least tapered off over sufficient period of time. Harden: Who made this decision? Foege: It was a decision, as far as I can tell, of one person at USAID, who was new, who didn't have an emotional commitment to the measles vaccine program and who wanted to do his own things. That made it extremely difficult, and as hard as we argued, we could not persuade him. I actually wrote a letter for Dave Sencer's signature to go to the head of USAID, which hopefully would put some pressure on them to continue the program. It went to someone in USAID, who sent it to me for a response. And that's when I realized how much fun government could be, that you could write your own letter and respond to it, also. The second thing that we did was to look at the rest of the world with an eye to smallpox eradication. We were very concerned about India. India turned out to have more intense smallpox than what we encountered in Africa, although we didn't realize it at the time. India had had smallpox eradication efforts for decades, going back to the early 1800s. But somehow, they never quite worked in India. After discussing this with Dave Sencer, we made a decision that I would go to India for reconnaissance, to see whether it was possible to do a smallpox eradication project there. In August and September of 1973, I went to India and spent time with their Ministry of Health people and with people in the regional office for WHO [World Health Organization]. The result was that India turned out to be the site of our next smallpox eradication venture. India was, in many ways, so much more difficult than anything we had faced in Africa. The peak of smallpox in India was in May of 1974, when we had the highest rates that India had seen for decades. They were much higher than anything we had suspected we would have. In the fall of 1973, D.A. Henderson [Donald A. Henderson] asked me, "What's the largest number of cases that you can expect in any week in any one state next year in India?" We did some calculations and decided it would be about 300 to 400. He said, "Just to be sure, we're going to program our computers with four digits, and not with three. I recall in May of 1974, having to call him and say that in Bihar, India, in one week, we had over 11,000 new cases of smallpox. I mean, it was just overwhelming. But we went from that high in May of 1974, to zero for the entire country of India in twelve months. Harden: Using the same surveillance/containment method? Foege: Using the same surveillance/containment, which many people did not think would work in India, because of the population density, and the high incidence of smallpox. And yet, smallpox was eradicated in twelve months' time, once we got geared up to have really good surveillance. I'm talking about surveillance that was so good that every three months, we would visit every house in India, looking for smallpox in a six-day period of time. In six days, 100 million homes would be visited to see if there was anyone with smallpox. And this was before computers. The logistics of trying to get people to 100 million homes in six days, and then finding, on evaluation, that over ninety percent of those homes had actually been visited, demonstrated the effectiveness of the Indian bureaucracy once they commit to something. Harden: That's very interesting. So you were working with the Indians, then, and they were going into the homes. That requires huge manpower and management resources. Foege: It required, in those six days' time, to mobilize lots and lots of the health workers, to take them off of other things for six days. It also meant hiring a lot of day laborers in order to get the work force to do this. For me, the interesting thing was that we did not have the government of India and WHO and other groups officially involved. We worked so closely together, and I think part of the reason we were able to do that is, that we started traveling by train together. This meant being together overnight in a compartment, which gave us the opportunity to talk in a way that we never would have by going into someone's office for an hour's meeting. I mean, we were really in this together. Harden: What impact did your years in Africa and India, and the smallpox program in general, have on your family? Foege: I think the family saw our time in Africa and India as interesting times. I mean, our children often look back on India as something they really enjoyed doing. For birthdays, the person with the birthday gets to choose where we go for dinner, and inevitably, they want to go to an Indian restaurant. That's the way they feel about India. I took one of my sons back to India when he was 18, when I attended a professional meeting there. It was in Udhampur, and we decided, rather than fly down from New Delhi, that we would "experience" India again. We hired a car and a driver and began the thirteen-hour trip. This was in July, when it is very hot in India. I recall, two hours into the trip, saying to myself, "This was a mistake." It was so hot. And of course the windows had to be open, because we didn't have air conditioning. Diesel fumes from the exhaust and dust came in, and I looked over at my son, who had sweat rolling off his face, and I asked, "Michael, how are you doing?" He looked at me, and he said, "You'll crack before I do." I mean, they just enjoyed India. And it's given every one of them a feeling about the world that I like to see. They are concerned about the developing world, they're concerned about the inequities that one sees in this country, and between this country and other countries. It's something that I attribute to their having lived in other areas. Harden: Did any of them follow you into a medical career, or public service, or public health? Foege: Two of them are teachers, and I consider this to be even more difficult than doing public health work, because you don't get compensated well for your work as a teacher. What we pay teachers is a crime. The third one went into anthropology. All of them have this feeling of concern about needing to help and understand other people. Harden: Before we stop, is there anything else that you would like to add? Foege: I see war around the world. We have over a hundred conflicts going on at any one time. But if you're not actually in the area, it's just a news story. I think of what it was like during the Nigerian Civil War, the kind of devastation, and people starving. People actually starved during that war. I went back to work in the relief action. I went into one town where you actually had to step over dead children as you walked down the street. This is not the way the world should be, and yet we don't seem to learn. How do you actually get people to make eye contact, to engage with this sort of thing? For example, what's happening in Iraq right now shouldn't be happening at all. How do you get people to understand that this is absolutely the wrong way for us to be living? Harden: Thank you for a very fine interview. </pre> Player html for embedded player to stream video content <iframe src="https://www.youtube.com/embed/KLP2W9BNOMw" frameborder="0" width="560" height="315"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-13 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15jvg emory:15jvg Subject The topic of the resource USAID Smallpox Eradication CDC WHO Biafra War Surveillance Format The file format, physical medium, or dimensions of the resource 16113480000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harden, Victoria (Interviewer) Foege, Bill (Interviewee); CDC Title A name given to the resource FOEGE, WILLIAM H. Description An account of the resource Dr. Wlliiam Foege served in the smallpox program in Nigeria, first as a missionary and then a staff member. The highlight of his oral history is the description of the origin and utilization of the surveillance/containment management of outbreaks. He also discusses experiences during the Biafran conflict and other anecdotes. Bill subsequently was assigned by CDC to assist the WHO in its work with the Government of India reorienting the approach to eradication in that country. He was Director of CDC from 1977-83 and is currently a Senior Fellow at the Bill and Melinda Gates Foundation. Language A language of the resource English https://www.globalhealthchronicles.org/files/original/9f4a484948cb66105bff34d84316b2ed.jpg b77a45cec35285408854f749ee7fa489 https://www.globalhealthchronicles.org/files/original/43c2f056200aa55ab4bc62102f00d50f.pdf 69b5d960281a63c73923be9bd28e2b15 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> Interview Mr. Jay Friedman with Dr. David Sencer &amp; Maddie Maddie Transcribed: January 2009 Maddie: My name is Maddie Halendonie [inaudible name0:00:12] and I am student of Emory College, and I am sitting here today with Mr. Jay Friedman. It is March 31st, 2008 and we are in the CDC. So welcome! Thank you for coming. J. Friedman: Thank you for having me. Maddie: Just to get started, if you could tell us a little about your background, your hometown, where you come from, your education? J. Friedman: I was born in New York City at 123rd Street, and grew up in the Borough of Queens, went to college at Florida State University and then joined the Peace Corps where I spent two years in Sierra Leone, West Africa. Following the Peace Corps I went to graduate school at American University in Washington D.C. where I studied International Economics and Languages. Towards the end of my two-year course I was reading a Notice in the Return Peace Corps Volunteer Bulletin which asked for ex-volunteers who had lived in West Africa, who could speak French which I could; and who knew how to fix a car, which I also could, having worked my way through college as an auto mechanic at an Oldsmobile dealer in New York. Well, the notice was from the Centers for Disease Control asking for people with those qualifications to go back to West Africa and work on the Smallpox Eradication Program and it seemed like that fitted me perfectly. So I made a phone call to the number in the Notice and spoke to a person called Leo Morris. He was the Deputy Branch Chief or Deputy Director of the program who happened to be coming to Washington the very next day where we met, and he hired me on the spot, which I am certain is no longer possible at CDC, to hire anyone so-shall we say unknowingly, or without knowing all that much about him. Today there are all kinds of background and security checks. Anyway it worked out well. Later that year which was 1966, on July 1st I reported here in Atlanta and went to work for the Smallpox Eradication Program whose Director at the time was Dr. Donald Henderson - D.A. Henderson, and whose deputy of course was Leo Morris aforementioned. Dr. Henderson not long afterwards left to head up the smallpox program at the World Health Organization in Geneva. Meanwhile I joined roughly 40 other people, newly hired, some of whom had been CDC employees, others like me were not, to go through a - I've forgotten how many months exactly - about three or four months' training course in epidemiology, about which I knew nothing, about the characteristics of smallpox which I also knew nothing about. We also learnt quite a bit about the culture and the politics, if you like, of West Africa which I knew a bit more about. We also were sent - we were divided into two: medical officers and what were called operations officers. I was an Operations Officer and the operations officers were also sent to the Chrysler Corporation Service Training School, it was somewhere in South Atlanta, I think on Moreland Avenue, I forget exactly; and we went through a course learning how to work on Dodge pickup trucks with which we were going to be equipped in West Africa. The Medical Officers studied more epidemiology than we did. Anyway, following a couple months of this, those of us going to French- speaking countries, of which I was one - I was assigned to the Republic of Mali; stayed behind I think and went through a very intensive French language course. I knew a lot of French, but obviously I didn't know everything and learnt a lot at this course which was run by Emory University. Then in December of '66, the medical officer I was working with in Mali, Dr. Pascal Imperato, we left for Mali and we started working on eradicating smallpox. Mali was a difficult country among the - I think it was 20 countries we were working on in Western Central Africa - because in the early 60s a Leftist Government took over from the French Colonists - the French Colonial Power; and they were very close to the Soviet Union and North Korea, and all the Communist countries at the time. The fact that this program was financed by the United States, specifically the U.S. Agency for International Development meant it wasn't easy for us to work at first. But Dr. Imperato and I, if you like, made friends with all the principal characters we had to work with, and gradually we gained their confidence and we didn't have any further problems. Initially in West Africa the approach was called mass vaccination. Smallpox being what it is, I am not going into detail, but the reservoir is human beings. There is no animal or water or other insect borne way of transmitting the disease, it's human to human, and the vaccine works. So the idea was that we vaccinated a certain proportion of the population which the doctors in charge of the program thought would be 80%, we'd stop the transmission of human to human smallpox. Mali was very difficult because through the country runs the Niger River. It's called in French the buckle of the Niger River, the bend of the Niger River, which creates a large swampy area in which lived the Nomadic cattle herders, and these people moved with the rising and the falling of the river depending on the various seasons, rainy, dry and cold are the three seasons of the year there. Dr. Imperato, fortunately, was an amateur anthropologist which I believe was one of the reasons he was selected to work in Mali. He studied the movement of these people quite thoroughly and actually wrote some scientific papers on it, and figured out where vaccinators should be at certain times of the year, etc. So we began vaccinating in this area, which is right in the middle of Mali, very difficult to access. We had to use boats and other means of transport. At the same time, besides mass vaccinating our other task was to look for smallpox cases. This was done by having or alerting local health workers all over the country to alert the Ministry of Health in Bamako, the capital, if they found or noticed any smallpox cases, and we had an agreement that if smallpox cases were found we would go out there and investigate, being trained of course in recognizing smallpox and knowing how it transmitted etc. etc. So meanwhile there were cases of smallpox in the country in Mali, and we investigated several outbreaks I remember, and we kept vaccinating at the same time. Meanwhile, one of the medical officers in the program, Dr. William Forge who later became Director of CDC in Eastern Nigeria had come up with another methodology for attacking smallpox. That was called surveillance containment. I believe, Dr. Sencer can correct me if I am wrong, he felt that you really couldn't vaccinate enough people purely to stop the transmission, given the various problems with Nomadic populations and that sort of thing. The best approach would be just to look for cases and put vaccination on the backburner if you like and contain every outbreak with various strategies, one of which was Ring Vaccination Containment, that is: you vaccinate the people right around each outbreak and check everyone coming in and out of the outbreak area with people called watch guards, and sooner or later you would interrupt the transmission, and even if there were unvaccinated people, the fact that you interrupt the transmission, since it's only transmitted from human to human, that eventually you'd stop the transmission of smallpox; and in fact this is the way smallpox was eradicated. So I spent two years in Mali, I was there till September of 1968. Then I was transferred to Gabon, the Ex-French equatorial Africa. It is around the bends of the armpit of Africa if you like. A very rich country on the North-South Coast; it is an oil producer and all sorts of minerals, and it's in a part of Africa that is very under-populated for various reasons: issues with fertility and venereal disease, that sort of thing. So the population there was very low and smallpox is a disease that requires a certain density of population to transmit and there hadn't been cases in Gabon for a long time. The reason we were working there was that it was surrounded by countries that did have smallpox. Anyway, I spent about a year - almost two years in Gabon and didn't have a lot to do; actually we concentrated on vaccinating there because there were no cases. Gabon being a wealthy country had a Mobile Health Service called - it's in French, I'll translate it, it was called the Endemic Disease Service set up by the French military whereby health workers would be transported from village to village on trucks and they would treat people for various illnesses and also do five vaccinations at once, look for leprosy and sleeping sickness and other diseases. Anyway I was an advisor to this Endemic Disease Service for smallpox eradication; and I forgot to mention: in all these West African countries we were also doing measles control. This was also in Mali, I forgot to mention. The West Africans were not so much interested in smallpox eradication which was a public health problem, but not, in their eyes, a major one. It was a major one in our eyes as Americans and Westerners, because it did have worldwide implications. But in West Africa they had many greater problems among which was measles, which unlike the United States and developed countries where it is a benign childhood illness, or somewhat benign, in West Africa where children's immunity, or immunity systems are a little weak because of malaria and other diseases they have. Am I on the right track Dr. Sencer? Dr. Sencer: You're doing fine, except move along a little bit so we can get to India. J. Friedman: Okay, alright. Anyway we also gave measles vaccinations. I was in Gabon for two years and then I was sent to Northern Nigeria to the city Cano where I also spent two years. There was no smallpox in Cano either. In April of '72, I received a telegram from Dr. D.A. Henderson who I mentioned earlier. He knew I was due to go back to Atlanta for CDC. There was a limit on the amount of time you could stay overseas. He asked me if I would be willing to resign from CDC and go to work for the World Health Organization and go to Nepal where they needed an operations officer like myself, and I did. I resigned from CDC went home to New York for two weeks and then I was on a plane for Geneva where I went to an orientation course, just a couple of weeks, and then arrived in Katmandu, Nepal at the end of April 1972. Nepal of course is in the part of the Indian Subcontinent where there were lots and lots of smallpox, much more than in West Africa. The population is denser, those countries are somewhat less well organized than West Africa and vaccination levels were low. They had constant endemic smallpox which kind of moved around the Indian Subcontinent in a big circle and the year I arrived, in 1972, the endemic areas were much further South in India. It was nowhere near Nepal which is on the Northern border of India. At the end of 1973 the big track of smallpox moved up to Northeastern India very close to Nepal and we were immediately inundated with lots of cases. We had adopted the surveillance containment approach and I became busy investigating outbreaks. I had as colleagues there, another operations officer and a medical officer. All the cases in smallpox practically were - every case was the result of cross-border travel from India to Nepal. That border is open like the US-Canadian border; people just walked back and forth. Some places you can't tell which country you are in even, and we had lots of cases, first in the Western part of Nepal, which was at the time in the 70s, very underdeveloped. No roads at all from the capital there. You had to drive to India or fly in a plane. There were even places where there were airports but no roads. So the only modern means of conveyance the local population had ever seen were airplanes or aircraft and helicopters. They had never seen a car or a truck. You had lots of anomalies like that there. This is 1973; I spent a lot of time trekking in Western Nepal looking for smallpox cases. At one point when I wrote this up which is part of the smallpox archive somewhere, I was flown to an airport in Western Nepal where there was no road, and walked a couple of days to an outbreak area along with my Nepali colleagues, there were about five of us. We found that the local smallpox people had contained the outbreak. They had done all this ring vaccination that I mentioned, and we spent a day or so there and realized there was nothing more for us to do. So we decided to visit other neighboring districts and just look for cases. There had been no reports. So I was with a doctor named Benu Bado Kaki [inaudible name 0:17:16], who was the Deputy Smallpox Chief in Nepal, and we started walking and after a day or so, he branched off to one district and I to another. I walked and walked for several days and got to the next district where there were American missionaries living. I spent several days with them and ate steak and mash potatoes and stuff like that which you couldn't get elsewhere in Nepal. There were no smallpox reports from this area. I then walked several days down to the plains of Nepal which borders India, a very flat area, unlike the mountains in the rest of the country; and spent several days there also looking for smallpox along with local smallpox staff- found nothing. Then the town I was in right on the border with India had a once a week plane service back to Katmandu. So I bought a ticket and the plane never came. It only came as I said once a week. I didn't know what to do. I was stuck in this place. There was no road back to Katmandu and I had no car with which to get home. So I was hanging around the airport and there was a very wealthy Nepali who belonged to the upper crust of society, who was there with a Land Rover. He was also trying to get on the plane. He had been hunting elephants or something, and I started chatting with him, and he said, "Well, I am going to drive to Lucknow," a big city in India several hundred miles South of where we were, "and I am going to fly home from there and you are welcome to come with me," which I did and arrived home a couple days later. I had been gone two weeks and essentially had fun and really didn't do anything. So the World Health Organization - well I had done something, I had done some surveillance but not anything concrete. The World Health Organization then got money for helicopter charters which were very expensive; it was 400 Bucks an hour to run a helicopter. For the next - this is in 1973; I was in Nepal till '77, for the next four years we used helicopters to go to these remote areas where we could do what I did in two weeks in a day, just go and come the same day, and since we had so much smallpox, the circle now moved a little differently in India such that now eastern Nepal was full of smallpox. A third operations officer came, by the name David Bassett, who had also worked for CDC, so we were four people actually working there and inundated with cases all the time. 1974 was the worst year in Nepal. It was also the worst year in India as I remember. The state of Bihar in India which borders on Eastern Nepal was loaded with smallpox all throughout '74 into 1975 such that in - I am trying to remember the dates here - November '74 I was asked to stop working in Nepal where we had things more or less under control and spent three months in India along with many other people. At the time the Indian Government couldn't scare up enough people to work on smallpox. The problem there was so enormous, tens of thousands of cases, that they not only hired young medical guys who had just gotten out of medical school I guess, who've been studying public health; and non doctors, people like me we are called technical officers, but also CDC and WHO brought in people to work on smallpox for three-month periods. Some of these were ex- West African people who had done what I had done. Some of them I think knew nothing about smallpox at all. On the other hand, the epidemiology of smallpox is such that you can teach any intelligent person in 15 minutes everything he has to know. As I said, it's human to human, there's no other reservoir, in a day you can make anyone, truly without too much exaggeration, an expert on smallpox. So CDC sent a lot of people, WHO recruited others in Europe, along with our Indian colleagues, we were an army. I can't tell you but my job in Bihar State in India was to be in charge of paying everyone. They wanted a full time WHO employee in charge of the money and I guess I was one of the few. So I was in charge of paying hundreds of people, both Indians and non-Indians in Bihar State for which they gave me a suite in a very rundown hotel in the capital of Bihar, which is Patna. This was just a low-down dingy [inaudible 0:22:27] Indian hotel but it had a suite, and since I was in charge of all the money, I had a safe; they gave me this suite in which I lived in luxury essentially, but I was very busy. We had an office there with a number of people. Dr. Larry Brilliant was in charge of the office, and believe it or not I was busy fulltime paying people. All these people in the field had to have money because the Indian Government Rules and Regulations were so Byzantine. For example, if you had an official jeep and it got a flat tyre, you had to fill up forms and get some senior person somewhere to approve spending a dollar to fix the flat. So WHO got a system going whereby everyone had an Imprest Fund they called it. What it meant was that you had $100 in your pocket to freely spend as you saw fit to, fix flat tyres and grease the skids so to speak. So I was in charge of replenishing all this money. There were some bizarre scenes with all the money. Everything was in cash. Once a month I would get a large cheque from the WHO headquarters in New Delhi for $100,000 or something like this, I can't remember. It was still lots and lots of money, and I'd take it to a local bank there in Patna and deposit it. Then everyday I had to go back to the bank and withdraw enormous amounts of cash. It is in Rupees, I can't remember; say $10,000 everyday, something like that. I carried this in my briefcase, all this cash. Indian banks being what they are, it took sometimes three hours from the time I walked into the bank and said I wanted this cash for them to count it; they had guys sitting on the floor counting it - I'm exaggerating - 5 or 7 people to sign out on this money and they would give it to me wrapped in - the money is wrapped in pieces of paper and I'd stuff it all into my briefcase then walk down the street holding it unguarded. Anyone could have walked behind and whacked me on the head and run away with it, but nothing ever happened. Anyway I would get back to the office and spend the day passing out money to people who'd come in to get it. I kept very detailed account books. At the end of every month, they sent an accountant down from New Delhi to go through my cash and my cheque books and there was always some discrepancy of $1.00 or something like this and I can never figure this out. The night before this auditor came; I'd be up all night going through the books trying to find out why there was a $1.00 discrepancy. This guy was an Indian, he'd spend five minutes, he would go through the books and say, "There's your $1.00;" after I had been up till three in the morning trying to get it straightened out. Anyway I did this for three months-handled the money. Then I went back to Nepal where we still had some cases. We had the very last cases. This was in early 1975, February 1975, which was complicated by the fact that the King of Nepal, it was a new king who had his coronation that very month and you couldn't travel anywhere. Meanwhile, we knew there was smallpox in certain places. To make a long story short, some of these cases spread indigenously in Nepal which hadn't happened before, because nobody could go anywhere. The country was more or less locked down for long durations. Anyway in March and April '74 in the southeastern corner of Nepal, we had our last cases, which were very well documented. Many photographs of the last three cases which was a husband and wife and a child. In April '75 we had our last case and sent a telegram to WHO headquarters in Geneva, I remember it. The telegram read: "D.A. Henderson, World Health, Geneva-No pox!" The signature was Nepal Smallpox Eradication Program. They still have it on file somewhere I guess. I stayed there another two years. The task of the last two years was to look for non- existent cases. They had their last case in Nepal, I believe the following month in May; and in Bangladesh that August I think. Anyway India, Bangladesh, Nepal, we spent the next two years until '77 looking for smallpox and we had armies of people out doing surveillance. I think in India I read, at some point they had a 100,000 people do surveillance for a week or two weeks. Dr. Sencer: More than that. J. Friedman: More than 100,000 people. Anyway there were lots of people working on this. We looked for two years, didn't find a case. There were lots of reports because we were offering rewards at this point. We were offering initially a reward of Rs.100 which at the time was $10.00 or something, and then the reward was up to Rs.1000 which was a $100.00. Anyone who reported a case that turned out to be smallpox would get a small fortune by the standards of India and Nepal and Bangladesh, and we got lots and lots of reports, many of which turned out to be other skin rashes including chicken pox, scabies, I don't know about some of the others; but we were all trained in doing this differential diagnosis and so was everybody else. All the workers at the lowest level, all knew about this. In fact they eventually knew more about it than we did, the foreign advisors, which was the nice thing about smallpox. Nobody really knew more than anyone else. Everybody knew everything there was to know about smallpox. Remember my job during this period in Nepal, being a foreigner, I could do things and go places around the bureaucracy in such a way that my Nepali colleagues running the smallpox program couldn't. For example, I knew the Minister of Health when he was a young junior doctor when I had arrived five years before. Literally I'd could go to his office, knock on his door wearing a T-shirt and jeans and sandals and walk in and he'd greet me warmly. No Nepali official could do that. That was the anomaly of being a foreigner in a country like that, one of them. Anyway, at the end of the two year period, WHO constituted committees for each country, Dr. Sencer was on the one for India, as I remember, who would come to the country. These were usually very senior virologists and epidemiologists from various parts of the world. The committee that came to Nepal was headed by the Polish Minister of Health, whose name was Yang Kartuski, and there were other people. I remember there was a Japanese scientist who was a virologist and various others. I don't remember everyone, but I had to take these people around the country looking at the work we were doing and at the end of - they were there for two weeks in Nepal, they certified smallpox in Nepal as being eradicated and this coincided with Nepali New Year as I remember. Nepal calendar is April to April. They made this certification, they left, and then the head of WHO in Nepal and myself were invited for an audience with the King of Nepal which doesn't sound like much, but it was very rare for a foreigner to meet this guy, which I did. I have a photograph of it. Unfortunately he was the King of Nepal assassinated in the year 2000, I think. He was a young guy, spoke beautiful English and I had seen his picture everywhere for two years, but I had never seen him in the flesh. It is very funny, the WHO representative Veri[inaudible name 0:31:24] Mills and I were leaving, and we said to each other, "He is a nice guy, we wouldn't mind drinking a beer with him or something." Anyway, a couple of months later I left Nepal. My work had been finished. I was then transferred by WHO to the Philippines where I worked for a year. In the Philippines I lived in the Pasay City, traveled all over the Philippines for the expanded program on immunizations, childhood vaccinations, somewhat related to smallpox which is quite different in many ways though. A lot of the work I had to do regarded smallpox vaccine production, there is a big lab there - not smallpox - vaccine production, no more smallpox. This was diphtheria, ptosis, tetanus, and other childhood diseases. The lab knew nothing about how many doses they had to produce. So a lot of my work was figuring this out based on my experience with traveling around the country as well as getting reports from hospitals and doctors all over the place. I first learnt to use a computer there. I also traveled a lot in the Philippines, saw the country. It was the only country I was in where outside the capital was nicer than being in the capital. Manila is a huge tropical city full of traffic, not very pleasant. All these secondary towns and cities there were very nice, I liked that. Anyway I spent a year and a half there and then I came back to CDC, went to work in the division of reproductive health working on first what was called Contraceptive Prevalence Surveys; looking at women of reproductive age in a population usually 15 to 44, sometimes 49, and looking at the proportion using contraceptive methods: which one, and most importantly, of those not using a contraceptive method, why they weren't. I did that for a number of years. Then I did something slightly different which was contraceptive logistics. AID, Washington State Department, as part of foreign aid distributes contraceptives all over the world-I worked with a group of people here at CDC and it was very similar to what I was doing in the Philippines, figuring out how many contraceptive methods each country needed, which ones, and when they should be delivered and all that. Next, since I had worked a long time at CDC - sorry contraceptive prevalence surveys - excuse me, I am getting mixed up, along with few other people in the Division of Reproductive Health, since we were so called experts on surveys, got some money from the Indian Health Service to do behavioral risk factor surveys on Native American Reservations in the United States. This was looking at smoking and drinking and car accidents and other stuff that Native Americans are prone to, to a point. In doing this, I traveled all over the United States; went to some areas I'd never ever gotten to, Idaho and Northern Maine and lots of places where Indians live which sometimes you don't realize they are there. We even did a survey in New York City where there are 35,000 Native Americans. Having grown up in New York, I had no idea these people were there, and towards the end of my career, we are now in the 2000s, I started working again on maternal risk - maternal health surveys including contraceptive prevalence mostly in Southern Africa and Jamaica. I worked on four surveys in Jamaica in the Caribbean and one enormous survey in Zimbabwe in Southern Africa and then retired in January 2003, five years ago. Here I am. I'm having a good time being retired. Dr. Sencer: What was the most important thing that your experience in smallpox [inaudible/low audio0:35:32]? J. Friedman: Well, it's easy. Achieving smallpox eradication in Nepal where I had spent five years. It was the only country I came to call home, being there so long, and I liked it the best. I was married by this time and we had two kids who spent their first years of their lives there and it was quite an achievement. It was much more difficult than West Africa, for lots of reasons, among which was that the people didn't accept vaccination as readily as the West Africans. There was a lot of epidemiology which I had learned pretty well, a lot of logistical problems. So it was very satisfying eradicating smallpox in Nepal. It was in West Africa also, but quite frankly it was a lot easier in West Africa in my opinion. That was the most rewarding thing I think. Dr. Sencer: One final question, Jay. What did you bring out of Nepal? J. Friedman: Personally, I learned a lot. I learnt to speak a little bit of Nepali. My wife and kids learned it fluently. I think I brought out mostly an ability to - I'm going to put it in very metaphorical terms, speak to the Nepalese. By that I mean, I learnt their rhythms, I got into their rhythms, so I knew when to appoint, insist on something, when to not insist on something, when to hold back, when to be a little more assertive. A lot of this I learnt from my boss who is a guy named Dr. M. Mitchell Satyanathan[inaudible name0:37:33], who was Sri Lankan. He was in charge of smallpox there, as far as the WHO people were concerned and he taught me a lot of that, being an Asian himself. He knew when to go along with what the Nepalese wanted to do, and at the same time when not to, and I picked up what I learnt from him from him - that's an oxymoron what I just said - and I think this carried over to my later career where I was working on the surveys, here back at CDC many of which were in foreign countries; I did lot of work as I mentioned in Jamaica and Zimbabwe, also in Senegal and other West African countries. I even went back to Nepal a couple of times as a foreign technical advisor in Family Planning and Reproductive Health, and I think I was much better at doing this than when I was a young guy in my 20s and 30s starting out, when I, as an American, didn't really empathize with foreign cultures - not foreign - I mean I was used to England and France and other countries, but dealing with people in Asia and Africa, it's very different from dealing with the European or an American; specially different from being an American. I think I got pretty good at that. Dr. Sencer: Did you bring anything material out of Nepal? J. Friedman: Well, my younger daughter is an adopted Nepali orphan. She is now 35 years old and married, but I guess you could call her a material thing. I'm kidding of course; I think she'd laugh at this though. I also - you mean possessions? I bought an antique car in Nepal, which I brought back here to Atlanta, which I drive around in still. Dr. Sencer: How antique? J. Friedman: It's a 1932 Ford which had belonged to a Nepali General who gave it to his daughter who gave it to her driver from whom I bought it. I had it restored there and shipped back home in a big crate. Dr. Sencer: How did you get it out of Nepal? J. Friedman: A local moving company who is the agent of Allied Van Lines here in the States made a big crate, this is before containers, in 1975; a big crate as long as this area here. They drove the car into the crate and they tied it down with chains and ropes and everything, they had hooks on the top. We hired a crane, or they hired a crane, and lifted it up and went onto a truck. The truck drove the crate to Calcutta in India near a seaport; it was loaded on a ship, of course. The ship landed in Los Angeles and it was loaded on another truck and came here to Atlanta. I drove it out of the crate-same crate. Dr. Sencer: The mythology is that you brought it out on an elephant, but you didn't? J. Friedman: No, but I would have liked to. Well, I'll tell you if you want to hear this too. The car was brought to Nepal in 1932 before there were roads to Katmandu from anywhere. There were roads in Katmandu; it's in an enclosed valley. The car was made in Canada, shipped through India to the Nepal-India border where the railway ended. It was put onto a bamboo platform, the car. The bamboo platform had handles at the end, pieces of bamboo sticking out. I can't tell you how many, but 30 porters carried this bamboo platform with the car on top over the foothills of the Himalayas to Katmandu. If you don't believe me, there are pictures in National Geographic of the 30s and 40s showing porters carrying cars. There were lots of cars in Katmandu carried in that way including this one. Anyway that's an aside. Dr. Sencer: With that I think we'd better quit. J. Friedman: I think so. Dr. Sencer: Thank you very much, Jay. J. Friedman: You're welcome. Maddie: Thank you. [End of audio 41:58:5] </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/JCOr2EkMygk" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2008-03-31 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15pbt emory:15pbt Format The file format, physical medium, or dimensions of the resource 9059160000 bytes video/x-dv Creator An entity primarily responsible for making the resource Halendonie, Maddie (interviewer) Friedman, Jay (Interviewee) Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource FRIEDMAN, JAY Description An account of the resource Jay Friedman an Operations Officer, describes his assignment to the World Health Organization to work in the Smallpox Eradication Program in Nepal. Subject The topic of the resource Smallpox Eradication Smallpox Eradication WHO Language A language of the resource English https://www.globalhealthchronicles.org/files/original/54a001c3adbdad32e563666a7e044879.jpg