Don Stenhouse

Don H. Stenhouse

TORGHELE: It is January 24, 2017, and we are at the Centers for Disease Control and Prevention [CDC]. I'm Karen Torghele, and I'm going to be talking with Don H. Stenhouse. Mr. Stenhouse joined CDC in 1963 as a Public Health Advisor. By the time he retired in 1995, he had become the Assistant Director of Surveillance, Investigation and Research, Immunization Services Division, where he served for the majority of his 31 years at CDC. Welcome, Mr. Stenhouse, and thank you for agreeing to be interviewed for the Global Health Chronicles Polio Oral History Project.

Before we begin, I wanted to read a description of a public health advisor, which you were, by CDC's Dr. Kathleen Irwin: "Public Health Advisors make it happen. They make the logistics of doing research and program evaluation much easier. They make our projects better managed. They let scientifically trained people do the scientific tasks for which they're skilled and handle 00:01:00administrative, physical and other tasks so scientists don't fumble them." Do you think that's a good description?

STENHOUSE: That would be acceptable, yes, and other duties as assigned.

TORGHELE: That seems like a good lead-in for what we're going to be talking about today. So, to begin, Mr. Stenhouse, would you tell us a little bit about your background and how you came to be involved in public health and later at the Centers for Disease Control and Prevention?

STENHOUSE: I finished my college education in Middle Tennessee in 1963. I had an interview with an individual by the name of Preston Fish, who was in the Department of Health in the State of Tennessee, Nashville. I interviewed with Mr. Fish, and a few days later he called me and he said, you've got the job. That's great, when do I start? He said, you're going to start April the 8th in 00:02:00Fulton County in Atlanta, Georgia. I said, I beg your pardon? Because I thought I was interviewing for a job in Tennessee. I said, I'm going to have to call you back, because I've got to talk to my wife about this. I was planning on going to law school at that point, and I thought I was getting really a part-time job kind of thing. We talked it over and said well, I can always go to law school along the way, and it will be an interesting start. So, I ended up entering the STD [Sexually Transmitted Diseases] Co-op Program in '63 and remained in Atlanta in Fulton County for about a year and a half, a year and three-quarters.

Then once I became a public health advisor, which you converted [to] normally after a year of co-op activity, they had created a new program, Immunization Activities, which was created by President Kennedy in 1962. At that point, I was 00:03:00interviewed for that program and assigned to Chatham County Health Department in Savannah, Georgia, as an immunization rep. In those days and times, our major focus was getting immunizations up for childhood vaccine-preventable diseases, being polio, diphtheria, tetanus and pertussis (whooping cough). So that's basically how I got into the public health sector, through the VD [Venereal Diseases] program and then into the immunization activities.

TORGHELE: So you started by doing surveillance around sexually transmitted diseases and venereal diseases?

STENHOUSE: That's correct.

TORGHELE: So tell us a little bit about what that was like for you.

STENHOUSE: It was quite a change for a college boy from Tennessee, I can guarantee you that. They were interesting times, in that you were taught how to interview your contacts, you went to interviewing school. I went to Chelsea Health Department in New York City and was up there for two weeks, which was 00:04:00very interesting, working in a completely different area than I had ever been to before. But you do case follow-up, investigation, contacting the individuals who had been exposed, trying to ensure that they get in and get treated, and determine any other contacts that may have been exposed to the disease. In the meantime, you also learned things about how a clinic was controlled. We also drew bloods at the time. You ended up setting up programs and handling the number of people coming through at a time, so you ended up really setting up as a program control officer. The first time that I guess I got a chance to do any of that was in Atlanta, Georgia, when they had the "Sabin on Sundays" activity. The VD group in Atlanta was assigned to various clinics for operational activities, and we were out there with the sugar cubes for the three different Sundays that they did the polio immunization activity in Atlanta.

TORGHELE: Before you came and became a public health advisor, do you know anything about the history of how public health advisors came to be and some of the impact that some of the directors of CDC had on the development of that program?

STENHOUSE: Basically, my public health experience starts with my co-op years. Public Health Advisors basically were created in the 1940s to deal with venereal disease control. Initially that program was started by the Public Health Service, and it was transferred to the Communicable Disease Center at that point. They took over the VD program, which later became the STD programs. The people that were hired at that point came in, were trained, basically did the same type of work that you ended up doing as a co-op, and worked their way up 00:06:00through a variety of areas, helping either at county levels, city levels or the state level in programs developed for VD control. From there, you got…there were spinoffs, obviously, and public health advisors were widely used in smallpox eradication and then in our program, [which] came into being in '62. We had a field staff of 56 when I joined. Public health advisors were at the state level, the county level and the city level across the board.

TORGHELE: Were there any women or people of color in the program then?

STENHOUSE: In not knowing all of the people at the time, I can say that I knew some that, yes, were in the program at the time; these were small groups at the time, when you started out. As the program expanded, more and more people came 00:07:00into the program through the years. Obviously that then included more women, more black personnel and more white personnel, and the program just grew and expanded. Everybody had their assignments, and everybody did their assignments then.

