2 12 68 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> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Player html for embedded player to stream video content <iframe src="https://w.soundcloud.com/player/?url=https%3A//api.soundcloud.com/tracks/310124529%3Fsecret_token%3Ds-0tVCk&amp;color=ff5500&amp;auto_play=false&amp;hide_related=false&amp;show_comments=true&amp;show_user=true&amp;show_reposts=false" frameborder="no" scrolling="no" width="100%" height="166"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource 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 The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/vGm3xkyWv9o" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource 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> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/J6D0d_hy66g" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-16 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15jtb emory:15jtb Subject The topic of the resource CDC Smallpox Eradication USAID WHO Life as expatriate wife Format The file format, physical medium, or dimensions of the resource 9808800000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harden, Victoria (Interviewer) Foege, Paula (Interviewee); CDC Title A name given to the resource FOEGE, PAULA Description An account of the resource 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. Language A language of the resource English https://globalhealthchronicles.org/files/original/08c7c49aad0df2cab4a6bb2c95047808.jpg bb93d5d769875424d1fb491adc0ad51d https://globalhealthchronicles.org/files/original/817185efe3d9b4f4fe6938e66252dcac.pdf a2f11c309db619cc07e145849f2cbe0b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> This is an interview with Dr. William Foege about his activities in the West African smallpox eradication project. The interview is being conducted July 13, 2006, at the Centers for Disease Control and Prevention. It is a part of the 40th anniversary celebration of the launching of the West African smallpox eradication project. The interviewer is Victoria Harden. Harden: Dr. Foege, would you briefly describe your childhood and your pre-college education--who influenced you to go to medical school and get interested in public health? Foege: I started out in northeast Iowa, and lived in a small town of 100 people. When my family moved away, the population went down eight percent. I went to a one-room schoolhouse for the first five years. We then moved to Chewelah, Washington, and I thought I was really in a big city. It was about 1500 people. Harden: And why did you move? Foege: My father was a minister, and he got a call to a new church in Chewelah, Washington. We moved for that reason. From there, I went to Colville when he started a new church in Colville, and that's where I graduated from high school. I went from high school to Pacific Lutheran [College], what is now Pacific Lutheran University, in Tacoma, Washington, and became interested in biology, because of a very forceful biology teacher who was a man I've never seen the likes of. Harden: What was his name? Foege: His name was William Strunk. In class, he would walk into the room, lecturing as he walked in. He would go to the board and actually write with both hands simultaneously, putting up phyla and families and classes and genera. He would still be talking as he left the room. I was a lab assistant to him and also worked at his place on weekends, doing yardwork. He played an important part in getting me into science. My older sister, Grace, four years older, had gone to the same school, and she went to medical school. She also was an influence. I was also influenced as a fifteen-year-old when I spent three months in a body cast, unable to turn over or do anything. That was in the days before television, so I was doing a lot of reading. I began reading about Albert Schweitzer, and medicine, and Africa, and all of this became very interesting to me. Harden: Had you had an accident, or...? Foege: I had a problem with my hip that required three months of immobility. The hope was that it would heal correctly, and it did, but the hip was always off a little bit. This period was a time of reflection and reading that I might not have had without that physical problem. In medical school, I began working after school and on Saturdays for a fellow by the name of Ray Ravenholt. Ray Ravenholt had been one of the first EIS officers, Epidemic Intelligence Service officers, at CDC [Centers for Disease Control], and he was always pushing the idea of public health and also the idea that I should think about joining the EIS at CDC. I went off to New York for my internship, and I had been accepted in an internal medicine residency, when I got a call from Don Millar [J. Donald Millar] at CDC. He said they had just received some positions that enabled them to expand the EIS class, and would I be interested? I abandoned my idea of going into internal medicine, and went to CDC in the EIS class of 1962. Harden: Had you always been interested in public health, or was that just a sideline until you got to CDC? Foege: Ray Ravenholt was such a powerful influence on me that I was interested in public health by the time I graduated from medical school. Of course, I didn't see exactly where I was going until Don Millar called with this EIS opening, but then I never looked back. I was extremely pleased at CDC with the EIS program. I was first assigned to Colorado, a state assignment, and while there I did two overseas TDYs [Temporary Duty]. One was to India, in 1963. At an EIS conference, they had announced that the person holding the Peace Corps position in India had taken sick. It was going to take some time to replace him, so they were looking for a volunteer to go as the Peace Corps physician. This I did, and it turned out to be important in so many ways. I saw global health close up. I saw my first cases of smallpox. I made rounds at Holy Family Hospital in New Delhi. I worked for a man by the name of Charlie Houston, who was key in mountaineering. In 1953, he had actually led a group up K2 [Karakoram 2 mountain in Pakistan], and before getting to the top they were stuck in a storm. One person developed deep vein thrombosis in one leg and then developed it in the other leg. Charlie Houston said that they had to get him down, but everyone said, "We can't go down in a storm." Houston said, "It's his only hope." So they attempted to rescue him in a storm, and as they were descending across an ice field at a forty-five degree angle, one person slipped and fell. This person got tangled up in another rope, and then four people were falling. They hit Charlie Houston, who was on a third rope and knocked him unconscious. The four people plus the three on Charlie Houston's rope were all falling, and they were held by a man by the name of Peter Schoening, who, with his ice axe, was able to stop all of them. It's an incredible story, and to make it even more incredible, two months ago I went to the University of Colorado, where they gave Charlie Houston, at age 93, an honorary degree. They had a half-day program giving him an honor. All of the survivors of that 1953 expedition were there, including Bob Bates at age 95, former headmaster at Exeter, and Bob Craig, the youngest of the group, who was now in his late 80s. Charlie Houston was spectacular person to work for. He was able to demonstrate that you can work in a developing country and not get overwhelmed by it. He always got up every morning just happy to be working and was never overwhelmed. Harden: I believe that you also were involved as an EIS officer with the group that went to Tonga to evaluate the smallpox vaccine, and the jet injector. Would you talk about that? Foege: The other overseas TDY that I did was to Tonga, a group headed by Ron Roberto [Ronald R. Roberto]. The idea was to see could you dilute smallpox vaccine and use it in a jet injector. Tonga had not done routine vaccinations since 1905, so it provided a virgin population in which you could measure antibodies and so forth, and the Tongans were agreeable to having this study done. We wanted to evaluate the effectiveness of different dilutions of smallpox vaccine--a one-to-ten, one-to- fifty, one-to-one hundred, and so forth. It turned out to be a very good study that demonstrated you could dilute the vaccine one to fifty, and that you would still get uniform take rates. We also demonstrated that the vaccinations could be given with the jet injector, which didn't require special training in technique to have the vaccinations come out the same with every person. It was easy to train a person to use a jet injector. This turned out to be a very important study. Harden: May I ask you to describe how the jet injector worked? Did it actually touch the people's skin, and if so, did you have to sterilize it between uses? I don't understand how you could do thousands a day, if you had to sterilize between every one. Foege: The jet injector nozzle actually did press up against the skin. At that time, people were quite sure that there was no chance of cross-contamination, that the vaccine came out at high pressure, but we've subsequently changed our mind about this, and that's why we don't use jet injectors at this point. But because we believed it completely safe at that time, one could actually do people almost as fast as they could walk by. You set up a rhythm: grab the arm, step on the hydraulic lever, shoot, and the person would continue on. You could do a thousand people an hour, and I remember at one point doing a prison in eastern Nigeria, where they had the inmates lined up, and they were actually pushing them through by hitting them with sticks. I did 600 people in twenty minutes, because it was such a regimented line that you could just grab people and do them so fast. At one point, I recall doing over 11,000 smallpox immunizations in one day. So, yes, you could do this very quickly. Harden: Before we move on in your career, is there anything else that you would like to comment about in your EIS training here at the CDC? Foege: In those days at CDC, anyone in the EIS program saw Alex Langmuir [Alexander Langmuir] as a mentor. He was a very powerful personality. He knew what he was doing, he was inspired and inspiring. And so I'd look back on those days as days where Alex Langmuir was reaffirming how important it was to do public health, and how important it was to do global health. He was interested in everything. Also during that time as an EIS officer, I read an article in the New England Journal of Medicine. It was called AQuestions of Priority,@ written by Tom Weller [Thomas H. Weller]. I had no idea at the time that Tom Weller was a Nobel laureate, but when I read the article, I knew I wanted to know him, because he was saying in the article things that I believed. It was a commencement address to the Harvard Medical School, and he was essentially saying, "You're only going through life once, you might as well try to get it right, and here [at Harvard] you come out with all these skills and this knowledge, and you have to ask how you're going to use it. Think about using it in the parts of the world that can best use these resources. The developing world doesn't have the resources of skills and knowledge, and now that you've gone through, think about using what youve learned in the developing world." Harden: Maybe I can digress here for one philosophical question. The early 1960s were an idealistic time, in a variety of ways, and the idea that to get it right in life you went and served people is a very different idea from getting all you can for yourself. Would you comment on the idealism of your peers in this period? Foege: The early 1960s turned out to be a very nice time to be growing up in the United States. President Kennedy inspired people with the idea of the Peace Corps. People thought about how best to serve their country and how best to serve the world. So when I read an article by a Harvard professor saying the same thing, I decided that I wanted to get to know him. I applied at Harvard, and no place else, and I spent a year with Tom Weller. Harden: As I understand, you did this on your own, rather than having the CDC sending you. You received a Master's of Public Health degree.Foege: That's right. CDC actually offered a career development program to me, which meant that I could have training paid for for a number of years, and then I would pay back a certain number of years. But by this time, I already knew I was going to Africa or someplace else in the developing world, and it didn't seem fair to have CDC pay for my education and then, even if I paid back a certain period of time, leave for another job. So I went to Harvard on my own. I did get a scholarship, but I went on my own, and it turned out to be everything that I had hoped it would be. Tom Weller was an inspiring person. He worked with an inspiring group of people, including Frank Neva [Franklin A. Neva], who was my faculty advisor. Neva is the father-in-law of Peter D. Bell, who became president of CARE, and the father of Karen Bell, who ended up teaching here at Emory University in the School of Public Health. And so it turned out to be a very nice experience. When Tom Weller retired from Harvard, it so happened that I gave the commencement address that year. I got out that New England Journal of Medicine article, and I read the portions that I had found so attractive before, and made the point that you never know what will ripple downstream from what you say or what you write. Well, Tom Weller got a standing ovation in the middle of my commencement address, and it completed a circle. I've remained in contact with Tom Weller, who's in his 90s, just as I have with Charlie Houston and some of my other mentors. Harden: When you finished your training at Harvard, you joined a medical missionary program in the Lutheran church. Apparently it took a bit of effort to convince them to let you do a public health mission, as opposed to a primary care mission. Would you talk a bit about that, and what you finally set up? Foege: Let me mention one more thing about Harvard before going to that. In one of Tom Weller's classes, we had to do an independent project and present it. I happened to do a project on the feasibility of smallpox eradication in the world. I had no idea that I would ever be involved in this, but I found it an intriguing topic. There was a person in this group, Yeme Ademola, who was the head of preventive medicine for Nigeria. He had taken a year off to get a master's degree at Harvard, so Yeme and his wife Rosa were there, and he was part of that class. After graduation, Yeme Ademola came down to CDC, and talked to people about his interest in smallpox eradication in Nigeria. This is a small aside. After graduation from Harvard, I went to Nigeria to work for a church group. I knew that most of the hospital beds in Africa were provided by church groups, so they had a big influence on health in Africa. But almost all of them were involved in clinics and hospitals, not in community work. It's easy to see why that would happen, because church programs had found that medicine was a great proselytizing tool. People in hospitals and clinics felt real gratitude, and so medicine turned out to be a form of recruitment. I always felt that was wrong, I felt that churches should be working in Africa or other places because of what they believed, not because of what they were trying to get other people to believe. I wondered what would happen if you could get this force looking at community medicine instead of hospital medicine. Community medicine takes a far different approach to things. In the end, it made no difference that I actually went to Africa to try to make that change. There were other things happening at the same time that would cause church groups to shift to community medicine. The World Council of Churches had a Christian medical commission, and there was a fellow by the name of McGilvray [James C. McGilvray] who headed that up. He believed in community medicine. He was so influential that, in a period of years, he got medical mission programs to change in three fundamental ways. Number one, he got them to understand they had to work under governments. Colonialism was over, and they had to work under sovereign governments. Number two, he got them to work together. They had been very competitive in the past. In many countries there would be one person who was the coordinator for all Protestant work, and another one who was the coordinator for all Catholic work. McGilvray's influence resulted in--at least, in a few countries--those two sitting in the same office. This was an incredible change. Number three, he got them interested in community medicine. So I could have saved my time. I didn't prove anything by going over. It was happening anyway. But I did go over, and I was trying to promote community medicine. I would probably have spent decades working on this, except that when the war in Nigeria came, it went through our medical compound within the first weeks. Harden: Would you back up and tell me exactly where you were, what was happening, and what you were doing when the war came? Foege: I graduated from Harvard in 1965, and that summer, we left for Nigeria. We went to a medical center in the eastern part of Nigeria. In those days, Nigeria did not have states. It had only four regions. The north, the east, the west, and the midwest. We were in the eastern region. This was the region that was dominated by Ibos, who would later form the Republic of Biafra. We were in a minority area of the east, in a place called Ogoja province, up near the Cameroon border. In this area, there was a medical center at a place called Yahe. It was a crossroads town, and that's where we went. We spent the first six months living in a village in order to learn the local language. It was an eye-opener, because it was a village with no electricity, no running water, and no indoor bathrooms, that sort of thing. We had an opportunity to see what life was like in a village. We had a three-year-old son at the time. Harden: So you were married, with children, at this point? Foege: Yes. I had a wife, Paula, who will be the next interviewee, and a three-year-old son, David, and we had the naive notion that we would actually know what it was like to live in a village. There's actually no way to know that, because we could leave any time. The people living there couldn't leave. Living there was a form of bondage that I don't think it's possible for us to understand. But we were trying to. We lived in the village for six months and then moved to the medical compound. While we were at the medical compound, CDC asked if I would spend time as a consultant for the smallpox eradication program. Harden: This was before or after the revolution? Foege: This was before the war broke out. We had been in Nigeria for almost a year at the time that Henry Gelfand came to Enugu to ask me if I would be a consultant. Our medical center was ninety miles from Enugu, the capital of the eastern region, but we agreed that for a period of one or two years, I would work as a consultant on smallpox eradication, and I would go back to the medical center on weekends. I would try to do both things, ninety miles apart. In 1966, Paula and I returned to CDC to take the summer course for the people who were first going out to Africa on the smallpox eradication work. This is the group now meeting for a reunion. It turned out to be a very nice time for us to be back, because my wife was pregnant, and she delivered our second child, a boy, in September. It all worked out that we came back here, and she had the baby in Walla Walla, Washington, where my folks were living, and I attended the summer course and then met up with her. Now, an interesting aside. It takes a while to get a passport for a baby, to get a baby added to a passport. I even contemplated taking a picture of any baby and getting this on the passport before ours was born, so that we could move more quickly. I did not take that route, showing more sanity than usual. We waited, and I returned to Nigeria. Paula came over with the two children when the baby was about six weeks old. Harden: These are the small logistical problems, personal logistical problems that people rarely think about. Foege: Sometimes they turn out to be overwhelming. When I knew that I would be coming to the US for the summer course at CDC, I bought tickets for my wife and for David. CDC would send the ticket for me. We got to Lagos, ready to board the flight, but my ticket had not arrived from CDC. I talked with the Pan-Am manager, and he said, "You're in luck, because the plane is late by twenty-four hours. We have more time to try to get the ticket." But it was July fourth. That meant nothing in Nigeria, but it meant we couldn't get anything out of CDC. And so the next day, we went right down to the line with tickets for them but no ticket for me. About an hour and a half before flight time, the manager called me in, and he said, "We haven't heard anything. But I'll tell you what I'll do. If you write out a check for the amount of the ticket, I'll put it in my desk drawer, and so I'm covered if I get audited." I told him, "I can't do that. I don't have that amount of money in my account." We were at an impasse, but an hour before flight time, he said, "I'll tell you what I'm going to do, and I've never done this before. I'm going to give you a ticket." And he said, "I'm going to have to write out the check if I get audited." He gave me a ticket, and we got in line. But the airline representatives said, "This ticket was for yesterday." I said, "Of course it was. The plane was supposed to be here yesterday." Then I had to go back to the Pan-Am agent and say, "They won't take this ticket." He was exasperated by that time, but he got us through. We got on the plane finally, and at last I felt that we could relax. I actually said to my wife, "Isn't it going to be nice to get back to the States, where things work?" We got to New York. It was hot, it was at night, and we were twenty-four hours late, so, of course, everyone had to have new connections. My wife and son had a new connection, but I didn't, because I didn't actually have a ticket. This caused a problem. Pan Am said that they would put everyone up overnight and that we would all get out in the morning. We stood in the heat, and even though we were coming from Nigeria, it struck me how hot it was in New York. We were waiting for the bus to take us to the motel, the traveler's motel. There was a Pan-Am man there in a suit and a tie. He was very efficient. He picked me out and asked me to give them a hand. And then he picked out another person, and I realized he picked us for our size. He took us outside and said, "The battery's dead on the bus. Would you help push it to get the bus started?" And we did. We pushed it fast enough to get the motor to turn over, and the engine caught. Then he called for men to board first. I wondered why he did this, but the men, like sheep, got onto the bus. It turned out that the back of the bus was very hot. He was saving the front of the bus for the women and children. I heard him say to the bus driver, "Remember to stop at the first service station and put in three quarts of oil." I thought, "Three quarts of oil. This is a real problem." The bus driver let out the clutch and killed the motor. Everyone was told to stay on the bus, as hot as it was. The Pan-Am man said that another bus was coming to push this one to get it started, and that's what happened. And again he said to the bus driver, "Remember, three quarts of oil." We went down the highway, and it must have been eleven or eleven-thirty at night by then. He pulled off into a service station and sat there for a moment. Then he turned around and said, "You know, folks, if I stop the engine to put in oil, we're not going to get it started again." And so off he went onto the highway, and soon the motor froze up. There we were, on the side of the road, with the motor frozen, and he told everybody to get off the bus because it was too hot to stay on. He made a phone call, and pretty soon this Pan-Am agent comes screaming up in a car, and by this time he had his tie off and his jacket off and he was starting to look disheveled. He said, "Don't worry, we have some cars and another small bus coming." When the cars and the small bus came, he told the women and children to get in the cars, and the men to get in the bus. All the women and children did as they were told, except my wife, who stayed with me. She said, "The way things are going tonight, I may never see my husband again, so I'm not moving." Finally, we got on the bus and we get to the motel. But to have said, AWon't it be nice to get back where things work?@ and then run into this, it was ironic. Harden: Would you now walk me through the events in the Nigerian war that forced you to end the mission program and moved you into CDC? Foege: In the last part of 1966, and the early part of 1967, there was a lot of tension in Nigeria. The east kept threatening to form its own country. In retrospect, I suppose oil was behind this, but we didn't quite understand it at the time. We continued working. In late 1966, two very important things relating to smallpox happened during my time in eastern Nigeria. One was a mass vaccination program we did in a place called Abakaliki. We were very successful, getting about ninety- three percent of the population vaccinated. We were pleased by this kind of coverage, only to see an outbreak of smallpox a few weeks later in Abakaliki. We didn't think that this should have happened, because we believed in the idea of herd immunity. What was different about the outbreak was that it occurred in a religious group, Faith Tabernacle Church. All of the cases were in the Faith Tabernacle Church. The members of this church had refused vaccination. The source of the outbreak had probably come from another Faith Tabernacle member outside of Abakaliki. The point is that we found that no level of vaccination in a population was so high that you could exclude the possibility of smallpox. That's one thing that happened. Harden: You said that your independent project at Harvard was to come up with a smallpox vaccination strategy. Had your strategy for that project been mass vaccination? Foege: Everyone in those days was thinking in terms of mass vaccination, and that's what I was thinking of when I was at Harvard, that if you got to a certain level of vaccination, you would make it so difficult for smallpox to be transmitted that it would just die away. That's what we thought, but the experience in Abakaliki proved otherwise. The second thing that happened occurred on December 4, 1966. It was a Sunday. I got a radio message from Hector Ottomueller, a missionary, who asked if I could come to look at what he thought might be smallpox. We went to the area, which was probably six, seven miles off of a road. We used Solex bicycles, French bicycles with a small motor on the front. They were so light that when you came to a creek, you could actually walk across on a log holding the bicycle in one hand. They were a very efficient method of transport. Sure enough, these were smallpox cases. It was so early in the program, we didn't have much in the way of supplies, and then I learned we wouldn't get any more supplies. We were faced with the question of how to use our small amount of smallpox vaccine most effectively under these conditions. That night, we went to a missionary's house to take advantage of the fact that they got on the radio with each other at 7:00 pm each night to be sure no one was having a medical emergency. With maps in front of me, I was able to give each missionary a geographic area, and ask if they could send runners to every village in that area to find out if there were any smallpox cases in any of the villages. Twenty-four hours later, we got back on the radio to see what they had found. That night we knew exactly where smallpox was. Our strategy was to use most of the vaccine in the villages where we knew that smallpox existed. Second, we tried to out-figure the smallpox virus. I mean, we literally asked ourselves, "If we were a smallpox virus bent on immortality, what would we do?" The answer was to find susceptible hosts in order to continue growing. So we figured out where people were likely to go because of market patterns and family patterns. We chose three areas that we thought were susceptible, and we used the rest of our vaccine to vaccinate those three areas. That used up all of our vaccine. We didn't know it, but in two of the areas, smallpox was already incubating, but by the time the first clinical cases appeared, those areas had been vaccinated. And so smallpox went no place. By three or four weeks later, the outbreak had stopped. And we had vaccinated such a small proportion of the population! There was this contrast between the situation in Abakaliki, with a very high percentage of coverage and still a smallpox outbreak, and that in Ogoga province, with very poor coverage, but with an outbreak that was halted. We began to wonder if this new strategy might be worth trying in larger areas. We talked to the Ministry of Health. It was a very crucial time, because war was being talked about every day. The Ministry of Health said that in the eastern region, they were willing to change the whole strategy against smallpox. We could put all of our attention on finding smallpox and containing each outbreak. Five months later, when war fever was at a peak, we were working on the last known outbreak in that entire region of twelve million people. In five months, we'd cleared out every outbreak. We were working on the last outbreak when war broke out. Now I didn't know that war was going to break out at that moment. The smallpox program had planned a meeting in Accra, Ghana, for the first of July, 1967. I went to the American consulate in Enugu and asked, "What's the chance that there will be fighting in the next weeks?" And they said, "Not a chance. Neither side is strong enough at this point to actually initiate anything." But the border had already been closed between the east, which called itself Biafra, and the rest of Nigeria, and six weeks earlier, we had sent our wives and children out. We had gone to Port Harcourt, where our wives and children got on planes. They were DC-6s, I can still recall. It took forever for them to get off the runway, because every seat had an adult and a child. Harden: And where did the planes go? Foege: From Port Harcourt to Lagos. Port Harcourt was in the east, but they had received permission for people to fly out. When the smallpox meeting was about to start in Accra, Ghana, I determined from the consulate that we would not have to worry about fighting in the short term. We crossed the Niger River in canoes. They were slightly big canoes. There was no formal border between the two regions. And yet, we got our passports stamped on each side, by people who were pretending that this was all legitimate. We got taxis from the other side of the river to Lagos, and from there we got to Accra. We were in Accra at this meeting when the fighting broke out. The American consulate had it all wrong, and we couldn't get back. We did not know for months whether that last outbreak had actually been contained or not. It turns out that it was contained. There was never any smallpox in the area of fighting during the Nigerian-Biafran civil war. That turned out to be a real blessing. But think of how close we came. There was a window of opportunity because of our December experience with the small outbreak. We had asked if we could try this strategy on a larger area, and in five months we had cleared out smallpox from the entire region. Because of that, smallpox turned out not to be a factor in the war. Harden: So you knew by then that this method of "surveillance/ontainment" or "eradication escalation"--whatever term we are going to use--was a more effective way to eradicate smallpox. And at this point, when you were asked to come back into CDC, you must have had to sell this idea to people. Tell me about whom you had to sell it to, and what you did to sell it. Foege: At the end of the meeting in Ghana, I wasn't quite sure what to do, since the east was now closed because of the war. I went back to Lagos, and it was decided that I would work in northern Nigeria for a while. I also need to step back just a few weeks, or a few months, to say that on one morning, in Enugu, a Saturday morning, we went in to work and found that there were cases of smallpox in the hospital in Enugu. And suddenly we knew we had to do something in Enugu itself and spent the rest of that day planning for doing vaccination in Enugu. That afternoon, I went out in a VW bug, and mapped out the places in Enugu where you had enough room that you could actually have people lined up to do vaccinations. I was not thinking of anything except smallpox at that point. But suddenly, I was surrounded by police. Someone had reported that there I was with maps, and of course that looked suspicious, so I was arrested. It took hours before they would allow me to make a phone call. I wanted to call my wife, so that she would know why I wasn't coming home for dinner. They would not let me do that. But they eventually let me call my counterpart, Dr. Anazanwu, in the Ministry of Health, and he came down and got me bailed out. I tell this just to make the point that I had been arrested by the Biafrans. When I went to work in northern Nigeria, I was in Sokoto province, which is up in the northwest part of Nigeria. I had just set up a tent for the night, and was getting ready to cook dinner, when a pickup drove up and police officers got out. A man came up to me, gave me a piece of paper, and asked me,"Is this you?" And there was my name on the paper. And I said, "yes." And he said, "You're under arrest." He would not communicate anything more. He would not say why I was under arrest, but I had to put everything together and get into the back of the pickup. And we started the long trip back. At one point, they stopped at a guest house in order to go in and drink beer. They left me alone, sitting in the back seat of that pickup, with a pistol on the front seat. I knew I didn't want to move at all, which I didn't. They came back, and we continued to ride. In Kaduna I was put under house arrest, and after several days, they said that they would allow me to leave the country, if I would never return. I left and flew out to Ghana. But a few weeks later, I was asked to go back to Lagos by the regional office of the smallpox eradication program. I knew how poorly official records were kept, so I went back, and there was never any problem. The point I am making is that I was arrested by both sides, which showed my neutrality. When I went back to CDC, I expected that the war was going to be finished within weeks. That was my thinking, and when I returned to CDC, I came back as a contract employee for what I thought would be a period of weeks or months. I began working on the idea of using surveillance/containment throughout West and Central Africa. That's what I worked on--selling the idea. Some people were sold immediately. I mean, I think of Don Hopkins [Donald R. Hopkins] going to Sierra Leone, which had the highest rates of smallpox in the world. Sierra Leone at that time had poor communications and transportation. He started out from the beginning, doing surveillance/containment. He never bothered with mass vaccination, and surveillance/containment worked, well. Other people were more reluctant, and I can understand that. We had sold most of the governments on universal vaccination. Eastern Nigeria had been easy to convert. They saw the logic, but it was not that easy every place. But gradually, place after place did do this, and the bottom line was, we were able to eradicate smallpox in five years. In country after country, smallpox disappeared. I'm quite sure that in any geographic area where they converted to surveillance/containment, twelve months later, it was smallpox free. Nigeria had its last cases in May of 1970, and the whole twenty-country West African area had smallpox disappear in three years and five months, a year and seven months before the target, and under budget. Harden: What I'm hearing from you is that each group working in the field had to choose to adopt this approach, that there was no top-down direction from Atlanta. I thought that an order might have come from headquarters in Atlanta, instructing everybody to stop doing mass vaccination and start doing surveillance/containment. That was not the way it happened? Foege: It's hard to make that kind of change when countries are autonomous and they have their own programs, and they've not been sold on a new approach. Don Millar was an immediate convert to surveillance/containment, and he was in charge of the entire West Central African program. Mike Lane had a fiefdom, a region that he was in charge of, and he was an immediate convert. So, right from the beginning, we were talking this out. With each meeting, it was possible to demonstrate that surveillance/containment was working in particular areas, and so gradually, everyone did come on board. But it took a little while. Nonetheless, to have smallpox disappear in three years and five months--it didn't take long. Harden: So the program agreements that were initially signed with each country had described mass vaccinations, and in shifting to surveillance/containment, you had to "sell" each individual country, correct? Foege: That's right. And to me, the amazing thing is not that it took some period of time. The amazing thing is how fast we changed strategy. I mean, we just turned things upside-down, and it happened in twenty countries. Harden: To me, as a historian, the fascinating thing is how that flexibility was embraced. So many times change is not embraced when somebody has a new idea and can demonstrate that it works, because people are so invested in the old idea. Foege: It also shows the value of having young people involved in the project. Julie Richmond [Julius Richmond], the former Surgeon General, once said that the reason smallpox eradication worked is that the people involved were so young they didn't know it couldn't work. And you know, that's probably true. People were very flexible. And when you think of the number of people that went from CDC into West Africa, most of them had never had experience in West Africa. And yet, they adapted fast. I think, when you look at the group as a whole, what characterizes them is that they were problem solvers. Everyone has mixed motives, of course. It's hard to know exactly what motivates people. Today I am often asked, "What is Bill Gates's motivation? And I say, "How do I know? I don't even know my own motivation, it's such a mixture of things." The people involved in smallpox eradication had a lot of interest in doing new things, and exploring, and so forth. But the thing that characterized them all was that they were problem solvers. You couldn't give them a problem that was so difficult they didn't want to try to solve it. And so, they were very adaptable. When a new idea came out, they quickly used it. Harden: In the middle of the West African smallpox eradication effort, there was a recommendation that smallpox vaccines be stopped in the United States. Were you involved in these discussions? Foege: