Christopher D'Amanda Oral History

Interview Transcript
	   
This is an interview with Dr. Christopher D'Amanda about his experiences in
the West African Smallpox Eradication Project. The interview is being
conducted at the Centers for Disease Control and Prevention in Atlanta,
Georgia, on July 13, 2006. This is a part of the activities for the 40th
reunion of the West Africa Smallpox Eradication Project. The interviewer is
Victoria Harden.

Harden:     Dr. D'Amanda, you were born on July 14, Bastille Day, in 1934.
           I would like you to describe briefly your childhood, pre-college
           education, influential family and friends, if you would be so
           kind.
D'Amanda:   May I begin by saying I prefer, if it's all right with the
           project, to just call me Chris, or Christopher.
Harden:     That is fine.
D'Amanda:   Yes, July 14 was the day that my mother described as her day of
           liberation, so it wasn't only the Bastille that was taken care
           of. And that was in Rochester, New York. I was in school there,
           at a co-ed country day school, until the 7th grade, when my
           parents decided I should go to Exeter. So I went to Phillips
           Exeter Academy for 4 years. And then, in those years it was very
           easy-in fact, the Exeter senior classes were told this-that if
           you wanted to go to any college in the country, even if you were
           not in the top 75%, you could go to any college without applying
           to more than one. So Exeter seemed to be a precursor, in my
           mind, to Harvard. Then I went to Harvard for 4 years, where I
           majored in English.
Harden:     I'm fascinated by how somebody majoring in English literature
           then decided to go to medical school, so can you slow down and
           tell me here?
D'Amanda:   Well, the sequence really began in my father's family, where we
           would repair every Sunday for supper or luncheon cooked by his
           mother, and her 5 children, one of whom was my father. Her other
           son was a doctor. And her daughters had married doctors. So I
           grew up in a family of physicians, even though my father was a
           lawyer. And my older brother had already claimed, as the older
           (as I've learned later in my role as a family therapist), he'd
           already claimed law as his future. So I declared for medicine,
           following in some ways Papa's injunction that D'Amandas never
           worked for anybody. They were their own bosses. Little did I
           know that that was a little bit illusory. We all have bosses,
           one way or another, even in medicine. But anyway, we all have
           bosses.
Harden:     Indeed.
D'Amanda:   So as far as I was concerned, I was destined to be a physician.
           My choosing English, and all the humanities I could at Harvard,
           was in full recognition that once I got to medical school I'd
           have no time-or at least, I didn't know that I would have time-
           to read history, enjoy music.
                 I started playing the piano when I was at Harvard. I took
           6 courses every semester, even though we were only required to
           take 4, just because I wanted to get my fill of everything I
           could. And then, after that, after Harvard, I went to medical
           school at the State University of New York in Buffalo.
Harden:     And would you comment on any influential teachers at Harvard or
           in medical school that helped direct you towards thoughts of
           public health?
D'Amanda:   Well, we'll get to why I got here, but it was totally
           serendipitous, if you will, or fortuitous. Both of them were
           very positive moments, but not by design. When I first arrived
           at the medical school, my dean told me that I needed to work
           very differently at the University of Buffalo School of Medicine
           than I had at Harvard, in the sense that, it was very clear,
           looking at my transcript, that I could get As when I wanted to,
           but if I wasn't interested in a class, I would get a C. And he
           said, "Here, you have to do all the work we tell you to do
           because we want everybody to excel, and we want everybody to
           pass the medical boards." So a large part of their teaching was
           designed toward doing. The testing, anyway, was designed to
           replicate a large part of the medical boards which consisted of
           multiple-choice questions, which I've never enjoyed, and still
           don't. I prefer essays, and thinking a little bit, rather than
           having a thought done for me. In any event, that was the medical
           school experience. There were some wonderful professors there,
           particularly one in. in pathology,. Cornell Terplin [ph.].
                 Back at Harvard. Oh, I guess the tutor at Elliott House,
           where I lived, was a seminal person in my experience there, in
           retrospect, as he told me that Harvard was a molecular society.
           Now, I didn't quite know what that meant, but then he explained.
