Dr. Ralph "Rafe" Henderson

Rafe Henderson

TORGHELE: It is November 4, 2016, and we are [at] the Centers for Disease Control and Prevention [CDC] today with Dr. Rafe Henderson to talk about his various roles and perspectives on polio as it relates to the CDC [Centers for Disease Control and Prevention] and the World Health Organization [WHO] and other organizations in which he's worked. So I want to say welcome, Dr. Henderson, and thank you for agreeing to be interviewed for the Global Health Chronicles Polio Project.

HENDERSON: A pleasure and an honor. Thank you.

TORGHELE: I am Karen Torghele, and I will be interviewing Dr. Henderson today. To begin, I think it would be interesting to hear about your unique family background and how it may have impacted the direction your life took—or may or may not have. So can you tell us a little bit about your upbringing?

HENDERSON: Yeah. It's probably not that relevant, but my father was born in Burma. His father was born in Jamaica, and his father's father had come to 00:01:00Jamaica as a teacher from the U.K. [United Kingdom] and became a minister in a church in Jamaica. My great-grandfather—my grandfather, rather—I'm getting confused because my father was in Burma, but his father, then, was one of a large number of children and came over, did medicine in the United States, and went as a medical missionary to Burma.

And that's the origin of my funny name. Because in the British system—the British Raj, as it was in Burma those days—there were a lot of British soldiers, and their nickname for Ralph, which is my father's name, was Rafe. And so to avoid confusion in my family, when I was the youngest and came up and named Ralph, they said, "Oh no, we'll call him Rafe". And I've always preferred 00:02:00that, although it's been very embarrassing, because if you are not familiar with Rafe and you say the name Rafe Henderson, it sounds like "Ray Fenderson." And that always confused me and confused others. So that was the downside of it. In later years, I have relished the name.

TORGHELE: It's unique. You're probably the only Rafe that a lot of people know.

HENDERSON: Maybe that's just as well.

TORGHELE: Were you the first in your family to go into medicine?

HENDERSON: Well, no. Of course, my father was the black sheep. He went into publishing. His father was a medical missionary and certainly a doctor, and then my father's younger brother went into medicine, and my older brother went into medicine. So we have a lot of doctors in the family.

TORGHELE: And the others were medical missionaries in different places?

HENDERSON: No. My uncle was a general practitioner in Ambler, Pennsylvania, and my brother has been doing research work for Baxter, doing artificial kidney research and very much a clinician, domestic-based.

TORGHELE: Where did you go to medical school?

HENDERSON: I went to Harvard. I went to Harvard undergraduate and I went to Harvard medical school and then I went on to Harvard School of Public Health and then I went on to the Kennedy School of Government. I never got out of the Harvard cycle of education, for good or for bad.

TORGHELE: When you were there in that area, do you have people that you remember who were especially influential to you, or inspiring?

HENDERSON: Yeah. There were a number, of course, but the person who is most 00:04:00responsible, I think, for my veering into public health—that was not my initial intention, it was to practice—was [Dr.] Thomas Weller, who is famous for getting a Nobel Prize in developing some of the tissue culture methods for measles, along with John Enders and others. Weller was one of the popular lecturers in—I forget what the course was called, but basically Tropical Public Health. And he actually arranged for me to take an elective course at Harvard where he sent me to Barbados for six weeks to look at the public health system there.

And I then matched that with another sort of independent initiative to go to Twillingate, Nova Scotia [Newfoundland], to fill in for some of the physicians 00:05:00who would then go off for the summer. And we would come in and try to fill in for them in their absence. I learned how to run an x-ray machine, and I learned how to pronounce somebody dead, which was a new experience for me as a third-year medical student. I had to go visit a household, and there was a lady lying there and everybody was standing around. I didn't know what I [was] supposed to do, and they kept saying, you know, Is she dead? And I said—after examining her several times to be sure that there was no mistake—I said yes. Then they said, well, we can begin, then. They wanted to have that official declaration before they prepared the body. So it was one of those interesting cultural experiences. It was fun.

TORGHELE: So it sounds like you had some really good mentors for you.

HENDERSON: Yeah, that's for sure.

TORGHELE: How did you then come to be a part of the Epidemic Intelligence 00:06:00Service at CDC?

HENDERSON: It's funny, I was thinking about that, because I was doing an internship—and don't know if I'd started the residency yet, but—at the Boston City Hospital. And somehow [Dr.] Bruce Dull was there, and I don't remember him being either a resident or assistant resident. He certainly was not part of my group, but I remember him talking about the CDC and the EIS [Epidemic Intelligence Service]. And at that time, as you know, it was Vietnam—maybe you don't know, the Vietnam War—and many of us would be drafted either into the Public Health Service or into the Army or other military services. So many of us, in those days, tried to get an appointment either at NIH [National Institutes of Health] or in the Public Health Service, as an alternative to go 00:07:00actually to hard fighting. That, for me, was a combination of something that I really wanted to do and also a very convenient choice to make. The long and short of it was that I applied for the EIS and was accepted.

TORGHELE: Do you remember how big your class was, or who else—?

HENDERSON: Yeah, I do. Of course, I've kept up with [Dr.] Alan Hinman, who—of course, we've had parallel tracks in much of our career, Alan doing a lot of work in malaria and then doing immunization, and then I doing smallpox and then by default falling into immunization, really by accident as much as anything else. I haven't kept up with so many other people. [Dr.] Lyle Conrad has been another member of our group, and, again, have not maintained so much contact 00:08:00with Lyle either.

Class was small, something like thirty people. And I go nowadays to the EIS Tuesday morning seminars, where the rooms are not always full, but we're dealing with an audience not only in that auditorium, but also, by the phone bridge and video bridge, all over the world. So it's quite a different Tuesday morning seminar than when [Dr. Alexander D.] Alex [Langmuir] used to be lecturing us and making us feel bad or feel good—not so often. I was thinking about it that all the kids now come in—"kids"—officers come in with their iPhones and their laptops. To tell them that we had slide rules, and there was nothing like a phone or a laptop or anything of that sort—and the computers that we had, I remember, were the things that you cranked to make calculations, and they were 00:09:00very slow and very difficult to use. It was a whole different world in those days.

TORGHELE: I don't imagine they know what a slide rule is.

HENDERSON: No, they may not indeed. But one of the reasons I go back now to try to sit in is not only do I continue to learn, but I keep trying to, in my own small way, try to inject the kinds of atmosphere and kinds of remarks—the kinds of support—that we used to get in a much smaller group. I felt it was important to have some of the older folks come in and give them that sense of who they are. I don't succeed, but I try.