I was involved during those years. In 1971, we really did attempt to stop smallpox vaccination in the United States. It took a lot of courage to support that, because there was still smallpox in Africa, Pakistan, India, and Bangladesh--lots of places. But but by then Mike Lane and John Neff and other people had done the calculations that showed what the risk was of the vaccine. The United States had a risk of smallpox coming in from another country, but we concluded that the risk of importation was less than that of the vaccine itself. Part of the reason is geography. Europe acted as a filter for smallpox cases. People coming from Africa or from India or Pakistan, often went to Europe first, and then to the United States, so Europe continued to have outbreaks, and we didn't. We calculated the risk of smallpox coming to the United States. For instance, if you look at ships, because of the time it takes to get here, and so forth, we were able to calculate the risk of smallpox coming to the United States by ship was about one importation in 600 years. It is far greater than that for airplanes, but it gives you an idea that it was possible to calculate the risk based on the incidence in a country, how many people go from that country to the United States, what percentage of them are probably not adequately protected, and so forth. The recommendation to stop giving smallpox vaccinations in the United States came out in 1971. It took quite a while before it was actually followed by everyone. As a part of that recommendation, we also developed a plan for what to do if there was an importation. Some of us went to the states-we got to all of the states--to train their public health officials as to what would be needed if a smallpox case was imported. We used what was called the CASE manual. "CASE" stood for Comprehensive Action for a Smallpox Emergency. Inside the front cover of that notebook was a big chart that you unfold and put up on the wall. It showed every step that you had to take. And every step had a place in the notebook that gave the details. Our point in designing this manual was that people did not have to study this ahead of time. They just needed to know that it was available to tell them what steps to take if they thought they had a case of smallpox. This was very important so that no one would panic if a case appeared. The chart in the CASE manual was very clear. I think we did a good job of educating the state health officers, the counties and so forth, on what to do in case of a smallpox outbreak. Harden: Is there is anything else about the West African program you would like to talk about? Foege: I think we've covered the main things. The only other things I had were stories of various kinds, but I don't think they're as important as the big picture. Harden: I'd like to hear those stories! Foege: The program itself, as you can imagine, was very difficult. Communications were bad, transportation was difficult, it was often hard to get food. It was not an easy time to be in an area in which civil war was about to break out. There were many tensions. There were roadblocks where teenage boys with guns were drinking beer and making decisions. This was difficult. Harden: Were you afraid? Foege: You always had to be a little bit afraid of a teenage boy with a gun who's drunk. They do irrational things. So, yes, you never wanted to talk back. There are many stories from that time. Once at these roadblocks, they looked into the trunk of one woman's car and saw that she had a labeling machine. A labeling machine looks a little bit like a pistol, but not much like one, but they were curious to know what this device was. She explained that it would make their name, and then she showed them. They spelled out their names, and she made a label for each of them. When they cleared her to proceed, she continued down the road but heard a rattling in the trunk of the car. She stopped to look and found three guns in the trunk. Each boy had taken his label and walked off with it, leaving his gun. She immediately drove back to return the guns, and of course, the boys were very nervous, thinking a commanding officer was going to come by and see that they didn't have their guns. You worried about the roadblocks. As the wives were leaving from Port Harcourt, one of our people had gotten a little upset with a guard who asked them once more to open their suitcases. He said, "We've already opened it." Of course, the guard did not like his response. Next thing, he had him in a room, with a guard and a gun. Then this person realized that he had the key to his wife's suitcase. The other guards continued to ask her to open it, but she couldn't because he had the key. He asked the guard, "Couldn't I just go out and give her the key?" The guard said, "No." So he said, "What would you do if I just stood up and walked over and gave her the key?" The guard said, "I'd shoot you." My friend stood up, and the guy cocked the gun. And my friend sat down again. Then he asked me to come in, and I talked to the guard and asked if I could give the key to my friend's wife, and the guard let me do that. But because of this confrontation, my friend was never even able to say goodbye to his wife. So you just did not want to fool around with people. One day, I was in a big, green International van, and we were driving down the road and saw a checkpoint up ahead. The driver-there were just the two of us in the car--started putting on the brakes, but the brakes had gone out. He tried to pull the emergency brake, but it did not work, either. The last thing he was going to do was go through that barrier, and so he went off the road, into a ditch. We bounced around, hit a tree, and ended up against a building. Suddenly, we were surrounded by people. This is a common thing in Africa. You think you're out in deserted land, but as soon as something happens, you're surrounded by people. It took a while for me to realize what was happening. The local chief came, and he was a real orator. He began telling me what we had just done. He said that that tree we hit was a juju tree, and that we had offended it by knocking it down with our vehicle, and so he would have to do a sacrifice. He would sacrifice a chicken. This chicken would cost ten shillings. When he was all done, and it took him a long time to get to that point, I breathed a sigh of relief, because I hadn't known what was coming. Ten shillings--that was nothing. But then something perverse took over in my mind, and I began talking back in the same way that he did, telling him that I understood all of this, and that, yes, we had our own kind of customs where I came from. Where I came from, this vehicle was considered to be a juju god, and it had been very offended to have that tree there in its way, and that I would have to sacrifice a goat, which would cost twenty shillings. And then I pulled out ten shillings, and asked, "To whom do I give the ten shillings, and who will be giving me the twenty shillings?" There was such a silence that I feared I had made a mistake. It was just deathly quiet. And then, one man started laughing. And with that, a few others laughed, and pretty soon everyone was laughing, they saw the joke. No money changed hands, and we got out of there. Harden: I would also like to ask you: When you have lived like this in Africa, how you readjust to living in suburban U.S., with all the fast food, with all the affluence? Foege: It's an interesting experience to live overseas, and many people find it a great experience, because they have servants and they get privileges that they wouldn't have in the States. We didn't quite have that experience, having started out in a village, where living was very difficult, and much of your day was consumed in just boiling water. We didn't have electricity, so we couldn't even have a fan to help deal with the heat. Despite these difficulties, it was hard to come back. Everything seems too easy to you when you return. But there was a good part of this change. When we were using many CDC people in India on ninety-day TDY projects, I got a letter from Don Millar, who was providing a lot of the people. He said, "I don't know if they're helping you at all with smallpox eradication, but keep asking for them, because they come back different people. They have now experienced what it's like to have real problems. They don't put up with a lot of the things in the United States that cause problems. They just steamroll over them." So there are good points and bad points about coming back to the U.S. Living overseas is a broadening experience, and I think it's so important for people to have that experience. They come back with some difficulty, but they come back with a different perspective of how fortunate they have been. Harden: When zero pox was achieved in West Africa, the outside funds for the CDC efforts pretty much dried up, but Dave Sencer [David J. Sencer] was unwilling to let the program die. He appointed you to be head, and sent you out to insure that the worldwide effort was going to be successful. Can you tell me about this transition, and what actions you took? Foege: There were two things that happened after smallpox disappeared in West Africa. First, we must remember that this was always a smallpox and measles program. Measles was a major cause of death in West Africa, and it's interesting that USAID, the funders for the program, always referred to this as the measles/smallpox program. The CDC always referred to it as smallpox/measles, not because smallpox was more important than measles, but because it was part of a global effort, and eradication was uppermost in our minds. We believed that if we were not able to achieve eradication in West Africa, the global effort would most likely not succeed. At the end, we assumed that USAID would see the benefit of continuing the measles part of this, because measles deaths had been greatly reduced, hospital beds that had been taken up by measles cases had now been freed up for other patients. We had no idea at that time that they were being freed up for AIDS cases in the future, but that's what happened. I was very surprised and shocked when USAID made a decision to stop the measles part of the program. It was very shortsighted to get West Africa accustomed to having measles vaccine available to reduce this terrible plague, and then to say, "We're going to stop the program. Now you're on your own." We tried very hard to get the measles program either continued or at least tapered off over sufficient period of time. Harden: Who made this decision? Foege: It was a decision, as far as I can tell, of one person at USAID, who was new, who didn't have an emotional commitment to the measles vaccine program and who wanted to do his own things. That made it extremely difficult, and as hard as we argued, we could not persuade him. I actually wrote a letter for Dave Sencer's signature to go to the head of USAID, which hopefully would put some pressure on them to continue the program. It went to someone in USAID, who sent it to me for a response. And that's when I realized how much fun government could be, that you could write your own letter and respond to it, also. The second thing that we did was to look at the rest of the world with an eye to smallpox eradication. We were very concerned about India. India turned out to have more intense smallpox than what we encountered in Africa, although we didn't realize it at the time. India had had smallpox eradication efforts for decades, going back to the early 1800s. But somehow, they never quite worked in India. After discussing this with Dave Sencer, we made a decision that I would go to India for reconnaissance, to see whether it was possible to do a smallpox eradication project there. In August and September of 1973, I went to India and spent time with their Ministry of Health people and with people in the regional office for WHO [World Health Organization]. The result was that India turned out to be the site of our next smallpox eradication venture. India was, in many ways, so much more difficult than anything we had faced in Africa. The peak of smallpox in India was in May of 1974, when we had the highest rates that India had seen for decades. They were much higher than anything we had suspected we would have. In the fall of 1973, D.A. Henderson [Donald A. Henderson] asked me, "What's the largest number of cases that you can expect in any week in any one state next year in India?" We did some calculations and decided it would be about 300 to 400. He said, "Just to be sure, we're going to program our computers with four digits, and not with three. I recall in May of 1974, having to call him and say that in Bihar, India, in one week, we had over 11,000 new cases of smallpox. I mean, it was just overwhelming. But we went from that high in May of 1974, to zero for the entire country of India in twelve months. Harden: Using the same surveillance/containment method? Foege: Using the same surveillance/containment, which many people did not think would work in India, because of the population density, and the high incidence of smallpox. And yet, smallpox was eradicated in twelve months' time, once we got geared up to have really good surveillance. I'm talking about surveillance that was so good that every three months, we would visit every house in India, looking for smallpox in a six-day period of time. In six days, 100 million homes would be visited to see if there was anyone with smallpox. And this was before computers. The logistics of trying to get people to 100 million homes in six days, and then finding, on evaluation, that over ninety percent of those homes had actually been visited, demonstrated the effectiveness of the Indian bureaucracy once they commit to something. Harden: That's very interesting. So you were working with the Indians, then, and they were going into the homes. That requires huge manpower and management resources. Foege: It required, in those six days' time, to mobilize lots and lots of the health workers, to take them off of other things for six days. It also meant hiring a lot of day laborers in order to get the work force to do this. For me, the interesting thing was that we did not have the government of India and WHO and other groups officially involved. We worked so closely together, and I think part of the reason we were able to do that is, that we started traveling by train together. This meant being together overnight in a compartment, which gave us the opportunity to talk in a way that we never would have by going into someone's office for an hour's meeting. I mean, we were really in this together. Harden: What impact did your years in Africa and India, and the smallpox program in general, have on your family? Foege: I think the family saw our time in Africa and India as interesting times. I mean, our children often look back on India as something they really enjoyed doing. For birthdays, the person with the birthday gets to choose where we go for dinner, and inevitably, they want to go to an Indian restaurant. That's the way they feel about India. I took one of my sons back to India when he was 18, when I attended a professional meeting there. It was in Udhampur, and we decided, rather than fly down from New Delhi, that we would "experience" India again. We hired a car and a driver and began the thirteen-hour trip. This was in July, when it is very hot in India. I recall, two hours into the trip, saying to myself, "This was a mistake." It was so hot. And of course the windows had to be open, because we didn't have air conditioning. Diesel fumes from the exhaust and dust came in, and I looked over at my son, who had sweat rolling off his face, and I asked, "Michael, how are you doing?" He looked at me, and he said, "You'll crack before I do." I mean, they just enjoyed India. And it's given every one of them a feeling about the world that I like to see. They are concerned about the developing world, they're concerned about the inequities that one sees in this country, and between this country and other countries. It's something that I attribute to their having lived in other areas. Harden: Did any of them follow you into a medical career, or public service, or public health? Foege: Two of them are teachers, and I consider this to be even more difficult than doing public health work, because you don't get compensated well for your work as a teacher. What we pay teachers is a crime. The third one went into anthropology. All of them have this feeling of concern about needing to help and understand other people. Harden: Before we stop, is there anything else that you would like to add? Foege: I see war around the world. We have over a hundred conflicts going on at any one time. But if you're not actually in the area, it's just a news story. I think of what it was like during the Nigerian Civil War, the kind of devastation, and people starving. People actually starved during that war. I went back to work in the relief action. I went into one town where you actually had to step over dead children as you walked down the street. This is not the way the world should be, and yet we don't seem to learn. How do you actually get people to make eye contact, to engage with this sort of thing? For example, what's happening in Iraq right now shouldn't be happening at all. How do you get people to understand that this is absolutely the wrong way for us to be living? Harden: Thank you for a very fine interview. </pre> Player html for embedded player to stream video content <iframe src="https://www.youtube.com/embed/KLP2W9BNOMw" frameborder="0" width="560" height="315"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-13 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15jvg emory:15jvg Subject The topic of the resource USAID Smallpox Eradication CDC WHO Biafra War Surveillance Format The file format, physical medium, or dimensions of the resource 16113480000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harden, Victoria (Interviewer) Foege, Bill (Interviewee); CDC Title A name given to the resource FOEGE, WILLIAM H. Description An account of the resource Dr. Wlliiam Foege served in the smallpox program in Nigeria, first as a missionary and then a staff member. The highlight of his oral history is the description of the origin and utilization of the surveillance/containment management of outbreaks. He also discusses experiences during the Biafran conflict and other anecdotes. Bill subsequently was assigned by CDC to assist the WHO in its work with the Government of India reorienting the approach to eradication in that country. He was Director of CDC from 1977-83 and is currently a Senior Fellow at the Bill and Melinda Gates Foundation. Language A language of the resource English https://globalhealthchronicles.org/files/original/42d04a0c043e1465edf7c4378eee44a0.jpg d2c372713d2f2b6caeadd4c850063f28 https://globalhealthchronicles.org/files/original/6c150150e330f9800b99042053735aae.pdf 09ea4693dcc7561feed6cda13b5624fc Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> This is an interview with Dr. Stanley Foster about his activities in the West Africa Smallpox Eradication Project. The interview is being conducted at the Centers for Disease Control and Prevention as a part of the 40th anniversary observance of the launching of the West Africa program. The date is July 14, 2006, and the interviewer is Victoria Harden. Harden: Dr. Foster, would you begin by just briefly describing your childhood and your growing up, and who made you who you are. Foster: Okay. I grew up in Melrose, Massachusetts. My family was very religious. My father died when I was 9 years old, and one of the things that happened soon after that was I met Gordon Seagrave. He was the famous missionary surgeon whose Burmese nurses provided the medical care to Stillwell's troops during World War II. And he became my role model. From that stage on, I was going to be a doctor. I went to Williams College and then went on the University of Rochester. I think the connection to CDC was through D.A. [Donald A. Henderson], who also graduated from Rochester, as did Deane Hutchins. At that time, in early '62, they were drafting doctors, so I decided I'd rather come to CDC than go to the Army, so I came here. One of the interesting things that sort of started it off was that with 2 "F" names, Bill Foege [William H. Foege] and I sat next to each other in the EIS class of '62. I was assigned to the Indian Health Service in Arizona and carried out 18 epidemiologic studies. My basic assignment was for trachoma. At that time, about 20% of the Indian children had trachoma. Harden: Had you specialized in infectious diseases or anything in your medical training? Foster: Internal medicine was my field. And, as was often the case, Alex [Alexander Langmuir] would try to seduce officers he wanted to stay. He sent me to Bolivia to investigate an outbreak of conjunctivitis in Peace Corps volunteers. I came back to my home in Phoenix, got to Atlanta at about 3:00 in the morning, and at 6:00 in the morning I was on a plane back to Phoenix and on the way to the Truk Islands in the South Pacific to investigate an outbreak of diarrhea with Palmer Beasley. The assignment was an epidemiologist's paradise because a boat would only go out to an island once a month. You would know the entry point, and there would be a health worker there who would write down the cases and the names. It was a great epidemic. And the pattern of transmission was that of influenza, but the disease was diarrhea. We brought back the specimens, and the lab tested them out. They couldn't come up with an agent. We tried to write up the article several times, but without an agent, we couldn't. Twelve years later, when I came back from Bangladesh in '76, the lab called me and said, "We just found out what your '64 outbreak was. It was a rotavirus." Harden: Rotavirus. Ah. Foster: So we pulled out the article, finished it, and got it published. Harden: So you were doing epidemiology up until 1966? Foster: Well, no, that's not quite true. I did my EIS training from '62 to '64. Then I left CDC and went back to Rochester for a year of residency. Then I went to the University of California in San Francisco and did a fellowship in pulmonary disease. I probably would have stayed on in San Francisco in pulmonary disease, but I got the call from D.A., saying, "Do you want to go to Africa and get rid of smallpox?" My wife and I thought about it, and we decided after 24 hours that was right. We had 3 kids at the time, and I think one of the things we need to discuss is wives and kids. Harden: Yes. Foster: In terms of the impact of those experiences on the kids. Three or 4 of my kids' careers developed out of experiences with smallpox. My oldest son was interested in traditional medicines, and he now does Internet work in China. My second son, when he was in the 8th grade in Dhaka, Bangladesh, did a study of rickshaw drivers and how much of their income they spent on food. Now he's the chair of the Department of Economics at Brown. My third son got his start, really, in 1974 in Bangladesh, when we had tremendous floods and a famine. People were dying on the streets in front of our house. And he decided to go into medicine. I had no knowledge of the impact that the famine had on him until I read his Peace Corps application. And then I understood that that experience, back in '74, was the major event that sent him into medicine. Harden: This is very interesting. You said you came from a religious family. Were they missionaries or ministers? Foster: No, my wife's folks are missionaries. They went to Guatemala on their honeymoon. And her mother was interesting. She refused to go as a missionary wife. She said she'd only go as a missionary, and that was back in the '20s. They went down to Guatemala and learned Spanish. Then they learned Mayan and put the Mayan writing into a written language. And then they translated the New Testament. They had a school and a clinic. They stayed there for 45 years. Every year or 2, my wife and I go back to that same town. My wife is fluent in the Mam language. We have a nurse we work with, and she tells us what she wants us to teach. Harden: I'm interested in this streak of idealism. Foster: Oh, you should get a copy of my college caricature. I have a digitalized copy. It shows me sitting in a pot in Africa, with the pygmies standing around. "Bless this food to our use" and "Dr. Stanley, I presume" written at the bottom. I did have a missionary bent at that point in time. Harden: I'm seeing a different type of person who has been involved here at CDC with the smallpox program than what I have seen with investigators at NIH [the National Institutes of Health] in terms of the things that motivated them to go into research. Let's talk about once you were recruited into the program. They asked you apparently to recruit others, as well. And you mentioned that the recruitment of this 1 person. Foster: Andy Agle [Andrew N. Agle]. Harden: . . .was interesting? Foster: Yes, it was very interesting. Andy was a public health advisor and a good mechanic. I remember, I met him at a building in San Francisco. He walked in, and he said, "I saw this advertisement that you wanted a public health person who spoke French and was a good mechanic, and I knew you needed me." That was it. Harden: Very confident. Foster: Yes, he was, there was no question about it. Andy turned out to be one of the best. He worked for a long time in West Africa; then he was working with smallpox in Afghanistan. He was getting bored with Afghanistan, and I brought him to Bangladesh. Then he worked for many years at the Carter Center and was very close to [President] Jimmy Carter. He did a lot of agricultural stuff and really worked incredibly well with the Carter Center. And then he took a job in Nigeria. He died about a year ago. Harden: Initially, you were the medical officer in Nigeria. Would you tell me which region you were in, and what you found? Foster: Well, I was responsible for the whole country. At that time, Nigeria had 4 regions. the West, the Midwest, the East, and the North. About half of the population was in the North and about half in the South. We had Margaret Grigsby and Jim Lewis in the western region; Warren Jones was in the Midwest; Bill Foege, Dave Thompson [David M. Thompson], and Paul Lichfield were in the East; and Deane Hutchins and Vicky Jones [Clara Jones] were in the North. And it was a very different program in the North than in the South. Harden: Would you tell me about that? Foster: In the North, the traditional leadership was incredibly strong. I remember the first village I went to, Gwadabaw, in '66.I got there at 6:00 in the morning, and there were 6,000 men in a line. We vaccinated the men, and then they went home, and then the women came out. Well, for the women to come out was a big social occasion. They really didn't want to go back in. But I learned something that day, which was very interesting. It was a big district, and I told the district head that we should have 3 vaccination sites in his town because it would take us too long to do it at 1 site. He said, "I forbid you for doing that." He says, "Everybody has to be vaccinated in front of me. Nobody will tell me that they were vaccinated if it had to be in front of me, whereas if there were 3 sites, they could be tell me they were vaccinated when they weren't. The Emirs of Sokoto, Katsina, Kaduna, and Kano were very powerful people. The Emir of Sokoto would ride around in his Mercedes every night, and if there was no petrol, the Mercedes got pushed around town. But he was very powerful. So the only thing that you had to do in the North was to convince the Emir, and he would call in his district heads, and then everything would happen. It was easy to get 96%-98% coverage in that region. In the South, it was much more difficult. The people would not go 200 or 300 yards for vaccination. People were much more independent in the South. There was not the structure, and it made it much more difficult to get people to come for vaccination. Harden: Why would they not want vaccinations? Foster: Well, I think if you go historically back, there was a demand for injections. We believe that occurred secondary to the yaws program, which gave shots of penicillin to treat yaws. But it cured venereal diseases and pneumonia and everything else. So injections were always sought after. In the North, the structure was such that people would be told to do it and they'd do it. In the South, you had to really convince them or use enough publicity to get people to come for vaccination. So it was a totally different thing. And the epidemiology of measles was different. In the North, where the women are in purdah, or where the population density was relatively low, the median age of measles was about 36 months. In Lagos, where you have mothers carrying their babies on their backs to market, the median age was around 14 months, and then that was with a population of 600,000. When I went back in the '80s and '90s to Lagos, which now has a population of over 10 million and possibly 20 million, the median age of measles had dropped even further, to around 8 months. Controlling measles was impossible. Harden: What was the toughest problem you encountered? Foster: Oh, the Biafran civil war. I had flown to Benin to see Warren Jones there. I got off the plane, and Biafran hijackers got on and hijacked the plane. And that plane later was used to bomb Lagos. It was very interesting: we believe that they were using the passenger plane as a bomber, defusing the bombs, and throwing them out the door. We felt that probably the reason that the plane exploded was because the bomb went off before it got out the door. Of course, they had to find somebody who was asleep at their gun to reward for shooting this plane down. That was tense, and a lot of people were evacuated. I was talking with Deane Hutchins at lunch. I took the kids and my wife up to Kaduna because I thought it was safe. The next day, they bombed the Kaduna airport. But one of the interesting things at that time, we knew there was no smallpox in Biafra; but I was really afraid smallpox would get into Biafra. So I convinced the government that the safest thing for them to do was to vaccinate a large area around Biafra so that the smallpox wouldn't get out of Biafra into Nigeria. That way we kept it out. We also vaccinated a lot of children coming through the lines. The malnutrition in pockets of Biafra was just absolutely terrible. I think the war was really the toughest obstacle. The regional office was shattered by the bombings in Lagos, and it was not as safe a place as it had been before that. Harden: How did you get along with your counterparts? Foster: Oh, I had the most wonderful counterpart in the world, a fellow by the name of Yeme Ademola, who had gone to the Harvard School of Public Health. If you go back into the history of the smallpox/measles program, USAID [US Agency for International Development] wanted to do all the countries except Ghana and Nigeria. And Ademola was one of the ones who achieved its inclusion in the program He actually went and met with Senator Kennedy [John F. Kennedy] to push that. Yeme was just so honest. He looked out for the poor. For example, he had a cooperative grain bank, where he would buy produce when the price was low, and then they would sell it when the price was high. He supported a clinic. He was just an absolutely wonderful guy, and he also was my neighbor. So he and my wife would often go out and have tea with Yemi and his British wife. He also is the subject of the most traumatic part of my time in Nigeria. I got a call one night about 3:00 in the morning, Rosa, his wife said that he had been attacked. When I arrived at the front door, the murderers went out the back door. He had been macheted across the neck. I went in and tried to save him, but I couldn't. And at that time, I wasn't thinking of my wife, who was pregnant. Panicked about me, she started to abort. It was a horrible day. And then the next day, the police came and wanted to put me under arrest for Yemi's murder. After a 6-hour standoff, the American Embassy got me off on account of my diplomatic status. So that was the single most traumatic event of my years in Nigeria. We had an incredibly interesting team. We had Deane Hutchins and Vicki Jones. My favorite story of Vicki was when she went out in the field once for 4 or 5 weeks, and she'd either broken or forgotten her mirror. When she came back to Kaduna and looked at the mirror, she said, "Something's wrong." And then she realized it was that her face was white. In other words, she'd only seen black faces for 6 weeks. But she was wonderful. The teams in the North were also just absolutely extraordinary people. They had a driver there. He would know, when he went into a village, who you needed to see first, who you see second, and who you should see third. He had driven for a political figure before that, and he was just good. The teams would go, and they could vaccinate with the jet injectors, 8,000- 10,000 a day. The most I ever remember vaccinating in a day was once in the Midwest: with 4 lines we vaccinated 14,000. Harden: Wow. Foster: I think it's important to put in perspective what Henry Gelfand had learned about India. The Indians had vaccination numbers greater than the population, but they still had lots of smallpox. So Henry Gelfand went out there and did an assessment. And he found the vaccinators were vaccinating the schoolchildren regularly, so that they could get high numbers of vaccination, but coverage was very low. So when we went to West Africa, we were absolutely sure that with high coverage (Rafe [Ralph H. Henderson] and Don Eddins adapted coverage surveys from the US immunization survey to Africa) we would stop smallpox. There was no question about it. And that was our strategy, and we were absolutely sure that with high coverage with the jet injectors and coverage surveys-if we got above 90% coverage, or 95% or even better-we'd stop smallpox. Four or 5 major events led to a change in that strategy. The first was that when we first arrived in Nigeria, there was a smallpox outbreak in eastern Nigeria, in Ogoja, where Bill Foege had been a missionary. They had a limited amount of vaccine. But by focusing the vaccine on the infected area, they stopped the outbreak. The second important thing was a series of spot maps that Bill Foege drew. Each year the smallpox would come from the North, and there'd be a few outbreaks on the northern border and in the East. Then the outbreaks would increase in number and frequency, so you could just see it spread southward. And although Bill doesn't remember this, I remember Bill sitting on the steps, looking at these monthly maps and seeing how the smallpox spread. And he raised the question, "If we stop these first few outbreaks, will we stop them all?" The third major event in the shift in strategy occurred in Abakaliki. (There's a nice paper about this by Dave Thompson and Bill.) They'd done a coverage survey, and Abakaliki had over 90% coverage. Then all of a sudden they had an outbreak of smallpox. The outbreak occurred in a religious group that had refused vaccination; I think it was called Faith Tabernacle. Smallpox even though the coverage in that area was 90%; the small group of unvaccinated people was able to sustain an outbreak. The fourth factor was the shape of the epidemic curve-a low in September-October and epidemic in the early spring. Bill figured it out that every chain of transmission in the fall caused 74 cases in the spring. He realized that the peak time for surveillance was when the chains of transmission were fewest. So, in my opinion, those were the major events that shifted the strategy from mass vaccination and surveys to surveillance/containment. And that was certainly a major shift. And I think, although the disease eradication programs were different, when you compare smallpox to malaria, malaria was a centrally directed program, and they never really responded to the signs of drug resistance, and insect resistance, and the program failed. Smallpox was different. The program was driven by data collected in the field. We learned from our failures and changed strategies to address them. When I teach on lessons learned from smallpox/measles, one of the major things is learning from our mistakes, being willing to learn from our mistakes. My favorite story on this is about Sabour. He was one of my team leaders in Bangladesh. At this time, India was free of smallpox, but we were still having trouble. And I went up to see Sabour in Mymensingh, near the Indian border. If we did everything right, once we found an affected village, there should be no cases after 14 days-after 1 incubation period. So I asked Sabour, "How many outbreaks do you have?" And he said, "Sixteen." And I asked him, "How many had gone more than 14 days." And he said, "Eleven." Well, this was a disaster. The people could've walked those cases across to India, where the reward was big, and made a lot of money. And so I said to Sabour, "What are you doing?" His response was, "I'm doing everything the book says. I'm putting the patient in the house; I'm putting a guard at the front door and the back door. I have an extra guard at night to keep the guards awake. I am making a list of visitors, vaccinating them, and putting them under surveillance. I'm vaccinating everybody in the household. I'm vaccinating everybody in a half-mile. And I'm searching every place in 5 miles." And then, across a cup of tea, an incredible smile. And Sabour said, "And today I found out why. I'm going in, and I'm asking for a list of visitors. They are not giving me the names of relatives who came to visit because they don't consider relatives as visitors. And so we added a list of relatives to the procedure and solved the problem." I think that this story illustrates one of the main points to get at, that a lot of us at CDC who are in leadership positions got a lot of credit for smallpox eradication, but it's these people who worked 28 days a month in the field, month in and month out for 5 years, some of them, who were the real heroes of smallpox. The other lesson to get out of this story was the importance of giving workers at the field level the indicators to assess their own performance. When they didn't meet them, they asked why and come up with a solution. There's 1 other similar story from India, which is really important. At a critical time in the program in India, things were going to hell in a basket in Bihar, and the numbers were going up. And the Minister said, "I'm sorry, no more surveillance/containment. We're going back to mass vaccination." Bill spent the whole weekend with the Minister, trying to convince him to continue surveillance/containment. But the Minister said he couldn't take the political pressure and he had decided that the only solution was to mass-vaccinate. At the Monday meeting, the Health Minister of Bihar got up and said, "I'm sorry, WHO [the World Health Organization] has recommended we continue to do this, but I can't stand the political heat any more, so we're going back to mass vaccination." In the back of the room, a hand raised. And a man got up and said, "Mister Minister, I am a poor country doctor. But when we have a house on fire in our village, we direct the water at that house and not the whole village." And the Minister said, "You have 1 more month." And fortunately