Ralph "Rafe" Henderson

CRAWFORD: This is Hana Crawford, the oral historian for the GPEI [Global Polio Eradication Initiative] History Project, the oral history portion. I'm interviewing Dr. Rafe Henderson today [September 29, 2017] at the Roybal Campus of the CDC [U.S. Centers for Disease Control and Prevention], and we are going to talk about the foundations of GPEI.

Would you say your name, introduce yourself, and say a little bit about where and when you were born?

HENDERSON: Yes. I'm Rafe Henderson. My formal name is Ralph H. Henderson. I was born in 1937 in New York City.

CRAWFORD: Could you talk a little bit about your early life and early career?

HENDERSON: I went to a public school, grammar school in Pleasantville, New York. 00:01:00My brother, who had run into some difficulties, some disciplinary difficulties, went off to sort of a loose military school in Massachusetts. I followed him because I thought that was just super. That was Tabor Academy, and that is now featured because of our special prosecutor who has got a granddaughter there, and every time you see his face, you see "Tabor Academy" behind him. It's a small school and a sailing school, very nice. I was able to compete for the English-Speaking Union scholarships there, where they do exchange students. They take people from a public school in the UK [United Kingdom] and a private school in the U.S. [United States], and they switch them around. I spent a year in England, which was really a transition year. I graduated from Tabor, and this 00:02:00extra year I spent in Eastbourne College in the UK--a difficult year in some ways.

Then when I came back, I entered Harvard [University] with advanced standing because they gave me credit for the year in England, which was good and bad. I only had three years at Harvard, but I missed out on getting into some of the early athletic training. I didn't get the tennis training that I would have liked to do, because I was a tennis player in those days, but then I went on to medical school and went on to an internship and first-year residency at the Boston City Hospital.

There I was recruited or met somebody who was very enthusiastic about CDC and the EIS [Epidemic Intelligence Service]. A number of us in that group that I was 00:03:00associated with at Boston [City Hospital] and Harvard came down to join the CDC. At that time there was just the beginning of what was called the smallpox eradication-measles control program in West Africa [the West Africa Smallpox Eradication/Measles Control Program]. It hadn't been created there [at CDC]. I was a first-year EIS officer looking to what program I would like to go into after my training [the two months of EIS training], and I opted for the smallpox program. Lickety-split, by September, having entered the EIS in July, in September or October I was sent over to West Africa to be an advisor for a French public health organization. It's a complicated name, the [spells] 00:04:00O-C-C-G-E [Organisation de Coordination et de Coopération pour la Lutte Contre les Grandes Endémies], but it dealt with the grand endemic diseases of importance to public health in West Africa. I was there to help out with the logistics of some of the programs dealing with measles vaccination.

That's another whole history on its own, but in brief, the U.S. had developed a successful measles vaccine, and there was a need for large-scale trials. The NIH [National Institutes of Health] did such a trial in Upper Volta, which was the Burkina Faso of today, and it was a wild success. The U.S. decided that it would be a diplomatic coup to provide measles vaccine in West Africa as an inroad 00:05:00particularly to French West Africa, where the French were really dominant in every other sector. Here was something that we had, and the French didn't, and it was a very popular program.

I went over as the second person. [Lawrence K.] Larry Altman [MD], who became a distinguished correspondent for the New York Times, was my predecessor and gave me some guidance about what to do and what not to do over there. I spent six months running around most of the countries of French West Africa, dealing with problems of lack of diluent for the measles vaccine or running out of spare parts for the jet injectors or dealing with general complaints between the 00:06:00ministries of health and the USAID [United States Agency for International Development].

CRAWFORD: Would you speak a little bit about the FMM officers with-- HENDERSON: Speak about what?

CRAWFORD: The Médecine Militaire?

HENDERSON: The Médecine Militaire--yes, the people that I often dealt directly with were the French-side Médecine Militaire, who acted as advisors for ministries of health. They were, to a person, generous and understanding. I spoke very little French when I first went over. I knew nothing about anything, and they were extremely helpful in taking me out in the field and showing me what was going on. There was one occasion, however, that wasn't so nice.

When I first met the person who was advising the minister in Burkina Faso, he 00:07:00just excoriated me because his Dodge trucks that had been delivered by USAID to help with the program ate up his entire gasoline budget. They were large trucks, and USAID did not provide any help with the running of the trucks. That was the ministry's responsibility, and he was just furious about it. The odd thing was that his name was Hubert Sansarricq [-Meterie, MD]. I went to WHO [World Health Organization] some years later, and there was Hubert, who was sitting in the Communicable Disease Division. I was at that point in a more senior position than he was, and we never actually acknowledged the fact that we had known each 00:08:00other in West Africa. I don't remember any sort of--I mean we perfectly well knew who we were, but I don't remember any actual meeting and saying, "Hi," and, "How was it?" and, "How were the old days?" That was interesting.