eca63236a0238d140a941f47d4589827 https://www.globalhealthchronicles.org/files/original/cf36c4cf42ab778f098348ab7657d124.pdf 87532066f4be21f88ff723979948bbb8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> Interview Dr Mark Rosenberg with Interviewer Dr David Sencer Transcribed: January 26, 2009 | Duration: 0:40:25 David Sencer: I am David Sencer. I am interviewing Dr. Mark Rosenberg. We're on the stage at CDC: April 3, 2008. Dr. Rosenberg has been informed that he is being filmed and audioed and has signed a release for us. So we'll start. Tell me a little bit about your early days. Mark Rosenberg: I grew up in a family that was committed to social service and community action: health, medicine, public welfare, and I had a father who was very interested and active in his unions. He was in a good union, the International Typographical Union, and didn't go to college until he put all his kids through college, and my mother was a physician and she practiced for 61 years in Montclair, New Jersey, the town where we grew up, and she did some very good things, socially active things in New Jersey. She was the first physician ever to see black people as patients in her office. She volunteered for Planned Parenthood and she was the physician at Montclair State College for about 35 years and maintained a private practice for a long time. I think she was a very important influence. I'd like to think that I made a rational choice to go into medicine for reasons X, Y and Z, but I think probably trailing her around for a long time, seeing what she did, and having that kind of spillover, being exposed to how much she valued what she did, probably influenced me to go into medicine. I went into medicine I guess after college, I went to medical school and was always still interested in public service and during medical school, took time off to go study Government and Public Policy at the Kennedy School for the first year that it never had a combined MD/MPP program. So I went there, spent a couple of years there and then did an internship, and a residency and then I had signed up for a draft deferment, but the draft had ended before I went, and came to CDC because it was something I wanted to do. It seemed like an interesting way to learn about Public Health and came here and was in the Enteric Diseases Branch for two years with a very, very good crew of people, and it was an exciting branch. We had lots of outbreaks. We had salmonella, shigella, botulism, waterborne diseases, and the opportunity came up to go work on smallpox in India and it seemed like a fascinating chance to do something very different from enteric diseases in the United States, so I signed up to go off to India. I did not have any idea what to expect. David Sencer: What was your first impression of India? Mark Rosenberg: I thought I had stepped into the set of a movie, a movie that started 2000 years ago and was an unbelievable mix of people. I went to West Bengal and we were around Calcutta and spent a lot of time in Calcutta, and I just thought that it was a fascinating city, and an incredible place, the mix of people, people driving in cars and people living on the streets. The other thing, I've always been interested in photography and I decided then to do a lot of photography in India and I just remembered the scenes of incredibly beautiful brown bodies throughout the States. I mean, people in the fields, working in the sun and starting to sweat, people getting up in the morning on the streets as the sun started to go up, living on the streets, but living very clean lives, bathing, living, feeding, raising families while living on the streets. Visually, it was an incredible place to be. David Sencer: Was all of your time in India spent in West Bengal? Mark Rosenberg: Just about-the time working was in West Bengal, but then at the end I took an extra month and went with Jill who was to become my wife and we traveled around to more of the standard tourist places. We went to Delhi, we went to the Taj Mahal, we went to the Ganges, we went to Asan; we went to Darjeeling, Nepal, Katmandu. We traveled a fair amount. David Sencer: Was there much smallpox in Calcutta when you were there? Mark Rosenberg: Unfortunately, there was none that I could find. When we got there in 1976, we were searching for cases and that was basically the work that I did during the day and evenings. We went around; a team with myself, the driver and an interpreter, looking for cases of smallpox and we put out rewards, but the cases that were reported to us were really chickenpox at that time, and the reward started going up and up and up, and we didn't find a single case of smallpox. It made me feel like we were kind of in a second wave and I wished I had been there when there was smallpox because we were kind of the clean-up crew. David Sencer: Were you there on your own or were there other people from CDC and WHO? Mark Rosenberg: There were other people from CDC who went over with me at about the same time. Dick Jackson, I remember went at the same time, then we ended up back at CDC. We both left for awhile after our EIS time and then came back to CDC and serve there at the same time. So there were several people from CDC. David Sencer: Was he in West Bengal or no? Mark Rosenberg: I don't think Dick was in West Bengal. David Sencer: But you were there alone? Mark Rosenberg: No. There was someone from Czechoslovakia, Fred Bagar [inaudible0:06:41] and he was there. He was an older person who had served as a Community or State Epidemiologist in Czechoslovakia and then had come back to do this service, so we were there together, and saw each other when we came back to the city. We spent most of our time in the - suburbs isn't the right term, but outside of Calcutta, in the very small villages, driving around routinely, but also then taking detours where there was a report of a case, we'd go check it out. David Sencer: Who handled your administrative details? Mark Rosenberg: There was someone assigned from WHO and I don't remember the name of the person, but someone in Calcutta itself. David Sencer: Bill Foege had left India by then? Mark Rosenberg: I think he did. I think he was ordered back by someone - or no, he wasn't ordered back, he came back against orders- that's right. That was the amazing story that Bill had left. So I didn't really encounter Bill in India at the time that we were there. The person who was in charge was a French person who was assigned by WHO. David Sencer: Nicole. Mark Rosenberg: I think so. David Sencer: Grasset. Mark Rosenberg: Yes; and [pause] no - Bill had been there; and I didn't really get to know Bill until we came back and then he was - there was a Preventive Medicine Residency Head back here, so what Dave worked with Bill on was back here, at the case of Crater Lake. We worked that up into a teaching case for Preventive Medicine Residence, but unfortunately, he wasn't in India when I was there. I'm sure you have this story about Bill's departure from there, but it's one that impresses me. One of the things that we work on now is the issue of collaboration and coalitions, and we've looked at lots of coalitions in global health, looking for the elements that make them work: When are they successful, when are they not? What you need to think about when first putting them together? How do you frame that last mile? What do you set as your goal? Because the most important element in any successful coalition is framing that last mile in a way that everyone develops this shared goal; and that is an overriding goal and a motivating goal to keep you together. So we've studied a lot of coalitions in global health because as it turns out, even though there are many coalitions formed, very few of them succeed. So one of the stories that we talked about is what's necessary for a good leader to be an effective leader of a coalition; and one of the things that you need is really this quality of ego submersion. You need to be willing to step back and let your partners stand in the spotlight and get the attention, get the publicity, let them get the credit. I don't think there's ever been anyone as good as Bill in doing that; and the story that always impresses me whenever I think of this notion of ego submersion is Bill going to India, when he was sent there by you to work and to apply the containment theory and as I heard it, Bill decided that several months before the last case was eradicated in India, he would come back home; and he could come back home because the containment theory, even though it was questioned at times and almost reversed by the Minister of Health, they were able to continue it long enough to see it succeed; and within a very short period of time, less than two years, the cases started to fall very close to zero. When Bill saw that they were going to eradicate the last case maybe six months later, he called you, his boss at CDC and said I'm coming home and I'm bringing my family home; and he told me you told him, "You can't come home. You've got to stay. Don't you realize that what's going to happen in six months is some historic landmark that's never been matched in the annals of Public Health? They're going to go from 83,000 cases down to zero in two years and this is going to be a momentous day. You've got to stay there for this." And Bill said, "No. I'm coming home and my family's coming home because if I'm still here when this last case is eradicated, then all the credit is going to go to the foreigners. It's going to go to the Americans-and this is something that's got to be credited to the Indians. They did it. They made it happen; and if I'm here, they won't get the credit that they need. I'm coming home." And you said, "No. You're not." He said, "Yes, I am." He packed up, he put his family together and they left India and they came home. They weren't able to get into their home because the keys that were sent to him to get in were not the right keys to get in, but he came home. He packed up and left. That was an extraordinary thing, but I've never come across an example of ego submersion that's so complete and so universal in everything he does. Still-in everything he does. David Sencer: What effect on your life did your short term in India have? Mark Rosenberg: I think I'm just learning the ways that it had an effect on my life. It gave me an experience in global health that complemented what was mostly a domestic outbreak investigation that I had. I don't think there was ever any question in my mind even when I was doing outbreak investigations as an EIS Officer. There was no question that I wanted to stay with public health and would stay with public health. But I think this really solidified it. It was just - it was going into another world. I mean, stepping off the plane out of the modern world, into the world that was 2000 years old and unchanged; and you could step onto a street where there were cows and elephants, people walking, people sleeping, people selling, people eating and bathing, and shaving on the street in a scene that was unchanged for hundreds and hundreds of years. To have witnessed that and to have been there was an amazing, amazing experience. It made me see that there's not just one world, but there are multiple worlds that exist at the same time, and I don't think there's any place as rich as India. Even today, you see multiple worlds existing side by side, people being shaved in the middle of a street that's now a major road around the modern city of Delhi. People living their lives somewhat oblivious to the motorized traffic that goes by and to the people who go by in Mercedes, and to the people who are doing business in high skyscrapers, but multiple worlds living together at the same time. I think you need to understand that if you're really going to work in global health, that there are multiple worlds where people live and are born and get sick and die, in parallel universes at the same time. But it was an amazing impact on me. I went on to go back - we went back from Atlanta up to Boston. I'd signed up to do a Fellowship in Infectious Diseases at Mass General, but I decided that I had done a lot of photography in India and wanted to do more photography; and so, deferred this fellowship in infectious diseases and ended up spending a couple of years, working on a photographic documentary of patients and illness, trying to show what it was like to be sick. I knew what it was like to be sick, but during this experience I realized that being a doctor is a separate world from being the patient. It's like these separate worlds that existed in India. The same thing exists here and doctors think they know the world of patients, but doctors know the world of doctors. They know sickness from the perspective of the doctor, not from the perspective of the patient. So I spent some time doing this photographic documentary and spent hours and days and weeks and months with the patient seeing their story and taking photographs, and interviewing them to put together their stories. Again, that was a transformative experience for me. It was an amazing experience; and I really realized that I didn't have the faintest idea of what it was like to be a patient. I didn't even know that I didn't know what it was like to be a patient, and this experience really showed me that other world. It was also an amazing experience. David Sencer: Did you hear Anne Fadiman[0:16:17] when she was here? Mark Rosenberg: I didn't hear her. I was sorry to have missed her, but I think she tells the story in an amazing way. David Sencer: One of the things that I remember is, she said, "You don't catch a disease. The disease catches you." She was advocating - one of the things that she advocated was that every chart should have a picture on the cover of the family. Mark Rosenberg: [Pause] - That is a powerful voice. David Sencer: Yes. Mark Rosenberg: You know, for the patient. David Sencer: Is there anything else about smallpox you'd like to say? Mark Rosenberg: I'd like to say that this revisiting it for this 30th Anniversary of the eradication has been a wonderful thing. It made me realize what a significant event it was; and again, the idea that we could eradicate a disease has certainly affected a lot of the other work that we do. I work now at the Taskforce for Child Survival and Development, the taskforce that was started by Bill Foege when he left CDC and we work on a number of diseases where we're aiming for - if not complete eradication, at least elimination as a Public Health problem or eradication of one aspect of the disease. So we work on river blindness and there's been tremendous progress. We've delivered over 700 million treatments of Mectizan for river blindness. We're embarking on a program where we're treating intestinal infections, intestinal parasitic infections in young children probably is the most widespread infectious disease of children in every place in the world. There are probably two billion people at risk for these intestinal parasites. I think in all the work that we do, we're inspired by the idea of eradication, and by the possibility of eradication. I think we think very differently about eradication, knowing that it was done and it has been done even in diseases that are not infectious diseases. The latest example is an area of road traffic injuries, but most people think of road traffic injuries as accidents, things that just have to happen, and in fact, road traffic injuries are an epidemic. They're an epidemic beyond people's ability to imagine, but there are more than 1.2 million road traffic deaths every year. For every death, there are between 20 and 50 serious injuries; and the predictions are that, if we don't do anything about this problem, most of which exist in the developing world. It's 85-90% in low and middle income countries. If we don't do anything to speed their ability to address the problem and turn this around, and if it takes them as long as it took us as being the United States, the U.K. or New Zealand, Australia. If it takes them as long as it took us then we will loose 100 million lives to road traffic injuries. We have the tools to prevent it. We have the equivalent of vaccines for road traffic injuries right now, but it's a horrible epidemic that's coming. For many people, they don't pay much attention to this. They say these are just accidents, they are just part of modern day life and it's this fatalism that's so bad and that keeps it going. But in Sweden - in Sweden, a group of dedicated people said, "We can eradicate road traffic deaths. We don't have to have any of them at all. We can completely eradicate this problem and wipe it out." They said, "We can do the same thing to road traffic injuries that was done for smallpox. We can eradicate it." They started talking about this about 30 years ago, and when they started talking about it, people just laughed and said, "You're crazy." As you add more cars, as more people start driving, you build more roads. The number is going to go up. Inevitably, it'll go up; and they said: it's not inevitable that we can eradicate this. They started working to build safer roads. For example: they took out red light intersections and put in traffic circles. They told me, "Red light intersections cause deaths. How? Because what happens when you get to a yellow light? When the light turns yellow, many people speed up; you cause a high speed collision and that high speed collision is fatal, and red lights actually kill people." So they took all of these red light intersections out and they put in traffic circles, and the death rate came down by 90%-ninety percent. That's as effective as our very best interventions in public health or global health. It's as effective as our best vaccines. So step by step, they built safer roads; they put barriers down the middle that also brought the rates down by 70-80%. They built safer cars, Sweden is famous for that and they made people obey speeding and drinking and driving laws; and by doing that, they brought their death rate down incredibly low. They started with a focus on children and 30 years ago there were probably about 137 children who died in the road traffic crashes; gradually came down 135, 131, 127. Three years ago, there were 11. Two years ago, there was just one death of a child in the road traffic crashes. Vision Zero is what they called this campaign and it's inspired by smallpox and they're going to eradicate road traffic deaths. I think this is going to inspire the world to start to turn this down. Three days ago, we were at the UN; the general assembly met and it met just on the topic of road traffic deaths. This epidemic now is really bad. The global burden of disease from road traffic deaths is greater than malaria and it's greater than TB, greater than both of those, and the general assembly met and they passed a resolution that for the first time ever, there will be a UN Global Ministerial Conference on this issue. It's going to come to light, and this notion of Vision Zero that you can eradicate road traffic deaths is going to drive this Ministerial Conference, and it's going to drive the world to change-that comes from smallpox. It's a lesson learned from smallpox. They wouldn't have been so brazen. They never would've thought of the idea of eradication, had it not been for the success of smallpox. So I think we often think: How has it affected our notion of infectious diseases? It's gotten well beyond infectious disease and this whole notion of Vision Zero really owes a big debt of gratitude to the eradication of smallpox. I think it has affected our thinking; it has affected our approach and hopefully it will affect what we can deliver for the good of mankind. David Sencer: Thank you. If we could just switch gears for a minute: Do you want to take five minutes and tell us about St. Helen? Mark Rosenberg: St. Helen? I didn't - Crater Lake or St. Helen? David Sencer: Crater Lake, rather. Mark Rosenberg: Crater Lake. Yes, [pause]. David Sencer: This is for the other archives. Mark Rosenberg: Okay. So I don't have to tie it into smallpox eradication? Crater Lake was an incredible adventure. We got a call one day in the Enteric Diseases Branch that Jean Gangarossa[0:24:29] and Mike Merson who were our supervisors and they said that a lot of people were getting sick at this park in Crater Lake, Oregon; and they think maybe there's a problem there. They're not sure, but maybe it's a problem that CDC ought to help them with. So the Preventive Medicine Resident was sent out there to do a quick and dirty survey to find if there really were people still getting sick and was it widespread. This Preventive Medicine President named Jeff Koplan, did this quick and dirty survey and then we had a conference call back in the Enteric Diseases Branch. Everyone huddled around the phone while Jeff said: yes; it had an attack rate that seems among the staff to be well over 80% and that on tour buses, people were still getting sick after going to the park. They had no idea what was causing it, but could we send someone out from Enteric Diseases and could we do an epidemic aid investigation. So I got sent out the next day. I flew out. I had to fly first to San Francisco then Crater Lake, a National Park. It's a 200-square-acre track that has the main point of interest as an extinct volcanic crater that's been filled completely with water. This lake is 2,000 feet deep and it's billed as the world's cleanest water, and it's billed as one of the Seven Wonders of the World, Crater Lake. So I got sent out to Crater Lake because something was wrong. I got to San Francisco but I missed the connection. I left home, probably at about 5:00 a.m. to get to the airport here. I missed the connection there, then waited around five hours in San Francisco, flew up to, I think Medford, Oregon, and then rented a car. This was now late at night - very late at night and I had to drive through woods and through forestland for about four more hours, finally arriving at Crater Lake at about 2:00 a.m. Eastern Time; and when I got there and everyone was sitting around: the Youth Conservation Corps, Jeff Koplan; people were sitting there and I was more than ready for bed, but they showed me some reports of the water and I looked at these reports of very high coliform content and then they said, "What do you think about this?" I guess I told them what I thought about that. Then the next day, we got up early. It was still all covered in snow, because even though it was in July, the snow doesn't melt except for a very short period, at the end of July and August. So we started out and because of these high attack rates, we thought this was waterborne, but we couldn't prove it. So we set out collecting some water samples. We tried to look at the water delivery system in the park. They said, "You don't have to worry about the water because this is the cleanest water in the world and this water comes from a deep underground well- it's got to be clean. It can't be the water." Well we were nervous because everyone on the park's staff was sick. The Park Superintendent had been sick for so long, he'd lost 35 pounds. Everyone in his family was sick. The attack rate among the staff was over 80%; among the Youth Conservation Corps it was almost 100% attack of a disease characterized - people were throwing up, vomiting and then they had sustained diarrhea, and the Park Superintendent, until two days ago, hadn't even thought this was a problem. He thought, Ah! 35 pounds of weight loss, three weeks of diarrhea, my whole family is sick. It's just the bug. This is the flu bug. In fact, the person who ran the concession at Crater Lake told them, "This is just the flu. This is what comes every year. It's nothing. You don't have to look into this." In fact, he had told all his employees to keep working; and so the Chef was sick, had this vomiting illness, but he kept a little bucket on the stove where when he got sick, he could use his bucket, and the owner of the concession had told everyone, "Just keep working. You know, if you have really horrible diarrhea or if you're vomiting, carry a bottle of Pepto-Bismol around with you and sweak[inaudible0:29:00] that as you go. After a day, the snow started to melt so we could start to get some water samples and see that the sewer system had been jerry- rigged and water was going up to the area near the lake with no chlorine in it. So we sent some more samples to be analyzed. It turned out, these also came back highly contaminated and people were still getting sick. We did some quick and dirty surveys; and by the end of the next day, we had rough estimates that there were 3,000 visitors a day to the park and that about 70- 80% of them were still getting sick. So we spoke to our bosses back here at CDC. We said, "We think you ought to close the park." They said, "On what basis do you propose closing the park?" And we said, "It's a very high attack rate. It's a very serious illness. There are old people who come here. If they get sick and dehydrated, they could die. We think we ought to close the park, and we think there's nothing else that explains this high attack rate: that is food and waterborne and we think it's the water, but we'll get the evidence." Our bosses said, "No. You need to keep the park open. You need to collect evidence. You just have convenient samples of people calling in from the buses and tours who come, and you need to keep checking." And they said, "Besides, how'd you know it's the water? Maybe this is some mosquito-borne illness. But we have never heard of a mosquito-borne illness that causes this level of attacks in diarrhea, but we kept working. The snow kept melting and the next day, I was doing rectal swabs because we had to get cultures, bacterial cultures to look for the culprit, and I think I had finished about 230 rectal swabs. I was ready for a break and Jeff Koplan called me up. He said, "You've got to come out here and look at this." The snow had melted and they found a sewer that had been blocked and it had all backed up and the sewage looked like it was running downhill towards the stream. We put some fluorescence dye up behind the sewage to see if there was contamination from the sewage into the drinking water, then we used fluorescence because just one part per million would show up under ultraviolet light; and we thought no one would be bothered by seeing this in the drinking water, but we could see if the water got contaminated. But it turned out that the drinking water was this little surface stream. The surface stream was just downhill from where the sewage was backed up. So if you can imagine, bright fluorescent green sewage flowing down the snow-covered hill into the drinking water, turning the water green. This was incredibly heavy contamination and we decided at that point that - and this is the drinking water for the whole park. People would come to the park. There was no other source of water. We thought we could bring in bottled water, but that would take days to bring it in. So we thought that the park really needed to be closed down. So we started issuing signs and putting them around, "Don't Drink the Water. Don't Touch the Drinking Water. It's Not Safe for Anything Except for Flushing Toilets." We went to the concessionaire, we said, "Don't share food to the people who are here because you are going to serve food cooked with contaminated water. You're going to serve on plates that have been washed in contaminated water. Don't do it." He said, "I've got to serve them breakfast. I've got to serve them breakfast." Then we said, "Okay. Then serve potato chips and things that come in bags, but nothing cooked." He served breakfast the way he usually does with oatmeal made with this crate water, with eggs made with this crate water, on plates cleaned with this crate water, but we had a conference call, there had never been a case of a National Park being shut down due to illness in the history. So we had to figure out how do you close a National Park that had never been shut? And so CDC didn't have the ability to declare it shut, but CDC dealt with the Bureau of the Interior and they finally got permission to shut down this park, and it was shutdown that next day. It was the first time in history that a National Park had been shutdown due to illness. The park was closed and they had this massive cleanup job. Massive because all the water, all the pipes were contaminated basically by sewage, and then the drinking water, if you let it settle, you could see particulate sewage in the water. After several weeks the park was re-opened and people went back. There were sporadic cases of continuing illness, but we went back to investigate that. It turned out that that was just sporadic illness and the water was clean; there is no more waterborne disease: and we thought, Thank goodness. Thank goodness we're finished. This was one big outbreak. Then, I think a few weeks later you, Dave, came into my office with your sleeves rolled up and you were carrying a letter. You said - so I was this EIS Officer, still pretty intimidated by what went on - and this was a letter; and I think it was from Congress and it was saying that; "There's going to be a congressional investigation of whether or not there was a cover-up at Crater Lake. They said, "Would you please explain, Dr. Rosenberg for the record, if what you said when you first arrived there that night when they showed you these water samples, would you explain if you really said this; and if you said it, why didn't you close the park as soon as you got there?" And it said, "This is what you're quoted as saying Dr. Rosenberg; when you got there that night and you were shown the water samples, you said, 'You've been drinking pure shit.' If you said that, why didn't you close the park right away?" So this became a long series. We had to prepare - it wasn't clear to me how you respond to that kind of letter. You were very cool. You were very calm. I would've thought that if I had one of my low level employees saying this kind of thing, and on the Congressional record, that I would've gotten rid of him post haste. But you were very patient. You said, "We're going to prepare a response. We'll figure this out. We'll figure the right way to respond." And we did. Then we testified. There was a Congressional hearing out there in Medford, Oregon, and we went and we testified, and I still have the Congressional record from that hearing because the first three pages are solely devoted to whether or not, Dr. Rosenberg actually said, "You've been drinking pure shit." Three (3) pages of Congressional record; and the Superintendent of the park was very sympathetic; he said, "Dr. Rosenberg never would have said that. He must've said: You've been drinking animal waste." Then someone else asked him, "How would he know it was animal waste instead of human?" I'm sure I said what I was accused of saying. I was tired. I was exhausted. I thought I was talking to friends, but that became a teaching case of Crater Lake and there are lots of lessons to be learned, both how we handled it and what you might expect. David Sencer: After that, your name was Shit? Mark Rosenberg: It was and in certain places, it still is. But we survived. David Sencer: Those were my - [crosstalk 0:37:24] Mark Rosenberg: Let me just add. I think for me, I always knew that the Director of CDC, when I was there as the EIS Officer, was special, because you would always come around - we were in the Enteric Diseases branch and you would always come around the day before the MNWR was coming out. We have lots of stories about whether it's Salmonella outbreaks, church picnics, eating contaminated food, and there's always something in Enteric Diseases Branch coming out in the MNWR; and you always came by. You always came by with your shirt sleeves rolled up and you would sit down with us and go over it and ask us some questions about it, and you cared about what we were doing. You spoke to us and we were EIS Officers, and you were the Director of CDC and you came by, totally without pretense, without arrogance, just to sit down with us with your shirt sleeves rolled up, and that had an incredible impact. Not just on me, on all the EIS Officers. You knew them. You spoke to them. You deigned [0:38:28] to have contact with them. It was an amazing and wonderful thing. Then when this letter came from Crater Lake where you came and you sat down with me and you had that letter, I thought I would've been fired on the spot; and instead, you said, "Let's figure out how we're going to respond to this." And it was together. Let's figure out together how we deal with this. I thought, "What an amazing man?" What an amazing man you were? You remained so and you still are, but that was certainly a formative experience for me; an amazing experience and a wonderful experience. David Sencer: Just one of those things at CDC-Just another day. Mark Rosenberg: It wasn't just one of those things. Not at all! There are some things small that happens everyday, but something really, really important. I think as an EIS Officer, one of the things you learn is how to bear yourself and how to conduct yourself in this world and with your colleagues and in your business, and I think if you're lucky - if you're lucky, you get to connect with mentors who are an example that's always held out there. I always remember a book by William Golding, the author of "Lord of the Flies" and in his book, he said that, "Our lives are constructed out of bricks and we build our lives one brick at a time. But the bricks aren't the ideas. The bricks with which we construct our lives are people. They're the people that we meet." You've been a brick for me, a very important brick, a very important part of my life, and an amazing thing and I am so ever grateful that I had the chance to work with you. David Sencer: You were one of the products of Montclair, New Jersey, that wasn't cheaper by the dozen. Mark Rosenberg: Well, thanks. David Sencer: Thank you, Mark. Mark Rosenberg: Thanks, Dave. [End of audio - 0:40:24] </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/6tqcIUqtGxs" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2008-07-29 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15pd3 emory:15pd3 Format The file format, physical medium, or dimensions of the resource 8724720000 bytes video/x-dv Creator An entity primarily responsible for making the resource Rosenberg, Mark (Interviewee); cdc Sencer, David (Interviewer) Contributor An entity responsible for making contributions to the resource Centers for Disease Control Reunion of Southeast Asia and East Africa Smallpox Workers (2008 : Atlanta, Georgia) Title A name given to the resource ROSENBERG, MARK L. Description An account of the resource Dr. Mark Rosenberg served as an field epidemiologist in India with the Smallpox Eradication Program. Subject The topic of the resource oral history Language A language of the resource English https://www.globalhealthchronicles.org/files/original/ae283c36492aea299ab0b89dcd2ae4dc.jpg f0d4a4924b280243ce2018d0f9bf5f3b https://www.globalhealthchronicles.org/files/original/da2113082249191878b93b8f89cc5bdb.pdf aca0615c0585e539e2c4bb36c56a3825 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> Interview Patrick McCannon | with Interviewer [unnamed] Transcribed from audio: January 28 2009 | Duration 0:07:47 Interviewer: This is an interview with Patrick McCannon on April1, 2008 at the Centers for Disease Control and Prevention in Atlanta, Georgia, about his involvement with the India Smallpox Eradication Project. How did you get involved in Public Health? Patrick McCannon: I was a recent graduate or about to graduate from the University of Wisconsin and back in the stone age when they actually sent people to recruit new graduates on the campus, and I went to several interviews and I had job offers from Dunn &amp; Bradstreet, DOW Chemical and outfit that was trying to eradicate Syphilis from the United States and that one sounded interesting and I'd never heard of CDC before then. They talked about it being with the Public Health Service. So I put in my application for the recruiter and followed up several times, and that was it. Interviewer: So was Public Health something that you always knew you were interested in? Patrick McCannon: No. I absolutely had no idea of public health. I wish I could say that I was dreaming about a career in public health since I was eight years old, but I didn't have a clue about it. Interviewer: So how would you describe your early life and education through high school? Patrick McCannon: Wow! I grew up in small towns in Minnesota and Wisconsin. Sort of typical for that area, interesting, I enjoyed school immensely, I played all the different sports and got involved in all the different kind of activities in school that they offered and had a very good time, enjoyed it. I went to Catholic school early on and then public school. Interviewer: So how did you decide that you wanted to go to India on the Smallpox Eradication Project? Patrick McCannon: Well actually, it wasn't India, for me, it was Bangladesh, but I had joined CDC in 1967 - February of 1967, and one of the programs that was rolled out several years after that, I think it may have been '69 or '68 was the Smallpox Campaign in West Africa and I desperately wanted to get involved in that. I'd been on the job for several years and it sounded exciting and really sort of a golden opportunity, but I wasn't able to compete. I didn't have enough years in service and they had a lot of people volunteering for the West Africa Campaign; and I kept an eye on things as they were looking for volunteers for Bangladesh, I put my name in and went through some interviews and I was selected to be one of the people to go over on the first team that they sent after they discovered the re- introduction of smallpox in Bangladesh. Interviewer: What were some of the hardships that you faced upon arriving in Bangladesh; any culture shock? Patrick McCannon: I'm sure I'd suffer from culture shock. Like everybody I had limited travel experience. I'd traveled in Europe but nothing that approached a third world country, and at that time Bangladesh was just coming back from a terrible war with Pakistan and for the entire country there were either news reports of Bangladesh being the basket case of the world. You know, very, very difficult living in Bangladesh at the time, for the residents there. So I'm sure that I had culture shock seeing third world country and people living in very deprived conditions. Interviewer: Were there any main changes between the work that you did here and the work that you did in Bangladesh, with the new responsibilities? Patrick McCannon: The environment in which we did the work was just totally different and it required a lot of attention to be attentive to the environment around you and the people and all the things that make up a third world country and the condition that Bangladesh was in; and then you add on the disease that you're dealing with. Smallpox was a real killer and this really very major and as soon as we arrived we went to the old cholera hospital that had in part been turned into a smallpox ward for the indigent and isolation area and we were given a three-day course on differential diagnosis of smallpox and identification of smallpox, and how to handle specimens and how to handle patients, and how to set up remedial care for the people that were afflicted with smallpox; and this was prior to our going out into the areas that we went to. So just the foreign environment, the sort of dealing with the disease that basically there was no treatment for except for to care, remedial care, and with substantial mortality. So that combined to be a very unique experience, regardless of the background that I had. There were some things that I was very pleased with, I mean in retrospect, like the training that I had had and I was a public health adviser, and basically that was CDC's management entry point for people that they would build into managers, who eventually would be, maybe, in senior management positions at CDC, and you learn by doing, you had mentors that provided you assistance along the way. You were put into State assignments and moved all around the country in different assignments and progressed up the ladder, and then some people came to CDC [Audio ended prematurely - 0::07:47] </pre> Player html for embedded player to stream video content <iframe src="https://www.youtube.com/embed/vjCOeeNtJC8" frameborder="0" width="560" height="315"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource MCCONNON, PATRICK Subject The topic of the resource WHO oral history smallpox eradication CDC Bangladesh Description An account of the resource Pat McConnon was a Public Health Advisor assigned to Bangladesh Smallpox Eradication Program. Creator An entity primarily responsible for making the resource McCannon, Patrick (Interviewee) Date A point or period of time associated with an event in the lifecycle of the resource 2008-07-29 Contributor An entity responsible for making contributions to the resource Centers for Disease Control Reunion of Southeast Asia and East Africa Smallpox Workers (2008 : Atlanta, Georgia) Format The file format, physical medium, or dimensions of the resource 9170640000 bytes video/x-dv Language A language of the resource English Type The nature or genre of the resource interviews motion pictures moving image Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15pgc emory:15pgc https://www.globalhealthchronicles.org/files/original/1b69668fd433228d7257c8f5d9a17d22.jpg 