TORGHELE: I wondered if there was any difficulty for…

STENHOUSE: Never. At least as far as I'm concerned there wasn't any. Those were times when everybody was basically absorbed in doing their job and getting rid of disease, and that was the primary focus for anybody that was hired. That was the focus that we had when we were hired, and we carried it out, to the best of our ability, across the board. At immunization conferences that we had, they came in from all over the country. You shared information of what worked in your area versus what you had tried in your area, and it didn't make any difference if it was a boy, girl or what have you. It was a completely good group of folks 00:08:00to work with, all the time. Never had any problems, at least that I'm aware of.

TORGHELE: Now you came to work at the Communicable Disease Center in 1963. Can you tell us what it was like then? What were the physical facilities like, and how many people, and what you can remember about what it was like then?

STENHOUSE: I can remember it was a very large yellow-trimmed brick building on Clifton Road. Right across the street was a fire department that fire engines went in and out of all the time. I interviewed with the staff at that point when I was converting to immunization activities. It was Dr. [Robert] Freckleton and Harold Mauldin and [Dr.] John Witte, he was the assistant director, and [Dr. J.] Lyle Conrad was there as our epidemiology contact. Harold and I, at that point, were the only public health advisors in there talking to each other. But from 00:09:00that point on, I saw public health advisors when I got to Savannah, because they were there with VD and TB [tuberculosis], but that was it. They had their programs, I had mine, and we ran and we saw each other all the time. CDC [in Atlanta] I didn't get back to until 1967, because I was in the field, either in Georgia or in Pennsylvania. When I came back it was still a yellow-trimmed brick building, and we were still on the fourth floor. That's when I came into the central office and worked with that group in the central office.

TORGHELE: Do you have any concept of how many people worked at CDC then?

STENHOUSE: I know it was in the small hundreds. It was not a big place. There were a few extensions to that brick building, but it was--at the time, everything around the brick building was parking lot, because you couldn't have 00:10:00tiered parking; it was against the rules for the government to have that. So you could have ended up parking all the way out to the railroad tracks in the back and walk back to work. There were a lot of things back then that certainly got changed over the years. But CDC, at the time, was a very small nucleus of very dedicated people. By that time, when I came in, all of the programs had basically fully developed as far as VD, immunization [and] TB. Later, while we were still in the building and later, as we expanded out of it, HIV [human immunodeficiency virus] became quite an activity and was basically a spinoff of the STD Program. But it was a small group.

TORGHELE: You mentioned the bill that President Kennedy signed, was that the Vaccination Assistance Act? Because that bill was signed right before you came, I think.

STENHOUSE: That was in '62; I came in in '63. It was about a year, I came in just about a year after it had been enacted, and there were already programs throughout the United States, but it was not 100%. I'd say probably two-thirds of the states may have had programs at that point. Eventually we had [programs] in all the states and in multiple city areas like New York City, Los Angeles, Puerto Rico, Guam, Mariana Islands, any of the territories and this sort of thing, so it spread, at least with immunization. VD [was the] same type of situation, and the same was true with basically any of the public health advisor-type programs. They were developed and running at that point.

TORGHELE: How did that particular bill change things for immunization? In your program…what about funding, and how did that impact what you did day to day?

STENHOUSE: Like I said, I was in the field at that point, and funding was handled at headquarters. The grant mechanisms were also handled at headquarters; they were reviewed here and signed off on. They worked through the regional offices assignment down to the state health departments and then the local health facilities. All of that was worked out at headquarters level, and I wasn't in here then. All of that was established long before I came here. The only thing I can say as far as the finances are concerned is over the years, as we expanded our activities because of new vaccines that were included, it also increased our funding levels as well and staffing in the field, as well as the central office.

TORGHELE: It would be interesting to hear what your day-to-day experiences were like. Can you walk us through what your typical day would be like in the field then?

STENHOUSE: Hmm. Basically, I guess the most difficult and probably…would be your outbreak control activities; trying to get your clinics set up, get those running, get your vaccines to the area, make sure you had a cold chain so your vaccine was going to be in good shape, and make sure you had proper and necessary personnel to manage the clinic. You had to have door-knockers to get through the area to contact all the people where you were concentrating and running your outbreak control program. So, yes, I would say that probably outbreak control was a very trying time. Mass immunization programs also fell into that same bailiwick, because you're talking then either citywide, countywide or statewide programs. In the instance of many of the states, you're talking about 100 volunteers, doctors, nurses, public health advisors, working to get something done, normally in one or two days. And that was quite a job.

TORGHELE: How did you get volunteers to knock on doors to notify people?

STENHOUSE: You went to various agencies, like the Kiwanis [International], Rotary [International] and PTA [Parent Teacher Association]. If you had school outbreaks, you talked to their people about what we needed to do, get flyers out around all the houses and let them know we're going to have a clinic in the school at such and such time, and make sure all the kids in school got covered. But if you had children outside [school], below age group, below school age, [you had] to bring those in, and they would be immunized as well. These went back to, even when I was in Savannah, we did door-to-door and community-organized immunization, particularly for preschoolers, and that's exactly the way we handled that part of it. Back then, of course, we were giving DPT [diphtheria, pertussis (whooping cough), and tetanus] and polio vaccine, and you had to come back for your second doses of DPT and polio. So you had to have 00:15:00people to go back and remind people you have to come back. So, you had really three shots at this, and that filled up your timeframe.

TORGHELE: How were you able to determine if your coverage was what you hoped?