           Everybody at Harvard is, at least in those days and probably
           still (I just came from my 50th reunion there, a couple of
           months ago) is so busy doing their own world. They're like
           atoms, spinning in their own spaces, and they bump up against
           each other from time to time. But don't expect enduring
           friendships or things to grow out of the Harvard experience, was
           his way of defining it. And that wasn't particularly true for me
           because I did find friends there, but actually, in retrospect,
           the friends whom I still have are the friends that I made at
           Exeter, 3 or 4 years before I got to Harvard.
                 The experience for me at Harvard was probably, at least in
           my mind, better capsulated by the excitement, the intellectual
           stimulation, and the fact that I was taking a graduate course in
           my first year because I could do it. I mean, I was allowed to do
           it, put it that way. It was just endlessly enthralling. But it
           was also sufficiently intellectual that by the time I got to my
           senior year I knew damn well I had to leave because it just
           didn't seem like a real world to me. I had an instinct that
           there was something else besides Harvard out there, but there
           was no way to enjoy it at Harvard. I have always been the second
           child, the explorer, the traveler (which is also part of family
           therapy: tradition of birth order). Anyway, I left very gladly.
           I left Cambridge and I left Boston, and went back to upstate New
           York.
Harden:     When you finished medical school, in 1966, obviously the
           Vietnam War was going on, and the military always needs
           physicians. But you joined the Public Health Service and came to
           CDC. Now, you said it was a serendipitous experience. You want
           to walk me through this?
D'Amanda:   I stayed in Buffalo to do my internship in medicine, and then
           chose to do a full medical residency with 2 years, and then
           stayed on a third year as chief resident. And during those
           years, I had a hand in teaching and being aware of research
           activities, journal articles, and so on. I envisaged myself
           becoming a full-time academic researcher in some ivory tower
           someplace.
                 However, the draft still loomed. So I had a good friend
           who knew about the Centers for Disease Control, and I was
           interested in statistics as a way of sort of separating the
           wheat from the chaff in so much of the stuff that was being
           published in journals. Too much of it was anecdotal and not
           enough well-designed so that you could produce some kind of
           conclusion that might bear benefit in the practice of medicine.
           In any event, I came down to CDC to see if I could enroll in the
           EIS [Epidemic Intelligence Service] program.
                 But when I got here, I was older than most of the people
           who were being recruited, having finished not only my
           internship, but my residency. A lot of the other doctors, my
           peers in the program, had just finished an internship. Secondly,
           I was bilingual in French and... from earlier travels I'd done
           in Europe, and training I'd had as a schoolboy in Rochester. So
           somehow that word got to D.A. [Donald A. Henderson], and D.A.
           came over and basically hijacked me out of EIS, and put me in
           the smallpox program.
                 And I thought, what a wonderful opportunity. Here it is,
           I'm going to get to Africa, where I've never been, much as I had
           traveled before in other parts of the world. I was going to get
           to really perfect my French because it was clearly destined that
           I was going to a francophone country. And thirdly, I was not
           serving in the military, except in this wonderful sort of almost
           Gilbert and Sullivan way. My title was Lieutenant Commander, JG.
           But clearly I never had a uniform, never learned to salute. But
           because the Public Health Service had started with the Navy,
           taking care of the sailors who were getting sick on their early
           transatlantic voyages, the Public Health has always used naval
           military designations. So that was the serendipity. That was
           chance.
Harden:     So this is 1966, and you were taken out of the full EIS
           program, but they were training...
D'Amanda:   Oh, yeah, we still did the biostatistics course, we did all the
           other things. But then, one of the things that amazed me, we had
           a special program that went on for some time, learning how to
           take apart a Dodge truck and put it together again. Not part of
           the usual epidemiologic training, I'm sure. And I learned to do
           that. I'm not a mechanical genius, by any means, but in one of
           the letters I wrote at the time, I was describing that we all
           had to learn how to take the Ped-O-Jet apart and put that
           together. That was a piece of cake compared to a large motor
           vehicle. But it was stuff that I learned to do, and in fact was
           able to train people to do before my operations officer got to
           Ouagadougou in Africa. And it certainly helped me in when we had
           une panne, which means to have an accident, a breakdown.
Harden:     But you did have an operations officer supporting you? You
           didn't have to do both roles by yourself?
