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https://globalhealthchronicles.org/files/original/2004fffab008be1051279b90bc2a4356.pdf
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Smallpox
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<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>
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<pre><strong>
Interview Transcript
</strong>
Conversation
Dr. William Foege & Dr. William Foege
Transcribed: January 30, 2009 | Duration 0:41:22
A Conversation between Dr Mahendra Dutta & Dr William Foege
Introduction
Today is the 9th of July, 2008. This is a taping as part of the Continuing
Series of all Histories of Smallpox Eradication Program. Today Dr. William
Foege and Dr. Mahendra Dutta are going to have a conversation. Both of them
know that this is being taped and they've signed permission for us to tape
and to use it in appropriate manners.
Dr. William Foege: Okay. Mahendra, 30-plus years ago, we spent so much
time together working on smallpox, but I never asked you, how
did you happen to get into the program? Did you volunteer? Was
this dictated?
Dr.Mahendra Dutta: Yes, I did volunteer. I had returned from my
training in Epidemiology for nearly 9 months back to the office
where I worked with the Director General of Health Services and
the campaign was being mounted and they needed more people to
help in the campaign, and that's how I volunteered.
Dr. William Foege: Ah, ah. So you did volunteer. Now, we've often
talked about the top group of people. You, M.I.D Sharma, C.K
Rao, Pidish, and so forth, an extraordinary team, but how did it
happen that they came together, because I don't think you could
have found a better group of people if you'd searched the world.
How did that happen?
Dr Mahendra Dutta: There was a continuous process of selection. People
at the helm of affairs in the Ministry of Health, technocrats,
were getting involved and those who could not perform they were
quitting also. So ultimately the fittest survived. So that's how
you saw them all together.
Dr. William Foege: Ah! So this was evolution. Okay-Survival of the
fittest. Now there was a person I was very fond of early on in
the program who was running the program in Bihar. I totally
missed the fact that he was extracting funds from us at an
alarming rate. How did you pick that up and how did you handle
it?
Dr Mahendra Dutta: I got involved with the program in February when Dr.
Dish[inaudible name0:02:49] asked me to visit and see how things
are moving there because he was not comfortable.
Dr. William Foege: This was February 1974?
Dr Mahendra Dutta: February 1974, and in this visit, when I reached, I
went to a district, Munger, there is a district by that name,
where I spent a week seeing how things are happening. The
reports we were receiving were that people do not accept
vaccination; and when I went there I was surprised. Every
morning we went to villages, we had a team of 20 people to
vaccinate with us, and one after another village where we went,
people were pleading to get vaccinated; and the stories that we
got were: so many died in this village, people were really
alarmed. They wanted vaccination, then the civil surgeon, the
head of the health administration of the district was hostile to
Dr. Sinha and he narrated me all those stories, how he is
employing over and above the normal staff, some extra workers,
and virtually paying them 1/5th or 1/6th of the money that they
are supposed to get and the remaining is being pocketed. So this
was corroborated by another colleague who had worked with me
earlier who was my other class fellow in the public health
training, and he corroborated that this is actually happening. I
finally met the Health Commissioner at a very personal level in
a club and told him. He said that this is no news to him. So
then everybody knew-so I said then, "What to do." The gentleman
said, "Well! I am not heading the health services. It is a
technocrat there. He has to come. I am a bureaucrat. Then only,
I will step in." It went on like this, till fortunately, let me
say, may be you are aware, in 1974 May, there was a nuclear
explosion in India.
Dr. William Foege: I remember that!
Dr Mahendra Dutta: Pokharan, and after Pokhran, the Newsweek in its
front page carried a report, "Another Explosion in India" and
this was the smallpox explosion in Bihar, when you will
recollect that in our May search, we discovered over 8,500 new
outbreaks with 11,000 cases. So -
Dr. William Foege: In one week, 11,000 cases - if I can just interject
here - The previous Fall, D.A Henderson had asked me, "What's
the largest number of cases you will find in any State in a week
in India?" And we actually took this quite seriously, and we
concluded that it would be less than1,000 cases. So we suggested
that they use 3 digits for their computer programming. D.A-
always suspicious of us; added 4 digits, and then we had to call
and say, we've had 11,000-plus cases in one week, in one State,
and so even the computers were not cooperating anymore. Okay, so
go ahead - then May of 1974...
Dr MahendraDutta: Yeah, then the stage came that the government of
India and the State Government, they all got really startled
because a lot of journalists who had come to Rajasthan to cover
the nuclear explosion, they moved into Bihar and started
reporting. Now at that point of time, we were asked by the
Health Commissioner there who was the chief bureaucrat in the
Health Service. Earlier he took the stand that the Technical
Head should come to me but now he himself went to the political
head and told him that this is the problem that they want the
Program Manager Dr. Sinha to be moved out; and then he was - a
substitute was selected by consensus. He was a very good person.
Everybody felt that he was going to deliver, and he moved in and
then things moved. So after that, we had very fast track
movements on the program.
Dr. William Foege: I want to come back to this, but this has always
been an example to me of an outsider not able to see what was
actually happening and an insider understanding immediately what
was happening. What else did I miss?
Dr Mahendra Dutta: Well, you didn't miss much because even in this
case, I recall you were believing that smallpox will definitely
go sooner or later. I wanted it to be sooner.
Dr. William Foege: Yes,
Dr Mahendra Dutta: That's about the only difference of you.
Dr. William Foege: So the reporters came to India, they did their
reporting on the nuclear test and now looking for other stories,
suddenly this becomes a very good story. Smallpox is out of
control and they have no background to know that this is partly
due to the improvement of the program and surveillance was
improving and there were a lot of people now on the problem, but
it caused Parliament to make life miserable for you because
everyday they were asking for explanations; and how important
was that in diverting people from smallpox eradication to
answering Parliament?
Dr Mahendra Dutta: Well, the group of workers who were handling at the
National level for the Parliament was only being fed by the
peripheral workers. We were not disturbed much in the field. In
fact, we were helped by this lot of reporters coming in and
giving the stories. It was a helpful thing because the
Government at that time asked us to request whatever we needed
more and we increased our efforts far more then.
Dr. William Foege: What was Karan Singh's, the Minister of Health, what
was his approach to all of that bad news?
Dr Mahendra Dutta: Oh! He was the real support. He recognized that the
disease is being tackled in other States and it was only the
problem of inactivity in Bihar, that's why they were lagging
behind. So he himself visited later in Bihar and emphasized that
we put in more efforts and things were already showing up, and
very soon things will be completed. In fact, we recollect that
he all along was a big moral support.
Dr. William Foege: So, at the very top, you had all the support you
needed. If you go down a layer, to the Director General of
Health Services, to Dr. J.B Srivastav, what was his role at this
time?