That experience was one that was invaluable later on because I had come back after the West Africa experience--when I was in West Africa, the Smallpox Eradication Program got formally established. Because I had been there and was there in West Africa, they asked me if I would be the deputy director of the regional office that they established in Lagos, Nigeria, for running that program, which was now twenty countries in West and Central Africa. I was there as an epidemiologist, and I was really assigned to look after especially the French-speaking countries. The experience, the combined experience, of being 00:09:00over there alone and then being a member of the regional office and doing troubleshooting all over the region was just invaluable for a later portion of my career, when after coming back to the U.S. and having training and serving in the VD [Venereal Disease] division, I went back to WHO to run the Expanded Program on Immunization.

CRAWFORD: Can you share some of the details of your field experiences?

HENDERSON: In West Africa, the issue was that--and I was just at the EIS Conference, the Tuesday morning seminars, and somebody was asking, "Was it typical for health facilities to have problems with infection?" I was going to make a comment--which I didn't--which is, if you go to the field and you look 00:10:00closely, you find incredible things going wrong all over the place. It's just amazing that anything ever goes right, but it does. Programs do succeed, despite enormous things that don't go right.

In the early days, when I first went over, we were using electrically powered jet injectors, and you had to have generators that you'd start up because there was no electricity locally. They all ran on local generators. The generators kept breaking down. The jet injectors would get clogged, which they often did. When you broke down the injector, then you'd have to clean it out, and then you'd have to reassemble it and, of course, this was done in the field. There wasn't much sterilization going on. There wasn't any real sterilization going on. So that was a whole issue of difficulties of trying to get people to use the 00:11:00jet injectors safely.

In fact, I came back from the field and said, "This is a major problem." I went to the lab here and worked with a very nice laboratorian, John [R.] Boring [III], who helped me set up an experiment of shooting staph [Staphylococcus] aureus through the jet injectors and then shooting iodine through, and then measuring the fact of how much sterilization occurred after using iodine as a sterilizer. It worked like mad. It was very good. We adopted it for a while in West Africa, until there came situations where people put the iodine vial on the jet injector rather than the diluent and got some injections of iodine. That 00:12:00didn't seem to be a good idea. Then we found out that the measles vaccine was so fragile that even a small contamination of the diluent with iodine would kill the measles vaccine that we were using. We phased out the iodine quickly.

CRAWFORD: Could you speak a bit about smallpox and some of the things leading up to polio and eradication that you were bringing in?

HENDERSON: The issue with smallpox was that now we look back on it, [we're] saying, "Well, that wasn't so difficult to do." It's a disease that you have to work hard to get--that if you're sitting across from me [and] have smallpox, and I'm over here, there's not much [if] any hazard of my getting infected. Usually, I have to come in direct contact with body fluids and [have] very intimate 00:13:00contact. The disease is silent for a couple of weeks before it breaks out into an infectious stage, so if I know that you've been infected, I've got two weeks or at least a week to get you vaccinated. If I vaccinate you within the first few days, you won't get the disease. It gives you a good window of opportunity to move quickly around cases that exist to then prevent those cases from leading to other cases. That technique of ring vaccination, as it's called, was really pioneered by [William H.] Bill Foege [MD], again a CDC person, very famous, who was working in Eastern Nigeria. He ran out of smallpox vaccine in the middle of an epidemic, and so he used the small quantities he had in the most efficient 00:14:00way that he thought was possible by just doing the ring vaccination.

CRAWFORD: And that's [by] the lancet, is that correct?

HENDERSON: At that time, we had--yes, we had moved from using the jet injectors for smallpox, which is a vaccine that is needed to be delivered really just between the upper layers of the skin. We call it an intradermal vaccination. There was a wonderful device that was developed in the U.S. by Wyeth [Laboratories], and I've forgotten the inventor [Benjamin A. Rubin, PhD]. I should know his name, but he invented this little needle [bifurcated needle]. It wasn't a needle; it was just a little wire that had two prongs on the end, very shallow prongs so that you punch them into the skin, but it wouldn't go very 00:15:00far. It just entered into the superficial layers of the skin, and that made the whole vaccination [process] with smallpox much, much simpler than it had been. It had been previously a very complicated technique. Bill was certainly using the bifurcated needle at that point. The breakthrough, the intellectual breakthrough, was not doing mass vaccination of everybody, which was what the standard procedure had been: to vaccinate eighty percent of the population, another funny statistic which really doesn't apply in many cases. But Bill used this [ring vaccination] and used the bifurcated needle in controlling this epidemic. He thought about it and then decided that this was a very good strategy to promote, and very quickly Bill had this promoted as the strategy for 00:16:00the West African program. It was very quickly adopted and proved extremely successful and then was used in the global program again. It was really the secret of that global program's success.

CRAWFORD: You came into EPI [Expanded Programme on Immunization] in the WHO, correct?

HENDERSON: Yes.

CRAWFORD: I want to go ahead to conversations about eradication and polio and how that came into this era of public health. Finding the beginning.