STENHOUSE: Basically, by the response and the number of individuals that you had in the area. You had physicians who were doing their job at the time, you included how many people they were immunizing; you knew how many people you were immunizing; you knew how many people were in the area. Out of that, you figured out basically what the immunization levels were. One, you had immunization records, and two, you had certificates that they signed at the time to verify that they had been immunized and to give you their permission to do so. Those things were the way, basically, that you did your tally work. When they came to the clinic, you would count them that way; if you went door to door, you counted 00:16:00them that way; and in a high rise, you had them upstairs, they came downstairs, you immunized them and they went back upstairs. The tallies were fairly easy to maintain and keep up. Your ongoing activities--when you had a school program that had a thousand kids in it, you were then facing a thousand children to be immunized. Some had to have doctors' certificates that they had been prior immunized if you were using live virus vaccines or something. But for the most part, our programs got their statistics [by] just the hands-on [counts] and coming through the clinics and health department, private physicians, and the way all of that came together and [was] tallied. Private physicians, of course, had to report any incidence of disease, so we knew how many cases of disease were going around. Health departments were reporting, and so when you also had an outbreak control program, when that incidence stopped, you knew you were 00:17:00successful. Then you had given enough vaccine in the target areas that you find where you had your initial spread.

So, all of these things came into being, you knew how much vaccine you needed when you went out there, because you were basing your clinic on certain sizes. If it [case load] got a little heavier, you transferred some more vaccine; if it got less, you moved that vaccine to another clinic. So, it was kind of an ongoing operation that worked very well eventually. Immunization levels were, as I said, we expanded vaccines from DPT and polio to include measles, and then the next [that came] out was rubella vaccine. We had a large-scale rubella activity to get it up to date, because the next real rubella outbreak at the time was basically expected in 1969. We had vaccines available, and we got vaccines out to the states, the county health departments, the private physicians and 00:18:00everything we could to make sure that vaccine was in individuals' arms by the time we got there. Of course, that incidence dropped dramatically over the years. Initially, I guess, that's the way all of the programs operated in a variety of degrees, depending on the population base.

TORGHELE: It sounds like you had to do all the tabulation by hand.

STENHOUSE: Not necessarily. We had computers back then, and a lot of this information was tabulated and then put into computers. If you had a statewide program, their counties reported to the state, so you had all of that information compiled, so yes, you had computers. Some of them were better than others, and some of them were newer than others, and they also got smaller as time went by. The EIS [Epidemic Intelligence Service] Officers were carrying very large Compaq computers when they went on an outbreak, and these got smaller 00:19:00and smaller. So yes, it made a difference. The better the computers they use, the easier in the processing and the faster we got data in.

TORGHELE: Did the parents have those immunization cards? What I remember is the blue cards that had all of the immunizations on them, and they checked off which the kids had and when?

STENHOUSE: Depends on the state and type of immunization records they passed out at the time. The main thing is that every child had an immunization record, particularly when you started in your preschool group, so when they got to school age, they had documentation that they had their preschool immunizations. Even then, you went through booster programs for school entry to make sure that they had those six-year old shots that they may not have gotten, or if they hadn't finished a series because they moved. There are a variety of reasons for those things. So that way, you always were able to track how many doses of vaccine each child had with their record.

Then as we developed more and more, it became more essential that everyone had a 00:20:00record based on their private physician's immunizations as well as the health departments' records, and individuals were given those records. In fact, there was an incident when we were in Guam, we gave immunization records to them when we gave the immunizations. We found out that they were losing them, so we gave them immunizations again and immunization records when they got on the plane to leave Guam. Then when they got to the States, they had lost them again, so lo and behold in the States many of them got re-immunized again. So, the key was to keep up with your immunization record—it became very helpful.

TORGHELE: I guess parents here had to have them to get into school then?

STENHOUSE: Eventually we had, at least in the immunization program--many states had immunization laws for [school] entry. A lot of states still did not have or did not have laws that covered all the vaccines that were available. One of the big major focuses with immunization program at the time was to make sure that 00:21:00each state ended up with an immunization law for at least school entry and as well for preschool. These individual programs, many of them were acts of their legislature to get these things done in governors' offices. So, it was very important that we got that and there a vital boost to getting the immunizations into the children's arms and making sure that they were immunized. There was major decrease in immunization or in disease through immunization while they were in school, because they ran a close compact group. When you have a lot of unimmunized kids in one spot and somebody comes in from outside their area and exposes them to it, you're going to have a lot of disease, be it polio or measles or anything else.

TORGHELE: Now you mentioned the cold chain.

STENHOUSE: Yes, that cold chain was very important. When you get out in the field…our program distributed vaccines to the state health departments, and 00:22:00the state health departments distributed them to local health departments or private physicians' offices if they needed them. The cold chain meant getting it to one of the states and then making sure the state had facilities to store it properly and then from the state's office down to the county level, making sure they had places. Then it was out to the clinic settings to mak sure that the [refrigerators] had the proper settings and then mak sure that people went through and checked the expiration dates on these vaccines to make sure that they were still good. If you went out on outbreak control, you had to make sure that you had coolers, to keep the vaccine cool and cold until you had finished your program and got back, or if they had refrigerators, great.