TORGHELE: That must be very helpful.

HENDERSON: Well, it's freeing for me. It is. I'm not sure it is for them, but sometimes I get a nice feedback.

TORGHELE: And your experience is worth a lot.

HENDERSON: Yeah, but hard to tell them I know everything and they know nothing. 00:10:00Of course, they know everything, and my experience really doesn't count for very much about what they're doing now. Maybe once in a while I can come through.

TORGHELE: Do you remember your instructors during your EIS course?

HENDERSON: No. Hardly any, except for Alex. That's unfair to them, because we had a bunch of good ones, I'm sure. But, of course, in those days the first-year officers would be taught by the second-year officers. I went to Africa very soon after completing the EIS course in the summer, and came back from Africa to then be one of the instructors in the course for the next generation of folks coming on. There was a lot of teaching that went on from us, who were the recent 00:11:00graduates—or not graduates, but the second-year folks. So I don't really remember so many of the folks who were there. [Dr.] D.A. [Henderson], of course, was part of the scene, [Dr.] Phil Brachman was part of the scene. I'm hard-pressed to remember other names.

TORGHELE: Can you describe one of the Tuesday morning seminars? What kinds of things would you do during those seminars?

HENDERSON: Much of what goes on today, which is a presentation of something that you had done in the field, and then questions and criticism about, Why didn't you do this? or, Why wasn't that explored? or, What's the best way of doing something? That's more or less what I reconstruct now, thinking back. Now, whether that's accurate at all—it may be complete fantasy. I can't bring up to 00:12:00mind a specific Tuesday morning seminar and exactly what went on, but I know that has been the procedure—that you present and then you're criticized and you try to respond. I think that's exactly what we did.

TORGHELE: Did you have slides for results, or did you just present?

HENDERSON: I don't remember presenting, so it probably was the older folks that did that. I was probably just sitting there taking notes. Yes, it would have been slides. They were certainly on a projector. Just like now, when the computers break down, or the projector used to break down and didn't work. There was not much difference in those days.

TORGHELE: It would have been nice, though, to have smaller groups.

HENDERSON: Yeah. Much more intimate. Then, you knew everybody. That's an era that's not going to come back. But there you are.

TORGHELE: You were involved in immunization programs early on, including measles 00:13:00and smallpox, right?

HENDERSON: Yeah, but it's a funny business. I'd have to say that my role has been as a manager. I went over, as I said, just after I'd completed the EIS course, as a replacement for [Dr. Lawrence K.] Larry Altman, who was an advisor to the OCCGE [Organization de Coordination et de Cooperation pour la Lutte Contre Grandes Endemies], which is a French public health organization based in Bobo- Dioulasso, now in Burkina Faso. Larry scuttled around seven or eight countries in West Africa that were members of this organization, trying to help out with the initial USAID-sponsored [U.S. Agency for International Development] measles immunization program in West Africa. But we weren't dealing so much with 00:14:00immunization, we were dealing with trucks breaking down and the jet injectors not working and the supply chain for the vaccines and there was no diluent, and running around doing troubleshooting in that sense. So it was not really knowing much about immunization, but I learned an awful lot about what can go wrong.

I didn't know anything. I hardly spoke any French, although I was learning rapidly when I was over there, listening to the foreign service tapes as much as I could. But the French médecin folks, who were advising the Ministries of Health, that were the médecins militaries—young, enthusiastic, for the most part, guys, all men—and they would go around and they would be driving around in their trucks, and they would take me out to look and see and be advised as to 00:15:00what was going on, mainly so I could know what was going wrong and could help them get things going right. They were wonderful teachers. And, as I say, that was a terrific experience in learning the things that go wrong, and what you need to do to help and support the field teams.

TORGHELE: On the ground.

HENDERSON: Yeah. That was the best training for all the rest of my career, outside the Boston City Hospital, which was where you had to do everything yourself and deal with everybody to get things done. Both of those experiences were really formative.

TORGHELE: There were three people at CDC who seemed to influence the role of CDC and EIS the most during those years. One was D.A. Henderson, one was Alex Langmuir, and one was [Dr. David J.] Dave Sencer. Can you tell us, from your perspective, how those people affected the roles of EIS officers and other 00:16:00people at CDC?

HENDERSON: I can say what had happened to me. I'm not entirely clear how they impacted the other folks. D.A. had a real fight with Alex about getting EIS officers assigned to the smallpox program, which was just starting in West Africa. D.A. was able to negotiate the starting of that with USAID, and suddenly had a need for all sorts of people going to West Africa to staff the field offices and the regional office. D.A. wanted to use EIS officers, and Alex absolutely refused, much to D.A.'s surprise. They were very close, and I think 00:17:00that was a falling-out that they had over that. I didn't know when it happened to me, because I got sent over there as a first-year EIS officer. Since there was only one of me, I guess it wasn't so important, and then I had spent six months running around all the countries in West Africa. I knew quite a lot about what was going on by the time I came back. In fact, while I was still over there, D.A. appointed me the deputy director of the regional office. I was much too young to do anything at all, but deputy director is a pretty important assignment.

When I went over, of course, that was for my second-year EIS, and I had some concerns, because you're supposed to do two years of EIS, and there was a lot of domestic stuff you're supposed to get done. I don't remember the details, but I 00:18:00do remember talking with Dave Sencer, who said, Don't you worry, you go over and we'll take care of the rest. I did go over. There was never any hassle about the EIS or completing this or completing that.

I applied, when I was over there, to Dave for a career development grant, because I knew that having just an internship and residency was not really the background I needed for a public health career. That really determined me when I went over to Africa—if I had not been committed to public health before, I really got committed at that point. I realized that it was a management job, and I wanted to get two years' training at the Harvard Business School. I applied to get a two-year grant to go to Boston to do that, and I said the first year I 00:19:00would get an MPH, which everybody's supposed to do. The second year I will see what I can do for business. The business school wouldn't have anything to do with me. The program was not suited for me at all. And the Kennedy School of Government had just created the master [of] public policy program for young hotshots. They wanted them right out of college, and maybe just three years of either medical school or law school. By that time, they said, I was much too old. I was thirty-one, thirty-two. I had to fight my way into the program and say, I'm just the person—kind of person you need to train, because I'm ready to do this. Anyway, I got in and had that training.