HENDERSON: OK. I'm sure that [Albert B.] Sabin [MD] and probably [Jonas E.] Salk [MD] in the early days both had the idea, an image of global eradication. It certainly would have fit very well with both of their personalities. But there 00:17:00really wasn't the delivery system for being able to consider a worldwide program that would do eradication. In the U.S., certainly we had that, and certainly by the early '60s, if not the late '50s, polio circulation had diminished, and then [it was] pretty well wiped out. I don't remember when the last case was, but it was certainly not later than the early 1960s.

In the EPI, when I came in--I came in 1977. At that time, we estimated at least at the beginning of the program that less than five percent of the kids in the developing countries were receiving routine childhood immunizations, as a maximum. Those that were sometimes were getting an impotent vaccine and 00:18:00unsterile vaccine, as well. There was really no delivery system available to even think about eradication of polio, which was really a disease of infants and required a very sophisticated delivery system with a cold chain, specifically, to keep the very fragile polio vaccine stable. The smallpox vaccine was very stable. You didn't have to worry about it. But polio is not. The liquid vaccine is not; the live vaccine is not.

When I came to the EPI, oddly enough, there was talk immediately about polio eradication, because my name was Henderson. I came after [Donald Ainslie] D.A. 00:19:00Henderson [MD, MPH]. I had worked in the smallpox program. We had eradicated smallpox. So the idea was, you know, "Aren't you going to come in with the EPI? Isn't that what you really want to do, eradicate polio?"

I had this friend the first few years saying, "Not at all. We're not interested in eradication at all; we're interested in a continuous childhood immunization program. It's going to be delivering vaccines forever to each cohort of children that get born into the world."

CRAWFORD: Is that more of a primary health care approach? HENDERSON: That's the primary health care. That's really one of the nuggets of primary health care. But even that caused controversy, because it could be seen--and was seen by many--as another vertical program. "Oh, you're only going to immunize children. What are you doing about maternal child healthcare in general? What are you doing about the unsafe births? What are you doing about all the other general 00:20:00health problems that are afflicting the population? You're just doing the childhood immunization program. That's not primary healthcare."

CRAWFORD: Would you detail a vertical approach and what that means?

HENDERSON: It had been the modus operandi, the standard way that major public health programs had been done in the past. Malaria was one of the big examples, partially because you didn't have the infrastructure to do everything. People said, "Look, this is a major epidemic disease, malaria. At least we can do something about that." You develop a whole logistics and specialized personnel, specialized reporting systems, specialized transport, specialized storage that just dealt with malaria eradication, and the hell with the rest of the 00:21:00program--the rest of the health system. With that approach, as you began to get further economic development and more capacity to do other things, the perception, or at least the reality, was that some of these vertical programs were actually harming the development of the more general health system. There came a shift from doing these specialized, or "vertical" programs, into doing more general programs.

The big example of this was occurring in the 1970s, or at least publicized then, with the barefoot doctors in China. That really opened people's eyes to the possibility of providing widespread general public healthcare, not very 00:22:00sophisticated, but making a big impact using resources that were appropriate to what was available at the local level. That example of the barefoot doctor in China led to a consideration by Halfdan [T.] Mahler [MD], the director-general of WHO, and James [P.] Grant [JD], who--

Well, now I'm getting myself into problems, because there was the Primary Healthcare Conference in Alma-Ata, which was in about 1977, if I recall correctly. I had just come into WHO at that time. That was really enunciating the principles of primary health care, and that was WHO's slogan of "Health for All" by the year 2000. That all got created in 1977--Jim Grant did not come into 00:23:00UNICEF [United Nations Children's Emergency Fund] until about 1980. So, I was doing anachronism.

But clearly, UNICEF was very much a partner with WHO in that Primary Healthcare Conference and in support for the concept of primary health care.

CRAWFORD: I wonder if you could talk about the first time you recall hearing about polio eradication, especially in meetings with the partners WHO and UNICEF?

HENDERSON: Actually, I was visited in Geneva. I think it was in 1979 or so. You have a monograph by [Robert A.] Bob Keegan, who talks about the polio initiative for Rotary [International] that he dates a little later. It may have been an expansion of those efforts, but it was quite soon after I became director of the 00:24:00EPI. I was visited by some representatives of Rotary, who told me about their ideal of polio eradication by the year 2005. I was polite and happy to talk with them and mentioned to them that we were really not in the polio eradication business, but trying to build up the delivery systems. They were very understanding of that and still wanting to cooperate closely.

We continued cooperation with a series of different Rotary folks over the years, and that initial contact then grew and grew and grew. Rotary had established very strong contacts with PAHO [Pan American Health Organization], where our EPI 00:25:00advisor, who had come from smallpox as well, Ciro [C.A.] de Quadros [MD, MPH], was dealing with a number of countries who had advanced immunizations systems.