4f42519dab2c70d3d3646f95bd737664 https://www.globalhealthchronicles.org/files/original/2721a24d7815c916703b202fa7a95885.pdf 2b23c7214e5cad978f34e1027ba3b779 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> INTERVIEW Audio File: Tim Miner Audio File Transcribed: January 28, 2009 Interviewer: My name is Ted Tolavoil. I'm a senior undergraduate at Emory University. We are at the CDC today interviewing Tim Miner and today's date is April 2nd, 2008 and the interviewee has given permission for this taping. First of all Tim if I could have you introduce yourself. Who are you and tell me a little bit about your background? Interviewee: Okay. My name is Howard Gordon Miner but I go by the nickname Tim and I've had that nickname from birth because when I was born there were already two other Howards in the family and they needed something to differentiate me from the rest of the Howards so I got the moniker Tim. I grew up in Detroit Michigan and left in nineteen seventy. I taught for a couple of years in the inner city in Detroit. I went to Swaziland in the peace corps in nineteen seventy and I'd just like to say [Foreign Dialect] which is Siswati for I'm very happy to see you now. So, I do recall some of the languages that I picked up along the way. I taught in Swaziland for a year until I discovered that we were taking jobs away from unemployed Swazi teachers so I mentioned to my peace corps director at the time I would like to go and do something else. I wasn't real enamored with teaching anyway and I certainly didn't want to un-employ a Swazi teacher. So because I spoke French they sent me to Zaire with the smallpox eradication program but they almost sent me to Morocco as an agricultural photographer so I could be in a whole different career by now if had I not gone to Zaire. In Zaire the smallpox program was headed by Dr. Pierre Ziegler and when I landed in Kinshasa I went first to the peace corps office and signed in and did all the paperwork and met all the people. And then went over to the WHO office in Kinshasa and had this lengthy conversation in French with Dr. Ziegler and I realized that I really needed to get up to speed on my French rather quickly. And so I did and he showed me how to give an immunization and he had a clinic there once a week. So there was a lady that came in and you know you have the bifurcated needle and you take the arm and kind of squeeze the flesh and rest your wrist on the arm and you just jab it a couple of times. So he said, "Why are you doing that? Tell me exactly what you're doing so that I know that you understand what I told you." So, I'm giving her the immunization and you're supposed to just prick the skin a little bit until there is a trace of blood. Well for those who speak French, the word for blood and the word for monkeys sound about the same. So as I was explaining what I was doing I said, "You just prick the skin until you see a trace monkeys." And everybody just broke out laughing because they couldn't understand why and the lady wondered what kind of vaccination I was giving here that she'd get a trace of monkeys on her skin. So, that was my introduction to the immunization program there. I went to my field station which was then in northern Shaba, ex- Katanga Province and there was another peace corps volunteer there, Ken Bloom. And so we did a [inaudible 03.39] in the field first and then came back and then he left and left me there but I'm getting a little bit ahead of myself. While I was in Kinshasa with Dr. Ziegler he said, "All right you're peace corps volunteer but we don't want you to conduct yourself as a volunteer, tell anybody that you're a volunteer or live like a volunteer." I don't know what his preconceptions of volunteers were but I listened intently. And he said, "To make sure you don't live like a volunteer we're going to supplement your $75 a month income from the peace corps with an additional $400 from WHO." I said, "Works for me," so went out there in the field and took my station. I had three Land Rovers, an office, a furnished two bedroom apartment and a staff of four. So I was the [inaudible 04.35] to keep the team leader of a epidemiological investigation team and we were in the field about twenty eight days a month, back at the home base only two days a month because I like to travel and be in the field and there wasn't a lot to do at home base. And my African staff liked to be gone more so that they could be making money and they wouldn't be home spending it and having relatives come around and so and so forth as it was explained to me. So we were in town maybe two days to file a report and I had a two way radio so I could talk to Kinshasa. And there was Mr. Ali an Egyptian that ran the radio and I was talking to him and I said needed this piece of equipment to repair a Land Rover. And he said, "But what is it?" And I said, "Well I know what it is in French." I'd been so immersed in French I forgot, even though I grew up in Detroit, what this particular part was. And so I said, "Well I'll tell you in French and if you know what it is, you tell me what it is in English because I forgotten." So, he did that and we got the parts and went on. I was in Zaire at a particularly historical moment when Mobutu Sese Seko wa za Banga, the president of Zaire at the time was just initiating his authenticité campaign. So he renamed the Congo River the Zaire River, renamed the country Zaire, renamed the currency Zaire and told all Zairewa's, all citizens that they had to change their names from Christian names to African names. So I talked to my team and I said well - after I learned all their names I said, "Well you're going to have to tell me what you're African name is and then tell me whether you - how you want me to address you." And so that worked out fine. That wasn't a problem. When it came time for me to leave, when I went to Zaire I had to give another year to peace corps. Normally it's two years but since I had done one in Swaziland I went to Zaire for two years and part of the way through that I got home leave and I went to Geneva. And on a Sunday afternoon I went to the WHO headquarters and walked into D. A. Henderson's office and he was there on a Sunday afternoon. And I said, "Well D.A. I'd like - you know I've done this work in Zaire, I'd like to have a job. I'm going to be leaving the peace corps, I'd like to have a job with WHO if you think that's possible in another country." And he said, "Well, I'll look into it." Four weeks later I got back to Kinshasa and I was offered a job with WHO in Bangladesh but I had to go back to my post and turn over all the operations to the African staff at the time which I enjoyed doing because they were certainly capable of doing everything that I did. And it became a philosophy of mine in working in a host country to always whenever possible to have a host country counterpart working with me. And try to - I would try to build as much infrastructure or leave more than what I came with and that has been one of my standards that I've had. So I left the post, went to Kinshasa to visit peace corps and I couldn't find the office. The office had changed locations. So I found the office, walked into the office and they weren't the same people that were there. So I said - introduced who I was and said I'm ready to check out and that time John McEnany who I think also has done some work in smallpox was there and he said, "Oh yes, Tim Miner. I think I've seen your name somewhere. Where have you been? You've been gone for about two years." So all the staff, the office, everything had changed, all the people so we signed out of there and I headed off to Zaire via Nairobi - to Bangladesh via Nairobi. In Bangladesh, let me see, I - let me back up a little bit and tell you a brief story in Zaire about an immunization campaign. We used (pedajets) but we also used the bifurcated needles. Because the city of Kalemie on Lake Tanganyika was bordered on a rebel occupied area and we had some reports of smallpox in there but we really couldn't go into that area to investigate, what we decided to do, Ken Bloom and I was to hold a mass immunization campaign in that town or a little bit outside of town with the hopes that the people from that area would come in and be immunized. So that was my first mass vaccination campaign and we called Kinshasa and had them send us immunization certificates and some additional (pedajets) and vaccines and things and we held a mass campaign and that was really exciting because we had - the local person said everybody should come and you will get a certificate and they may be checking people to make sure that they had a certificate, that they had an immunization. So we had large crowds of people and we had to spread this out over about ten days to get everybody vaccinated but that was - that was a pretty exciting thing. And there's another city we visited on Lake Tanganyika and it was a mission there and I tried to stay at the missions because they had the best food, the best accommodations and a variety of beverages and the best conversation that was available at that time and if I were to fall ill I'd been in pretty good hands because there's nurses nearby and so on. At this one mission there was a Belgian Father, actually he was a German Father and he tanned hides. So I said well can you make me some shoes because my store bought American shoes didn't last very long and were getting kind of threadbare. He said sure. So I had him make a pair of boots a year for me and that's about how long they lasted but there was also - he tanned some other hides. I bought, and this was before environmentalists and so on and so forth so I had an alligator hide, a python skin that was probably about thirty feet long and a puff adder. And I sent those home to the States where my nieces and nephews used them as show and tell in schools and they were a big hit. So I'm back in - headed for Bangladesh now and I'm in Nairobi, through Nairobi to New Delhi and got an orientation in New Delhi and then went to Bangladesh. When I arrived in Bangladesh Stan Foster was there, Stan Music was there, Neilton Arnt from - Stan Foster and Music are from CDC, Nielton was Brazilian with WHO. Nick Ward, Dr. Ward is a physician from U.K. and then there was myself and I was the youngest, only non physician and I was the only one that wasn't married. So guess where I ended up working in Bangladesh? The most remote river line areas of the country. I had Barisal, Patuakhali and Faridpur and there was a hospital ship that the Germans had donated to Bangladesh a couple of years before I arrived and Stan had arranged for a bunch of -- they were moped like or vespa like Honda -- motor scooters to be put on all over the deck. And he said, "I want you to get on that boat and go down there and eradicate smallpox from those three provinces down there. I said, "Is that all? Any other instructions?" And so I did, got on the boat, introduced myself to the captain and I was able to supplement the pay of the crew nominally, nominally for the extra expenses I incurred and what they did. And so we towed a speedboat. This was - this ship was probably forty five, fifty feet long and had a draught of about three feet, three/four feet. It was fairly shallow and I had a forward cabin. And we had our immunization team on there and we went down to Barisal first and docked and stayed at a mission there for a couple of days. Met with the chief medical officers and then went on down to Faridpur. I taught my self Bengali, smallpox Bengali and to this day when I speak with Bengalis I meet in Atlanta and elsewhere I've been informed that I speak sort of like a villager or a fisher person not like a university professor which is fine because those are the people with whom I communicated all the time and didn't have any problems doing that. I was able to conduct a smallpox investigation by using my Bengali. All right an interesting - our team was made up of myself and we had a combination of Muslim and Hindu staff on the team. Vaccinators and interpreters and there was a chief and so on and everybody got along fine and it was just a wonderful experience. We had a speedboat driver as well and so we would get down in the morning into the speedboat and go off and investigate the reports that we had. And one time we were coming back rather late at night and there was a full moon and we were in the Brahmaputra which is the main river in Bangladesh. Then the river line areas there are a lot of channels and we were out in the main river and we were going rather fast. And the next thing we knew we were out of the boat, head over heels in the river but we weren't in the water. We had hit was is called a mud flab and in a mud - when the - you have a mud flab in the water and you can't tell because the water is just barely over the mud and the mud in the dark or in the moonlight reflects - seems to be water. So we hit that and the motor went up and all of us were thrown out of the boat in the middle of the river on this mud flab, covered in mud and when we got - regained our senses we were just laughing hysterically at the absurdity of the situation. We put our stuff back in the boat and pushed off and got back to the speed boat. One particular investigation that stands out to me is I went to a village and the villagers - this young man and some other people took me to this brand new hut. I mean it was just brand new, it had just been built and they said the patient is in there. And they led me inside and on the mat on the floor -- there was no furniture or anything else, there was just this mat on the floor in the middle of the hut -- was a person under a cover, a cloth, completely covered. And I was prepared to take the cover off and examine and see if it's smallpox and they just - they took the whole cover off themselves and there was this young woman covered with smallpox from head to toe of the confluent. There wasn't a space on this person that there wasn't a pox and so I knew right away what it was and thanked them and stepped out. And this young man starts explaining to me that this is his new wife, his new bride. And I said, "Gosh I feel very badly about that. I know that vaccinators had been in this village before would you - how come she wasn't vaccinated?" Was she away or something?" He said, "No." He said, "I hid her from the vaccinators because I didn't want her to have a smallpox scar on her skin." I said, "Oh I see." And you can't be judgmental or demonstrable, demonstrative or emotional at times like that. You have to really kind of step back emotionally a little bit from that. So I said "Well what would you do differently?" He said, "Well, I'm looking for another wife and my next wife will be vaccinated." But what struck me was that it was preventable and here was this young person, a young woman in just the beginning of her life with so much in front of her to look forward to, to being a mother, a grandmother, a husband, a sister and so on. And her life ended in such a tragic way. So I had several of these reminders throughout Bangladesh. I might add also that while working in Zaire I hadn't actually seen a real case of smallpox. It had been eradicated but we were monitoring it at the time. So Bangladesh was the first time that I had seen live smallpox and... Interviewer: What was your first impression when you arrived in Bangladesh? Interviewee: Well, when I arrived in Bangladesh and the subcontinent, I was impressed by the density of population. I had never seen, apart from a market in Africa, I had never seen so many people. I once did an experiment driving on the road trying to count ten seconds, just one and two and - up to the number ten, looking out the side of my window to see if there was ever any space where there wasn't evidence of human beings being there. So the land was either occupied by a house or a structure of some kind or it was planted. That was it. There was no vacant land, no land in Bangladesh that was not touched by human hands. We also because of the density when I was there, we had confined a lot of the smallpox cases and isolated them and we were in the process of eradicating them when the government tore down the basties or the slums of Dhaka. Just went in with bulldozers and it acted as a centrifuge spinning out cases of smallpox all over the country reintroducing smallpox into areas that had recently been freed of the cases. So that - our numbers of cases went sky rocketing again so that it was little disheartening. Another time I was down in the river line areas and Stan Foster was up in Dhaka and I think I was at the furthest most remote place at the time on the ship and I got on the radio and talked to Stan. And what we were trained to do was to investigate the cases of smallpox and find out who had been visiting and what were there names and where did they go and where did they live and so on and so forth. So as a matter of routine I gave Stan this information about who this person was and the name and when they visited and so and so forth and not really expecting that you know all these millions and millions he's going to find him but he did. He went to the address and he asked for the person and he found the person and immunized the person and was able to prevent the next generation of smallpox from that person having visited there. So anything is possible. We lived with the people in the host country. I lived on the ship, I lived with Bengalis all the time, I rarely saw another European. There was some care people that I would meet on occasion but I learned the language and the culture and they embraced me and I embraced them figuratively and it just worked very well. And I can't imagine eradicating smallpox with a kind of a visit and come out and then visit and come out type of approach. It didn't occur to me to do it any other way other than to go to a respective country and live there and work there and learn about the people and the culture and the religion and so on. I worked for six months in the river line areas on the hospital ship and was fairly able to get smallpox under control there. And then I was transferred to the north, Jamalpur and went from a boat to a motorcycle and that's when I met after I'd been working up there getting things organized, I met Steven Jones. Dr. Jones was up there and Marty Litz and Peter Hargrove and these are people I met and known since then. And we had people come from CDC, a lot of consultants as well, short term consultants for three months or six month stints. And I was having breakfast with one of the fellows and it usually consists of a chapatti and some eggs or something like that. And he said, "Well how do you manage with all of these poor raggedy kids and poor people and people kind of on their last leg and they look very unhealthy." And I said, "Yes I never know when I walk past someone coming back in the afternoon whether they'll be alive or dead," and that has happened many times. And I said, "Well you know, it's not that I'm unsympathetic or that I don't care but I know well enough that I can do one of two things. I can either devote my life to trying to alleviate the pain and the suffering and feeding and clothing of less fortunate people or I can do my job and eradicate - working to eradicate smallpox and that will benefit them. At least they won't die of smallpox." Well since then I've learned that Bangladesh has done quite well economically. Many of the clothes that I buy today are made in Bangladesh that weren't made in Bangladesh at the time and I understand that they are doing much better than when I was there at the time. So that's heartening to know. Interviewer2: In the book that's been written about smallpox in India, the author postulates that the only reason that smallpox was eradicated was by compulsion. Interviewee: Yeah. Smallpox could not have been eradicated by compulsion. People all over the world cannot be coerced for long to do something that they don't want to do themselves, that they don't want to do willingly. And I relied on reason and understanding and cultural sensitivity when explaining the benefits of immunizations and if somebody that chose not to then so be it. I felt very disappointed because I knew the preventive benefits of that but nobody was ever forced. And I had people approach me afterwards as I was leaving and say, "Come we've decided we want you to do some immunizing." We also out of respect for a variety of cultures engaged female vaccinators and that worked very well and so that we were able to honor the customs of the country and have ladies vaccinate ladies and so I think we did much better that way. But in Zaire and in Bangladesh and in Somalia where I worked there was never any thought of coercing people. Governments may issue declarations that there's a smallpox vaccination day or you should immunized for smallpox and so on but even when we were doing the mass campaign and there were police officials organizing the lines of people, there was nobody - they were there voluntarily and they recognized the benefits of the immunization as opposed to having the disease. So that's an important point to clarify. And by way of this tape I want to thank all of the host country nationals that have kept me safe over the years and to this day when I travel overseas. They're very protective and solicitous and very good people to be working with and I did not eradicate smallpox. I worked with hundreds, hundreds or thousands of Bengalis and Zairewa's and Somalis to do that and so it is - it's to their credit. They're the ones that are responsible for our success because if you show sensitivity and you show honesty and a true spirit, they'll go with you anywhere, any time, day or night, seven days a week to carry out the work. So this is something that I want the people that will view this tape in the future to know. That this was truly a global effort of people all over the world coming together for this - for this one cause and I don't think there had - apart from World Wars and even in World Wars there wasn't all the countries coming together. Some were in conflict but in this particular case to achieve the eradication of smallpox it's the first time in human history that a disease has been eradicated by human beings. That human beings have rid themselves of this pest that goes back to recorded history. And so I really would like to see something like that happen again because it's - they were really heady days and really wonderful, wonderful things to experience. After I finished in the northern in Bangladesh in the motorcycle, last six months I came down to Dhaka to be the finance officer and we had as many as seventy five or a hundred short term volunteers in Bangladesh at one time and everybody had to have money and everybody had to have a system of accounting for it. So based on my year and a half and handling and accounting of money I developed a spreadsheet. Now, we call it a spreadsheet but we didn't have Excel at that time. You had to draw something by hand and then had people look at it and review it and then it went to the printer and then they sent you a proof and then you looked at that to make sure it was all right because they were going to print a million copies of it so it better be right. And so I developed this spreadsheet about yea big and people would put a carbon paper. That's a - not too many people know what that is but anyway it allows you to write down one side of the paper and it will come through on the next page. So that's what we used and I was in charge of training the volunteers, the short term consultants that come in to account for this system. Very simple system. You get a receipt, make sure it has the date, write down what it was and put the number in sequence of what it was and put that number on your spreadsheet and just write down what it was and your beginning balance and then you're ending balance. That's all you have to do nothing more than that. And we gave them a briefcase of money and - of taka and they went off. And while we had these people out there with their briefcases full of money containing smallpox and what not, the government decided to have a demonetization effort. And they demonetized all the money and said all the money had to be returned to the bank and they'd give you a receipt for it because they're going to issue new currency. Well needless to say that put our campaign in a bit of a bind because people then couldn't get paid and so on. So our people had to go to the banks wherever they were in the field, turn in the money, get a receipt and we got a special dispensation from the president of the country and the head of the treasury that said we would be given - among the first ones to be given the new currency as soon as we turned in the old money so that we could keep the campaign going. So there were little exciting moments like this that happened from time to time and we were working with nationalities. All nationalities were involved and as you know the Americans and the Russians and I forget if it was originally the Russians idea and the Americans joined it or what it was but we got WHO to accept this program. And so in Bangladesh we were working occasionally with Russians and they liked our cigarettes and we liked their vodka so we'd you know trade and that stuff but they thought that were working for the CIA and we knew they were working for the KGB. I mean there just wasn't any way they'd be let out of the country if they weren't. None of us were CIA but you know you couldn't change their mind on that. So we worked with a lot of different nationalities and one character in particular stands out, Dr. Larry Brilliant. And he's a physician from Detroit and went to study with a guru in India and the guru said, "You're going to eradicate smallpox from India. You're going to join the smallpox eradication program,." and he went to D.A. and said, "I need a job." And the Nicole Grasset who's a French woman physician who headed the regional office of smallpox campaign in Delhi said, "No we really don't have anything for you." Went back to the guru and the guru said go back. Anyway he ended up working in the smallpox eradication program and was instrumental with others in getting Tata Industries to put in money and to organize their workers and have - support eradication efforts there. Now Tata Industries as you know just bought Jaguar and Land Rover from Ford Motor Company so gives you an idea of how the world has changed. When I left Bangladesh I had decided that I needed - global public health was the love of my life. It was what I felt I was born to do. I wasn't going back to teaching. I really couldn't do anything else after having done something this exciting so I went back to Michigan via Asia and signed up at the University of Michigan School of Public Health to do an MPH. Well, who should I find there but Larry Brilliant as my academic advisor and Steve Jones is a student there as well. So I tell you, you just can't get away from these people. But I had to delay my admission to the University of Michigan. I had to call them up and said, "Well I have to go to the Cameroon." Stan Foster wanted me to go to Cameroon to do an assessment of the whole country's health system for the program that was to follow on from smallpox campaign which was the expanded program on immunization. So I designed a questionnaire, visited the whole country, every health facility in the whole country and left the report there and then went back to the University of Michigan to start my degree. While I was there I met Dave Hayman who was assigned there and he was taking over after Bernie Gayer that had left. And so I talked a little bit with Dave and showed him the report and he thanked me and we went off. And two years later, I forget what country I was in, maybe I was in the Philippines at the time, I got this note from David Hayman thanking me for this report. That it was so comprehensive that it has been the principal reference document for them in establishing their expanded program on immunization. And again that was made possible by traveling and working with and the support of the Cameroonians. I had a small staff and a driver that we went around to do that. That it's nothing I did by myself. So it's good to know that what you do, do works out quite well. Okay. A little bit about smallpox in Somalia. I was at the University of Michigan and Michigan liked the idea of a student coming in with the experience that I had and in the summer times working as a consultant. So I was invited to go and work in Somalia as a consultant for three year four months and I was assigned to a small town of Marka which is just south of Mogadishu. And Somalia was very safe at the time and there wasn't any problems, anything like there is now and because of the lack of availability of food we were on sea rations. So we had little Bunsen burner and we opened the cans and cooked our food. In the town of Marka lived the world's last case of smallpox and I've forgotten his name but he - we were doing a scab survey so I needed to interview. The word went out that I needed to interview anybody that had pox or of course scabs. And he showed up and introduced himself and I knew who he was and he said, "You know I've been interviewed by The New York Times, The Washington Post, The London Times and The Straits Times and newspapers all over the world by these reporters and they pay me handsomely for the interviews. What do you have for me?" And I said, "Well I don't work for a fancy newspaper, I'm not a reporter and all I have is you know a couple of cans of this sea rations that I have, a couple of aspirin and maybe some malaria tablets but to tell you the truth that's all I have." With a little bit of pause he said, "Okay. We'll do it." So I interviewed him and that was a telling moment. Another instance Dave - not Dave - Peter Kraskow and I went -- he was working there as well -- went and lived with the nomads and their camels for about a week. And we did some blood sticks for antibody levels in neonates and I did a paper at the University of Michigan on those findings. And it was really enjoyable. Whenever I go to a country I really like to be with the people and learn of their customs and certainly their language which is a beginning to opening doors to their culture. I always try and learn just a few words of a language and in Somalia there were no smallpox cases at the time but we almost lost a couple of people. I remember one time coming back to a base camp that we had with some officers and things, finding Peter Kraskow on the floor of the lavatory. He had passed out so I got him back up and we got him healthy again and that was all right but Steve Fitzgerald who was working in the north -- I forget the name of the districts, were way, way in the north there -- almost died of dehydration. He had a bad case of diarrhea and all that he and his driver could do is pull off by the side of the road and underneath the tree and he had some re- hydration salts and some purified water and so the driver nursed Steve back to health enough so that he could get back to Mogadishu and continue his work. Interviewer2: I think we could go on all afternoon with this Howard. Interviewee: We could Interviewer2: [Inaudible 40.12] finish off with... Interviewer: What this means or how it has changed me or... Interviewer: Exactly, yeah. Interviewee: Okay. Interviewer2: I think you have pretty much told us what it's done for you. Interviewee: Right. In fact it has changed my life. Just a couple of sentences. When I had dinner with Ken Bloom and his wife Lois who also helped with the eradication program in Bangladesh and we ran into them in Boston many years ago, they had children at the time, my wife and I didn't. They said, "Well if you had children it's going to change your life forever," and I didn't quite know what they were talking about until we had children and it will change your life forever. And it's how I would attribute my work and experience with the smallpox eradication program. It has changed my life, changed my life forever. I wouldn't trade any of it, I wouldn't do any of it - I would do it all over again about the same way that I had in the past but it's just a rare opportunity. And when I'm back and I meet with people and tell them a little bit about that I make an effort to thank them for their contributions to the programs because they're tax payers and it's rare that a taxpayer really has any kind of connection with what's going on overseas and how their tax dollars are being spent overseas. So I try and make an effort to that to bring them into the activity of it themselves. I'm grateful for the opportunity. Interviwer2: That was a great interview. It truly was. </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/VIKcPkaZ0Kk" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2008-04-02 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15pjn emory:15pjn Format The file format, physical medium, or dimensions of the resource 9037560000 bytes video/x-dv Creator An entity primarily responsible for making the resource Tolavoil, Ted (Interviewer); Emory University Miner, Tim (Interviewee); CDC Contributor An entity responsible for making contributions to the resource Centers for Disease Control Reunion of Southeast Asia and East Africa Smallpox Workers (2008 : Atlanta, Georgia) Title A name given to the resource MINER, HOWARD "TIM" Description An account of the resource Tim Miner was a Peace Corps volunteer assigned to the Smallpox Eradication Program in Zaire, now known as the Democratic Republic of the Congo, and then later Bangladesh. Tim recounts many tales from the field and how this experience has influenced his life. Subject The topic of the resource Smallpox Eradication Language A language of the resource English https://www.globalhealthchronicles.org/files/original/50b3f4ada4d41f0636d0e4d61bc6e2ca.jpg 7079ea50612266f212c4d24ec9e70931 https://www.globalhealthchronicles.org/files/original/0cb9c7a848420abc2241387e68394d57.pdf 834491e360520ec38f1af20e92a67030 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> This is an interview with Mr. Billy G. Griggs, who was Deputy Director for the Smallpox Eradication Program in West Africa. This interview is being conducted on July 7, 2006, at the Centers for Disease Control and Prevention as a part of the 40th anniversary reunion for the launching of the program. The interviewer is Victoria Harden. Harden: Mr. Griggs, I would like to get a little background, to set the stage for your role in the smallpox program. I know you were born in Ripley, Tennessee, on November 20, 1933. Could you, just briefly, give me a little indication about your growing-up years, your pre-college education, who influenced you, how you grew up? Griggs: Well, Ripley is the county seat. Actually, I was born in Ashport, a port on the Mississippi River, 15 miles west of Ripley. And in 1933, this was boondocksville. In every way. Most of the things that came into Ashport came in by river boat. I went to school in Ripley-was bused 15 miles to school. I lived on a farm, of course. I had a rather uneventful, typical farm boy's life. I did all sorts of activities going on with farming. I went to high school at Ripley High School and graduated in 1951. I started to college my freshman year at Union University, which was a Baptist college in Jackson, Tennessee, about 45 miles east of Ripley. I was influenced largely by the pastor at the church, which happened to be located on the farm. He kept pestering me to come to Union. So I went to Union freshman year and met a senior girl, who I was infatuated with. She finished that year and was teaching in Memphis, so I decided Memphis State was probably better than Union. We got married Christmas my sophomore year. I was self-supporting, and I worked my way through college, working all sorts of jobs and I graduated in 4 ½ years. I came out of school with a house, 2 kids, a wife, and no debt, I might add, which is very good for college years. Harden: It certainly is. Griggs: I finished up the undergraduate work in January and decided to go on and do a master's in geography at Memphis State. I did the first semester but I was working, at that point, 48 hours a week at a soybean/cottonseed-oil mill at night. I decided that maybe I'd better slow down just a little bit. I knew there was a job opening down at the Shelby County Health Department for a VD [veneral diseases] investigator. On arrival down at the health department, I found out that not only was there the state job but there was also a federal co-op job vacancy. Tom Davis (from Atlanta) and Press Fish from the Nashville state office were there interviewing for the co-op job. The jobs were virtually the same, in terms of interviewing VD patients, locating their contacts, and referring them in for treatment for VD. The only difference in the state and federal jobs was that the federal job paid $500 a year more than the state job, and at the end of the year you were subject to transfer throughout the United States. This was a cooperative appointment between the State of Tennessee and the federal government. The feds paid the salaries, and you worked literally as a state employee on a local level there, at the City of Memphis. Keep in mind that my motivation for coming down was going through school, working full-time, and making a living. And it was beginning to get a little tiring. I decided that I probably ought to slow down a little bit and finish this master's degree. So I applied for the federal job, thinking that I would just do a year at it, and I'll have my master's, and I'll get on with what I was planning on doing. Harden: Which was? Griggs: At that point I was still thinking possibly about law school. But some things had happened while I was working in a real estate company. I was manager of a rental department at one of the oldest and largest realty companies in Memphis and going to school at night. We had several young lawyers on retainer who were very smart, but they were having a tough time making a living. So I wasn't sure that I wanted to do another 4 years of law school after the master's. So I applied, got the co-op job, and went to work. Two co- ops were hired, I might add. This was mid-June of '56. In early August, late July, Carl Hookings, who was the director of VD there, got a call that l of the co-ops was needed to go to the Mexican border to work with the Bracero Program. There was a pilot project being run to see if Braceros, who were Mexican agricultural workers, could be blood-tested for syphilis at the border. Then you could only have to follow up those scattered throughout the states when they went out from the border. Syphilis was the only blood test they were doing at that time. The Braceros were visually checked for syphilis and gonorrhea by a male nurse coming through. I was married with 2 children. The other young co-op was married with no children, and he made a long pitch to Hookings why it really wasn't in his best interest to go to the border. I didn't have any strong feelings, and I thought the program was going to be over with by the time school started back. So I went out to El Paso. The 2 kids stayed with their grandparents. My wife went with me. She was going to stay 2 weeks and then fly back and take care of the kids. She was a teacher in Memphis. Well, we got to El Paso, and she decided that she didn't really like the idea because the program was going to take longer than we thought. So we made a hurried trip back to Tennessee, got the kids, rented an efficiency apartment, and started work. And, believe me, in those days, things were a little different than working now-a-days. The Braceros came across the border at 6:00 in the morning, went out to the reception center, and we started work. They were processed through, and that meant a complete physical (in terms of looking at them, a chest x-ray, a blood test since we were there to do that), and then they were checked and recruited by the farmers, processed, and then went to the farm that afternoon. The Braceros were all young, male agricultural workers, who were coming in for limited farm work. So our day started at 6:00; usually we were through about midnight. The largest day of processing workers was 4,500 people who came through that kind of process all in one 24-hour period. We finished up in late September or October. And I returned to Memphis. The good thing about the Bracero Program was that Bill Watson [William Watson], who was then the Program Management Officer of the VD program, and I became quite good friends. In the spring, I had taken the federal service entrance exam and made fairly high marks on it. I had gotten a lot of job offers from other agencies, at a considerably higher grade than the VD program co-op salary. Bill and I talked about this, and then Bill had a long conversation with Johannes Stuart, who was in Washington then, and then Stu and I had a long conversation. The sum total of it was, by the time I got back to Memphis, I was converted from being a coop appointment to a regular appointment career status as a GS-5, as opposed to the normal GS-7. I used to kid Bill that at that time he was the longest co-op that had ever been, and I was the shortest co-op. I was converted in about 5 months. So I returned to Memphis. By the second year on the job, I was, as a GS-7, the federal city rep in Memphis for the VD program. I recruited all over west Tennessee and eastern Arkansas. I gave the people we brought into Memphis a rapid training program on how to draw blood. Then they went to the interviewing school in Atlanta, and then they were transferred throughout the United