Dr Mahendra Dutta: Unfortunately he belonged to the group of
unbelievers. There were people, I believe in every country, who
did not believe that Smallpox can be eradicated vis-à-vis the
others. He belonged to the other group and he was always
pessimistic about our claims of eradicating it very soon. So all
I recollect is that I had a very good liaison with him and he,
several times, enquired of me, "Is it real what you are
reporting-so good a progress in so short a time?" So that was
the main thing he would always accept when I say so and I
recollect when later we were so close to the endpoint and we
were going in for announcing a reward for a case. The minister
was to make that announcement on July 1, 1974. He was asking,
"Isn't it too early to make such an announcement?" And I said,
"Well the amount of money and effort we are putting in each day,
I shall be so happy that if I can have all the remaining few
hundred cases discovered by this reward and it will save a lot
of money and time." It was a matter of chance that not a single
case was found and we didn't have to pay a single reward but Dr.
Srivastav had apparently not been at the most peripheral level,
in the field level; that is why he couldn't appreciate how
thoroughly the things were happening.
Dr. William Foege: How powerful was his pessimism in influencing the
Minister of Health of Bihar when they wanted to change back to
mass vaccination.
Dr Mahendra Dutta: He came to Patna on the asking of the Minister of
Health and addressed the civil surgeons and at this meeting he
pleaded that the ultimate solution of the problem would be
covering backlog of mass primary vaccinations; children who have
never been vaccinated. Unfortunately, the minister took it very
seriously and wrote to Dr. Karan Singh, the Indian Minister for
Health that your Director General has requested that we should
cover the backlog of primary vaccinations, children who have
never been vaccinated. He asked for money; vaccine and
bifurcated needles for vaccination to harness a new
organization, the block level health staff to complete it.
Because Dr. Srivastav said he is not against the firefighting
efforts that are being carried out. So Dr. Srivastav's comments
were sought about the statement that he made and I recollect
that Dr. Srivastav was uncomfortable how to respond to it and he
asked me, I had to go back from Patna and I said there is an
anomaly. They too are saying the same thing; that first we bring
the disease to zero level and thereafter we can concentrate on
the backlog of primary vaccinations which we never needed there,
probably; and it was completed without the backlog. Nobody
needed it.
Dr. William Foege: Now you talked about the believers and the
unbelievers. Do you recall the day you became a believer?
Dr Mahendra Dutta: I recall the day when the non-believers were
shunted out. I was responsible myself. Several of my Indian
colleagues who came to work in Bihar with me in the initial
discussions, they belonged to that thinking, though they were
working and I pleaded with them, if you don't believe, probably,
morally, you should not agree to do it. Couple of them did go
back instantly, because unless you have a conviction that you
can achieve, then you are not doing it.
Dr. William Foege: The National Institute of Communicable Diseases put
a lot of effort into this program. Did they take great pride at
it when it succeeded; and did it make a difference in the way
the Government of India supported NICD.
Dr Mahendra Dutta: Oh! Tremendously; I believe they are surviving on
the laurels of achievement of smallpox even today. That's the
biggest thing they did. Of course, they did a couple of other
good things after that but smallpox is a feather in their cap.
Dr. William Foege: There were very many foreign workers and often
times coming for three months and then leaving, and that's the
most difficult, to get people acclimated in 3 months to get some
productive work out of them and then have them leave. What were,
from your point of view, the biggest problems of having these
foreign workers in India?
Dr Mahendra Dutta: Well, I recollect when they landed in Patna, they
volunteered, many of them came through CDC, and when they
arrived in Patna, they were very enthusiastic in performing. At
the same time, probably, they have never worked in a developing
country before. So they were also apprehensive. What we did was
that upon their arrival, besides the technical briefing, a
sociologist was made to speak with them; and this session
attracted them the most. They had so many things to ask the
sociologist. Probably, this was the longest session in the
briefing in Patna, three to four hours, and they were told about
the communities in India, how they operate and how they live
together. So that helped them to know quickly, in the filed, how
to perform. I recollect that the work to be done was so much
that many of them did long extended hours of the day in the
field. From morning till late evening, and we were always
telling them that in the summer months, you should not be out in
the peak hours in the noon but they were defying it also in the
enthusiasm that they must complete the work before they leave.
Fortunately, some of them, and they were good, those some of
them; they asked for extending their period of stay so that
before they leave they could see things happening and I
recollect at least, a couple of them, Steve Jones and David
Hyman; they were later on moved to Bangladesh but they stayed
for about five months in India. So that was their enthusiasm to
show the results. The small mistake that happened in the
beginning, a couple of them arrived with their better-halves and
they couldn't perform because field conditions in India were not
so conducive for their wives to stay alone; and they did not
perform well in the field, and subsequently we had to advice
that anybody coming here must come without their spouse.
Dr. William Foege: So you worked them so hard maybe 90 days was as long
as they could actually take. We wore them out. Have you ever
thought pf what were the biggest mistakes that were made in the
program. If you were doing it all over again, what would you
avoid doing?
Dr Mahendra Dutta: I don't see back, anything wrong, the only thing
that for this short program, as I said, it lasted hardly an year
or so, and there were other programs that suffered because
everybody was occupied with this program, but we had to pursue
with those programs. I recollect that Family Planning was our
biggest competitor as a program, and time and again, the people
in the family planning were disturbed but we had to tell them
that ours was going to last a few more months, and later on we
can join with you in the program.
Dr. William Foege: That brings up the question; if the National
Institute of Communicable Diseases took great pride in this, did
Family Planning take pride in the contribution they made-because
it was an enormous contribution?
Dr Mahendra Dutta: Well, maybe that was only after April or sometime in
1975 that the Family Planning was given a top priority during
the emergency era in India. Before that, they had certain target
approach and that's why they were more eager to perform and let
not their workers be diverted to help in smallpox. Because in
the smallpox, we involved every month, for a week all health
workers for the search and that's what was disturbing them but
seeing the results, they also agreed that we are doing some job
and let it be finished.
Dr. William Foege: You mention that it was in truth a very short
program, at the time it seemed to go on forever. But it only
took us three months to sort of come up with the system, another
four months to perfect the system and then, India went from the
highest rates in May of 1974 to zero twelve months later. No
place else in the world was the change so fast, so dramatic,
it's amazing in retrospect to even look at that. But then you
went on from India to work in Ethiopia. Compare the two
programs.
Dr Mahendra Dutta: Things were very different in Indian program. We did
not have the difficult terrain working conditions in the field.
In Ethiopia, the communications in the field was so difficult,
and here I recollect when at the end phases, every case
occurring in Bihar, I personally went to that village, I could
reach in less than 24 hours. But this could not happen over
there. They needed a much prolonged sustained effort, and I was
part of it that was done from moving from one district to
another so that you make one area free. There, the people also
do not move so much as they do in India; because here in the
Indian program, fortunately, when our efforts were at the peak
that was the lean season for transmission. The disease was
expected to come down with the onset of monsoons but our efforts
were peaking up further. So that's how we could come over so
soon. Because around October-November, when the rains cease and
people started moving about again, we were left with very few
cases; 150 odd villages where the disease was present, and I
recollect later in July, we had some junior teams, mobile teams,
we stationed a team in every outbreak and these young doctors
who were coming as medical interns, they performed so well
because they were all trained, they were all relied upon, they
were amazed at what kind of faith we were placing upon them.