So, unlike my problem at the global level, where in Africa in particular, we had just nothing to speak of with immunization, in PAHO you had relatively well-developed immunization systems, but targeting the vaccines to schoolchildren, which was beyond the age when the kids were getting the diseases. Ciro's job there was to turn those programs from a school-based program into getting infants and young children under two years old, particularly. As he did that, then he saw that the disease incidence was just 00:26:00dropping rapidly.

He had Albert Sabin, who had been doing polio eradication work in Brazil. He was actually thrown out of Brazil because they didn't want to do as much as he wanted them to do. But Ciro, with the close support of Albert Sabin, got really going on polio eradication in the Americas and got the PAHO directing council [PAHO Thirty-First Directing Council] to endorse this in 1985. By 1990, Ciro was convinced that they had done away with polio. My first contact was with Rotary in Geneva.

CRAWFORD: In 1977?

HENDERSON: In 1979, or earlier than that.

CRAWFORD: Do you remember who it was?

HENDERSON: No, there were two gentlemen, and they faded out. There were other people who were very prominent. John [L.] Sever [MD] was one of the medical 00:27:00advisors, who was very important. Herbert [A.] Pigman was somebody who was very, very strong and very helpful in the later years of the program. But when we asked Rotary for help, as we often did, either at a national level or sometimes helping us with staffing or helping a regional office staff--a position or fund a position, which was hard for us to do at WHO--Rotary always responded, whether it was a direct relation to a specific eradication project, or whether it was strengthening the general system, which helped the polio project. They were just superb with that.

CRAWFORD: Do you remember a few specific occasions in which you asked their help?

HENDERSON: Too long in the past. Wish I could, but I just know that we did on a 00:28:00number of specific occasions ask for staffing help, which was hard for them to do, but they'd get that support from them.

CRAWFORD: That contributed so much. I was wondering also if you could talk a bit about the personality of Ciro de Quadros. HENDERSON: He has passed away now, but he started, as I understand it--I didn't know him at that time--but he was working in Ethiopia with smallpox and [was] just an indefatigable worker, just absolutely applauded by D.A. and everybody else he worked with. I don't know exactly when he came back to become the EPI advisor for PAHO, but I think he came back from the field and probably almost immediately went to PAHO. He was 00:29:00there, certainly as I was starting, or at least soon after I started as the director or program manager of the EPI in 1977. He and I got along very, very well. He was, as I say, just doing a super job in the Americas, and that continued until a little later.

It must have been in the mid-eighties or maybe a little earlier than that, that he had a very good staff member, a young person starting out, and I knew of a position that had opened up that would allow him to proceed in his career. I was in the regional office and talked directly to this individual and encouraged him to apply for this other job, which he did, successfully. Ciro was just beside 00:30:00himself, angry that I had offered this opportunity or at least informed this individual that the opportunity existed. I strongly disagreed with him. [David J.] Dave Sencer [MD, MPH] here, the director of the CDC, had supported me, had used CDC support to send me off for training. When I came back, Dave said, "Rafe, you can look anywhere you want in the Public Health Service"--because I had to pay back two years--"I think you'll come back here after you've looked at it, but there's no restraint on what you can do. You do that which you think is best suited for you."

Indeed, he was right. After I looked in Washington, I did not like the 00:31:00bureaucracy I found. I did come back to CDC, and that had been really my training from Dave--that that's what you do as a manager: you offer the best opportunities you can to those that are there who are younger in their careers. Ciro felt that he was in control of this person and that he would offer him the opportunities as he saw fit, later on. But he didn't. As I say, he was very angry that I had intervened, and I did not appreciate--well, I thought I was right.

But Ciro had terrific loyalty from his staff. They loved him. And he did a super job. I always have thought of him as a go-for-the-jugular manager. He was not at 00:32:00all wishy-washy in things he did. He was very direct. He was very aggressive in all the things he did.

Later on, when I was picked to go up in the bureaucracy and become an assistant director- general, the question came of whether Ciro should replace me as the director of the EPI. My very good deputy [Jacobus] Ko Keja, who was older than I was and was due to retire and not really a candidate to replace me, he and I conferred. Ko said, "No," this would just be so damaging to have Ciro's strong personality trying to deal with the regional offices and regional directors. "It'll just kill our collaboration with the other folks and other partners that we need to collaborate with."

Now, Ciro collaborated very, very well when he wanted to, and with the Rotary he was extremely good. I'm sure he might have been extremely good as the director of the EPI, but Ko said he didn't think that was a good idea, and I went along with that. It wasn't particularly the specific incident that I talked about that was the major issue. It was really Ko expressing reservations that that would be a good idea.

Ciro was extremely competent. In fact, Ciro came over to interview with Dr. [Hiroshi] Nakajima [MD, PhD], who had then been the director-general, and Dr. Nakajima I think was very interested in having Ciro come in. Ciro decided, in fact, discovered that if he came to Geneva, he'd lose his permanent residency in 00:34:00the United States, and he was not willing to do that. So, in fact, he turned down the job.