States. We hired some 50 people that second year in Memphis. Harden: How did you decide who was going to work out and who wasn't? Did you talk to each person? Griggs: I interviewed them all. I was the major interviewer at that point. There was not a central interviewing team; it developed later within VD for the large-scale interviewing. But we visited colleges, had an ad in the paper, and interviewed people. We tried to pick people who were resourceful, self-starting, understood kind of what they were getting into. Then in the summer of the second year, because the pilot project had been very successful on the border, I went back to El Paso, which was the headquarters of the program. Five reception centers along the border, El Centro, AA, Nogales, AZ, El Paso, TX, Eagle Pass and Hidalgo, TX processed the Braceros who were initially screened at three centers in Mexico. We had 1 assignee in southern California, 1 assignee in Hidalgo, Texas, and me. I covered the Nogales, Arizona, and the El Paso station out of El Paso. That was my first real exposure to international work. We visited down in Mexico at the reception centers. Mexico had 3 such places, where the overall health of the workers was checked before they came to the border. Harden: And this experience is what made you the logical person, I suppose, to be coordinator for the International Symposium on Syphilis and Treponematoses in 1960-1961. Griggs: Right. Harden: This symposium was bringing together people from all over the world, then, or the Western Hemisphere? Griggs: It was worldwide. There were about 1,500 people at the symposium, held in Washington, D.C., at the Sheraton Park, from some 65 or 70 countries. It was a large meeting, probably a first-class meeting, with translation in French and Spanish. There were lots of papers, a lot of coordination in terms of getting the people together, letters out for the invited speakers, establishing everything that goes along with a meeting of that size. I had left El Paso and gone to Houston as the city rep. Then I went from Houston to Atlanta, when I was interviewed for this job as the coordinator of the symposium. I was offered the opportunity to live in Washington and commute to Atlanta. The VD program had moved from Washington to Atlanta in '57. Or I could live in Atlanta and spend a lot of time commuting to Washington and New York. The other sponsor of the program was the American Social Health Association in New York City. And with Atlanta being a much better place to live than Washington, that wasn't much of a problem. That was a supposedly temporary assignment for 22 months to hold that symposium. At the end of that particular assignment, I went back into the VD program at headquarters as the Assistant Chief of Operations and Development. I had responsibility for the grant program, in terms of working with the states and the major cities in submitting and approving VD control grants. By now it's late '64. I got a call from Bill Watson 1 day, and he said, "There's going to be a program for smallpox and measles control, with USAID [US Agency for International Development] sponsorship and funding, that D.A. Henderson [Donald A. Henderson] is starting to get together, or and I'd like for you to go over and talk to D.A. about being the Program Management Officer and deputy of that program." So I went over and talked to D.A. Harden: And I understand that you had to do some selling about how to structure the personnel for this program. Griggs: D.A. had come out of the Epi program, and while he had had some exposure to Public Health Advisors, he had not really worked very closely with them at that time. I had to sell the idea of a joint effort with an M.D. epidemiologist and an Operations Officer. It clearly was going to be a program of operations, not just one of technical expertise. Harden: This is very important. Would you talk a little more and define what a Public Health Advisor did, how he was trained, and then explain if Operations Officers did the same thing or were slightly different? Griggs: The title "Operations Officer" was created for Africa, but they would actually have been civil service Public Health Advisors in the United States. The Operations Officer title was more descriptive for the African people than the title "Public Health Advisor" because we wanted it clearly understood that these guys were operationally involved. Just like in the Public Health Advisors in the United States, they worked with local health or state health departments or regional offices. But they pretty much had the understanding and expectation that they were responsible for getting the job done. Generally speaking, it was a situation in which, not that we can't do it, but how can we do it? In other words, if it needs something else, what do you need to get it done? Public health advisors started out just interviewing and running down contacts, and then moved up to supervisory positions, grant writing. In some instances, they were literally functioning as VD control officers. So it was a multitask, multifaceted background and job. I might add that growing up on a farm didn't hurt any, either, because it was all of the kinds of things that you have to do in getting jobs done. And if I may digress for one second, we had a problem out in El Paso, in terms of who was running the public health aspects of the bracero program. When we got there with 4 people, the quarantine people asked where the other 20 people were. But we couldn't slow down. We had to run these people through at that speed. So we had to work out a system that would let us, with 4 federal employees and a couple of local hires, handle that-drawing bloods and processing them; getting the results shipped to Austin and back again. So there was a lot of that kind of thing that came along. So I was used to multitasking and making do with what we had. Harden: So after you convinced Dr. Henderson to have Operations Officers in the smallpox program, what was the next step? Did you have to go out and hire people? How? Griggs: When I started with D.A., probably in November, there was an expectation that there was going to be a program, but there was a daunting list of things that had to be done before July 1966. When we started, no project agreements had been signed with any country in Africa, and there was no project proposal. We had to recruit personnel. We had to negotiate a PASA (Participating Agency Service Agreement), which would provide the funding for the program. We had to negotiate project agreements with Country- Specific Plans for each country in Africa. This would require an agreement between the US Government and each of the Ministers of Health of those countries to do the program. We had to develop a training program for the new employees to begin in July; it had to include language training as well as epidemiology and technical matters. We had to develop needs and specifications for all materials that would include quantity and quality and develop the Requests for Proposals (bids) for the equipment. We had to develop a comprehensive Manual of Operations, both technical and operational (which WHO latter took and issued it as though they had written it!). We had to develop the knowledge required to write individual country agreements that would be negotiated and signed by the host countries. All of this went on simultaneously. And we did it! I think D.A. came around relatively quickly to understanding the need for the Operations Officers. He and Henry Gelfand, who was one of the other physicians in the office then, did a fair amount of interviewing physicians. Not only were we looking within the current EIS class, since we had the opportunity to get the young docs who came to CDC as an alternative to serving their draft time, but we were also looking outside of the Commission Corps. I might add that we got some very outstanding physicians that way. Don Hopkins [Donald R. Hopkins] was an individual who was hired as a physician from outside of the EIS, a direct hire. We also hired several more experienced physicians who went overseas. In most countries, the model was to have a physician epidemiologist and an Operations Officer. In a few of the smaller countries, the physician epidemiologist served 2 countries with an Operations Officer in each country. In Nigeria, because of its size and complexity, in addition to the headquarters office in Lagos we had multiple docs and OOs. Harden: My understanding is that there were an awful lot of details regarding the equipment that had to be used in the project. You had to deal with trucks, with doing procurements for trucks that were U.S.-made, getting them rigged up to have refrigerators for measles vaccine. Can you tell me about what all you had to do at this time from that standpoint? Griggs: Well, we had the benefit of a little bit of history of this. To backtrack 1 second . . .When measles vaccine was first in the process of development at NIH [National Institutes of Health], the Minister of Health from Upper Volta came over on a leadership grant visit. He was being shown the measles vaccine, and he said, "Measles is a major killer of children in my country, and I would like to offer my country as a place to field test the measles vaccine for you." So in '63 or thereabouts, the USAID signed a project agreement with Upper Volta to go out and do several hundred thousand measles immunizations. CDC was asked to provide an EIS Officer to work with Hank Meyer of NIH as an advisor in the field for this team. USAID provided some trucks and the Ped-O- Jets (foot-operated hydraulic instruments that give an injection of the vaccine) to use the vaccine with; Merck, which had the measles vaccine, provided the unlicensed vaccine. And the program went to Upper Volta. The first year, it was more successful than expected. I think they did about 700,000 vaccinations, and the next year the measles incidence in Upper Volta just dropped off to practically nothing. So the surrounding countries said that they would like to have a measles program, and USAID was negotiating to do that. They asked for 3 or 4 EIS Officers, and the program was expanded to 2 or 3 countries. The second year, they did not do the program in Upper Volta; they did the surrounding countries. The third year, Upper Volta got measles back-right back where it was to start with. So it was known early that in order to be successful in measles, it was going to require a fast-hitting, multiple repeat because the birth rate was so high that you built a new supply of susceptibles each year. So the reason the smallpox program actually came into existence was that USAID come back to CDC and said, "We would like to have a major measles program, and we need 20 EIS Officers to be assignees to work with these countries on doing this." And D.A. picked up on this and said, "Measles is going to be a never-ending problem." So D.A. proposed the business of adding smallpox eradication to this measles program for West and Central Africa. The idea of pushing for a global smallpox eradication program had come up in WHO [the World Health Organization]. And this part of the world was probably going to be the toughest to try to do it in. So it was proposed as a 19-country program, starting in Congo, and over to Chad, and Central African Republic, the whole West and Central Africa. That, USAID would consider doing. We were putting together this proposal as to what it was going to cost for such a program-this was the project agreement proposal that I was talking about earlier. For that proposal, based on what information was available from the old measles program, we had to determine what kinds of vehicles were going to be required for each country, what kinds of vaccine, how much refrigeration space, the whole bit. This was all calculated into this project agreement for each individual country. It totaled up to a $46 million, 5-year eradication program for smallpox and control of measles in the 19 West and Central African countries. Subsequently, the other, 20th country was added, which was Fernando Po, which became Equatorial Guinea So we did our best guess as to needs on the basis of the life expectancy of the trucks, in terms of replacement on a 2-year basis; the life expectancy of the Ped-O-Jets; etc. All of this was listed by country. We started with 16 countries the first year. The second year we added 3 countries, Sierra Leone, Guinea, and Liberia. The third year, the 20th country was added. Harden: When you had to estimate the life expectancy and plan for the budget, were you correct? Did the items last that long, or longer, or not as long? Griggs: Well, we had some problems with vehicles that had not been expected. The Dodge truck was the vehicle that was chosen by bid. Bids were requested from Dodge, GMC, and Ford, and Dodge won the bid. And it was an eminently suitable vehicle. I was familiar with Dodge and was pleased that they won the bid. But we ran into the difficulties with the roads. This truck, being a long-bed crew-cab, had a lot of weight on the 2 axles, so a lot of axles were broken in Africa. And while we sent over with each truck each year a best guess as to what was going to be needed for repair, replacements to keep the vehicles running, it soon became apparent that we needed a system that would provide rapid turnaround in emergencies because if a vehicle was down, everything came to a stop. So we negotiated with an Atlanta Dodge dealer, a parts replacement general contractor, on a task order. We could just order what we needed, and it would be air- freighted to Africa. We would get a cable saying, "Gotta have this," and that day it was ordered and put on an air freight shipment. And it was usually in Africa in about a week, 10 days. Harden: And who actually did the replacement of the part? The Operations Officer? Griggs: Yes. But I'm getting ahead of myself a little bit. Going back to the spring, when we were writing these agreements, we actually had people start in late spring-Henry Gelfand, for example. And George Lythcott, who was a doctor working on a program in Ghana from NIH, was selected as the director for the regional office to be established in Lagos. Mike Lane [J. Michael Lane] and a couple other people were visiting the countries, negotiating project agreements, explaining the program, moving towards getting signatures. After the participating agency service agreement had been signed with USAID and it was a pretty sure bet that we were going forward with this, we started recruiting people and started security clearances on doctors and Operations Officers. They were to report to Atlanta the first of July to go through the EIS course, which was normal training for that period. And then these recruits were to stay on for an additional training course in smallpox activities, in which there was a mechanic's course. It was lengthier for the Operations Officers, with a shorter version for the Medical Officers, to learn all about these Dodge vehicles and how to repair them. Now, keep in mind that the repair of the trucks was the responsibility of the host country. I mean, their facilities, their mechanics, supposedly. And they had had some exposure to Dodges, but not a lot. But the Dodge turned out to be a very good vehicle. I was last in Africa shortly after retirement in 1989, in Togo, and I saw 2 of the Dodge trucks that had been there. The last one was probably sent to Africa in '70 or '71. And in '89, 2 of them that I saw out in the field were still running. Harden: Let's talk about going to Africa. Being the headquarters operation, you had to help all these people get settled in all these different countries. How did that work? Griggs: After the decision was made to have a regional office in Lagos, we were going to send 9 people there. We had a young, not brand- new EIS officer who was going to be the epidemiologist. George Lythcott was going to be the director. Jim Hicks [James W. Hicks], a senior Public Health Advisor, was going over as the administrative officer. Bill Despres [William Despres] was the assistant administrative officer. We also had a Muriel Roy, a US secretary, Gordon Robbins, as a health educator and Nat Rothstein [Nathaniel Rothstein] as a virologist. We were going to be there primarily to work with the vaccine production facility, to develop a creditable one there in Lagos to make smallpox vaccine. We also had a statistician, Davis [Hillard Davis] and Bill Shoemaker as an equipment specialist. So 9 people were sent there. And they were to provide a nucleus of expertise. They could rapidly get from Lagos to the surrounding countries in those various areas statistics, senior epidemiologic skills, or an administrative function, or whatnot, rather than trying to have all that kind of expertise in each country or from CDC. I first went to Africa in the summer of '66, with responsibility for working with the Department of State, embassy, and USAID, in terms of lining up office and housing space for the regional office people. We located offices, prevailed upon USAID to sign the contracts for the offices and houses. An activity out of Washington, called the regional office, had the responsibility for several of the smaller countries. So really all of the administrative sorts of activities were handled by the embassy, on agreement between USAID and the embassy and those countries. Providing office space was the responsibility of the host country, and they actually had an office in the Ministry of Health, or in an appropriate health building with the Ministry of Health. And the housing was provided by the US Embassy on a contract basis. Harden: And that worked out okay? Griggs: Worked out fine. Harden: In 1966, D.A. Henderson moved to Geneva, with WHO, and Don Millar [J. Donald Millar] came back from London to take over, is that correct?. Griggs: Don had been at the London School of Tropical Medicine, getting a degree, and he came home in the summer of '66. Don was missing during most of the preparation for the smallpox program. He got back just as we were getting folks to start. Harden: And I have a quote here that you said to him, "Welcome to the NFL." You want to explain that, and talk about how it was to shift from 1 leader to the other leader? Griggs: Well, Don and D.A. had a considerably different management philosophy, I guess you would say. I didn't know Don. I may have met him, but I had not remembered meeting Don until he showed up at the office coming back from England. We hit it off quite well. Don was completely unexposed to the operations office or the Public Health Advisors, but he quickly saw their value and was a champion of the Public Health Advisor throughout the remainder of his career, even after he became Director of NIOSH. So after Don came in, the program was moving right along, in terms of the training activities; project agreement signings were slow. We had planned on sending the first people to Africa in September to get things kind of on the road at the end of the rainy season and be ready to start at the beginning of the dry season. The last pro-ag [USAID term for a project agreement] was signed, I think, in March of '67. There were considerable delays in getting all of these, and there was some very fancy footwork involved in getting pro-ags signed. It's too bad that George Lythcott's not here. George was a master at getting things done in Africa. I won't say how, but he wound up getting an appointment with the head of the government of Nigeria at the time after the coup. And he got a commitment that the pro-ag would be signed, and it was signed. That was the big one, with the regional office going into Nigeria and the 3 or 4 regional assignments within Nigeria. And because of its size and complexity, northern Nigeria had a Medical Officer and 2 Operations Officers. It had a male and a female Operations Officer, the only female Operations Officer we had, because of the expected difficulty of working with purdah, in terms of getting the women vaccinated. And it worked out quite well. Harden: What was her name? Griggs: Vicky Jones [Clara Jones]. Harden: Were there any unusual occurrences that you can think of that you can tell me about? Griggs: There were so many things that were happening. We had some problems with 1 individual, I recall, who had difficulty with a security clearance. He never got it cleared, so he was very unhappy. The people who were sitting in Atlanta with families, living in temporary quarters, and being delayed about going overseas, were considerably unhappy. Harden: And this was all coming back to your desk? Griggs: Mine and Don's. For the docs, it would go to Don, and Don would come to me. If it was the Operations Officer, he'd come to me, and then we'd try to get it resolved. Don and I went to Nigeria, for a meeting-it was after the program had started. The folks who were in Africa came to it, and they were less than happy campers, I guess is a good way to describe it. For a variety of reasons. During the training session, because of the cross-cultural problems they were going to be facing, we tried to give some insight into the things, the do's and don'ts, or at least, "Think twice before you do it" type things. And I remember very vividly, one of the wives who had been aghast at the thought of having a cook, a nanny for the kids, a gardener, and a night- watch person, and maybe a small boy for the kitchen, depending on how many kids they had. This was the typical number of servants a family would have. She didn't want that. But when she got to Africa, she was very unhappy because she was in an apartment. (We lived by the ground rules that the American embassy had, that folks with no children and single people were usually put in flats and apartments. If possible, families with children were given a house with a yard.) So when Don and I got to Yaounde, this woman was very unhappy because she was in an apartment when other folks had houses. So the uptightness about the ugly American with hiring the people and going to the market and sending the local hire to the market to buy food and whatnot, and not shopping for themselves, soon became a thing of the past. People realized that they just couldn't cope with that kind of activity. Harden: Very interesting. What was the toughest problem that you recall in this whole endeavor? Griggs: Oh. I hadn't even thought about that. I guess what caused the most consternation were the delays in getting project agreements and getting people out there, ready to go. Harden: So the beginning was [the hardest?] Once it was going, it was [ok]? Griggs: As you can imagine, people have a tendency, if a program says they're going to do 300,000 vaccinations, to want 400,000 doses of vaccine because they're going to have some loss at the end of the day. (Vaccine that is opened is discarded at the end of the day.) So they ordered more vaccine than they needed. Or some didn't order enough vaccine. It was a problem trying to second- guess people in the field, or respond back and forth to people in the field about what the realities of the program are. For example, you've got to have the vaccine, you have to discard it if it's at the end of the day, but if there are only 2 people left and you're going to be there in the morning, you don't necessarily open a large vial of vaccine to throw away-that type deal. And the business of getting the parts. Having been in the field myself, I know it's never fast enough. "How come I didn't get it yesterday?" is the attitude. So there was a certain amount of confusion and consternation constantly. But the program had a budgeted cost of $46 million. It was completed at a cost of just over US $30 million-largely through some good work on the contract officer's part, being innovative and looking at alternative sources for things. So it was $16 million under cost, and it was completed in West and Central Africa a year ahead of schedule in terms of smallpox eradication. Harden: That is an amazing story. Tell me about the bureaucratic relations between headquarters in Atlanta and the regional office in Nigeria, in Lagos. Griggs: Sore point. The regional office was designed to start with as a resource of experts to be available for the countries. I wasn't involved in recruiting George Latchet, so I don't know what was said to him. George felt that the regional office was the director and that Atlanta was to provide support to the staff in the Regional Office. This misunderstanding was resolved, I think amicably, and George stayed through to the end of the program, and I think he was satisfied. He would have much preferred to have been running the program, but I don't know how to say much more about it than that. Copies of memos and reports went to the regional office so that they were aware of what was going on, but things did not go through the regional office to be signed off on. Dave [David Sencer] just walked in, and I 'm sure that he may have a different story about this regional office conflict, but it was resolved. People were not ecstatic over the way it resolved, but the program operated. Harden: If you were going to undertake the program again, would you do anything differently? Griggs: Knowing what I know right now, I might do something differently. Not a lot. This doesn't sound right coming from me, but we didn't make a lot of mistakes in the smallpox program. Things were thought out, were worked out. We had a couple of people who I might not have recruited, but we didn't bring anybody home for improper action, or for not doing their job. And to have had 46 people in the field at 1 time-and overall, I've not even looked at the number, but probably with replacements, probably 60 or 70-people overseas-and not to have had somebody that didn't work out? We had a medical evac [evacuation] or 2, now. But I 'm talking about bringing somebody home for either being unable to carry out their work or the host country's saying, "Get this guy out of here"-that just didn't happen. Harden: That's also very impressive, is it not? Did you ever have any doubts that the program was going to be a success? Griggs : No, none, after it got off the ground, in terms of smallpox eradication. Success in terms of measles control? An awful lot of people thought it couldn't be done. It was proven that it could be done with the right kind of input. Bob Helmholtz [Robert C. Helmholtz] ran the program in Gambia out of Senegal, and Tom Leonard [Thomas A. Leonard] doubled with Bob in Senegal for a short period of time. Tom was in Mauritania, when the '68 conflict occurred there, and the US Government left. Tom went and finished his tour in Senegal, but The Gambia had a good person who was in charge of the program, had a Minister of Health who was very much in favor of this. It was a small enough country, and while it was had poor roads, it had a river that ran through the middle of it, and you could get up and down the river. And The Gambia interrupted measles transmission and kept the country measles free for a couple of years. So it could be done. But it required an awful lot of effort, and I don't think Africa was ready for that effort. But smallpox was a success. Harden: How did you all, in headquarters, deal with the feedback you were getting, in terms of your conversations? The feedback from the people on the ground, and what you then said back to them? Griggs: There was a weekly newsletter that went out to all the field staff, which was kind of folksy. It originated in Atlanta. Don dictated material for it, and I added to it. It covered what was going on, what the problems were, what some solutions to problems were. There were lots of phone conversations. In those days, you connected to French West Africa through Paris, and English West Africa through London, with a radio call from there on down. So you started out with a voice that they could hear at least 2 floors above you, to build up impetus on the radio, and after a long conversation you almost lost your voice sometimes. Harden: What do you think that the Africans learned about CDC and about America from this program? Griggs: Some of them already had exposure to CDC. They had been CDC EIS officers in with the measles program a little bit earlier. The Operations Officers were told that their responsibility was to get the job done, but not to do it. If you do it, if you're out on vacation or out sick, things are going to go to hell in a hand basket quickly. So while it's much more difficult to train your counterpart to do the work, it's worth the effort if you want something left when you are not there. And you could very quickly see the difference when this philosophy was accepted and followed through on, as opposed to when work was done directly by the Operations Officer. Harden: So that was a legacy, then, that was left from the program? Griggs: That was a legacy that was left. To each of the training programs each year, we brought a cadre of docs and nurses. Now, Africa had a few docs, but most of the actual field activities of the program were carried out by nurses or kind of an African Operations Officer, if you want to call them that. A group of those came to Atlanta each summer-probably at least 100 people over the 5 years. The last year of the smallpox program in Africa, when the CDC people were brought home, was '71. USAID wanted to follow up with a program for childhood immunizable diseases. Such a program subsequently came to CDC, through a participating agency service agreement. And the activities, the countries that were involved in this were virtually the same as those involved in the smallpox program, with some expansion into eastern and southern Africa. So, all in all, I would think that from the standpoint of foreign relations-forget about the health aspects of it-the money spent on the smallpox program was probably better or equal to anything that was spent otherwise. In the 20 countries, there were a lot of coups and counter-coups, changes of government, and a civil war in Nigeria right in the middle of starting the program. And no one was evacuated except the team that was in eastern Nigeria. But in terms of a coup and a change of government, the smallpox and measles program proceeded as if nothing had happened. Harden: What impact did the program have on your career? Griggs: Hard to say. I guess it was probably good. Dave Sencer came in as the Director of CDC during the program, and I could have said this better if he wasn't in here, but I'm going to say it anyway. The smallpox program was accused of being Dave Sencer's pets, the fair-haired boys, but I might add that when Don and I, or subsequently after Don, when Bill Foege [William Foege] and I went to Dave and laid out what we needed, Dave bent over backwards and gave us what we needed, to the extent possible, and it was sufficient. Harden: Did this program have any impact on your family? Now, you were here in Atlanta primarily; you visited Africa but you weren't living there. But how did your family think about it? Griggs: I had a good wife, who understood being gone 3 weeks at a time. George Lythcott tried his damnedest to recruit me to go to Africa, to the regional office. And I turned him down. And obviously he had talked to D.A., and maybe to Dave, and I think they turned him down. Other than being away from home a short period of time, while I was in VD, I was home on weekends. But I traveled more days when I was working the 50 states than I did when I was working Africa. Harden: Did any of your children go into health-related work? Griggs: No. Harden: Not a one? Griggs: Not a one. As a matter of fact, my son may have had a negative impact from this. He was, I think, pleased with the work that I was doing, but he was adamant that he did not want to work for the government. I don't know who brainwashed him. Harden: Very interesting. Is there anything else you can think of about the program that we should capture in this interview, before we stop? Griggs: Well, I'm sure that Don Millar and others will say it better than I would, but the things that were really learned about doing immunization work from the smallpox program, in this country as well as other countries, have made a big impact on US activities, as well as on international activities in other countries. Obviously, D.A. was head of the smallpox program in Geneva. West and Central Africa cleared up right quickly. It was obvious that some problems were occurring in India, Bangladesh, and other places. CDC people from the West Africa program went overseas into many of those countries, to either get them kick- started or to stay there and wind up. In Bangladesh, India, Andy Agle was in Afghanistan, so it was a maturing of CDC's international venture, I think. While CDC is a domestic organization, when I left CDC we had people assigned in probably 25 or 30 countries around the world, through WHO or through other avenues-the World Bank, UNICEF, etc. And this has contributed, in my estimation immeasurably, to other health activities. I think the Gates Foundation's work in international health goes back to the smallpox program. Bill Foege was a missionary in eastern Nigeria, and I guess was happy when we recruited him to be a contract doc for eastern Nigeria for us. And when he was evacuated, we brought him back here, and he became one of the lead people in smallpox. When Don left, Bill of course became the director. Went back to India for the wipe- up on that. I'm sure, no question in my mind, that the Bill Gates Foundation would not be doing what it's doing, if it were not for Bill Foege. Harden: Thank you so much for speaking with me. ### </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/u3ZkP0e4TzI" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-07 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15n65 emory:15n65 Subject The topic of the resource CDC Smallpox Eradication USAID WHO Operations Officer Format The file format, physical medium, or dimensions of the resource 13350960000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harden, Victoria (Interviewer) Griggs, Bill (Interviewee); CDC Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource GRIGGS, BILL Description An account of the resource Bill Griggs started his career as a Public Health Advisor in the Venereal Disease Program of CDC. He became known as a person to turn to in order to get something done. When the Smallpox Eradication effort began he was assigned to recruit people to act as Operations Officers, a concept that was new to international health programs. Bill was Assistant Director of CDC for International Health at the time of his retirement. Language A language of the resource English https://www.globalhealthchronicles.org/files/original/f1eec475aead321aab77fd9586897e4b.jpg ed27ff0a478edeff2ae768916d4b0e70 https://www.globalhealthchronicles.org/files/original/d08991f0e2870b095f71d695a274516a.pdf f3de315218b237c7fc13e8d2a0699437 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> This is an interview with Jean Roy about his experiences in the West African Smallpox Eradication Program. The interview is being conducted on July 13, 2006, at the Centers for Disease Control and Prevention. The interview is a part of the 40th anniversary celebration of the launching of the project. The interviewer is Victoria Harden. Harden: Mr. Roy, would you briefly describe for me your childhood, pre- college education, and talk about influential people-friends, parents-in your life. Roy: Yes. I was born in Maine, in 1941, and grew up there, went to primary school there. And then I went off to Pennsylvania for high school, at a Catholic school in Scranton. I had read a book earlier-oh, I must have been 12 years old-The Keys of the Kingdom. I'm Catholic, but it was about Baptist missionaries in China. And I was fascinated by life in China, and the Chinese. And if you know something about Maine, there aren't many opportunities economically, for jobs, and so on. People either went into the Foreign Service or became missionaries. Throughout my life and career overseas, now, I've run into so many Maine natives who were part of the foreign service, working for USIS [the US Information Services], or are missionaries. So that was my background. So I wanted to be a missionary to China. So I went off to Maryknoll College, a Catholic college in Glen Ellyn, Illinois. It was associated with Loyola University in Chicago. I was intending, always, to become a missionary. By then, China was closed because of the communist revolution, so I aimed towards Africa. Now the college campus happened to be on a former golf course, which had been taken over by the seminary college. And, of course, I was addicted to golfing. But I made a tragic mistake one day by going golfing with the sister of a colleague. And as a future Catholic priest, this was a real no-no. I got called in and disciplined, and asked, "Why were you out there? Think of what the public will think, a young seminarian out playing golf with this young lady on a Sunday afternoon" (which was visitors' day). And that's when I started to rebel. I thought, "Do I really want this kind of life?" So I graduated, got a degree in philosophy, and then said, "What am I going to do for the rest of my life?" And this brings me to the Peace Corps. After being in the seminary for 8 years, I still wanted to go overseas. This was 1963. John Kennedy had just announced the formation of the Peace Corps. So I sent in my application to Washington, thinking I would never be accepted, but at the time they liked idealists, and they liked the seminary background, and I got accepted. I was assigned to West Cameroon, in West Africa. Harden: Would you tell me what you did in Cameroon between 1963 and 1966, when you got into the smallpox program? Roy: Several things, and it all has a relationship with the work I've done in the last 40 years. 1963, if you recall, was the year that measles vaccine was licensed in the United States. And that's the year they did trials in Upper Volta, which is now Burkina Faso. As a Peace Corps volunteer, I knew nothing about public health. I knew all about philosophy. I spoke French-I'm of French Canadian background, so that's where the French influence came in-and that helped me to get the assignment to French West Cameroon. West Cameroon is English-speaking, but there's also a larger section of the country that is French- speaking. My assignment was actually to start the first Federal Bilingual Grammar School in the Cameroons. In 1961, West Cameroon (British Cameroon) was part of Nigeria until the U.N. referendum when the citizens voted to leave Nigeria and join East Cameroon, which was of French colonial descent, French-speaking, and much larger. The Ex- British Cameroon tribal groups were much closer to the French ex- colonial Cameroon, and it made sense to vote to join together. The French government then poured massive amounts of aid into the British Cameroon, to make it French. British Cameroon, with 1 million people, was a very small sliver of land between Nigeria and the Eastern Cameroon section. The British Cameroonians drove on the British side, they used the common law code, used the pound sterling. Just a few miles away in the French section, the French franc and the Napoleonic code of law were used, and they drove on the American side of the road. The referendum changed everything in the former British territory. I was there just when all of this was changing, and naturally the 3 million francophones dominated the 1 million anglophones. But the French started something that was very clever. They were going to make all Cameroonians bilingual. 