over that month things got better, and so they continued surveillance/containment. Both of these examples illustrate the really major contributions that poorly paid and unrecognized field workers made. They really deserve a great deal of credit for what went on and the success achieved. Harden: But don't you think it was also remarkable that the bureaucracy and the people at headquarters were flexible enough to ask for and act on that kind of information? Many times you get bureaucracies that think they know best, no matter what's coming in. I think the synergy was quite remarkable. Foster: Yes. Well, I think that's the main difference between smallpox and malaria. When we introduced the reward for reporting smallpox in Bangladesh, I introduced a single reward. But after about 6 months, only 35% of the public knew about the reward. And then all of a sudden, I discovered my mistake. None of the health workers were telling the public because they didn't want the public to claim the money. So we doubled the reward to pay both the health worker and the public, and within 4 or 5 months, 80% of the country knew about the reward. Harden: So getting the word out, and knowing how the culture operates, also played a huge role. Foster: The Bangladeshi field staff used to say that working for the smallpox program was the best form of family planning (they were never home) because at least their wives didn't get pregnant. As you look at the evolution of surveillance/containment in West Africa to the rest of the world, it's a steady thing. .Probably the best place it was demonstrated was in Sierra Leone. Don Hopkins didn't have enough material to do the whole country. So on 1 side he did mass vaccination, the other he did surveillance/containment. Smallpox stopped in the southeastern area but continued on in the mass vaccination area. That proved surveillance/containment worked. Secondly, the legacy of surveillance/containment out of West Africa clearly was key to the success of global eradication of smallpox. Had it not been developed, it is unlikely that we would have ever stopped smallpox, in Asia especially. Harden: What about the role of the bifurcated needle? In my mind, West Africa was the jet injector and Asia was the bifurcated needle. Foster: This is not quite true. When we shifted from mass vaccination to surveillance/containment, the bifurcated needle became the preferred route of immunization. The bifurcated needle was developed to vaccinate chickens. It had 2 main advantages. It increased the amount of vaccine available 100- fold. It only took 1/100 the vaccine required by the multiple pressure method, where a drop was put on the skin and the site was scarified by pressing a needle parallel to the skin 15 times. The bifurcated needle take rates were 99% effective versus the traditional method's effectivity of 90%-98%. In Bangladesh, the bifurcated needle totally transformed containment. We could train a villager to use the bifurcated needle in 10-15 minutes. This brought ownership of containment to the village and quicker, more effective, control. It also solved the problem of getting health workers to spend nights in the infected villages, a major problem in the early stages in containment in Asia. Once you were hiring vaccinators to vaccinate their village, the barrier of the stranger was removed, and accommodations in the infected village were possible and acceptable. I think we go should back just a little bit, to 1945. After World War II, smallpox was endemic in most countries of the world, especially in tropical areas, where the liquid vaccine was unstable in the heat. So the development of the freeze-dried vaccine (you could carry it in your pocket, it didn't require refrigeration, and you could mix it up for the day and it would be good) was a big thing. New topic relevant to West African program but not to smallpox And then the initial development of measles vaccine, the Edmonston B measles vaccine, it could only be given with gamma globulin. And the vaccine was not, at that time, licensed. It had been tested in about 20,000 kids. At just about that time, 4 Ministers of Health visited the States and NIH. Harry Meyer happened to talk to them, and one of them got very excited. The Minister of Health of Upper Volta said measles was killing 20% of the children in Africa and Meyer should come to Upper Volta (now Burkino Faso) to test the vaccine there. So the first year, Harry went to Upper Volta and tested the vaccine. The vaccine proved its safety and efficacy without gamma globulin: that was a major step forward. The demand was such that the next year they vaccinated 700,000 in Burkina Faso. It was a tremendous success medically and politically. Then the United States expanded to the other countries in OCCGE [Organization de Coordination et de Cooperation pour la Lutte Contre Grandes Endemies] and that was when CDC first became involved. Probably the best story about that concerns Larry Altman [Lawrence K. Altman]. Larry's now a science writer for the New York Times. He was sent out to Mali to address problems with the measles program there. One day he sent back a cable to Washington that said, "The trucks don't keep the vaccine cold." And a cable came back from Washington, "Park in the shade." And so Larry sent a cable back, "Send trees." The measles program was a smashing success medically and politically. You had 3 parallel channels. You had the smallpox channel going on at CDC; you had Harry Meyer, who had proved the safety and effectiveness of given multiple vaccines at the same time. And then USAID and measles. USAID for some reason thought they could vaccinate a fourth of the children the first year, a fourth the second, a fourth the third, a fourth the last, and they would be done. That was totally wrong. I was talking to Dave Sencer about a phone call he got from A.C. Curtis from USAID, who called him and said, "What about a measles eradication program," and Dave said, "No, it can't be done. Measles is only control, Smallpox is eradication. Why don't we marry smallpox and measles?" Without measles, there would have been no West African Smallpox Eradication measles Control Program, no global program, and probably no eradication of smallpox. The WHO 1,000-page history of smallpox has several flaws, the major one being the order of chapters. They placed the West African chapter after India and Bangladesh. Bangladesh and India built on the lessons learned in West Africa and succeeded because of it While the marriage of smallpox and measles was key to smallpox eradication, the effects on measles were short-lived because of the lack of infrastructure to maintain vaccination. Successful control of measles has only been achieved in the last 5 years with a new strategy. It should be recognized that Jean Roy, the Operations Officer in Benin, has been a key player in this success in bringing the League of Red Cross Societies into play-resources from the wealthier countries and Red Cross volunteers on the ground to mobilize the public. It should also be said that the marriage of smallpox and measles was a major barrier between USAID and CDC. USAID felt they had been been conned. This was really the basis of a lot of the angst between USAID and CDC because essentially USAID paid the whole bill. And I was talking to D.A. last night on the phone, trying to clarify a few pieces of history, which is always difficult with D.A. When the United States first agreed to do smallpox, there was a briefing of the US delegation to the WHO Assembly. Even the secretary of HHS [Department of Health and Human Services; then, it was Health Education and Welfare] was not aware of the plan. So then the announcement went out at the assembly, from President Lyndon Johnson, that the United States would support a smallpox eradication program in West Africa. Later, the smallpox/measles marriage took place. Clearly, Dave Sencer was a key actor in this. D.A. told me last night-which I didn't know-that that press release about smallpox was written by Bill Moyers. That was the international Year of Cooperation, or something like that. And smallpox eradication and the US contribution fit this like a glove from 3 perspectives: science, development, and politics. Harden: You have mentioned the 2 women who were professionals the West African Program. Neither of them is here for the reunion, but could you talk about who they were and how exceptional they were? Foster: Yes. Two very different people. Vicki Jones, young, free spirit, guitar-playing, and Margaret Grigsby, an older, African- American woman professor at Howard, very prim and proper. I remember we had some issues insuring that there was a proper latrine arrangement for her when she went to the field. And it was difficult in the area that Margaret was in, in terms of getting cooperation. Margaret was great. She had her heart and soul in the program and bonded well with her African colleagues. I do remember the first outbreak I went to in the western region. They had isolated the smallpox patients in a cocoa farm, and the only people who were allowed to go there were those who had the scars of smallpox. This is very, very interesting. On the other hand, you have the smallpox cult, Shapona cult, where if you didn't want to get smallpox, you paid the priest. If you got smallpox and didn't want to die, you paid the priest. And if you died, the priest got all of your worldly possessions. So they couldn't lose. There are historical accounts, in the 1800s, of priests actually infecting people who didn't pay up by putting smallpox scabs on sticks going into houses. Actually, I remember the last African outbreak I visited, in Togo. A couple of the traditional healers were there trying to pick scabs. Fortunately, the scars were from a vaccinial modified case, so it was not likely that there was much virus left. Harden: What did Africa teach you about yourself and about public health? Foster: We were young; we were bright; but we were not bright enough to say we couldn't do it. I mean, that was really important. In other words, there was never a sense that we couldn't succeed. It was a totally different story in Bangladesh. But we learned as we went along. We had pretty good government response and fairly credible civil service. At least, we were paying per diems and that sort of thing, kept people working. It was a well-oiled machine. I mean, we had something like 80 Dodge trucks in Nigeria. We had lots of spare parts. I think the last one I saw running was in the late '80s. Harden: What kind of impact do you think the whole West African program had on the global eradication program? Foster: Had West Africa not succeeded, it's doubtful that the global program would have succeeded. I have no question in my mind that it laid the foundation, and one of the great injustices in the smallpox book is that the West Africa chapter is put after India and Bangladesh. This is extremely unfortunate and historically incorrect because a lot of the lessons learned out of West Africa laid the foundation for what went on in Asia, and Ethiopia, and Somalia. Harden: Indeed. Is there anything you would change if you were running the program all over again? Foster: What we did then, we couldn't do now. Harden: Say again? Foster: What we did then, we couldn't do now. Harden: Why? Foster: I mean, it was pretty much an expatriate-run operation- money-driven, technology-driven. We did not have the proper amount of deference to local culture and societies and governments. Harden: I wondered about that. Foster: It was pretty much a technology-driven program. It was marvelous in terms of the teams we had. Some of the Operations Officers, Dave Bassett for one, George Stroh for another. George was driving from Jos down to the South when his motor mounts broke, and his motor fell out of his engine. He put the motor back in and drove home. I mean, just that kind of ability, to react in the field. So that was important. In Asia, several things were key. One was that the monthly meetings were incredibly important. People came in, they gave their reports, they shared the successes, they shared their failures, they got drunk, they sobered up, they got their money, they went back to the field. And most of them spent 25-28 days in the field. And as I look at CDC people going in the field now, they don't do that much any more. Harden: Are there any final things that you want to say? Foster: The challenges of West Africa were nothing compared to what it was in Bangladesh, especially in the floods of 1974, when the 2 remaining areas of infection were totally flooded out and people went into motion. We went from 89 infected villages in October of '74, to 1,500 the following May. We were all depressed. We lost it. A wonderful guy, Rangaraj, was my deputy; he was the first Indian physician parachutist. He had fought with Stillwell in Burma. And every morning, he would say, "It's going to be all right. Hang in there." Every day, he was like that. There was no rationale for that. Later on, when I was working in Somalia, I had a beer with Rangaraj 1 night, and I said, "Ranga, how could you have been so optimistic?" He said, "I didn't think you had a chance in hell in winning, but when I fought with Stillwell in World War II, I learned that if you ever thought you'd be dead the next day, you would be dead." So it was his military training and his optimism that enabled us to keep going, during incredibly difficult times. When I walk into an HIV/AIDS village today, I feel Ranga's hands on my shoulder. "Hang in there it will be all right." Harden: And eventually, to win. Foster: Yeah, and eventually to win. And Ranga was incredibly important. And there were lots of people like that. In Bangladesh, we had 22 nationalities on our staff, and they were they best. I mean, they were family. We were all 1 family. The monthly meetings were key. Then surveillance got incredibly better, and we were able to track things. And we used money. We paid $25,000 in rewards starting at $2.50 per report of an infected village and increasing to $50 as the number of infected villages in Bangladesh decreased. And we learned. For example, when we started in Bangladesh, we were having trouble with containment until we started hiring people from the village. The reason we were failing was because health workers had no place to stay in the villages. Once you started hiring villagers to do the work, you had a place for your health workers to stay. And so there was a tremendous lesson. </pre> Player html for embedded player to stream video content <iframe src="https://www.youtube.com/embed/0m-qj2HereE" frameborder="0" width="560" height="315"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-14 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15nd0 emory:15nd0 Subject The topic of the resource CDC Smallpox Eradication USAID WHO Combating Childhood Communicable Diseases (CCCD) Format The file format, physical medium, or dimensions of the resource 9738000000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harden, Victoria (Interviewer) Foster, Stanley (Interviewee); CDC Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource FOSTER, STANLEY O. Description An account of the resource Dr. Stanley Foster traces his early years and interest in international health. Describes his recruitment into the EIS and subsequent assignment to Lagos, Nigeria as the Epidemiologist for Nigeria in the Smallpox Eradication Program. Following that he was assigned to Bangladesh's smallpox program and then became the Project Director for the Combating Childhood Communicable Diseases (CCCD) project at CDC. Language A language of the resource English https://globalhealthchronicles.org/files/original/4dc6ef937719dd6fa6d83fd77f250dc9.jpg c4add24234d15f08afd1581c7c14dd6e Omeka Image File The metadata element set that was included in the `files_images` table in previous versions of Omeka. These elements are common to all image files. Bit Depth 8 Channels 3 Height 178 Width 184 https://globalhealthchronicles.org/files/original/683280d25992d65aedc92146052f9d32.pdf 8cb9282c57c5ecde06ed0cd89986795c 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. Duration Length of time involved (seconds, minutes, hours, days, class periods, etc.) 1:04:45 Player html for embedded player to stream video content <iframe src="https://w.soundcloud.com/player/?url=https%3A//api.soundcloud.com/tracks/310210147%3Fsecret_token%3Ds-71EQF&amp;color=ff5500&amp;auto_play=false&amp;hide_related=false&amp;show_comments=true&amp;show_user=true&amp;show_reposts=false" frameborder="no" scrolling="no" width="100%" height="166"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource 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 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 November 2, 2011 https://globalhealthchronicles.org/files/original/e1c18afedacb87edf4a9b2915a19473e.JPG 5b8895f58592b571e06589f4d4dd0cff Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Player html for embedded player to stream video content <iframe src="https://www.youtube.com/embed/fO5wY6PUheA" frameborder="0" width="560" height="315"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource 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 A related resource from which the described resource is derived David J. Sencer CDC Museum at the Centers for Disease Control and Prevention https://globalhealthchronicles.org/files/original/f6c18e9dd450faa83afa9f0244d0b85e.jpg b77a45cec35285408854f749ee7fa489 https://globalhealthchronicles.org/files/original/773af72412b35b19ffeb3e0caf818550.pdf fd6cc275654113293071c9e2e5b12efb 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 Jay Friedman on July 13, 2006, at the Centers for Disease Control and Prevention in Atlanta, Georgia, about his involvement with the West African Smallpox Eradication Project. The interview is being conducted as part of a reunion marking the 40th anniversary of the launch of the program. The interviewer is Diane Drew. Drew: Would you mind giving me a little bit about your background, where you grew up, what's your education, that kind of thing? Friedman: I was born and raised in New York City, in the borough of Queens. I went away to college at the age of 17, to Florida State University in Tallahassee, Florida, where I graduated in 1961. Drew: And what was your field of study? Friedman: I majored in business administration-not that I was so business oriented, but I wasn't a great student and thought that was an easier path to grey hair. I was the equipment manager of the baseball team, which was a championship team. And, as equipment manager, I had a full scholarship, which my father loved, which is why I stayed at Tallahassee. Following that, I went to law school for a year. But I didn't like it very much, and joined the Peace Corps in 1962. I spent 2 years in Sierra Leone, West Africa, mostly teaching English, math, and motor mechanics- Drew: That's quite a combination. Friedman: -in a vocational high school in the city of Freetown. Motor mechanics because I had put my way through college working as a mechanic at an Oldsmobile dealership in Long Island, New York. Drew: How cool. Friedman: Learned how to work on cars, which perplexed my father totally. Drew: That's a very handy skill to have. Friedman: Yes. One problem is my knowledge of cars ended when I graduated from college in 1961, so I know nothing about newer cars, just old ones. Following the Peace Corps, in 1964, I went to American University in Washington, D.C., majoring in international relations and economics, and, if you like, a minor in French, which I learned to speak fluently. I spent 5 months in France to that end. Drew: What part of France? Friedman: I was in Paris, then in a small town called Boulogne-sur-Mer, which is right on the English Channel. From the high part of the town, you could see the White Cliffs of Dover. Drew: Oh, wow! Friedman: We used to go on weekends in France. Drew: So you were really immersed in France, I'm sure. Friedman: Yes. I was living with a family in Boulogne. The husband was a fishing-boat captain. And Boulogne is the world's capital for mussels. So I had mussels smothered in loads of butter at night and gained lots of weight. Thankfully, though I still love mussels, I left the French way of cooking behind. I finished at American University with a master's degree in 1966, at which time I didn't know exactly what I wanted to do. I was approached by the Coast Guard to become a Coast Guard officer, which I seriously considered. I had been getting a Peace Corps bulletin for returned volunteers, which came every month or so. And at this very juncture of my life, the issue that was delivered to my apartment in Washington had an advertisement from CDC. They were looking for people who had lived in Africa, who could speak French, and who could fix a car. Drew: This sounded like it had your name written right on it. Friedman: It just jumped off the page. Drew: Really. Friedman: So it had a phone number in Atlanta. And this was in the days-I don't know if you remember these-when making a long-distance phone call was a big deal. Quite a big deal. So I dialed the phone number and got a gentleman named Leo Morris on the phone. He was the assistant branch chief or the assistant chief in the smallpox program. He was coming to Washington the next day for some unrelated reason, and we made an appointment to meet. We did. He interviewed me, and he hired me on the spot. Drew: That seemed so fateful. Friedman: But I don't think at CDC today, anyone can hire anyone on the spot. Drew: That's true, that's true. Friedman: And certainly not anyone without any public health background whatsoever, who could merely speak French, fix cars. I don't think such qualifications would get you anywhere today. Drew: But it's the perfect combination. Friedman: Right. And Leo said, "You're hired." I don't know what bureaucratic shortcut he used, but that certainly was the case. And 2 weeks later, in July 1966, I was here in Atlanta. I flew down from Washington and rented an apartment-an apartment, which I believe is where this very building, Building 21, is now. If you're looking at the buildings, to the right of the building they just tore down, there was an apartment house. CDC was much smaller then. Drew: Sure. Friedman: And there's still a pine tree growing right there, which was right next to my bedroom. Drew: Oh, how funny. Friedman: The tree is still there; nothing else. Drew: That's funny. Friedman: In any case, I was the closest person at CDC to the office. We met every day in the auditorium, which has just been torn down. And I literally awakened at 10 to 8:00 and would be sitting in the place where we had our training course 10 minutes later. Drew: You had a really easy commute. Friedman: I had an easy commute. The apartment became a motel later. Drew: Didn't CDC take it over and have offices there? Friedman: The motel closed, and there were CDC offices there. Through the '80s. And it was only in the '80s, I believe, or the early '90s that they built Building 21. But, thankfully, did not cut my tree down. I have a picture of me in front of it in 1966. Anyway, I began at CDC as a trainee in the Smallpox Eradication Program in July '66. Leo Morris, the guy who hired me, was my boss. Drew: And you were in the public health advisor series? Friedman: Yes. There were 4 of us hired through this Peace Corps advertisement: myself, Jean Roy [Jeannel A. Roy], Tony Masso [Anthony R. Masso], and Mark Pointe, all of whom are going to be present at the reunion. And the others-I think all of them-were public health advisors for the VD [Venereal Diseases] program, the VD branch, who had been chasing syphilis up and down the streets of New York City. Drew: Yeah, [looking for] the contact persons. Friedman: It was felt that their expertise in that regard would be useful in smallpox. The 3 other guys and I who were coming from the Peace Corps did not have that expertise, but we knew the language and other things, fixing cars. Tony was with the Peace Corps in South America somewhere. But Mark, Jean, and I had all been in Africa and all spoke French. Anyway, we started a training program here in Atlanta, which went on for several months. We were taught epidemiology, the epidemiology of smallpox in particular, which was very simple, actually, in the scheme of things in the world of epidemiology; and administration, how the government works. We would be going to 19 countries. The majority of them were French-speaking countries, French colonies in West and Central Africa. Drew: And did you know ahead of time which country you were going to go to? Friedman: Not at the very outset. When the program began, I think none of us knew, although I assumed, having learned French, I'd be going to a French country. At some point during the training course, which went on for 3 months, we were told. Originally, I was to go to Niger, and then, for various reasons-I forget what they were-I was told I would be going to Mali. In most countries, we had both a medical officer and what were called operations officers, of which I was one. Our jobs were to assist the medical officer with the epidemiologic work- ups of smallpox outbreaks. More importantly, we were in charge of the logistics of the whole enterprise because the people who organized the program-D. A. Henderson [Donald A. Henderson], Leo Morris, Henry Gelfand, Rafe Henderson [Ralph H. Henderson], and others-wisely realized that smallpox was not so much a medical problem as a management and logistics problem. The means for fighting smallpox were mostly known, not totally. Its epidemiology is very simple. Vaccination is an absolute preventive measure for varying periods of time. It's a simple disease epidemiologically in the sense that only human beings are the reservoir, meaning the virus doesn't lurk in water or in insects or in the environment in general. The virus is only found in humans, which makes a huge difference. Once you interrupt the chain of transmission from human to human, you can stop the disease in its tracks, which had been done in much of the world by 1966. The major foci, or the focus-I'm not trying to impress you- Drew: Hey, I'm already impressed. It's okay. Friedman: Remaining in the world were foci in Brazil and East Africa, which was variola minor; an attenuated form of smallpox, and variola major, the real smallpox, with a 25% death rate, in West and Central Africa, the Indian subcontinent, and Indonesia. Almost all other countries had eradicated smallpox through vaccination activities. And it was, of course, eradicated in countries with the best-and I'm going to use this word loosely- management. Drew: Sure. Friedman: So, naturally, in developed countries, they had mass-vaccinated enough of the population years before that it never really even got a foothold. Well, we had it in the United States, I guess, in great amounts in the 19th century. In the 20th century, there were just sporadic outbreaks. I remember as a child in New York City, there was a scare, around 1947, right after the war. I think there were a couple of cases of people coming from other countries where it was endemic. There were 1 or 2 cases in New York City. But the entire city got vaccinated immediately, including me. I remember it well as a child. I believe the last cases in the United States were in the very late '40s, I think in Texas. They might have been imported cases from Mexico. I don't remember exactly. In Europe, there was an outbreak in the '70s in Yugoslavia of some Muslims. I believe it was involved pilgrims from Mecca to Yugoslavia. Most cases outside the endemic areas I named were imported, usually traveled from an endemic area. Mecca was a big point for the transmission of many communicable diseases because masses of people gathered there. But there were other areas where smallpox cases would come from. Anyway, I went to the training course, and I was assigned to work under a medical officer named Pascal James Imperato, known as Pat, who's going to be here also. In fact, he and his son are staying at my house. Pat and I went to Mali. I went in December of '66 and Pat a month or so later. And the original strategy for eradicating smallpox in West Africa was to use mass vaccination of the population with jet guns. Drew: Right. Friedman: Now, you've heard of these. They were developed by the military to quickly vaccinate the recruits, I guess anyone in the military. Drew: Were these the ones that were powered, that required electricity?? Friedman: Mali had a measles control program, also directed by CDC people, including Rafe Henderson, that began a year or so before; it used the military jet guns. And the jet gun consisted of a thing that looked like a gun, 2 hoses, and then a pump to pump hydraulic fluid into it and charge it, to load it, if you like, against a spring. The military once had an electric pump, which ran at 110 volts US current. To use the military jet guns in West Africa, you had to use a transformer and plug them into the wall, or, in this measles campaign, which predated smallpox, they had International American trucks with a refrigerator and generator mounted on the back. The generator generated 110 volts, and they could use the electric guns in the field. This was all very unwieldy. The trucks would break; the generators would break. The electric pumps were very well made, made on a military, I believe, cost-plus basis so they were very solid. And the guns themselves rarely broke. Drew: It was all the other things they were connected to? Friedman: Yes, the refrigerators, the trucks, even though Internationals are very good trucks. They decided, wisely, that the electric guns weren't the way to go with smallpox, although we had a number of them in Mali. We assigned those to fixed health facilities, where they could plug them in the wall and transform them. Drew: Where people could come to you. Friedman: Yes. This was mostly in the capital city. Everywhere else in Mali, and everywhere else in West Africa, they used something called the Ped-O-Jet. It was the same gun part, upon which you put a bottle of vaccine and a needle. But instead of the pump on the ground, the 2 hoses coming to it being powered electrically; it was a pedal. The operator would step on the pedal-and I'm making a stepping motion. Drew: Yes, right. Friedman: I'm telling the recorder that. Drew: Please note. Friedman: And it would charge the gun, and the bottle of vaccine, of course, would be on the top. And then you pulled a trigger, and the vaccine would be injected forcibly into the skin of the vaccinee. We had 2 types of nozzles on the guns. One was for intradermal smallpox injections, right on the top of the skin, and one for the measles vaccine, which was intramuscular, where it would go straight in as if it were a needle. Smallpox, you just deposit the vaccine on the surface of the skin and then prick the skin, normally with a needle. And this nozzle on the jet performed that function. Unfortunately, the Ped-O-Jets were not made for the military. They were made for CDC by a firm in New York, and I don't think they were up to the same quality level. The guns would break-not so much break, as their internal valves and springs would wear out or get stuck. The nozzles would clog, for which we had special wires to ream them out. And especially the pedal, the pedal pump. I think they were made of aluminum with Teflon O-rings acting as piston rings. And this aluminum, being a soft metal, would wear out very quickly. Being an ex-mechanic, I had to fix them all the time, although I trained Malians to work on them, which is not very difficult. And we spent a lot of time fixing these Ped-O-Jets. In fact, in Mali, we had 1 guy, a vaccinator, assigned full-time to work on Ped-O-Jets that were being used out in the field. So we had to transport them back to the capital to have this guy work on them. The simple repairs could be done in the field. But any time the pedal pump broke, you had to send it in. You had to re- machine the whole piston when that happened. Drew: Sure. Was this whole process of doing the foot stroke on the pedal and shooting the gun difficult to coordinate? Friedman: Yes. That's a good question. In the French-speaking countries, we were very fortunate. The French had set up decades before something called a Service des Grandes Endemies (SGE), which in English is the Endemic Disease Service. It consisted of mobile teams of male equivalents of registered nurses, which in French are called Infirmier d'Etat, which is literally "state nurse," but it really means registered nurse. These are very high-level people with excellent training. These groups of Africans would go in the bush, as we called it in Africa, on vehicles, sometimes walking or on horses or whatever, and attend to the public health needs of the population on a scheduled basis. Drew: Making rounds in different areas? Friedman: Yes. And it was run as a military service. The workers in it had ranks, and they were, by and large, headed by French military doctors with military ranks. And under them were-it sounds very racist today-what they called in French Medecin Africain, which means African doctor. These were Africans trained in the university in Dakar, Senegal, to be medical doctors, but on a lower level. Shall we put it this way: they received less training than a medical doctor in France. So the heads of the Endemic Disease Service were usually the French medical doctors, and sometimes the French medical officers were in charge of actual teams. But, more frequently, they had what they called these African doctors, who, in my opinion, were superb people in the field. They really knew medicine on a field level. But, in fact, when you were sick, you didn't go see one of them. And they really had good training. Drew: Well, it sounds very systematic, too. Friedman: It was very systematic. And they had a load of military [unclear]. Below them were the nurses, the Infirmier d'Etat, the male nurses. And below them were other ranks, vaccinators and so forth. Everyone had a rank. And these teams were, as I say, run in the military way. A team would line up in the morning in front of the Medicin Africain, or the senior guy on the team, to show their fingernails and show that they had cleaned them the night before. Etc. etc. It sounds colonial and semi-racist, but it worked. They actually eradicated sleeping sickness. Drew: Great! Friedman: The formal name of sleeping sickness is trypanosomiasis, and the Africans used to call it the trypano service, service de trypano. And over the years-I think this began after World War I- they added other conditions and other diseases to the service, among which was treating lepers. They had lepers who would wait, for example, under a certain tree every month to get a drug called, I believe, Lomidin, if I'm not mistaken. I may have the names of the drugs wrong. So the guys on the teams would refer to them as "my lepers." Drew: Because they'd meet with the same people on a regular basis? Friedman: Yes. The leper had to wait by a tree, by a bush, or on the side of the road, or a certain spot every month. The team would pass and give him his drugs. And they managed to control leprosy. I remember going with some of these guys in the field, and you'd see some leper walking down the road. He'd say, "That's one of my lepers!" They knew them personally. They treated leprosy. They started vaccinating against yellow fever, with BCG against tuberculosis, which was never used in the United States. They'd treat malaria patients. When I got there, we wedded our resources-our trucks, our jet guns, and our smallpox and measles vaccine-to the Endemic Disease Service. Drew: You kind of integrated into that existing system? Friedman: Exactly. And at one time, they were doing 5 vaccinations at once. They were looking for malaria, leprosy, sleeping sickness. Of course, there was smallpox, measles, BCG, yellow fever . . . What was the fifth one? I don't know. There was a fifth one. They'd go into a village. They'd announce that they were coming. They'd send a runner or something. They'd say, "We're coming next week," or whatever. Believe it or not, the team would arrive in the village, and the villagers would be lined up by age and sex. Drew: Wow! Friedman: I mean, this was fabulous! The head of the team would climb on the top of a truck and make sure everybody was lined up. They'd go to the whole village. I've seen this; it's almost unbelievable. And the villagers were lined up by age and sex because each cohort of people and each age group got different vaccines and different treatments. If the teams were looking for sleeping sickness, they'd feel under the chin for swollen glands or something. (I think that was for sleeping sickness. These are other diseases I didn't know much about.) And these guys dealt with everything. They'd feel everybody. They'd palpate under the chin and they'd feel for sleeping sickness and leprosy. We had a vaccinator arranged on each side of every person, and they'd get different vaccinations in each arm. Drew: And the indigenous people apparently were very cooperative and willing? Friedman: Yes. And this operation was run like the military. The village chiefs were, of course, [unclear], and they loved us, and the people loved us. Anyway, that's how we did our smallpox vaccinations in Mali, and it worked very well. And the chief of one of these teams was a very senior guy. He'd climb on the top of the truck and start barking orders, and they'd actually obey them. Anyway, Pat Imperato, the doctor I worked with in Mali, was an anthropologist also. He had actually written books on African culture and stuff. Mali was very complicated because there were nomadic peoples in the country in what was called the delta of the Niger River, which is a big swamp area. It's not a delta at the mouth of the river at the sea; it's a delta in the middle of Mali, in the desert area, where the river would just spread out into a big swamp 100 miles across and then re-form as a river 100 miles later. There were nomadic cattle keepers in this area. And one of the major challenges we had was how to vaccinate those people. So Pat, the doctor I worked under, studied them and figured out that they moved with their cattle in different ways and in different directions. Drew: There was some pattern? Friedman: Yes, there was a pattern to their movements. Drew: It wasn't just like a random kind of thing. Friedman: No, not at all. In fact, he did this along with Malian colleagues who knew all this. Pat sort of systematized their movements, on paper, and figured out how to position these vaccination teams in order to get these people when they were accessible. I think at certain times of the year they gathered in larger groups when the river got dry, which would be in April and May, just before the rainy season began. They'd sort of come together in a much smaller area in large numbers, where the remaining water in the river was present, where the cattle could graze and water. So Pat figured out that's the time of year when they should vaccinate the nomads. The word for their movements in French was called transhumains [sp.], trans humans. I'm sure there's an English equivalent word, but I don't know what it is. I've never talked about this topic in English. But Pat was studying that. In any case, we vaccinated the area. Drew: And did you have the same degree of cooperation? Friedman: Probably a bit less among these nomads. Not living in villages- Drew: And kind of