D'Amanda:   No. That was the design. It's one of the designs I'd hoped
           would follow me when I came back to work in America 4 years
           later: the balance between an administrative person and a
           physician, a medical person. But it doesn't work outside of this
           environment.
Harden:     Why is that?
D'Amanda:   I think it's because the administrators are too hungry. They
           don't want to share the glory. Put it this way: When I went to
           work in Philadelphia, after I'd come back here, I had talked to
           the director of the program that I was being hired into as the
           Chief Medical Officer for Drug and Alcohol Services in
           Philadelphia. And I described this. He had been a Peace Corps
           director. And he assured me that, yes, we would be a team, and
           so on and so forth. Well, that wasn't the way it worked out. He
           clearly wanted to be the major person, and it was a major
           administrative job, just like smallpox was. But there were
           clearly a lot of clinical, medical issues to be addressed, in
           terms of providing service. Philadelphia at that time was the
           4th largest city in the country. We had 14 different treatment
           programs; we had 10 methadone programs. I mean, addiction is a
           medical disability or a medical problem.
                 In any event, I made do by inventing things for myself.
           That's how I got to do a lot research for the people in
           Washington. But this model that exists here is very special. And
           I don't know whether you saw it at the NIH [National Institutes
           of Health], but it's a wonderful give-and-take because clearly
           the administrator has his or her areas of expertise and
           implementation and experience, just as a good doctor does.
Harden:     No, I did not see it at NIH, and that's why I have found it so
           interesting, the 2 working together . . .
D'Amanda:   None of us can know as much as we need to know. No single
           person.
Harden:     Yes.
D'Amanda:   But when you get into a complex project or major issues of
           administrative health programs...One of the things I did in
           Philadelphia was to start an Employee Assistance Program for the
           City of Philadelphia employees. I figured if we were taking care
           of the citizens of the city, we ought to try and figure out how
           to take care of our own because the statistics were clearly the
           same: 10%-15% of the people in any work force are involved,
           either actively or just recovering from, some form of addictive
           disorder. So anyway, I started this program.
                 I had the city administrator working with me, as well as
           the union person. Because city employees, of course, were all
           union, and it was very clear from the model that I'd learned
           employee assistance from, that if you didn't involve the union,
           they would never cooperate with administration, and vice versa.
           So I got to be the middle person as the doctor, saying, "Look.
           This man has just driven a truck of hundreds of thousands of
           dollars worth of equipment, nearly off a bridge"-which was one
           of the headlines that occurred at one point when I was doing
           this-because he was drunk. But he was also a member of the
           union. So if the administration had tried to fire him, the union
           would have put up a battle. And if the union tried to brush it
           under the carpet, the city would have said, this doesn't work.
                 So anyway, employee assistance was a beautiful way to give
           everybody a piece of the pie. And my job was, first of all, to
           train administrators to not be diagnosticians, just to pay
           attention to the job that needed to be done, and if somebody
           wasn't doing their job, they just had to report that, period.
           And then to get the union people to trust me enough to say that,
           even though I belong to administration, I'm not selling you out.
           I'm here to keep your voting member alive and well. So it
           worked, very well. The model is a tremendous model. It came out
           of the Cornell School of Labor and Management. A guy named
           Harrison Trice.
Harden:     Let's transport that back to Niger, now. Tell me how you
           conceptualized what you had to do and worked with your
           operations officer to do it.
D'Amanda:   Niger was a special project that we all shared, doing an
           assessment of neighboring countries. My countries were Ivory
           Coast and Upper Volta (now Burkina Faso). My home was in
           Ouagadougou, which is the capital of Burkina Faso.
Harden:     So perhaps we should start with Upper Volta and Ivory Coast?
           Okay. Sorry.
D'Amanda:   No problem. Well, one of the things I learned very quickly was,
           because I'm blue-eyed and white-skinned but happened to be
           bilingual, I was frequently taken to be a French person. And I
           learned very quickly that all the French carried a very
           significant and generally pejorative aura because they were the
           colonial powers. And they were still interfering with the local
           African people too much with their autonomy or their hoped for
           or desired autonomy in whatever francophone countries that I
           went to. So I learned very quickly to identify myself as an
           American, and of course that was very popular because Kennedy
           was President, and everybody loved Kennedy and loved the
           Americans.