1963 was the first year of the first bilingual grammar school, a pilot effort to merge a French lycee with a British grammar school curriculum. I was the first foreign teacher on the campus at Man O'War Bay, which is famous for the slaving interceptions. The British Man O'War used to anchor in the small bay on the coast of Cameroon and intercept the slaving ships after the British outlawed slaving. It's a beautiful site, at the foot of Mount Cameroon. It's a wild, wild place, very much like Hawaii, with volcanic peninsulas into the ocean. Te setting was that of a former Outward Bound camp that had been turned into this new secondary school campus. So there I was, the only person who had a driver's license, so I got to drive the school's only Land Rover and serve as Chief Administrator. I actually became the Assistant Principal. This was September 23, 1963. Within 6 weeks, 35 students came in from the anglophone sector of the country, and a few weeks later, 35 students from the francophone side. And that was the idea. Every year for 7 years (it was a 7-year course), 35 students from each sector joined to learn the other sector's colonial tongue, until they were well-versed in the other language to be mixed. By graduation, the students had reached the equivalent of a second year of university-high school plus 2 years. Today, there are many bilingual grammar schools, or lycees, and 3 very large bilingual universities in the Cameroon. And these young men are now ministers, diplomats, teachers, and doctors. The notable thing, though, was that it was September 23, 1963, when John Kennedy sent us off to Africa, and on November 22, that fateful day, I still did not have a short-wave radio. I was 7 miles from the nearest town and had no bicycle or motorcycle and still did not have access to the Land Rover. Late Friday afternoon, I believe, on the 22nd, an African came running up to me, and he was saying, "Your President, your President is dead." I had no idea what he was saying. It didn't register. He didn't know very much, but he must have heard it on the radio, and all day Saturday I wondered what had happened. On Sunday, still being a good Catholic, I walked my 7 miles through woods and over 15 bridges to go to the main town for church, and at the same time I visited the Peace Corps volunteers at the girls' school in town. I walked into their house; they were all sitting on the sofa crying, and I said, "What is going on?" And someone said, "John Kennedy is dead." Immediately the next day, I took my 4,000 or so West Africa francs that I had saved and bought a short-wave radio. But that was the beginning of the Peace Corps. I spent 2 wonderful years, working in an administrative and teaching capacity, doing all the things to make a school work. But the special thing that I remember was the vaccine trials, the measles vaccine trial. Africans were talking about it because measles had always been the greatest killer of children in Africa. And this vaccine was like a silver bullet, a magic bullet. After the Peace Corps, I returned to the States. I sort of enjoyed the idea of the bilingualism, and I went off to get a master's degree in linguistics at Columbia University. That was 1965. I was back in New York City, and I said, "Great, I'm back in civilization." John Lindsay was the mayor. I was thinking, "Gee, that'll be great. I'll have newspapers again, I'll have running water again, I'll have electricity again." What happened between September '65 and June of '66 in New York City? The railways, the metro strike. The huge metro strike against Lindsay. Then came the first ever newspaper strike in New York City. And for long periods, I said, "This is like Africa." And then the blackout occurred. The most famous NYC blackout. I was at Columbia University; I had an exam that night, which I didn't take. So I said, "Gosh, I came back to the biggest city in the United States, and it's more like Africa than Africa." I worked in a halfway house with the Presbyterian Church to earn my living. So I started with the Baptist Chinese missionaries, and here I was in New York City, working with the Presbyterian Church, helping them out. I was just doing their Sunday bulletins. I was a great typist, and again, doing administrative sort of things. The Peace Corps was excellent about helping us find jobs and careers. And every month, we'd get a "Green Sheet," we called it. It contained all the job announcements from universities, foundations, private corporations. At that time, everybody wanted returned Peace Corps volunteers because they were thought to be serious, and so on. And 1 month the Green Sheet had an announcement for this institution called CDC. And I said, "Gee, that's the Cameroon Development Corporation." The Cameroon Development Corporation is now called the Commonwealth Development Corporation, but it was an old British colonial company, which had large plantations: palm oil, bananas, pineapples, rubber trees, and many other products in Cameroon. So I read that the CDC is looking for somebody for Africa with French-speaking ability, some administrative experience, and previous experience in Africa. I said, "Boy, this is great." But then they had all the public health requirements, and I said, "Oh, this will never work." I also had another wonderful job offer, after I' received my master's in linguistics. USIS was starting up English language schools throughout the world at the time, in 1965. USAID [US Agency for International Development] gave the contract to a group; it may have been the Academy for Educational Development in Washington. But they were hiring a director of English language schools, English as a second language, for Leopoldville, in the former Belgian Congo, Kinshasa. I was accepted to be the director there, so I had a choice to make. I decided to apply to CDC, and eventually did get recruited, but perhaps that's where we can start talking about CDC because it's an incredible saga of how I jumped ship from linguistics to public health. Harden: This is fascinating. Is it unusual for CDC to recruit from outside, and what made them decide to recruit you? What qualifications did they want? Roy: Excellent question. It was a lot of luck on my part, a lot of trust and risk-taking on CDC's part. And I hope it was worth it. I. For me, it was. CDC had recruited, I think, something like 60 staff people to go to the West and Central Africa Smallpox/Measles Program, which USAID was funding in 1965. The idea was to send epidemiologists and Public Health Advisors paired together-the Public Health Advisor as an Operations Officer, to make things work-what I used to say (and Public Health Advisors didn't like it), the manpower part-and the epidemiologist for the brainpower part. However, to be fair to my colleagues, we had brainpower as well. But it was a great combination of having the epidemiologist and the Public Health Advisor. So they'd already recruited the epidemiologist for the country that I eventually was assigned to, which was Dahomey, now called Benin. It's just west of Nigeria, and east of Togo, sandwiched in between Togo and Nigeria. It is just a sliver of a country, with, at the time, 1.5 million people. Not very large. But the first Public Health Advisor that CDC recruited had a heart attack. So he had to decline. So D.A. Henderson [Donald A. Henderson] and Leo Morris and Billy Griggs, who were all trying to put a staff together for West Africa, went on to their second candidate, who accepted the job. He was a traditional, well- trained Public Health Advisor, a VD [venereal disease] type, as we called them back then. And he was raring to go, but his wife says, "Oh, I'm not going to Africa, I can't move the family," and so he declined. At that point, there were very few or no Public Health Advisors who had been trained, and who had come up through the ranks at CDC from the '50s, available to go to Dahomey, and that's when CDC, Leo Morris, and D.A. Henderson reached outside, and they eventually hired 3 Public Health Advisors from outside: me, Mark LaPointe, and Jay Friedman, all 3, ex-Peace Corps volunteers. All 3 of us had French experience. All 3 of us had teaching or administrative experience. None of us had public health experience. So that was the risk, I think, and the trust. So anyway, they sent Leo Morris out to New York City to interview me. He came to the halfway house at the Presbyterian Church where I was working, on 36th Street, and we had an interview, then we went to the bar and had a beer. I remember saying, "Oh, I'll never get this job." Meanwhile, I had heard that CDC had commissioned officers. And again, what was happening in 1965? Vietnam. And you saw my career path to that date: I had been deferred because of the seminary. I'd been deferred from the draft because of the Peace Corps. I'd been deferred again because I came back to get a master's degree at Columbia. And I had an 81-year-old lady in Augusta, Maine, who was my draft board representative, who had been after me for about 12 years. And I thought, "How am I going to get around this?" While I was in New York, I visited an ex-colleague from Peace Corps Cameroon, who was an urban planner living in an apartment in Greenwich Village, and he said, "I'm doing my Vietnam duty." I said, "What?" He says, "Yes, I'm a commissioned officer. I don't wear a uniform. I go to work every day. He was a sort of a sanitation engineer, urban planner, and he fit right in to the category for the Commissioned Corps." So I said, "Boy, that's a fantastic way to do your Vietnam service." And then I found out that CDC had this Commissioned Corps, and I thought that perhaps I should put my money on CDC rather than the Leopoldville, Kinshasa, linguistic directorship. But meanwhile, just to protect myself, I took the Army Officer's Candidate test, and also qualified. I said, "If I'm going to Vietnam, I'm not going as a grunt, I'm going as an officer." Those were my 3 options at the time: the CDC, the Congo, the army. Leo Morris came, interviewed me, and D.A. Henderson sent a letter later saying, "We'd love you to join us, we'd like to assign you to Dahomey." I had visited Dahomey in 1964, when I was a volunteer, so I knew exactly where I was going, beautiful little place. So on July 6, 1966, I came to CDC. I was sworn in, along with Jay Friedman and Mark LaPointe. All 3 of us came on July 5, started auditing the EIS course, and started doing all the training to get ready for the smallpox/measles program. Harden: Did you know anything about Dodge trucks when you got here? Roy: No, that was great. We learned all about jet injectors, the vaccination guns, and Dodge trucks, with training down at the Chrysler Corporation down near the airport. We went together with Bill Foege [William H. Foege], Rafe Henderson [Ralph H. Henderson]. It was just amazing. I was 25 years old, and it was my first time in the South. I lived in a rooming house across from what is now the Rollins School of Public Health. "Ma Moates" had a typical clapboard house, a porch, just right out of any novel of the South of the '20s, '30s or '40s. Matter of fact, we had rocking chairs on the porch where Gordon Robbins and I spent many evenings. The Moates chewed tobacco, and each had spittoons in their living room; they both chewed tobacco. It had no air- conditioning, of course. So it was so humid that the ceiling over my bed fell on me while I was sleeping. Here, I was a Maine boy who had been to Africa, but arrived in Atlanta and found a whole new culture, way of life. I never dreamed that I'd spend the rest of my life based out of Atlanta. Harden: The summer of 1966, then, when you got here, you were sworn in, but were you a commissioned officer yet? What about your lady at the draft board in Maine? Roy: No, it took quite a while. I was sworn in as a civil servant and started the training. About 2 weeks later, July 10 or July 14, I received another letter from my draft board saying that in October I would get my final notice and I would have to report to Fort Dix. So I went to D.A. Henderson and said, "D.A., look at this. All this work you've done. I'm your number-3 candidate for this job. The first one had a heart attack, second one didn't want to go, and now I may not be able to go." Then I said, "But I hear you have the Commissioned Corps at CDC." And D.A. says, "Yes." And I said, "Well, do you think I could, you know, be accepted?" To which he says, "No, it's for doctors, dentists, nurses, statisticians, epidemiologists that have PhDs. If we do it for you-[Vietnam was getting other boys as well, and CDC was filled with Public Health Advisors of draft age]-we'd have to do it for everybody at CDC." So I resigned in July at the only time that Delta went on a massive 2-week strike, in the summer of '66. No Delta flights out of Atlanta. And I was supposed to leave. But then D.A. says, "You know, if you get commissioned, that's fine. But we can't do it for you. Do you know anybody in Washington?" I said, "Yeah, I know Ed." And he says, "Which Ed?" I said, "Ed Muskie [Senator Edmund Muskie. He's from my hometown, Waterville, Maine, and he knows my mother, knows the family, was a neighbor." And D.A. says, "Well, when you go back. . ." I was going back by Greyhound bus, so it took me a day and a half back then to get to Washington. I went to Ed Muskie's office and saw his secretary, Virginia, and told her the story. She said, "Ed's not here; he's meeting with Bill." And I said, "Bill who?" And she said, "Bill Stewart [William H. Stewart]. I didn't know who Bill Stewart was. And she says, "But let me give him a call." So she called, and told him that I was from Waterville, who I was, what I'd done, Peace Corps, blah blah, and smallpox eradication in Africa, and Ed told Bill, and Bill says, "Gee, that sounds good. Tell him to go over to the Commissioned Corps office, to fill out the form." So, great. I went over there and started to fill out the form. Which medical school did you go to? Doesn't apply. Which dental school? Doesn't apply. Which nursing school? Doesn't apply. Well, do you have a degree in chemistry? Engineering? Nyet, nyet, nyet. I signed it, dated it, and submitted it. Just before leaving Washington, I called D.A.-it was about 4:00 in the afternoon. I told D.A. that I'd seen Ed Muskie and this fellow Bill Stewart. He says, "Who did you say?" And I said, "Bill Stewart." He says, "Holy smokes." (D.A. is always saying "Holy smokes!") He reminded me "That's the Surgeon General." And I said, Oh, I guess, well I knew Ed Muskie was the sponsor of the Clean Air bill, the very first Clean Air bill, in 1965. And Ed was speaking with Bill when his secretary called about my situation. So I told D.A. that I filled out the form, but, I didn't think it's going to go anywhere. I then took the bus, went up to Maine, another 2 days on the bus. And then after about 3 days in Maine, D.A. called me. "Jean, do you want to come back to Atlanta? We think it's going to work." So I took the bus all the way back, 3 long days, because there were no flights. I came back and continued the program. I did all the training, the Dodge trucks, the jet injector, the French training, the statistics, and listened to all of the fantastic speakers from London, people who had been to Africa, the public health workers who had been working on sleeping sickness, and leprosy, and other diseases. They were just the greats of public health. They're all dead now, I'm sure. But just inspiring. That whole summer was just like a graduate Peace Corps training Program. My Peace Corps training had been 3 years before at Ohio University for 3 months, but this was just an upscale version of that training, which was absolutely fantastic. And here I was, a very timid, shy fellow from Maine. Although I'd traveled all over the world, I was still very timid and shy, but extremely impressed with CDC and what went on that summer. In September, everybody started going off to their assignments. The critical thing that everybody needed to have was a security clearance. You couldn't move until the whole family had security clearance because you were going with the US government. And 1 or 2 didn't get security clearance. After all the training, they had to pack up their children and then go back home and start a life again, where they'd left off before. Very disappointing. So we were all very nervous. I'd gotten security clearance from the Peace Corps, so I was a little optimistic, and I hadn't done anything strange, hadn't been burning flags or draft cards, like everybody else was doing. So September comes around and everybody went off to Africa. October 1, I got my draft notice. "Please report to Fort Dix October 17." And I went up to D.A. again, "D.A., here's my draft notice. This is it. And I'm still not commissioned." Three or 4 days later I was commissioned. Meanwhile, just for protection, Mark LaPointe, who's also from Maine and had a very similar background as myself with the same old lady on the draft board in Augusta, was commissioned as well. We did it at the same time. Jay Friedman was from New York City and he was not commissioned. He was not being hounded and did not need the commissioning, and so he did not get it. But both Mark LaPointe and I stayed 3 years in Africa as commissioned officers, fulfilled our military duty. I was sworn in, again, and then sent the draft notice back and signed it, Lieutenant JG. And that was the end of the story. On December 15, I went off to Dahomey, which had the second-highest incidence of smallpox in the world at that time. Harden: And you were commissioned at... Roy: At CDC for service to the Smallpox Program in Dahomey. Harden: So your commission of the Public Health Service was as? Roy: As a Public Health Advisor, literally. Or do you mean the commission title? Harden: Yes. Normally it's Assistant Surgeon, or Sanitary Engineer, or... Roy: It was Assistant Surgeon, more precisely, Junior Assistant Surgeon General. Harden: Some title they had made up that would fit. Okay. Roy: I don't recall. I was elated to have any title. The pay was not great, but the experience and the opportunity were fantastic. Harden: Tell me a bit about Dahomey, and what you found in terms of smallpox, and describe the people. Roy: Dahomey was a very small country, a sliver of a country, maybe 300 miles long, and 60 miles wide, 1.5 million people. And of course, I was 25 years old, and I'm thinking I'm going to have to vaccinate, with the Ministry of Health teams, all 1.5 million people. I was overwhelmed. Because that was the strategy: start at the coast, go up north, and vaccinate all the tribes, all the people, the cities, the towns, and villages. At the time, as I said, Dahomey had the second-highest incidence of smallpox in the world. Harden: And why was that? Roy: A lot of it was because of the fetisheurs. These are the medicine men. The people are of Fon origin. The Fon people are connected to the Yoruba people. And Yoruba is a tribe in western Nigeria. So the Yoruba Fon people are related. They practice voudoun, and the word voudoun comes from the Fon Yoruba language. The Haitians and Brazilians use that word because the slaves came from that area and brought the language. So the voudoun is very big in Benin, even today. In their mythology, there are 2 very important gods. The god of earth is one, and his power is called sakpata, which is smallpox. The other god is Shango, and the African-Americans talk a lot about Shango here in Atlanta, I've heard. Shango is the god of the heavens, the sky; its power is lightning. But sakpata is the power of the fetisheurs, who are sort of the religious representatives of the gods. They were responsible for purification and cleansing smallpox-infected people in villages. This was how they made their living. So, when smallpox broke out, the people normally went to their native medicine men, the fetisheurs, to find a solution. Smallpox was the scourge, of course, of the world, and of Africa, and Dahomey. During my lifetime, I saw hundreds and hundreds and hundreds of cases of smallpox. This horrible disfigurement. And the smell. I think everybody will tell you when you walked into a house with a smallpox patient, right away you knew it was smallpox, and not chickenpox or some other disease. The smell was very, very strong. And of course, total disfigurement, and pustules, and so on. But the fetisheurs would hide the smallpox patients because the villages paid them to heal them. So the only time we heard about smallpox is when it totally got out of hand. The fetisheurs did not have a vaccine. They did variolation. They would take scabs from some of the patients. They would dry them, grind them up, and blow them in the air. And so they would actually infect people. So they wanted to perpetuate smallpox. And we were there to stop it. So you see, we had a common enemy, and it was very clear, very, very soon, that this was a major cultural barrier to the eradication of smallpox. And that's when we started doing anthropological studies. Gordon Robbins, who was a health educator at our regional office in Lagos, which was an hour away, came and studied the situation. How do we deal with it? Sort of how we dealt with chickenpox. When I first arrived in December 1966 in Dahomey, I'd heard there was a massive outbreak of smallpox in the prison in the town of Ouidah, an old slaving town with a fort, and a big prison. So my driver took me there. I said, "Ah, I'm going to see my first cases of smallpox." I went into the men's prison, and they were all covered with pustules and vesicles. I quickly came back and told my epidemiologist, Bernard Challenor, who is deceased now, but he was a young, Barbadian-origin doctor- epidemiologist. I said, "Bernie, Bernie, there's a tremendous outbreak of smallpox in the prison." So he got into his vehicle, goes to the prison, comes back smoking a cigar, and says, "Oh, Jean, you've got a lot to learn about differential diagnosis. That's chickenpox." And that was the answer for the fetisheurs, and that's what ultimately happened. To make a long story short, over 2 or 3 years, as we gradually contained smallpox in Dahomey, in spite of and with the fury of the fetisheurs because we were taking away their business, they started focusing on chickenpox. And to this day, I'm told, chickenpox is what they're now declaring as the power, or the anger, of the gods, who punish you by giving you, not smallpox now, but chickenpox. And I bet you they still call it sakpata. There are still fetisheurs, there is still voudoun, highly practiced in Benin today, but I think that's one of the reasons why. Our surveillance was very, very bad, and as D.A. said, surveillance was the key to any disease eradication scheme. I wasn't a real great-I'm not even a good-epidemiologist. Thank God, that's why I had Bernie, and Rafe Henderson, and Mike Lane [J. Michael Lane], who would come to Dahomey and give the support I needed. But even with the French colonial approach to public health, which we used, the Service des Grands Endemies- very effective health personnel providing curative and preventive services throughout French West Africa, and which controlled yellow fever, leprosy, and the other major diseases, through their roving mobile teams. These ex-French colonial teams would go off for 3 months -with tents, cooks, you know, all the luxuries of home-with the French Medical Director, leading all the African nurses, who were very well supervised. They loved it; there was an esprit de corps, teamwork. After 3 months, they'd come back, rest a month, and go off. And at the end of a year or 2, they would have covered the whole country. It was a good outreach service. We used the same approach with smallpox, using those same teams that had sort of gone defunct because the French stopped supporting the colonial public health services when these countries gained their independence in 1960 and 1961. When I arrived in Dahomey, I found all these nurses, male health workers, laboratory technicians, who were ready to go out on tour, as they say, for 6 weeks, l month, 3 months. They were ready. They loved it. That was their work, and they were helping people. But for 2 years previously, they had done nothing. So when I arrived there and set up an office, I found 15 of these teams. And I had 15 Dodge trucks that arrived at port and started setting them up. And at age 25, this was an awesome responsibility. But I think all the previous experience in Cameroon and the Peace Corps really helped me. Great support from the American embassy. USAID was not so supportive, but they weren't too keen on the smallpox part, but they were keen on the measles part of the campaign. So I just replicated the training I had received at CDC in June, July, August, September. Then in December, January, February of '66-'67, we trained all these nurses, and then organized them so that we did the mobile teams again. Again, they would go out for a month, come back and rest for 2 weeks. Their mission was to use the jet guns and to vaccinate everybody from the coast, to the north, up to the desert. And of course, we'd done about a third of the country, so about 400,000 vaccinations, and we thought that was great. Today (2006), we are doing a million vaccinations a week now in Africa; in Kenya we did 14 million 2 years ago. But 400,000 back then seemed incredible. And everyone was doing that in all the countries in West Africa. But Bill Foege noted back then, "How come we still have smallpox where we vaccinated everybody?" It's because we weren't looking for cases. Our surveillance was not good. Just by vaccinating the masses, we were missing the people who didn't want to get vaccinated. The fetisheurs were hiding them. The fetisheurs were against us, and they were telling the population not to get vaccinated. So these were the reservoirs for smallpox. So Foege saw this, Rafe Henderson saw this, and that's when we started the strategy of search and destroy, using Vietnam language. Eradication-escalation. But again, we had this esprit de corps. Rafe Henderson came to Dahomey and said, "Let us try something." He said he wanted 12 motorbikes, 12 vaccinators, who he trained to identify smallpox, to go out and look at suspected cases. So this was the start of a very intense surveillance program. Rafe came and lived for almost 3 months in Dahomey. We got him an apartment. And I gave him free rein. I said, "Rafe, I don't understand this search and destroy stuff, eradication-escalation. Go for it." So I gave him a free hand, and I kept on running the regular operation, the systematic, rational, ancient method, which I hope is a lesson learned. Malaria eradication failed in the 50s because it was too systematic, too military, too rigid, not flexible, and every country did the same thing. That's stupid. You must be constantly changing, adapting. I think Bill Foege and Rafe did. That was the genius of those early days of smallpox: figuring out that mass vaccination is not the answer. Sure, for some diseases like measles that are highly contagious, you want herd immunity, and so on. But in this instance, it was search and destroy. So Rafe had his 12 motorbikes, his 12 vaccinator- the "dirty dozen," as we called them, and he had a great time. He had his Land Rover, and he would follow them, supervise them. They went off, and they would probably go to 12 different sites and report back whether there was smallpox or not. If it was smallpox, they would go right back and start the containment, vaccinating everybody in and out of the village, not let people out or let people in, and make sure that everybody was vaccinated. By doing this strategy, within 3 or 4 months, smallpox just started going down tremendously. And then, it was a secondary goal to vaccinate everybody. It was good policy to give vaccination to everybody because, again, for 4 or 5 years, we conducted surveillance, regional surveillance for smallpox to be sure that there was no appearance of hidden cases. So it was good to have as many people vaccinated. But the key to eradication was the search and destroy, the containment, and the flexibility to adapt to new diseases, new approaches, and not use the old ways. I'm very active in vaccination and public health in Africa today. And every time I see young people wanting to do things I did, I say, "No. That is totally wrong. Do not. You might have learned this as an MPH student, but no. What is the situation? Everyone and everything is different; it must be customized." Harden: Well, and one of the most important things that I have gleaned is that, not only figuring this out, but the importance of the logistical support of getting out into the villages, having those trucks and having them work, finding housing for these people. That it was certainly much more than a medical problem. Can you talk about that a bit? Roy: Absolutely. These are logistics problems. They're management problems. They're operational problems. This is very controversial, and not really fair to our medical colleagues, but a lot of the problems in public health today are because we've used a medicalized approach. Let's take HIV, for instance. I give this talk-I give it to old ladies, to governing boards of the British Red Cross, Belgian Red Cross, because I'm with the Red Cross in Europe, and I shock them. I say, "Do you really think that doctors and nurses in hospitals and laboratories can stop HIV? They can't." And remember now, I'm with the Red Cross, so I'm talking about civil society. I say, "The people in the villages are going to stop the HIV. Because to really stop HIV, you have to be in the bedroom. Are the doctors, nurses, hospitals, medical centers in the bedroom?" And then somebody, a Belgian HIV activist said, "No, it's behind the bus stop, too." And I said, "Well, are the doctors behind the bus stop, too, where you go for a quickie?" Smallpox was eradicated in Bangladesh and India because we removed the task from the medical community. We allowed thousands and thousands of ordinary people, with the magic of a bifurcated needle, to do the vaccinating. And you can learn that in 5 minutes. Tens of thousands of ordinary people, using bifurcated needles, eradicated smallpox. We must beware that what we think is a medical, a public health, problem, is really a people problem. You must change behavior. In my talks, I go through the helmets, the seat belts, the condoms. Those things have nothing to do with doctors and medical schools and hospitals. It is people behavior. Harden: But it's an awful lot to do with culture, and religion, and values. Roy: Exactly. Major lesson learned. I use the Kano experience for polio. There was a major outbreak of polio in Kano, Nigeria, and they've now exported their polio cases all over Africa, to countries that had not had polio for 10 years. And what was the problem there? I'm told that they perceive the vaccine to be an "American vaccine" (but it isn't; it's made in Indonesia) "to sterilize the Muslim girls so they wouldn't have babies." But actually, the vaccine is made by Muslims, in Indonesia, to vaccinate against polio. And of course I agree that in Nigeria maybe it was a political problem as well. But, this was not a medical public health problem. It was a communication problem. And had we spent, in the last 40 years, USAID funding, public health funds, on people rather than on consultants and white elephants of hospitals, I think we'd be further ahead today. In Kano, we should have spent our polio eradication money on schools, mosques, churches, people, Boy Scouts, Girl Scouts, and the Red Cross. As I say, people. If people know that the vaccine is good, they'll get vaccinated. Like measles: they know measles kills. But they don't see a lot of polio. Now they are, however, because they stopped vaccinating for 3 years, and there's a resurgence. And that has cost hundreds of millions of dollars. But just to get back to a point of the importance of people in public health, the polio-eradication effort would not have occurred if it had been left only to the medical institutions and the public health agencies. It was Rotary International, the ordinary business people out of Evanston, Illinois, with the help of CDC by assigning a CDCer there, because they said, we're not a health agency. They had raised $50 million in 1982. I was there at the Evanston headquarters in 1986, when Rotary was ready to give up. "We can't continue raising money for polio eradication because we're not a medical health institution." No problem. We'll give you somebody. And they went on to raise $600 million. Now, measles elimination is occurring in Africa as we speak. Shamefully it is 32 years after measles vaccine was introduced in Africa by the measles program. Africa is now starting to use measles vaccine in a big way. And that's because of the American Red Cross. We started in 2001. And of course, the cases have just gone down tremendously, a 60% drop globally and a 75% drop in Africa. Because measles was the biggest killer. It no longer is today. But it was Rotary, a civil society for polio eradication. It was the American Red Cross, a civil society, for measles elimination in Africa. Not a health institution. If we do an analysis of the really successful public health programs in the last 40 years, you will see that the most important common denominator was the people who are victims themselves. You must involve them, and I think it's a lesson learned for the future. Harden: So let's get back to smallpox. One question: if you were going to do the program over again, would you change anything? Roy: No. We had some assumptions to begin with, but we were very flexible. I think it was a brilliant group. I've had 40 years. I started with the Bill Foeges, Stan Fosters, Don Millars, D.A. Hendersons. I mean, how many people in this world have had that privilege? Especially somebody who didn't know any public health was not qualified at all for a job like this by standard rules. Today, if I tried to get into CDC with the qualifications I had back then, I would never get my foot in the door. You'd need an MPH and PhD, if not an MD, and so on. But I think they took risks; they had a lot of trust. They worked with the African governments. While our mission was with smallpox eradication, the African governments wanted measles vaccine. And again, ask the people what they want, and measles vaccine, which we thought was going to destroy the smallpox part of it, actually enhanced it because many more people were dying of measles than of smallpox. But smallpox was a threat to the Western world, to the Soviet Union, and so on. And so the world wanted smallpox eradicated, and sure, there were a few countries in Africa that had smallpox, so they were a major global threat. But measles was killing millions and millions of children under age 5, every year in Africa. But listening to the people, taking risks, being flexible, constantly changing, and learning, those were the keys. And I think the legacies of smallpox are tremendous. You would not have had measles control in the United States. We all came back, in '69 to '71, to the United States. Even as public health advisors, not epidemiologists, we knew a heck of a lot about surveillance. We knew about containment, and so we started closing down schools with measles in the United States. In '72, '73, I ended up in upstate New York with Alan Hinman, who was an EIS Officer then. And we started closing down schools, doing search and destroy, containment vaccinations. So I think we all brought back to the United States real tools, learning lessons that were applied, that helped control measles in the United States. Ciro de Quadros, a former smallpox eradicator, went on to PAHO [the Pan American Health Organization], and became a major player in polio eradication in the Americas. PAHO associated measles vaccination with polio vaccinations after noting that their surveillance of AFP (acute flaccid paralysis) for polio revealed a lot of measles. And then the Guinea Worm eradication program, with Don Hopkins [Donald R. Hopkins], another former smallpox warrior, who came back to The Carter Center. I mean, the legacies, the spinoffs from the smallpox/measles program are incredible. Rafe Henderson with the global EPI [Expanded Program on Immunization] at WHO in GENEVA is a great global contribution. I guess it was 1976 or 1977 when Rafe went to the World Health Organization (WHO) in Geneva, and he expanded immunization. People in Europe ask, "Why the Expanded Program on Immunization?" And I laugh, because I'm the only one in Europe that was part of the smallpox group. And I say, "Oh, that's the expansion of the smallpox/measles." And this is another lesson, and I'm sure Rafe has talked about it. All of it is about management. Good management. And I hope D.A. gets interviewed, and he says this, and I'll say it for him. D.A. was of course head of smallpox at WHO in Geneva for many, many years. And on the day he left, he had a press conference, and they asked him, "D.A., now that you've eradicated smallpox, what's the next disease to be eradicated?" And he said, "Bad management." Harden: Let me just say, thank you very much for speaking with me. Roy: Good. </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/4dKI8HqEJ8Y" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-13 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15n9k emory:15n9k Subject The topic of the resource Smallpox Eradication Public Health Advisor Smallpox gods Fetisheurs USAID WHO CDC Management Format The file format, physical medium, or dimensions of the resource 11645880000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harden, Victoria (Interviewer) Roy, Jeannel (Interviewee); CDC Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource ROY, JEAN Description An account of the resource Jean Roy served as a Public Health Advisor in Dahomey, now known as Benin, which had the second highest incidence of smallpox in the world at that time. Jean describes early lessons learned from his work in the Peace Corps in Cameroon and how it led him to a job with the Smallpox Eradication Program at CDC. Jean talks about the role of fetisheurs and smallpox gods in Benin and getting the program started there, as well as the importance of logistics, management, and local context. "All of it is about management. Good management." Language A language of the resource English https://www.globalhealthchronicles.org/files/original/68de525d7f5fa3c3c42bff173506f244.jpg f9786e0a554f8333b966fd8608dc3bc3 https://www.globalhealthchronicles.org/files/original/66711c57ca73ce1171f2df08ca66088e.pdf 2564d1a739212d82f7916cb2aa441533 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> This is an interview with Dr. David J. Sencer, former Director of CDC, about the West Africa Smallpox Eradication Program in the 1960s. The interview was conducted on July 7, 2006, at CDC during the 40th anniversary of the launch of the program. The interviewer was Victoria Harden. Harden: Dr. Sencer, before we get to smallpox, I'd like to establish that in 1966 you were the Director of CDC and managed the overall direction of the West African Smallpox Eradication Program. You were born in Grand Rapids, Michigan, on November 10, 1924. Would you describe your childhood and your pre-college education? Sencer: I don't remember very much about the early years. My father died when I was 4, in 1929, just at the beginning of the Depression, and my mother had to go to work. I was an only child in an empty house and had to fend for myself. I went to elementary school in Grand Rapids and started high school there as well. My mother felt that I needed to be in an environment where there were more men, however, rather than living just with a lonely widow. So she encouraged me to apply for a scholarship to Cranbrook School, a boarding school outside Detroit, and I was awarded one. My mother had to pay $32 a month, which in 1936 was quite a burden on her, but between that money and the scholarship, I was able to attend Cranbrook School for 5 years. I think I received a very good basic education in an environment which was much more masculine than being home with my mother. Harden: At that time, did you have any notion of what you wanted to do for a career? Sencer: When I was in high school, the things that really interested me were the sciences: biology, chemistry, geology. I was more interested in the sciences than I was in the "softer" things. Harden: You went to Wesleyan for your college education in the middle of the war, in 1942. Tell me about going to college at this time, and how this prepared you for medical school. Sencer: Actually, that's the beginning of the war, 1942, not the middle. Harden: Yes, the beginning, you're correct. Sencer: My first year was a normal undergraduate year. There was no pressure to speed up my education, and the draft was not threatening. I took normal liberal arts courses-English, German, history, and 1 course in biology. The next year, however, the pressure began to build. The military had a variety of programs-the Naval V-12 Program and the ASTP[Army Specialized Training Program]-through which college students could actually enroll in the military, be paid a small stipend as able-bodied seamen or privates, and continue their college educations with a commitment to become military officers after graduation. I was in the Naval V-12 Program at Wesleyan. By that time, assessing my various interests, I had also decided that medical school would be the best career route for me, and I was thinking of getting into biomedical research. We didn't call it biomedical research at that time, but doing research in medicine was my goal. Suddenly, however, I found that I had to accelerate my program. I took organic chemistry first thing in the morning, followed by inorganic chemistry, which actually provided the introductory material for organic chemistry, plus physics. The only things that I could find to fill out my schedule were 2 courses in German literature. That year I struggled with a very heavy classroom load and completed all of my pre-med credits. Although I had not expected it, the Navy officials at Wesleyan informed me that I had to leave the undergraduate program because I had completed my pre-med credits. There were no openings in medical school, however, so I was sent to naval boot camp. Harden: Let me interrupt you, just for 1 moment before we go forward. You said you had determined that you would go into medicine. Would you explain how you came to that decision? Did anybody push you in that direction? Sencer: No, no. There was no role model. That was the way my own thinking just evolved, considering my various interests. I went to boot camp and learned close-order drill, how to evacuate a lifeboat, how to climb a rope, and other things like that. I became a hospital corpsman, which at that time was known as a "pharmacist medic." I was at Mare Island Naval Hospital and then at the Naval Hospital, Camp Pendleton, the Marine Corps base. My name was on a list to be transferred to the Marine Corps. During this period, someone asked me if I wanted to go to medical school. I said, "I have a choice between the Marines and medical school? I'm a coward. I'll go to medical school." Initially, I went to a 2-year medical school at the University of Mississippi, in Oxford. I was in a class of 27 people. After I finished my 2 years there, I transferred to the University of Michigan for the final 2 years of medical school. Soon after I got to Ann Arbor, a routine chest x-ray showed that I had minimal tuberculosis. For a year, I was hospitalized at the university hospital because effective drugs had not yet been discovered and so tuberculosis was treated with bed rest. In Ann Arbor, when they said bed rest, that is what they meant: bedpans, meals in bed, etc. Once