That was at a later time. I had, at the time I talked about with Ko, we had offered the job to [Robert J.] Bob Kim-Farley [MD, MPH], who was another CDC EIS graduate and who had been working in the South-East Asia region [of WHO] with the EPI. Bob came to Geneva to head up the EPI and did not thrive very well. It was in that instance where we were looking for another director that Ciro's name came up again very strongly, and he actually came over and went so far as to threaten to fire a couple of our very good staff. He talked about reorganization. He proposed becoming an assistant director-general running the 00:35:00EPI, not being a director as I had been running it. He was full of plans and full of enthusiasm. But the issue was that he turned down the job finally because he found that it would be detrimental to his coming back to the U.S. to be a permanent resident. He probably would have been just a super director. I can't really say one way or the other. But he was certainly aggressive, and he would have done a lot of shaking up had he come.

CRAWFORD: Do you remember some of the responses to Ciro de Quadros--not necessarily his personality, but his work in the Americas?

HENDERSON: Oh, everybody just absolutely applauded it. Just absolutely. I didn't hear any criticism of it that I can recall about that.

CRAWFORD: I was wondering too--I know that the successes of PAHO and success in Cuba had led to the resolution in 1988, and I was wondering if you could speak about Cuba.

HENDERSON: I wish I could. I don't really know much about it. I don't think that that had anything to do with the World Health Assembly [WHA] in Geneva, where they passed the polio resolution.

If we go to 1988, that was the culmination of Jim Grant's really pushing the EPI and childhood immunization as UCI [Universal Childhood Immunization], which he really promoted as a--I don't really know how to call it. We were the EPI, but 00:37:00Jim needed something different for UNICEF. He couldn't be promoting a WHO program in UNICEF, so he created UCI, Universal Child Immunization, and we had to work together with the UNICEF colleagues. We finally invented the fact that UCI was the goal--that's where we wanted to be--but the EPI was the actual mechanism through which we were going to get the UCI. EPI was the program, and UCI was the goal. We tried to work that out and make that happen.

The 1988 meeting was after the decade where childhood immunization rates had really skyrocketed, largely due to Jim Grant and UNICEF's promotion, but also because of the groundwork we had done in management and evaluation in developing the cold chain. Our folks had actually invented a lot of the cold chain 00:38:00materials and certainly helped manufacturers develop the syringes, the sterilizers, the cold boxes, all of the logistics behind it. But in any case, in 1988, we had done a super job, and Jim was anxious to declare victory and go on to the World Summit for Children in 1990. For that World Summit for Children, we had developed in WHO a set of health goals, which Jim was anxious to promote as part of his program for the World Summit, and we had gotten UNICEF to be in accord with that. We were the technical agency, so we promoted a health goal. UNICEF was pretty much obligated--well, not obligated, but it was pretty hard for them to go against it if we had enunciated it, so they were happy to support that.

Jim wanted polio eradication along with the other goals we had proposed. We had not included polio eradication in that, although by that time, PAHO had done a very good job. As I said, Ciro felt that there were no more polio cases in PAHO. I didn't think that was the case, and we thought that he was a bit optimistic. I think that the data might show that there were still polio cases that were identified even into the early 1990s. Be that as it may, I didn't want to start a global program until we had confirmed that PAHO had achieved eradication. If that had been the case, then suddenly you had the entire PAHO countries committed to not have reimportation of polio, because they had eradicated it. 00:40:00They would automatically be coming [out] very strongly in support of the global program, just to protect themselves.

I didn't want to move globally until we had that assurance from PAHO and the U.S., in particular. But Jim said to Halfdan Mahler, who was just ending his term, that he would really like to have polio included. Part of the reason was that Dr. Nakajima was to come in in a few months' time. I think our Talloires meeting might have been--

CRAWFORD: Was it 1988?

HENDERSON: 1988, but the question is what the month was, whether it was the fall of 1988, as I think it was.

CRAWFORD: I believe it was fall. Yes, October.

HENDERSON: Yes, because Dr. Nakajima would have come in in July of 1989 if those 00:41:00are the correct dates.

Be that as it may, Jim Grant was very concerned that Nakajima, who was a controversial character, to say the least, might not be supportive of polio eradication, and he wanted to get that solidified before Nakajima came in, if he could. Jim Grant and Halfdan Mahler came to me at the Talloires meeting and asked if I thought this was going to be something we would endorse sooner or later anyhow. I said, "Absolutely," that we're just waiting for this confirmation in PAHO to go forward with it.

Then they said, "Well, look, would you consider doing it now rather than later?" because of the concern with Dr. Nakajima. I said that's fine. I understood that.

At that point, we prepared the resolution for the World Health Assembly [WHA]. 00:42:00That's why I'm getting a little confused about the dates, because we didn't have that much time to work on the resolution, as I can recall it, so that I'm now thinking it might have even been in March 1988 that that meeting was.

CRAWFORD: So just before the WHA?