                 The second thing I learned very quickly was I had access
           with my OOs [operations officers]-a brilliant guy named Bill
           White [William J. White, Jr.], in Upper Volta, and then Tom
           Leonard [Thomas A. Leonard], and then Bob Hogan [Robert C.
           Hogan]. They were just special, wonderful human beings, as well
           as highly skilled technical people.
                 I had to learn to be patient. Because even if I declared
           myself an American, it didn't mean that that would work all the
           time, and it didn't mean that it worked right away. So for the
           first year in Ouagadougou, I can remember still having to learn
           to wait for 3 hours to get to see the Minister of Health, whom I
           needed to see to discuss the program. And so I used to bring
           books and I used to read, and I used to get restless. But I also
           reminded myself that I was a guest; this was their country. They
           could treat me any way they wished. But after about a year of
           what I now think of as eating humble pie, so to speak, then I
           got to be able to get in ahead of people.
                 I used to say to the Ivorians, as well as to the Voltaic,
           "You know, I'm being paid by America, but I'm not working for
           America. I'm working for your country." And that was the way we
           felt. That's the way I felt. And it was important as I see the
           practice of medicine now, and certainly family therapy, you
           don't tell people what to do. You ask the questions, you learn
           the ways, and then help them make decisions. So it was not in
           any way dictatorial, "we know better than you."
                 The difficult part was, in some ways, working with the
           French, especially the man I worked with in Ouagadougou. There
           was a fair amount of disregard between the French and the
           Americans anyway, at least the French didn't like the Americans
           very much in those days. I'm not sure they're that much more
           comfortable with us now. But in any event, Colonel Sansarricq's
           first words to me were, "You know, D'Amanda, I don't know why
           you Americans think you can get rid of smallpox in 5 years. You
           know, we French have been here for 30 years, and this disease is
           not going to go away just because you came here."
                 But that was another lesson I learned. We can segue up to
           Niger at this point because I was involved with the actual
           campaign in Ivory Coast and Upper Volta, in terms of the up-
           front sort of dealing with the higher-ups in the health
           administration. I'm an internist, and trained, as we all were,
           to identify smallpox, to determine whether an illness really was
           smallpox or not. The longer we were there, smallpox was getting
           less and less common. I ended up seeing about a hundred people
           with smallpox in Upper Volta. But near the end of my stay, most
           of the time, people who did not know the distinguishing
           characteristics thought that a lot of the old, but most of the
           young, people who had these particular kinds of rashes had
           smallpox, when in fact they had chickenpox.
Harden:     People have talked to me a little bit about differential
           diagnosis, but nobody has actually gone into detail. Can you?
D'Amanda:   Sure. First of all, smallpox is what's called an exanthem. It
           affects the skin. Virus affects basically lining, or squamous,
           cells. Squamous cells are on our skin, but they also line all
           our insides. They line our gut, they get modified in various
           specific ways. But, for instance, one of the common problems
           with measles patients is that they get otitis media; they lose
           their hearing. One of the worst things that happens to children
           who have measles and are nursing is that the whole lining of
           their mouths and their intestinal tract get these lesions on
           them, so they can't swallow; they can't even nurse. They get
           chronic diarrhea. That's how so many of them die. Or they get
           bronchitis. Again, these same cells are being infected with the
           same virus. So the distinguishing characteristic to do the
           differential diagnosis is really on the skin.
                 And also time course of the illness. Each disease has what
           I call choreography, which is one of the words I use to define
           the withdrawal symptoms of various drugs that people take in the
           street. The time course, the process of smallpox, is 3 weeks
           long. And the lesions are in specific locations on the body.
Harden:     As opposed to chicken pox.
D'Amanda:   Chickenpox is sort of a flood of these same-looking lesions. On
           a black-skinned person, they're called taches blanches, white
           spots. Because as they erupt, they look like little blisters or
           pustules; but when they become scars, the black melanin hasn't
           gotten to that space; in fact, it's new tissue and it may never
           be replaced.  In fact, that's how we do the assessment: we look
           for the white spots, the taches blanches. But the white spots
           have to be in different locations, and the patients have to have
           been sick for a different period of time. So that was a
           differential diagnosis.