So it was Dave Sencer that was really driving that for me and then arranging the assignment back here. He said to me, You know, you have to come back and do some 00:20:00domestic work. I was really wanting to continue my international career. He said, No, you've got to establish some domestic credibility, or else you'll just be put in a pigeonhole, and you'll never be seen as anybody except somebody who does something internationally. So he said, You come back. Actually, he said after the Kennedy School, You can go anywhere you want, but I think if you look around you'll find you'll want to come back to CDC.

I did look around and found the upper echelons, which is what the Kennedy School was really preparing us for—top-level advisors to the executive branch and Congress. When I looked around, it was so bureaucratic that I really found nothing that I liked there, and came back to CDC. And Dave said, Okay, we'll find you something, and for the moment we'll park you in my office—in the office of program and evaluation, which I hated. I absolutely hated it. I did 00:21:00that for about six months, which was writing papers and going to Washington and diddling around with the ups and downs of the bureaucracy. Dave said, Now we've got an opening in the VD [venereal disease] branch, and we'll sign you as a deputy to [Dr. J. Donald] Don Millar, who is the director. And that worked out fine. Within a few months, Don was kicked upstairs to the next bureau level and I became the director.

It was not at all like smallpox. In smallpox, I knew everybody and I knew everything going on—nothing I didn't have my hands on. And suddenly I get into this VD organization, which is huge—five hundred federal employees, maybe a thousand, five thousand state and local health officers, all running around doing this. And just as I didn't know anything about immunization in particular, 00:22:00I didn't know anything about VD in particular. But it was a management job, and that I was able to understand a bit more. Management and epidemiology—they're so tightly integrated it's sometimes harder to keep them apart. But I found that although I was very uncomfortable in that position, since I didn't know anything and didn't know anybody, it very quickly turned into a very engaging and exciting time, because it was a time when the CDC and the VD branch moved from being a syphilis control organization to look at more sexually transmitted diseases.

The first one was gonorrhea. Gonorrhea just took off as an epidemic, and that's exactly when I came into the VD division, when we had the authorization from 00:23:00Congress to deal with gonorrhea. We remade a lot of the operations, retrained, had a different look at the epidemiology, had people coming in who were not dermatologists. Nothing against dermatologists, but that's who the medical officers were who were, in the old days, syphilologists. It was the syphilology/dermatology specialty. Now we began getting the infectious disease people coming in. [Dr. James W.] Jim Curran, who then went on to do a super job in AIDS [acquired immunodeficiency syndrome], now is the Rollins School of [Public] Health dean. One of the young people that came in at that time, [Dr.] Harold Jaffe, worked for us as a young first-year guy in the public health service in those days. Many others that came in—a whole new generation of 00:24:00people, so it was a very exciting time.

Then, five years later, the program was going very well. D.A. Henderson leaves WHO [World Health Organization]—or says he's leaving WHO—he's fed up and is going to go to Johns Hopkins [University] to become dean; leaves a gap in WHO as far as the U.S. and CDC is concerned. Yeah, he's the most senior person. And they want somebody to come in and not let the legacy of the smallpox program fail, which was the expanded program on immunization. D.A. and others had helped found or establish that program in 1974, and it was crawling along under a sort of temporary management. The idea was as soon as D.A. had finished with smallpox and being sure that was declared eradicated, that he would then take on the expanded program on immunization, and just stay on and take on that challenge. 00:25:00But he didn't want to do that. He wanted to get out. So Dave called me at home in November and said, Look, this is something opening up, do you want to try it?

I jumped at it because of going back now in international health—By the next February, Ilze and I had moved from here and established ourselves in Geneva and started out with the EPI [Expanded Program on Immunization], and it was really glorious. It was a wonderful, exciting time. The program was just beginning, and it just grew up. And we piggybacked on all we had known in smallpox, and a lot of the old smallpox veterans were now working for the EPI. The same spirit of 00:26:00getting something specific done, measuring what you do, looking at immunization coverage, trying to cover morbidity, mortality, get the diseases down, not just throwing vaccines out and into the field, and being sure that you went to where the problem was, not just using through fixed health facilities. That was the mantra before I came into the EPI. The old director was saying, We will only expand as fast as the health services expand. If there's no health center there, we're not going to do immunizations, was the message. Of course, smallpox took anybody, anywhere, trained them up and got into where the problem was. That was our spirit coming in, or at least I was able to enforce that for the program, and change that kind of philosophy. It was just wonderful.

I came in, in March. I called on the CDC Bureau of Training to help create a 00:27:00course for program managers so the national program manager could write a plan of operations, so that they could then get funding and support from the outside and begin to start up their operation. We ran our first course that October—six months, it was pretty fast. And we trained ourselves in that first course. We were the counselors for the people who participated, but the course itself was done in modules where you worked through a problem that was posed, and then your solution could have been any of a hundred, all of which would have been perhaps equally valid. So if you'll discuss, argue, and talk about best policies and problems—and it was a very, very powerful, motivating course. CDC was very important in getting that all off the ground.

We go back to the role of Dave and Alex and D.A. D.A. was very supportive when I 00:28:00came to WHO. He helped me make a presentation or say how much staff I should ask for from the director-general, because coming in with a new program, there was some extra money that was available. I knew that I had a chance to try to compete for it. D.A. was helpful in making the arguments that I should make, and I was successful in doing that. Of course, then D.A. left, and most of the people didn't realize that D.A. had left and I had come. I always seemed to be the same person by a lot of the people who didn't know very much better about it. There had been a confusion for some time. That's a long story about D.A. and Dave, but Dave was very supportive. And Dave was really the most important 00:29:00person in the mid-later part of my career, always been supportive helping me with the training. Always been supportive, as CDC was in general all through the EPI.

TORGHELE: It sounds like he gave you a lot of freedom to make your own decisions, too.

HENDERSON: Very much. I think we'd discussed that in another context a little earlier. What was my role in WHO? I was seconded from CDC. Well, what did that mean? It meant I worked for WHO. There was no link that was enforced with CDC saying, You have to do this, this is CDC policy, look out for this issue, that this is a CDC domestic issue. It was, No, you go, you do the best job you can for WHO. That will be serving CDC and the U.S. government the best of all things. Do that job, not try to do some other job. It was superb in terms of the 00:30:00freedom it gave me.

TORGHELE: It sounds almost like you were an ambassador from CDC.

HENDERSON: I didn't feel that way. I felt I was actually just doing the WHO job. I never tried or felt that was a response. Maybe I should have, but I never did. CDC was so evidently there, I didn't have to cheerlead it. It spoke for itself.