HENDERSON: Yes, just before the WHA. I know we didn't submit the resolution to the Executive Board [of the WHO]. That's the usual way that you would have done it. The Executive Board looks over a draft or proposed resolutions and then often changes them or decides not to adopt them before sending them on for formal resolution by the World Health Assembly, formal adoption by the Health Assembly. This one did not go through that [process]. I wrote it, and we presented it directly to the World Health Assembly. That's why I say-- I don't 00:43:00remember Cuba's role in that.

Now Cuba may have had a real role in the Health Assembly, but I was there shepherding the resolution, and I did not really see any particular opposition to it, and that would have been where I would have been alerted to it. Many people might have supported it, and I could well imagine that Cuba could have supported it strongly. I'm just not aware of it.

CRAWFORD: I was curious about Cuba as setting precedent of success.

HENDERSON: Yes. I don't know that for sure. CRAWFORD: I wanted to see if you would mind backtracking a little bit because there were a number of meetings. One would have been in June 1980, at the Fogarty International Center, the Symposium on Disease Eradication. I'm hoping to document the progression of conversations around eradication versus elimination.

HENDERSON: If it was held at the Fogarty Center, I'm not sure about that. I'm 00:44:00not sure I was a part of that. I don't recall that.

CRAWFORD: OK. I wonder, too, about whether you thought early on--whether you believed there was a suitable candidate for eradication?

HENDERSON: I think I had been pretty convinced that polio was a good candidate. People talked about polio and measles in the same breath. I don't think I was ever very enthusiastic about measles eradication.

CRAWFORD: Why?

HENDERSON: I wonder about that. Certainly, when I started at EPI, there were measles outbreaks in Europe and [there was] very little enthusiasm for doing measles immunization. I was appalled, because here were the countries that were 00:45:00sophisticated, had well-developed systems, and yet they were ignoring measles. In India, I could understand it. India also was really reluctant to take on measles until we were able to do some [studies]. I don't think we did it, but a study showed that there was enormous mortality being caused from measles epidemics in India, and that was part of the things that persuaded them to come into it. But Europe should have known that. There's still a very flaccid response, I would have to say, to measles and measles epidemics. It's a lot better than it was, but it never really took on the emotional appeal that polio did. Polio was, absolutely immediately, when people got the chance, they were just all for it.

CRAWFORD: Could you share your thoughts on why that was? How that developed?

HENDERSON: Maybe two things. Certainly, the Sabin oral vaccine seemed to be such magic. That's just a couple of drops in a child's mouth, easy to do. You could do mass campaigns. They were being done. You could extend the cold chain for a short period of time and keep the polio vaccine stable. It was easier to do. Measles required an injection, so you needed to have a needle, a syringe, all issues of sterility, enormous multiplication of the logistics difficulties.

Polio, certainly with the oral vaccine--I mean, look what happened in the U.S. with the Sabin orals--Sabin Sundays, the great outpouring. That was more or less 00:47:00what happened in most of the countries throughout the world. It never happened with measles.

CRAWFORD: You attribute it, partly at least, to the technology?

HENDERSON: Partly, yes. Partly to the emotional impact of seeing a paralyzed child. With measles, kids die, and so you don't see them. I think that's another part of it that goes on. Having said that, there's an enormous push for measles eradication now. There's been great success in getting measles as a component of the EPI really strengthened in countries, and they're doing really a very good job. I still think there's reluctance in Europe. But undoubtedly, there is a shift in priority that is being seen, and it may well be that measles will be 00:48:00something that we can get rid of in the future. I don't think so yet.

Bill Foege and I have [had] arguments about that. He's arguing that polio's going to be eradicated soon and that we need to use the infrastructure for polio and have it turn to measles. I think that's very powerful as an argument. Well, I hope he's right. I hope you get rid of measles. That would be good.

CRAWFORD: I was wondering if you could share a few stories about the Bellagio meeting.

HENDERSON: Yes, well, not that [it] is a long story. I thought it might be a short one.

CRAWFORD: Is my date correct--the first Bellagio meeting being in March of 1984, two years after Jonas Salk--

HENDERSON: That's right, yes.

CRAWFORD: --and the Five-Point Plan? OK.

HENDERSON: Yes. All right. We'll forget about the Five-Point Plan for the moment.

Anyhow, Salk and Sabin had been arguing since I think they were infants with each other about the relative merits of their vaccines. It turned out that in the late 1970s, technology was developed, and it might have been earlier than that--in the Rijks Institute in the Netherlands, where they created these huge aerated vats for growing pertussis vaccine. Pertussis is a witch's brew. Nobody knows how to make it very well. There's great controversy about not only the vaccine, but how it works and how long does the protection last and what to measure as protection.

But in any case, they developed these huge aerated vats where they could grow gallons and gallons of vaccine. Somebody had the bright idea--I don't know who--of using little Styrofoam beads to grow poliovirus and then put the beads coated with the poliovirus or put the virus in the beads in the vat and they get coated--but in any case, these little beads can grow poliovirus, and it expands the volume in which the cells can grow.