I recollect those who were bearded Sikh gentlemen, when I met
them in the field, they removed their beard; I have no time to
wash every day; and those who didn't have the beard, they were
having beard, I have no time to shave everyday. So those young
people changed the whole complex. Then we introduced the
strategy of guarding the case which was paying dividend that the
case would not be allowed to spread the disease to another
place, around the clock, 8 hour shifts, watch guards were
placed, watch guard supervisor was placed. The family was
compensated that they can't go out for work. So therefore we
will pay rent for the house where our guards will stay; so all
these strategies helped in achieving a very fast disappearance
of the disease.
Dr. William Foege: Its nice, 33 years after the last case, to hear you
talk about it and still have the enthusiasm that you had 33
years ago. What is it though that you would like to tell to
young public health workers that you've learned from this
experience that you hope you can pass on.
Dr Mahendra Dutta: All I could say in brief was that in public health,
community approach, your conviction, your devotion and team
effort, that's what matters the most. The entire team of workers
national, international, higher, lower level functionaries, they
all worked like a very close team; and that's what I can believe
public health team-effort approach-is pride.
Dr. William Foege: I agree with you. I think that's the lesson of
smallpox in India; that the team worked as a unit. It was a
coalition in truth, and people lost their national identities...
Dr Mahendra Dutta: Absolutely, absolutely.
Dr. William Foege: ...their personal identities and it seems as though
we made decisions based on everyone agreeing, I can't remember
that we ever took a vote or had really strong disagreements. So
it seems to me that it was a coalition that was quite unique.
Now, I worry that we have lost the words now of people like
M.I.D Sharma. You talked to him a great deal after smallpox
eradication and I don't know if you have any message that you
would like to pass on from MID Sharma or Dr. Pidish, or some of
the other people who we don't have a chance to question.
Dr Mahendra Dutta: I was meeting them till/[while] they were alive, and
my only understanding was that they felt that the success story
of smallpox eradication was also an achievement which gave them
satisfaction in their life, and the only thing which I felt they
wanted the young generation to follow or emulate what they saw
was, the same thing as I said earlier, that devoted efforts,
team efforts always mattered in community health work.
Dr. William Foege: Years later, I had lunch with Dr. Pidish and he said
something similar, that it was quite different to be on an
Indian team than to be on an international team working on an
Indian problem, and he said to me at that time that, "If you
come back to India, I will come out of retirement," we will do
this again.
Dr Mahendra Dutta: I would say the same. Working with you was a real
pleasure.
Dr. William Foege: Thank you. How did you get into public health
though?
Dr Mahendra Dutta: That was a very different story. My father was a
Public Health Physician.
Dr. William Foege: I know, the Rockefeller Foundation sponsored him.
Dr Mahendra Dutta: Yes, he was a Rockefeller Fellow and right from when
I graduated from the medical school, I made the choice that I am
going to study in the School of Public Health. I didn't waste
any time. Very next year, I joined the School of Public Health.
Dr. William Foege: Where?
Dr Mahendra Dutta: In Calcutta in India, and then pursued the career
through married[inaudible0:28:34] life, and I have no regrets.
Dr. William Foege: And what did you do after smallpox eradication?
Dr Mahendra Dutta: Oh! After smallpox I worked with the Municipal
Corporation of the City of Delhi. I was their Chief Health
Officer for a few years.
Dr. William Foege: Your father had done the same thing?
Dr Mahendra Dutta: Oh, he'd done the same thing too, and then I was the
Chief Epidemiologist of the NICD for a three-year period, and
finally I was the Deputy Director General for the public health
work in the Ministry of Health, and looking back I feel very
happy that I worked in these positions and got a satisfaction.
Dr. William Foege: But there is something genetic here also. Talk about
your son.
Dr Mahendra Dutta: Oh, he chose it himself, that he wants to also be a
Public Health Physician. He came to the U.S. He was a bit
disgusted about the policies of reservation for certain backward
classes, and he said that he may not get the opportunity in
India to work in the specific field where he wishes to work, and
he will choose to go to public health work and go to U.S. for
training. So I said, "If you wish to go, its up to you." So he
is working here.
Dr. William Foege: Three weeks ago, I was at my final meeting at the
Rockefeller Foundation and I was asked to speak to the staff,
and I said: when people ask me what the Rockefeller Foundation
has done, I resist talking about the Green Revolution, or the
Yellow Fever Vaccine, or the Hookworm Program; I said-I talk
about the scholarships that they gave to people around the
world, and I talked about your father getting one of those to
study public health and that for three generations, this
investment by the Rockefeller Foundation has continued to pay
off. I mean, it's just a wonderful story.
Dr Mahendra Dutta: Very nice of you to say that. My father has left
behind his writings of life and he feels the same, that I
received the training in public through the Rockefeller Program
and I owed a lot to repay it, and I have repaid it because my
son followed the same, my grandson followed the same. So that's
the same way he thought.
Dr. William Foege: In India, how do we improve the number of people
going into public health? You've done it. You've found it to be
a very enjoyable satisfying profession. How do we increase the
number of people doing this?
Dr Mahendra Dutta: It has been a dilemma for all the years but I don't
know how, but things appear to be going haywire now. More and
more people are interested in public health. It's a big change
happening in recent years, and I recollect that four years ago,
a Foundation with the collaboration from the Harvard University
was established to raise Public Health Schools in India -
establish new Schools of Public. Medical Research Council also
following the same example, they are also supporting
establishment of new schools of public health; and the young
doctors are also getting more interested in pursuing Public
Health as careers. Unfortunately, so far the Governmental System
doesn't create more opportunities or caters for public health
people. But I am sure there are two ways of doing it. One is
that you train the people and there will be careers coming up,
the other way is you create careers and then you find shortage
and then people will be trained. So apparently we are going the
other way round. People will get trained and opportunities will
be created to meet those demands. Already several programs,
National [inaudible0:33:06] Programs have started creating posts
for public health physicians at district levels and lower. So
that approach probably is going to be there.
Dr. William Foege: I think we are seeing a renaissance of global health
interest in recent years and I am just pleased that we both
lived long enough to see what's going to be a great change in
the future.
Dr Mahendra Dutta: I wish too.
Dr. William Foege: Are there stories or things that you want to say
about the Smallpox Eradication Program because, you know, we may
never get an opportunity like this again to talk about it. Are
there things that you want to make sure that people hear?
Dr Mahendra Dutta: We have said a lot but the only thing I'll add will
be that in achieving success, besides technical things, there is
also an element of administrative tact, I would call it; whether
you say diplomacy in the modified terms but we, people in public
health, should use this more often and after all you have to
work with your own team, and also this is the team in our
system: there is a bureaucracy, there is a political leadership.
So you have to work along with them and carry them with you.
Dr. William Foege: I hope to make that point at our reunion that behind
every public health decision, there is a political decision...
Dr Mahendra Dutta: True.
