Bill White Oral History
Chillag, Kata (Interviewer); CDC; Anthropologist
White, William (Interviewee); CDC; Operations Officer
Bill White was an Operations Officer assigned to Upper Volta (Burkina Faso). Bill describes his work in Upper Volta, the complexities of daily life, his son's illness, and negotiating CDC infrastructure once he returned to the United States. Bill reflects on the impact living abroad had on his children and the role of CDC today in public health.
Chillag, Kata (Interviewer); CDC; Anthropologist, “Bill White Oral History,” The Global Health Chronicles, accessed March 27, 2017, http://globalhealthchronicles.org/items/show/3502.
Interview Transcript This is an interview with William J. White, Jr., 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 Kata Chillag. Chillag: How did you come to public health as a career? White: When I graduated from college, I was looking for a job. During an interview, I was asked, "Do you want to go to New York City and talk to people about sex?" So I went to work for CDC as a Public Health Advisor in the syphilis eradication program in '62, right out of college. Chillag: And how did you come to work in smallpox? White: I had been working for CDC recruiting personnel to work in the venereal disease program. I was getting a little bored, and I went to visit a friend who was at CDC operations in Hartford, Connecticut. He said he had heard that CDC was getting involved in smallpox, in international work. And I said, "Well, that sounds like something really interesting to do." So I put my name forward and said I was interested in being part of the group that was going to be looked at as possible candidates to work overseas. Chillag: Had you worked internationally? White: No. I had not even traveled outside of the continental United States. Chillag: So it was a big change. So, what were your expectations of the work before actually doing it? White: I thought that it was going to be an opportunity to be exposed to a different culture and a different environment. Then the project became more exciting as we went through the training in Atlanta before we went overseas. Chillag: And your role was what? White: I was to be the Operations Officer, based in Conakry, Guinea, but there was a disagreement between USAID [US Agency for International Development] and Guinea about assigning a team to that country. So the next assignment I was offered was in Upper Volta, which is now Burkina Faso, inland from the Ivory Coast . Chillag: And you were paired with a Medical Officer? White: Yes. I was paired with was Chris D'Amanda, who had responsibility as the Medical Officer for both Upper Volta and Ivory Coast. When I found out I was going to Upper Volta, I had a chance to meet and talk with a person who had been a US ambassador to Upper Volta, Thomas Estes. At that point my wife was 6 months pregnant. So we asked Estes, "Can you give us some insight into Ouagadougou, and whether or not it's even possible to think about delivering a child in the hospital there?" and he said, "Oh, yeah, no problem." Fortunately, my daughter was born stateside. Chillag: Did you come back, or you hadn't gone yet? White: No, we hadn't gone yet. It was clear that there was going to be a delay in the assignment and clearances and a whole series of things. There was an interim assignment arranged in Pennsylvania. So our daughter was born in Harrisburg. And then we went from there to West Africa. Chillag: What experiences, skills, and training from the VD program-and it doesn't just have to be that-were most relevant in terms of what you did next in Upper Volta? White: Even though I started off in the venereal disease program, I think that the next step, my assignment in Pennsylvania, was more critical because I was involved in recruiting for CDC on college campuses. The capability of interacting with people in a setting other than just a VD clinic was more useful. But I also think it was just kind of an understanding of what I was interested in at that time. It was the late '60s and getting beyond the United States and looking at international issues seemed to be relevant, at least for the folks that I knew in my generation. Chillag: If there was such a thing, what was a typical day like in your work in Upper Volta? White: Some of it was boring because it was basically office work and staying on top of issues, such as the budget. But other parts were interesting, such as the interaction with the vaccination teams, the development of the training of the teams, making certain that they understood what was expected, tackling issues like where we were going to store vaccine in a country, and looking at the cold chain. I did not understand, when I got in-country, what the issues were going to be in terms of being able to store smallpox and measles vaccine. We wound up having to find a large locker in which to store vaccines, and the only large locker that could keep things cold was at the abattoir, the slaughterhouse. So the vaccine was stored there. So when vaccine came in from the airport, getting it from there to the slaughterhouse was one of the major undertakings of the day. Chillag: And I assume part of your role was to negotiate things like storing it in the slaughterhouse. White: Yes. And that was made easy by being able to negotiate with the French, who really still formed the underpinning for the government agencies and were helpful in some ways, racist and hostile in other ways. I think that they were competitive in some ways with the American team there, but at the same time they wanted to see success with smallpox eradication. Chillag: So the remnants of the French infrastructure, is that who you primarily dealt with? White: No. There were Africans, but the French influence permeated a lot of the areas in the ministries, finance, health, and other agencies. This was