But in many of the smallpox programs you didn't have that luxury; you operated in anything that you could put a cold dog [reusable cold pack] in, Styrofoam or what have you, and carry that type of thing. When we were in Nepal, we had 00:23:00coolers; they were transported by the Ghurkas when we would go out and do clinics. We had packed those with cold dogs and then had our vaccines in the bottom of it. We'd go out and do the immunization program and come back and put it back in the refrigerator again. But in many of those areas and particularly in developing countries, you don't have a lot of cold storage out in the local areas. So you had to make sure that [maintaining correct temperature] was always possible when you were going to do a program.

TORGHELE: So there must have been places, too, that didn't always have electricity?

STENHOUSE: Absolutely! In many of those they still had those - -a lot of times you can use generators and they would take generators out, if it was going to be a longer program. Otherwise you would use what you could, cold dogs, dry ice, freezing compartments where you could freeze your particular - -. A lot of your vaccines were lyophilized, so as long as you kept them good and cold, they were 00:24:00freeze dried. Until you reconstituted them, they were perfectly good as long as they were cold. Once they were reconstituted, you had to use the vaccine up very quickly and it didn't go back, but the main thing was keeping it cold. For transporting it, yes, [keeping it cold] was an issue, particularly when you went out in the field and particularly in foreign countries. The cold chain was very important to those programs.

TORGHELE: Can you tell us what the term lyophilized means?

STENHOUSE: I'm sorry?

TORGHELE: The term lyophilized.

STENHOUSE: Lyophilized, freeze dried. It comes out--they take the vaccine, which is basically a liquid at the time, and freeze drying it removes the moisture so you have nothing but a powder left or a pellet, depends on how they use it. Then when you get to your spot that you want to immunize, you add your water that's provided with the vaccine. Distilled water and the lyophilized product are then 00:25:00mixed, and you then use it. Syringes are basically the same way: you have your product in there, and the liquid is in the syringe when you push it down, it pops the tube, mixes, shake it and then you give it by syringe. So, all of it worked out the same way.

TORGHELE: Must have been quite an advance in some places you were….

STENHOUSE: Oh yes, it certainly was. Certainly was. When we were doing mass immunization programs, you could have, like with smallpox, you had a vial where you could end up giving 100, 200, 500 doses out of the same vial, using a jet injector. Depending on how big that you wanted to put on and mix at the time, you only mixed up [for] what you hoped was going to be the number of people you had. If you mixed up too much, you were going to lose it. Most of your lyophilized products came along like with measles, mumps, rubella type activities.

TORGHELE: So you had to do very careful calculations.

STENHOUSE: Certainly was.

TORGHELE: And tell us about the jet injectors.

STENHOUSE: Jet injectors were used, I guess, starting with the smallpox eradication programs and used [at a] minimum for, here again, large-scale mass immunization programs, at least with our group. Jet injectors were also used in the military for recruits, so it made it much faster going through using a jet injector than it did needle and syringe. Some very, very big people had been known to pass out just seeing a needle, so it made things a little bit better. People had a concept that a jet injector was painless. It was not painless. When you're putting anything into your arm, it's going to hurt. If you didn't use it correctly, you could make it hurt even more. So, training with the equipment was very necessary, and keeping it sterilized was necessary. Using it correctly, you could run immunization programs and immunize 200, 300 people with an injector in 00:27:00an hour without any trouble. In smallpox, I was in a clinic over in Yugoslavia with the last smallpox outbreak in Europe, and we immunized 250 miners coming out of the mine and 250 miners going into the mine in 30 minutes. Dr. [Tim] Townsend had an injector on his side, and I had an injector on my side, and that was it. So, we did a lot of people very quickly.

TORGHELE: Was anyone scared by the sight of the jet injector? They are big, aren't they?

STENHOUSE: That brings up an interesting point also. In Yugoslavia, when we were doing the smallpox program there, I took 20 jet injectors with me. The news got out that we had come, the Americans had arrived in Yugoslavia, and we had brought our jet injectors and smallpox vaccine to help them fight off the smallpox. Well, they had immunization programs set up, and I traveled around 00:28:00through the country in our area, Belgrade and as far as Split. We came to one clinic, and getting people into the clinic wasn't a problem because Yugoslavia was very strict about following directions. When they said they were going to immunize everybody in town, they meant it. So, everybody lined up, and I looked at one of the ladies that came in. She was about 4'6"-4'8," and I looked at her and I said--I had a translator--and I said, tell this young lady--she was probably 80--that she doesn't need smallpox vaccine, she's had smallpox. And he translated it to her, and she got, I mean you could see, she bowed up and she said, "American pistol." And the translator said, she wants the vaccine, and I said, yes, she does. Thank you very much, ma'am, and off she went, and that was 00:29:00the end of that. So, you have some interesting situations that develop.

TORGHELE: She didn't want to miss out.

STENHOUSE: No. On the other hand, a child might have seen it [the jet injector], and it took two or three public health nurses to deal with that particular situation, so yes. However, I also, at the airport, had trouble when I passed through some of the customs areas, particularly in places like Nepal and into Yugoslavia. When they said, what are in these little typewriter-looking cases? I said, well, they are jet injectors. They said what's that? I said, it's like a pistol you give shots with. Boy, that was the wrong thing to say. So, we had to open up the cases and show them what we had in there, and I had to demonstrate the blasted thing. Luckily, we had water in it to keep it sterile. They said, oh, how fascinating, and that was that. I closed it up, and everything was fine. But yes, they can get very interesting attention at times.