a month they would weigh you. You would roll out of bed onto a stretcher, and they would weigh the stretcher and you. After a year of bed rest, you collapsed on the floor when you tried to stand up because your knees weren't used to carrying your weight. Harden: What did you do all that year? Did you read? Sencer: I read and listened to the radio. I read the New York Times, Harper's, the Atlantic Monthly, and the Saturday Review of Literature. The hospital's 1 rule was that you could read anything you wished as long as it had nothing to do with your job. I read no medicine, no journals. This was good because it opened up a whole new variety of things to me. When you have been in the grind of pre-med and medical school, you don't have time to think about a world outside of science. I also listened to the radio. I had an FM radio, and in those days, that was unusual. I could get the political broadcasts, the Town Meeting of the Air, and similar things that got me interested in politics. That year was a life-changing interlude. I won't say I enjoyed it, but it was probably the best thing that happened to me. I also learned to knit. Harden: And would you say this had a lot to do with your later interest in worldwide public health? Sencer: I think it planted seeds. I did not immediately become an advocate of anything, but the reading, listening, and thinking planted seeds and gave me a background in things other than science and medicine. I went back to medical school and finished on a part-time basis because they were very cautious in those days about not over-stressing patients with tuberculosis. I finished in January 1952 or December 1951. I have the distinction of being both the first and last in my class. I was a class of 1, so if I want to brag, I can do it. If I want to poor-mouth, I can do that, too. I'd met my wife before I went into the hospital, and after I got out, we got engaged and got married. I started my internship in Ann Arbor, a rotating internship in medicine. I continued with what we called a residency in those days and call a fellowship nowadays. I had a residency in internal medicine for about a year and a half. One day on grand rounds, the Chief of Medicine said to me, "Sencer, you know the military's looking for you?" I said, "Well, no. I'm 4F." He said, "Not anymore. They say you're 1A, and they want you. They wrote and asked if you were essential, and I told them the department would fall apart for exactly 2 minutes if you left." By this time, we were also expecting a baby, and we were preparing to move out of our apartment before the baby arrived because no pets or children were allowed. Here I was, then, faced with 2 decisions: what to do and where to stay. I contacted the navy to see if I could re-enlist, but they turned me down because of my medical history with tuberculosis. The navy did say that if I were drafted, it would be happy to take me into its quota. I thought that was a terrible way to do business. One night, I was at a concert in Ann Arbor and saw a friend who was a professor of public health, Cy Axelrod [S.J. Axelrod]. I told him my problems, and he said, "Join the Public Health Service (PHS)." I said, "What's that?" He explained and said that the PHS had a tuberculosis research program that I might be able to join. I wrote the Public Health Service and said that I want to join their tuberculosis program. They responded with the question "Why?" and I answered, "I know why, what I want to know is when." Finally, in January 1955, I became a Public Health Service officer in the tuberculosis program. Harden: Do you think you would have stayed in internal medicine and gone into private practice had you not come into the PHS to satisfy your military? Sencer: We liked Ann Arbor, and I thought that I might just stay on at the university. Harden: But instead, you joined the Public Health Service and began to work in tuberculosis and migrant health. Sencer: At first, I just sat around in Washington. They did not seem to know what to do with me. I worked as a code clerk on some research projects in tuberculosis. Eventually, I was sent to Idaho to run a survey of the health status of migrant laborers. When I arrived, I found a little caravan of 2 house trailers used as examining rooms, a mobile x-ray truck, and a mobile laboratory. To gather data, we had to drive to labor camps around the Snake River Valley, so I learned how to drive a car with a trailer attached. We would go into a labor camp, hook up the water, and talk with them about coming in for examinations. Several things about this assignment changed my whole attitude about medicine. I began really seeing people who were disenfranchised. These were people who claimed to be from Eagle Pass or Farr, Texas, but you knew very well they were from the other side of the border. They had come to Idaho for 6 months, but they could not get citizenship during those 6 months, so they had no rights in Idaho. The farmers weren't interested in paying them anything more than the minimum wage, and there was no health insurance. We didn't see much disease in these camps, actually, because the migrants were a fairly healthy group. They had to be in order to work in the fields 12 hours a day. One case we did encounter was that of a young man who had a tuberculosis of the knee. Idaho had agreed to accept people in the hospital if they had infectious tuberculosis, but he didn't have infectious tuberculosis. We were faced with the question, "How do we get him treatment?" Finally, we decided that the only way was to bend the rules a bit. We convinced the young man that he was under 18-he was actually 20-because if he was under 18, he qualified for Crippled Children's Services, a federally funded service. By this subterfuge, we were able to get him treated. A few days later, we found a 12-year-old girl who had far- advanced tuberculosis in the hospital in a town we visited. The hospital administrator called us and said, "Get her out of here." He obviously did not want to have to treat her any longer. I went to see her parents, and I said, "Don't visit your daughter, because if you do, they'll make you take her home." Instead, we made arrangements to have her transferred to the tuberculosis hospital about 100 miles away. To go to the hospital, however, she had to possess 2 pairs of pajamas and a toothbrush. Well, pajamas, what are they? Migrant workers did not own them. I said, "Let's see what we can do." I went to the TB Association, but they would not provide the money to buy the pajamas. Their attitude seemed to be, "She doesn't buy Christmas Seals, so we won't help her." I went to the Latter-Day Saints, as this was a big Mormon area. "She's not one of ours," they said. I went to the Catholic church, and the priest said, "They never baptize 'em down there in the valley," but he gave me $10 anyway. I gave it back to him. There was a small community of Quakers outside of town, and I went out and met with their elders, and they said, come back at 6:00 PM. I went back at 6:00, and there was a whole pile of clothes. I thought, "Oh boy, this is an opportunity to talk to them about problems with the migrants." But they wanted to talk about the fact they were playing baseball on Sunday in Boise, not the thorny and politically volatile problem of migrant people. People were willing to help a little on an individual basis, but no one wanted to address the larger problems. Those problems, however, got me interested in public health because public health measures provided a way in which you could do more for large groups of people than what you could do trying to help 1 individual at a time. I had begun thinking of a career change into public health when I got a letter saying, "You're being transferred to Columbus, Georgia, to run the tuberculosis research station there." This seemed like a great opportunity to me, so we moved, but it was my wife's first experience in the South, and Columbus, Georgia, was really "South" at that time. She was not a bit happy. I, on the other hand, had a wonderful job. And the PHS then sent me to the School of Public Health at Harvard. Getting a Harvard MPH [Master's in Public Health] was in my view a necessary "union card" for moving forward in a public health career. I learned very little at Harvard, except from the other students. What they taught me was much more important than many of the courses that I took. After finishing my MPH, I returned to Columbus for a year and then transferred to Washington, to a job that I thought was just terrible. Finally, however, I realized that it provided an excellent opportunity to learn how things really happen in Washington. I worked in the Bureau Chief's office essentially as a "gofer," but I learned about the budget process, about interagency problems, and about how things really transpired at this level. Then, in 1960, I was transferred to CDC as the Assistant Chief, and I fell in love with an agency. Harden: That is what I understand. Elizabeth Etheridge stated in her history of CDC that you always thought the best job in the world was to be Director of the CDC. Sencer: Absolutely. Harden: So, obviously, your mind had shifted. Your Washington training served you well in learning how the bureaucracy functioned. Now walk me through your rise through CDC until we come to the beginning of the smallpox program. Sencer: For the first 2 years, I was the Assistant Director. Larry Smith [Clarence A. Smith] was the Director. To become familiar with all of the activities of CDC, I obtained copies of all articles published by the print shop at CDC and scanned them. During those 2 years, I was intimately involved with decisions relating to how polio vaccine would be licensed. In 1955, when the Public Health Service licensed the inactivated vaccine [Salk vaccine], the PHS bought all of the existing vaccine and distributed it to the states but did not give the states any money to help organize distribution programs. For the states, the easiest way to reach children was to give it through the public schools. The result was a shift in polio cases back towards what was known as "infantile paralysis." By the 1950s, polio had become a disease more of older children and young adults, but after school-aged children began receiving routine vaccinations, it was the preschool-aged children who became vulnerable to infection with polio. These tended to be the children of people living in the inner cities with low incomes, who could not afford to have pediatricians vaccinate their children. There were outbreaks of polio in the late '50s and early '60s in Kansas City, Chicago, and other cities, all concentrated in the inner cities. When oral polio vaccine came on the horizon, the Surgeon General's Public Affairs Officer J. Stuart Hunter suggested following the same distribution procedure. We at CDC opposed this. We wrote legislation stipulating that the Public Health Service would provide vaccines, not just against polio, but also against all childhood vaccines, to state and local health departments and that this vaccine could be used for children under 5 years of age. The legislation also included money for the states to organize immunization programs. This shifted federal law from a focus solely on polio to a broader emphasis on general immunization against childhood diseases, including diphtheria, tetanus, and whooping cough. This law stood as basic immunization legislation for a long time. Vaccines against measles, German measles, and chickenpox were subsequently added to the law's coverage. Between 1963 and 1966, I was CDC Deputy Director; Jim Goddard [James Goddard] was Director. Jim was a wonderful guy. He was gung-ho, do everything. After about 6 months, however, Jim decided that he was in the wrong job. He thought he was better suited to run a small agency that needed to grow or an agency that was in trouble and needed to be fixed. CDC was neither. So Jim began looking for another job, and, basically, I did the day-to-day management of CDC during those years. In 1966, Jim was appointed Commissioner of the Food and Drug Administration, which was an agency that was in great trouble at that time and still is. I became CDC Director in 1966. At the same time, USAID [US Agency for International Development] transferred the Malaria Eradication Program, which was in great trouble, to CDC. Malaria eradication was failing because it was based on premises that did not work. Suddenly, CDC had the responsibility for a program that was failing. We also inherited staff in 16 different countries, and we had to fund them out of the CDC budget. It was a huge problem. CDC became the biggest employer of people in Haiti through the program. The whole Malaria Eradication Program became a direct CDC hire, and we could imagine the staff of the Malaria Eradication Program 1 day marching down the streets as part of a political uproar in Haiti. But over time-not in 1966, but over time-we brought about major changes in the way malaria was approached around the world. We worked with WHO [the World Health Organization] to get away from the concept of eradication and to begin emphasizing control and prevention of deaths in children. Later, in 1966, the smallpox program started. Actually, it goes back before that. Let me reconstruct the history as well as I can remember it. I will talk about CDC's involvement in smallpox, not the whole smallpox eradication effort around the world. During World War II, Alex Langmuir [Alexander Langmuir], the Director of Epidemiology at CDC, had been very interested in biological warfare. The Epidemic Intelligence Service (EIS) was created, in fact, because of the threat of biological warfare during the Korean War. During Congressional testimony, Dr. Justin Andrews, who was the Director of CDC at that time, was asked about how we planned to address biological warfare. Justin thought real quickly on his feet, and said that since military draft obligations could be fulfilled through service in the Public Health Service, CDC would establish an epidemiology service of young people who would be trained to recognize abnormal occurrences and thus be able to provide early warning against biological warfare. That is how the EIS began. Alex, of course, had been plotting for such a program, and he happily seized the opportunity posed by biological warfare to implement it. For a long time, he had been interested in smallpox, and he got D.A. Henderson [Donald A. Henderson] interested as well. In 1962, Don Millar [J. Donald Millar] was sent to Indonesia as an EIS Officer as part of a malaria assessment program, and while there, he saw smallpox for the first time. He became very interested in the disease, and when he came back, surreptitiously carrying some scabs of smallpox for the lab, he was put in charge of what was called "smallpox surveillance" in the Epidemiology Program. He was it. No one else was involved. Henderson and Millar began discussing whether smallpox was a disease that could be eradicated. In contrast to malaria, which has a mosquito vector and animal hosts as well as human hosts, smallpox is directly transmitted from person to person and has no animal reservoir, which makes it possible to eradicate. We had a good vaccine, which made the disease susceptible to eradication. The military had invented a jet injector, which could be used to give rapid vaccinations to large numbers of people. CDC helped the military modify the jet injector so that it was possible to give intradermal injections, since smallpox injections had to be given intradermally. The intradermal jet injector was tested with smallpox vaccine in the friendly islands of Tonga. Everybody made cynical jokes about why they picked Tonga-why not choose a lovely Pacific island with gorgeous beaches? Our audiovisual group here at CDC made a beautiful movie of this, called Miracle at Tonga, with the waves crashing up on the scene. But the actual reason it was chosen was that Tonga had never had smallpox, and there had never been any vaccinations, so it was a virgin territory in which to try out vaccinating people with a jet injector, and it worked very well. In 1965, after a couple of years in Geneva, the World Health Assembly of WHO passed a resolution calling for the worldwide eradication of smallpox. President Lyndon Johnson also issued a statement saying the United States would support this initiative and contribute to the effort. Harden: Was CDC involved with getting President Johnson to issue that statement? Sencer: Yes, but I had nothing to do with it. Alex and D.A. Henderson worked with Jim Watt [James Watt], who was the Director of International Health for the Public Health Service. They also worked the streets of Geneva to get the resolution passed, and they deserve a lot of credit for this. It involved a lot of hard, political horse-trading. The Indians were against it, and representatives from countries that had been burned by the failed malaria eradication said, "Oh, no, no, no." But D.A. Henderson had become quite familiar with WHO, and WHO had become quite familiar with D.A., which I think becomes important as we go on. One day in 1965, Jim Goddard was out of town, so I took a phone from Dr. A.C. Curtis [Arthur Clayton Curtis], who was in the African Bureau of USAID. He asked if CDC would like to take on a measles eradication program in West Africa. This call came at a propitious time. Dr. Harry Meyer at NIH [National Institutes of Health], in the old Division of Biologic Standards, was testing out different strains of measles vaccine in large populations. Measles was a terrible disease in Africa, with high mortality in children. It was a real killer. Many of the field trials in which Dr. Meyer was involved were done in West Africa, and the measles vaccine proved to be a tremendous success. USAID looked at the results of Meyer's efforts and decided that it might be a good time for CDC and USAID to expand the measles vaccine program in West Africa. I told Dr. Curtis that we were not interested in measles eradication, because measles eradication was not feasible, but that measles control might be feasible if we could couple it with smallpox eradication. If we could do that, CDC would be interested. And he said, "Sure." It was as simple as that. Then began the hard work of negotiating agreements with USAID, writing what they call pro-ags [program agreements or E- 1s], and all sorts of documents that had to be written about each country, and getting each country's agreement with the documents. Dr. Henry Gelfand, on CDC staff, spent lots of time going from country to country, getting country agreements, getting things signed, trying to recruit people to become part of the program. All of this was happening in late 1965 and early 1966. Finally, all of the paperwork was done. USAID had agreed to fund the program. We had a 5-year agreement with USAID for a program to start on July 1, 1966. D.A. was a good friend of mine, and of the family, and his daughter and our oldest daughter were also very close friends. They were in the same grade in school. His daughter often told my daughter that they were moving to Geneva in November, but when I would ask D.A. about this, he would reply, "Oh, no, I'm not going. I want to stay here and run the CDC program." His daughter Leigh, however, continued to say, "We're getting ready to leave in November," and D.A. continued to insist, "Oh, no, no." But finally, he said that he was moving to the WHO in Geneva, arguing "I was ordered to do it." Well, you know his mouth was drooling to take on the WHO program all the time. When D.A. was transferred to Geneva, Don Millar was appointed head of the Smallpox Eradication Program. Don had been studying at the London School of Tropical Medicine for a year. He had gone there because there were people in England who were very much interested in smallpox and could provide him with additional experience and training. You will be interviewing Dr. Millar, I'm sure, and you might want to ask him about his dissertation at the London School. I'll let him tell the story. By the fall of 1966, Don had come back from England. He was the logical one to head up the Smallpox Eradication Program (SEP). In the early part of 1966, the SEP had been run out of D.A.'s Epidemiology Program. The people in the Epidemiology Program were provincial in some ways. They thought that epidemiologists were the only professionals needed to craft a solution to any infectious disease problem. A big program like this, however, requires logistical experts as well as epidemiologists, so I pressed the Epidemiology Program to add Public Health Advisors to the staff of the SEP... I pushed hard to have Billy Griggs appointed as a deputy to D.A. Henderson, to deal with the nitty-gritty of organizing and paperwork and so on. As the SEP began staffing up for the West African program, Billy made sure that there was a person called an "Operations Officer" with each of the epidemiologist "Medical Officers." The Operations Officer took care of the logistical things that had to be done. You'll be talking to many of those. Harden: As CDC Director, what made you buy into that idea? Did the time that you had spent with the migrants influence your realization of how many "operations" details were involved in such a public health effort? Sencer: Yes. When I first came to CDC, there was an older man (he's 9 days older than I am) by the name of Bill Watson [William C. Watson Jr.]. He had been in the Venereal Disease (VD) Program for a good number of years, and it had been transferred to CDC. Larry Smith was the Director of CDC at that time, and he had previously been the Director of the VD Program. He knew Bill's capabilities. He had moved Bill out of the VD Program and appointed him Assistant Executive Officer at CDC. I got to know Bill very well-he was a close personal friend as well as a professional colleague. He often told stories about how the VD investigators worked, and through listening to him, I began to understand that the logistical effort was a key part of disease control programs. People who could get out in the field, knock on doors, talk to people, and understand how people behaved were essential. The first assignments given to VD Public Health Advisors usually were in local health departments. They tracked down contacts of cases of syphilis and gonorrhea and tried to bring them in for treatment. After a couple of years of this work, they would become supervisors, with responsibility for several other people. Harden: And they weren't physicians. Sencer: Oh no. They were a group of people who were recruited at the baccalaureate level. They were not disappointed pre-meds, but rather people who were interested in people. There were certain schools at which the PHS traditionally recruited because the PHS knew that these schools would turn out the sorts of people that they wanted. The recruits would move up in a supervisory managerial chain that stood behind the physician in charge. In a state health department, there would always be a senior Public Health Advisor behind the physician who was the state VD Control Officer. The Public Health Advisor pushed, pushed, pushed. He or she never made a medical decision but pushed the physician to make the necessary decision and assume the leadership role. And they learned quickly that this was how you get things done. You don't have to make the decisions yourself if you can get somebody else to make the right decisions. Harden: That's very interesting. Sencer: Yes. A history of the Public Health Advisors is being written. I think they're looking for a publisher. Harden: You were explaining how the SEP was organized-what types of people were needed. What did you look for in your staff? What did they need to be able to run this program successfully? Sencer: I looked for Billy Griggs to make good personnel decisions. The physicians had already been pretty much recruited by D.A. We lost a few real misfits the first year in training. Many of the physicians who were recruited were EIS Officers. Stan Foster [Stanley O. Foster], for example, had been an EIS Officer. He had left CDC and was back in residency training. D.A. called him and said, "You want to go to Africa?" And Stan said, "Sure," and he came back to CDC. Rafe Henderson [Ralph H. Henderson], who had been appointed to be the regional epidemiologist on the ground in West Africa, had been at CDC for quite some time. He had been on some of the early trips to West Africa. Rafe had very good sense about people, too. I put my trust in the people who were running the program. I knew Billy Griggs made good decisions; I knew Don Millar made good decisions; I knew D.A. was charismatic and a great stimulator. He was not the best manager, but while he was here, he developed some excellent management techniques. I knew what was going on, but I did not micromanage. My philosophy is to hire good people to run something, and then you let them run it. Harden: When did you make your first trip to Africa? Sencer: In the smallpox program? I think my first trip was for the 25 millionth vaccination event. They had a big celebration in Ghana, in 1968, to mark the 25 millionth vaccination that was given. This was a great public relations opportunity for the Smallpox Eradication Program. USAID thought it was wonderful. Many ambassadors were there. Jim Lewis, who you'll be interviewing later, was the Operations Officer in Ghana. He made most of the arrangements for this great to-do. It was out in the country, about 90 miles north of Accra. There were tribal chiefs in uniform, with umbrellas and gold robes and dancing, and so on. Events like this were called durbars. I remember that the American Ambassador shook his head, saying, "I've been to a 12- chief durbar, but this is the first time I've ever been to an 18- chief durbar." The Surgeon General was there, and he gave the 25 millionth vaccination to a screaming little girl. After the event, while we were there, we had more meetings. USAID had also recruited a reporter from the New York Times,. Fred Friendly's son. They had the military attaché's DC3 from the embassy in Dakar. The next day we flew for breakfast from Dakar to Abidjan, had breakfast at the airport with the Minister of Health and the ambassador; flew to Monrovia, Liberia, for lunch with the Minister of Health and the ambassador; and to Freetown, Sierra Leone, for dinner. We refer to that as "breakfast in Abidjan." All of this was good public relations. It showed that the Surgeon General of the Public Health Service was with us-that is, that we had support from the top. It reinforced at USAID, too, the importance that we gave to the program because we were able to get the Surgeon General to participate. From Sierra Leone, we flew to Bamako, in Mali. The pilot had never been there. He flew east until he found the Niger River, and then he followed the river up to Bamako. Mali, at that time, was a Marxist country, with mostly Chinese activity there. It was Chinese construction, Chinese this, Chinese that, Chinese all over the place. We spent some time in Bamako, then flew out to a market town, and then took the Dodge trucks out to the Dogon Territory. This was located at the "end of nowhere," out with cliffs that fall off into the sub-Saharan plateau. The Dogons are the people who had the big, big masks. They had dancing and thousands and thousands of people getting vaccinated. It was very colorful. There was a missionary there, with whom we stayed. He had been in the mission field for 40 years. Ten years out, 2 years back, 10 years out, 2 years back. We slept under the stars, where there were no artificial lights. It was a wonderful experience. The next day we flew to Timbuktu and then went on through Niger, Togo, Dahomey, and back to Lagos, and home. That was my first major trip to Africa during the Smallpox Eradication Program. Harden: Tell me more about how you ran CDC as Director at this time. Sencer: Even in those days, I was known for "walking around." I wanted to know what was happening, so I walked around to see things. I would ask questions, and it scared people sometimes. There was 1 person I recall, into whose office I seemed to walk every time he was reading his paperback instead of working. Finally, he didn't even put it in his desk drawer when I came in. Harden: Could you say a little more about the bureaucratic relationship of the Smallpox Eradication Program to the Department of Health and Human Services, to the Public Health Service, to the National Institute of Allergy and Infectious Diseases at NIH, and any other federal agencies? Sencer: The West African program was self-contained as far as budget and management were concerned. We had our money from USAID. Billy Griggs handled most of the dealings with USAID concerning paperwork. At the front office level, we did not have too many problems with USAID. The collaboration was something that we knew about on a day-to-day basis, but it was not something that gave us problems. We had good leadership, and our philosophy was to get good people and let them do the work. Harden: What was the toughest problem that you faced? Sencer: During the African program? You know, most of the problems, Billy handled. Ask him about that because the toughest problems were paperwork and things like that. Our real problems with smallpox began after the African program. The 1 thing that the African program did was to demonstrate that mass vaccination was not the way to go in smallpox eradication. You'll get Bill [William H. Foege] to tell this story himself, but early in the program, Bill was working as a medical missionary in eastern Nigeria. He was volunteering as the smallpox epidemiologist for that area. He did not have enough money to buy enough vaccine for the mass vaccination program, so he began looking at spot- maps of how smallpox was moving from village to village and how long it took to move from village to village. He said, "If we could prevent smallpox from moving from 1 village to the next, maybe we could break the chain of transmission." He developed a scheme of getting village leaders to tell them when there was a smallpox case. He and his team would then go in and vaccinate the people in that village and around it-the contacts of those with smallpox-to contain the disease. And suddenly, smallpox in his area began disappearing. He hit it at the low point in transmission, so he was able to get to all of the foci of smallpox, and smallpox disappeared from his area. This strategy was presented in a variety of ways to others in the program. Finally, it became possible to see if it would work on a large scale. In Sierra Leone, Don Hopkins [Donald R. Hopkins] was the Medical Officer and Jim Thornton was the Operations Officer. Sierra Leone had the highest rates of smallpox in Africa and was as backward as they come. Don and Jim knocked out smallpox in months. This impressive demonstration caused Foege's strategy to be adopted for the whole West African program. Harden: What mechanism did you use to tell everybody, "We're changing the way we're doing the Smallpox Eradication Program?" And what convinced you that Dr. Foege's approach was the way to go? Sencer: This was a scientific study. They needed to show convincing data that the strategy worked, and they did. I didn't have anything to do with it other than to say, "Yes, you've got the data to support your argument. We will do it that way." Harden: But I understand the World Health Organization's approach to smallpox eradication did not change so rapidly, even in light of these data. Sencer: Yes. WHO was reluctant to accept this. They had been selling the concept of mass vaccination, and they were reluctant to begin talking about a new approach. They had sold countries on mass vaccination, and to change strategies would require that they go back and re-educate them. After the West African Program was completed, D.A. finally accepted that this was the way to go, and it was after the African program that the hard work in smallpox eradication began. That is another story, of India and Bangladesh and so on. Harden: Once you had achieved zero pox in West Africa and had finished the program, CDC no longer received funding from USAID. You did not want to let the program completely die, however, because you wanted to continue surveillance activities, as I recall. At that point, you appointed Bill Foege to be head of the Smallpox Eradication Program. Would you talk about the follow-up from CDC to the West African program? Sencer: When we reached zero pox in West Africa, Bill came back to CDC. Don was still in charge of the CDC smallpox program for a while. Then the International Red Cross called and said that they were concerned about the famine in West Africa, which occurred as a result of the Nigerian War. The Red Cross asked if Bill Foege-they asked for him by name-would come and do surveillance of how bad the famine was. Bill went, even though his wife was very reluctant to have him go because she knew if he went, he might not come back soon because he would want to stay and see things through. He went out and developed a surveillance technique for the famine, and we began feeding CDC people in, to maintain the surveillance activities and to identify where the famine was at its worst, so that relief activities could get to those places. This was being done with CDC money at this point, but we had little authority to pay for famine management in African countries. We were able to do it under the guise of protecting the United States from the possibility of the recrudescence of smallpox. Some of the travel was being paid for by USAID, but CDC was paying all the salaries. Then the State Department began getting worried about what was happening in Biafra, the secessionist state. State asked if we would send somebody in to do a rapid assessment. Karl Western [Karl A. Western], who had been at CDC for a good number of years, agreed to go. He was taken out to 1 of the islands off of Nigeria and flown in at night to Biafra. We had no official presence in Biafra. Karl did a magnificent job of showing that the famine in Biafra was the worst famine that had occurred since the potato famine in Holland after the war, but that it was localized. He also showed that 1 organization's relief activity would set up in a village, and then other organizations' relief activities would come in in competition. You'd get the Lutherans, you'd get the Catholics, you'd get the Worldfam, Oxfam, and so on. This meant that some villages were getting all of the aid, but the major part of the country was not getting any. Aid was flowing to places where it was easy to get to but not out in the bush. As a result of Western's work, I got a call 1 night from Jesse Steinfeld, the Surgeon General. He said, "You and Western get to town, right now." On a snowy January night, we went to Washington, to the White House. We went into the Situation Room, and who should show up but Henry Kissinger. Suddenly, we were briefing Henry Kissinger on famine in Biafra. At that time, Kissinger was the National Security Advisor. In typical Kissinger fashion, he was playing USAID, which was arguing that there was no problem in Biafra, against the State Department, which was arguing that there was a serious problem in Biafra. He was enjoying the bureaucratic struggle. He didn't give a hoot about famine. It was the bureaucratic struggle. Kissinger later became Secretary of State. We also briefed the State Department person who was going to Congress the next day. One of the major signs of malnutrition is edema of the legs, which is caused by protein deficiency. Assessing edema in a population was a quick way of determining how bad the famine was. This Assistant Secretary of State kept calling it "endema," and we kept saying, "No sir, it's 'edema.'" "Oh, yes," he would say. He got to Congress, however, and in his testimony, it was "Endema, endema, endema." Harden: I want to drop back into the smallpox program and ask if there is any other event of significance that springs to your mind like the 25 millionth vaccination event you described? Sencer: We went to a village, Ede, in Nigeria, for the observance of the 10 millionth vaccination in Nigeria. When we got there, there was the Timi, who was the chief of the village. He was wearing a leopard-skin cap and robes, and when he went out into the town square, everybody gathered around. He stood up and gave the most erudite history of smallpox in Nigeria, back into the early days of colonialism. It was beautiful. Afterwards, we went in to his house and saw a plaque on the wall that said, "Honorary Kentucky Colonel," and another plaque that said, "Honorary Alumnus of Western Michigan University." Surprised, I asked him to tell me about those plaques. He said, "I'm an expert in the talking drums, and the State Department takes me to the United States to give lectures on the talking drums. In return, Kentucky made me an honorary colonel, and Western Michigan made me an honorary alumnus." We asked, "What are talking drums?" He said, "The drums talk. They don't talk in code, they talk in Yoruba. Would you like a demonstration? I always keep a drummer out in the courtyard across from my house in the morning, so he can tell me what's going on in the village on the drums." He then asked his drummer to demonstrate the drums. One of the USAID people said, "Have that man across the way come in and bow to the Timi and throw the cat out." So the drummer pounded away, and this guy came running across, bowed to the Timi, picked the cat up, and threw it out. I said, "Hmm, put-up job." He said, "All right, you tell him what to say with the drums." I was smoking in those days. I said, "Tell the man to come and take a cigarette out of my pocket and light it. He pounded the drums, and this guy came in, counted 1, 2, 3, 4, to me, reached into my pocket, took out a cigarette, put it in my mouth, reached into his robes, and pulled out a lighter. He said, "You know, it's true. We speak in syllables. The drum has a head that you can squeeze the side of, and it changes the sound, the tone, but it has trouble with English words. Don Millar said, "How would it say 'Dr. Millar?'" He said, "Oh, that's Yoruba. Do-ki-tar-mil-lar." And that drum began going, "Do-ki-tar-mil-lar, do-ki-tar-mil-lar." You could hear it. Bill Foege-he was known as the tallest man in Africa-said that when he was coming to a village, the drums would pound out, "The tallest man in Africa is coming." Learning about the talking drums was a wonderful experience. Harden: What else did you learn about Africa in the program? Sencer: What did I learn about Africa? Oh, my goodness. In those days, it was a wonderful, wonderful part of the world. There was a lot of concern about improvement, but they were not as highly politicized as they are now. You would get outside the capital city and find wonderful people who were shaking off colonialism. One of the things about the West African program is that there were 2 very distinct parts of Africa in which we worked: francophone Africa and anglophone Africa. Each had a very different medical system. The French were much better organized than the English. When colonial government ended, the English just picked up and left. The French left things behind and left some Frenchmen behind, too. They pretty much controlled the currency, and communications, and so on. Harden: Let me change the question slightly. What did Africa learn about the United States and CDC? Sencer: Thank you for asking. One day in 1969 in the World Health Assembly, the Minister of Health of Mali, which had been a Chinese-Marxist country, made a speech. This man said, "I want to thank the United States for giving us assistance in our smallpox eradication program, but not so much for the vaccine or the machinery or the Jeeps but for the people that the United States sent to help us." That, to me, was the crowning glory of the program. The Africans recognized that it was people rather than things that the United States gave to Africa. We had sent to Africa young guys and gals who had had no experience in diplomacy, who had no experience with politics and so on, and they went out, altruistic and wanting to get a job done. "We've got a job, let's go do it, we can't do it ourselves, and we've got to get the people in Africa to do it. We'll be there to stand behind them and push. We'll give them the tools, we'll give them the know-how, but they've got to do it." And they did it. Harden: I have just a few more questions. In the middle of the West African project, some people recommended that smallpox vaccinations be stopped in the United States, and this became a hot topic of discussion at CDC. Would you comment on that? Sencer: Actually, it was a little after the West African program, because it was in 1972 that we really came to the belief that we could safely stop smallpox vaccinations. By then, enough eradication had been achieved, not only in Africa but in other parts of the world, to minimize the threat to the United States. The risk of importation was so slight that the risks of continuing vaccination with the predictable adverse reactions that occur with smallpox vaccine far exceeded it. As usual, we had a meeting of our immunization advisory committee to go over all of this. We met on a Saturday morning. I had invited the Medical Officer of Health of Great Britain, George Godber, with whom I had seen recently, to come to our meeting. George was a fascinating person. He was the architect of the National Health Service in England. Ruddy-faced, white hair, monocle. He had lost this eye, and he said, "Why spend money on 2 lenses? I only need one." He kept a handkerchief up in his sleeve