not having the structure of like a chief per se- Friedman: Exactly. That's an excellent question. I didn't even think of that. Not living in villages, they were much less easily ordered about, if you like. In fact, you couldn't order them about. They did their own thing with their cattle. And that was the challenge. And so the normal tactics used in villages had to be modified. I would suggest you alert the interviewer who's going to work with Pat to ask him about vaccinating the nomads in the Niger delta. He's a very serious anthropologist. He's written books about this. He'll talk your ear off about it. All right. So we finished vaccinating Mali. By this time, I had been there 2 years. It was September or October of 1968, and I was transferred to Gabon in Central Africa, which is around and below the [unclear] of Africa. It's a totally different country from Mali, which was semi-desert with many logistical problems. I'd spent a lot of time in Mali working on trucks, fixing them, and fixing jet guns, and doing a little bit of epidemiology on smallpox outbreak investigation. We did have a couple of smallpox outbreaks. When I went to Gabon, there was no smallpox, and my job was very different. First of all, there was no American medical officer there. I was on my own. I was working under a French military medical officer named Jean Claude Jeel [phonetic]. I was sort of his advisor on smallpox and measles vaccinations. There, I got involved in surveillance, looking for smallpox. I also did maintenance for the jet guns and the trucks, although the French in Gabon and my predecessor in Gabon, Mark LaPointe, had set up an ongoing training course whereby the French and the Gabonese trained people on jet guns, so I didn't have a lot to do with jet guns. And I didn't have a lot to do with trucks. In Gabon, which was a much more economically advanced country than Mali, there were lots of garages in various towns, and it was possible to get things repaired. We didn't have to have our own mechanics, as we did in Mali, working on the trucks. If a truck broke, you'd move it to a garage and they'd fix it. I learned a lot about surveillance, but I didn't have a lot to do, really. I mean, besides surveillance, there wasn't much. Plus, in May of '69, we achieved an interruption of the transmission of smallpox in West Africa, and I arrived in Gabon in late '68. So there was really less of a threat of smallpox transmission anywhere in West Africa. We were still looking for cases. I stayed in Gabon from late '68 until April of 1970. So I wasn't there all that long, 18 months. And then 2 things happened. Personally, I got married to my first wife, Lindsey Craper. She's British and was a professor at a university in Ghana. We met at a party given by George Lythcott, who was our CDC regional smallpox director. George lived in Lagos, Nigeria, where I went for a meeting in May of '69. Lindsey was a friend of George and his wife Jeannie. Lindsey was at the party, too, visiting Lagos from Ghana. So anyway, Lindsey and I met at this party. And, to make a long story short, a year or so later, we got married. Interestingly enough, Jean Roy told me, the Jean and Betty Roy told me - you have to confirm it with him - that they met at the same party. Drew: Oh, how funny! Friedman: You'd better confirm it with him. But I believe . . . Drew: Was it a New Year's Eve party, by any chance? Friedman: It was in May of '69, when we had a big meeting in Lagos. Drew: Yeah, so it wouldn't have been New Year's Eve. Friedman: No, because we had achieved . . . Drew: Because I may be mistaken. I was thinking that Betty told me that they met at a New Year's Eve party. Friedman: A New Year's Eve party. Drew: But I may be mistaken. Friedman: I may be mistaken. One of us is mistaken. Drew: Yeah, hey. Friedman: Anyhow, I think Betty knows. Drew: It still sounds like a nice situation. Friedman: Betty knows. If Betty said it was New Year's Eve . . . Maybe it was at George's house for a different party. Drew: Yeah, yeah. Friedman: So, anyway, Lindsey and I got married, and my term in Gabon ended, and it was decided there was no need for any further CDC operations overseas in Gabon. But Nigeria had been the site of the last outbreaks of smallpox. It was a very large, very populous country, and it was felt we should really do much more intensive surveillance in Nigeria. Nigeria had just reorganized itself politically, the entire country. Instead of large regions, there were now states- I think there were 11 or 15 or something like that. And they wanted an operations officer in each one of the states to be in charge of the surveillance efforts and continue with mass vaccinations (although, at the time, we were switching away from mass vaccination). Drew: And Nigeria was colonized by the British? Friedman: Yes. It was an English-speaking country. But my first assignment, Gabon, was French-speaking, of course. Nigeria is my first English-speaking country. Drew: My son says that the health care systems left behind by the respective colonial powers were somewhat different in terms of how well or maybe not so well they worked. Friedman: Exactly, very different political and health structure in Nigeria from the French, ex-French colonies like Mali and Gabon. Anyway, I was assigned to Kano state in northern Nigeria. It's at the very northernmost part of Nigeria. So my new wife Lindsey and I moved to Kano, where I was assigned to what was called the Epidemiology Unit in the Ministry of Health of this state of Kano. My boss was the chief medical officer of the ministry, Dr. Patel; he was Indian. Northern Nigeria is an interesting area. The people are Hausa-that's the name of the ethnic group; it is a very large ethnic group. And the Hausa language was spoken all over that part of Africa, even among people who were not Hausa ethnically. It's a much simpler language than the languages further south in Africa in that it's Hamitic. It's more like Indo-European languages. So foreigners tend to learn it to a greater or lesser extent. My wife, Lindsey, learned it perfectly. Her field is linguistics. I learned it a bit, enough to talk to villagers. In any case, our job was continuing mass vaccination, although, as I started to say, we were switching to what was called the surveillance-containment approach to eradicating smallpox. Instead of vaccinating everyone, we'd merely do surveillance for smallpox outbreaks. When we found an outbreak, we'd do what was called ring vaccination around the outbreak area, including the immediate contacts of each case. Eventually, this strategy was adopted for the rest of the world, especially in the Indian subcontinent. And that was the strategy that eradicated smallpox. In densely populated countries, including northern Nigeria, mass vaccination really couldn't work. It really couldn't get everybody, get enough of a herd immunity whereby by the disease transmission would be interrupted, especially in India. You could never mass vaccinate there. So, in any case, we started doing surveillance-containment in Kano state and continued vaccinating, continued looking for cases. We never found any. All the while, we were doing vaccinations against measles also. The problem with measles was the vaccine. It was much less heat stable than the smallpox vaccine. The measles vaccine had to be kept frozen. With the smallpox vaccine, we learned that (although officially it was supposed to be kept cold) because it was freeze-dried and very heat-stable, you didn't have to keep it cold. It stayed potent. You couldn't have it out in the sun, but as long as you kept it covered, it would stay potent for a long time. But with measles vaccine, in spite of our best efforts, I'm certain that there were occasions where we were vaccinating with impotent vaccine because the cold chain, with the fridges and little cooler boxes that the vaccinators carried to keep the measles vaccine frozen, just broke down. Drew: Sure. Friedman: We did control measles in certain countries. Gambia was 1 example. But in other areas, we had greater or lesser success with measles control. It was never thought we'd eradicate it, although they did in Gambia for a while. In any case, I spent 2 years in Kano, which were delightful. I was newly married. It was a very large and well- developed city with an international airport, direct flights to London and elsewhere in Europe. I joined a British club, which I thought I'd never do, learned to play squash; I really had a nice time in Kano. I mean, I worked very hard, but the state of Kano was very heavily populated, and the area was rather small. So I rarely had to spend the night out in the bush as I did before. Drew: You could do what you needed to do on certain day trips? Friedman: Exactly. And so I slept at home most nights. And my older daughter, Laraba, was born. Laraba is a Hausa name for girls born on Wednesday, which we had chosen from the pantheon of girls' names-7 of them, one for each day of the week; well, there's more also-before we knew, of course, what day she was going to be born on. It was a 6:1 bet. She was, in fact, born on Sunday, but .she still wound up being named Laraba. Drew: A very pretty name. Friedman: Which is the name she retains to this day, of course. She is now 35 and living in London. What else happened in Kano? We had a very congenial work experience there. The epidemiology unit that I worked with was headed up by a man named Al-Haji Mohamed Kozoray, he and I became quite good friends. We worked together well. Everything was nice in Kano. I liked it. Drew: And so your eldest child basically was a toddler in Kano. Friedman: She was an infant. She was actually born in the U.K because my wife was English, as I mentioned. Laraba came to Kano in northern Nigeria at the age of 2 weeks. And we stayed there until April of '72, which was the end of my West African sojourn. I went on to do smallpox eradication in Nepal, which is not the topic at hand. So I guess I ought to end right here. Drew: Well, it's a shame because I'd love to hear that story too. Friedman: Oh, really? I'd be glad to tell you that one. Any other questions? Drew: Well, are there any other things that you can think of about your experiences that you'd like to share? Friedman: The only thing I could say about my experience is that it introduced me to public health. As I said at the outset, it was not my field at all, unlike the other operations officers who had come from the VD branch. Eventually, after living in Nepal and then the Philippines, where I was in the Expanded Program on Immunizations, I came back to CDC in 1978. I joined the Division of Reproductive Health and spent 25 years working on contraceptive-prevalence surveys, largely in foreign countries. But towards the end of the 25 years, I was also working on behavioral risk-factor surveys on Native American reservations. We had monies from the Indian Health Service to run surveys on Indian reservations similar to those I had done in foreign countries on contraception. We looked at behavioral risk factors. As you know about Native Americans, smoking, diabetes, and other conditions related to behavior are important. So I would say my last 5 years at CDC, before I retired in 2003, were spent working on Indian Health Service stuff, surveys; and they paid half my salary. So I had a rather diverse career. Drew: It sounds really interesting and rewarding. Friedman: I think so. And I think I was lucky. As a public health advisor, I was never pushed up into administration like so many people were. I remained in science my entire career. I never had to supervise anyone really, which I found much more enjoyable than working in administration, which is not my cup of tea. So I had a very rewarding career. I always liked going to work in the morning. Never in my wildest dreams, before coming to work at CDC in July of '66, would I have thought I'd work in anything having to do with health, public health, epidemiology, survey data analysis, and everything else I did here. So I really had a very rewarding career at CDC. Drew: That's great. And that's very interesting to hear about, and I really appreciate it. Friedman: You're welcome. # # # </pre> Player html for embedded player to stream video content <iframe src="https://w.soundcloud.com/player/?url=https%3A//api.soundcloud.com/tracks/310125121&amp;color=ff5500&amp;auto_play=false&amp;hide_related=false&amp;show_comments=true&amp;show_user=true&amp;show_reposts=false" frameborder="no" scrolling="no" width="100%" height="166"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource sound recording - nonmusical interviews Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-15 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/158h8 emory:158h8 Subject The topic of the resource USAID Endemic Disease Service Ped-O-Jet Smallpox Eradication WHO CDC Operations Officer Format The file format, physical medium, or dimensions of the resource 495841584 bytes audio/x-aiff Creator An entity primarily responsible for making the resource Drew, Diane (Interviewer); CDC; Nurse Friedman, Jay (Interviewee); CDC; Operations Officer Contributor An entity responsible for making contributions to the resource Centers for Disease Control Reunion of West and Central Africa Smallpox workers (2006 : Atlanta, Georgia) Title A name given to the resource FRIEDMAN, JAY Description An account of the resource Jay Friedman, served as an Operations Officer in Mali, Gabon, and Nigeria. A former Peace Corps Volunteer, Jay came to the Smallpox program by responding to an advertisement in the Peace Corps bulletin looking for people "who had lived in Africa, who could speak French, and who could fix a car." Jay speaks of his work assisting medical officers in investigating outbreaks and managing the logistics of the eradication effort, using Ped-O-Jets, the structure of the national Endemic Disease Service in countries where he worked, tracking Malian nomads, doing surveillance in Gabon, and finally life in Kano, Nigeria. Jay went on to do smallpox eradication in Nepal, and joined the Expanded Programme on Immunization in the Phillipines before returning to work for the next 25 years at CDC in Reproductive Health and Indian Health Services. Language A language of the resource English https://globalhealthchronicles.org/files/original/9f4a484948cb66105bff34d84316b2ed.jpg b77a45cec35285408854f749ee7fa489 https://globalhealthchronicles.org/files/original/43c2f056200aa55ab4bc62102f00d50f.pdf 69b5d960281a63c73923be9bd28e2b15 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> Interview Mr. Jay Friedman with Dr. David Sencer &amp; Maddie Maddie Transcribed: January 2009 Maddie: My name is Maddie Halendonie [inaudible name0:00:12] and I am student of Emory College, and I am sitting here today with Mr. Jay Friedman. It is March 31st, 2008 and we are in the CDC. So welcome! Thank you for coming. J. Friedman: Thank you for having me. Maddie: Just to get started, if you could tell us a little about your background, your hometown, where you come from, your education? J. Friedman: I was born in New York City at 123rd Street, and grew up in the Borough of Queens, went to college at Florida State University and then joined the Peace Corps where I spent two years in Sierra Leone, West Africa. Following the Peace Corps I went to graduate school at American University in Washington D.C. where I studied International Economics and Languages. Towards the end of my two-year course I was reading a Notice in the Return Peace Corps Volunteer Bulletin which asked for ex-volunteers who had lived in West Africa, who could speak French which I could; and who knew how to fix a car, which I also could, having worked my way through college as an auto mechanic at an Oldsmobile dealer in New York. Well, the notice was from the Centers for Disease Control asking for people with those qualifications to go back to West Africa and work on the Smallpox Eradication Program and it seemed like that fitted me perfectly. So I made a phone call to the number in the Notice and spoke to a person called Leo Morris. He was the Deputy Branch Chief or Deputy Director of the program who happened to be coming to Washington the very next day where we met, and he hired me on the spot, which I am certain is no longer possible at CDC, to hire anyone so-shall we say unknowingly, or without knowing all that much about him. Today there are all kinds of background and security checks. Anyway it worked out well. Later that year which was 1966, on July 1st I reported here in Atlanta and went to work for the Smallpox Eradication Program whose Director at the time was Dr. Donald Henderson - D.A. Henderson, and whose deputy of course was Leo Morris aforementioned. Dr. Henderson not long afterwards left to head up the smallpox program at the World Health Organization in Geneva. Meanwhile I joined roughly 40 other people, newly hired, some of whom had been CDC employees, others like me were not, to go through a - I've forgotten how many months exactly - about three or four months' training course in epidemiology, about which I knew nothing, about the characteristics of smallpox which I also knew nothing about. We also learnt quite a bit about the culture and the politics, if you like, of West Africa which I knew a bit more about. We also were sent - we were divided into two: medical officers and what were called operations officers. I was an Operations Officer and the operations officers were also sent to the Chrysler Corporation Service Training School, it was somewhere in South Atlanta, I think on Moreland Avenue, I forget exactly; and we went through a course learning how to work on Dodge pickup trucks with which we were going to be equipped in West Africa. The Medical Officers studied more epidemiology than we did. Anyway, following a couple months of this, those of us going to French- speaking countries, of which I was one - I was assigned to the Republic of Mali; stayed behind I think and went through a very intensive French language course. I knew a lot of French, but obviously I didn't know everything and learnt a lot at this course which was run by Emory University. Then in December of '66, the medical officer I was working with in Mali, Dr. Pascal Imperato, we left for Mali and we started working on eradicating smallpox. Mali was a difficult country among the - I think it was 20 countries we were working on in Western Central Africa - because in the early 60s a Leftist Government took over from the French Colonists - the French Colonial Power; and they were very close to the Soviet Union and North Korea, and all the Communist countries at the time. The fact that this program was financed by the United States, specifically the U.S. Agency for International Development meant it wasn't easy for us to work at first. But Dr. Imperato and I, if you like, made friends with all the principal characters we had to work with, and gradually we gained their confidence and we didn't have any further problems. Initially in West Africa the approach was called mass vaccination. Smallpox being what it is, I am not going into detail, but the reservoir is human beings. There is no animal or water or other insect borne way of transmitting the disease, it's human to human, and the vaccine works. So the idea was that we vaccinated a certain proportion of the population which the doctors in charge of the program thought would be 80%, we'd stop the transmission of human to human smallpox. Mali was very difficult because through the country runs the Niger River. It's called in French the buckle of the Niger River, the bend of the Niger River, which creates a large swampy area in which lived the Nomadic cattle herders, and these people moved with the rising and the falling of the river depending on the various seasons, rainy, dry and cold are the three seasons of the year there. Dr. Imperato, fortunately, was an amateur anthropologist which I believe was one of the reasons he was selected to work in Mali. He studied the movement of these people quite thoroughly and actually wrote some scientific papers on it, and figured out where vaccinators should be at certain times of the year, etc. So we began vaccinating in this area, which is right in the middle of Mali, very difficult to access. We had to use boats and other means of transport. At the same time, besides mass vaccinating our other task was to look for smallpox cases. This was done by having or alerting local health workers all over the country to alert the Ministry of Health in Bamako, the capital, if they found or noticed any smallpox cases, and we had an agreement that if smallpox cases were found we would go out there and investigate, being trained of course in recognizing smallpox and knowing how it transmitted etc. etc. So meanwhile there were cases of smallpox in the country in Mali, and we investigated several outbreaks I remember, and we kept vaccinating at the same time. Meanwhile, one of the medical officers in the program, Dr. William Forge who later became Director of CDC in Eastern Nigeria had come up with another methodology for attacking smallpox. That was called surveillance containment. I believe, Dr. Sencer can correct me if I am wrong, he felt that you really couldn't vaccinate enough people purely to stop the transmission, given the various problems with Nomadic populations and that sort of thing. The best approach would be just to look for cases and put vaccination on the backburner if you like and contain every outbreak with various strategies, one of which was Ring Vaccination Containment, that is: you vaccinate the people right around each outbreak and check everyone coming in and out of the outbreak area with people called watch guards, and sooner or later you would interrupt the transmission, and even if there were unvaccinated people, the fact that you interrupt the transmission, since it's only transmitted from human to human, that eventually you'd stop the transmission of smallpox; and in fact this is the way smallpox was eradicated. So I spent two years in Mali, I was there till September of 1968. Then I was transferred to Gabon, the Ex-French equatorial Africa. It is around the bends of the armpit of Africa if you like. A very rich country on the North-South Coast; it is an oil producer and all sorts of minerals, and it's in a part of Africa that is very under-populated for various reasons: issues with fertility and venereal disease, that sort of thing. So the population there was very low and smallpox is a disease that requires a certain density of population to transmit and there hadn't been cases in Gabon for a long time. The reason we were working there was that it was surrounded by countries that did have smallpox. Anyway, I spent about a year - almost two years in Gabon and didn't have a lot to do; actually we concentrated on vaccinating there because there were no cases. Gabon being a wealthy country had a Mobile Health Service called - it's in French, I'll translate it, it was called the Endemic Disease Service set up by the French military whereby health workers would be transported from village to village on trucks and they would treat people for various illnesses and also do five vaccinations at once, look for leprosy and sleeping sickness and other diseases. Anyway I was an advisor to this Endemic Disease Service for smallpox eradication; and I forgot to mention: in all these West African countries we were also doing measles control. This was also in Mali, I forgot to mention. The West Africans were not so much interested in smallpox eradication which was a public health problem, but not, in their eyes, a major one. It was a major one in our eyes as Americans and Westerners, because it did have worldwide implications. But in West Africa they had many greater problems among which was measles, which unlike the United States and developed countries where it is a benign childhood illness, or somewhat benign, in West Africa where children's immunity, or immunity systems are a little weak because of malaria and other diseases they have. Am I on the right track Dr. Sencer? Dr. Sencer: You're doing fine, except move along a little bit so we can get to India. J. Friedman: Okay, alright. Anyway we also gave measles vaccinations. I was in Gabon for two years and then I was sent to Northern Nigeria to the city Cano where I also spent two years. There was no smallpox in Cano either. In April of '72, I received a telegram from Dr. D.A. Henderson who I mentioned earlier. He knew I was due to go back to Atlanta for CDC. There was a limit on the amount of time you could stay overseas. He asked me if I would be willing to resign from CDC and go to work for the World Health Organization and go to Nepal where they needed an operations officer like myself, and I did. I resigned from CDC went home to New York for two weeks and then I was on a plane for Geneva where I went to an orientation course, just a couple of weeks, and then arrived in Katmandu, Nepal at the end of April 1972. Nepal of course is in the part of the Indian Subcontinent where there were lots and lots of smallpox, much more than in West Africa. The population is denser, those countries are somewhat less well organized than West Africa and vaccination levels were low. They had constant endemic smallpox which kind of moved around the Indian Subcontinent in a big circle and the year I arrived, in 1972, the endemic areas were much further South in India. It was nowhere near Nepal which is on the Northern border of India. At the end of 1973 the big track of smallpox moved up to Northeastern India very close to Nepal and we were immediately inundated with lots of cases. We had adopted the surveillance containment approach and I became busy investigating outbreaks. I had as colleagues there, another operations officer and a medical officer. All the cases in smallpox practically were - every case was the result of cross-border travel from India to Nepal. That border is open like the US-Canadian border; people just walked back and forth. Some places you can't tell which country you are in even, and we had lots of cases, first in the Western part of Nepal, which was at the time in the 70s, very underdeveloped. No roads at all from the capital there. You had to drive to India or fly in a plane. There were even places where there were airports but no roads. So the only modern means of conveyance the local population had ever seen were airplanes or aircraft and helicopters. They had never seen a car or a truck. You had lots of anomalies like that there. This is 1973; I spent a lot of time trekking in Western Nepal looking for smallpox cases. At one point when I wrote this up which is part of the smallpox archive somewhere, I was flown to an airport in Western Nepal where there was no road, and walked a couple of days to an outbreak area along with my Nepali colleagues, there were about five of us. We found that the local smallpox people had contained the outbreak. They had done all this ring vaccination that I mentioned, and we spent a day or so there and realized there was nothing more for us to do. So we decided to visit other neighboring districts and just look for cases. There had been no reports. So I was with a doctor named Benu Bado Kaki [inaudible name 0:17:16], who was the Deputy Smallpox Chief in Nepal, and we started walking and after a day or so, he branched off to one district and I to another. I walked and walked for several days and got to the next district where there were American missionaries living. I spent several days with them and ate steak and mash potatoes and stuff like that which you couldn't get elsewhere in Nepal. There were no smallpox reports from this area. I then walked several days down to the plains of Nepal which borders India, a very flat area, unlike the mountains in the rest of the country; and spent several days there also looking for smallpox along with local smallpox staff- found nothing. Then the town I was in right on the border with India had a once a week plane service back to Katmandu. So I bought a ticket and the plane never came. It only came as I said once a week. I didn't know what to do. I was stuck in this place. There was no road back to Katmandu and I had no car with which to get home. So I was hanging around the airport and there was a very wealthy Nepali who belonged to the upper crust of society, who was there with a Land Rover. He was also trying to get on the plane. He had been hunting elephants or something, and I started chatting with him, and he said, "Well, I am going to drive to Lucknow," a big city in India several hundred miles South of where we were, "and I am going to fly home from there and you are welcome to come with me," which I did and arrived home a couple days later. I had been gone two weeks and essentially had fun and really didn't do anything. So the World Health Organization - well I had done something, I had done some surveillance but not anything concrete. The World Health Organization then got money for helicopter charters which were very expensive; it was 400 Bucks an hour to run a helicopter. For the next - this is in 1973; I was in Nepal till '77, for the next four years we used helicopters to go to these remote areas where we could do what I did in two weeks in a day, just go and come the same day, and since we had so much smallpox, the circle now moved a little differently in India such that now eastern Nepal was full of smallpox. A third operations officer came, by the name David Bassett, who had also worked for CDC, so we were four people actually working there and inundated with cases all the time. 1974 was the worst year in Nepal. It was also the worst year in India as I remember. The state of Bihar in India which borders on Eastern Nepal was loaded with smallpox all throughout '74 into 1975 such that in - I am trying to remember the dates here - November '74 I was asked to stop working in Nepal where we had things more or less under control and spent three months in India along with many other people. At the time the Indian Government couldn't scare up enough people to work on smallpox. The problem there was so enormous, tens of thousands of cases, that they not only hired young medical guys who had just gotten out of medical school I guess, who've been studying public health; and non doctors, people like me we are called technical officers, but also CDC and WHO brought in people to work on smallpox for three-month periods. Some of these were ex- West African people who had done what I had done. Some of them I think knew nothing about smallpox at all. On the other hand, the epidemiology of smallpox is such that you can teach any intelligent person in 15 minutes everything he has to know. As I said, it's human to human, there's no other reservoir, in a day you can make anyone, truly without too much exaggeration, an expert on smallpox. So CDC sent a lot of people, WHO recruited others in Europe, along with our Indian colleagues, we were an army. I can't tell you but my job in Bihar State in India was to be in charge of paying everyone. They wanted a full time WHO employee in charge of the money and I guess I was one of the few. So I was in charge of paying hundreds of people, both Indians and non-Indians in Bihar State for which they gave me a suite in a very rundown hotel in the capital of Bihar, which is Patna. This was just a low-down dingy [inaudible 0:22:27] Indian hotel but it had a suite, and since I was in charge of all the money, I had a safe; they gave me this suite in which I lived in luxury essentially, but I was very busy. We had an office there with a number of people. Dr. Larry Brilliant was in charge of the office, and believe it or not I was busy fulltime paying people. All these people in the field had to have money because the Indian Government Rules and Regulations were so Byzantine. For example, if you had an official jeep and it got a flat tyre, you had to fill up forms and get some senior person somewhere to approve spending a dollar to fix the flat. So WHO got a system going whereby everyone had an Imprest Fund they called it. What it meant was that you had $100 in your pocket to freely spend as you saw fit to, fix flat tyres and grease the skids so to speak. So I was in charge of replenishing all this money. There were some bizarre scenes with all the money. Everything was in cash. Once a month I would get a large cheque from the WHO headquarters in New Delhi for $100,000 or something like this, I can't remember. It was still lots and lots of money, and I'd take it to a local bank there in Patna and deposit it. Then everyday I had to go back to the bank and withdraw enormous amounts of cash. It is in Rupees, I can't remember; say $10,000 everyday, something like that. I carried this in my briefcase, all this cash. Indian banks being what they are, it took sometimes three hours from the time I walked into the bank and said I wanted this cash for them to count it; they had guys sitting on the floor counting it - I'm exaggerating - 5 or 7 people to sign out on this money and they would give it to me wrapped in - the money is wrapped in pieces of paper and I'd stuff it all into my briefcase then walk down the street holding it unguarded. Anyone could have walked behind and whacked me on the head and run away with it, but nothing ever happened. Anyway I would get back to the office and spend the day passing out money to people who'd come in to get it. I kept very detailed account books. At the end of every month, they sent an accountant down from New Delhi to go through my cash and my cheque books and there was always some discrepancy of $1.00 or something like this and I can never figure this out. The night before this auditor came; I'd be up all night going through the books trying to find out why there was a $1.00 discrepancy. This guy was an Indian, he'd spend five minutes, he would go through the books and say, "There's your $1.00;" after I had been up till three in the morning trying to get it straightened out. Anyway I did this for three months-handled the money. Then I went back to Nepal where we still had some cases. We had the very last cases. This was in early 1975, February 1975, which was complicated by the fact that the King of Nepal, it was a new king who had his coronation that very month and you couldn't travel anywhere. Meanwhile, we knew there was smallpox in certain places. To make a long story short, some of these cases spread indigenously in Nepal which hadn't happened before, because nobody could go anywhere. The country was more or less locked down for long durations. Anyway in March and April '74 in the southeastern corner of Nepal, we had our last cases, which were very well documented. Many photographs of the last three cases which was a husband and wife and a child. In April '75 we had our last case and sent a telegram to WHO headquarters in Geneva, I remember it. The telegram read: "D.A. Henderson, World Health, Geneva-No pox!" The signature was Nepal Smallpox Eradication Program. They still have it on file somewhere I guess. I stayed there another two years. The task of the last two years was to look for non- existent cases. They had their last case in Nepal, I believe the following month in May; and in Bangladesh that August I think. Anyway India, Bangladesh, Nepal, we spent the next two years until '77 looking for smallpox and we had armies of people out doing surveillance. I think in India I read, at some point they had a 100,000 people do surveillance for a week or two weeks. Dr. Sencer: More than that. J. Friedman: More than 100,000 people. Anyway there were lots of people working on this. We looked for two years, didn't find a case. There were lots of reports because we were offering rewards at this point. We were offering initially a reward of Rs.100 which at the time was $10.00 or something, and then the reward was up to Rs.1000 which was a $100.00. Anyone who reported a case that turned out to be smallpox would get a small fortune by the standards of India and Nepal and Bangladesh, and we got lots and lots of reports, many of which turned out to be other skin rashes including chicken pox, scabies, I don't know about some of the others; but we were all trained in doing this differential diagnosis and so was everybody else. All the workers at the lowest level, all knew about this. In fact they eventually knew more about it than we did, the foreign advisors, which was the nice thing about smallpox. Nobody really knew more than anyone else. Everybody knew everything there was to know about smallpox. Remember my job during this period in Nepal, being a foreigner, I could do things and go places around the bureaucracy in such a way that my Nepali colleagues running the smallpox program couldn't. For example, I knew the Minister of Health when he was a young junior doctor when I had arrived five years before. Literally I'd could go to his office, knock on his door wearing a T-shirt and jeans and sandals and walk in and he'd greet me warmly. No Nepali official could do that. That was the anomaly of being a foreigner in a country like that, one of them. Anyway, at the end of the two year period, WHO constituted committees for each country, Dr. Sencer was on the one for India, as I remember, who would come to the country. These were usually very senior virologists and epidemiologists from various parts of the world. The committee that came to Nepal was headed by the Polish Minister of Health, whose name was Yang Kartuski, and there were other people. I remember there was a Japanese scientist who was a virologist and various others. I don't remember everyone, but I had to take these people around the country looking at the work we were doing and at the end of - they were there for two weeks in Nepal, they certified smallpox in Nepal as being eradicated and this coincided with Nepali New Year as I remember. Nepal calendar is April to April. They made this certification, they left, and then the head of WHO in Nepal and myself were invited for an audience with the King of Nepal which doesn't sound like much, but it was very rare for a foreigner to meet this guy, which I did. I have a photograph of it. Unfortunately he was the King of Nepal assassinated in the year 2000, I think. He was a young guy, spoke beautiful English and I had seen his picture everywhere for two years, but I had never seen him in the flesh. It is very funny, the WHO representative Veri[inaudible name 0:31:24] Mills and I were leaving, and we said to each other, "He is a nice guy, we wouldn't mind drinking a beer with him or something." Anyway, a couple of months later I left Nepal. My work had been finished. I was then transferred by WHO to the Philippines where I worked for a year. In the Philippines I lived in the Pasay City, traveled all over the Philippines for the expanded program on immunizations, childhood vaccinations, somewhat related to smallpox which is quite different in many ways though. A lot of the work I had to do regarded smallpox vaccine production, there is a big lab there - not smallpox - vaccine production, no more smallpox. This was diphtheria, ptosis, tetanus, and other childhood diseases. The lab knew nothing about how many doses they had to produce. So a lot of my work was figuring this out based on my experience with traveling around the country as well as getting reports from hospitals and doctors all over the place. I first learnt to use a computer there. I also traveled a lot in the Philippines, saw the country. It was the only country I was in where outside the capital