TORGHELE: You were in a number of countries, different countries, and I know 00:30:00[for] part of the program you were usually paired with a medical officer. So, the medical officer's job was to do the medical stuff, and you did all the, you did the ground things. Right?

STENHOUSE: Well, yes, like in Yugoslavia, I was the PHA there. We had, I believe, eight or nine medical epidemiologists that went in, [Dr. J. Michael] Mike Lane was the team leader, the medical officer. They were basically epidemiologists that were looking for all of the cases. They did all of the medical work-up, they did the investigation for the outbreak, and where was it existing and where were our target areas. My job was basically to train the people to use jet injectors, make sure the vaccine got on board, make sure we had record-keeping activities so that we knew who was coming in, when they were coming in, and set up the clinics accordingly. So yes, in those situations, they were. In some situations, pairing I think is probably the best word, EIS 00:31:00Officers and medical officers and public health work well together. The EIS Officer was in the medical arm, and the Public Health advisor was the managerial administrative arm, so between the two, you got a pretty good job done.

TORGHELE: You were involved in some very major immunization campaigns, one of them was smallpox and one of them was polio. Can you talk about what that was like? You were there for the final phases of smallpox in Europe, it sounds like.

STENHOUSE: The Yugoslav outbreak was quite surprising, because they hadn't had any smallpox really in those areas for a number of years, and if so, it was usually imported. That's exactly what happened in Yugoslavia; it was imported. The people had been on a hajj to the end of the Mediterranean area, they had 00:32:00been exposed to smallpox in the Middle East, and they brought it back with them. It started in one area of the country; it was misdiagnosed at the time because they hadn't had any smallpox in years. By the time they realized they had smallpox on their hands, they had a lot of smallpox. And so, when our team went in, the doctors were faced with tracking down all of the cases and all of the contacts throughout the country. Then making sure that everyone got immunized was basically then in my court. So that's how we usually worked together. It was a big program and it was very successful; [it] stopped it [the outbreak]. One or two cases got out of Yugoslavia into Europe, but they were caught coming in through airports or by train. So for the most part, everything settled down pretty well after that. But that was the last major one. Mike Lane and I went out to the smallpox ward in Belgrade and at the time they had 60 smallpox cases there. That's when you're very, very happy the smallpox vaccine works. Very happy.

TORGHELE: When you saw the cases and the consequences…

STENHOUSE: And you had to make sure that you didn't want to get smallpox. So, we were all well immunized against that by the time we got there.

TORGHELE: Now did you combine--it sounds like you combined some of the immunizations, you gave DPT and polio and smallpox maybe, how did you…?

STENHOUSE: Well, smallpox was all out of the country. In the United States, we did not have smallpox. That eventually led to the elimination of those countries that did have it, so it could be totally eradicated. With the other diseases, it's not as easy. You're still going to have spreads such as diphtheria, pertussis (whooping cough), it's reoccurring in adult populations. Diseases such as those can reoccur easily, such as polio. With polio you have to have a 00:34:00continual level of immunity in the community to make sure that you're going to keep that outbreak from occurring. In these days and times, with travel as easy as it is, if you're in Turkey today, or any place else for that matter, Timbuktu, and come back and you're exposed to a disease, you could bring it to the middle of the United States within 12 hours. So, it's very important to make sure that you keep your immunization levels up in all diseases and track down those cases just as quickly as you can and the contacts that they may have had.

TORGHELE: What was the impetus for starting…it sounds like some of what you did was, you responded to where there were outbreaks by bringing in that specific vaccine for that specific disease.

STENHOUSE: That is correct. That is basically what I did from headquarters area. 00:35:00When I was assigned here, I worked with outbreak control programs, and the Center maintained a stockpile of a variety of type of vaccines as well as jet injector equipment. So, if you had an outbreak in another country, many times they would request our support, EIS Officers, medical officers, to participate in the epidemiology and work-up of the program, as well as equipment and vaccine. Sometimes, I would go out for that. It was a short-term thing where you had the delivery; it could be anything from two weeks to six weeks, depending on the size of the program. But my activities outside were of that ilk—outbreak control. Smallpox was long-term, you were assigned there for a year, two years and these were assignments. You were the representative in that country, you were the help to coordinate, you trained the people onsite there, just as we did here in the States. And you trained them how to give smallpox [vaccine]; you 00:36:00trained them how to give the immunizations that were necessary in those countries. So those were long-term assignments, just like we have long-term assignments here in the States. My overseas assignments were short-term.

TORGHELE: You talked about going to Guam at one point; can you tell us about that and what was the purpose and how did you get there?

STENHOUSE: Dr. [William H.] Foege came into the immunization office and sat down with Harold Mauldin, and Harold called me into the office. Bill said, what do you have on your schedule? And I said well, I'm not doing too many things. He said well, we have some diphtheria and we have some measles in Guam with the refugees that are coming out of Vietnam. How soon can you be there? I said well, that depends, I guess, on getting the equipment together, and getting plane fare. He said, there is a plane at 12:30 this afternoon, and I said, that's fine. So, I went to Guam, and when I got there, an immunization rep was there 00:37:00who was assigned to the Mariana Islands. He met me at the airport, and we went out and started looking at things, at the tent city, which was out at Orote Point, outside of Agaña, Guam. That's where the refugees were coming in from Saigon. These were mothers, fathers, grandfathers, great-grandfathers, grandmothers, children, infants and then ex-soldiers that had fought as well. They came in by ship, mostly, there were a few planes initially, but the majority arrived by ship. The 101st Airborne was there at the time, and we were assigned a squad that worked with us medically, and we trained them with the jet injector usage. We met every ship that came into port in Orote Point in Agaña 00:38:00and immunized every child under eight years of age with everything we had, which at the time, was DPT and polio, as well as the measles, mumps, rubella vaccines. We were there for several weeks until the last refugees arrived by ship. Then from there they left Guam and went either to Canada or the United States.