TORGHELE: Having worked in both places, how would you compare them? What were the main differences in how they were run and what the atmosphere was like and what they did?

HENDERSON: My brief time for five years with the VD division, it was dealing directly with the field staff and with the problems of trying to teach the 00:31:00epidemiology and learn the epidemiology of gonococcal disease, and trying to control both of those diseases while keeping an eye out for the other sexually transmitted diseases we knew were coming about. There was a lot of dealing with the staff and a large staff at CDC. I thought I mentioned fifty or sixty people that were in the VD division at CDC, and concerns with Congress. We declared a gonococcal emergency. I decided that was the best way to get some resources. And then all hell broke loose, because once we declared the emergency and took it up to the secretary and the secretary declared the emergency, then everybody wanted in. All the departments wanted a part of the emergency and their role in it. 00:32:00It's just like AIDS, that once monies have become available, everybody's got a role to play and wants to do it. We had a lot of bureaucratic fence mending, infighting, whatever you want to call it, in that era when we got gonococcal disease up in a big way.

There was that, and of course the Tuskegee scandal that broke at that time, which was fortunately kicked upstairs from me and dealt with, with Don Millar and a wonderful, wonderful administrator named Bill Hosking who dealt with that, which was really a nightmare for so many people.

TORGHELE: Can you just give us a brief review of that?

HENDERSON: I'm reluctant to. I will, but just remember, it's a biased view from 00:33:00somebody who really didn't have a lot of intimate detail with that. If I give my own thumbnail: back in the thirties there was concern about tertiary syphilis, and I won't go into the details about primary and secondary. The primaries and secondaries are mainly infectious stages, but then in a proportion of cases, the parasite gets into the brain and can cause long-term dementia and death. There was never much good treatment for any of the syphilis stages. There was a desire to keep under observation people who were known to have had primary and secondary syphilis, to have a history of what happened with the tertiary stages. 00:34:00In about the thirties, this long-term study was set up in Tuskegee, where there was a high incidence of syphilis. The scandal revolved around the fact that when penicillin became available for widespread use in the late forties, '46, '47, there was an opportunity to treat these folks that were now under long-term observation, and they weren't treated.

This is where my own experience gets a little fuzzy, because my understanding was that there was real concern from the clinicians that treatment of tertiary syphilis with penicillin, which would kill the spirochetes, might cause acute 00:35:00damage. There was fear that treatment might be worse than continuing the observation. That was in the initial time when penicillin became available. Now once that decision had been made, I think it got carried on, and it's not clear to me when the balance tipped to say, Okay, enough is enough, now we've got to treat everybody. I know that there had been some concern as late as—or early as the 1960s, where one of the public health advisors (a category within CDC of folks who are trained to do management and were part of the VD investigators, and they would help with the annual time where people went out to follow up the 00:36:00Tuskegee survivors and do medical examinations on them)—one of the folks at that point said, Hey, these folks ought to be treated. But it wasn't until the mid-seventies—'72, I suppose, '73—where it became acute and people would say, This is a scandal. We have to treat them, this is a racist problem that's there.

It's very confusing to me as to what the balance of all that was. I know that Bill Hosking and Don and others here felt that one of the real tragedies was that the lawyers kept rushing in, and their concern was the lawyers are going to suck up all the funds that are now being made available. There is going to be very little that's going to be left for the survivors of this experiment, as it was called.

It was something started with the best of intentions. It was something ended, I 00:37:00think, for good reason, and from here to there, who knows—ups and downs. But it was never the kind of extreme portrayal that was made, of this sort of folks being held, and racist because they're black and not being treated. It did not originate from that specifically. It did originate because this was a high-incidence area among black folks for sure, but that was a social problem that existed. Anyway, that's my take on Tuskegee.

You were saying, going back to say—difference between the VD division and WHO. WHO I had a staff of twelve, not sixty. I was trying to fight for program funds, not that came to WHO or to our program—although I did fight for that—but 00:38:00we're trying to get other programs. USAID, other development organizations in the Dutch, the Norwegians, the Swedes, who were putting money into developing countries for development purposes, to get those funds into immunization and then to look at the training courses to try to get an information system established, so we had some idea about what was going on. We estimated that when the program was begun in '74, immunization coverage couldn't have been more than about 5%. The vaccine manufacturers weren't making any more vaccines than that. We didn't have any information that was better than that, so we needed to get that established.

We developed a survey technique for estimating immunization coverage, one that 00:39:00[Dr. William H.] Bill Foege and Don Eddins, a statistician here, had worked on first in the Gambia in the mid-sixties for an immunization coverage survey in the Gambia. I had taken that technique, which was also based on something that Robert Serfling and Ida Sherman had developed here at CDC for doing domestic immunization. Bill Foege simplified it from Serfling and Sherman. I took Bill and Don Eddins' simplification and further codified and simplified it, because I ran into a problem, being in the regional office in Lagos thinking I knew everything about the field, and then the folks in headquarters not being too happy when I would come back and criticize what they thought was the best. I was 00:40:00being a little obstreperous.

It's always been my contention that I was punished by saying, Stop doing this epidemiology in the regional office. Now you have to go do these coverage immunization surveys for USAID and for us and get on with that, which I did for a year or so. An enormous task of developing the survey technology, codifying it, carrying out the surveys. Having done all that while I was in the smallpox program, I knew that technique, and I carried it then through WHO and we made that a real central portion of the expanded program on immunization. It became the most widespread survey technique used in the world. It was just amazing. Not very good, but it did the job. I don't know why I got into the coverage survey.

TORGHELE: We were talking about the differences between CDC—

HENDERSON: Small staff, and then trying to deal with the information system, 00:41:00dealing with partial information system, get back information from our coverage immunization survey so we knew what coverage was like, and then dealing with UNICEF trying to get their support in. To see this just wonderful rise in immunization coverage and the enthusiasm going on, and then dealing with the World Health Assembly. And again, I was there in the World Health Assembly, which meets once a year. All the Ministries of Health, or most of them, come, and then they divide the Assembly into a Committee A, which looks at technical programs, and B, which looks at financial matters. In Committee A I was able to present the results of the program and argue for support and ask for resolutions 00:42:00to be passed, and I was doing all that kind of activity, which was never a part of the CDC job. It was quite a different sort of job in some ways, but very much similar in other ways. The regional directors at WHO are not so different from the regional offices here in the public health service. There are many, many, many similarities. You're dealing with people, and that, of course—no matter where you're dealing with people, they are people, and you have some of the basic issues going on.