to pull out and wipe his eye. He was a real character but highly articulate. He wrote and spoke beautifully. At that meeting, we struggled mightily with the wording of our recommendation on smallpox vaccination. George finally said, "Dave, excuse me, this is your country. But it is my language." He clarified the wording for us. Harden: If you were going to start the program over again, would you change anything about how it was run? Sencer: No. Harden: Not a thing? Sencer: Not a thing-as long as I could have the same people. Harden: How did the program change your career at CDC? What impact did it have? Sencer: It changed CDC, and since I was part of CDC, it changed my career. What it did was push CDC into international health, into global health. It was the first time that we had responsibility for a large international program from its inception. We had inherited the malaria program, but the West African Smallpox Eradication Program was totally a CDC operation. This was the beginning of CDC's global involvement that continues to this day, not just of ideas and equipment, but of people. In Dakka, at the old cholera lab; we started the field epidemiology training programs in different countries. It just goes on and on and on. I think that individuals grow with the organization. You don't pull the organization. The organization pulls you. Harden: Since your role in the smallpox program was here at headquarters in Atlanta, did it have any impact on your family? Sencer: Not as much as it might have, although I did a lot more traveling after the program began. I was not a traveling salesman, just home on the weekends, but I did have to travel a lot. It became worse with traveling to Washington, but I think my family were envious of my going to Geneva for 2 or 3 weeks every year for the World Health Assembly meeting, and things like that. But I don't think it had any great impact on the family. Harden: But all 3 of your children are in the field of health in 1 way or another. Am I right? Sencer: Yes. Our oldest daughter, Susan, is a pediatric oncologist. Our middle daughter, Ann, is a nurse practitioner in oncology, and our son, Stephen, is Deputy General Council at Emory, but he handles a lot of the research and intellectual property sorts of things there. Harden: Before we stop, is there anything else that you would like to add? Sencer: I'm tired. Harden: Thank you very much for speaking with me. I think this gets us off to a wonderful start for these recollections. </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/d7nxhL9ZWaA" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-06 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15nbq emory:15nbq Subject The topic of the resource WHO Legacy of Smallpox Eradication Smallpox Eradication USAID CDC Management Format The file format, physical medium, or dimensions of the resource 14949480000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harden, Victoria (Interviewer) Sencer, David (Interviewee); CDC Title A name given to the resource SENCER, DAVID J. Description An account of the resource Dr. David Sencer served as Director of CDC from 1966-1977. Dr. Sencer describes how his career brought him to CDC and the early days of getting the Smallpox Eradication Program started. He discusses his philosophy of management, his trips to Africa, shifting the smallpox program to Asia, and the legacy that CDC and the smallpox program left in Africa. Language A language of the resource English https://www.globalhealthchronicles.org/files/original/e7e81b68fcf0968506a76bad6f69091e.jpg 0929000669383a01f855c8d9ec805ee0 https://www.globalhealthchronicles.org/files/original/20bde83a0bf8cc195ef1f2909f16b36f.pdf dde2403f413cec4e8af73567f2080cec Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> This is an interview with Dr. Ralph H. "Rafe" Henderson, about his role in the West African Smallpox Eradication Project of the Centers for Disease Control. Today is July 7, 2006, and this interview is being conducted as a part of the 40th anniversary reunion of the launching of the Smallpox Eradication Project. The interviewer is Victoria Harden. Harden: Dr. Henderson, I want to begin by setting the stage for who you were in the smallpox project, and I'd like to start at the beginning. If I am correct, you were born in New York City, on March 5, 1937. Would you give me a brief account of your childhood and education, who your parents were, and whether any of these early experiences nudged you towards medicine or public health? Henderson: Yes. My father was born in Burma, which is the explanation for my nickname, Rafe. The British soldiers in Burma, who were then in charge, used Rafe as a nickname for Ralph. My father's name was also Ralph, and when he named me Ralph, then they called me Rafe as a nickname. So that explains that. But it also explains my orientation for international health. My grandparents were medical missionaries; their grandparents were also medical missionaries in Jamaica. My uncle was a medical missionary in China. My father was the black sheep of the family: he went into publishing with the Reader's Digest. But my brother and I became physicians. When I was doing my internship at Boston City Hospital, I was contacted by somebody from CDC, who told me about the Epidemic Intelligence Service (EIS). And that, combined with a lot of my other interests in the international sphere and missionary work- although my father was not religious and I'm not particularly either-seemed to be a very good next step for my career in public health. Harden: Let's drop back a little bit and ask you to talk about your years at Harvard. You were at Harvard for both your undergraduate education and medical school. Was there anybody on the faculty who was particularly important to your career? Henderson: Yes, obviously in college, one always has heroes. Mine was a psychologist named Jerry Bruner [Jerome S. Bruner], who was dealing with cognitive psychology, and I found that very interesting. I won't tell you the funny things we did, but in any case, it was an interesting time at Harvard. I was there only 3 years because I had spent the year before going to Harvard as an exchange student for the English-Speaking Union. So I was in the U.K. for a year, in what was a public school, before coming to Harvard, so I was only at Harvard for 3 years. Then I went on to medical school. In medical school, many of us were very, very influenced by Professor Thomas Weller, who had worked with Enders [John Franklin Enders] and Robbins [Frederick C. Robbins] in developing the polio vaccine and later on the measles vaccine. Weller was very eloquent about tropical public health and the challenges and the needs that were going on. As I say, a whole bunch of us came out from under his tutelage very interested (well, let's say interested because we were too young to be career-committed at that point). I think he was a strong influence. Harden: You joined CDC immediately after your internship and residency in Boston City Hospital. Were you one of the folks joining initially to avoid-pardon me, to discharge-your military obligation? Henderson: Well, I think "avoid" is a very good term because I think for many of us, that was 1965, '64, '65, when the Vietnam War, was just starting. And how does one want to spend one's military career? Well, it was certainly a very easy choicevivid one for us. I would like to think that my own reflexes-both seeing the difficulties of practicing in a city hospital, where you're seeing end-stage disease and not being able to do very much about it, and my interest in international health-made CDC a choice whether or not there had been a military draft. But it was clear that that served the best of all purposes as far as I was concerned. I was not interested in serving in other areas of the military. I was very interested in serving in what I knew, at that point, CDC was doing. Harden: In public health service. Henderson: Right. Harden: So in 1965 and '66, you were an EIS Officer. Would you talk a little bit about your EIS training and assignments? Henderson: Well, it was incredible. In those days, they used to call the interns "the iron men" because we didn't get salaries, we ate at the hospital, we often slept at the hospital, we had 1 set of clothes. But we came to Atlanta and we're presented with a slide rule; we got a salary; we were treated like important individuals. It was incredible. Absolutely incredible. And we had a very exciting 6-week EIS course, training us in shoe- leather epidemiology. Because of my interest in international health, I applied to the smallpox unit. I was lucky enough to be selected. And then, lo and behold, I was sent off, very shortly after the training, to West Africa as a technical advisor to the French public health organization in the western part of West Africa, called the OCCGE [Organization de Coordination et de Cooperation pour la Lutte contre Grandes Endemies]. That's a very long name, but part of it, the Grands Endemies, translates into the "great endemic diseases." I have to back up a couple of steps to explain why I was going over there. In about 1963, roughly, the NIH [National Institutes of Health] conducted a major field trial of measles vaccine in West Africa, beginning in Upper Volta, as it was called. And it was an astounding success. They covered most of Upper Volta in a few months, with mobile teams, and did it very well. They had high vaccination coverage, and measles pretty well disappeared. Now, that was a self-serving exercise, in that we, the United States, wanted to test the measles vaccine on a large scale. Here was an area where this could be done, where it was desperately needed, where kids were dying of this disease, and you would have had to have a very, very bad vaccine indeed, not to be ethically justified in doing a combined trial of the immunization and of the vaccine itself and seeing what impact you would have on public health. Well, the impact was absolutely astounding. One of the reasons that USAID [US Agency for International Development] was willing to go along with D.A. Henderson [Donald A. Henderson] and others at CDC in joining a smallpox eradication program, which USAID wasn't interested in, with the measles program, which USAID was interested in, was that they knew that they couldn't do much with the measles program unless they had some good technical support. USAID had some disastrous experiences without technical support, before they funded the full program in '66. Because the United States had the measles vaccine and no other nation did, it was perceived that a measles immunization program allowed the United States an entryway into West Africa, where the French culture was dominant, one that did not compete with the French either on educational or economic grounds. But here was a neutral health ground-very popular concept. All the countries desperately wanted the measles vaccine because measles was such a bad disease. And so I went over as one of the people to help out in the stages before the full program got going. I was advising OCCGE in running these mass immunization campaigns with measles vaccines. Now, the French were very good at doing mass campaigns; there was no problem with that. The problem was that they were not very good at dealing with this funny, electrical jet injector, which we were using to administer the vaccine. And they were not very good at dealing with the many, many difficulties in supply and logistics posed by our USAID and U.S. Government contributions to the programs. And so, when I arrived, or at least one of my interviews was with the Ministry of Health in Upper Volta and with the Chef des Grands Endemies, the French advisor who was running the Grands Endemies. The Minister was furious because our 5 Dodge trucks that had been given to help administer the vaccines were consuming his entire budget of gasoline for his entire Grands Endemies. And the USAID deal was, "We give you the trucks, but you run them. You pay for the gasoline." And of course, that just wiped out the budget for the Ministry of Health for gas. All of these enormous trucks were consuming all the gasoline. And so he was not a happy person. Harden: Was there any solution to this problem? Henderson: They did the best they could. They were unhappy, but they did not do a bad job with the things. One of my problems as advisor was firing off cables about getting spare parts for the jet injectors. They kept running out of some tiny points-I didn't know what they were, but I think that on a regular engine they'd be called the points. They relate to the electrical system. Forget it. But that's all I knew. And I knew that they were burning out, and they couldn't get spare parts. So one of my jobs as a technical advisor, very technical, was to send cables back saying, "Send more of these things because they can't run the injectors." Nor did CDC send enough diluent, so we were often using Evian, one of the French bottled waters, as diluent for the measles vaccine. I was overseas for about 6 months, traveled widely in those countries. I was treated extremely well by the French advisors, even though they knew I didn't speak very good French and they knew a lot more than I did about anything they cared to ask me about. But they were very gracious, very good about teaching me and helping me learn about things. I think I saw in those 6 months enough problems to last me the rest of my life about what can go wrong with an immunization program and with other kinds of public health programs that you're running. It was extremely valuable. Harden: One of the points that has been made over and over here is that medical knowledge about smallpox was really only the first step to eradicating it. The logistical problems, and the personnel problems, and the diplomatic problems, all of these things were key to eradicating the disease. So you were seeing this in advance of the project. Henderson: Yes, I think that's very true. I think the CDC tradition, though, is an important one to emphasize. We medical people went over with public health advisors, who joined us as nonmedical people, who were there exactly for the management issues. CDC had had a long tradition of this in the venereal disease control program, as it was called in the old days, and the advisors then branched out into tuberculosis and many other programs. There were always public health advisors who were trying to get the logistics and the management right. And so I think the CDC position was, "We've got to have some medical expertise to be credible, but we really need the management to be sure that we can be effective." And I think that was really the key to the success of much of what we did. We didn't have such great medical knowledge of smallpox, if I can say that. The program was designed to immunize everybody in West Africa against smallpox, sort of a 100% vaccination coverage. And we didn't find out until a couple of years into the program that we didn't need to do that. That was one of the really startling breakthroughs in the program-the ring vaccination strategy of simply immunizing around active smallpox cases, breaking the cycle of transmission, and not going all-out to maintain high levels of immunity in all sectors of the population. We learned that relatively rapidly, I must say, within a year or so of the program. But it was a major conceptual breakthrough for us. Harden: Would you walk me through setting up the regional office in Lagos? You were the Deputy Director and the epidemiologist. I know that the Director, Dr. Lythcott [George I. Lythcott], is no longer alive. So will you tell me about how it was formed and how it functioned? Henderson: Well, it's a funny thing. I have very little idea about that. I knew that there was to be a regional office and that George was the Director. When I was in West Africa, and the full program came into being, I was then recruited from my role as an EIS Officer to join as the Deputy Chief of the regional office. George had worked in Ghana, and was a senior person, very well respected. It was perceived that if we were going to have a regional office, we should have a good regional office. And in the early days, as I understand it, the idea was that this would be the first regional office. Then, as the program expanded worldwide, as we got rid of smallpox in West Africa and then moved to other regions, there would be other regional offices in other regions, which were similarly constituted. In any event, we never did that. Ours turned out to be the only regional office. I was there as an epidemiologist, but I was one of the few people who spoke French. So even though I didn't speak French very well, my responsibilities were mainly for looking after the francophone countries. My role as deputy was sort of doing all- hands work. We had an equipment specialist with us, a very good health educator, a statistician, and a secretary who was knowledgeable about local and embassy issues having worked in West Africa before. And we also had Jim Hicks [James W. Hicks], our Senior Administrative Officer, who was very effective. George, as the Director, dealt with all the terrible, terrible political problems that were really insolvable, and he managed to solve most of them. Jim Hicks dealt with equally difficult administrative problems, like who had furniture in their houses just in Lagos; could we get transport from the embassy in the early days; what was going on with the financing of things. He had all sorts of fights with the embassy and the USAID mission, who didn't really have the resources to give the support that they were supposed to to our group in the regional office. Harden: Now you, as I understand, wrote most of the E-1s, the programs for each of the countries, in the francophone countries. Is this correct? Henderson: I don't remember that. At my age, I'm finding that happens more and more often. I do know that I spent some time going around with George Lythcott and Henry Gelfand trying to finalize and write what we called pro-ags, project agreements. Harden: Yes, that's what I meant. Henderson: That's right. I recently got a communication from a colleague who was working with us in West Africa. He sent me some of the letters he had sent me then. And he quoted me asking if we could give some of the cars that had been assigned to us, as advisors, to our national counterparts? And he said in the letter to me, "Rafe, you had already anticipated this and put the request in for these cars. You knew that they would be needed by the ministry, and that you couldn't justify it just for the ministry, but you would justify it by giving it to the advisors who were there, anticipating that they would then be shifted back." I have no recollection of that at all. Harden: There was, at this point, however, some tension between CDC personnel and USAID as to whom the CDC reported to-whether they reported to USAID, or reported to CDC through the regional office . And I think it fell on you to clear the air about this, if my reading is correct. Henderson: Boy, I don't remember that either, very much. I do remember going to a couple of countries; my wife and I were talking about that. I remember being in Chad, and I was trying to recall, 40 years later, why was I in Chad? And then it occurred to me, there was something going on with USAID and our staff there that I apparently was trying to mediate. Again, I don't remember the details of that. I do remember that there was a general problem when we from CDC came into the West African countries, and we felt we were masters of the universe, and there was nobody about to tell us what to do, certainly neither USAID nor the embassy. We had a mission. We were going to get our stuff done. And so that was a general tension that I do recall. I don't remember my role exactly, and what I did about it. Harden: You started to tell me about developing the cluster sampling system and the instruments we adhered to, to do the sampling. Would you explain, for the record, what cluster sampling is, and how you developed it? Henderson: I can, but I would also like to go back at some stage, to lead up as to why I ever got into that. Harden: Okay, let's go back. Tell me how you got into cluster sampling. Henderson: I had come back from India in the spring of 1967, when there was a smallpox outbreak. We had been expected to eradicate smallpox in India in a very short period of time. We did not succeed in doing that. My wife and I came back to CDC, and found that, in the interim, the Biafran War had broken out. She was then not allowed to go back to Lagos as a dependent. I would not go back to Lagos without her, and we arranged a compromise, as my range of responsibilities was the francophone countries anyhow. I did a whole series, 6 months or so, of continuous consultancies, firefighting, and all sorts of stuff in West Africa. And then the Biafran War settled down, and we were able to go back to Lagos. I got back to my regular job, as Deputy Chief of the regional office. And I promptly got myself into trouble with headquarters because I kept feeling that the policies that we were being asked to follow by headquarters were not the best ones for us in the field and that there was not a very good understanding of what was needed in the field. Harden: And when you say headquarters, you mean here in Atlanta? Henderson: In Atlanta. So I became a very shrill voice, I'm afraid, demanding and troublesome. And I don't remember whether I was called back, or whether I had to come back on for another occasion, but when I did get back here at CDC, I was pretty well told, "Enough of this nonsense. We need some assessments done. Go do them." Again, my memory is foggy, and it may be that there was a lot of help, but I don't remember. What I remember was going off and saying, "Oh yeah. Okay. We need to do assessments." And it turned out to be 3 major assessments, one in northern Nigeria, one in western Nigeria, one in Niger. And I brought some reports that I'd been looking at recently, and trying to scratch my head, and yeah, the cluster sample survey was part of that assessment or evaluation. There were also aspects of the assessments where we reviewed records, interviewed people, looked at the health centers, inspected vaccination teams, and the rest of it. So it was a very extensive project. Now on cluster sampling: if you do a random sample, if it was the Gallup polls that we do in the United States, you can get away with sampling a relatively tiny fraction of the population. But you have to do it in a very meticulous, random manner, so that the individual that you select is not selected with any bias that you can imagine. This is very intensive, very expensive, and very difficult to do. A compromise that was developed by CDC staff, Serfling and Sherman (Robert Serfling and Ida Sherman of CDC), here in the United States, was a cluster technique. And that meant that, rather than taking a single individual and asking questions, you could take a group of individuals. But if you did that, you had to compensate for the fact that they were a group and no longer independent. So one of the group had more similarities to the other members of the group than if you'd taken a totally different person from a different area because the cluster was a geographic cluster. So you would get households that were all together, or members of a household that were all together-that was the "cluster" part of the cluster . Rather than sampling as individual people, you sampled them in groups. I had learned the Serfling-Sherman technique as an EIS Officer. We had done a sample in Atlanta. Bill Foege [William H. Foege] did a modification of that in The Gambia early on. I knew about that. So when I was asked to run these surveys, run these evaluations, and do a cluster survey as part of that, I further adapted that survey. To look back on that, it was incredible. How am I going to do a survey in a huge area of the country? What kind of a sample do I select? How do I get the records done? How do I collate them? I taught myself to type; I didn't know how to. I realized I was going to have to write these long reports, so I was going to have to type. I realized I was going to need some way of recording the data. So I had worked on my own files with McBee cards-strange animals. I'm just going to hold up one. It's a strange card with a lot of holes on the sides of it. And you punch a notch in a hole. Each hole corresponds to something you've written on the card. So, for example, is this person who you're sampling a male or a female? Male, 1; female, 2. If they check 1, I punch 1, which is numbered on the edge of the card. At the end of the day, I get a hundred cards together, and with a sort of knitting needle, I run through the hundred cards, at the number 1. And lo and behold, all the cards that have this number punched fall out, if I shake them vigorously enough. These cards were fascinating to use-difficult to use, but a godsend because I could then train teams, who would go out with these cards and then, while they were in the field, simply mark a number for each of the data points I had. Then at the end of the day at their leisure, they would take a paper punch and punch out the holes that corresponded to what they had found during the survey. Then I collected all the cards from all the teams at the end of the survey, went home, and spent a long time shaking knitting needles and having the cards fall out. And I'm sure there were a lot of errors involved with the things. But it was absolutely an incredible exercise, and I can't believe, even to this day, that I was able to do that, with very short notice, to go in, to design the cards, to decide on the sample surveys. But I want to talk a little bit about the actual sample survey design because that was fascinating. What are you going to do with a population that is as varied as you have in West Africa? Yes, you've got some people in cities, but you've got people in villages. You've got people that don't particularly go to a village; they're nomads; they're all over the place. And, again, I'm just impressed with ourselves, myself, in that time. We designed the sample surveys to try to get if not a valid sample, at least an idea of these various groups. So, for example, we could have a sample survey that said, let's take a valid statistical survey of all the villages in a catchment area, or a state, or a country, that are under 5,000 population. Perhaps we thought under 5,000 would be a high-risk group for smallpox. We'd get all the villages. So you select, say, 30 villages out of those. And then we said, "You get your sample from that village but then leaving the village, for the next 10 kilometers, you stop every person you see, and you interview them-no matter who they are, or what they're doing." And then we said, "In addition to that, you go to some of the local markets, and you do a market survey and find out who's there. And within the market, sometimes you can select individual groups." We knew there were nomadic tribes, and we could recognize them because they wore distinctive things. So we could say, "Survey 10 of the nomads from this area, and 10 from that area." In western Nigeria, we had an area of the state that was very heavily influenced by fetisheurs, by the traditional healers. And we knew that they had a cult, the Shapona or smallpox cult, that did not appreciate being vaccinated against smallpox. They were against vaccination. And we knew that vaccination coverage was lower in that area than in other areas. So we did a separate sample of the fetish area and the nonfetish area. We did all sorts of tricks to try to probe where we were weak. It wasn't so much that the sample was going to give us a wonderful average of what was going on in the country, but my idea was, let's point the finger at where we think we're doing least well. Let's find out what's going on there; that's where we need to make the changes. It was just a fascinating experience. As I said earlier, the survey was only part of the full assessments we did. We also looked at records, we interviewed people, we inspected vaccination teams. We found faults everywhere. There were problems everywhere. And that was one of the great lessons that I learned in my life-despite all the problems that you find every day, and despite the fact that you think nothing's going well, that isn't always the case. You can have some success despite it. The other thing that was impressive looking back now on this, is that there was no stopping us. I mean, getting a sample survey, doing these assessments, that's no problem. We'll just do it. And I think it was the attitude of the entire program. We had a goal; we were going to do it; nothing was going to stop us. I'll tell you 1 other anecdote that illustrates that. We got stuck in western Nigeria during one of these assessments. We got often stuck in western Nigeria. It was during the rainy season, and we spent more times pulling ourselves out of mud holes than anything else. But we were in a rubber plantation, for reasons I don't understand, but we were doing a survey there. And it turned out that the vehicle was running down on hydraulic brake fluid. The brake pedal kept getting weaker and weaker. And we knew when we left in the morning that we needed some extra fluid. We had some, but by the middle of the day, it was getting low, and we were running out. And we finally looked under the hood and found that the brake line was rubbing against the engine, and it had cut a little hole in the hydraulic line. And I said, "Right, okay. I know how to do that from an intern in Boston City Hospital. Give me some tape, and I'll tape it up." I taped it up. But each time I did it, because the brake line has a lot of pressure it just blew the tape away. It didn't work at all. We were down to our very last little bit of hydraulic fluid, and I said, "Right. What am I going to do?" And we got some cotton that we had for first aid. I took some sap out of a rubber tree, chewed the sap into the cotton to make it a solid compress, and tied a whole series of very tight suture knots around the hydraulic line. Amazingly, the thing held 'til we got back at the end of the day. But that was the attitude: "This isn't going to stop us. We can fix this. Nothing is going to stop us." And that happened over and over and over again, to everybody in the program. It was incredible. And I think it was one of the things that made the program just such a success. People would not be stopped. Harden: Now, do a little analysis here. Was it just because these particular people were so special? Was it an American thing? Was it inspiration from above? What do you think made this group? Obviously, it's a very special group. Do you have any opinions on this? Henderson: I hesitate to say it, but I'll say it anyhow. It's not a very special group. And I think that's the magic of it. Special in that the challenge was there, yes. Good leadership. Good support. A strong image of what needed to be done. But by God, when you do that, and you give people responsibility and things that they've never met before, most times, most people will rise to that challenge. And I say that because I then had experiences later in life, in the World Health Organization (WHO), or other programs, where we had the same sort of thing. We had specific goals to achieve and people from many cultures, many different backgrounds, still rising to that challenge in an extraordinary way. And don't forget, as I'm sure that nobody will, that we were a tiny fraction of those who did the work. Most were the nationals - the vaccination teams, the staff, the people living in the endemic villages. So let's be clear that we were helpers in a project that was done largely by national staff. Harden: Were there any particular problems in dealing with the national staff that you recall or were there good relations from start to finish? Henderson: I would have to say mixed. I think the relationship got better as we all got more familiar with the environment and the cultures with which we were dealing. When we arrived, we, the CDC people, fresh out of the U.S., were impatient. We didn't understand why something couldn't be done yesterday; what was the problem? And of course, the folks we were dealing with- whether it were the national ministries of health, the French or English advisors who were there, the other expatriates-they thought we were nuts when we first arrived. They couldn't understand why we were having these expectations. Many of the French thought that the word "eradication" should be eradicated. They had very little little time for this eradication concept. And so, yes, there were a lot of tensions with that. But I would have to say, again, that the experience of the public health advisors-who had dealt with those kinds of issues in the United States with state and local health departments and recalcitrant public officials at all levels and learned to find ways of getting things done so that everybody went along with it- these types of situations are where they really shone. We in the medical officer field were often not so good at that, and I think we were very well served by having the public health advisors with us. Harden: In December 1969, there was an observance of the hundred millionth vaccination in Niger. Were you involved in that at all, and do you have any special memories of that event? Henderson: That was in Ghana, and I have some memories of it. I wasn't involved with the organization of the event, thank goodness, because it was a massive affair. But I do remember going and giving an interview to the Ghanaian newspaper about things. The report of the interview in the press talked about our work in eradicating rabies or malaria, or something totally not having anything to do with what I had said or what the program was about. One of the reasons I was doing that interview was that, I think the Minister of Health and George, the Director of the program, were off doing the hundred millionth observance, and they needed somebody to satisfy the local news media who could speak about the program. So my role was a very minor one. But it was a grand affair. Harden: If you were going to do the program all over again, would you change anything about the way it was run? Henderson: Given that it worked, I think not. Harden: How did the smallpox eradication program change your life and career, or did it? Henderson: Oh, very much. When I came to CDC, my idea was to work in public health for a while, go back to internal medicine, and maybe get a joint accreditation in public health and internal medicine, as many of my colleagues were doing. But when I got to West Africa and had a little bit of experience there, 2 things happened. One, I was addicted to public health. Two, I knew I had to go back and get some management training. So I applied to the Director of CDC, Dave Sencer, and asked him for a career development extension to go back and get a degree in public health at Harvard Medical School. And I said, "I know Harvard. I will look during that first year at the School of Public Health and I will find some management training I can do during the second year." I was sitting in Lagos, so I couldn't tell Sencer exactly what that second year was about, but I said it would be management. And, in fact, I tried to get into the Harvard business school, but they had a very rigid program that I thought was very unhelpful. The Kennedy School was just starting a program of Master of Public Policy. They wouldn't let me into it because they said I was too old. I think I was 28 or 29. I insisted that I was just the right person and talked my way into it. So that was my second year of training. So it did change my life in a radical way. Harden: What impact do you think the program had? What impression did it leave in Africa about the United States, about CDC? Do you think it had an impact on the end? Henderson: I think it was good. I mean, it may have been astounding. When you're working down in the guts of an organization, one doesn't see the perspective of what others have about the whole range of things. I don't think we left a bad impression, by any means. But that was nothing I was aware of, or got feedback on. Harden: You said your wife was traveling with you. What impact did the smallpox eradication effort have on your marriage, in terms of anything? Traveling? Henderson: Well, we were unusual. We had just gotten married. My wife is a pharmacist, and we didn't have kids. And I thought that she could be extremely helpful in what I was doing. Sample surveys are not difficult to do. Keeping the records, drawing maps, things of that sort, she does very well, and so we worked as a team. And we continued to travel wherever we could as a team, together. Now, she wasn't paid by anybody. I paid for whatever travel was going on, but we worked together all the time. And in fact, when I think about it now, it set an unusual precedent. We kept running into problems later in life, when she would sit in on staff meetings, or go to meetings with other organizations, and they would say, "What's your wife doing here?" Well, there would be administrative assistants, other people who would not be contributing from a professional perspective but would be sitting and listening in. But the fact that she was a wife alienated a lot of people. Eventually, she began introducing herself as my personal assistant. That seemed to work a lot better. But it had a very strong bonding affect on our marriage and lasted throughout our professional lives and through the present.. Harden: Before we stop, is there anything else about the Smallpox Eradication Program that you think of, that we should discuss? Henderson: I think that one of the extraordinarily important legacies was the group of people. Now, I have just told you that the group of people was not extraordinary, that they were ordinary people. But having gone through that experience, many of them continued on working together as colleagues throughout their careers. And the smallpox program in West Africa morphed into the larger global program, with many of our staff from West Africa joining the global smallpox eradication program and having major roles in that. After spending some time at Harvard and back at CDC, I went back to WHO in 1977. I had left West Africa in '69. So almost a decade later, I came back to international health at the recommendation of Dave Sencer, to go and replace D.A. Henderson at WHO and to run what was then a new program, the Expanded Program on Immunization, which was a child of the smallpox program. Even in the smallpox days, we were looking at how to use other vaccines with smallpox vaccine, how to do combined immunizations. So a lot of the science had already been done by us in West Africa, plus other colleagues elsewhere that were working on the same issue. When smallpox success seemed assured in 1974, the Expanded Program on Immunization was adopted by WHO. The idea was to take what we knew about the smallpox experience, providing immunizations for a disease, and do a childhood immunization program. The program faltered for a couple of years, and I was called in both because the program was faltering and D.A. who everyone assumed would take over the program decided to leave WHO. There was a desire on the part of the U.S. to have a CDC US person replace D.A. and I went back to do that. Now, when I went back, a lot of the "mafia" I worked with were the smallpox mafia-both the smallpox mafia that we had in West Africa and the larger mafia that was then created when the global program was created because the global smallpox program was just phasing out. So suddenly I had a whole large staff of people who had that same motivation, who had that same perspective, coming into my program now, into the Expanded Program on Immunization. They continued on to do polio eradication, the diarrheal disease program, a whole slew of very, very important public health initiatives. And that came, I think, directly from this initiative in West Africa, the smallpox group, then going to the larger, international group, and then the international group coalescing around several extremely important public health programs. Harden: Do you think there will be another disease we can eradicate? Henderson: Well, we're certainly trying with polio. Harden: And having some very difficult problems, I think, and discussions about whether it will be done. Henderson: Yes. It's a very interesting quandary in public health because you don't know, when you're beginning, if you're going to succeed. If you knew that, it wouldn't be a problem. You'd just get it done. We didn't know when we did smallpox in the beginning that we would succeed. In fact, we had to change the program radically in order to succeed. The same is happening with polio-major, major technical breakthroughs, change your philosophy, change of the way we approach things-learning as we go, and having a lot of problems on the way. But that's the way you make progress in science. That's the way you get better. Now, there may come a day when we say, "Okay, enough is enough. We've got to call it quits." But until that very end, I think it's absolutely well worth giving it the best shot that we can. Malaria was a situation where we tried and tried, and then it became increasingly apparent that this was not going to work. We didn't have the science. We didn't have the technical skills or the technical equipment to do the job. We had to change the goal of the program. That's not happened with polio, yet. We have a lot of good irons in the fire, and I don't think we should be anywhere near