Dr. William Foege: ...and that we end up trying to educate politicians
but it's a very labor-intensive sort of thing to do because the
politicians keep turning over; that they have a limited time in
office and that I now miss no opportunity to try to get public
health people to go into politics. It seems to be a shortcut,
more efficient, if we can get more public health people to
actually become politicians.
Dr Mahendra Dutta: I wish it happens in my country too. At the moment,
we are facing a dilemma because more and more politicians are
coming from another group, the group which is rather not
desirable but they are the people who flout laws and more and
more of them are entering into politics. A separate stream has
come. Formerly, most politicians were coming over from
categories like rich people, business people, like accepted
heads of the communities. Now some bad elements have started
infiltrating into politics.
Dr. William Foege: We are years ahead of you.
Dr Mahendra Dutta: It is worrying, not me, but it is worrying the
Indian Government itself; how to get rid of these elements in
the politics. Anyway, it's not for me to too much comment on
that.
Dr. William Foege: But that seems to be a chronic problem in many
countries. Let me ask you one final question and that is, the
remarkable contribution made by TATA for the Smallpox
Eradication Program where you had a private corporation agree to
work under Government rules and to use the same approaches and
so forth. It now has happened with other corporations, MURK with
what they have done with River Blindness and Glaxo Smith-Kline
with lymphatic psoriasis and so forth, but that was a very early
example of what TATA did. Has this continued? Do you have
private, public collaboration in health programs from that TATA
experience?
Dr Mahendra Dutta: All I would say is that per force, we had to go for
that collaboration because the Southern Bihar lacked adequate
infrastructure of health from the Government side and TATA has
had a very good infrastructure in that region. They have their
[inaudible0:37:35] and coal fields and factories all over-
spread. Therefore we approached them and they readily agreed
because they were working with the people there where it was
benefitting. I have seen that now it has become a Governmental
Policy in recent years to accept that kind of - because the
medical care itself is going to the private sector more and
more; and government is only obliged to deliver public health
service to the community; the preventive medical care, and in
these efforts, they know that we cannot invest so much, so they
are seeking collaborations from non-governmental agencies
including the private sector.
Dr. William Foege: Well, this has been great fun to get together again
after - we have done it before, but till now at 33 years to talk
a little bit about this, and I will say this on Saturday, but I
want to be sure that it gets recorded now. How wonderful it was
to work with you, what a hard field worker you are, that you
never shied away from doing anything that needed to be done in
the field, and you were just the epitome of deliberate
approaches to solving problems, rather than getting excited when
things went wrong, you would sit down and ask how do we solve
this problem and so it was great to work with you then, and it's
great to hear you reminiscence now.
Dr Mahendra Dutta: I am also pleased that I'd worked with you, and in
fact I learnt also a lot of things, but basically, as I said,
our team-approach was the most successful approach.
Dr. William Foege: Great-good. Thank you.
Question from Audience: May I ask one question? Did he play jokes on you?
Dr Mahendra Dutta: He played rings because whenever he had nothing -
rather, he had something in his brain lurking to solve, he would
have a set of rings how to unfold them. But I don't think Bill
was that kind of person. He was a serious person. The best thing
I recollect is he was a very good assessor. He could assess how
people are performing and that's what we got from him; his
personal assessment of people who were coordinating, who could
survive.
Dr. William Foege: But the ring story reminds me of an absolutely true
story; where we were going to a meeting where another person had
absolutely different ideas than I did, and I knew that because
we discussed it quite often; and it was a 2-day meeting. It was
early in the first meeting when I took off my puzzle ring and
let it fall apart, and I just said, "Oh could you put this back
together? He had had a puzzle ring as a child and he said sure.
He spent the next six hours on this puzzle ring. He even missed
the discussion of the issue that I was worried about where he
would bring up the other side. We were passed on other things
before he realized that the puzzle ring had kept him occupied.
***
Thank both of you.
[End of audio]
</pre>
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DUTTA M. WITH FOEGE W.
Description
An account of the resource
A Conversation between Dr. Mahendra Dutta and Dr. William Foege, two of the key people in the smallpox eradication program in India.
Dr. Mahendra Dutta, former New Delhi, India Health Commissioner
Dr. William Foege, former CDC Director
Source
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The David J. Sencer CDC Museum at the U. S. Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333
www.cdc.gov/museum
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July 10, 2008
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8928960000 bytes
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English
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http://pid.emory.edu/ark:/25593/16rk2
emory:16rk2
-
https://globalhealthchronicles.org/files/original/15cff6897b42722de6d85ec8ddd53485.jpg
96f9857b18795fa6e75ffee8451b5e43
https://globalhealthchronicles.org/files/original/3f591a9f59cfa5f845cac4a292f46849.pdf
cbe8473a9db438866875ed8550f218c2
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>
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<pre><strong>
Interview Transcript
</strong>
INTERVIEW
Audio File: Dawn Eidelman Audio File
Transcribed: January 23, 2008
Interviewer: This is just formality. Now I'm David Sensor. I'm
interviewing Dawn Eidelman on the third of April, two thousand and
eight at CDC. Dawn knows that she is being taped and has signed
permission.
How old were you when you went to Africa?
Interviewee: When we went to Africa I was five years old so I started
my formal schooling in Lome, Togo at L'ecole de la Marina, not
speaking a word of French on day one and it was a rather traumatic
first day of school. I about half way through the day had to use the
facilities but didn't know how to ask. They figured out what I needed
but then when they showed me the facilities I had no idea how to use
the drain in the ground. So luckily we had a long school day and a
long lunch and I went home for lunch and my ingenious mother noticed
that I had an outfit that was almost identical, persuaded me that
nobody would know the difference. I went back for the afternoon and
she clued me in how to use the little drain in the ground and
astonishingly within a month I was starting to understand the French.
They only white kid in the class, pigtails, we had the little
inkwells in the desk and by the end kindergarten my father was I think
a little bit jealous that my French was pretty solid and quite
effortlessly. So, in my line of work now I'm a huge advocate of total
immersion for English acquisition. I don't believe in segregating
students for a lingual education because I know that children are
really like sponges.
Interviewer: How long were you in school in Togo?
Interviewee: In Togo I was there through middle of the third grade. So
kindergarten first and second, at L'ecole de la Marina, French system
but African private school. Third grade was an interesting
experience. The first half of the year we were still in Lome and the
first house that we had lived in, the bottom floor - excuse me - the
bottom floor had become Boutique Togo Agogo and the top floor our
school house for the American kids. And we used Calvert which is
still in existence now for distance learning and one or two of the
moms who had teaching experience facilitated. And we had assembly in
the living room and the two bedrooms were I think the odd grades and
the even grades. So we did distance learning in an American program
and that's when I first started formal studies of English.
Interviewer: In addition to learning about how to use the toilette what
are some of your other interesting experiences in your formative
years?