I'll tell a story now that goes back a bit, because I know that you want to know a little bit about [Dr. Jonas] Salk and [Dr. Albert] Sabin. I've taken you to my coming to the WHO in 1977, and the initial scrambling to get training going and get the program started. And indeed, they did get started. By 1980, we had 00:43:00enough of an information system—not very good, but to say, Okay it was 5% coverage in 1974, and by 1980 we think it's up to about 30% of the kids getting at least a first dose of DPT. We were that specific, and could be.

Now just about that time, Merieux Laboratories made a collaboration with the Dutch, and the Dutch Riks Institute had developed a technique for making pertussis vaccine for whooping cough. That's a terrible vaccine. It's a soup—it's really a mystery what goes into it and how it works. They had developed these big fermenter tanks, so they could make a whole lot of pertussis vaccines at not much cost. Then somebody had the bright idea of putting little 00:44:00Styrofoam beads in these tanks and growing poliovirus on the beads. Up to that time, poliovirus and many other viruses were grown—well, they are grown in tissue culture, but that culture is done on plates, flat plates, and the number of cells as you can lay out on a flat plate is a certain amount. But if you now take a little ball and put those cells on that little ball, you multiply by severalfold the number of cells that are available for the virus to grow on.

They figured out, between the Riks Institute and Merieux Laboratories, that they could use these immense fermenter tanks and fill them with these little balls and grow poliovirus on these little balls, and they could produce poliovirus by the kazillions. It made the manufacture of inactivated poliovirus a lot, lot 00:45:00less expensive. Remember, with the oral vaccine, the live virus, you could see a small number of virus particles. They multiply in the gut. They are their own multipliers. You don't need so many of them. With inactivated vaccine, you need a whole bunch of the inactivated particles before they have the mass to make that antigenic response and get a good immune response for the vaccine. With this development, you suddenly had an opportunity of making inactivated polio vaccine at a price that was more affordable than it had been before. So Salk and Merieux began doing studies along with the Dutch in West Africa to show that they could use this vaccine. And Salk's idea was, I only need two doses of my vaccine, not like the Sabin vaccine where you need three, and I can do this 00:46:00immunization schedule very easily. It only takes two doses, and I can vaccinate the world with a small amount.

That was late seventies, early eighties. By 1982, we were really a growing concern in WHO, and the EPI was really making inroads. It was popular, well-established, but we weren't moving as fast as I wanted to. We were only, I said, 30% in 1980. We weren't so much farther along in '82, but a little further. I presented to the World Health Assembly that year an action play saying, We're not getting their folks. We've got to do something dramatic, and here's what we gotta do, otherwise we're not going to make our 1990 goal. Because our goal was, for the beginning of 1990, to get all the kids immunized. 00:47:00I said, We're not there yet, we've got to get going. Well, Salk came into that and said, Aha, there's a problem with the immunization program in WHO. It's not moving fast enough. I've got the solution. I've got two doses, and we'll use inactivated polio vaccine, and it'll solve all the problems, rather than having to do these three-dose schedules.

So Salk goes to talk to [Dr. Kenneth S.] Ken Warren at the Rockefeller Foundation, and then Ken Warren goes to Robert McNamara, then president of the World Bank, and he goes to Jim Grant, head of UNICEF [United Nations International Children's Emergency Fund]. They say, Look, this is gangbusters, we've got to go forward with this. McNamara gets very enthusiastic about it, but he says, Oh, we've got to bring WHO into this. Well, they did. They brought [Dr. Halfdan T.] Mahler into this, and of course, when they brought Mahler into this, they brought me into this, and they brought the EPI. And poor old Salk, having initiated this, got the enthusiasm up, found his prize being taken away from 00:48:00him. Because we, of course, are going to be using the Sabin vaccine, not the Salk vaccine.

The upshot was that, having started this, they decided they would do a big donor meeting in Bellagio, Italy, at the Rockefeller Conference Center. And everybody came. Salk—Sabin was not there. Salk came. The Merieux folks came, all the donors came, UNDP [United Nations Development Program], UNICEF, the World Bank, WHO. McNamara made the plea of saying, Look, we've got to get this program, it's a wonderful program, let's fund it. All we need is $100 million. The donors all sat back and said, Yeah, boy, it's a wonderful program, but you know we're giving millions of dollars to these countries already—all they have to do is say, We'd like to do this other thing with our money coming in. They don't need 00:49:00any more money, they just have to take the money they've already got and switch it to immunization.

Well, that was potential for a big disaster, having all this fanfare and everything going on. It was at that point that the conveners got together and decided—and I'm not sure, Bill Foege will tell the story about the intimate details of this, but the upshot was that the outcome of the meeting—rather than big money—that was established was the establishment of the Task Force for Child Survival and Development, with Bill at the head of it. So that was the big outcome, and, in fact, it was a terrific move. And it set the stage for a lot of other meetings that got convened by UNICEF and Bill and the Task Force, and getting a lot of other donors involved, and the enthusiasm. And the 00:50:00immunization coverage continued to grow from then on and reached near the 1990 goal by the end of it. But it was Salk who was the initiator of this. Poor guy, had to see this sort of taken away from him.

We had an interesting time, because in the days that he was demonstrating the efficacy of this two-dose schedule, one of the Merieux operatives, a wonderful rogue named Philippe Stoeckel, was being the principal organization of these vaccine trials in Upper Volta, Senegal—Mali, I think, also—showing that with outreach teams giving two doses a year, they could get coverage and, they said, 00:51:00eliminate polio with that. They did reasonably well in very difficult logistical circumstances. I have to say that they had a pretty good outreach, but they set up a place for Salk to visit in Senegal, and I somehow got along to observe with him the visit. Phillipe had set up the whole—it was a small village, and he had kids lining the streets waving little flags. I mean, it was the most Potemkin [model] kind of artificial setup. It was nothing remotely like what it was really like in the field, but it was all set up for Salk, and he came and he was delighted. He saw the things going on. The one thing that happened was that as they were leaving, Philippe slammed Salk's hand in a door of a car, which 00:52:00really hurt him. It was sort of a downside to the thing.

Salk was interesting. He was always very polite, but I think it was Richard Feynman at one point who wrote about people who are famous in one field deciding that they now have a legitimate reason for then talking about other fields, and Salk suddenly would talk about philosophy in a large sense, and many things that—okay, he was Salk, he'd done this wonderful thing, but he was talking, from my point of view, sort of nonsense in a lot of other things he said. But he was always polite, as was [Dr.] Charles Merieux. He was another rogue who—Dr. Mahler felt he had done badly by Brazil, by selling them a noneffective 00:53:00meningitis vaccine. But to meet Charles—I had a couple of conversations, and he couldn't have been nicer. He remembered U.S. support during World War II, and just a wonderful, wonderful person to meet.