in the late '60s, and the underpinnings were very much French. They still subtly controlled what happened in the economy and the government infrastructure, at least in Upper Volta, and, my understanding was, in some of the other francophone countries as well. Chillag: What were some of the challenges in dealing with Africans there? White: In our preparation for going overseas, there was a lot of attention paid to our becoming aware of the vehicles that we were going to be using and the maintenance and operation of those vehicles. Well, as it turned out when I got in-country, you could hire very qualified drivers and mechanics for relatively small dollars, and so it didn't make a whole lot of sense for me to figure out how to repair a Dodge truck. I also had political interactions within the American Embassy as well as within the French structure and with the Voltaic government in general. Chillag: So, starting out with the government in general and the French infrastructure, what were some of the politics that you faced? White: Initially, as I said, there was what I would regard as-jealousy is not quite the word-concern among the French that the Americans were there not just to do the job they were there to do but to basically insert ourselves between the French and the Africans who were ultimately in charge of the country and of the government. Even though there was a president then in Upper Volta, there was always the potential of a revolution. Interaction within the American community was also a concern because when we arrived, my family was located in Ouaga. There was a sense that we were somehow not just with the USA and USAID and not just with the Public Health Service. There was some suspicion that because we had learned some French, we were somehow connected with an agency based in Langley, Virginia. The suspicion was enhanced because our housing was outside of the immediate American compound. The other thing that made it complicated was that, as the smallpox/measles team, we had freedom to go almost anywhere within the country. And that was unusual; other Americans in the country had more limited passage for their visas. Chillag: So, how did you deal with those things? White: Ignored them, basically. I expanded and made changes. I just thought it was kind of funny that I would be considered as linked to the CIA [Central Intelligence Agency]. That connection was not anywhere near where my interests and politics were. So, I mean, it just made it kind of funny and interesting. I think the other challenge was being able to deal with the USAID infrastructure and how they perceived what we were there for-that we were really part of their operation but not quite part of their operation. I generally had a style of ignoring a lot of the paperwork and a lot of things that they were concerned about. My issues were public health issues-dealing with what we needed to do to train the teams, to get the vaccines out there, and to get out to assess outbreaks. I didn't pay a whole lot of attention to the USAID and embassy bureaucracy. I remember just the complexities of living. When we got there, I have a fairly vivid memory of getting off an airplane at like 5:30 in the morning, having left Harrisburg about 2 days before with a stopover in Paris. When we left the United States, I think it was probably about 30°F. When we got to Upper Volta, it was probably 30°C. I had second thoughts after we got off the plane and got located, and the housing we were supposed to be in wasn't ready yet. I'm thinking, "Wait a minute. My daughter is 6 weeks old, my son is a little over 2. What the hell did I get everybody into?" But then I think that there was a lot of interest in the American community, of seeing that somebody new had come to town. The Americans in-country were welcoming, even though it was a small community. So I think that that was helpful in adapting. But just learning that the electricity was going to out for so many hours, that the water was going to be out for so many hours, and that when the water was on, it was going to be on for a very specified period of time during the hot season- just coping with the living experiences in some ways helped us deal with things there. And we eventually realized, in spite of what former Ambassador Estes had said, that the health service and health options that were available in the community were not first-class or even second-class. Chillag: How did your wife feel with all this? White: I think that initially, she had some anxiety. She was nursing our daughter when we got there, and she had some concern because she had not been successful in nursing our son. But basically it was in some ways more relaxing and less stressful there than it was stateside; so she was able to get comfortable nursing our daughter. I think the next thing was that Claire needed to be able to find something to do, and that was unusual because I think other American wives who were there didn't necessarily feel that way, but Claire did. So she went out and found something connected with the USAID program and was able to work on that part-time. By background and training, she was a teacher, and so she arranged for Africans to come to the States through the African American Institute (which turned out later was funded by the CIA). That gave her a role in activities outside of the home. Both of us came from middle-income backgrounds, so it was ironic that one of the things that we were expected to do was to hire servants. Initially, we balked at that. But it turned out that it was an expected part of being in the community because you were contributing to the economy. So even though we hired a blanchisseur, which is basically somebody who did laundry and housework, you were expected to at least hire somebody to do some of the cooking and cleaning within the house. It turned out that