The previous technology was that you grew the poliovirus on plates, where one cell was next to the other cell next to the other cell that would be growing the virus, and it meant that the volumes were relatively restricted. But when you put the little beads in there, the cells could grow. In each bead, you could 00:51:00have cells growing, and the poliovirus then replicating in these cells on the beads. If you put the beads in these giant fermenter tanks, you suddenly had a huge production facility. It meant that you could now produce inactivated polio vaccine for a very much lower cost than it used to be. That set Salk thinking, why don't we do a major childhood immunization initiative?

That comes back to my Five-Point Plan.

I don't know whether Salk ever read the Five-Point Plan or even heard about it, but in about 1982, I guess, about that stage, we were going very, very well with the EPI. But it needed to expand. We had gotten the basis established. We had 00:52:00the training programs. We had the management. We had the logistics. We had the cold boxes. We had the cold chain. But now we had to really expand it very quickly if we were ever going to get to where we needed to go.

CRAWFORD: By 1990?

HENDERSON: By 1990. We were still working on the 1990 goal.

I wrote a resolution for the World Health Assembly proposing they adopt a five-point action program. What the actions were, I don't remember, but it was basically to accelerate the program. I warned in that resolution that unless we accelerated, we weren't going to get there. That something needed to get done that hadn't been done before. I believe Salk used that in part for proposing to 00:53:00the Rockefeller Foundation and to UNICEF that we adopt his vaccine; we provide it in two doses because he felt that two doses of this killed vaccine would be sufficient--there's still a little question about that--and [he proposed] that we could do it cheaply and vaccinate everybody in the world with a two-dose regimen, using mobile vaccination teams. He started that lobbying. The Rockefeller Foundation and UNICEF then decided they would bring in Robert McNamara of the World Bank. Robert McNamara decided that this wasn't going to go anywhere without WHO.

WHO came into it, with McNamara saying that he could raise whatever it was, eighty million dollars a year or one hundred million dollars a year. I don't 00:54:00remember what his figure was, but he thought that would be the amount needed to then provide the acceleration. And that they would have a meeting in the Rockefeller facilities in Bellagio when they would get all the donors together and they would talk about how wonderful an opportunity this was.

CRAWFORD: For fundraising?

HENDERSON: For fundraising. If the donors would fundraise, they would get this one hundred million dollars and then we would just go forward with the plan.

But then it got transformed from Salk's plan, from using Salk's vaccine in a two-dose schedule to the WHO program, the Expanded Programme on Immunization using the oral Sabin vaccine. So, poor old Salk had initiated this and got this going, and then he just saw this prize taken away and off it went.

CRAWFORD: The date that I have from the Bob Keegan paper for Salk's involvement 00:55:00in that way was 1982, and then I have the first Bellagio date as being 1984.

HENDERSON: Yes, I think that's right.

CRAWFORD: I'm wondering, do you know why there would have been a two-year delay?

HENDERSON: I don't know exactly what that would have been, but I know that the conversations might well have been initiated in 1982 or even earlier. It would have taken that long to get things ginned up and really planned and done. Just to get the Bellagio facility is one. You don't just walk in there to an empty place. All the scheduling had to take place. It would have surprised me that it would have been a two-year incubation period that would not have taken place.

CRAWFORD: Okay. Then there was a second Bellagio meeting, but I think in your book you referred to it as "a second Bellagio," with air quotes, because it was 00:56:00actually in Cartagena, Colombia?

HENDERSON: That's right. Jim wanted to take on the cachet of Bellagio, so it was in Cartagena.

President Betancur [Belisario Betancur Cuartas], who was president of Colombia, had done a super vaccination effort. A one- or two-day jornado--a day of vaccination. He got everybody involved in it: the military, the teachers, all the health departments, the police--and it opened Jim Grant's eyes to the potential of the immunization programs in general.

Jim had been very, very enthusiastic about oral rehydration. D.A. Henderson and 00:57:00I had met with Jim when Jim became the director of UNICEF, I think in 1980, to try to persuade him that immunization was something that UNICEF should really get behind. Jim was accepting of the idea, a little reluctantly, but not really enthusiastic. He's bringing out of his pocket the old rehydration pack, and that was the thing that he felt was ready to sell very strongly, and he could do that. That was something he could just get the public to understand immediately.

CRAWFORD: Sounds like public primary health care.

HENDERSON: Yes, in a sense, although Jim would then be persuaded that he needed to do selective primary health care.

CRAWFORD: What does that mean?

HENDERSON: That means that you do the whole shebang; that's too much, so you want to do immunization. He invented "GOBI": G for growth, which was growth 00:58:00monitoring charts, O for oral rehydration, B for breastfeeding, and I for immunization. GOBI.