TORGHELE: So this would have been at the end of the Vietnam War?

STENHOUSE: That's correct.

TORGHELE: About what year was that, can you remember?

STENHOUSE: 1975, I believe, when they came out.

TORGHELE: And you were in Yugoslavia. Were you in any other countries? You were in Nepal.

STENHOUSE: In Nepal, they had the meningitis outbreak in Kathmandu Valley, and we went in and we did the same type of operation basically that we had done in Yugoslavia. I went and a deputy epidemiologist from our program, [Dr. Stephen 00:39:00L.] Steve Cochi, went who was the medical officer, and a medical officer also joined us from India, [Dr.] Lauri Markowitz. They did the epidemiology, tracking down the cases of meningitis, where they were occurring. I trained the people here again in jet injector usage, made sure the vaccine got there and was well stored, trained the people that were going to be working in the clinics and then set up the clinic schedule and where the programs would be. They'd had several hundred cases of meningitis, and it was expected to peak at even higher levels. We ran the outbreak control program, and they dropped down to like six, seven cases within the next reporting period over that next month. So, it was fun to be there, to be with the people, they were great to work with. We trekked out to some of the little villages out there, and the workers carried the vaccine in 00:40:00coolers, and we set up and gave the injections out in the…and always had tea with the chief at the village and then got started. The chief was always the first one to receive his immunization, and then we'd do the rest of the village, kids and what have you, they'd line up, and then we'd come back to Kathmandu. But it was a good program and a very successful program. Then Steve Cochi went on, years later, and he led the Global Polio Eradication Program, which I guess you're familiar with?

TORGHELE: Mm-hm. That's so interesting that you first had tea with the chief of the village. Is that so he could set the example for the rest of the people?

STENHOUSE: Exactly, exactly. And it didn't hurt, it was nothing to be feared, you follow me. So, you're the head person one way or the other. And it worked. 00:41:00In Kathmandu, per se, we actually went from various school districts around the city and had workers go out and then scan the areas and bring people into the clinics. We did all the school kids as well, and then had a separate clinic for all of the preschool kids and had them brought in. Those that didn't come in, we even took vaccine to them, and their nurses gave it to them in their houses. It worked out pretty well.

TORGHELE: So we were talking about different countries you were in, I imagine you had to use different communication systems to convey that you were going to be there. How did they do it? How did, you know--there must have been some interesting situations there.

STENHOUSE: In Kathmandu, English was pretty well spoken in the country, so that wasn't really a problem. But when we went out, all of my team people were mostly ex-British soldiers, Gurkha troops, and they were used to this 10,000-foot 00:42:00altitude. I was a wimp, I mean, I had trouble breathing, period, and they were carrying these loads in when we'd go out. We had a couple of vans and we'd get out in the country, and then we'd have to hike it up a ways to get to the little village. But English was not really a real problem there, and we had translators. In Yugoslavia, we had people that spoke English, and in fact, when we were on our free time in Belgrade, it was fascinating because the university students would gather where they knew that we were gathering, because they wanted to practice their English. That was kind of interesting. In Guam, there's no problem at all, it's all English speaking. But obviously for PHAs that were working in Africa or in the Middle East, you have a different ballgame, and you have to work through translators in many instances.

TORGHELE: And there were places that didn't have telephone service...

STENHOUSE: I'm sure that there was. Kathmandu, the year before we got there, had 00:43:00electricity on one side of the city one day and electricity on the other side of the city the next day. So, the day we were there, they had electricity on both sides of the city. Some of these things were still in developmental stages when this was happening. People had bought refrigerators, because they had to use ice boxes up until that time. What they would do is they would get everything put in the freezing unit when it was their day, and then they could take it out and thaw it on the day that it wasn't, when the electricity wasn't on. So they kind of alternated their programs. But with vaccines and this sort of thing, all of our facilities when we had it in there were always occupied, in freezers or in refrigerated containers in the state level or the national level.

TORGHELE: So you adapted to whatever situation you were in.

STENHOUSE: Exactly—you had to.

TORGHELE: That's part of what you all had to do.

STENHOUSE: Exactly.

TORGHELE: That must have been very interesting.

STENHOUSE: It was, and you meet some very interesting people that way.

TORGHELE: Did you ever have times in your work, either domestically or foreign places, where you had vaccine shortages?

STENHOUSE: I'm not sure I heard that correctly.

TORGHELE: Did you ever run out of vaccine in places, or have problems with allocating it for the numbers?