It wasn't so easy dealing with the Merieux operation and the inactivated polio vaccine, but it was interesting. We had several meetings at a conference. Oh, we really need to go back, because it was not actually the Merieux facilities, but Merieux had facilities in France close to Talloires, which is near Lake Annecy. One of these promotional meetings that had started with the Bellagio meeting and 00:54:00then went on to Cartagena, in 1988 wound up in Talloires, France. And this was a preliminary meeting, from [James P.] Jim Grant's point of view, to the World Summit on Children, which he was going to convene at the time of the U.N. [United Nations] General Assembly in September of 1990. He was already looking forward to that, and in preparation for that meeting in Talloires, I got together with my colleagues in WHO and we put together a platform of goals to be achieved by the year—I guess 2000 was what we were setting the goals for then. I worked with the MCH [Maternal Child Health] folks to get MCH coverage and morbidity and mortality goals. I worked with the diarrheal disease program. We 00:55:00had our own immunization goals that we set up.

So I had that all set up for Talloires and was going to make the presentation, or it was in the background paper. Then, during that meeting in 1988, it was the end of Dr. Mahler's tenure and he had decided he did not want to run another term. He was not under term limits at that point. They came in with Mahler's departure, so he could have run another term. He'd already run two or three, but he decided he was no longer going to do it. So we were meeting in Talloires, sort of in September, I think, and it was going to be in January that the executive board would nominate a new director-general. Grant was very worried, because with Mahler leaving he didn't know who was going to come into WHO. Grant 00:56:00was eager to go along with what had happened in PAHO [Pan American Health Organization]. PAHO had done a super job in polio. Ciro de Quadros was the advisor to PAHO and come in from smallpox working in Ethiopia, and had come into PAHO, and had the PAHO directing counsel also announcing the polio eradication goal as early as 1985.

In PAHO it was good. The immunization programs were pretty far along. They were going like gangbusters, and so Ciro had a good reason for doing that, and by 1988 they were pretty far along. They were close to eradication. Ciro thought they had done it. We didn't think so, and I didn't want to have a global program goal for eradication until I felt that we had PAHO really in the bag. Because I felt if PAHO had done it, then there would be real motivation from the Americas 00:57:00to give support to polio eradication, whereas if they hadn't done the job themselves in the Americas, there would be less support to the other countries to carry it on. But with Grant worried about Mahler leaving WHO, he went to Mahler and said, Look, can't you get polio on the agenda—polio eradication on the agenda? Mahler came to me and said, Look, Rafe, can we do this for the assembly? And I said, Look, the only reason I was holding back on it is I wanted to be sure about PAHO, but in this circumstance—and I understand that you're concerned about the transition—sure, let's do that.

So we wrote polio eradication into the goals, and I got the assembly, that following spring, to endorse polio eradication. Dr. [Hiroshi] Nakajima was the new nominee and was then confirmed as director-general. I had to go to Nakajima and say to him—as he was still interim, having been nominated, but not 00:58:00actually confirmed as director-general—about, Look, I'm getting this polio eradication initiative before the assembly, what's your attitude toward that? Fortunately, he said, Well, that's fine. I'm not director-general now, you do what you want to do, what you have to do. He probably wasn't against it, but he certainly made himself clear that he was neutral. He wasn't going to make a move one way or the other. But he was not a very good and supportive director-general for anything with dealing with UNICEF, with any collaboration at all. That was not a good time for collaboration at that time. Anyhow, that's my story on polio.

TORGHELE: That's a great story.

HENDERSON: It's too long.

TORGHELE: No, it's very interesting to hear how things worked and how they came about, because we don't know. Since you talked about UNICEF and the World Health 00:59:00Organization and CDC and the Task Force, UNICEF and PAHO, these are all organizations presumably working on immunization as well.

HENDERSON: Yep.

TORGHELE: How did that work? Did you all meet together and share resources and divide up places where you would go to work? How did that work?

HENDERSON: It was pretty clear that WHO—Mahler used to say—WHO knows everything and does nothing. UNICEF knows nothing and does everything. The World 01:00:00Bank knows everything and does everything, and UNDP knows nothing and does nothing. His characterization of WHO and UNICEF—that we know everything and do nothing, and UNICEF knows nothing and does everything—was what we played out. We were the drivers of the intellectual background for the expanded program in immunization. We designed the training, we designed the information system, we did the procurement specifications, we designed the program. UNICEF more or less carried it out. They had the money to put in. They bought the refrigerators, they bought the vaccines, they bought the syringes and needles. It worked out fine. It was the best partnership in all of the U.N., the EPI and UNICEF. We, of course, got irritated with UNICEF claiming all the things that they did, and 01:01:00more than they should have. But never mind, it got done.

The UNDP didn't have much of a role. We did meet with the Task Force. The Task Force convened WHO, UNICEF, UNDP, the World Bank. So we did have those meetings a couple times a year, and that [was] helpful, but it was more the personal contact with the staff that worked out. We had quite a lot of contact between ourselves and UNICEF. CDC was a support role. It didn't have much voice in those fora, but CDC staff was serving for all of us and, I mean, there was no real difference from that. It was a facilitator for all of us. And PAHO was doing its own thing here. We never bothered with PAHO, because PAHO was getting things done fine, thank you very much. It didn't need any interference from us at all. 01:02:00So PAHO really was not involved in the things.

I was mentioning the organizations. Rotary [International] should come into it, because when I first came to WHO in '77, one of the first people I met with was some of the representatives from Rotary, who said, Look, we want to get rid of polio by the year—whatever it was. I think their goal was, at that point, 2000. I don't really remember, but they had a goal and they wanted to do it, and we welcomed them in, and they have just been absolutely super and couldn't be more supportive.

I was talking about UNICEF, and being irritated sometimes with UNICEF trying to take too much what we thought was credit—although they deserved an awful lot of credit with Jim Grant. But the Rotarians are just absolutely unstoppable at 01:03:00country level, and they funded things. They got T-shirts for the vaccinators. They were at high level to communicate with ministries of health, and they continue to do that. It was a wonderful thing for Rotary, because they could be behind this very successful effort and everybody could see what was going on in this success. We could all feel good about it. And they've just done a super job, and they have been a very, very warm and effective partner for the EPI in general, as well as for polio.