was nicer than being in the capital. Manila is a huge tropical city full of traffic, not very pleasant. All these secondary towns and cities there were very nice, I liked that. Anyway I spent a year and a half there and then I came back to CDC, went to work in the division of reproductive health working on first what was called Contraceptive Prevalence Surveys; looking at women of reproductive age in a population usually 15 to 44, sometimes 49, and looking at the proportion using contraceptive methods: which one, and most importantly, of those not using a contraceptive method, why they weren't. I did that for a number of years. Then I did something slightly different which was contraceptive logistics. AID, Washington State Department, as part of foreign aid distributes contraceptives all over the world-I worked with a group of people here at CDC and it was very similar to what I was doing in the Philippines, figuring out how many contraceptive methods each country needed, which ones, and when they should be delivered and all that. Next, since I had worked a long time at CDC - sorry contraceptive prevalence surveys - excuse me, I am getting mixed up, along with few other people in the Division of Reproductive Health, since we were so called experts on surveys, got some money from the Indian Health Service to do behavioral risk factor surveys on Native American Reservations in the United States. This was looking at smoking and drinking and car accidents and other stuff that Native Americans are prone to, to a point. In doing this, I traveled all over the United States; went to some areas I'd never ever gotten to, Idaho and Northern Maine and lots of places where Indians live which sometimes you don't realize they are there. We even did a survey in New York City where there are 35,000 Native Americans. Having grown up in New York, I had no idea these people were there, and towards the end of my career, we are now in the 2000s, I started working again on maternal risk - maternal health surveys including contraceptive prevalence mostly in Southern Africa and Jamaica. I worked on four surveys in Jamaica in the Caribbean and one enormous survey in Zimbabwe in Southern Africa and then retired in January 2003, five years ago. Here I am. I'm having a good time being retired. Dr. Sencer: What was the most important thing that your experience in smallpox [inaudible/low audio0:35:32]? J. Friedman: Well, it's easy. Achieving smallpox eradication in Nepal where I had spent five years. It was the only country I came to call home, being there so long, and I liked it the best. I was married by this time and we had two kids who spent their first years of their lives there and it was quite an achievement. It was much more difficult than West Africa, for lots of reasons, among which was that the people didn't accept vaccination as readily as the West Africans. There was a lot of epidemiology which I had learned pretty well, a lot of logistical problems. So it was very satisfying eradicating smallpox in Nepal. It was in West Africa also, but quite frankly it was a lot easier in West Africa in my opinion. That was the most rewarding thing I think. Dr. Sencer: One final question, Jay. What did you bring out of Nepal? J. Friedman: Personally, I learned a lot. I learnt to speak a little bit of Nepali. My wife and kids learned it fluently. I think I brought out mostly an ability to - I'm going to put it in very metaphorical terms, speak to the Nepalese. By that I mean, I learnt their rhythms, I got into their rhythms, so I knew when to appoint, insist on something, when to not insist on something, when to hold back, when to be a little more assertive. A lot of this I learnt from my boss who is a guy named Dr. M. Mitchell Satyanathan[inaudible name0:37:33], who was Sri Lankan. He was in charge of smallpox there, as far as the WHO people were concerned and he taught me a lot of that, being an Asian himself. He knew when to go along with what the Nepalese wanted to do, and at the same time when not to, and I picked up what I learnt from him from him - that's an oxymoron what I just said - and I think this carried over to my later career where I was working on the surveys, here back at CDC many of which were in foreign countries; I did lot of work as I mentioned in Jamaica and Zimbabwe, also in Senegal and other West African countries. I even went back to Nepal a couple of times as a foreign technical advisor in Family Planning and Reproductive Health, and I think I was much better at doing this than when I was a young guy in my 20s and 30s starting out, when I, as an American, didn't really empathize with foreign cultures - not foreign - I mean I was used to England and France and other countries, but dealing with people in Asia and Africa, it's very different from dealing with the European or an American; specially different from being an American. I think I got pretty good at that. Dr. Sencer: Did you bring anything material out of Nepal? J. Friedman: Well, my younger daughter is an adopted Nepali orphan. She is now 35 years old and married, but I guess you could call her a material thing. I'm kidding of course; I think she'd laugh at this though. I also - you mean possessions? I bought an antique car in Nepal, which I brought back here to Atlanta, which I drive around in still. Dr. Sencer: How antique? J. Friedman: It's a 1932 Ford which had belonged to a Nepali General who gave it to his daughter who gave it to her driver from whom I bought it. I had it restored there and shipped back home in a big crate. Dr. Sencer: How did you get it out of Nepal? J. Friedman: A local moving company who is the agent of Allied Van Lines here in the States made a big crate, this is before containers, in 1975; a big crate as long as this area here. They drove the car into the crate and they tied it down with chains and ropes and everything, they had hooks on the top. We hired a crane, or they hired a crane, and lifted it up and went onto a truck. The truck drove the crate to Calcutta in India near a seaport; it was loaded on a ship, of course. The ship landed in Los Angeles and it was loaded on another truck and came here to Atlanta. I drove it out of the crate-same crate. Dr. Sencer: The mythology is that you brought it out on an elephant, but you didn't? J. Friedman: No, but I would have liked to. Well, I'll tell you if you want to hear this too. The car was brought to Nepal in 1932 before there were roads to Katmandu from anywhere. There were roads in Katmandu; it's in an enclosed valley. The car was made in Canada, shipped through India to the Nepal-India border where the railway ended. It was put onto a bamboo platform, the car. The bamboo platform had handles at the end, pieces of bamboo sticking out. I can't tell you how many, but 30 porters carried this bamboo platform with the car on top over the foothills of the Himalayas to Katmandu. If you don't believe me, there are pictures in National Geographic of the 30s and 40s showing porters carrying cars. There were lots of cars in Katmandu carried in that way including this one. Anyway that's an aside. Dr. Sencer: With that I think we'd better quit. J. Friedman: I think so. Dr. Sencer: Thank you very much, Jay. J. Friedman: You're welcome. Maddie: Thank you. [End of audio 41:58:5] </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/JCOr2EkMygk" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2008-03-31 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15pbt emory:15pbt Format The file format, physical medium, or dimensions of the resource 9059160000 bytes video/x-dv Creator An entity primarily responsible for making the resource Halendonie, Maddie (interviewer) Friedman, Jay (Interviewee) Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource FRIEDMAN, JAY Description An account of the resource Jay Friedman an Operations Officer, describes his assignment to the World Health Organization to work in the Smallpox Eradication Program in Nepal. Subject The topic of the resource Smallpox Eradication Smallpox Eradication WHO Language A language of the resource English https://globalhealthchronicles.org/files/original/50b3f4ada4d41f0636d0e4d61bc6e2ca.jpg 7079ea50612266f212c4d24ec9e70931 https://globalhealthchronicles.org/files/original/0cb9c7a848420abc2241387e68394d57.pdf 834491e360520ec38f1af20e92a67030 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> This is an interview with Mr. Billy G. Griggs, who was Deputy Director for the Smallpox Eradication Program in West Africa. This interview is being conducted on July 7, 2006, at the Centers for Disease Control and Prevention as a part of the 40th anniversary reunion for the launching of the program. The interviewer is Victoria Harden. Harden: Mr. Griggs, I would like to get a little background, to set the stage for your role in the smallpox program. I know you were born in Ripley, Tennessee, on November 20, 1933. Could you, just briefly, give me a little indication about your growing-up years, your pre-college education, who influenced you, how you grew up? Griggs: Well, Ripley is the county seat. Actually, I was born in Ashport, a port on the Mississippi River, 15 miles west of Ripley. And in 1933, this was boondocksville. In every way. Most of the things that came into Ashport came in by river boat. I went to school in Ripley-was bused 15 miles to school. I lived on a farm, of course. I had a rather uneventful, typical farm boy's life. I did all sorts of activities going on with farming. I went to high school at Ripley High School and graduated in 1951. I started to college my freshman year at Union University, which was a Baptist college in Jackson, Tennessee, about 45 miles east of Ripley. I was influenced largely by the pastor at the church, which happened to be located on the farm. He kept pestering me to come to Union. So I went to Union freshman year and met a senior girl, who I was infatuated with. She finished that year and was teaching in Memphis, so I decided Memphis State was probably better than Union. We got married Christmas my sophomore year. I was self-supporting, and I worked my way through college, working all sorts of jobs and I graduated in 4 ½ years. I came out of school with a house, 2 kids, a wife, and no debt, I might add, which is very good for college years. Harden: It certainly is. Griggs: I finished up the undergraduate work in January and decided to go on and do a master's in geography at Memphis State. I did the first semester but I was working, at that point, 48 hours a week at a soybean/cottonseed-oil mill at night. I decided that maybe I'd better slow down just a little bit. I knew there was a job opening down at the Shelby County Health Department for a VD [veneral diseases] investigator. On arrival down at the health department, I found out that not only was there the state job but there was also a federal co-op job vacancy. Tom Davis (from Atlanta) and Press Fish from the Nashville state office were there interviewing for the co-op job. The jobs were virtually the same, in terms of interviewing VD patients, locating their contacts, and referring them in for treatment for VD. The only difference in the state and federal jobs was that the federal job paid $500 a year more than the state job, and at the end of the year you were subject to transfer throughout the United States. This was a cooperative appointment between the State of Tennessee and the federal government. The feds paid the salaries, and you worked literally as a state employee on a local level there, at the City of Memphis. Keep in mind that my motivation for coming down was going through school, working full-time, and making a living. And it was beginning to get a little tiring. I decided that I probably ought to slow down a little bit and finish this master's degree. So I applied for the federal job, thinking that I would just do a year at it, and I'll have my master's, and I'll get on with what I was planning on doing. Harden: Which was? Griggs: At that point I was still thinking possibly about law school. But some things had happened while I was working in a real estate company. I was manager of a rental department at one of the oldest and largest realty companies in Memphis and going to school at night. We had several young lawyers on retainer who were very smart, but they were having a tough time making a living. So I wasn't sure that I wanted to do another 4 years of law school after the master's. So I applied, got the co-op job, and went to work. Two co- ops were hired, I might add. This was mid-June of '56. In early August, late July, Carl Hookings, who was the director of VD there, got a call that l of the co-ops was needed to go to the Mexican border to work with the Bracero Program. There was a pilot project being run to see if Braceros, who were Mexican agricultural workers, could be blood-tested for syphilis at the border. Then you could only have to follow up those scattered throughout the states when they went out from the border. Syphilis was the only blood test they were doing at that time. The Braceros were visually checked for syphilis and gonorrhea by a male nurse coming through. I was married with 2 children. The other young co-op was married with no children, and he made a long pitch to Hookings why it really wasn't in his best interest to go to the border. I didn't have any strong feelings, and I thought the program was going to be over with by the time school started back. So I went out to El Paso. The 2 kids stayed with their grandparents. My wife went with me. She was going to stay 2 weeks and then fly back and take care of the kids. She was a teacher in Memphis. Well, we got to El Paso, and she decided that she didn't really like the idea because the program was going to take longer than we thought. So we made a hurried trip back to Tennessee, got the kids, rented an efficiency apartment, and started work. And, believe me, in those days, things were a little different than working now-a-days. The Braceros came across the border at 6:00 in the morning, went out to the reception center, and we started work. They were processed through, and that meant a complete physical (in terms of looking at them, a chest x-ray, a blood test since we were there to do that), and then they were checked and recruited by the farmers, processed, and then went to the farm that afternoon. The Braceros were all young, male agricultural workers, who were coming in for limited farm work. So our day started at 6:00; usually we were through about midnight. The largest day of processing workers was 4,500 people who came through that kind of process all in one 24-hour period. We finished up in late September or October. And I returned to Memphis. The good thing about the Bracero Program was that Bill Watson [William Watson], who was then the Program Management Officer of the VD program, and I became quite good friends. In the spring, I had taken the federal service entrance exam and made fairly high marks on it. I had gotten a lot of job offers from other agencies, at a considerably higher grade than the VD program co-op salary. Bill and I talked about this, and then Bill had a long conversation with Johannes Stuart, who was in Washington then, and then Stu and I had a long conversation. The sum total of it was, by the time I got back to Memphis, I was converted from being a coop appointment to a regular appointment career status as a GS-5, as opposed to the normal GS-7. I used to kid Bill that at that time he was the longest co-op that had ever been, and I was the shortest co-op. I was converted in about 5 months. So I returned to Memphis. By the second year on the job, I was, as a GS-7, the federal city rep in Memphis for the VD program. I recruited all over west Tennessee and eastern Arkansas. I gave the people we brought into Memphis a rapid training program on how to draw blood. Then they went to the interviewing school in Atlanta, and then they were transferred throughout the United States. We hired some 50 people that second year in Memphis. Harden: How did you decide who was going to work out and who wasn't? Did you talk to each person? Griggs: I interviewed them all. I was the major interviewer at that point. There was not a central interviewing team; it developed later within VD for the large-scale interviewing. But we visited colleges, had an ad in the paper, and interviewed people. We tried to pick people who were resourceful, self-starting, understood kind of what they were getting into. Then in the summer of the second year, because the pilot project had been very successful on the border, I went back to El Paso, which was the headquarters of the program. Five reception centers along the border, El Centro, AA, Nogales, AZ, El Paso, TX, Eagle Pass and Hidalgo, TX processed the Braceros who were initially screened at three centers in Mexico. We had 1 assignee in southern California, 1 assignee in Hidalgo, Texas, and me. I covered the Nogales, Arizona, and the El Paso station out of El Paso. That was my first real exposure to international work. We visited down in Mexico at the reception centers. Mexico had 3 such places, where the overall health of the workers was checked before they came to the border. Harden: And this experience is what made you the logical person, I suppose, to be coordinator for the International Symposium on Syphilis and Treponematoses in 1960-1961. Griggs: Right. Harden: This symposium was bringing together people from all over the world, then, or the Western Hemisphere? Griggs: It was worldwide. There were about 1,500 people at the symposium, held in Washington, D.C., at the Sheraton Park, from some 65 or 70 countries. It was a large meeting, probably a first-class meeting, with translation in French and Spanish. There were lots of papers, a lot of coordination in terms of getting the people together, letters out for the invited speakers, establishing everything that goes along with a meeting of that size. I had left El Paso and gone to Houston as the city rep. Then I went from Houston to Atlanta, when I was interviewed for this job as the coordinator of the symposium. I was offered the opportunity to live in Washington and commute to Atlanta. The VD program had moved from Washington to Atlanta in '57. Or I could live in Atlanta and spend a lot of time commuting to Washington and New York. The other sponsor of the program was the American Social Health Association in New York City. And with Atlanta being a much better place to live than Washington, that wasn't much of a problem. That was a supposedly temporary assignment for 22 months to hold that symposium. At the end of that particular assignment, I went back into the VD program at headquarters as the Assistant Chief of Operations and Development. I had responsibility for the grant program, in terms of working with the states and the major cities in submitting and approving VD control grants. By now it's late '64. I got a call from Bill Watson 1 day, and he said, "There's going to be a program for smallpox and measles control, with USAID [US Agency for International Development] sponsorship and funding, that D.A. Henderson [Donald A. Henderson] is starting to get together, or and I'd like for you to go over and talk to D.A. about being the Program Management Officer and deputy of that program." So I went over and talked to D.A. Harden: And I understand that you had to do some selling about how to structure the personnel for this program. Griggs: D.A. had come out of the Epi program, and while he had had some exposure to Public Health Advisors, he had not really worked very closely with them at that time. I had to sell the idea of a joint effort with an M.D. epidemiologist and an Operations Officer. It clearly was going to be a program of operations, not just one of technical expertise. Harden: This is very important. Would you talk a little more and define what a Public Health Advisor did, how he was trained, and then explain if Operations Officers did the same thing or were slightly different? Griggs: The title "Operations Officer" was created for Africa, but they would actually have been civil service Public Health Advisors in the United States. The Operations Officer title was more descriptive for the African people than the title "Public Health Advisor" because we wanted it clearly understood that these guys were operationally involved. Just like in the Public Health Advisors in the United States, they worked with local health or state health departments or regional offices. But they pretty much had the understanding and expectation that they were responsible for getting the job done. Generally speaking, it was a situation in which, not that we can't do it, but how can we do it? In other words, if it needs something else, what do you need to get it done? Public health advisors started out just interviewing and running down contacts, and then moved up to supervisory positions, grant writing. In some instances, they were literally functioning as VD control officers. So it was a multitask, multifaceted background and job. I might add that growing up on a farm didn't hurt any, either, because it was all of the kinds of things that you have to do in getting jobs done. And if I may digress for one second, we had a problem out in El Paso, in terms of who was running the public health aspects of the bracero program. When we got there with 4 people, the quarantine people asked where the other 20 people were. But we couldn't slow down. We had to run these people through at that speed. So we had to work out a system that would let us, with 4 federal employees and a couple of local hires, handle that-drawing bloods and processing them; getting the results shipped to Austin and back again. So there was a lot of that kind of thing that came along. So I was used to multitasking and making do with what we had. Harden: So after you convinced Dr. Henderson to have Operations Officers in the smallpox program, what was the next step? Did you have to go out and hire people? How? Griggs: When I started with D.A., probably in November, there was an expectation that there was going to be a program, but there was a daunting list of things that had to be done before July 1966. When we started, no project agreements had been signed with any country in Africa, and there was no project proposal. We had to recruit personnel. We had to negotiate a PASA (Participating Agency Service Agreement), which would provide the funding for the program. We had to negotiate project agreements with Country- Specific Plans for each country in Africa. This would require an agreement between the US Government and each of the Ministers of Health of those countries to do the program. We had to develop a training program for the new employees to begin in July; it had to include language training as well as epidemiology and technical matters. We had to develop needs and specifications for all materials that would include quantity and quality and develop the Requests for Proposals (bids) for the equipment. We had to develop a comprehensive Manual of Operations, both technical and operational (which WHO latter took and issued it as though they had written it!). We had to develop the knowledge required to write individual country agreements that would be negotiated and signed by the host countries. All of this went on simultaneously. And we did it! I think D.A. came around relatively quickly to understanding the need for the Operations Officers. He and Henry Gelfand, who was one of the other physicians in the office then, did a fair amount of interviewing physicians. Not only were we looking within the current EIS class, since we had the opportunity to get the young docs who came to CDC as an alternative to serving their draft time, but we were also looking outside of the Commission Corps. I might add that we got some very outstanding physicians that way. Don Hopkins [Donald R. Hopkins] was an individual who was hired as a physician from outside of the EIS, a direct hire. We also hired several more experienced physicians who went overseas. In most countries, the model was to have a physician epidemiologist and an Operations Officer. In a few of the smaller countries, the physician epidemiologist served 2 countries with an Operations Officer in each country. In Nigeria, because of its size and complexity, in addition to the headquarters office in Lagos we had multiple docs and OOs. Harden: My understanding is that there were an awful lot of details regarding the equipment that had to be used in the project. You had to deal with trucks, with doing procurements for trucks that were U.S.-made, getting them rigged up to have refrigerators for measles vaccine. Can you tell me about what all you had to do at this time from that standpoint? Griggs: Well, we had the benefit of a little bit of history of this. To backtrack 1 second . . .When measles vaccine was first in the process of development at NIH [National Institutes of Health], the Minister of Health from Upper Volta came over on a leadership grant visit. He was being shown the measles vaccine, and he said, "Measles is a major killer of children in my country, and I would like to offer my country as a place to field test the measles vaccine for you." So in '63 or thereabouts, the USAID signed a project agreement with Upper Volta to go out and do several hundred thousand measles immunizations. CDC was asked to provide an EIS Officer to work with Hank Meyer of NIH as an advisor in the field for this team. USAID provided some trucks and the Ped-O- Jets (foot-operated hydraulic instruments that give an injection of the vaccine) to use the vaccine with; Merck, which had the measles vaccine, provided the unlicensed vaccine. And the program went to Upper Volta. The first year, it was more successful than expected. I think they did about 700,000 vaccinations, and the next year the measles incidence in Upper Volta just dropped off to practically nothing. So the surrounding countries said that they would like to have a measles program, and USAID was negotiating to do that. They asked for 3 or 4 EIS Officers, and the program was expanded to 2 or 3 countries. The second year, they did not do the program in Upper Volta; they did the surrounding countries. The third year, Upper Volta got measles back-right back where it was to start with. So it was known early that in order to be successful in measles, it was going to require a fast-hitting, multiple repeat because the birth rate was so high that you built a new supply of susceptibles each year. So the reason the smallpox program actually came into existence was that USAID come back to CDC and said, "We would like to have a major measles program, and we need 20 EIS Officers to be assignees to work with these countries on doing this." And D.A. picked up on this and said, "Measles is going to be a never-ending problem." So D.A. proposed the business of adding smallpox eradication to this measles program for West and Central Africa. The idea of pushing for a global smallpox eradication program had come up in WHO [the World Health Organization]. And this part of the world was probably going to be the toughest to try to do it in. So it was proposed as a 19-country program, starting in Congo, and over to Chad, and Central African Republic, the whole West and Central Africa. That, USAID would consider doing. We were putting together this proposal as to what it was going to cost for such a program-this was the project agreement proposal that I was talking about earlier. For that proposal, based on what information was available from the old measles program, we had to determine what kinds of vehicles were going to be required for each country, what kinds of vaccine, how much refrigeration space, the whole bit. This was all calculated into this project agreement for each individual country. It totaled up to a $46 million, 5-year eradication program for smallpox and control of measles in the 19 West and Central African countries. Subsequently, the other, 20th country was added, which was Fernando Po, which became Equatorial Guinea So we did our best guess as to needs on the basis of the life expectancy of the trucks, in terms of replacement on a 2-year basis; the life expectancy of the Ped-O-Jets; etc. All of this was listed by country. We started with 16 countries the first year. The second year we added 3 countries, Sierra Leone, Guinea, and Liberia. The third year, the 20th country was added. Harden: When you had to estimate the life expectancy and plan for the budget, were you correct? Did the items last that long, or longer, or not as long? Griggs: Well, we had some problems with vehicles that had not been expected. The Dodge truck was the vehicle that was chosen by bid. Bids were requested from Dodge, GMC, and Ford, and Dodge won the bid. And it was an eminently suitable vehicle. I was familiar with Dodge and was pleased that they won the bid. But we ran into the difficulties with the roads. This truck, being a long-bed crew-cab, had a lot of weight on the 2 axles, so a lot of axles were broken in Africa. And while we sent over with each truck each year a best guess as to what was going to be needed for repair, replacements to keep the vehicles running, it soon became apparent that we needed a system that would provide rapid turnaround in emergencies because if a vehicle was down, everything came to a stop. So we negotiated with an Atlanta Dodge dealer, a parts replacement general contractor, on a task order. We could just order what we needed, and it would be air- freighted to Africa. We would get a cable saying, "Gotta have this," and that day it was ordered and put on an air freight shipment. And it was usually in Africa in about a week, 10 days. Harden: And who actually did the replacement of the part? The Operations Officer? Griggs: Yes. But I'm getting ahead of myself a little bit. Going back to the spring, when we were writing these agreements, we actually had people start in late spring-Henry Gelfand, for example. And George Lythcott, who was a doctor working on a program in Ghana from NIH, was selected as the director for the regional office to be established in Lagos. Mike Lane [J. Michael Lane] and a couple other people were visiting the countries, negotiating project agreements, explaining the program, moving towards getting signatures. After the participating agency service agreement had been signed with USAID and it was a pretty sure bet that we were going forward with this, we started recruiting people and started security clearances on doctors and Operations Officers. They were to report to Atlanta the first of July to go through the EIS course, which was normal training for that period. And then these recruits were to stay on for an additional training course in smallpox activities, in which there was a mechanic's course. It was lengthier for the Operations Officers, with a shorter version for the Medical Officers, to learn all about these Dodge vehicles and how to repair them. Now, keep in mind that the repair of the trucks was the responsibility of the host country. I mean, their facilities, their mechanics, supposedly. And they had had some exposure to Dodges, but not a lot. But the Dodge turned out to be a very good vehicle. I was last in Africa shortly after retirement in 1989, in Togo, and I saw 2 of the Dodge trucks that had been there. The last one was probably sent to Africa in '70 or '71. And in '89, 2 of them that I saw out in the field were still running. Harden: Let's talk about going to Africa. Being the headquarters operation, you had to help all these people get settled in all these different countries. How did that work? Griggs: After the decision was made to have a regional office in Lagos, we were going to send 9 people there. We had a young, not brand- new EIS officer who was going to be the epidemiologist. George Lythcott was going to be the director. Jim Hicks [James W. Hicks], a senior Public Health Advisor, was going over as the administrative officer. Bill Despres [William Despres] was the assistant administrative officer. We also had a Muriel Roy, a US secretary, Gordon Robbins, as a health educator and Nat Rothstein [Nathaniel Rothstein] as a virologist. We were going to be there primarily to work with the vaccine production facility, to develop a creditable one there in Lagos to make smallpox vaccine. We also had a statistician, Davis [Hillard Davis] and Bill Shoemaker as an equipment specialist. So 9 people were sent there. And they were to provide a nucleus of expertise. They could rapidly get from Lagos to the surrounding countries in those various areas statistics, senior epidemiologic skills, or an administrative function, or whatnot, rather than trying to have all that kind of expertise in each country or from CDC. I first went to Africa in the summer of '66, with responsibility for working with the Department of State, embassy, and USAID, in terms of lining up office and housing space for the regional office people. We located offices, prevailed upon USAID to sign the contracts for the offices and houses. An activity out of Washington, called the regional office, had the responsibility for several of the smaller countries. So really all of the administrative sorts of activities were handled by the embassy, on agreement between USAID and the embassy and those countries. Providing office space was the responsibility of the host country, and they actually had an office in the Ministry of Health, or in an appropriate health building with the Ministry of Health. And the housing was provided by the US Embassy on a contract basis. Harden: And that worked out okay? Griggs: Worked out fine. Harden: In 1966, D.A. Henderson moved to Geneva, with WHO, and Don Millar [J. Donald Millar] came back from London to take over, is that correct?. Griggs: Don had been at the London School of Tropical Medicine, getting a degree, and he came home in the summer of '66. Don was missing during most of the preparation for the smallpox program. He got back just as we were getting folks to start. Harden: And I have a quote here that you said to him, "Welcome to the NFL." You want to explain that, and talk about how it was to shift from 1 leader to the other leader? Griggs: Well, Don and D.A. had a considerably different management philosophy, I guess you would say. I didn't know Don. I may have met him, but I had not remembered meeting Don until he showed up at the office coming back from England. We hit it off quite well. Don was completely unexposed to the operations office or the Public Health Advisors, but he quickly saw their value and was a champion of the Public Health Advisor throughout the remainder of his career, even after he became Director of NIOSH. So after Don came in, the program was moving right along, in terms of the training activities; project agreement signings were slow. We had planned on sending the first people to Africa in September to get things kind of on the road at the end of the rainy season and be ready to start at the beginning of the dry season. The last pro-ag [USAID term for a project agreement] was signed, I think, in March of '67. There were considerable delays in getting all of these, and there was some very fancy footwork involved in getting pro-ags signed. It's too bad that George Lythcott's not here. George was a master at getting things done in Africa. I won't say how, but he wound up getting an appointment with the head of the government of Nigeria at the time after the coup. And he got a commitment that the pro-ag would be signed, and it was signed. That was the big one, with the regional office going into Nigeria and the 3 or 4 regional assignments within Nigeria. And because of its size and complexity, northern Nigeria had a Medical Officer and 2 Operations Officers. It had a male and a female Operations Officer, the only female Operations Officer we had, because of the expected difficulty of working with purdah, in terms of getting the women vaccinated. And it worked out quite well. Harden: What was her name? Griggs: Vicky Jones [Clara Jones]. Harden: Were there any unusual occurrences that you can think of that you can tell me about? Griggs: There were so many things that were happening. We had some problems with 1 individual, I recall, who had difficulty with a security clearance. He never got it cleared, so he was very unhappy. The people who were sitting in Atlanta with families, living in temporary quarters, and being delayed about going overseas, were considerably unhappy. Harden: And this was all coming back to your desk? Griggs: Mine and Don's. For the docs, it would go to Don, and Don would come to me. If it was the Operations Officer, he'd come to me, and then we'd try to get it resolved. Don and I went to Nigeria, for a meeting-it was after the program had started. The folks who were in Africa came to it, and they were less than happy campers, I guess is a good way to describe it. For a variety of reasons. During the training session, because of the cross-cultural problems they were going to be facing, we tried to give some insight into the things, the do's and don'ts, or at least, "Think twice before you do it" type things. And I remember very vividly, one of the wives who had been aghast at the thought of having a cook, a nanny for the kids, a gardener, and a night- watch person, and maybe a small boy for the kitchen, depending on how many kids they had. This was the typical number of servants a family would have. She didn't want that. But when she got to Africa, she was very unhappy because she was in an apartment. (We lived by the ground rules that the American embassy had, that folks with no children and single people were usually put in flats and apartments. If possible, families with children were given a house with a yard.) So when Don and I got to Yaounde, this woman was very unhappy because she was in an apartment when other folks had houses. So the uptightness about the ugly American with hiring the people and going to the market and sending the local hire to the market to buy food and whatnot, and not shopping for themselves, soon became a thing of the past. People realized that they just couldn't cope with that kind of activity. Harden: Very interesting. What was the toughest problem that you recall in this whole endeavor? Griggs: Oh. I hadn't even thought about that. I guess what caused the most consternation were the delays in getting project agreements and getting people out there, ready to go. Harden: So the beginning was [the hardest?] Once it was going, it was [ok]? Griggs: As you can imagine, people have a tendency, if a program says they're going to do 300,000 vaccinations, to want 400,000 doses of vaccine because they're going to have some loss at the end of the day. (Vaccine that is opened is discarded at the end of the day.) So they ordered more vaccine than they needed. Or some didn't order enough vaccine. It was a problem trying to second- guess people in the field, or respond back and forth to people in the field about what the realities of the program are. For example, you've got to have the vaccine, you have to discard it if it's at the end of the day, but if there are only 2 people left and you're going to be there in the morning, you don't necessarily open a large vial of vaccine to throw away-that type deal. And the business of getting the parts. Having been in the field myself, I know it's never fast enough. "How come I didn't get it yesterday?" is the attitude. So there was a certain amount of confusion and consternation constantly. But the program had a budgeted cost