STENHOUSE: At times, when you're having a large-scale program, a city program particularly, you estimate how many people you expect at a particular clinic and you stock the vaccine for that, plus an overrun. In some instances, that doesn't happen. For some reason, a lot of people show up at that particular clinic who actually belong in another area, and for some reason they came that direction. Maybe they were going someplace else and it was on the way. In that case, yes, 00:45:00you can run short of vaccine, but that means these other clinics are not getting used as heavily, and so you transferred vaccine from one side to the other. Plus, we had reserve vaccine in the place where we were working. So, no, we didn't run out of vaccines. Cold chain, here again, was the main thing. But getting vaccine to clinics in some of the places we worked, in large-scale statewide programs, they move vaccine from area to area by helicopter or by truck or what have you. But all of the clinics were covered; you never ran out.

TORGHELE: That's because you planned ahead.

STENHOUSE: Absolutely. Like in Arkansas, they planned weeks ahead to get that operation under way, setting up programs where they were going to be in the counties, and each county had their own program. When you're doing a statewide program, all of that comes together at one time. So you have to be ready with 00:46:00back-up supplies in each of the counties as well as at the state level, so that you could back up those supplies out in the state. So, it's a very necessary--and the same thing happens with jet injectors. If a jet injector breaks, you have to have that gun replaced very quickly. We usually try to have, at least, an injector close by as a spare, and then we could back that one up someplace else. So, you make sure that that didn't happen. The needle and syringe group, the same type of thing, you estimated how many needles and syringes you're going to have to have and have a backup. If you ran short and had to go to your backup, you notified somebody, and they got new reserves out there so you didn't run out.

TORGHELE: You mentioned earlier "Sabin Sundays." Can you tell us about those, how those came to be, and what they were like for you as a public health advisor?

STENHOUSE: The only one that I participated in was in Atlanta, and that was when I was in the co-op program. We were assigned to clinic locations in Atlanta, 00:47:00Georgia. You had long lines of people, long lines. This was back in the days when you had the sugar cubes in little cups, and the person was there putting the drop on the sugar cube or when their babies came through, they'd put the drop in the mouth. But these were usually all-day sessions. In those days, you had basically three different types of polio vaccine being used, so you usually had three different clinic days. That usually occupied your time for a while there in the clinic. For each type of vaccine, you'd usually have the same amount of people come through. So yes, it was an interesting time. That's the only association I had with oral polio vaccine clinics, short of what they used in the day-to-day routine that we were doing in immunization programs.

TORGHELE: When you came, had they already switched from the Salk vaccine to the Sabin vaccine?

STENHOUSE: Sabin vaccine was being introduced, as I said, in Atlanta basically, in '63 when they were doing the outbreak control measures at that point. Sabin vaccine was available prior to that, as was Salk, and Salk was still used in many instances. The DPT and polio vaccine was used. For a period of time then, polio vaccine started, at least in our country, to be generally used as a trivalent vaccine. The vaccines were combined into one dose, and you ended up with all three with your booster dose. But here, we were finding that possibly you had more reactions with the oral from time to time, since it was a live-virus vaccine. Consequently, if people who were in close contact with 00:49:00individuals who had received vaccine recently and had exposed an individual who had never had vaccine, the potential was there for infection. Those infections did occur from time to time. These were all watched very closely by the American Medical Association, the pediatric societies, the health departments, and the Advisory Committee on Immunization Practices. Eventually, they decided that the number of cases we were experiencing in the United States that were oral polio cases, connected cases, could be basically eliminated by changing to the Salk vaccine again, the inactivated type vaccine. It was a long and hard debate, and it took some time to get changed, but it did eventually become changed, and they 00:50:00moved back to the inactivated Salk vaccine types.

TORGHELE: So speaking of the cases, vaccine-associated paralysis: did you ever become involved at all by providing information or anything to litigation related to those cases?

STENHOUSE: No. There was, I know, litigation from time to time, we would get requests for information; they had the information normally put together in packets of all of the information that CDC, at least, had records on that particular occurrence, and they furnished that to the local health departments and to the attorneys if that was necessary. But that was basically the only extent I had in it, at least that I saw… possibly sending a packet out every now and then.

TORGHELE: I'm going to give you some names that we have mentioned before and 00:51:00just have you elaborate on them and how they were related to the Public Health Advisor program. If that's okay?

STENHOUSE: All right.

TORGHELE: Bill Foege.

STENHOUSE: Bill Foege, of course, was very active for years and years in smallpox eradication and became Director of the Centers for Disease Control. He was one of those people that was basically on the job, he was on the spot when he was in the smallpox programs. When he became director, he was the same there. He was a very good individual to work with and have around and experience; he was a very nice fellow. He and I traveled to, on one occasion, to Arkansas when they had finished their Every Child [by Two] Program in 1974. Bill Foege and I went out to the governor's mansion, which at the time was Bill Clinton and 00:52:00Hillary Clinton. Mrs. [Betty] Bumpers and Dale were there [We were] introduced and went through the program together, so I got to brief him a little bit about the program that was going on, and he got to meet some of the people out there. They were very approachable at all times and very knowledgeable. They knew public health advisors, they had worked with them, and there was a mutual respect.

TORGHELE: [Dr. David J.] Dave Sencer?