TORGHELE: So Rotary had their Polio Plus program, and there was EPI, and there was Stop Polio, which is CDC?

HENDERSON: I don't know.

TORGHELE: There were all these programs to end polio. Did you then unite in this, or were there any conflicts where you disagreed on ways to do things or 01:04:00how to get it done or if it would get done?

HENDERSON: I'm going to make an admission to you, which is that in 1990 we had more or less gotten our goals achieved for the EPI. We'd gotten immunization coverage way up. Things were going very well. Nakajima came in to replace Grant, and he wanted to shake up the organization of WHO. He did not want the U.S. assistant director general—I have to be careful about this because in WHO the assistant director generals have traditionally, or were traditionally appointed from members of the Security Council of the U.N., so there was always an American, always somebody from the U.K. or France, always from China, always from the USSR [Union of Soviet Socialist Republics]. And the American ADG 01:05:00[assistant director general] was always in charge of the finances, because we paid most of the budget. It was limited to 25% after some time, but it had to be limited to 25% because we were paying more than they wanted, to limit the influence. But in any case, Dr. Nakajima did not want the U.S. in charge, or the ADG being related to the budget. So he needed to negotiate who was going to be the American ADG and what would that ADG do. So he used me as a bargaining chip, to say that he would appoint me as ADG if he could then appoint a Brit in charge of the financial—to be the financial ADG.

I didn't want to be an ADG. It's a terrible job. You're an advisor. You lose the hands-on things, and it was not something I wanted. I kept nominating other people, and he wouldn't hear of it. So I accepted it. All right, it's a higher 01:06:00position, a lot more visibility, a lot more prestige, but I didn't like it. It was not easy to do. In any case, when I was ADG, then, Look, the other programs, they run their program. I'll help them with what they want to do, but I stepped out of any of the technical roles. So you talk about the Stop Polio, the other things going on—I didn't have anything to do with that. I lost any contact with it, so I'm not sure about how all that worked. A confession.

TORGHELE: That's interesting. I can picture them being in the same place and planning to immunize the same people, and that not working very well.

HENDERSON: I don't think that happened, but I don't know.

TORGHELE: Presumably they worked that out.

HENDERSON: I would think so.

TORGHELE: So you mentioned Rotary and UNICEF and Task Force. Were there other 01:07:00organizations? There were a lot of you working on immunization.

HENDERSON: I have not mentioned all the development agencies. USAID, I mentioned the Scandinavians [were] heavily involved, all the national development agencies engaged in helping developing countries. They were all involved with it. So what we did in the EPI was to convene what we called the Global Advisory Group—GOOP, it's just as bad—the acronym is GAG, which is just as bad as GOOP. But it was, again, an extremely powerful coordinating and motivating meeting, because the global advisory group was just twelve people, some taken 01:08:00for technical expertise, some taken for political—being ministries of health, and important politically. That small group—although it approved formally our meetings and our recommendations and conclusions and recommendations—they were really an excuse, a catalyst, for a much larger group that came to the meetings and were active participants in all the things.

If we put forth a suggestion, like, We need to immunize sick children and here's the resolution that says what we do, they would debate that. And our Global Advisory Group was there, and yes, they would approve formally the things, but it was the general discussion. And all the development agency people would come and participate, and felt—and did have a legitimate part in making policy and seeing what was going on and getting the feedback. Those annual meetings were really a very, very important motivational, technical kind of meeting that went 01:09:00on. I think they were just as important as the big meetings that Jim Grant helped to do with the Cartagena and the Bellagio and the Talloires meetings. It really helped to get everybody together at the same table.

TORGHELE: So these were more like local people who knew the cultures?

HENDERSON: We would try to get at least six of our members from developing countries, usually not ministers of health, but usually technical. Then we'd try to get six who were—at least a few of those that were noted as experts in immunization or epidemiology, that would provide some credibility to approving some of the recommendations that we made.

TORGHELE: I was going to ask you, also, speaking about people who were local and 01:10:00who did other jobs, what role did public health advisors play when—this is going back, and I read that one of the things that you did, and that you realized when you were doing your work—that EIS officers could do just so much, but they needed someone to help, and that was public health advisors.

HENDERSON: I don't know if I came up with that, but I think I was faced with that when I went to West Africa—that it had been decided that each medical officer would be accompanied by a public health advisor. I'd not known public health advisors. I knew nothing when I went over there as a young EIS officer. But when we had the program, we trained together with the public health advisors, and were a family that went together with a medical officer and public 01:11:00health advisors. The public health advisors were the people who knew everything and did everything. They repaired vehicles, they were management types, they had grown up in the public health advisor system. It was really the VD program which had generated these groups, and they would grow up in the VD program as disease investigators. Then there would be supervisors of other investigators. Then they'd run a city program or even a state program, and then they'd go to the regional office. So these were very, very experienced folks, that were then selected for their management skills as well as their general know-how, that went over to West Africa. It was very clear from that experience how valuable that group was in any public health program. And it's certainly the case when I came to EPI, there's no question about that not being an absolutely important, essential complement to whatever we did.

Although my staff—the staff in EPI that we created—was medical officers, I had two administrators. Actually one, Jock Copeland, who worked on the smallpox program, he was the chief administrator for that program, and we got fortunate enough to get him to come to the EPI. And then the other person was Val Kasatkin. D.A. had instructed me that it was extraordinarily important to have on the staff at headquarters at least one or two from the Soviet Union, because they had been and were an important partner in the program, and we needed to show that this was not just an American program, but that the Soviets [had] an important role in it. So Val came in as Jock's assistant, and he was a piece of 01:13:00work. We found out he had a difficult time with the U.S. alphabet or the English alphabet, and so he kept misfiling things. My supervisor, assistant director general Dr. Ladney, who was from the Ukraine—a wonderful person—warned me that I had better be careful in my staff meetings about what I said, because Val was reporting things back up about what was going on. I had made a disparaging comment about Aeroflot, where I had to go to a regional meeting in Ulaanbaatar, Mongolia, and I was concerned about taking Aeroflot. I said as much in the staff meeting that got quickly back to Ladney.

TORGHELE: That was a problem, then.

HENDERSON: Better quiet down on that. So we didn't have the public health 01:14:00advisors, as such, at headquarters, but they're certainly an extraordinarily important part of any public health program.

TORGHELE: It sounds like what they did was enable the EIS officers to do their work.

HENDERSON: Certainly in West Africa that was the case.