of $46 million. It was completed at a cost of just over US $30 million-largely through some good work on the contract officer's part, being innovative and looking at alternative sources for things. So it was $16 million under cost, and it was completed in West and Central Africa a year ahead of schedule in terms of smallpox eradication. Harden: That is an amazing story. Tell me about the bureaucratic relations between headquarters in Atlanta and the regional office in Nigeria, in Lagos. Griggs: Sore point. The regional office was designed to start with as a resource of experts to be available for the countries. I wasn't involved in recruiting George Latchet, so I don't know what was said to him. George felt that the regional office was the director and that Atlanta was to provide support to the staff in the Regional Office. This misunderstanding was resolved, I think amicably, and George stayed through to the end of the program, and I think he was satisfied. He would have much preferred to have been running the program, but I don't know how to say much more about it than that. Copies of memos and reports went to the regional office so that they were aware of what was going on, but things did not go through the regional office to be signed off on. Dave [David Sencer] just walked in, and I 'm sure that he may have a different story about this regional office conflict, but it was resolved. People were not ecstatic over the way it resolved, but the program operated. Harden: If you were going to undertake the program again, would you do anything differently? Griggs: Knowing what I know right now, I might do something differently. Not a lot. This doesn't sound right coming from me, but we didn't make a lot of mistakes in the smallpox program. Things were thought out, were worked out. We had a couple of people who I might not have recruited, but we didn't bring anybody home for improper action, or for not doing their job. And to have had 46 people in the field at 1 time-and overall, I've not even looked at the number, but probably with replacements, probably 60 or 70-people overseas-and not to have had somebody that didn't work out? We had a medical evac [evacuation] or 2, now. But I 'm talking about bringing somebody home for either being unable to carry out their work or the host country's saying, "Get this guy out of here"-that just didn't happen. Harden: That's also very impressive, is it not? Did you ever have any doubts that the program was going to be a success? Griggs : No, none, after it got off the ground, in terms of smallpox eradication. Success in terms of measles control? An awful lot of people thought it couldn't be done. It was proven that it could be done with the right kind of input. Bob Helmholtz [Robert C. Helmholtz] ran the program in Gambia out of Senegal, and Tom Leonard [Thomas A. Leonard] doubled with Bob in Senegal for a short period of time. Tom was in Mauritania, when the '68 conflict occurred there, and the US Government left. Tom went and finished his tour in Senegal, but The Gambia had a good person who was in charge of the program, had a Minister of Health who was very much in favor of this. It was a small enough country, and while it was had poor roads, it had a river that ran through the middle of it, and you could get up and down the river. And The Gambia interrupted measles transmission and kept the country measles free for a couple of years. So it could be done. But it required an awful lot of effort, and I don't think Africa was ready for that effort. But smallpox was a success. Harden: How did you all, in headquarters, deal with the feedback you were getting, in terms of your conversations? The feedback from the people on the ground, and what you then said back to them? Griggs: There was a weekly newsletter that went out to all the field staff, which was kind of folksy. It originated in Atlanta. Don dictated material for it, and I added to it. It covered what was going on, what the problems were, what some solutions to problems were. There were lots of phone conversations. In those days, you connected to French West Africa through Paris, and English West Africa through London, with a radio call from there on down. So you started out with a voice that they could hear at least 2 floors above you, to build up impetus on the radio, and after a long conversation you almost lost your voice sometimes. Harden: What do you think that the Africans learned about CDC and about America from this program? Griggs: Some of them already had exposure to CDC. They had been CDC EIS officers in with the measles program a little bit earlier. The Operations Officers were told that their responsibility was to get the job done, but not to do it. If you do it, if you're out on vacation or out sick, things are going to go to hell in a hand basket quickly. So while it's much more difficult to train your counterpart to do the work, it's worth the effort if you want something left when you are not there. And you could very quickly see the difference when this philosophy was accepted and followed through on, as opposed to when work was done directly by the Operations Officer. Harden: So that was a legacy, then, that was left from the program? Griggs: That was a legacy that was left. To each of the training programs each year, we brought a cadre of docs and nurses. Now, Africa had a few docs, but most of the actual field activities of the program were carried out by nurses or kind of an African Operations Officer, if you want to call them that. A group of those came to Atlanta each summer-probably at least 100 people over the 5 years. The last year of the smallpox program in Africa, when the CDC people were brought home, was '71. USAID wanted to follow up with a program for childhood immunizable diseases. Such a program subsequently came to CDC, through a participating agency service agreement. And the activities, the countries that were involved in this were virtually the same as those involved in the smallpox program, with some expansion into eastern and southern Africa. So, all in all, I would think that from the standpoint of foreign relations-forget about the health aspects of it-the money spent on the smallpox program was probably better or equal to anything that was spent otherwise. In the 20 countries, there were a lot of coups and counter-coups, changes of government, and a civil war in Nigeria right in the middle of starting the program. And no one was evacuated except the team that was in eastern Nigeria. But in terms of a coup and a change of government, the smallpox and measles program proceeded as if nothing had happened. Harden: What impact did the program have on your career? Griggs: Hard to say. I guess it was probably good. Dave Sencer came in as the Director of CDC during the program, and I could have said this better if he wasn't in here, but I'm going to say it anyway. The smallpox program was accused of being Dave Sencer's pets, the fair-haired boys, but I might add that when Don and I, or subsequently after Don, when Bill Foege [William Foege] and I went to Dave and laid out what we needed, Dave bent over backwards and gave us what we needed, to the extent possible, and it was sufficient. Harden: Did this program have any impact on your family? Now, you were here in Atlanta primarily; you visited Africa but you weren't living there. But how did your family think about it? Griggs: I had a good wife, who understood being gone 3 weeks at a time. George Lythcott tried his damnedest to recruit me to go to Africa, to the regional office. And I turned him down. And obviously he had talked to D.A., and maybe to Dave, and I think they turned him down. Other than being away from home a short period of time, while I was in VD, I was home on weekends. But I traveled more days when I was working the 50 states than I did when I was working Africa. Harden: Did any of your children go into health-related work? Griggs: No. Harden: Not a one? Griggs: Not a one. As a matter of fact, my son may have had a negative impact from this. He was, I think, pleased with the work that I was doing, but he was adamant that he did not want to work for the government. I don't know who brainwashed him. Harden: Very interesting. Is there anything else you can think of about the program that we should capture in this interview, before we stop? Griggs: Well, I'm sure that Don Millar and others will say it better than I would, but the things that were really learned about doing immunization work from the smallpox program, in this country as well as other countries, have made a big impact on US activities, as well as on international activities in other countries. Obviously, D.A. was head of the smallpox program in Geneva. West and Central Africa cleared up right quickly. It was obvious that some problems were occurring in India, Bangladesh, and other places. CDC people from the West Africa program went overseas into many of those countries, to either get them kick- started or to stay there and wind up. In Bangladesh, India, Andy Agle was in Afghanistan, so it was a maturing of CDC's international venture, I think. While CDC is a domestic organization, when I left CDC we had people assigned in probably 25 or 30 countries around the world, through WHO or through other avenues-the World Bank, UNICEF, etc. And this has contributed, in my estimation immeasurably, to other health activities. I think the Gates Foundation's work in international health goes back to the smallpox program. Bill Foege was a missionary in eastern Nigeria, and I guess was happy when we recruited him to be a contract doc for eastern Nigeria for us. And when he was evacuated, we brought him back here, and he became one of the lead people in smallpox. When Don left, Bill of course became the director. Went back to India for the wipe- up on that. I'm sure, no question in my mind, that the Bill Gates Foundation would not be doing what it's doing, if it were not for Bill Foege. Harden: Thank you so much for speaking with me. ### </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/u3ZkP0e4TzI" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2006-07-07 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/15n65 emory:15n65 Subject The topic of the resource CDC Smallpox Eradication USAID WHO Operations Officer Format The file format, physical medium, or dimensions of the resource 13350960000 bytes video/x-dv Creator An entity primarily responsible for making the resource Harden, Victoria (Interviewer) Griggs, Bill (Interviewee); CDC Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource GRIGGS, BILL Description An account of the resource Bill Griggs started his career as a Public Health Advisor in the Venereal Disease Program of CDC. He became known as a person to turn to in order to get something done. When the Smallpox Eradication effort began he was assigned to recruit people to act as Operations Officers, a concept that was new to international health programs. Bill was Assistant Director of CDC for International Health at the time of his retirement. Language A language of the resource English https://globalhealthchronicles.org/files/original/189c6990eb95656e8ffa65d0f8bb8ee1.jpg fc484870df069fb62562aa7cae6e7ba4 https://globalhealthchronicles.org/files/original/03c080dab62178c653cac747f195f221.pdf 8b86e28aa2301d6f1ecb3e5fcd68ad68 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> Interview Dr. Mary Guinan | with Interviewer Melissa McSwigan Transcribed: January 28 2009 | Duration 0:54:36 Melissa McSwigan: This is an interview with Mary Guinan on July10, 2008 at the Centers for Disease Control and Prevention in Atlanta, Georgia, about her involvement with the Smallpox Eradication Program. The interview is being conducted as part of our reunion, marking the 40th anniversary of the program in Asia and East Africa. The interviewer is Melissa McSwigan. Now, with this interview, we are hoping to capture for future generations the memories of participants and their families involved in eradicating smallpox from Asia and East Africa. This is an incredibly important and historic achievement and we want to hear about your experience. I have some questions to guide you, but please, feel free to recount any special stories or anecdotes that you remember about events or people. So you sign the legal agreement which says that you were donating the oral history to the U.S. Federal Government and it will be in the public domain. You will have a chance to edit the transcribed interview and add or delete information as you see fit before it is made public. So at this point, I'm going to ask you to state your full name and that you know the interview is being recorded. Mary Guinan: I'm Mary Guinan and I know this interview is being recorded. Melissa McSwigan: Okay perfect. Could you maybe start out by talking about how your education and upbringing led you into working in Public Health? Mary Guinan: Well-I'm not sure how my education and upbringing brought me into Public Health, but I'll tell you how I decided that I wanted to be part of the Smallpox Eradication Program. I was born in New York City, a child of immigrants. My parents were immigrants from Ireland. They were farmers. They had maybe three years of education, 3rd Grade education level and they came to follow the American dream. There were lots of political persecutions in Ireland and they were - and it wasn't a good time. So they met on a ship coming here. Neither of them knew anyone here in America and they established a presence in New York. My dad worked with the Subway, the New York City Subway System. My mom had a job as a dressmaker I think first, and then she was working in a house as an Assistant to the Chef, in a house in New York. Many Irish women came to America worked as servants or assistants with large wealthy families and that's what my mother did; and they eventually got married years later - five years later. The Irish were very slow at this. I grew up in New York City and they believed in education. They believed that that was the way to move ahead and they loved this country because of its freedom and lack of persecution for your political views and they were very, very - they were very loyal Americans and felt that this was really an important place to be and that we should be grateful-I was the middle of five children- we should be grateful for being born in this country and for exactly what we had available to us. So when I was a young teenager my dad died very suddenly and my mother had no means of support and we all got jobs to work our way through school; and I worked my way through school and graduated from high school. I worked my way through college. I wanted to be a physician, but women weren't being admitted to medical school then; and also, one of the criteria for medical school was that you had to have money to pay for it; and there weren't scholarships available or other things available to students like me who really didn't have the means to do that. So I decided then that I would pursue other things. I majored in Chemistry in college and when I graduated, I couldn't get a job because they didn't hire woman Chemists. So I was interested in - I got a job in a Chewing Gum Factory... Melissa McSwigan: Really! Mary Guinan: ...making chewing gum. It was the American Chicle Company and they made Chiclets and all sorts of chewing gum. Black Jack chewing gum was one of them and I was the Flavor Chemist. I was hired as a Flavor Chemist so part of my job was making new flavors, developing new flavors of chewing gum. It was not terribly rewarding kind of existence, but there wasn't really much available for women then and I try to look for fellowships and I applied to many schools, to graduate school, and I was rejected mostly because I was a woman; and if I was accepted, I couldn't get a fellowship program because they didn't give them to women at that time. But at the time the Space Program was in full bloom and with Sputnik, President Kennedy had said we wanted to be on the moon; that we were going to the moon; and there were lots of became-available fellowships for scientists. They wanted scientists to be in the Space Program and I've decided that I wanted to be an astronaut. So I found out that the University of Texas was where the Space Program was, near NASA in Texas, Clear Lake City, but the University of Texas Medical Branch in Texas had a program for scientist in Aerospace Medicine and that the Director of the Medical Program, Chuck Berry - Dr. Chuck Berry, had an appointment at the University of Texas there. So I applied there to get my PhD in Physiology and Space Medicine and I wanted to be an astronaut. Of course I didn't tell anybody then that I wanted to be an astronaut because women didn't do those sorts of things. So I went to Texas and people in New York said: You won't last there-about six months. You know you're a New York person born and brought up in New York. But I did, I lasted four years and I went to NASA. I applied - all of my class in physiology and space medicine there at the University took a test for the Astronaut Program and I was the only woman who took it and I was the only one who passed the test. The reason I passed the test was I had 20/20 vision; and all the other people wore glasses. I mean that - and you also had to fit into the capsule. It was like the old days of being a flight attendant, you had to be a certain height and weight and not wear glasses. But I knew that it was unlikely that I was going to be an astronaut, that there was a great deal of competition for it. So I finished my - but I got to see all the astronauts, I took classes at NASA. The astronauts, you know like John Glenn and Neil Armstrong gave classes and talked about their experiences in space. It was really exciting; I was really excited as a Scientist; and I did a post doctoral fellowship; I got a Post Doctoral Fellowship at the National Institutes of Health in Bethesda, Maryland; and it was during the Vietnam War and I actually had gotten a place that was for a man who had been drafted. So I filled in and I knew that I wouldn't really be there very long because they saved the places for men who had been drafted and had gone to war; and it was very difficult for me to get a job at NIH because I didn't have an MD degree, and my mentor there at NIH said to me, "It would be so easy to get you a job if you had an MD." You know, this is always the case, you know, if you just did this, you know, we could get you a job. So I applied to two medical schools. Since I was living in Maryland, I applied to the University of Maryland to Johns Hopkins; and I got rejected from the University of Maryland and accepted at Johns Hopkins which tells you something about the crazy system we have about being accepted into medical school. I was very grateful because I was sort of an alternative student. I didn't go from college to medical school. I had done this detour and had been in Texas which most people think: What in God's name did you go to Texas for? In Texas, people said, "What is this New York girl doing in Texas?" So I think one of the presumption was I try and find a rich husband, you know, a Texas oil man or something and that was the assumption-there weren't very many women doing graduate work. So I went to medical school and I graduated from Johns Hopkins in 1972 and during that time period, I was continuing my career, I had done my PhD, my doctorate in physiology in the area of blood coagulation and I was wanting to continue my career and be a hematologist, oncologist, and go in academic medicine. That's what I thought I would want to do. Never thought about public health, didn't really know about public health. I went to medical school at Johns Hopkins where one of the premiere Public Health Schools in the nation is, and took courses but really had no interest in public health at that time. But I was interested in tropical medicine and I did a tropical medicine fellowship in Mexico during my senior year at Hopkins and was interested in tropical medicine. Then, as I was graduating, this was the end of the 60's and beginning of the 70's and what happened during my last year of medical school really changed my life, in that what happened was Kent State happened. People were killed for demonstrating. This is a free country, our Government. The United States Government, which I was very proud of being an American and was very, very upset about what happened in the anti-war demonstrations that went on; and then these students in Kent State were killed, unarmed students, by the National Guards that had been even called out. People killed and I thought: What has happed to this country that I live in? How can this be-that we're living in this country where they're killing unarmed demonstrators? Our whole history of our country was revolution and fighting for freedom and doing what we thought was right. So what happened was I decided I wasn't sure what I was going to do and so in my senior year I read in this magazine, sort of like a magazine at Hopkins about the Smallpox Eradication Program. That there was this idea to eradicate smallpox in the world and I thought, "Isn't that wonderful? What a great idea that we could eliminate a scourge. It would be the first time in history that by the design of man or woman, there would be a human disease eliminated from the world and smallpox, a very frightening disease." But you know, I just thought that, "Isn't that a wonderful idea?" I didn't really think about it much. Then after that Kent State and I started doing my internship in Internal Medicine with the idea that I would go on to be a hematologist and do a fellowship in hematology, oncology; and as I was going, during my senior of medical school, I was on the clinical service with someone who was going to be an EIS Officer at the CDC. I had no idea what an EIS Officer was and he told me that it was the Epidemic Intelligence Service at CDC. I said, "What's that?" He said it was a two-year program and you go there and you learn how to be an epidemiologist, which I really didn't have any interest in. Then I saw this other article in the Hopkins Journal Magazine. You know, they have an internal magazine, about this Smallpox Eradication Program worldwide, and how our Government was participating in it, our Government. So I thought, "Wouldn't that be wonderful to be part of a Government Program that was really doing something wonderful?" Then I found out that the people who were going were being assigned from CDC, so you had to come to CDC and somehow get a job at CDC and then you could be assigned to the Smallpox Eradication Program. So I talked to my friend at Hopkins about this program and he said, "Yes, it's EIS Officers who were going over there on the Smallpox Eradication Program." So I applied to the EIS Program and in 1973 I guess, I was accepted; and I came to interview and I was the only woman physician in my class that was accepted, and during that time, when you are hired at CDC you are hired in the commission core of the public health service which was an alternative to military service and the draft was still ongoing. So people would say, "We're not accepting women here because if we do, another guy has to go to Vietnam. So we're not accepting women." During the interview I was told this when I came to CDC for the interview. So I wasn't sure that I would be accepted, but I was. I don't know why, but I was. I was accepted into the program and so I came as an EIS Officer. I was assigned to hospital infections that's in bacterial diseases then and I would go - we used to have a Tuesday morning seminar in Auditorium-B every week for all the EIS Officers and we'd attend this meeting and there'd be announcements at the beginning and every time somebody from the smallpox program would go up and say, "We are looking for volunteers for the Smallpox Eradication Program." You know it was a three or four-month assignment in India now was the part; and I applied to go and they told me, they were not taking women. Now, Indira Gandhi was the Prime Minister of India so it's like to say, "Well, how is it possible?" That was the first round and then each week, you know, they'd have somebody and finally, Phil Brachman was head of the EIS Program and I said, "You know, I keep volunteering and I keep getting turned down, but I don't know why. Can you tell me what the criteria are?" So I think they thought I might make a fuss because I actually had made a little bit of a fuss although I didn't think it was a big deal, but everybody else thought it was a big deal. When I applied to the EIS, I was accepted, but we had to get three references from physicians who knew us, and they sent me the reference sheets that had to be completed and it was: "Will you please rate this candidate on his background on his - whatever he does and is he a leader? Is he going to..." You know, there wasn't a parenthesis with "she" and so I sent back the forms, I said, "I'm sorry. I'm a woman. Do you have forms for women?" and apparently that caused some issues here at CDC before I arrived, so they figured, "Oh, oh-this is trouble coming." They wrote back and said, "We do not discriminate, but we don't have any female forms." So, they crossed out the "he" and put "her" and "she" in the appropriate spots. So when I came, I think that there was an idea that maybe - feminism was just sort of coming into existence. It really didn't exist until later; it was funny. So there was this worry I think so finally, they said, "You're going. You're going to India." So I went in December of '74 through early May of '75. Melissa McSwigan: Okay. So that was about six months that you were in India? Mary Guinan: Probably less-somewhere in there. Melissa McSwigan: And what was your exact role while you were in India? Mary Guinan: What our roles were was that we would be assigned to a district, some district area that - and you did surveillance for smallpox, looked for smallpox cases and then if you found one, you quarantine the case and then surrounded it with a ring of immunity in a five or 10-mile radius around because smallpox spread locally; and this have been demonstrated in India, actually Bill Foege who really was a person who worked this out and really is probably one of the people responsible for the eradication of smallpox. Because he was in Africa and he probably told the story and you've heard it, but they would have a shortage of vaccine and they tried to figure out how to use it appropriately and they theorized that smallpox spread locally. So what you need to do is to surround the populate of the infected person with a ring of immunity and then it won't spread because it only spreads from person to person. There's no environmental reservoir for smallpox. Humans were the only source of smallpox; so you would find that - that was funny. Anyway that's what we had to do and we would be assigned. When I arrived at my destination, we first went to Geneva. On our first assignment, we'd go to Geneva and we met all the people who were being assigned; and I went with Walter Einstein from CDC who you probably will be interviewing too. He and I were both from New York City and we were assigned together to Uttar Pradesh; and then we were assigned to go to Uttar Pradesh. So we were in Geneva and then we were sent to Uttar Pradesh and there were still smallpox in Uttar Pradesh. There were two provinces in India, Uttar Pradesh and Bihar that still had smallpox. So it was like a competition between Bihar and Uttar Pradesh; who would come first down to smallpox zero? What we'd do is, we would go out into the field; we would go and do surveillance. You were assigned a driver and a paramedical assistant and then you were given all these traveler's checks like in Rupees because you had to hire people, and you had to pay them. Then I would go to the bank and cash these checks so I'd have lots of money to pay people to immunize. You had to get vaccinators. You had to get people to work for you. I didn't realize what the whole system was in India, but since my driver and paramedical assistant had been working, and my paramedical assistant was Shaffy[0:22:56] Mohamed, he was a Muslim, and my driver was a Hindu, and they spoke different languages actually. Shaffy spoke English perfectly, but his native language is Urdu not Hindi, so that we had this three way thing going on trying to communicate with Urdu, Hindi and English. I didn't speak any of either, but I learned to read the Hindi symbols so I could read the road signs and they were very small - rarely was there a road sign, but if there were, the driver couldn't read, so I would phonetically sound the symbols so I could tell which way the direction was pointing. I would say, "Kahnpour[inaudible 23:44]; that way, okay this is where we want to go." The paramedical assistant acted as your interpreter, your cook. To find a place to stay, we were issued Tenson[0:24:10] sleeping bags and these mattresses. You know, thinking about India, I thought it would be very hot and didn't bring any warm clothes, but Uttar Pradesh is up North near Nepal and it got very cold. It was three degrees (3º) centigrade when I arrived at the Delhi airport and it was cold. So I had made a quilt, so I would wrap it around me because I didn't have any warm clothes. We would go out and we would offer a reward; we'd go like to a village and the paramedical assistant would get up and say to the villagers, they had never seen a foreigner before so I was a great source of interest to people like: look at me, this is incredible.. This is an area of Uttar Pradesh which was 99% illiterate. They had never seen a foreigner before nor heard of America; and very often if we went to a Muslim village the women wanted me to come into their house because they didn't come out; they lived in - it was a part of their practice. So they always wanted me to come in to their house, their little mud hut, but they wouldn't allow my paramedical assistant in because he was a man, so I would go in there and we would do sign language. They couldn't understand; you know: Where were my babies? What was I doing there? I soon found out everybody - most of the women were pregnant, they had babies every year and while I was there, there were several babies that were named America because they heard this word America. They had no idea, they didn't have a concept of another language or another place; and if they asked my paramedical assistant where I was from, he'd say, "Oh, she's from the capital, Lucknow" Because they had no concept of another country and languages but they couldn't understand why I couldn't understand them. So it was that interesting. We would go to the village and we had these picture postcards that showed cases of smallpox and we would say, "Ten Rupees to anyone who can show me a case of smallpox" and it was increasingly - 10 Rupees was a lot of money then for the average person. So if there was smallpox in the village they would bring you to the person. Very often it was chickenpox, not smallpox; or something else. It wasn't smallpox; and you were supposed to be the expert, not having ever seen a case of smallpox, it was like strange to think that you were going to be the expert and tell whether this was smallpox or chickenpox. Of course we were taught at all of these training sessions how to do it. So we heard about a report of smallpox in a village that was supposed to be free of smallpox. So I was sent there out of my district, my district was Kanpur, but this was outside of my district, a place called Rampur Madras. So I went there and I looked at the case and it sure looked like smallpox to me; and at that time we took a culture of the lesions and put them in a little vial and a mailing case. Then I mailed it off to Delhi and they would either confirm, because they wanted to culture every case to see if it was really a case; but it would take weeks and weeks before the results came back. I declared it as smallpox and so we started our immunization. There were vaccinators who actually worked in all the villages. There's this infrastructure in India where they have these people who are vaccinators; and they could be hired. So my paramedical assistant would just let out the word and people would come and want to work for you because we paid very well. So what we would do, we would pay the people's family to be guards at the door. This is a mud hut in these villages and then we would pay a family member to be the guard at the door and the only people - they'd have to vaccinate them. Anybody who went in or out of the house had to be vaccinated. Melissa McSwigan: So this is the door of the house where the smallpox patient was? Mary Guinan: Yes, the smallpox case. So here's the case: this was a young man and nobody knew where he'd gotten smallpox from and he was a Brahman. The Caste System was a part of what was happening in India at the time although it was banned, it was outlawed, it was pretty much the practice. Everybody recognized - when you went into a village the first thing people asked was what Caste you were; and since I was an outsider, they weren't quite sure how to treat me, and so the Brahman didn't want me to touch him. You see this young man, they are Brahmans; but I interviewed him to try to find out where he got smallpox because he had to have gotten it from another person, and where he had traveled; and it turned out that he had travelled to a village somewhere, I'm not sure where; where he had received the services of a prostitute for his inauguration into his, you know, Right of Passage, but of course, this was not something that anybody could know about. Melissa McSwigan: Right. Mary Guinan: And it was not something that I would be able to track. You know, to find out that case. In fact, they were very vague about where the village was and how it was. So we just decided then to employ a member of the family, it was a father, to be at the door and then we paid a vaccinator to stay there to vaccinate. We paid the parents money to keep the person in the house-keep the young boy in the house and to get food so he wouldn't come out until we declared him to be non-infectious. So we went about, and I found out that when we go to the villages surrounding it, we didn't have maps, it wasn't like you'd say, "Okay let's draw a five-mile radius around this and try and find some maps to figure out what the radius was or how you could do this." So, we got these rather rudimentary maps and we started going to the villages to try to vaccinate. We found out when people would come - we had a jeep, they were Mahindra &amp; Mahindra jeeps I think is the name of them, and they were provided by the Indian Government, the jeeps; and when the jeeps came and the only time the villagers ever saw a jeep come in was when the Family Planning person came and there was a big initiative in India at that time to reduce the population and to introduce birth control, and they used to pay the men to have a vasectomy, gave them a portable radio was one of the gifts that the men would get. Melissa McSwigan: Mmh! Mary Guinan: And then were these - the Family Planning people had told us that they had to meet every month. They had to have so many vasectomies and so many tubal ligations and they were not terribly receptive people so they saw this jeep coming and they thought it was the Family Planning people and they all ran away. So nobody would be there. So we said, "We couldn't find anybody to vaccinate, everybody disappeared." In India, you know, people would disappear and then reappear; it was so incredible the number of people; when you go to India, all you see is people everywhere. There's never any privacy. You go out, you're on this road and you're there in this wheat growing and things, this farm area and you go, and if something happened, if you broke down, my driver would just shout out, and all of a sudden people would appear and they'd come out of the fields, there were people everywhere. They'd sleep in the fields, they were there, but you know, with the heat they'd be hiding in the shade. So the whole idea of us being Family Planning people caused problems for us to be able to do the immunization. So what we decided to do was to do a survey of the town, to get all the names, and this was something that we understood what the people used to do that gave - what the politicians used to do to give resources to a town or village. They would take a census of the village, and the village then - and then take the census of everybody who lived in each house in the village and maybe there were 50 or 60 or 70 houses in the village or less, and there usually would be sometimes 10 or 15 people living in that one room mud hut. So we would just go in and say we're doing a census; and we'd go to the village Elder and talk to him and tell him first that we were going to do the census; and then we would tell him after we did the census when we had all of the - then we would ask the Elder if we could vaccinate the village and why. If the elder agreed then, we could go and start the vaccination. So we would go, but we knew how many people were there. They would all sort of list all these children and you always knew that there was a child every year, so if you had a one-year-old that look like one, you would look for the baby somewhere underneath, hidden in blanket somewhere there was always a baby. So we would find a baby. It was just amazing, we would ask how old people were and they didn't know how old they were. That wasn't a concept to them, the children how old they were. So we would just guess at their ages, and then we would vaccinate them and vaccinate each village until we completed the circuit. Then I'd come back every once in a while to make sure that the guard was at the door. We had these surprise inspections because people didn't really understand what we were doing. They thought, you know: Okay, they're going to give me money for this, I'll do it, but then when I was out of sight, well maybe not understanding why they needed to keep this person inside, they might not, you know - So we would come back regularly to check every two or three days. Sometimes there wouldn't be the guard at the door and we say, "Okay, where is the guard?" and we had the guard and the vaccinator had a book in which he listed all the people he vaccinated so we'd know who were vaccinated. So that was my first start, and it was smallpox and then I kept finding more smallpox cases. Melissa McSwigan: So that was your first case, but there were more? Mary Guinan: That was my first case, and then as we went from village to village, I'd find another one and declare it then, I would culture the lesion and send it off to the post office and this is a big thing to do, to find a post office that would take this and send it off to Delhi. You'd never know if it would arrive there or not, because sometimes they didn't have stamps at the post office so you couldn't buy stamps and it was a complicated system that you had to try and figure out how to ensure that your specimen got sent. So I kept sending them off and then we kept moving around from village to village; and the person who was in-charge of Uttar Pradesh at the time of the Smallpox Eradication Program was Don Francis and he would come to visit. He came down to visit me about a month and two into it. I lived in a mud hut outside and my paramedical assistant would try and find some place for me to live, that would have a shelter; and sometimes we did and sometimes we didn't. It was very