giving up at this time. But there will also be interest in eradicating measles; there will be interest in eradicating other diseases. When I did the Expanded Program on Immunization, coming in in '77, people in WHO said, "OK Rafe, we know who you are. You're one of these eradication people. You are just interested in the short term." And I said, "Not on your life. I'm not interested in eradication. I'm interested in long-term childhood immunization." But I was interested in eradication. And I came back to that in the late 1980s, when our routine immunization had more or less done what it could do. It was reaching levels that were not too bad but were also not too good. And at that point, we adopted polio eradication, not only because we thought we were ready for it but also because the polio eradication effort was 1 thing that stiffened us up in the other efforts. Because we were dealing with a specific disease, that helped us do the rest of the things, gave us more enthusiasm for doing those other things, as well. And I do think that the occasional disease- specific initiative, whether it's eradication or radical control of a disease, can help strengthen a larger health initiative, or set of initiatives, and will remain a useful public health strategy as long as we have both the combination of large, integrated services that we're doing and some specific things that are within those integrated services. I think that combination remains extraordinarily important in public health and probably in other enterprises as well. Harden: Thank you so much for speaking with me. I think we've got some fine footage here. I am delighted about the details on the cluster sampling system. Nobody else has provided anything on that for me, so I'm very pleased to have that. Henderson: Good. ### </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/FlQOn2USRvU" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-07 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15ncv emory:15ncv Subject The topic of the resource Smallpox Eradication Survey Cluster sampling Surveillance USAID WHO CDC Expanded Programme on Immunization Format The file format, physical medium, or dimensions of the resource 10852080000 bytes video/x-dv Creator An entity primarily responsible for making the resource Henderson, Ralph (Interviewee); CDC Harden, Victoria (Interviewer) Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource HENDERSON, RALPH "RAFE" Description An account of the resource Dr. Henderson was Deputy Director of the West African Smallpox Program, stationed in Lagos in the Regional Office. He was responsible for the on the ground epidemiologic aspects of the program and developed methods of evaluation that have served in a multitude of other programs. He was subsequently assigned to WHO to initiate and direct the Expanded Immunization Program, and was an Assistant Director General of WHO. Language A language of the resource English https://www.globalhealthchronicles.org/files/original/42d04a0c043e1465edf7c4378eee44a0.jpg d2c372713d2f2b6caeadd4c850063f28 https://www.globalhealthchronicles.org/files/original/6c150150e330f9800b99042053735aae.pdf 09ea4693dcc7561feed6cda13b5624fc Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> This is an interview with Dr. Stanley Foster about his activities in the West Africa Smallpox Eradication Project. The interview is being conducted at the Centers for Disease Control and Prevention as a part of the 40th anniversary observance of the launching of the West Africa program. The date is July 14, 2006, and the interviewer is Victoria Harden. Harden: Dr. Foster, would you begin by just briefly describing your childhood and your growing up, and who made you who you are. Foster: Okay. I grew up in Melrose, Massachusetts. My family was very religious. My father died when I was 9 years old, and one of the things that happened soon after that was I met Gordon Seagrave. He was the famous missionary surgeon whose Burmese nurses provided the medical care to Stillwell's troops during World War II. And he became my role model. From that stage on, I was going to be a doctor. I went to Williams College and then went on the University of Rochester. I think the connection to CDC was through D.A. [Donald A. Henderson], who also graduated from Rochester, as did Deane Hutchins. At that time, in early '62, they were drafting doctors, so I decided I'd rather come to CDC than go to the Army, so I came here. One of the interesting things that sort of started it off was that with 2 "F" names, Bill Foege [William H. Foege] and I sat next to each other in the EIS class of '62. I was assigned to the Indian Health Service in Arizona and carried out 18 epidemiologic studies. My basic assignment was for trachoma. At that time, about 20% of the Indian children had trachoma. Harden: Had you specialized in infectious diseases or anything in your medical training? Foster: Internal medicine was my field. And, as was often the case, Alex [Alexander Langmuir] would try to seduce officers he wanted to stay. He sent me to Bolivia to investigate an outbreak of conjunctivitis in Peace Corps volunteers. I came back to my home in Phoenix, got to Atlanta at about 3:00 in the morning, and at 6:00 in the morning I was on a plane back to Phoenix and on the way to the Truk Islands in the South Pacific to investigate an outbreak of diarrhea with Palmer Beasley. The assignment was an epidemiologist's paradise because a boat would only go out to an island once a month. You would know the entry point, and there would be a health worker there who would write down the cases and the names. It was a great epidemic. And the pattern of transmission was that of influenza, but the disease was diarrhea. We brought back the specimens, and the lab tested them out. They couldn't come up with an agent. We tried to write up the article several times, but without an agent, we couldn't. Twelve years later, when I came back from Bangladesh in '76, the lab called me and said, "We just found out what your '64 outbreak was. It was a rotavirus." Harden: Rotavirus. Ah. Foster: So we pulled out the article, finished it, and got it published. Harden: So you were doing epidemiology up until 1966? Foster: Well, no, that's not quite true. I did my EIS training from '62 to '64. Then I left CDC and went back to Rochester for a year of residency. Then I went to the University of California in San Francisco and did a fellowship in pulmonary disease. I probably would have stayed on in San Francisco in pulmonary disease, but I got the call from D.A., saying, "Do you want to go to Africa and get rid of smallpox?" My wife and I thought about it, and we decided after 24 hours that was right. We had 3 kids at the time, and I think one of the things we need to discuss is wives and kids. Harden: Yes. Foster: In terms of the impact of those experiences on the kids. Three or 4 of my kids' careers developed out of experiences with smallpox. My oldest son was interested in traditional medicines, and he now does Internet work in China. My second son, when he was in the 8th grade in Dhaka, Bangladesh, did a study of rickshaw drivers and how much of their income they spent on food. Now he's the chair of the Department of Economics at Brown. My third son got his start, really, in 1974 in Bangladesh, when we had tremendous floods and a famine. People were dying on the streets in front of our house. And he decided to go into medicine. I had no knowledge of the impact that the famine had on him until I read his Peace Corps application. And then I understood that that experience, back in '74, was the major event that sent him into medicine. Harden: This is very interesting. You said you came from a religious family. Were they missionaries or ministers? Foster: No, my wife's folks are missionaries. They went to Guatemala on their honeymoon. And her mother was interesting. She refused to go as a missionary wife. She said she'd only go as a missionary, and that was back in the '20s. They went down to Guatemala and learned Spanish. Then they learned Mayan and put the Mayan writing into a written language. And then they translated the New Testament. They had a school and a clinic. They stayed there for 45 years. Every year or 2, my wife and I go back to that same town. My wife is fluent in the Mam language. We have a nurse we work with, and she tells us what she wants us to teach. Harden: I'm interested in this streak of idealism. Foster: Oh, you should get a copy of my college caricature. I have a digitalized copy. It shows me sitting in a pot in Africa, with the pygmies standing around. "Bless this food to our use" and "Dr. Stanley, I presume" written at the bottom. I did have a missionary bent at that point in time. Harden: I'm seeing a different type of person who has been involved here at CDC with the smallpox program than what I have seen with investigators at NIH [the National Institutes of Health] in terms of the things that motivated them to go into research. Let's talk about once you were recruited into the program. They asked you apparently to recruit others, as well. And you mentioned that the recruitment of this 1 person. Foster: Andy Agle [Andrew N. Agle]. Harden: . . .was interesting? Foster: Yes, it was very interesting. Andy was a public health advisor and a good mechanic. I remember, I met him at a building in San Francisco. He walked in, and he said, "I saw this advertisement that you wanted a public health person who spoke French and was a good mechanic, and I knew you needed me." That was it. Harden: Very confident. Foster: Yes, he was, there was no question about it. Andy turned out to be one of the best. He worked for a long time in West Africa; then he was working with smallpox in Afghanistan. He was getting bored with Afghanistan, and I brought him to Bangladesh. Then he worked for many years at the Carter Center and was very close to [President] Jimmy Carter. He did a lot of agricultural stuff and really worked incredibly well with the Carter Center. And then he took a job in Nigeria. He died about a year ago. Harden: Initially, you were the medical officer in Nigeria. Would you tell me which region you were in, and what you found? Foster: Well, I was responsible for the whole country. At that time, Nigeria had 4 regions. the West, the Midwest, the East, and the North. About half of the population was in the North and about half in the South. We had Margaret Grigsby and Jim Lewis in the western region; Warren Jones was in the Midwest; Bill Foege, Dave Thompson [David M. Thompson], and Paul Lichfield were in the East; and Deane Hutchins and Vicky Jones [Clara Jones] were in the North. And it was a very different program in the North than in the South. Harden: Would you tell me about that? Foster: In the North, the traditional leadership was incredibly strong. I remember the first village I went to, Gwadabaw, in '66.I got there at 6:00 in the morning, and there were 6,000 men in a line. We vaccinated the men, and then they went home, and then the women came out. Well, for the women to come out was a big social occasion. They really didn't want to go back in. But I learned something that day, which was very interesting. It was a big district, and I told the district head that we should have 3 vaccination sites in his town because it would take us too long to do it at 1 site. He said, "I forbid you for doing that." He says, "Everybody has to be vaccinated in front of me. Nobody will tell me that they were vaccinated if it had to be in front of me, whereas if there were 3 sites, they could be tell me they were vaccinated when they weren't. The Emirs of Sokoto, Katsina, Kaduna, and Kano were very powerful people. The Emir of Sokoto would ride around in his Mercedes every night, and if there was no petrol, the Mercedes got pushed around town. But he was very powerful. So the only thing that you had to do in the North was to convince the Emir, and he would call in his district heads, and then everything would happen. It was easy to get 96%-98% coverage in that region. In the South, it was much more difficult. The people would not go 200 or 300 yards for vaccination. People were much more independent in the South. There was not the structure, and it made it much more difficult to get people to come for vaccination. Harden: Why would they not want vaccinations? Foster: Well, I think if you go historically back, there was a demand for injections. We believe that occurred secondary to the yaws program, which gave shots of penicillin to treat yaws. But it cured venereal diseases and pneumonia and everything else. So injections were always sought after. In the North, the structure was such that people would be told to do it and they'd do it. In the South, you had to really convince them or use enough publicity to get people to come for vaccination. So it was a totally different thing. And the epidemiology of measles was different. In the North, where the women are in purdah, or where the population density was relatively low, the median age of measles was about 36 months. In Lagos, where you have mothers carrying their babies on their backs to market, the median age was around 14 months, and then that was with a population of 600,000. When I went back in the '80s and '90s to Lagos, which now has a population of over 10 million and possibly 20 million, the median age of measles had dropped even further, to around 8 months. Controlling measles was impossible. Harden: What was the toughest problem you encountered? Foster: Oh, the Biafran civil war. I had flown to Benin to see Warren Jones there. I got off the plane, and Biafran hijackers got on and hijacked the plane. And that plane later was used to bomb Lagos. It was very interesting: we believe that they were using the passenger plane as a bomber, defusing the bombs, and throwing them out the door. We felt that probably the reason that the plane exploded was because the bomb went off before it got out the door. Of course, they had to find somebody who was asleep at their gun to reward for shooting this plane down. That was tense, and a lot of people were evacuated. I was talking with Deane Hutchins at lunch. I took the kids and my wife up to Kaduna because I thought it was safe. The next day, they bombed the Kaduna airport. But one of the interesting things at that time, we knew there was no smallpox in Biafra; but I was really afraid smallpox would get into Biafra. So I convinced the government that the safest thing for them to do was to vaccinate a large area around Biafra so that the smallpox wouldn't get out of Biafra into Nigeria. That way we kept it out. We also vaccinated a lot of children coming through the lines. The malnutrition in pockets of Biafra was just absolutely terrible. I think the war was really the toughest obstacle. The regional office was shattered by the bombings in Lagos, and it was not as safe a place as it had been before that. Harden: How did you get along with your counterparts? Foster: Oh, I had the most wonderful counterpart in the world, a fellow by the name of Yeme Ademola, who had gone to the Harvard School of Public Health. If you go back into the history of the smallpox/measles program, USAID [US Agency for International Development] wanted to do all the countries except Ghana and Nigeria. And Ademola was one of the ones who achieved its inclusion in the program He actually went and met with Senator Kennedy [John F. Kennedy] to push that. Yeme was just so honest. He looked out for the poor. For example, he had a cooperative grain bank, where he would buy produce when the price was low, and then they would sell it when the price was high. He supported a clinic. He was just an absolutely wonderful guy, and he also was my neighbor. So he and my wife would often go out and have tea with Yemi and his British wife. He also is the subject of the most traumatic part of my time in Nigeria. I got a call one night about 3:00 in the morning, Rosa, his wife said that he had been attacked. When I arrived at the front door, the murderers went out the back door. He had been macheted across the neck. I went in and tried to save him, but I couldn't. And at that time, I wasn't thinking of my wife, who was pregnant. Panicked about me, she started to abort. It was a horrible day. And then the next day, the police came and wanted to put me under arrest for Yemi's murder. After a 6-hour standoff, the American Embassy got me off on account of my diplomatic status. So that was the single most traumatic event of my years in Nigeria. We had an incredibly interesting team. We had Deane Hutchins and Vicki Jones. My favorite story of Vicki was when she went out in the field once for 4 or 5 weeks, and she'd either broken or forgotten her mirror. When she came back to Kaduna and looked at the mirror, she said, "Something's wrong." And then she realized it was that her face was white. In other words, she'd only seen black faces for 6 weeks. But she was wonderful. The teams in the North were also just absolutely extraordinary people. They had a driver there. He would know, when he went into a village, who you needed to see first, who you see second, and who you should see third. He had driven for a political figure before that, and he was just good. The teams would go, and they could vaccinate with the jet injectors, 8,000- 10,000 a day. The most I ever remember vaccinating in a day was once in the Midwest: with 4 lines we vaccinated 14,000. Harden: Wow. Foster: I think it's important to put in perspective what Henry Gelfand had learned about India. The Indians had vaccination numbers greater than the population, but they still had lots of smallpox. So Henry Gelfand went out there and did an assessment. And he found the vaccinators were vaccinating the schoolchildren regularly, so that they could get high numbers of vaccination, but coverage was very low. So when we went to West Africa, we were absolutely sure that with high coverage (Rafe [Ralph H. Henderson] and Don Eddins adapted coverage surveys from the US immunization survey to Africa) we would stop smallpox. There was no question about it. And that was our strategy, and we were absolutely sure that with high coverage with the jet injectors and coverage surveys-if we got above 90% coverage, or 95% or even better-we'd stop smallpox. Four or 5 major events led to a change in that strategy. The first was that when we first arrived in Nigeria, there was a smallpox outbreak in eastern Nigeria, in Ogoja, where Bill Foege had been a missionary. They had a limited amount of vaccine. But by focusing the vaccine on the infected area, they stopped the outbreak. The second important thing was a series of spot maps that Bill Foege drew. Each year the smallpox would come from the North, and there'd be a few outbreaks on the northern border and in the East. Then the outbreaks would increase in number and frequency, so you could just see it spread southward. And although Bill doesn't remember this, I remember Bill sitting on the steps, looking at these monthly maps and seeing how the smallpox spread. And he raised the question, "If we stop these first few outbreaks, will we stop them all?" The third major event in the shift in strategy occurred in Abakaliki. (There's a nice paper about this by Dave Thompson and Bill.) They'd done a coverage survey, and Abakaliki had over 90% coverage. Then all of a sudden they had an outbreak of smallpox. The outbreak occurred in a religious group that had refused vaccination; I think it was called Faith Tabernacle. Smallpox even though the coverage in that area was 90%; the small group of unvaccinated people was able to sustain an outbreak. The fourth factor was the shape of the epidemic curve-a low in September-October and epidemic in the early spring. Bill figured it out that every chain of transmission in the fall caused 74 cases in the spring. He realized that the peak time for surveillance was when the chains of transmission were fewest. So, in my opinion, those were the major events that shifted the strategy from mass vaccination and surveys to surveillance/containment. And that was certainly a major shift. And I think, although the disease eradication programs were different, when you compare smallpox to malaria, malaria was a centrally directed program, and they never really responded to the signs of drug resistance, and insect resistance, and the program failed. Smallpox was different. The program was driven by data collected in the field. We learned from our failures and changed strategies to address them. When I teach on lessons learned from smallpox/measles, one of the major things is learning from our mistakes, being willing to learn from our mistakes. My favorite story on this is about Sabour. He was one of my team leaders in Bangladesh. At this time, India was free of smallpox, but we were still having trouble. And I went up to see Sabour in Mymensingh, near the Indian border. If we did everything right, once we found an affected village, there should be no cases after 14 days-after 1 incubation period. So I asked Sabour, "How many outbreaks do you have?" And he said, "Sixteen." And I asked him, "How many had gone more than 14 days." And he said, "Eleven." Well, this was a disaster. The people could've walked those cases across to India, where the reward was big, and made a lot of money. And so I said to Sabour, "What are you doing?" His response was, "I'm doing everything the book says. I'm putting the patient in the house; I'm putting a guard at the front door and the back door. I have an extra guard at night to keep the guards awake. I am making a list of visitors, vaccinating them, and putting them under surveillance. I'm vaccinating everybody in the household. I'm vaccinating everybody in a half-mile. And I'm searching every place in 5 miles." And then, across a cup of tea, an incredible smile. And Sabour said, "And today I found out why. I'm going in, and I'm asking for a list of visitors. They are not giving me the names of relatives who came to visit because they don't consider relatives as visitors. And so we added a list of relatives to the procedure and solved the problem." I think that this story illustrates one of the main points to get at, that a lot of us at CDC who are in leadership positions got a lot of credit for smallpox eradication, but it's these people who worked 28 days a month in the field, month in and month out for 5 years, some of them, who were the real heroes of smallpox. The other lesson to get out of this story was the importance of giving workers at the field level the indicators to assess their own performance. When they didn't meet them, they asked why and come up with a solution. There's 1 other similar story from India, which is really important. At a critical time in the program in India, things were going to hell in a basket in Bihar, and the numbers were going up. And the Minister said, "I'm sorry, no more surveillance/containment. We're going back to mass vaccination." Bill spent the whole weekend with the Minister, trying to convince him to continue surveillance/containment. But the Minister said he couldn't take the political pressure and he had decided that the only solution was to mass-vaccinate. At the Monday meeting, the Health Minister of Bihar got up and said, "I'm sorry, WHO [the World Health Organization] has recommended we continue to do this, but I can't stand the political heat any more, so we're going back to mass vaccination." In the back of the room, a hand raised. And a man got up and said, "Mister Minister, I am a poor country doctor. But when we have a house on fire in our village, we direct the water at that house and not the whole village." And the Minister said, "You have 1 more month." And fortunately over that month things got better, and so they continued surveillance/containment. Both of these examples illustrate the really major contributions that poorly paid and unrecognized field workers made. They really deserve a great deal of credit for what went on and the success achieved. Harden: But don't you think it was also remarkable that the bureaucracy and the people at headquarters were flexible enough to ask for and act on that kind of information? Many times you get bureaucracies that think they know best, no matter what's coming in. I think the synergy was quite remarkable. Foster: Yes. Well, I think that's the main difference between smallpox and malaria. When we introduced the reward for reporting smallpox in Bangladesh, I introduced a single reward. But after about 6 months, only 35% of the public knew about the reward. And then all of a sudden, I discovered my mistake. None of the health workers were telling the public because they didn't want the public to claim the money. So we doubled the reward to pay both the health worker and the public, and within 4 or 5 months, 80% of the country knew about the reward. Harden: So getting the word out, and knowing how the culture operates, also played a huge role. Foster: The Bangladeshi field staff used to say that working for the smallpox program was the best form of family planning (they were never home) because at least their wives didn't get pregnant. As you look at the evolution of surveillance/containment in West Africa to the rest of the world, it's a steady thing. .Probably the best place it was demonstrated was in Sierra Leone. Don Hopkins didn't have enough material to do the whole country. So on 1 side he did mass vaccination, the other he did surveillance/containment. Smallpox stopped in the southeastern area but continued on in the mass vaccination area. That proved surveillance/containment worked. Secondly, the legacy of surveillance/containment out of West Africa clearly was key to the success of global eradication of smallpox. Had it not been developed, it is unlikely that we would have ever stopped smallpox, in Asia especially. Harden: What about the role of the bifurcated needle? In my mind, West Africa was the jet injector and Asia was the bifurcated needle. Foster: This is not quite true. When we shifted from mass vaccination to surveillance/containment, the bifurcated needle became the preferred route of immunization. The bifurcated needle was developed to vaccinate chickens. It had 2 main advantages. It increased the amount of vaccine available 100- fold. It only took 1/100 the vaccine required by the multiple pressure method, where a drop was put on the skin and the site was scarified by pressing a needle parallel to the skin 15 times. The bifurcated needle take rates were 99% effective versus the traditional method's effectivity of 90%-98%. In Bangladesh, the bifurcated needle totally transformed containment. We could train a villager to use the bifurcated needle in 10-15 minutes. This brought ownership of containment to the village and quicker, more effective, control. It also solved the problem of getting health workers to spend nights in the infected villages, a major problem in the early stages in containment in Asia. Once you were hiring vaccinators to vaccinate their village, the barrier of the stranger was removed, and accommodations in the infected village were possible and acceptable. I think we go should back just a little bit, to 1945. After World War II, smallpox was endemic in most countries of the world, especially in tropical areas, where the liquid vaccine was unstable in the heat. So the development of the freeze-dried vaccine (you could carry it in your pocket, it didn't require refrigeration, and you could mix it up for the day and it would be good) was a big thing. New topic relevant to West African program but not to smallpox And then the initial development of measles vaccine, the Edmonston B measles vaccine, it could only be given with gamma globulin. And the vaccine was not, at that time, licensed. It had been tested in about 20,000 kids. At just about that time, 4 Ministers of Health visited the States and NIH. Harry Meyer happened to talk to them, and one of them got very excited. The Minister of Health of Upper Volta said measles was killing 20% of the children in Africa and Meyer should come to Upper Volta (now Burkino Faso) to test the vaccine there. So the first year, Harry went to Upper Volta and tested the vaccine. The vaccine proved its safety and efficacy without gamma globulin: that was a major step forward. The demand was such that the next year they vaccinated 700,000 in Burkina Faso. It was a tremendous success medically and politically. Then the United States expanded to the other countries in OCCGE [Organization de Coordination et de Cooperation pour la Lutte Contre Grandes Endemies] and that was when CDC first became involved. Probably the best story about that concerns Larry Altman [Lawrence K. Altman]. Larry's now a science writer for the New York Times. He was sent out to Mali to address problems with the measles program there. One day he sent back a cable to Washington that said, "The trucks don't keep the vaccine cold." And a cable came back from Washington, "Park in the shade." And so Larry sent a cable back, "Send trees." The measles program was a smashing success medically and politically. You had 3 parallel channels. You had the smallpox channel going on at CDC; you had Harry Meyer, who had proved the safety and effectiveness of given multiple vaccines at the same time. And then USAID and measles. USAID for some reason thought they could vaccinate a fourth of the children the first year, a fourth the second, a fourth the third, a fourth the last, and they would be done. That was totally wrong. I was talking to Dave Sencer about a phone call he got from A.C. Curtis from USAID, who called him and said, "What about a measles eradication program," and Dave said, "No, it can't be done. Measles is only control, Smallpox is eradication. Why don't we marry smallpox and measles?" Without measles, there would have been no West African Smallpox Eradication measles Control Program, no global program, and probably no eradication of smallpox. The WHO 1,000-page history of smallpox has several flaws, the major one being the order of chapters. They placed the West African chapter after India and Bangladesh. Bangladesh and India built on the lessons learned in West Africa and succeeded because of it While the marriage of smallpox and measles was key to smallpox eradication, the effects on measles were short-lived because of the lack of infrastructure to maintain vaccination. Successful control of measles has only been achieved in the last 5 years with a new strategy. It should be recognized that Jean Roy, the Operations Officer in Benin, has been a key player in this success in bringing the League of Red Cross Societies into play-resources from the wealthier countries and Red Cross volunteers on the ground to mobilize the public. It should also be said that the marriage of smallpox and measles was a major barrier between USAID and CDC. USAID felt they had been been conned. This was really the basis of a lot of the angst between USAID and CDC because essentially USAID paid the whole bill. And I was talking to D.A. last night on the phone, trying to clarify a few pieces of history, which is always difficult with D.A. When the United States first agreed to do smallpox, there was a briefing of the US delegation to the WHO Assembly. Even the secretary of HHS [Department of Health and Human Services; then, it was Health Education and Welfare] was not aware of the plan. So then the announcement went out at the assembly, from President Lyndon Johnson, that the United States would support a smallpox eradication program in West Africa. Later, the smallpox/measles marriage took place. Clearly, Dave Sencer was a key actor in this. D.A. told me last night-which I didn't know-that that press release about smallpox was written by Bill Moyers. That was the international Year of Cooperation, or something like that. And smallpox eradication and the US contribution fit this like a glove from 3 perspectives: science, development, and politics. Harden: You have mentioned the 2 women who were professionals the West African Program. Neither of them is here for the reunion, but could you talk about who they were and how exceptional they were? Foster: Yes. Two very different people. Vicki Jones, young, free spirit, guitar-playing, and Margaret Grigsby, an older, African- American woman professor at Howard, very prim and proper. I remember we had some issues insuring that there was a proper latrine arrangement for her when she went to the field. And it was difficult in the area that Margaret was in, in terms of getting cooperation. Margaret was great. She had her heart and soul in the program and bonded well with her African colleagues. I do remember the first outbreak I went to in the western region. They had isolated the smallpox patients in a cocoa farm, and the only people who were allowed to go there were those who had the scars of smallpox. This is very, very interesting. On the other hand, you have the smallpox cult, Shapona cult, where if you didn't want to get smallpox, you paid the priest. If you got smallpox and didn't want to die, you paid the priest. And if you died, the priest got all of your worldly possessions. So they couldn't lose. There are historical accounts, in the 1800s, of priests actually infecting people who didn't pay up by putting smallpox scabs on sticks going into houses. Actually, I remember the last African outbreak I visited, in Togo. A couple of the traditional healers were there trying to pick scabs. Fortunately, the scars were from a vaccinial modified case, so it was not likely that there was much virus left. Harden: What did Africa teach you about yourself and about public health? Foster: We were young; we were bright; but we were not bright enough to say we couldn't do it. I mean, that was really important. In other words, there was never a sense that we couldn't succeed. It was a totally different story in Bangladesh. But we learned as we went along. We had pretty good government response and fairly credible civil service. At least, we were paying per diems and that sort of thing, kept people working. It was a well-oiled machine. I mean, we had something like 80 Dodge trucks in Nigeria. We had lots of spare parts. I think the last one I saw running was in the late '80s. Harden: What kind of impact do you think the whole West African program had on the global eradication program? Foster: Had West Africa not succeeded, it's doubtful that the global program would have succeeded. I have no question in my mind that it laid the foundation, and one of the great injustices in the smallpox book is that the West Africa chapter is put after India and Bangladesh. This is extremely unfortunate and historically incorrect because a lot of the lessons learned out of West Africa laid the foundation for what went on in Asia, and Ethiopia, and Somalia. Harden: Indeed. Is there anything you would change if you were running the program all over again? Foster: What we did then, we couldn't do now. Harden: Say again? Foster: What we did then, we couldn't do now. Harden: Why? Foster: I mean, it was pretty much an expatriate-run operation- money-driven, technology-driven. We did not have the proper amount of deference to local culture and societies and governments. Harden: I wondered about that. Foster: It was pretty much a technology-driven program. It was marvelous in terms of the teams we had. Some of the Operations Officers, Dave Bassett for one, George Stroh for another. George was driving from Jos down to the South when his motor mounts broke, and his motor fell out of his engine. He put the motor back in and drove home. I mean, just that kind of ability, to react in the field. So that was important. In Asia, several things were key. One was that the monthly meetings were incredibly important. People came in, they gave their reports, they shared the successes, they shared their failures, they got drunk, they sobered up, they got their money, they went back to the field. And most of them spent 25-28 days in the field. And as I look at CDC people going in the field now, they don't do that much any more. Harden: Are there any final things that you want to say? Foster: The challenges of West Africa were nothing compared to what it was in Bangladesh, especially in the floods of 1974, when the 2 remaining areas of infection were totally flooded out and people went into motion. We went from 89 infected villages in October of '74, to 1,500 the following May. We were all depressed. We lost it. A wonderful guy, Rangaraj, was my deputy; he was the first Indian physician parachutist. He had fought with Stillwell in Burma. And every morning, he would say, "It's going to be all right. Hang in there." Every day, he was like that. There was no rationale for that. Later on, when I was working in Somalia, I had a beer with Rangaraj 1 night, and I said, "Ranga, how could you have been so optimistic?" He said, "I didn't think you had a chance in hell in winning, but when I fought with Stillwell in World War II, I learned that if you ever thought you'd be dead the next day, you would be dead." So it was his military training and his optimism that enabled us to keep going, during incredibly difficult times. When I walk into an HIV/AIDS village today, I feel Ranga's hands on my shoulder. "Hang in there it will be all right." Harden: And eventually, to win. Foster: Yeah, and eventually to win. And Ranga was incredibly important. And there were lots of people like that. In Bangladesh, we had 22 nationalities on our staff, and they were they best. I mean, they were family. We were all 1 family. The monthly meetings were key. Then surveillance got incredibly better, and we were able to track things. And we used money. We paid $25,000 in rewards starting at $2.50 per report of an infected village and increasing to $50 as the number of infected villages in Bangladesh decreased. And we learned. For example, when we started in Bangladesh, we were having trouble with containment until we started hiring people from the village. The reason we were failing was because health workers had no place to stay in the villages. Once you started hiring villagers to do the work, you had a place for your health workers to stay. And so there was a tremendous lesson. </pre> Player html for embedded player to stream video content <iframe src="https://www.youtube.com/embed/0m-qj2HereE" frameborder="0" width="560" height="315"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-14 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15nd0 emory:15nd0 Subject The topic of the resource CDC Smallpox Eradication USAID WHO Combating Childhood Communicable Diseases (CCCD) Format The file format, physical medium, or dimensions of the resource 9738000000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harden, Victoria (Interviewer) Foster, Stanley (Interviewee); CDC Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource FOSTER, STANLEY O. Description An account of the resource Dr. Stanley Foster traces his early years and interest in international health. Describes his recruitment into the EIS and subsequent assignment to Lagos, Nigeria as the Epidemiologist for Nigeria in the Smallpox Eradication Program. Following that he was assigned to Bangladesh's smallpox program and then became the Project Director for the Combating Childhood Communicable Diseases (CCCD) project at CDC. Language A language of the resource English https://www.globalhealthchronicles.org/files/original/2ffa4185e29a9f5cbf80f66d2198c74f.jpg a2ff1c9712acaf19cdebe58931e368c3 https://www.globalhealthchronicles.org/files/original/ed6714fdbb6f53f7cf845540ae859ced.pdf 1c0959f40c06224d41fb270b7512ce75 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/N0fa2YkH-wU" frameborder="0" allowfullscreen="allowfullscreen"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-14 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15nf4 emory:15nf4 Subject The topic of the resource CDC Smallpox Eradication USAID WHO 25 millionth vaccination ceremony Format The file format, physical medium, or dimensions of the resource 11757720000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harden, Victoria (Interviewer) Lewis, Jim (Interviewee); CDC Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource LEWIS, JIM Description An account of the resource Jim Lewis, served as an Operations Officer in Nigeria and Ghana. Jim began with CDC in the Venereal Disease control program, and then joined the Smallpox Eradication Program. He talks about establishing rapport with his national counterparts and training vaccination teams, as well as his role in organizing the 25th Millionth vaccination ceremony in Ghana. Language A language of the resource English https://www.globalhealthchronicles.org/files/original/200973fd962e0cec7f7f57328cf16160.jpg 65bb669418122fe48d75a93211cb7c41 https://www.globalhealthchronicles.org/files/original/0dcedd2f44a95819a5a796235a43f06e.pdf 451a4fd72af99c28a55df3379423af6e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> 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. # # # </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/d_ZA0Ce4c3Q" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-13 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15nrc emory:15nrc Subject The topic of the resource CDC Smallpox Eradication USAID WHO Missionary Format The file format, physical medium, or dimensions of the resource 11411040000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harrar, Linda (Interviewer); NOVA Thompson, David (Interviewee) Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource THOMPSON, DAVID Description An account of the resource 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. Language A language of the resource English