Harden:     Someone spoke about a different smell for smallpox. Does this
           mean anything to you?
D'Amanda:   Not one I remember. It may have been, but I used those measures
           that I just described for you. I did not use my nose.
Harden:     All right. You were going to talk a little more now about the
           Niger assessment. Would you?
D'Amanda:   Okay. Our primary job was to make sure that we vaccinated at
           least 94% of the people with smallpox vaccine. Smallpox, like
           all infectious diseases, has something called herd immunity,
           meaning that you don't have to really cover every individual
           with whatever vaccine or inoculation to get immunity for the
           population. The only reason smallpox was eradicable was because
           the virus only lived in human cells. So it was known from work
           done here, before we even got out to West Africa, that if we got
           90% of the population immunized, the virus couldn't survive. So
           our job was to first of all organize people in the various
           campements de marché [ph.], in whatever way we would bring them
           together to get them all inoculated with the Ped-O-Jet. And then
           going away and get the country done, within the 3-year period.
                 We thought we could do the same thing with measles but
           that was an error. We thought measles infected children who were
           5 or 6, when they first went to school. We did not understand
           that the epidemiology is a crowding phenomenon. And the crowding
           phenomenon in West Africa is going to marché. (market).
           Infants are carried on their mother's back. So as soon as they
           are born, they're introduced to the markets of whatever region
           they're in. And they get exposed. So in fact, the measles virus
           was transmitted very, very rapidly, and there was no way we
           could cycle in the 3-year time to get all the new children being
           born.
                 So measles became actually a sticking point because in
           some of the African countries, especially places like Ivory
           Coast, smallpox had virtually vanished before we even arrived.
           There were a few cases, but they were imported cases, usually
           from Upper Volta because so many of the men from Upper Volta had
           to come south to find work. There was very little employment in
           countries like Niger or Upper Volta, and they lived by
           subsistence farming. So they'd go south to get money. But they'd
           also bring disease with them.
Harden:     So some of the countries were not supportive, then [of the
           smallpox effort]?
D'Amanda:   Well, that had to do a large part with how they were beholden
           to the French, their agent technique [ph.] who were French. Some
           of them were upset that we weren't eradicating measles. We'd set
           out to do that. That was part of our title: Smallpox/Measles
           Eradication. We did it with smallpox, but we in no way did it
           with measles, and so they were disappointed. There were a few
           slings and arrows thrown at us, but we had to do a mea culpa, or
           effectively so, that we didn't understand that the crowding
           phenomenon [that we assumed] had occurred in this country at the
           age of 5 or 6 and which would have given our cycle of 3 years
           ample time to vaccinate everybody, simply didn't work in the
           developing world. And so we did the best we could.
Harden:     In the forward to your journal in Niger, you stated that after
           being in Africa for a while, "The stranger begins to long for
           the leisure that cannot be had here, and he knows, even as he
           does so, that he has become a devotee of the special non-leisure
           that is Africa." Would you comment on living in Africa?
D'Amanda:   Well, it has to begin with us. It has to begin with the
           enthusiasm and the excitement we felt. We've talked about it a
           couple of times already here, in this reunion. It was really a
           new adventure for all of us. It was a new program for the
           country. It had extraordinary benefit in the potential to think
           that we could be helping so many people in such a distant place
           live, survive. So we were all fired up. And some of us enjoyed
           the clique of the American, sort of ambassadorial, residence and
           everybody of that sort. But most of us had to be out in the
           field, and we got to know the countries we were in well.
                 I certainly got to know Upper Volta as well as anybody who
           was living in the capital because I was traveling all over the
           place. But in that process, you begin to realize that there's
           very little rest for these people. Subsistence farming is a
           cruel fate, and nature is there at every beck and call, either
           with too much water or not enough, either with seeds that can
           germinate or can't. There were very few animals in my area, so
           that there was no loss from predation. But it was just nature.
           And so people are always trying to take care of themselves, to
           get enough food just to survive. And then that's part of the
           traveling: people from Niger would travel through Upper Volta to
           go down to Ivory Coast, just to look for work.