cold at night. But there were all sorts of things; there were rats around that really used to scare me. They'd come in and run around at night and the Indians always respected life. So they never killed anything. The Hindus didn't kill anything and so there would be rats. One morning, there was a rat in my purse and I told my driver there was a rat in my purse and he just opened the purse and let the rat out. Okay! So Don Francis came down to visit to see what we were doing because they wanted to make sure, you know I was new, of what you were really doing and actually, I was a woman and they weren't sure women could do those things at that time. So Don came down and he said, "Listen, this place was declared free of smallpox and you are sending off all these sample saying there's smallpox. Are you sure these are smallpox?" I said, "As sure as I can be. I certainly - all I can say is, to the best of my ability I call them smallpox." "Sure they weren't chickenpox?" "I think they were smallpox, it's a possibility that they were." He said, "Are you sure because you're causing a big sensation here. The leader, the Indian Public Health leader in the area was very upset because he had declared his districts free of smallpox and I was saying it wasn't. So that caused a little political problem. Anyway, it was miles and it would take them several hours to come to where I was, and they went back. Then as I moved toward the other villages that were infected in this area, we had difficulty crossing the rivers. There were three rivers - parts of a river that intersected the villages and each time I would have to cross the river; and it was too deep for the jeep to cross it, so I decided the first day we came to this I said, "I'm going to wigan[inaudible0:41:35] and wade across" because the water was the water is about up to here maybe at my waist, and we're going to wade across with the supplies and everybody would wade across. So I always wore pants because showing your legs is not something that the Hindu women or Muslim women do, so I had made a series of Muslim outfits like pants and a long shirt, a Kurta, I think it was called and that's what Muslim women wore. The Hindu women wore Saris, but the pants were much easier for me to work in and I always kept my head covered. I had very long hair then, it was a braid and I decided before I went to India that I would dye my hair black so I wouldn't look so conspicuous. Melissa McSwigan: Did that work? Mary Guinan: No. Well, you know, when the white roots started coming out, they thought I was going grey; and it got streaked as it went, and I'm pretty tall; so I was taller than what most people saw, so I stuck out in the crowd no matter what. So I decided to roll up my pants-now I tell you that showing legs isn't a good thing in India, and there was nobody around, but after I rolled up my pants and started going across the river, a big crowd came out and there was a huge crowd, and I had rolled up my pants and I'd walked and crossed to the other side to get the supplies over, the vaccine, needles and things. Then we went and did the thing and on return I realized that I'd caused some sensation so I just didn't roll my pants up, I just waded across and word travelled fast, who knows how, but it went to Delhi; and people were saying, "Oh, I heard you went to..." Once a month we would have this meeting and Bill Foege would - Bill Foege was the head of the Indian Smallpox Eradication at the time when I arrived, and he would come up from Delhi. He would go to each of the districts once a month, and he would come to Uttar Pradesh one day a week and then we would all come in from the field, there were number of us; and he was the first person that we would talk with, and we'd take showers, I mean I might not have showered in weeks and weeks. So you would stay at the hotel and meet friends, and they would tell you what was happening, and they'd show you how many cases of smallpox there were and how they were decreasing and how close we were to zero- coming to zero in India; and that UP was winning from Bihar. We were ahead of Bihar. So that was a monthly meeting and when I was coming into town, we would stop at the railroad station and I would know whether Bill Foege was there or not because Bill was very tall, he's 6'6", and they would always know when he came from the railroad station. He was here. So they'd tell me, "He's here." So I would know he was at the hotel. People would know you were with the smallpox program and they'd let to know, I mean, word would travel fast and anything I did was reported. People knew what I was doing and all. That was interesting, I didn't do that again. Melissa McSwigan: How would you - let me interrupt you for a second. How would you say that this experience that you had, the six months that you had in India, how would you say that affected your career after that? Mary Guinan: Well, I became a believer. I believed that this was the way to go. I decided that I was going to have a career in public health because it was so successful. I mean, I couldn't believe it, what you were doing and all the things you were doing and all the problems you were having, and you would come, and it's working. It's actually working, so you were reinvigorated to go out in the field and keep doing what you were doing because you can't really see the results and you often see the errors that are made and sometimes things slipped through the cracks, somebody didn't guard the patient, and did they possibly infect someone else and you had a whole trail of smallpox moving about. You're always worried about that, but it worked. So I decided to work in public health-that changed my life. Melissa McSwigan: Did you keep travelling after that? Did you go to other countries as well? Mary Guinan: Yes, I've been probably all over the world. I've been to Asia: Thailand and China, Japan; and Central and South America. I guess the only place I really haven't been is to Eastern Europe. So it was the - during that time it was the Cold War so there were lots of difficulties getting in and out of countries. But I came back and then I left CDC after my EIS program and then was recruited back to CDC, and then I worked at CDC for 20 years then retired. I was part of the First Aid Task Force so I was a trained Virologist and that's how my career evolved. Melissa McSwigan: It sounds like you faced a lot of challenges before you went for the Smallpox Eradication Campaign. Particularly, you've talked a lot about being a woman and how that presented some obstacles as far as getting into school and so on. Did you find that in this particular campaign that being a woman affected the work that you were doing? You talked a little bit about when Don Francis, I think you said, came to visit you, how they kind of doubted maybe your effectiveness? Mary Guinan: Well, they were worried. You know, as I would've been in Don's place. It turned out they were all smallpox. But I think it did affect the people - I think it helped me a lot. People were much more trusting of a woman than a man in that situation when I'd go into a village. Melissa McSwigan: That was as far as the Indians were concerned? Mary Guinan: Yeah, as far as the Indians were concerned. Because I was such a curiosity to them; and also, people helped me a lot. I told you about these rivers. We had problems traversing the rivers and the only way to get across was a boat, a camel or an elephant. So there were always camel drivers and we would just wait until a camel came along then I would rent the camel and then we'd get across; and how I got back from over the other side; we'd hope another camel would come or somebody would show up with a rowboat and would row us across. We'd pay them to take us across. So one day, while we're working in the village, this local Raja Saab they call him came, and he said, "What are you doing?" And I told him what we were doing and he said, "That's wonderful." He said, "Well, since you're having this difficulty, I have an elephant and I'm going to give you an elephant so you can have this elephant to go across the river." So I got this elephant. I mean elephants swim and their wonderful. Camels are nasty and they want to bite you. It's really difficult getting on a camel. They'd turn around and bite you; and the elephant, very sweet and there was a Mahout, an elephant driver, and he said to me, "When the elephant swims over this river, he will take you up in his trunk, so you won't get wet" I said, "No. No. I'm not doing that. I'll get wet-it's okay if I get wet." So when we would go across, he would take the Mahout. The elephant would take - it was a female, she would take the Mahout in her trunk and carry him over, and swim to the other side and then I'd go; and then we'd come back and then somehow somebody would call an elephant. The elephant would come and then take me back to the other side. Of courts Don Francis heard about this naturally, and he came saying he wants an elephant ride. He came down, he says, "I want my first ride." So he got an elephant ride. So I'm not sure, I think this man, because I was a woman, he thought I needed help in getting across and so, he gave me an elephant. I gave it back to him. I didn't take it home. Melissa McSwigan: That would be kind of hard to fit and you're carry- on luggage I'm sure. What would you say is the most memorable moment that you have from your time in India with the smallpox program, the memory that sticks out the most? Mary Guinan: Well the memory is - and the first is the cultural shock of going to a country where you don't know the morays and learning them it's a bit of a - it was one of those culture shocks that it would take years to adapt to, you take these small steps. But I think that the most exciting thing was that it worked and that these monthly meetings that we would go to, we would learn that it was working. It was just - and that whole idea that this is actually going to work. I mean, it's actually going to work was intoxicating. So that was the most wonderful thing about - and the thing I remember, it was effective. Melissa McSwigan: Well, is there anything else that you would like to add, to tell future public health professionals like myself about the time and the program and so on that you would like to share? Mary Guinan: I don't think so. I don't know what I'd say except, an opportunity like this where your Government was doing something and you have an opportunity for public service, it's just - I don't know that I got any better satisfaction of anything I've done in my lifetime, than feeling like I participated with so many other people from other nations to do something that improved people's lives and you had an opportunity, I mean it was a privilege to have that opportunity, so I feel that our government who was doing what I thought, such terrible things, but somewhere there was someone doing this wonderful thing. It was in these rickety old buildings at CDC that nobody ever heard of then, CDC wasn't in the spotlight, and all these Quonset[0:53:41] huts out in [inaudible 0:53:43], that's what people were living in. I mean this is CDC and it was these old Government buildings, but these people planned; imagine, they planned as well. They were part of the planning of this momentous event, and I feel very privileged to have been a part of it. So it was that sense of, I guess, if you have that opportunity to do something that's outside of anything you could possibly do as an individual, do as a team, then that will surely be one of the greatest satisfactions in your life. Melissa McSwigan: Well, thank you very much for your time and thank you for sharing your stories. Mary Guinan: Okay. [End of audio - 0:54:36] </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/nxg5wfuUAtE" frameborder="0" allowfullscreen></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2008-07-10 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/16rrr emory:16rrr Subject The topic of the resource WHO Smallpox Eradication CDC India Format The file format, physical medium, or dimensions of the resource 11782080000 bytes video/x-dv Creator An entity primarily responsible for making the resource McSwegin, Melissa (Interviewer) Guinan, Mary (Interviewee); Epidemiologist Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource GUINAN, MARY Description An account of the resource Dr. Mary Guinan describes her experiences as an epidemiologist in India in 1973. Language A language of the resource English https://globalhealthchronicles.org/files/original/ee0ead593395bd00bb0f24999ae89aac.jpg 9feba0e305076cbf28b12294cf45b79e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Smallpox Description An account of the resource <div class="landing"> <p>Smallpox disease was declared eradicated in 1980, the result of a collaborative global campaign. To date, it is the only disease affecting humans to be eradicated from the world. Global eradication of smallpox ranks among the great achievements of humankind. Gone, through determined human effort, is a disease which has brought death to millions, frequently altering the course of history, and traveling through the centuries to every part of the world.  </p> <p>The vital contributions made by the Centers for Disease Control and Prevention are highlighted. Official government correspondence, meeting transcripts, policy statements, surveillance reports and mortality statistics tell a part of that story. Adding depth to these traditional archives are the personal stories of the public health pioneers who worked tirelessly on the frontlines of the smallpox eradication campaign.</p> <p>The links above connect you to a database of oral histories, photographs, documents, and other media.</p> <p>Use of this information is free, but please see <strong>“About this Site”</strong> for guidance on how to acknowledge the sources of the information used</p> </div> Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Transcription Any written text transcribed from a sound. <pre><strong> Interview Transcript </strong> Interview D.A. Henderson with Paul O'Grady Transcribed: February 2009 Paul O'Grady: This is an interview with D. A. Henderson on July 12, 2008 at the Center for Disease Control and Prevention in Atlanta, Georgia about his involvement with the smallpox eradication program. The interview is being conducted as a part of a reunion marking the 40th anniversary of the program in Asia and East Africa. The interviewer is Paul O'Grady. Can you state your name? D.A. Henderson: D. A. Henderson Paul O'Grady: And you understand that this oral history is being recorded? D.A. Henderson: Yes, I do. Paul O'Grady: Thank you. I would like to start off by having you give us a little bit about your background, what lead you to a career in public health and how you started working for the CDC? D.A. Henderson: Well, I was born and brought up in Lakewood, Ohio near Cleveland. Went to Oberlin College and then to the University of Rochester School of Medicine. After internship at the Mary Imogene Bassett Hospital in Cooperstown, I was told that my deferment from the draft was at an end and I had my choice either to voluntarily enlist in which case I would be a first lieutenant, or be drafted in which case I would be a private. So, like many of my colleagues who had been deferred since, in my case 1946, and this is 1955, I decided I could volunteer. I was having difficulty making up my mind whether it was army, navy or air force. I figured I am just an intern, all I am going to do are boring draft and do physical of new recruits. So about this time somebody shows up from something called the Communicable Disease Center, which I had never heard of. They are from the public health service which I knew nothing about, but they talked about working on infectious diseases which I didn't really much care for. As I thought about it, well it might be two years and I'd learn something, and as they pointed out we don't wear uniforms, we don't salute, you don't do basic training. I go, well, okay, doesn't sound too bad. So I enlisted, in the public health service. Now, this was the Epidemic Intelligence Service which at that time was only four years old. That created by Alex Langmere at the CDC. There were, however, quite a number of applicants every year who were anxious to do their required time and service at CDC would be challenging, interesting, so forth. Well, fortunately I had done a history of medicine paper in my last year of medical school. Why had a done the history of medicine paper? Because they offered $200 and a handy subject was something about cholera in upstate New York in 1834 and there was material available in the newspapers and so forth. So I spent time creating this paper, going through the newspapers, plotting cases, doing curves. I didn't know what I was doing in terms of training but it really was epidemiology and in fact it turned out to be rather fun. I had to see what the responses of the health department were, to the various challenges. Seeing how it spread through the city and so forth. So in advertently I'd become interested in a subject which we had no courses in at all and I got drafted to the public health service. That's where I got into public health and I had no interest in public health either at that time. I was going to be in my mind a cardiologist and this would be two years out and then I go back to my residency in cardiology. Paul O'Grady: What were the major public health concerns at that time? D.A. Henderson: There was one dominant major public health problem at that time or challenge and that was polio myelitis. There had been significant cases, significant outbreaks of polio myelitis. In the 1950s, there was a great deal of fear at that time about polio. In the summers there was - they closed swimming pools, parents kept their children away from other children. If there were outbreaks there was a great deal of anxiety in the community. The National Foundation for Infantile Paralysis was a very major foundation. It was the only categorical foundation at all that time. It had been started because of President Roosevelt's, Franklin D. Roosevelt's polio myelitis and they had raised for Warm Springs, Georgia rehabilitation center. They had been extremely successful and they took some of this money and they put it into some basic research of very good quality and development of the vaccine. There was great anticipation in 1954 because they began the first major study of the Salk vaccine and there was school children across the country. I forget how many were involved. As I recall it's 100,000 plus. The results were coming up in April of that year that I was doing my internship. Very soon thereafter they began to, in April, I guess they announced the results and they began vaccination around the country with the vaccine. About this time they found that some of the lots of vaccine were not quite - the virus was not quite as dead as it should be. They began to get cases of polio myelitis, paralytic disease caused by the vaccine. So I was being inducted into the Center for Disease Control. The epidemic intelligence service Alex Langmere's group were doing the work of compiling information on the cases in trying to find out which lots of vaccine were involved and trying to determine the magnitude of the problem and then what to do about it. So we were totally immersed, as I came into the service on the 1st of July with what was an ongoing investigation into what really was the end of the largest field trial ever conducted on a vaccine and the introduction of the polio myelitis vaccine which was - had been awaited for so long. At the same time we had what was amounted to a vaccine incident which was serious with a number of paralytic cases associated with the vaccine. The question was, was it the vaccine of all companies or was it maybe one company and only some lots of the vaccine or what was it. So this was all absorbing for many of those who came aboard at that time. Paul O'Grady: And how many years were you at CDC after your - so you got a two year government required service and then you stayed on? D.A. Henderson: Well it turned out be rather more exciting than I had thought. They had a matching program. So, that those who are recruited you then submitted your preferences on a list of different positions you could have. They in turn would look at the people who are coming in, about 30-35 of us and decide which ones they wanted and they would list their priorities and then they match them up. I matched up with a position which was called assistant chief of the epidemic intelligence service which would be as they called it a go-for job kind of putting things together, helping organize a course and doing things of this sort. Well, we would have a course to a one month at that time where they taught us epidemiology and bio statistics. Basically how to investigate an outbreak and at the end of the one month you are then a qualified epidemiologist in our terms and at the end of that course I had to go off the epidemic intelligence service did to an epidemic. We were constantly being called for various epidemics. There was a big epidemic of diphtheria in Phoenix City, Alabama. I went down, I spent three weeks down there and giving vaccine, taking cultures. The patients were housed in a big Red Cross tent. I came back and here was the chief epidemic intelligence service officer packing his bags. I said, "Where are you going?" He said, "I have another job. I am going to be a state health commissioner." I said, "Well, what do I do?" He said, "I guess you are the Chief EIS officer." I said, "I have no idea what to do?" He said, "You will learn." Sure enough, then I began working in a job that certainly I was not qualified for but plunged in. With the mentorship of this Alex Langmere who was a legendary epidemiologist, a rather difficult person but demanding and just a wonderful teacher, just an extraordinary teacher. At the end of two years of this, I finished my duty. I proposed to him, you know, we are not keeping many people on. The people were getting, so many people apply. They are well qualified. All of them wanted to do academic medicine or pediatrics. Just about nobody wants public health. Now, if we offered a 5-year training program in which you do two years of training, like a residency in cardiology that I was thinking for myself, and maybe then three years with the public health service. Maybe that would be a way to attract people, then by then you will have, say then, seven years and we might get people staying longer. Well, he liked the idea and then well, he submitted it up-line to the surgeon general. He liked the idea. So, I applied for a five year training program and went back to get my residency. At the end of the - well, during the course of the residency, I found this to be frankly rather boring. I was seeing patients and some of them had some heart disease and heart failure, a little diabetes, a little gastroenteritis. A little constipation and sort of the end of the day I felt, you know, if I really hadn't been there, I wonder if it would have made any difference and was I making any difference. Am I going to be doing this for my next 40 years? Well, meanwhile I had been two years in the epidemic intelligence service which some exciting outbreaks here and there including one which was an interesting one in Argentina. There was a big outbreak of food borne disease. They were stoning the restaurant, the Argentine government was upset. They thought it was a type of food poisoning due to the Botulinum toxin. They wanted our, what we had in the way of antitoxin to treat them. So I took off for Argentina with such supplies as we had. Paul O'Grady: When was this? D.A. Henderson: That was 1957. At the end of this I saw the secretary of health. He sort of offered "Well, let's go on a hunting trip or a shooting trip with me at my lodge." I said, "You know, I hear you have got an outbreak of smallpox." He said, "Yes." I said, "I would like to go see it." So he said, "Fine." We took off on an old Pan-Am clipper off the waters and the river on La Plata. On up to another place and we got in a two passenger piper cub and flew into a smallpox - the area where they had the smallpox and they had an outbreak of smallpox. The people were in tents in the field and so, about 30 different patients. We looked at the patients one by one, it was fascinating. And at that point, I had never seen a case of smallpox, really didn't know what it looked like. But it was my first contact with smallpox. Paul O'Grady: Was there at that point any national or international interest in trying to organize the fight for smallpox? D.A. Henderson: The international concerns about smallpox were there very, very strongly because all travelers were obliged to carry certificates indicating they've been successfully vaccinated within the preceding three years. Just about every country including our own enforced this. If you weren't vaccinated you wouldn't get admitted or they might vaccinate you on the spot. There was a great concern about importations of smallpox. It was in 1958, just about a year later after I had seen the cases that the vice-minister of the Soviet Union proposed to the World Health Assembly that they undertake a program to eradicate smallpox. That was the year the Soviets came back in to the UN family. They'd withdrawn because of the Korean War and they were - they just come back. So the proposal, they looked at this, delegates at the assembly looked at this and they really wanted to be helpful and encouraged the Soviets this time. So a year later they approved a program to eradicate smallpox. The only thing was that at - that same time the World Health Organization was deeply involved in a program to eradicate malaria. And fully a third of all staff were involved in that and all the spare money they could get together because it was very expensive, very costly. The idea of undertaking another eradication program was really not the intent of the director general. In fact the only thing he could do is say, "Fine." He really gave it very little money and a few countries then did some vaccinating and tried to get rid of smallpox. They did make some progress in this but it basically was going anywhere. That was the beginning. It was 1959 when they decided that they would undertake a global program but it really was not anything that was happening. It was seriously, it was not until 1966 that they really took it seriously. Paul O'Grady: What was the attitude of the United States government towards this program that it seemed to have gotten some impetus from the Soviet Union? Was there any political peculiarities about that? D.A. Henderson: There, clearly was an element of Cold War competition. The US was heavily supporting the malaria eradication program, both through the organization very heavily and through direct bilateral donations to the countries. So the US, you could almost say, owned the malaria eradication program. The Russians had no program at that point that they could say the same thing about. So, in a way they came in with this smallpox and said look, we got rid of it in the Soviet Union back in the 1930s when our vaccine wasn't so good, when health conditions were poor, where personnel were not well trained and we got rid of it. So, why can't the rest of the world get rid of it? So that's where they came in and then put after 1959, every year at the World Health Assembly they would really give the director general a very hard time. Why aren't you putting more money into the smallpox program? Why do you favor the malaria program? And so that went on as a continuing piece. The US really took no notice of it. It's really what it amounted to until really it came up to 1965 when a change came for the US. Paul O'Grady: Which was? D.A. Henderson: Well, in 1965 - I'll go back a little bit, 1961, Merck Sharp &amp; Dome, at that time, was introducing a new measles vaccine. It caused a lot of fever in children. So in the US, they were using it giving the measles vaccine and they gave them some immune globulin at the same time so that they wouldn't have so many reactions to the measles vaccine illness, if you will. This made little practical sense if you went to Africa. The idea of doing these two together and made life a lot more complicated. You really could not do large scale vaccination and try to preserve the immune globulin and deal with two shots to get this. So they undertook studies in Upper Volta, Benin. I am sorry Upper Volta is the place where they were doing the country. They did x number of children, 150 -200, kids reacted very well. They were no complications. Then they asked - the country minister said, could you give - do it for all kids under six years of age. So they gave them a vaccine enough for that. Then there was an organization, French organization that had a number of countries and he said, could we do it for six countries now. USAID said, "Okay, we will do it for six countries." Well, things couldn't go very well with six. I won't go into all of the complications but we got drawn in at that time to evaluating it. I sent one person over to evaluate. It was a disaster. Well, not to be deterred they decided we are now going to do 11 countries. We need from you, 11 people for six months each to help get the program started in each country. I thought, we can't do that. Really, it's - a good segment of my staff and signing people over for 6 months at a stretch is, without families and what have you, this is tough. So I thought, you know, I really have to work with AID, we really got to be responsive to them. I didn't know what to do. So I decided, all right, let's put together a proposal that we would say is sound from this public health standpoint. Why was the measles proposal bad? Well, they were going to give it for just four years and then stop. In other words AID would support it for four years and they expected the countries to continue. It cost a $1.75 a dose. The countries couldn't afford $0.10 a dose for yellow fever vaccine. So this is not good public health practice. To start a program, get the hopes of the public up and then drop it. This is terrible way to do it. Smallpox had vaccine however, cost a penny a dose. So they proposed the idea, well, suppose you take this whole block of countries, 18 countries and suppose you give, do smallpox vaccination - Paul O'Grady: And you talk about West Africa? D.A. Henderson: This is west, West and Central Africa as well called it. And so we do 18 countries. You give smallpox and develop a smallpox program there. We could get rid of smallpox in that whole area, they could then - would have as an established program for vaccination. They could continue it easily when that only cost them a cent a dose in vaccinating newborns and so forth. Then if they want to have measles vaccine added and the ministers think this is a good idea, we would be happy to give measles vaccine at the same time, but we can't eradicate it because measles spreads too easily. We couldn't get rid of it, but at least the countries would have to think through was this a good idea to do this with measles vaccine as well. Well, I think the cost - what USAID expected to spend was about five or $6 million. The proposal we submitted was about $35 million. So, I knew it can be turned down. But on the other hand I thought it was going to be a point of departure for discussion. I didn't know where we were going to find any sort of compromise on this. They just, their demands were so great that it was impossible. So I set it up through channels, through the surgeon general and very shortly USAID turned it down. We were just debating along about autumn what we would do subsequently on this. Paul O'Grady: And we are still in 1965? D.A. Henderson: This is 1965, when all of a sudden we got information that the president had decided to approve the program, the whole program. This shook everybody. My boss Alex Langmere was absolutely beside of himself. As I told him they were not supposed to accept it, that was - but the president was looking for an initiative which would be something that he could publicize that the US was contributing to a UN International Cooperation Year. There were several proposals that went forward. This I had no idea was even being considered and suddenly AID was told by the White House, fund it. All of a sudden, we are told, all of a sudden we have got 18 programs to set up in the West and Central Africa. We had never run a program outside the United States at all. Paul O'Grady: So you guys have been faced with a tremendous manpower problem? D.A. Henderson: Well, we would need about 54 people. That we are going to have to recruit. AID said that it probably would be - you can't do this under three years. They agreed finally to fund it then on November. They felt we could get it in three years. I said, no. This is wrong. It's just got too much of a delay. How about 13 months? We will have the people over there in January of 1967. They thought it was almost impossible. You've got individual agreements what every country. You have got to order the vaccine, you have got to put on training programs, you've got to recruit all the people. We did. Recruited the people, we got the vaccine ordered. We got vehicles. We had to use US American vehicles. There weren't any in all of these countries. No maintenance, no repair, so we had to set up workshops and everything else, to train our people to be mechanics. We had to lay out plans for all of the countries to get everything signed and we did. Paul O'Grady: Let's talk of, just for a second, about the attitudes of the countries involved. What was the interaction with the governments like? D.A. Henderson: Well, in November as soon as this was approved, I went over with a consultant that I had who, Warren Winkelstein, who was a good epidemiologist and spoke French, another person by the name of Dr. Henry Gelfand. The three of us went and visited each of the different countries. Fortunately a number of them were having a meeting, so we could present it to all of them at one time. They were enthusiastic. Why were they enthusiastic? More - most of them, more because of the measles vaccine because this is a very - in Africa, this is a very deadly disease. It's 10-15% death rate. The French speaking countries by and large had done some pretty good vaccination with pretty good vaccine. The English speaking countries had a lot of smallpox. They were more enthusiastic about the smallpox. But they were getting both and they were really very enthusiastic. We were coming up with vehicles. We were coming up with vaccines and consultant help but not a lot of people. It was by and large one or two people or advisors to be assigned to most of the countries with a few more in Nigeria. Paul O'Grady: And how about the Americans that were going to go over there as part of this program? Let's talk a little bit about their attitude? D.A. Henderson: Well, the Americans who were going over there, a number of the people I - some of them I had known. Basically called up and said, we have got this coming up, are you free, or would you be interested, people, contemporaries and so forth. I had a couple of people who are already serving in CDC and took them. Basically it was almost word of mouth advertising because there just wasn't very much time, and contact with people at schools of medicine and other places, infectious disease people that might know of people interested in this. People - the word of mouth, by word of mouth they learned about this and my goodness, we were able to recruit enough, so that we were able to begin the training program in July of 1966. Paul O'Grady: And people were on the ground? D.A. Henderson: Well, they had to finish up the training. We had to get all the agreements signed. I think we got all of them in to 16 of the 18 countries. We managed to put two, postpone two, but we had 16 of them by January of 1967. Meanwhile, there is a little problem. There was a debate coming up in the Assembly in May of 1966. So this is only like about 6-7 months after this approval for the whole West African program had come through. Paul O'Grady: Debate in the United Nations Assembly? D.A. Henderson: Debate in the World Health Assembly? Paul O'Grady: Okay. D.A. Henderson: Every year the ministers of health convene in May, in Geneva to look at issues of health. So they were debating the question of going with an intensified program of smallpox eradication with a budget of $2.4 million a year and an objective to complete that within 10 years. The director general Marcelino Candau, a very capable Brazilian knew that it was impossible to eradicate it. He felt you had to vaccinate everybody in the world and he was a Brazilian and he knew that there were tribes in the Amazon that hadn't been found. Or were just recently found or that sort of thing. So he knew it couldn't be done. There were a number of countries that were very doubtful of the concept of eradication at all because they were having so much trouble in malaria eradication. There were others who thought this was far too ambitious for an organization like WHO which is, where it's not, except for the malaria really it hadn't run programs or really coordinated that way operationally health programs. So it came to a debate in the assembly. The US had, as I said, been very quiet before this really in taking a position but at this assembly they were going to take a vote finally because it was very controversial, whether they went ahead or didn't go ahead. One of the strong arguments was well, the US is already committed, funds and personnel for - to take care of 18 countries. So that's a big start on this whole thing and after two o three days, three days debate, they did vote. They had about 58 votes to start the program and it passed by just two votes. It was the closest vote they have ever had in the World Health Assembly. The director general was furious and felt that the assembly had committed the World Health Organization to a program which is going to fail. It would bring the organization into disrepute and question the credibility of public health and the World Health Organization. He blamed the US for this. Well, in a way, it was true. If the US had not done this crazy thing in West and Central Africa that almost certainly the voting would not have gone as it did. So he was blaming the US. He, then, called the surgeon general in the US and said I want an American to run the program because when it goes down, when it fails, I want it to be seen that there is an American there and the US is really responsible for this dreadful thing that you have launched the World Health Organization into and the person I want is Henderson. Well, I was associated, of course, with the West African program of having gotten involved with starting it and so forth. So I got called to Washington and I was told I was being assigned to be head of the World Health Organization's Global Smallpox Program. I declined. I said, we are just starting this West African program. We have just - there is a huge amount of work and we have just barely started. The $2.4 million we got to go, we had programs in 50 countries. We don't even have enough money, $2.4 million won't even buy the vaccine we need. Trying, I had some experience in working with the World Health Organization and they really were not working well together. Each of the six regional offices were sort of wholly independent and trying to