Interviewee: So many. As I shared on the way over here I really did
not like the Sunday ritual of having to take Aralen. It was really
nasty and bitter and ugh I just couldn't abide it. So, I didn't take
it on a couple of occasions and I became quite ill with malaria and I
remember that fever and sitting in the tub taking baths, trying to get
that fever to break. That one is definitely a distinct memory. It
was actually an idyllic childhood. We didn't have TV. I had a record
player and a few records and I know those lyrics to this day backward,
forward, inside out. Just a couple of toys and what that really did
was promote a comfort level with time in solitude, time for
recollection, time to develop an expansive imagination and I regret
that more children don't have that experience in childhood now because
I think it's very important for really becoming who you're capable of
becoming. Having some quiet time and not being programmed all the
time with activities. And we had a lot of really cool pets. A family
of bush babies, we had a parrot, feisty Senegalese parrot Bud who came
back to the States with my mum and lived another twenty years or so in
captivity and remained feisty all the way. We also had a podo and
that was quite the dramatic story and a small python.
We kept mice in a cage. Every Sunday after waffles and Aralen we
would in the afternoon watch the python devour a mouse. That's what
we did for kicks. Some men came to paint our ceiling fans, let the
mice out of the cage. One of the mice bit the podo and the podo was
probably our closest family pet. She would pluck out my dad's chest
hairs when he was taking a nap. She got into my mum's birth control
pills. Very, very intimate family member and so it was really tragic
when she got rabies and she also bit my mother. So the whole family
went through the rabies series and I remember Dr. Henn would clean up
the syringes and obviously get rid of the needles and everything and
make them suitable for water fights so my brother Dave and I would
have water fights. But Christmas that year we had a rabies shot
because we were going through the series at that point.
So memories of pets and lazy days, a lot of reading, listening to
music, very few toys but the ones we had we really cherished.
Halloween was fun. We would -they thought that we were absolutely
nuts. My mum was a really fun hostess and I remember one year we put
sheets over the clothes line to make a tunnel of terror and we dressed
up in all kind of different costumes that our tailor made for us and
wondered what the crazy Americans were up to. I remember some
rollicking fun. There was some great adult parties and they never
seemed to mind that we were kind of milling around.
Interviewer: I remember visiting your house. It was probably in
seventy, no sixty eight, and George (Lithket) and Don Millar and I we
were making our big tour of Africa. It was a very pleasant evening I
remember. What was your feeling about life in - of other people in
Africa?
Interviewee: Of the Africans or the other Americans?
Interviewer: Africans.
Interviewee: Interesting again from a child's perspective. I did have
an awareness of being very privileged and I remember one day standing
out on the balcony with my doll and looking across the street at an
African girl who was about the same age who was also holding up her
doll. And just noting the disparity in the quality of the houses that
we were living in and feeling that somehow that wasn't fair but I
loved the experience of going to L'ecole de la Marina and I think that
too has had a profound impact on my world view as an adult. A lot of
what I do professionally is - most of our charter schools that we
start up and manage are in the inner city and Inc. magazine has
something called Inner City 100 the fastest growing companies that
serve, that revitalize, generate jobs for, really enhance inner city
populations in the U.S. and our company for three years in a row was
in the top five. So the need is really great in neighborhoods where
children live poverty.
And so much of what I feel really deeply about is not prejudging what
children are capable of accomplishing and really holding a high
standard and a high expectation for everyone and rising to the
occasion as adults to serve that need. And a lot of it I think goes
back to how I felt on that first day of school looking around me at
the all these kids, African kids who understood everything that was
going on in French. I didn't understand a word. It was a hugely
humbling experience and I think that that childhood experience and
being a minority having - really I recall that it was just a very
happy culture. It was a wonderful time in life and I think that that
had an impact on the way I see these children in the U.S. living in
poverty and not all of them. We serve children in affluent
neighborhoods too but I think that even as a child I was keenly aware
coming back to the States in seventy two how marginalized African
Americans were in this country and just being astonished by that
because I'd really idealized the States living overseas and it was -
it was a surprise.
Interviewer: Were you stationed in any of the other countries in
Africa?
Interviewee: We were in Nigeria for a year and we lived in Kaduna in
the Hogan's house after they moved out. That was - it was a huge
cavernous house great for telling ghost stories. There were parts of
the house we never even went into and that was during the civil war so
we stayed very close to home. There we ended up going to a Catholic
school, Sacred Heart and that's when I had my encounter with British
education and it really for years I had some issues with my spelling
as a result. But it was - Nigeria was a positive experience for my
brother and me as children but unfortunately that was the time that my
parents' marriage was starting to come apart. So that was for them I
don't think nearly as positive as Togo had been.
Interviewer: You were in a Muslim culture in Kaduna.
Interviewee: Hmm.
Interviewer: Did that hinge upon you in any way?
Interviewee: Not in a way that I can recall. I don't really - maybe it
had to do with the fact that we were going to a Catholic school but I
think I was a little bit oblivious to that because it was never much
of an issue with my parents and I don't think that that really
registered.
Interviewer: I would think that the environment in Togo was a much
happier environment then?
Interviewee: It really was. It was just such as positive place and
really all the other expats there that we met I loved the peace corps
volunteers for years as a kid that I aspired to serving in the peace
corps and it just - it was a great culture. Wonderful gatherings,
great music. The music too that my parents had on the reel to reel
tapes that we played over and over again. The top one hundred hits of
nineteen sixty six Bob Dylan, Blood Sweat and Tears, Beach Boys, but
they made for some really wonderful gatherings.
Interviewer: You spent some time in Bangladesh with you father?
Interviewee: We did. My brother and I spent about half of the summer.
The year must have been seventy five and we went to Bangladesh first
and stayed in (Aham) and he was wrapping up some work and then we went
together to Nepal and stayed in Dave Newberry's house in Kathmandu and
we went to India and we were in New Delhi almost the whole time we
were there. We did a couple of side trips. I think my brother and I
went to see the Taj Mahal one day and we spent a week on a houseboat
in Kashmir as well and that was an interesting experience because the
only meat that one could eat there was lamb. So we either ate lamb or
things cooked in lamb's grease. The left an impression too. French
toast in lamb's grease.
Interviewer: Do you still like lamb?
Interviewee: I really don't. Not so much, not if it's gamey.
Interviewer: And I think that's - to me that's one of the problems with
lamb today is not gamey enough. You hardly know you're eating it.
Were you in Bangladesh long enough to have any feeling for the
country?
Interviewee: I remember the crushing poverty of the country and seeing
a body on the street and I couldn't discern if the person was sleeping
or dead. It was, I was just really aware of the poverty and it was
also so incredibly muggy. That also left quite the impression.
Almost hard to breathe there and in India and you know this was in the
back half of the summer so it was incredibly hot and humid. No I just
- I remember Bangladesh as being - and I was a little older too. I
was fourteen when we visited Dad that summer so I was very aware of
children living in poverty and begging and you know missing limbs. It
was very hard especially coming from living in the States for a few
years then, living a very comfortable middle class lifestyle and then
experiencing the poverty was - it was a lot more shocking at that
point.
Interviewer: Is there anything else about your experiences that you
would like to get on the record?