you were paying the house staff the equivalent on a monthly basis of what the per capita income for the country was on an annual basis. It was complicated for us because the first thing that you learned was that they refer to you as patron, which means master, which didn't quite fit with who we were or what our self images were. It took a while to get the house staff to change that to monsieur. And they weren't quite comfortable with that initially but learned. So we learned to cope in an environment where things that you would normally expect that you'd have available, like fresh milk, weren't. There were things that you learned about shopping and buying things in the open market and things like that that made life interesting, fascinating, tolerable, and sometimes just really a huge pain in the ass. Every time you cracked an egg, you found blood in it. Chillag: You've alluded to some of the expatriate-like cultural differences, but were there other cultural differences that were really striking in the work or that affected your work? White: Mainly getting an understanding with the French that we weren't there to usurp what their authority had been. That we were there to contribute. That we were there because we wanted to encourage and teach the African teams that we were working with ideas that we believed they needed to know to be able to be effective in doing vaccinations and follow-up checks. It was clear that you could go back and check on the smallpox vaccinations and determine whether or not you had a take. You weren't always able to do that with measles, so you did the dipping of the fingers into-I forget what it was at that point, some kind of silver nitrate. Part of it was even learning to adapt and deal with the official American community that was in the country because it was a small community, but at the same time it was expected that you interact with them. Chillag: So your base was there, but I imagine you traveled out around the country. Is that correct? White: Yes. The base was in Ouagadougou. In the first several months we were there, we traveled to other areas of the country because we had a number of smallpox outbreaks. It was important to be out there with the teams if we were going to be able 1) to try to identify where the incident case came from and 2) to do the vaccinations and/or curtail what we thought might be spread of the infection. So I probably spent, on average, maybe 40%-50% of the time outside of Ouaga. The next largest city I spent time in was Bobo- Dioulassou, which was where the African/French regional health operation was located. Other parts of the country that I visited depended upon where there were outbreaks or where the teams were working. Travel slowed down some in the rainy season. Chillag: What were the biggest rewards of the work for you? White: I think part of it was realizing that there were opportunities to make a difference. We had conversations about this even during the course of the training in Atlanta. That, if we were successful in eradicating smallpox and controlling measles (measles had a 20%- 25% mortality rate then), what was going to happen in those countries? We weren't doing anything to change the economy; there wasn't necessarily anything else that we were doing that was going to change the larger health structure. And so from a philosophical point of view, one of the questions we asked ourselves in late-night conversations with wine and cheese was basically: What were we accomplishing? And I think we accomplished something for the United States in that it took away an infectious disease that could have come here. But the real question was: What was the real benefit in the areas in Africa that we were working in? I think some of the techniques that we taught folks about disease follow-up, learning about putting in place some modest epidemiology and epidemiologic approaches in surveillance and assessment of coverage, stayed with some of the teams. So I think we contributed to their having a better understanding of those things. But the ultimate, I think, was just the psychic kick of being able to demonstrate to myself that I could able to learn to function in a different culture, learn to function in a different language, and learn to be leading a team in accomplishing things. I wonder, frankly, with today's instant communication, whether or not the freedom that we had to go ahead and make decisions and take action would be allowed under today's circumstances. There were times when I was out in the field and I would come back and I would find a cable asking for one thing, and then 3 days later there was another cable countermanding that request, and then another cable saying, "Forget those two. They're not important." Today, if you had wireless access or a cell phone and a satellite communication or anything else, somebody would want instant response to things that may interfere with what really needed to be done . Being on the ground and being able to make the decision with the available information was key. The other thing that in some ways shaped my experience there was the fact that our son was discovered to have an illness when we were there, and the nature of his illness was congenital. It was Hirschsprung's disease, and that meant that he had a section in his colon that needed to be resected. This condition is usually discovered within the first few weeks of life, with newborns. In his case, it wasn't discovered until later, and so there were constant questions about whether or not there were parasites infecting him or something else causing his symptoms. And that caused a significant amount of stress for my wife and for me because you don't like to see your kid in pain and discomfort. And when his colon got enlarged, he had to have frequent enemas and other procedures to disimpact him, and they just weren't