TORGHELE: Now, you were in West Africa for some time, and you were there with your wife, and she also participated in some of the outbreaks and some of the work that you did, and I would love to hear more about that.

HENDERSON: Part of it is that we didn't have children, and Ilze was trained as a pharmacist and had been working at Emory as an assistant chief, I guess, at the Emory Hospital. When we went over, the atmosphere was one of a small family in 01:15:00general. And so Ilze trained, as all the wives did, in an intensive French course, and participated in other briefings that we had for the program. I didn't see any reason for her staying home if I was going to be traveling. She didn't have anything to do, particularly, and so, to the degree I could, we went together to do things.

In particular, there came a call—actually a telegram, actually a cable—to Lagos asking me to go to India to be the chief of a three-person team that was going to administer smallpox vaccine with jet injectors. India had undergone a 01:16:00major smallpox epidemic, and there were imported cases into Europe. Their source of vaccine had been the Soviet Union, and the Soviet Union got sick and tired of giving all its vaccine and then having these epidemics break out. They told the Indians, more or less, they weren't going to get any more vaccine. And the attaché—the U.S. medical attaché to the U.S. Embassy in India—saw an opportunity for the U.S. to step in and say, we've got the vaccine, we'll give you vaccine. He was clever enough to say, Not only will we give you vaccine, but our vaccine can only be used with jet injectors. Because part of the Indian problem was that they were using rotary lancets to give smallpox vaccine, and would smear this lymph vaccine on the skin and then plunge the rotary lancet, 01:17:00which is a little disk with tines on it, into the skin, and then you'd rotate it. It would cause a hell of a mess and painful and infection. It was terrible. So [Dr. Ernest S.] Tierkel, who was the man in question [medical advisor to the U.S. Embassy], said, "We will give you the vaccine, but it can only be used with jet injectors, and we will send you this team". And Lyle Conrad, who I mentioned as an EIS colleague, and Reid, who was an even younger person, came over from CDC, and I was sent from Lagos.

I took Ilze along. We went together. So that was the start of that. When we were there, the Biafran War broke out. And when we tried to go back, we couldn't go back together because they said, Look, it's too dangerous for dependents to go back to Lagos, so Ilze can't come. You can come, but she can't. I said to CDC, 01:18:00I'm not going to do that. Look, I know the area, I'm doing troubleshooting anyhow in the general area. Send me back and let me do troubleshooting until I can get back when this situation eases up. CDC was good enough to allow that, so Ilze and I went back to West Africa, and I don't remember where we started. It may have been in Benin. Jean Roy was the operations officer there, and they were having troubles with smallpox. There were little outbreaks all over the place. We devised a situation where we did outreach on motorbikes. Ilze made little aprons for the teams to wear, that they could put a smallpox vial of vaccine in one pocket and they could put the bifurcated needles in another pocket and go 01:19:00off and then they could do the vaccinations. I remember she made those aprons for them.

Then we had an outbreak in a village in Benin called Tofo-Gare, and we didn't know that it was an outbreak, but we knew we were doing a market survey. And Ilze would help out with the surveys, taking notes and helping out to interview people. We found out in the survey a lady with a big variolation scar on her forehead, which was used by the fetishers who took smallpox scabs from a person and then used those to inoculate other people. And it was okay, it worked as a vaccination, although it killed people and it could spread from one person to another. But it was better than nothing, so it persisted. Anyway, we knew that this variolation was going on. So we knew that if there was variolation, there 01:20:00had been an outbreak of smallpox somewhere, and we traced back to the village and did an outbreak investigation, which Ilze actually helped with and helped draw the map of the village. So Ilze was very much involved with the program, and continued to attend all the meetings and went with me on all our immunization coverage surveys to help out with the sample surveys, and very much a part of the program.

I think we talked before about how frustrating it is to have her accepted—or not accepted—as when she would come to some of the professional meetings and say it's my wife. It's your wife? What's she doing here? Why is she here? It always offended me that there was this lack of recognition that the important role that wives play in general—Ilze was exceptional in what she did professionally, but she also helped at home. She helped at receptions that we 01:21:00had to do. She helped in social ways that were extraordinarily important for the program. And I think that role generally gets not recognized, and means that wives are generally not given the recognition, if they wish it. Not every wife wishes to do that, but if they do, the fact to be pushed off and rejected like that just seemed to be ridiculous. But it was a fact of life.

TORGHELE: It sounds like she helped you in lots of ways.

HENDERSON: Oh, absolutely. Still does.

TORGHELE: And it sounds like you had some great adventures.

HENDERSON: Well, yes. The ones that were the most adventurous were probably the least pleasant, but best to remember.

TORGHELE: As we sort of wrap up, I'm thinking about two diseases. Smallpox is 01:22:00one. Polio is the next one that it's hoped will be eradicated, and you said at one time that a disease-specific approach to eradication is better than an overall vaccine program, or words to that affect. Can you say that in the words that you used?

HENDERSON: One of the things I used to do quite a lot—when I could remember my quotes—was quoting from William Blake, saying, "He who would do good must do it in minute particulars." He goes on, and I can't remember the second part of it, but the general good is the plea of the scoundrel, the flatterer, and somebody else—he had three people that was there—that general good doesn't do you. What are you going to do with the general good? I want to do good. Well, what are you going to do? The minute particular is okay—I want to vaccinate, which is one sort of particular thing, but the other things—why do you want to 01:23:00vaccinate? You're not just providing coverage, you're trying to do it for a specific end, so that the approach for eradication has always been that eradication requires—if the disease is susceptible to that; not everyone is—it requires that you go to the ends of the road where the least wealthy people, the most impoverished people are. You've got to get to every one of them if you're going to succeed with that, and that's a wonderful, wonderful motivation for equity. It requires you to deal with the most disadvantaged, and there is no other motivation or goal other than eradication that really requires 01:24:00going to that length.

Now, there's a downside to that, which is, if you're not able to do the eradication, you keep failing, the costs at the end of any eradication program become enormous. Certainly, in terms of the cost per case prevented. If you're not able to do that and carry it out, then you've created a problem with your credibility. So, it's not that you should do that except extremely thoughtfully. Once you've done that, it's a fantastic way of ensuring that you're getting your programs delivered to where they really need to go. Wonderful equity assurance program.

TORGHELE: That sounds like a wonderful place to end up. A good summary for your life and your career. I would like to thank you very much. It's been a pleasure 01:25:00talking with you.

HENDERSON: I've exhausted you, I think.

TORGHELE: It's been wonderful. Thanks so much.

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