STENHOUSE: Dave Sencer was the first medical officer I met. He was in Georgia when I was working with the co-op program. I met him there, and that was, of course, back in '63-'64, and then obviously he became Director of the Communicable Disease Control [Centers for Disease Control and Prevention]. We worked him just like every day. He had worked with public health advisors; he 00:53:00was very pro public health advisor. His assistant director was a public health advisor, [William C.] Bill Watson. It's just one of those areas where public health advisors and medical officers worked together as a team for major activities throughout all of our public health areas in CDC.

TORGHELE: Bill Watson and the Watsonian Society.

STENHOUSE: That basically says it all for Bill Watson. He was an epitome of what public health advisors had the opportunity to rise to. He was a very good person to work with, and I think everybody had quite an affection for Bill. He was quite a man, and obviously, we wouldn't have a Watsonian Society if he had not 00:54:00been well respected by the public health advisors. And in fact, even the medical officers were deemed in certain instances as a Public Health Advisor by an award ceremony. We would nominate a medical officer each year that worked very steadfastly with public health advisors to be an honorary public health advisor. That was started and carried out, and Bill Foege was one and so was Dave Sencer.

TORGHELE: You talked about Arkansas a couple of times and the Bumpers, can you talk about their work with immunization, Betty and Dale Bumpers?

STENHOUSE: Betty Bumpers was very pro-immunization in the State of Arkansas, and they had done several immunization programs. We had public health advisors there, and Clarence Wisecup and I went out. And she had decided that she was 00:55:00going to be, their State of Arkansas was going to be the best immunized and protected state and the first to do it. We made a road trip, myself and Luther Deweese, who was from the regional office in Texas, and we traveled by school bus just like Betty and Dale used to campaign around the state. We went from one public health office in one county to another public health office. When we didn't have public health office, we did them in a school where various groups came in from all of them, and we informed them of what the program was and what it was going to do. So, she was very supportive of immunization. After that she became a participant on the Immunization Action and Advisory Committee for Immunization Practices. Dale was always very, very supportive of immunization in 00:56:00the United States and a very good person to work with.

TORGHELE: I was looking at some of the history of the immunization department, and I read that Charles Schulz had some Peanuts cartoons relating to immunizations.

STENHOUSE: Yes, he did. He did that when we were doing our Immunization Action Programs. He did a week's series in the Peanuts cartoon where Linus was being taken down to get his measles shot, and I think they were pretty well received. How much influence it had on people getting measles vaccine, I don't know; we sure liked them. We used them as much as possible. He sent us a couple of copies of that thing to our office—we had them hanging up for a while. In fact, we still, every now and then, you'll see them run. Every school year when you get started, you'll see that same Schulz cartoon series come back out again about 00:57:00getting immunized. It was pretty effective, I guess. The other thing along that line was Star Wars, and we had posters that went nationwide with R2D2 and 3CPO standing there together and saying, "Children of earth, get immunized! May the force be with you!" So yes, we had some good support on the health education side through people like this.

TORGHELE: Did Bob Freckleton--was he also sort of a cartoonist?

STENHOUSE: I don't remember Dr. Freckleton being a cartoonist. He may have been, he was in the office here mostly in CDC when I was in the field, I came in from the field. Bob was here, but I don't remember him drawing cartoons, but he 00:58:00certainly could have.

TORGHELE: You worked with him though; can you talk a little bit about him?

STENHOUSE: Well, that's basically it. He was the Director for Immunization when I came with Immunization and was their director for a number of years. Here again, he was very supportive of public health advisors, he worked hard. He went out and visited the projects and supported the program and its expansion through the years. We moved basically from DPT vaccine and polio to the measles vaccines and then getting contracts with those vaccines. Then we moved on to rubella vaccines and incorporated those and then mumps vaccines. Then we had a mumps and rubella vaccine combined, and then we ended up with a measles, mumps, rubella. So, Dr. Freckleton was in on the ground floor of all of that and helped make all of that happen.

John Witte, the next director that came in, was in the same ilk. He had worked 00:59:00with public health advisors as well through his career. Then [Dr.] Alan Hinman who came in was the last director, well one of the last directors in. He had come in from the state of New York; he was the state epidemiologist. He too had public health advisors, and he worked with them extensively. Then we worked with--the last one I worked with was Dr. Walt Orenstein. Walt started out in Immunization and so I knew him from an EIS officer all the way up to when he became director of the program. He was a good guy to work with. He was a good director. All of them I have good memories of.

TORGHELE: We've been talking for a while now, so I wanted to give you a chance, before we end, if you have any memories or anything that you would like us to take with us from your experiences or your time at CDC or about public health 01:00:00advisors or immunization. You can tell us right now about those memories and give you a chance to finish up here with that.

STENHOUSE: I think most of them I've woven into the discussion we've already heard. My career as a Public Health Advisor was always an exciting journey. You never knew what was going to happen the next day. You tried to plan for all the things that could happen, and sure enough, something would happen that you'd never thought was possible. These things, public health advisors all got used to dealing with and accepting, and because of that, I never met one that really was determined to get out of being a public health advisor. If anything, more of the people that our people hired when they were out in the states and what have you, 01:01:00they wanted to join us. They wanted to be public health advisors. It was a good career, and I look back on it with very, very good memories. I met very good people, some very good friends who are public health advisors, and we still see each other from time to time.

TORGHELE: It's a great way to end. I want to thank you so much for all the information you gave us and the stories you related. It's been wonderful.

STENHOUSE: Thank you very much. It's been my pleasure.

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