very satisfactory, and it was a difficult way for a child to live. The dilemma occurred when the State Department physician, who was the first one who came up with a best assessment as to what was wrong, determined that it wasn't a reason for medical evacuation because it was a condition that was congenital in nature and should have been fixed before we were overseas. That, on the face of it, seemed preposterous. The folks like George Lythcott and others in the regional office backed the decision to allow my wife and son to leave the country on early R&R; (rest & recreation) to Germany. There, at Landstuhl in Frankfurt, they did a full evaluation; they weren't quite sure that what they saw was correct and sent them stateside. So I wound up being in- country probably about 4-6 months by myself while they were in Germany, then in the States, going through all of the diagnostic procedures as to what was really happening because it wasn't clear. Finally, Children's Hospital in Boston recognized the condition and corrected it. The other difficulty incurred by that situation was that some challenges were made to the State Department on its decision, not by me but by my brother, who was a physician in the States. He sort stirred up some shit-excuse the Spanish. The State Department got very huffy and essentially at one point made a note to the record that described my then-wife as a morale problem, and they would not allow her to return to post. The reason for that was that there were a few other Foreign Service officers at post who also had very young children, and they had seen circumstances in which they had seen a mother with a child who was somewhere around the same age as theirs who was not dealt with fairly, in their mind, by the State Department. The parents raised all kind of hell with the Ambassador, who just got all very huffy about the decision. The State Department rallied around itself and said that its decision was correct and there was no way to reverse it. So that changed the circumstances in terms of whether or not my wife was ever going to be allowed back in-country. She had been designated as persona non grata by the Ambassador and therefore DOS. And so that pretty much ended my career in terms of being part of the international group. From the CDC perspective, there were other opportunities to go overseas. One of them was Afghanistan at that point, which was not a likely choice, given the fact that I wanted to spend some time with my spouse and kids, and Afghanistan was not a post where that was going to happen. Chillag: So, one of the questions that we ask sort of follows from this in a different way: How did your experience working on smallpox affect the rest of your career and your life? White: It's a good question because one of the things that I saw coming back stateside, I think there was a lot of preparation done for us going overseas. There was a lot of instruction about things that you hope never happen to you and infectious diseases that you hopefully never come in contact with, around anti- malarials and getting your kids to take the meds; information about the smallpox program, and USAID relationships, and all of those things. When I came back stateside, I was dealing with relocating my family stateside, and the East Coast seemed to be the place. And since I had spent time in New York City before then, getting relocated in New York made some sense. The domestic side of the CDC operation had little, in my estimation, appreciation or understanding, at least from the perspective of what Operations Officers learned to do overseas. And questions around promotion, questions around understanding of those things, and, at least in my experience coming back, were not well understood by the domestic operations side of CDC. When I came back, they sort of grudgingly accepted me into the tuberculosis program in New York. But it wasn't clear, at least at that point, that the experience overseas translated into a kind of integrated career pattern within CDC. I would say the other thing, just from a personal point of view, that pissed me off even when I joined the tuberculosis program is that, what I was looking for was an opportunity to get into graduate school so I could get at least a master's level, beyond where I was, in public administration or public health. NYU [New York University] at that point offered the program. When I requested CDC to pay the tuition, that I was going to be going to school in the evening, so there was no time away from work, they denied it because they weren't certain that I had career potential within CDC. So I then went to work for the Office of Economic Opportunity and worked in community health centers and a variety of other kinds of things. I stayed in public service until sometime in the early '80s. When Joe Califano was Secretary of Health, Education and Welfare, I was the point person on his office for the Childhood Immunization Program. That caused some folks at CDC to be anxious because there had previously been somebody from CDC based in Washington who was heading that up. I wasn't at CDC then-I was in the other part of the Public Health Service-and there was a concern that I harbored ill feelings towards CDC, and I didn't. I mean, I just realized that they were going one way and I was going another way, and that was fine. I think that as far as I was concerned, I learned a number of things when I worked with CDC. I had a great experience from a personal perspective overseas in learning that I could go ahead and make decisions, and I could make decisions in complicated political and other environments that made sense, and I don't regret that experience at all. I don't. In terms of my kids and as far as what their perspective on all of this is, they purport to remember their time overseas. My daughter was 10 months old when she left