coordinate them was a terribly job. So I said, I really can't do it. I, you know, I think this is a very difficult task. I really, I think if we do a good job in West Africa, we are going to show what can be done. Maybe that will encourage the other countries but that's, I think, where I ought to stay. Paul O'Grady: Was this conversation going on between you and the surgeon general? D.A. Henderson: Yes. So I declined. He said - I said, you do not - we don't order people in the public health service to go from place to place. That we - we talk about career opportunities, and so forth and so on. It's not like the military services. He said, "Well, this is your career opportunity." I said, "And suppose I decline." He said, "You are fired." I said, "You are serious." He said, "I am very serious. I will tell you what, make a deal. You go for 18 months and if at any time during that 18 months you really feel it won't go, just send me a telegram, just put now and I will pull you out." So, I headed for Geneva to head up the Global Program. We left in October to go to Geneva, get a house. Wife and three kids, plus left half of our household goods in the storage because we knew we would be back pretty soon. Took over a program, which was a global program. This provided for headquarter staff eventually of nine of us. It never got bigger than that. So there were five medical officers, two admin officers and a couple of secretaries. That was our total staff. Paul O'Grady: Let me ask you about your own mindset at this point. You had mentioned the problems with the measles program and that malaria eradication had been problematic. Were you optimistic at this point about - at least with respect to the West African piece of the puzzle? You were optimistic about eradication's success? D.A. Henderson: This is a good question as to whether you would characterize what I felt is optimistic. My feeling was it was doable but without a full appreciation of everything, all the problems we would encounter. I must say because as I thought back on it, had I any idea of all the problems that we would face, I would have not been optimistic. You can't anticipate civil wars, floods, masses of refugees, one thing after another and bureaucratic blockage of things, countries refusing to participate. All of the difficulties you can have with this, but fortunately I was innocent of the problems, these problems that you would encounter or we couldn't anticipate, obviously, most of these. It was the fact we had a good vaccine and the vaccine we knew and I'd worked, we had done some studies at CDC while I was in charge of the surveillance program, showing the vaccine was very good. You could get virtually a 100 percent takes, using a proper technique. We had jet injectors that we had worked with and perfected these with the inventor in the US Army so that we could add jet injectors that could vaccinate a 1000 people an hour. They looked - we looked optimistic that we could do a lot of vaccination with them. So that, we had a good vaccine, we knew something about smallpox. You know that - we knew that there were a number of countries, developing countries who didn't seem to have any cases but the reporting was so bad that, little did we know that many of them just weren't reporting it. But we just - we really didn't have an idea but we thought there were large countries, free of the disease, certainly the US was and Canada was. Certainly there must be others that were involved too. So it was a feeling of technically this was doable but without an appreciation that experience would provide as to just how difficult the problem would be. Paul O'Grady: Let's take you to - take you back to Geneva. You have arrived, you had your family there and when did you start to realize that these challenges were going to present themselves? D.A. Henderson: We quickly found that we had problems. Within just the first couple of years, we ran into a number of problems. Paul O'Grady: Can you - ? D.A. Henderson: The West African program basically, Don Millar who took over from me, who had been my chief of my smallpox unit before. He was running it and he had a good administrative officer and he had some very good people in the field. My feeling was that they had to run that themselves and the only thing we could help them with, which they needed was some local costs. I think we gave them a couple of $100,000 a year to permit in some countries, purchase a vaccine, gasoline and a few other things, they couldn't get it, legally with their USAID funds. Other than that, they were on their own. So we worked at the world and saw well, we got, two countries are sitting rather at the far end. One is Indonesia, the other is Brazil. Now at that time, South America appeared to be free of smallpox except for Brazil. They had done vaccination programs in the other countries and one way or another, with their infrastructure, not perfect but they managed to get rid of smallpox. That of course was encouraging. But if we got rid of it in Brazil then they would be far away from endemic areas and indeed they could be basically the funds that we are putting into a Brazilian program could be withdrawn and we put it in other areas like Asia or Africa. Similarly with Indonesia, Indonesia sitting off where we are here and the countries nearby are free of smallpox. So the chances of smallpox being imported into Indonesia, if we got that free would be small and therefore the limited amount of funds we could use have, we could then transfer that to other countries and at least make a start in trying to get rid of the smallpox with the limited funds we had. So, that was the strategy. We almost immediately found we had a vaccine problem. The Russians had pledged 25 million doses a year and we had no idea how much vaccine we would really need. Most of the countries were doing some vaccination. The disease was so severe, it was such a problem that at least they had to vaccinate in the big cities simply because of civil disorder, with too much of this epidemic smallpox, it is destabilizing. So in all countries we are doing some vaccination and what we had - we made the assumption that most of them, already have vaccine and we have got 25 million from the Soviet Union. US is covering all the vaccine needs in their 18 countries, later 20 countries. So we got to be alright, but we - I thought we need to have some way to determine whether the vaccine is really, really potent, really good. So, I went to the Netherlands and asked if they would help in doing testing the vaccine, vaccine quality of the production that was there and then we went to Connaught Laboratories in Canada and they agreed to do that as well. So we began getting samples of vaccine from the different countries and they began testing it. Five percent of it was potent and stable. Five percent met the international standards. So we had a problem almost immediately. We couldn't afford to buy the vaccine. So I made a decision, we won't buy any vaccine. We are going to have to develop - improve the vaccine production facilities that are out there. We called a meeting of the vaccine producers from several major laboratories. From Wyeth Laboratories in the US, they were the producer here, they had one Lister Institute in London, where Netherlands were there, Soviet Union were there. I think that was it. We brought them together and we talked about vaccination and developing a standard manual. Every country was using where they were making a vaccine they were using all sorts of different techniques. So let's get what we think is the best way to do it in a simple manual that I can understand. Then let us then help these countries improve their vaccine. We will, then work with UNICEF to try to get them to provide some machines so that they could freeze dry the vaccine and we would use some of the people from these consultant laboratories that we had brought together to go out and train and help develop the vaccine. That's what we did. The vaccine quality began to pickup. It was by about 1972, we had more than 80 percent of the vaccine was being produced in the endemic countries themselves and it was good quality. So we were immediately involved in trying to solve just the vaccine problem. How to administer the vaccine was the second problem. The problem was this. You have a vaccine which is a very, has a vial, it's in a vial with about 0.25 milliliters of fluid. That is reconstituted. You have one vial that has dried powder of the vaccine, another which has a quarter of a milliliter of fluid which is a very small amount. To use a vaccine, you have to put the liquid into the dry powder and mix it up. Then you had to put it on the arm. The way they did this in most of the developing countries was take like a glass rod, dip it in and then put it on the - dip the rod against the arm, tip it against the arm and a little drop would be there. Then by and large what they did was scratch through the vaccine. They had a number of scratches through the vaccine, it was an old technique which goes back more than a 100 years. In the US we did a little bit differently but it was the same principle but it was important that the US did it this way. They took and took a needle and they put the drop back on the arm and then they gently pushed the virus through the skin and the idea was that if you got it just through the skin it will grow and produce something. If you push too hard you will get bleeding. If the bleeding occurs then it washes out the virus. You don't push hard enough, it doesn't go into the skin, and so the vaccination fails. Wyeth laboratories was developing a new device which I visited Wyeth laboratories because it was the question of improving our vaccine production capabilities in the other countries and they showed me this wonderful device which they developed. A little needle about - well, tube about so long. There are two little prongs on the end. They called it a bifurcated or sort of two fork needle. The idea was you put the needle into the vaccine and you just withdrew it. Between those two prong, the little bit of vaccine would be held and then they thought you press it through the skin. In this way the amount of vaccine you could get from a vial was 100 doses rather than 25 doses. Well, I looked at it and I know how much trouble we had had in trying to teach them to medical students how to vaccinate because they were forever not getting it quite - not enough pressure to break the skin. So it wasn't growing and then a number of them are getting a little bit of drop of blood and that was thought to be bad. So I raised the question of well, suppose that we take a needle and just hold it like this and poke it like this, we called it multiple puncture. Instead of scratching or pressing it through, do multiple puncture. You are going to get bleeding. So let's see what happens. So we tried a few of these, they all got very successful takes. We took it to the field into Kenya and Egypt and did several 100 children and we did it very vigorously. There was a little drop of blood on everyone. Every single one of them was successful. So this was incredible. All of a sudden we were going to have four times as much vaccine than we thought we had or we are getting, with these wonderful needles. The needles cost us, we shortened them up a little bit and make them cheaper than we made them out of a stainless steel virtually. We could get a thousand of them for $5. You could boil them and reuse them and we ran through about a 120 vaccinations perfectly good. So we had needles very inexpensively. We had a vaccine and suddenly we had four times as much vaccine as we thought we had. Then it was a matter of bringing those into play in the different countries and this went very rapidly. So it was another development, right at the beginning which made a huge difference. It was a crazy little thing. Now the important thing, I think was is that the - the inventor of this, a man by the name of Ben Rubin received a one time, to tell you, what's called the John Scott Medal of the City of Philadelphia for the best, most important invention of a particular year. Here he was getting this and it had gone back - the award goes back to the 1700s. Marconi has received it, Edison has received it so forth. He said, "This is the most insignificant patent or invention I have ever made," and he said, "And here I am receiving the John Scott medal." And it was - it just was like inventing the safety pin. It was so incredible. So we began using that, we had - introduced the jet injector for West Africa but very soon we said, for this price we don't have problems in mechanic to repair or what have you. It's very inexpensive, much less expensive than a bio - than jet injector. So pretty soon the bifurcated needles took over the whole of the world in terms of vaccination. Well, we had a couple of the very early problems that we had. There were many more. Paul O'Grady: So tell me how the smallpox program moved into Asia and East Africa? D.A. Henderson: Well, West Africa, I want to go back to the West African program which began in '67 and they managed to record their last case in 1971. Well, ahead of schedule and under budget. Not too many programs come through like that. Meanwhile, I had a man in East Africa and he was working with the people in the different countries and helping them and strengthening what they were doing, a Russian, Ivan Ladnyi and they began to make very good progress. We, from WHO, began supporting Central Africa, not Central Africa, but Sudan and Zaire are two huge countries across the middle. This was frightfully difficult but we had some very good people, incredible people. Some national, some internationals and they began to make a good deal of progress. Brazil, I got back to say Brazil became free in '71. We had, Indonesia was a bit of struggle but they became free by 1972. In fact the whole of Africa, was free of smallpox except for Ethiopia. The whole of Africa was free of smallpox by the summer of 1973. We were only six years into the program and here we were with a good piece of the world free now of smallpox. So, in the summer of 1973, we were down to - just five countries that had smallpox, just five. It was India, Pakistan, Nepal, Bangladesh in Asia and Ethiopia. When you looked at India and that group - that bunch of countries, I think the population then was maybe about 700 million. So you look at it and you say, only four countries in Asia but 700 million people is, at that time, almost three times the size of United States. So it was not a small undertaking to deal with that. Meanwhile in Ethiopia, they were doing a malaria program. They did not want to see a smallpox program. So, the Minister of Health refused to even have me go and talk with him about starting a program. So nothing had happened in Ethiopia at all on smallpox, up until late 1970 before I managed to get into Ethiopia and lay out a plan and by various devices working through the emperor to get approval to get started in Ethiopia. So we came in the summer of '73. We had programs in all the countries and we were very optimistic that now we are on our way. The big problem, frankly, at that time was India. Huge country, a number of people talked about India being like the native, like we talk about cholera being the home or India being the home of cholera. There are some who said, well, India with very dense population, particular climate and so forth. They must have something special here that maybe is the home for smallpox. Very difficult, you will never get rid of it there. That was the general discussion that was going on. We weren't making much progress. India had started a program back in 1962, not so long after the first World Health Assembly heads said, well, let's do an eradication program. By the time they got to 1973 it really, they'd made progress some of the southern states of India but most of India, they were still recording as much smallpox as they've had 11 years before. They were discouraged and really, not sure they would continue. There was a lot of discussion about it. It was a problem saying we really have to keep going. They agreed to do so and this was the earlier 70s. They agreed to keep on going but then we met and sort of the late spring of '73 and we said, we have got to do something different. Paul O'Grady: Who's meeting? D.A. Henderson: In India, well the strategy that we had had was not working. They had done a lot of vaccinating. They were doing mass vaccination all the time, they were then beginning to do what we called surveillance and containment. Really getting much better reporting and when a report came from a village, they would go out, send a team out. Try to vaccinate and control the outbreak. It didn't seem to be working and there was a still a lot of cases and we were - they were not making progress. So that spring we decided what we needed to do was find the cases more quickly. Find them before they became outbreaks. So the decision was made that we try to undertake a village by village search throughout the whole of India in 10 days time. Mobilize the health services for an intensive 10 day search. With this we were - would employ about a 120,000 people. And the idea initially was to go to selected parts of the village in a particular pattern to try and find cases and see what you could turn up. There was a lot of planning. A lot of organization went on. We got Bill Foege from CDC, was sent over. I had asked for more help. They sent over a couple of people but India is a big place and we have a very cracked team of international from France, from Czechoslovakia, from Soviet Union, but not a lot, we were very few. So the first search was completed in October in this one state of India. We were normally getting about 500 cases a week. That first search was completed and they recorded 10000 new cases found, 10000 new cases. This wasn't even the high point of the season. This was really at the - almost the beginning of when the seasonal increase occurred. Oh my gosh! This is far, far worse than we had ever imagined. Well, it was even worse than that, because it wasn't several weeks later I found that the search teams had not done a great job and they really reached only half of the villages. So it was probably twice as bad as bad as I thought it was. They repeated the search in another two months and they got better. By about the third search they got into the point where they would do house to house. We actually had a team following and doing a sample number of the villages to make sure that they had really reached at least 80 percent of the houses. So we began gradually to mobilize this tremendous force. It took 8 tons of paper for one search. We began getting more cases. The cases were increasing. The problems were that of mobilizing the staff, of supervision, quality control. It was a really tough job. We went on and through the summer of 1974, when at that time the smallpox goes down to its low as points. Some of - smallpox transmits best like measles in the winter. Measles is a winter disease, smallpox is the same. Whatever it is, whether it's being dryer air and cooler air that does it we don't really know all the answers. But certainly the summer months are where it gets to the lowest point. So the summers and the states, northern states where this almost all the smallpox was, the summers are terrible, 120 degrees. There is not - limited amount of electricity and there is certainly no air conditioning. We were bringing in a lot of people who are on 3-month volunteer stints with their Indian colleagues. That summer it was murder. We brought them together, once a month, looked at what they had done. Reports, we viewed all of these. We had no cell phones, we had no telephones. There were no computers. I mean, this was all done by hand. They'd come in for a weekend. We'd come in for work for a day and then they had one day of rest. Paul O'Grady: Can you identify a turning point in the Indian experience? D.A. Henderson: Yeah, I will come to that. At the moment, there was a turning point but a strange one. We worked through '74 but we got started going into late '74. The seasonal pick up, picked up. There were more cases than ever, it was really a going and there were several longer term trends in the disease in India and this was a little [1:03:18 inaudible] with a longer term trend. It was on its way up and we were not having that much of an effect. However, by the time we got to around February, we realized that the search system was in place. That we had some very good people supervising this and in fact I even remember the time it was with, Bill Foege, the two of us were looking at this and wondering now, where were we at this point in time and that - but as Bill said, I am not sure I am going to put out a weekly - putting out, I guess a bi-weekly report and the curve was going up and he said, the only thing I can do that's optimistic is turn it upside down. But we felt at that time, secretly that we are on our way and they got worse. It got worse for the bad time in a way and a good time in others. India detonated a nuclear device. They had people, press coming from all over. The theme of all of the coverage, news coverage was India detonates nuclear device, smallpox - their health system is so bad that they are the world's primary country for smallpox. So here is this advanced country with such primitive health facilities that it's epidemic for smallpox. This got a lot of interest. The Indian government was not pleased. They were very upset and they began making more resources available. Higher levels in government began paying attention to it and they assigned to the program, from the Indian side, four of their very best people to work with four of our central people. We call it the central appraisal team. Well, we got over that and for India at least, when we came to the end of the last cases in May of 1975, we thought we had the last case. There was a beggar woman out on a railway platform in the far eastern part of India going into a whole area and she had infected a bunch of people going after. We had no idea what was going on. By that time by October, the Minister of Health and the Prime Minister were very excited about this. We were not confident that we got rid of smallpox. October 5 - August 15th is India's Independence Day. They were determined to announce that this was India's Independence Day and it's freedom from smallpox for its first time in history. I would say we were chewing nails at that time, thinking, oh my gosh! If they have more cases, you know, the press coverage and these people don't know what they are doing, oh god. It would have been awful, that was the last case. Meanwhile, Bangladesh was going through tragedy after tragedy of flood and famine and we had an exhausted group of really fighting to get rid of it in Bangladesh which is a story unto itself. So, on August 15th, the Director General and I, headed for Bangladesh. They only had I don't know, something like maybe 80 villages infected at that point. It was just really coming way down and we felt, my gosh! I think we are going to have - be rid of this bad disease for all the world. It was a very severe time for smallpox. That would have been in. So we are on our way to the airport and got the word, all flights are canceled. The President of the country, the really the founding father of the country, Mujibur Rahman, had been assassinated along with his entire family. Martial law had been declared. Troops were moving to the border. Floods of refugees were expected. We thought, oh my god, once more, but for some reason, the international group, was laid low. They worked locally, they kept out of the way and the expected civil war that was expected to erupt immediately did not. They went back to work and finally in October of '75 it was all done in Asia. Then we were left with Ethiopia and Somalia, subsequently Somalia. Well, if you like to hear the rest of the story I can go on Ethiopia but Ethiopia is a huge country. People look at the map and they say oh, it's about the same size as Georgia, but not so. It's equivalent to all of the states on the eastern seaboard of the United States in area. It's huge. There are very few roads or where there are roads or even roads you can drive on. It's estimated I think that, two-thirds of the population lived more than one day's walk from any accessible road, at least one day. We had just - the government had only, I think, 2000 health workers in the whole country. For a while we were working with 20 Ethiopian sanitarians, 14 US peace corps, about six Japanese peace corps and some Austrian peace corps and some volunteers who kind of wandered in. Anybody who wanted to work, we put them to work and paid them the Ethiopian per diem which if you didn't [1:09:59 inaudible] high on the hog on that one, I can tell you. Then as they were making progress, slowly but it was difficult. Some of the - first time we ran into a huge area where the people fought against vaccination. They didn't want it. Trying to solve that problem, took us some doing but finally they wanted malaria drugs and we could give them malaria drugs. We got malaria drugs to give them, provided they got vaccinated first. So they got vaccinated first and then got the drugs. Not the way you like to run a program but that was the only way we were going to stop the disease. It was a less severe decision than let's say in Asia. So there is less motivation, less concern on the part of government. Well, we got all of a sudden the emperor Haile Selassie was in charge and had been there you know, as emperor for a long time. They had a coup, military coup. Marxist military group took over. Civil war broke out, so there was fighting in different parts of the country. The emperor was, I don't really know what happened to him. I think he was killed. Then it was the US Peace Corps had to pull out as did the other groups. A number of the embassy people pulled out and for a quite a period of time the only people allowed by the military to go outside of Addis Ababa were the smallpox group. We had some pretty very good people, particularly our person who was the real leader of the program, he was a Brazilian fellow by the name of Ciro de Quadros. He had a charm and an ability to persuade that was legendary. That's why we had permission to go outside the country but that wasn't much fun because they were - we had to go to many of the provinces with military escort because it was too dangerous. So they fought through all of that. It was really horrendous and then they came to a point. Finally we got additional people in, and then finally the surgeon general of the United States came up with a contribution of a million dollars for us to get three helicopters to transport people. It was so big. That made a huge difference. Well, one of them was shot down, one of them getting up there - I don't know, we don't know what reason went into like Kenya. Another one was hit with - they threw a hand grenade at it. They were a pair of those, of those and they took one for the - we had to get at one of them with a hostage and they were captured and we had ransom notes which I've still got a copy of the request for ransom from the people dictated by the rebels, written by the helicopter pilot. While he was captured took the vaccine and got all the rebels vaccinated, so took care of that, he was thinking all the time. Finally we got to this place in Dimo, a little village way down in the desert, last case. I flew down. We thought we got a television crew down there, film this and we did and got a lot of footage of Dimo, crazy little village sitting in the middle of a desert. We had a hard time even finding it with the - by helicopter, you couldn't spot at great distance. We went back and we waited and they searched. Nothing, nothing. It went on for eight weeks. We were about ready to make a statement at the press, we are done. There was a report came in of two cases in Somalia right next door. Well to make a long story short, the Somali government, even for the all the discussions we had had with them, had been hiding cases. They knew they had smallpox. They were admitting them to a hospital in a sort of secret ward, nobody knew about. They were trying to stop it but because they were embarrassed, the only country with smallpox. They hated the Ethiopians and they hated the thought that Ethiopia was free of smallpox. They refused to believe that they were free. This went on and as they would let our people come in but they would let them go out beyond the main city of Mogadishu. The cases kept occurring but they are having trouble finding out where were they coming from, in other words, who was infecting them. Finally, there was a great discussion about this and one of them, the turning points, I think it was that a couple of turning points had happened. One being they captured a Dutch adviser who we had working with Ethiopians. He was kidnapped, if you will, with his team and vehicle and taken to Mogadishu. I think we had eight or nine of these and then the UN commissioner would intervene and talk to president and minister. This fellow Bert van Ramshorst, finally they took him. He has to see the minister. So he spent, sat down with the minister and pretty well, persuaded him that Ethiopia was free of smallpox and that there was a problem and that the - WHO would be willing to help and so forth and so on. He made a quite a persuasive pitch here. Meanwhile, Assistant Director General, Ivon Lodney indicated he would want to come down and visit the city of Mogadishu at the capital and meet with the Minister. The Director General was threatening to do the same and I think the pressure was on. Then they began to loosen up. So from then until this was about March of '77 and the number of cases, I recall are about 3000 cases finally that they had troubles because they had nomad groups moving all over the desert area, couldn't find them. Smallpox kept spreading and you couldn't vaccinate them. It wasn't that they would resist vaccination, you couldn't find them. Then the great problem was, come November, was the Hajj. Somalia is right near Saudi Arabia. Many people come from Somalia to Mecca. All we could imagine were people and they would come from through Somalia from other countries, all we could imagine was can we possibly have at this time, one of these groups infected going into Mecca and spreading it among hundreds of thousands of people and watching smallpox go like this. So there was a frantic effort in terms of - they flew in vehicles, so we had more mobility and flew in all sorts of people and the government declared a national emergency and it went all out. On October 26, 1977, Ali Maow Maalin, a cook 23-year-old was the last case of smallpox. That was the end of the smallpox. We had to spend two more years working in the countries to make sure it was really the last one. Paul O'Grady: How did you find out about that last case, do you remember? D.A. Henderson: Oh, yeah. They had brought in some people at this point in time. They were moving people to an isolation camp to make sure that they would be held. There was two kids who were brought in by a vehicle from outside one of the program vehicles and they brought them in and they stopped at the hospital to inquire about where the camp was. Ali Maalin was a cook at the hospital. He was supposed to have been vaccinated but he wasn't. He had been a vaccinator, in fact but he hadn't been vaccinated. How we went wrong, - he got in the vehicle, rode for about 10 minutes till they got to the isolation camp. He got out and he came down with smallpox. Well, he came down with a rash, and as often the case the last is the worst. He was admitted in a hospital and diagnosed as chicken pox. Finally, they had discharged him with a mild case of chicken pox and it was one of the other people, friends of his, who said, I don't think this is chicken pox. It wasn't, smallpox. He was a very popular guy and he had contact with all sorts of people. So, there were everything from roadblocks to all night searches throughout Mogadishu to goodness knows what, trying to find possible other cases, but it was the last. Paul O'Grady: So do you have any final thoughts, anything you want to share about your experience with over the course of the years in the program? D.A. Henderson: Well, I think there were several things about the program that were very special and that is that we came together, people from across the world worked together very well. I worked very closely with the Russians. It was during the darkest days of the Cold War. Totally cooperative, we shared all sort of problems and they had some things that needed to be corrected and I flew to Moscow. We talked it over, they corrected them. We had people working across borders from one country to another. We had mix of nationalities out there. What was perfectly clear was that if we had a goal, we had leadership at all these levels that it became a very unique situation. Bridges were built such as you can't imagine. It formed the basis for going on from smallpox and we really convened a meeting and before the program was over, to say, the vaccination has been so inexpensive. We can vaccinate so many people in a day, so effectively so efficiently. We should be doing more of the smallpox vaccine. This was an international meeting we held and from that came recommendations for an expanded program for immunization, which was finally accepted by the World Health Assembly in 1974, even before the end of smallpox. The idea was to add other vaccines, diphtheria, whooping cough, tetanus, the DPT vaccine, measles and polio and add this to smallpox. That was adopted and then UNICEF got behind it and rotary got behind the polio side and the goal was at that time to reach 80 percent of the world's children by 1990 with these six vaccines. At the beginning, we estimated that at best about 10 percent were receiving these vaccines. So we had cases of tetanus and diphtheria. Totally preventable diseases, whole wards full of whooping cough and so forth and good vaccines out there, well, made it. So by 1990, 80 percent of the world's children had been vaccinated against these six diseases. So this was the expanded program in immunization which is going on, became in due course the eradication of polio. It served to eradicate measles throughout the western hemisphere. Measles was gone. We had so few cases of tetanus and diphtheria that it was a amazing, they were exceptionally, just throughout the whole of the Americas, they developed reporting system which I think, at the beginning we had 500 hospitals reporting once a month. The last count I looked at the reporting, they had weekly reporting from 42000 sites in Latin America. People just - it's better reporting for these diseases than it is in the United States of America. This is going on to develop the group that has convened here, have done all sorts of marvelous things and out of this came a feeling of we've done this, why can't we take on something else. They have done that with great success. So, if there is a real need for an international organization WHO, even though there is some of those like our President Bush who have not felt the need to work with other countries, this could never have been done in the United States, it could never have done by a few countries, it had to have an international organization. It showed also how much you can do if we have preventive medicine and public health vaccines. We were dealing with 10 to 15 million cases of smallpox a year, 2 million deaths a year and 10 years later we have zero cases, and zero deaths. This is pretty dramatic. Now you are seeing similar things happening with measles. Very dramatic changes and now we are talking about with the Gates Foundation supporting a lot of things, why can't we go and tackle malaria in a different way. Why aren't we doing research to get better vaccine for tuberculosis, why don't we have a vaccine against malaria? It's opened up, it's begun a whole revolution in prevention which is really something to see. Today or last couple of days, we have been hearing reports of, now, how many different fronts it's moving on very rapidly and really rethinking all of this. It has, I think, built bridges in the international field that you can't build in agriculture or education. Those are political. Agriculture, for obvious reasons, even education, it becomes quite political. With the health side, you really just don't get into political issues. It's amazing, you don't and thus it has built relationships in ways that are really quite unique across the Americas which I have spent more time with recently. There have been in other areas as well. They had days of tranquility in the Americas, where in the fighting in Nicaragua. The agreement was they would stop fighting for two days and they would and the vaccination team to go out. This has happened in Afghanistan, days of tranquility. So that even the rebel groups could be approached and could be helpful. So we got to Peru in the end of polio in the Americas, the last cases were in the area called the Shining Path, where the Shining Path was. They destroyed hospitals, they destroyed schools what have you. What the people really behind the scenes, Ciro de Quadros who was the head of immunization for the Americas had met with the commanders of the Shining Path and talked it through and got commitments from them, not to harm the health workers. Well, they went through and this is what the health workers are doing. Guess what, they searched this whole area which was so dangerous, it was a problem for the military to go into. So there, it's something that I think is unique about health here and something which gives you great encouragement for the future. Thus, I really feel quite, I feel like we have a made a difference well beyond smallpox eradication. I think, well smallpox eradication, I think has been the first step. We are now moving on well beyond that into many more exciting things. Paul O'Grady: Great. DA Henderson, thank you very much for this interview. D.A. Henderson: Yeah, you are very welcome. [End of audio 1:29:16] </pre> Player html for embedded player to stream video content <iframe width="560" height="315" src="https://www.youtube.com/embed/qbfMSB8kwAs" frameborder="0" allowfullscreen="allowfullscreen"></iframe> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Type The nature or genre of the resource interviews motion pictures moving image Date A point or period of time associated with an event in the lifecycle of the resource 2008-07-12 Identifier An unambiguous reference to the resource within a given context http://pid.emory.edu/ark:/25593/16rdc emory:16rdc Format The file format, physical medium, or dimensions of the resource 19266000000 bytes video/x-dv Creator An entity primarily responsible for making the resource O'Grady, Paul (Interviewer) Henderson, Donald (Interviewee) Contributor An entity responsible for making contributions to the resource Centers for Disease Control Title A name given to the resource HENDERSON, D. A. Description An account of the resource Donald Ainslie Henderson, MD, MPH, was seconded by Centers for Disease Control and Prevention to the World Health Organization in 1966 and served as the Director of the Smallpox Eradication Program until 1977. Subject The topic of the resource Smallpox Eradication Smallpox Eradication WHO Language A language of the resource English