Interviewee: Yeah. I think what's really most remarkable to me about
those years besides the fact that it was truly an idyllic childhood
and a time to be able to enjoy family, friends, gathering, time for
reflection, time to really, to read, to sing, to get to know a few
texts really, really well because there weren't a lot of other
distractions. And I'm very proud of having been a part of smallpox
eradication as a child experiencing that because it was such an
amazing endeavor and I remember upstairs in the bar you know the house
in Lome dad kept scabs in the freezer of the things of that - we just
never went into that refrigerator. It was also a bar. We weren't
supposed to be there but I remember even at the time - I remember even
at the time being very proud of the work that my dad was doing and
really liking the people he was working with and finding it really
interesting to hear the stories of when he was breaking bread with the
chief of the village and trying to negotiate access to the veiled
women so that he could vaccinate them.
I loved the time that I got to spend with both of my parents with that
lifestyle. Dad and I used to play chess all the time and that was a
lot of fun and we spoke French together and that was enjoyable. From
my perspective today it's - I'm very proud to have been a part of
something so historic and huge and I loved doing the reunion a couple
of years ago. The reflections about how the young doctors and - what
were they called? The operations...
Interviewer: Operations officers.
Interviewee: Officers, operations officers, really in many ways didn't
know what they didn't know. That's something as an entrepreneur that
I can really appreciate and it's something that I think it's what's
truly remarkable about this global endeavor that was really impressive
[inaudible 19.40] at the time. Sometimes not knowing what you don't
know, not knowing the magnitude of the project that you're taking on
is a blessing and thank goodness, thank goodness we had courageous,
bold, ambitious, tenacious, brilliant, dedicated people who with all
those qualities didn't know what they didn't know and they kept at it
and they chased this disease from the face of the earth.
Interviewer: And most of them were very kind people.
Interviewee: Absolutely. Absolutely so. It was, it was a great
community to be part of and I remember that vividly even as a child.
These were - several of these folks I called uncle for years to come
and even at the time I knew that it was special and we were part of
something that we could be proud of.
Interviewer: Thank you.
</pre>
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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
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interviews
motion pictures
moving image
Date
A point or period of time associated with an event in the lifecycle of the resource
2008-04-03
Identifier
An unambiguous reference to the resource within a given context
http://pid.emory.edu/ark:/25593/15jnn
emory:15jnn
Subject
The topic of the resource
CDC
Smallpox Eradication
USAID
WHO
Life as expatriate child
Format
The file format, physical medium, or dimensions of the resource
4466760000 bytes
video/x-dv
Creator
An entity primarily responsible for making the resource
Sencer, David (Interviewer); CDC
Eidelman, Dawn (Interviewee)
Contributor
An entity responsible for making contributions to the resource
Centers for Disease Control
Title
A name given to the resource
EIDELMAN, DAWN
Description
An account of the resource
Dawn Eidelman, daughter of Andy Agle, who served as an Operations Officer in Togo and later in Southeast Asia. Dawn begins by recounting her first day at a French school in Lome, Togo at age 5, coming down with malaria, their unusual household pets, celebrating holidays while living abroad, as well as realizing disparities of wealth as a child. Later Dawn accompanied her father on smallpox eradication work trips in Bangladesh, India, and Nepal. Dawn expresses her pride in being a member of the of the Smallpox Eradication Program community.
Language
A language of the resource
English
-
https://globalhealthchronicles.org/files/original/eaca2d3bc239342b014894f63aeb05c5.jpg
55676ea7b6bbf7b686871a6a40c769c7
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>
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Dublin Core
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Title
A name given to the resource
EWEN, NEAL
Description
An account of the resource
Public Health Advisor
Description
Neal Ewen was an Public Health Advisor assigned to Central African Republic. Neal speaks of the challenged working in the field, local collaborations with officials, and expatriate life. Neal continued working for CDC when he returned from West Africa. He was in poor health at time of interview and has since died.
Contributor
An entity responsible for making contributions to the resource
Chillag, Kata (Interviewer); CDC; Anthropologist
Date
A point or period of time associated with an event in the lifecycle of the resource
July 14, 2006
-
https://globalhealthchronicles.org/files/original/53da523d4271248d7d65d8b6a75dc881.jpg
b32364351a5ca7f3b07fdf5fff40a688
Dublin Core
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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
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Player
html for embedded player to stream video content
<iframe width="560" height="315" src="https://www.youtube.com/embed/vGm3xkyWv9o" frameborder="0" allowfullscreen></iframe>
Dublin Core
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Title
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FITZGERALD, STEVE
Subject
The topic of the resource
Somalia
Description
An account of the resource
Steve Fitzgerald describes his experiences in India, Somalia and Ethiopia during the Smallpox Eradication Program as well as, an outbreak of yellow fever in West Africa
Interviewed by Melissa McSwegin
Source
A related resource from which the described resource is derived
The David J. Sencer CDC Museum at the U. S. Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333
www.cdc.gov/museum
Date
A point or period of time associated with an event in the lifecycle of the resource
July 10, 2008
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
12417840000 bytes
video/x-dv
Language
A language of the resource
English
Identifier
An unambiguous reference to the resource within a given context
http://pid.emory.edu/ark:/25593/16s1z
emory:16s1z
-
https://globalhealthchronicles.org/files/original/9ae2195a0f0988c92e62f41dbc59c51b.jpg
8a5930840f0f1954aaf28635f78f4ea0
https://globalhealthchronicles.org/files/original/18cc416bb8a0448a8bf16e01856be42e.pdf
c5d255c9340c741c7f8d51df16584c06
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 Mrs. Paula Foege about her 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 40th anniversary reunion of the West
African Smallpox Eradication Project. The interviewer is Victoria Harden.
Harden: Mrs. Foege, could we start by your telling me briefly about
your childhood and pre-college education; growing up; and what
influenced your thoughts about what you should do in life?
Foege: I was born in Chicago, Illinois. My family moved when I
was 4 years old to Los Gatos, California, and my early memories,
then, are of that. It was a very simple time. My father was a
salesman, and he traveled to San Francisco every Monday and came
back every Friday. I just remember it as a quiet time with
neighbors, and going to school, small schools. Then from there,
we moved 3 different times in California, and ended up in Palo
Alto, where I went to high school.
Harden: Were there any particular people in your life-your mother,
ministers, teachers-anybody who inspired you as to what you
might want to be?
Foege: I think my teachers very much inspired me. From my very
first memories, I wanted to be a teacher. And back then, there
weren't that many vocations that were actually available for
women, but that was always my love and my goal. I love children.
At a very early age, I would babysit and play school.
My mother was a stay-at-home mother and my very closest
friend. Her parents were very influential. They had come from
Norway. I had a friend who had 3 sisters. I would say I spent
the majority of my time at her house.
Harden: Tell me about going to college, and how you met your husband.
Foege: Well, I went off to college. My grandfather was a
minister, and we were involved in the Lutheran church. My older
brother by 3 years went to a Lutheran college in Minnesota, and
I decided I would like to do that also. But I didn't want to go
to the same college that he did. We had taken a family vacation
up to the Pacific Northwest, and I really just loved it. And so
the Pacific Lutheran College was in Tacoma, and that's where I
chose to go. It's surprising to me that I did that because I was
a very shy child, and to make a complete break from home and
family was not characteristic of me.