                 And I became aware of this energy that was often physical,
           was certainly mental. And it's not to say that there weren't
           warm, wonderful family units. And the camp, the compounds that
           we visited and the ones that I got to know in Ouagadougou and
           would be invited into for evening tea, were special, warm,
           loving places. But the real world was much harsher.
                 That's what I was trying to get at: the fact that, in any
           developed country and certainly in America, we have the time to
           put punctuation marks. The time to take a break.  Read a book.
           Watch TV. Listen to a concert. But that can't happen there.
Harden:     The program obviously had a major impact on you and the rest of
           your life. Would you comment on this and on the idealism of the
           '60s?
D'Amanda:   Let me deal with the first question. I never thought of myself
           as belonging. In fact, one of my regrets was that I was so busy
           in medical school that I didn't get into the idealism of the
           '60s. I mean, much of the Vietnam War went by me like that
           because I was too busy focusing.
Harden:     But on the other hand, you could have just come back and gone
           into private practice and made lots of money, and ignored the
           rest of the world. This is the kind of thing I'm thinking.
D'Amanda:   Oh, okay.
Harden:     It sounds to me, from what I've read, that you were very much
           committed to these people, and that they grew on you a lot.
D'Amanda:   Yes, they did. And the exposure to them. The simplicity and the
           dignity and the integrity. And I've learned the same with the
           poor people I work with now, from the inner city of
           Philadelphia, many of whom have not had much education. Literacy
           was, I thought, the way to get ahead in life. I had no idea,
           until I went to Africa, that literacy had nothing to do with
           wisdom. We met lots of very wise men and women there who
           couldn't read, couldn't write. But they were wise in life. Did I
           come out of Harvard, thinking that was possible? Not at all. In
           any event, it was possible, and my goal of becoming an academic
           doctor in some ivory tower was totally blown.
                 One of the things that Sencer [David J. Sencer] asked us
           to do [to prepare for this interview] addresses that particular
           question. This was my number-one response: altered career plan
           and life: From academic medicine in an ivory tower, to addiction
           medicine in the trenches with citizens victimized by poverty,
           racism, and bigotry. Because that's what we've got here. We
           don't have subsistence farming, but we have people who are
           diminished in their value, and certainly in their ability to
           lead quality lives by a lot of "isms." And so, that's what, in
           the largest sense, those 3 years meant for me. Working with poor
           people, and, certainly in the northeast part of America, working
           with blacks, was not anything I had any experience with. We had
           had a black cook in the house I grew up in, and that was about
           my extent.
                 I had read about the Black Panthers, and I had read about
           the freedom movements of various groups, and the "Black is
           beautiful" concept that was being promoted in the '60s. I knew
           that Stokely Carmichael had taken refuge in, or been offered
           asylum (I'm not sure what the proper phrase should be) in
           Guinea, and was a guest of the president, Sékou Touré. So I had
           friends in the airlines business, a wonderful... Vert Comboree,
           an absolutely statuesque, brilliant, and very, very intelligent
           and wonderful woman. And I asked her if she knew anybody who
           knew Stokely. Oh, she said, "I do. Because I'm a friend of the
           president's." Vert was a friend of virtually every man of power,
           as far as I was concerned. And whether she was courtesan or not
           didn't make any difference. She was just a very special human
           being. So anyway, she set up an interview.
                 So I flew to Conakry and took a cab to the president's
           compound, a section of which he'd given over to Stokely. And I
           had a wonderful 3-hour talk with him. Strange, Caucasian-
           American, walking into this compound. . .I don't know whether he
           knew I was coming or not. I have no idea. In any event, one of
           the things he said, which was very, very special to me, was
           "Don't try and do things for black people in America." In other
           words, "Don't do a Teddy Roosevelt." He did use that phrase.
           Don't carry any big sticks on their behalf. He said (again, I'm
           having to paraphrase my own recollection, but basically, he
           said), "If you can open a door, that's fine. They may choose to
           go through it or not. But that's their business, not your
           business."
Harden:     Bill Cosby would tell them to walk through it.
D'Amanda:   Well, Bill Cosby's a newer generation.
Harden:     Right.
D'Amanda:   And one that has some legitimacy, I guess a lot, with the
           people who want to believe that they would or should. But a lot
           of people don't buy that.