Upper Volta, yet she still seems to have memories of that. I don't know if it's from family conversations or whatever. But both my son and daughter have spent a fair amount of time traveling internationally or working internationally and living internationally. My younger son, who wasn't even part of the group at that point, also has worked and lived internationally. In fact, my daughter lived about 8 years in Russia, and my son for 9 years. In fact, he's back there with his wife and daughter now. So I think they grew from that experience. You know, people perceive themselves as being more international in how they see the world. Chillag: I suspect you've touched on some of the things that would be the answer to this question, but if you had been in charge of the program as a whole, what would you have changed in terms of the approach or any dimensions of it? White: This was really CDC's first effort in international public health in any major way. I think the training of folks leaving country was pretty reasonably well done. I think training people about how to reenter and how to interact with folks domestically was not as well integrated as it could have been. Maybe it's changed now and maybe the career paths and the way that one can take a look at things are better thought of and better defined. Chillag: At what point did you think smallpox could actually be eradicated? White: Well, I think it was pretty clear. I mean, I never thought when I went to work for the syphilis eradication program, that syphilis was going to be eradicated, particularly given what I saw in New York, and at that point homosexuality was so hidden it was unbelievable, in '62 and '63. But I thought that given the availability of vaccine, if we could figure out the cold-chain issues, if we could figure out the trainings of teams and the distribution and early knowledge of what one could learn about managing the containment of smallpox outbreaks, smallpox could clearly be eradicated. The strategies were modified over time, and the availability of the bifurcated needle and better vaccines and all the rest of that really helped, but I think it really was in many ways sort of a simple disease to eradicate. That's why, frankly, I couldn't understand the hysteria around scurrying around and looking for millions of doses of smallpox vaccine that went on in the Tommy Thompson era. It just struck me as really stupid public health and a waste of monies and dollars. But I don't feel strongly about it. Chillag: Do you remember hearing about the last case of smallpox and how you felt? White: Yes. In my career I've been involved in eradicating syphilis and eradicating poverty, and the only thing I've ever been successful in eradicating was smallpox. It's not the only thing that I'm proud of, but having been part of the group of people who were able to contribute in some way to that, yeah, I think it's an impressive thing. My godson is getting married tomorrow, and the real question was whether or not I was going to come down for any part of this reunion. So we came down today, and we're going to go back up early tomorrow morning for the wedding. But it was important to see folks who were here and also just to reconnect with some people who were part of something I think that was a very interesting and I think a significant effort in public health. The other thing that I will say that has been a point of unhappiness for me in the last several years is the erosion of CDC as an agency that is seen as a significant presence in public health. I worked in Massachusetts for the Department of Public Health up there, and they don't look to CDC for direction and guidance. I think the agency, over a period of time, has become increasingly politicized in the appointments of its directors and its missions. I think some of that's been allowed by Congress, and a lot of that's been allowed by the secretaries. I think that that's unfortunate. Now it's even worse because it's happening at NIH [National Institutes of Health]. But it's an unfortunate legacy in the last 15 years or so in terms of what's gone on with CDC. Seeing Tommy Thompson out on television talking about anthrax, I just wanted to reach deeply into my throat and retch on the floor. The man had no reason to be that. You needed a scientist out there talking about that and reassuring people of what was going on. Chillag: And you feel that was very different at the time you were with CDC? White: Yes. I think that there were people here who were connected to the science. I don't care if it was Alex Langmuir, when he set up the EIS [Epidemic Intelligence Service] or Carl Tyler, when he was there and I was working with the Family Planning Program. They came to agreement on things that they could contribute to and make life better in the delivery of reproductive health services. I mean that the Reagan era began to deviate from science in the area of reproductive health, and I think it continued a little bit in Bush one and I think it's gotten worse in Bush two. And public health science is just not here. Chillag: So, is there anything else you want people to know for posterity about your experiences? White: Yes. I was 26, 27 years old at the time, and I was in an environment in which I was perceived as being in charge of a significant part of the development of a public health program in a country, and that was pretty heady stuff. We were the folks that people came to when the new Peace Corps group was coming to town because we were really the first American presence in that country that had gone outside of the major parts of the city. And when the Peace Corps came, I think that our presence there made that more accepting. And as long as you made it clear to folks that we didn't work for the CIA, I think it was ultimately fun. Chillag: Thank you very much. It's been a pleasure. # # #