But I got on the airplane, took off by myself, got a taxi
when I arrived, and went off to school, where I think 2 days
later I met Bill [Foege]. And he stood out because he was so
tall. He was a senior, I was a freshman, and was a prankster
even then. We had been to some parties where you get to know
other people, and he was not supposed to be there; the parties
were for freshmen. And he was casing out the new girls coming in
with the freshman class. And so I met him. I didn't actually
meet him at that party, but he stood out. Later on that week,
coming out from the cafeteria, he was with some of his friends,
and they had bets going on. "I bet you can't date the first
woman who comes out the door," and it happened to be me. And so
I said no. I don't know why I did; I just said no, that I
couldn't do that. And he kind of followed me home, and made
friends with my roommate, and I finally did date him, then. And
I was only 18 years old.
Harden: Only 18. When did you-all marry?
Foege: We married when I was 20, so 2 years later. Quite
surprising to me, my parents said yes and had no objections.
Bill had completed 1 year of medical school; I'd completed 2
years of college. And so we married December 23 because it was
the only day he could make it, and we moved up to Seattle. I
finished my undergraduate degree in the University of Washington
while he was going to medical school.
Harden: Now, I have just talked with him, and he was telling me a
little about your moving around. When he finished medical
school, he came down here to do the EIS training at the CDC, and
then you went to Boston for him to get a Master's of Public
Health at Harvard. I believe you had a child at some point along
the way. What was it like for you?
Foege: Our son, David, was born when Bill was an EIS Officer in
Denver. And those were very quiet years, very simple compared to
now. I had taught, a year before David was born, and then
decided I would like to stay home with the children, which I
did. It was somewhat difficult moving around because it was hard
to have sustained friendships. But with the children, that made
it easy because I would meet other mothers with children the
same age.
Harden: At that point. Now, it shifted pretty dramatically, though,
didn't it, when he went to Nigeria, and you all were living in a
very small village. Tell me about living in a small village and
having a toddler.
Foege: Well, it was good I was young because we just stepped
right into it and just accepted it. The people of the village
were just so kind to us. We would go to a market and people
would walk up to us and give us, you know, like sixpence. This
was just amazing to me because they had nothing. We didn't have
that much ourselves-we were missionaries at the time-but we did
compared to the people of the village.
It was extremely hot. We had no electricity. And even in
the cool season, the lowest temperature was probably 75° at
night, and the humidity was very high. And we slept under
mosquito nets, which was difficult because it was so hot.
Harden: Where did you get your water?
Foege: Oh, my goodness. We hired a young man, and that's all he
did all day. He had two 5-gallon drums-or 10-gallon drums, I
can't remember-one on each side of his bicycle. And he would
bicycle out to the water hole and bring water back for us. And
then it wasn't fit to drink; it wasn't even fit to wash in. And
so we had a stove, which was propane, and it went all day long,
boiling water. So not only was it hot to begin with, and high
humidity to begin with, but also we had this added to the house
all day long, as well.
Harden: And I presume if you had to go get your water, you didn't have
any sewage systems or indoor plumbing for toilets.
Foege: No, no. No, there was an outhouse, and I did not use it.
We had a special little potty situation set up in the house, and
then we would deposit it out in the outhouse.
Harden: How about your child? What was it like having a baby?
Foege: David was 2 at the time, and believe it or not, it wasn't
difficult. He played with the children in the village. The
reason we were living in the village was to try to learn the
local language. And he taught them little sayings in English,
something about a cereal. We had seen the advertisement on
television before we came. We went out in the village 1 day, and
all these little children were sitting on the ground, and they
were going, "We want Cheerios," or something of that sort. So
the children had no problems communicating with each other, as
children do. They just played together.
Harden: Were you lonely?
Foege: Yes. Yes.
Harden: Lonely for friends your own age?
Foege: Yes, and lonely for family.
Harden: And lonely for family.
Foege: Yes. It was a situation in which we were together as a
family all day long, so that was helpful. Bill and I would go to
language lessons together. There were other missionaries in the
area who didn't live in our village, but lived in other
villages. So we would all get together for our language lessons,
and that was helpful.
Harden: Now, as the political situation started heating up, you and
your son, I believe, moved to Lagos, and then Bill had to get
out fairly suddenly.
Foege: Yes, right.
Harden: How worrisome is all this for you at this time?
Foege: Well, while we were in Enugu, and people were so kind to
us; it was not frightening. There was high sentiment against the
English at that time, but not against Americans. So we felt
quite comfortable. When we were evacuated, Bill was actually
working for the smallpox program. He was on loan from the
mission, so that we had made close friends, Dave and Joanne
Thompson [David M. and Joan Thompson] and Paul and Mary
Lichfield. The women and the children were all evacuated
together. Bill describes-perhaps he did in his interview-how he
watched the airplane. Every seat in the plane was taken up with
a mother and a child or two, and so we were heavily weighted
down. So he watched the airplane, like, slowly, slowly try to
gather height. And then we were only in Lagos for a short period
before we were evacuated to the States. So it was difficult
leaving our husbands behind and not knowing exactly what was
going to happen, exactly what was going on. I had faith that
Bill would handle himself well, and I know he told you how he
went back and forth between the two fighting areas.
Harden: Yes. When you came back to the States, it was the summer of
1967, if I am correct? And you all were delighted that you were
coming back to civilization, only when you got to New York you
found out it was having some problems. Do you want to tell me
that story?
Foege: I can't say how many women and children there were, I
don't know, but a good many, probably 80. The pilot could only
fly so many hours so we hopped from country to country, trying
to find a second pilot, so that they could then take the long
journey across the ocean. Once we had, our first stop was Puerto
Rico, and we all had to get out of the plane. W all had to
gather our luggage and go through customs. And by then, our
nerves were pretty frayed. You know, children were crying,
everybody was tired, and people were complaining, "Why do we
have to do this?" and whatnot. At that time, we had two
children. Our second son was born when we were in the States,
but we had returned to Nigeria. So I have, you know, one child
on my hip and another one, making sure he stays close to me, and
gathering all our luggage and trying to get all our papers
together and whatnot. Bill had already done much, much traveling
around the world at this time, and my thought was, "Well, this
is one place I've been that Bill hasn't been." So it was worth
it.
When we arrived in New York, it was summertime and it was
hot. And we were put up in a hotel in which the air-conditioning
system was broken. But the heating system wasn't. And so it must
have been like 100° in our hotel room. And then the next day, we
all scattered out to our separate homes.
Harden: I understand there was a problem with the bus. Was this the
same trip?
Foege: That was a different trip. I know it was because Bill was
along. Did Bill tell you about that trip?
Harden: Yes, he was telling me some about it. I thought I might hear it
from your side, your perspective.