Harden:     There must be a thousand stories that you have from your
           experiences over there. Is there anything that just impresses
           you that you'd like to get on the record here?
D'Amanda:   One of my difficulties, I guess, in the life I've led, is that
           I am enough in the moment so that even though I've got a
           reasonable mind, I tend to forget moments. The memories that I
           could share at this moment are the friendships and the
           excitement of being on the move. That's why I took that little
           caper in Nigeria, even though I was supposed to only be working
           in Niger. And I loved the excitement. What stories, what
           stories...
                 Part of being bilingual in Abidjan, which was a much more
           sophisticated city than Ouagadougou, meant that I got to know
           people at the university. One friend of mine and I used to give
           great parties. Dominique would know various restaurants that
           would be available, and we would know lots of people at the
           various embassies, and so we had these wonderful, sort of all-
           night dancing, drinking, fun parties, in Abidjan.
                 On the work side, I would say that the most important
           piece for me was something I've already alluded to, which was,
           you don't walk with a big stick. You listen, and you are
           patient. You observe, and you figure out where the hook is, to
           use a family therapy term-how to get in. Because you've got to
           work on somebody else's territory, as well as your own, to
           influence change. And change is why I went into family therapy.
                 I'll share a story to give you a perspective of part of
           what made Africa so useful for me, and part of why it was such a
           powerful experience. My first day in family therapy, there were
           12 of us in the class. The supervisor was going around, asking
           each one of us why we had come. When she got to me, I said,
           without even thinking, it was totally reflexive, "I want to be
           free." And I'd be damned if I knew what I meant.
                 Well, part of Africa was being free from here, my
           particular family of origin, the issues that my parents had,
           that my brother and I sort of united to be safe and separate
           from. There was a lot coming in, in family dynamics, that in
           quite significant ways, affected who I was, and I knew that.
           Just like I had the instinct that Harvard wasn't the real world.
           I didn't know what the hell it was, but I knew that I wasn't
           participating, and that's one of the things that Africa let me
           do. It's probably why I was so active.
                 I had another fleeting thought. . .There are wonderful
           raconteurs that I have listened to. One of my favorite delights
           listening to Bob Hogan, who unfortunately isn't here. He could
           tell stories beautifully. Part of the issue of being over there,
           especially in Abidjan, was to go to the Fourth of July
           ambassadorial celebrations. You just talked to people you don't
           know and wandered around talking. And at one of them, I got into
           conversation with this fellow, who wanted to know how many
           people I knew in the government. He dropped some names. Did I
           know them? Yes, I knew them because I'd had to work with them
           and discuss things. A long story short, he began to ask me
           whether I would be willing to record my conversations with these
           people. I said, "What would I do that for?" "Oh," he said,
           "Well, there are people in America who would be interested."
           Well, it didn't take me long to figure out that he was a CIA
           [Central Intelligence Agency] operative, and he was trying to
           recruit me. And I just sort of stood back after a couple of
           minutes of this conversation. He even got to the point of
           saying, "Well, we know what you're doing here in Abidjan, and we
           could make it uncomfortable for you." I said, "What the hell do
           you mean? I don't play cops and robbers."
                 And I was so fascinated by the way the system apparently
           works. I have heard this subsequently. There are people who
           collect data., conversations. And they reel them off into these
           recorders, and then somebody, somewhere, tries to fit them all
           together. I suppose that's a large part of what our "war on
           terrorism" was all about. Anyway, that was a story that made me
           understand, again, so powerfully, as so many other things in
           Africa did, that I just don't fit into any of those kinds of
           skullduggery cowboy stories. Cops and robbers is not my style.
Harden:     Before we stop, is there anything else about the program that
           you would like to talk about?
D'Amanda:   I guess I'd like to hope is that there are other programs like
           it in the future-where there's a mission that is humanitarian,
           requires scientific and administrative know-how, and can move
           ahead and get things accomplished. I've not been in the public
           health world, other than looking at addiction sometimes as a
           public health process and as a behavioral disorder. But I know
           there's a lot to do. And this country does have inordinate
           resources. I think we lack the will, too often. But this
           organization, 40 years ago, didn't. And I think that that's a
           tradition that could be remembered with benefit to everyone,
           including CDC.
Harden:     Thank you so much.