Foege: Yes. Well, we arrived in, again, New York. And the bus
that we were put on was not working properly. So they put us all
on the bus, and they couldn't get the bus started, and so they
asked the men to all get off the bus. So all the men got off the
bus. Here, again, it was like 90° and probably midnight. And all
the men, then, were to push the bus so it could get a jump-
start. And we got on, and they went a ways, and the driver did
not have enough gas in the bus. So the situation was, do you
stop, or do you go? Do you stop and not be able to get the bus
started again, or do you just go and run out of gas? And so, he
finally decided he needed to stop for gas, and he filled up. And
then they couldn't get the bus started again. They were trying
to get us to our hotel so they sent out different cars and small
buses to pick us up, and they said, "All the men go on this
side, and all of the women and children go over here," and I was
like, the way this trip has been going, I'm not being separated
from my husband. So I think they took all the women, and all the
men and me and the children went in another vehicle.
Harden: They don't prepare you in college for this kind of thing, do
they?
Foege: No, they don't. No.
Harden: After you came back here in Atlanta, then did you-all go back
to Africa during the duration of the smallpox program?
Foege: Well, we went back for the relief program. If I recall
correctly, I don't think Bill was involved in smallpox at that
point. I think he was just involved with the relief work.
Harden: This was the survey of malnutrition?
Foege: Yes. Right.
Harden: And you and the children went with him?
Foege: And we went with him. To me, an interesting point on that
is that we started off in the village, with no electricity, no
running water, under mosquito nets-a really fairly
unsophisticated situation. And then we were in our village
mission compound, where we had only running water. And then we
moved to Enugu, and we lived in a very small flat. And then we
had running water and electricity. We didn't have air-
conditioning. Our salary was paid by the mission field, and not
by CDC. And that was very nice. And then finally we moved to
Lagos, where we were staying in somebody's apartment who was on
leave. It was very luxurious for us. So we had very different
living experiences in our two years in Nigeria.
Harden: Did you have servants at any point? I know you did not
originally.
Foege: We did, originally. His name was Lawrence, and he did the
cleaning and the washing. I did the cooking, but he did
everything else. He was a wonderful young man. When he first met
us, he thought we were brother and sister, and that we were just
children, because we were so young at the time. So he was a dear
man, and really, really special with our children.
Harden: I understand that it's kind of difficult for Americans in many
ways, when they come to Africa. Some people feel very unsettled
about having all these servants; they don't feel like they
deserve them. But other people feel like, "Gee, this is great.
Why should I go home?" Did you see all of this?
Foege: Well, I was so grateful for Lawrence to help me. I don't
think I could have managed everything on my own the way it was.
And then he came with us when we went to Enugu, so he was with
us for just about 2 years. I was grateful for him, and I didn't
feel embarrassed or guilty to have him working with us. He
became like a member of our family, really. He was probably only
about 5 years younger than we were at the time. Then he followed
us to Enugu, so he worked there, too. I continued to do the
cooking, which was no small feat because everything was made
from scratch. And he baked the bread for me, but other than
that, I did my own cooking. When we were in Lagos, we did not
have servants. There was really no need for it. What was very
difficult for me was re-entering the United States.
Harden: Why? Why was that difficult?
Foege: Well, I was preparing for the culture shock in going to
Nigeria. But I don't think other than the loneliness, that we
really suffered much from culture shock. I was not prepared for
the culture shock in coming back to the United States, where
everything is at your fingertips. Everything is really almost
overwhelming, just bombards you.
In Africa, we had a nice, quiet life, and Bill worked
hard. He traveled a good deal, and that was difficult for us as
a family. But life was sweet, and slow, and people were very
generous to us-with us, and to us. Very, very friendly. And I
found in coming back, you don't just step right back into your
old life. People have gone on, and it takes a while to fit
yourself back in again.
Harden: Did you find yourself impatient with people in the United
States when they complained, for example?
Foege: I suppose, yes. People at first had an interest in what
our life was like, but they were soon, you know, back to. . .It
was almost, you know, like a "sweep it under the rug" kind of
attitude. And, of course, they had not had the experiences that
we had, so, you know, you tell a few stories and then it's on to
life as usual.
Harden: How would you characterize the impact that these experiences
had on your family and on yourself?
Foege: It certainly made a difference in our lives. Our oldest
son still remembers Africa, and the children had later
experiences in India, so the two situations together made an
even stronger impression. But our older son was 4 when we came
back home, so that's still quite young. But he does remember a
good deal. I would say it gave our children a tolerance for
different styles of living, different religions, certainly the
impact of poverty compared to what it's like in the United
States. Empathy. Empathy for other people, definitely.
Harden: Before we stop, is there anything else about this program that
you would like to say?
Foege: Well, the program was wonderful in many areas-in helping
people, in discovering new ways to handle different health
programs, in the people that we met, who were basically not
people who were out for what is life going to give to me, but
what can I give to others. And that had a big impact on all of
us.
Harden: It was an idealistic time, I perceive.
Foege: It was. It definitely was. And it's so exciting to be here
now and to see some of these people we haven't seen for 38
years.
Harden: And I thank you very much for talking with me.
Foege: You're very welcome.
</pre>
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2006-07-16
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emory:15jtb
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Smallpox Eradication
USAID
WHO
Life as expatriate wife
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Harden, Victoria (Interviewer)
Foege, Paula (Interviewee); CDC
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FOEGE, PAULA
Description
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Paula Foege, wife of Bill Foege, who served as a consultant for the Smallpox Eradication Program in West Africa and Southeast Asia, relates her experiences of daily life in Nigeria, evacuation during the Biafra War, returning to Nigeria to do relief work, culture shock upon returning to the United States, and how the time abroad impacted her and her children's lives.
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English
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Smallpox
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<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>
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<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>
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interviews
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2006-07-13
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http://pid.emory.edu/ark:/25593/15jvg
emory:15jvg
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USAID
Smallpox Eradication
CDC
WHO
Biafra War
Surveillance
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Harden, Victoria (Interviewer)
Foege, Bill (Interviewee); CDC
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FOEGE, WILLIAM H.
Description
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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.
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https://globalhealthchronicles.org/files/original/6c150150e330f9800b99042053735aae.pdf
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Smallpox
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<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>
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<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>
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interviews
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2006-07-14
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emory:15nd0
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CDC
Smallpox Eradication
USAID
WHO
Combating Childhood Communicable Diseases (CCCD)
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Harden, Victoria (Interviewer)
Foster, Stanley (Interviewee); CDC
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Centers for Disease Control
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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.
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Smallpox
Description
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<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>
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1:04:45
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FOSTER, STANLEY O.
Description
An account of the resource
Dr. Stanley O. Foster, EIS Class of 1962 provides descriptions of the working
relationships he had with other people and organizations during the smallpox
eradication efforts in Africa and Asia.
Interviewed by Karen Torghele
Source
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The David J. Sencer CDC Museum at the U. S. Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333
www.cdc.gov/museum
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November 2, 2011
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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>
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FOSTER: CDC'S ROLE IN SMALLPOX
Description
An account of the resource
Stan Foster details the history of CDC's involvement in the Smallpox Eradication Program.
Source
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David J. Sencer CDC Museum at the Centers for Disease Control and Prevention