Then he divided "GOBI FFF." GOBI--Female something, but anyway, it was other good things. Family planning, I think. Literacy. Anyhow, some things added. But GOBI FFF was the selective primary health care, and it drove Halfdan nuts, because he said, "This is not primary healthcare." He actually was uncomfortable enough--well, in a sense, he recognized the pragmatism that was needed to support the EPI at the same time that he was supporting comprehensive primary health care.

He also supported the diarrheal diseases program [Diarrheal Disease Control 00:59:00Programme, WHO], which was using oral rehydration as the major intervention and as a separate element of primary health care. So he himself [understood] that these needed to be separate initiatives or could be useful as separate initiatives, but he always saw them enveloped in a very strong ethos of primary health care--that that's where we were heading: we were building primary health care, whereas I think he felt that Jim Grant's position was a little more limited. It was a little more short-term and not supportive enough of the general context of primary healthcare as he [Mahler] would have liked.

CRAWFORD: Because the audience for this recording is likely to be very broad, ranging from the general public to people with expert knowledge, could you define Jim Grant's version of primary health care?

HENDERSON: It's very difficult. I think he was being an opportunist and grabbing those things that he thought were doable. That was one of his great things, that it was "doable" and "scalable." That was another term he would use. I think he was a man in a hurry, that he saw this as an opportunity. He had the resources. He had UNICEF. He was a wonderful salesman. He was a wonderful mobilizer of things, and I think he was so busy doing those things and actively getting into it that I don't think that he was so concerned about having a comprehensive vision.

He probably had the vision. I don't want to take anything away from him. He knew the scenes very well. He was a very, very perceptive, intelligent guy. But I think he was captivated by what he could do, what he could mobilize, what he 01:01:00could get done in the immediate future.

CRAWFORD: That seems like one of the many lessons learned here. Actually, what you're mentioning reminds me of a keynote address that I read that you gave, I think it was in 1998. It was the Conference on Global Disease Elimination and Eradication as a Public Health Strategy [Conference on Global Disease Elimination and Eradication as Public Health Strategies, Atlanta, February 23-25, 1998].

HENDERSON: Oh, yes, OK.

CRAWFORD: You talked about the importance of narrow goals, which leads me to maybe introduce management and how you went about thinking about implementation. At the time you would have been--EPI was tasked, correct, by the resolution in 1988 to carry polio eradication out?

HENDERSON: Yes, that's right. But now, management in what terms? In terms of the EPI itself, or in terms of--?

CRAWFORD: I think in terms of approaching polio and all of the different moving parts. How did you approach polio as the director of EPI?

HENDERSON: As the director of EPI, I didn't approach polio. [Laughs]

CRAWFORD: Oh, I'm sorry!

HENDERSON: In 1988 Bob Keegan's monograph mentioned that Ko Keja and I had written a first global polio eradication strategic plan, or whatever it was called.

CRAWFORD: This is--

HENDERSON: I don't remember that. But our concept at that point was: you get the EPI out there because the kids are getting immunized. You spread polio vaccine around. You'll knock down polio transmission to a few islands where your immunization services are inadequate. Then in those islands where it's 01:03:00persisting, then you go after it with specific extra efforts, the immunization days or special focus on those. It was a nothing plan. I mean, it was a concept about, "We really do the EPI, and then at the end, we just get a few areas that we'll mop up for polio."

CRAWFORD: If you were to describe the tools of EPI, how would you describe them?

HENDERSON: You've got two senses of that. One is the actual physical hardware that are the tools. The other is the tool, the intellectual tool, from [smallpox]. Where the issue was smallpox, you find out your faults, and you 01:04:00identify your faults. You identify your failures. It's those failures that allow you to come back and change the program. That requires a surveillance system. That requires you to be looking actively for where you're not doing well and changing the program on that basis--as opposed to what happens in so many programs, where information is suppressed as it goes up the bureaucratic chain. To make your boss happy, you make your boss think that things are going well. You shade this, or you shade that, and your boss does the same for the boss above him or her. Up the line, it goes until the person at the top thinks everything is hunky-dory.

CRAWFORD: So what do you do?

HENDERSON: Well, what you do is you get the person at the top looking at that data flow that comes directly from the first level of intervention. You get that 01:05:00person at the top acquainted with immunization coverage surveys. who says, "Your information system says you're doing great. We just did this survey, and you're getting thirty percent coverage." The top of the chain gets to know what's happening. That assumes that the top of the chain wants to get it done--because, in some cases, they want to not learn about it. They don't want to know about problems, but you have to have a manager who is concerned about actually achieving a goal, and then, in achieving the goal, has to understand that that isn't just a paper achievement, but is achievement as documented by evidence as best you can get it, about what is actually happening on the ground.

It's that concept, and that has been something that we infused in EPI from the very beginning. As I say, that has been a legacy of the smallpox program, 01:06:00because that's how that program worked. We who came from the smallpox program into the EPI absolutely took that philosophy with us, and that really has been the continuing philosophy of the immunization programs, as far as I'm aware, across the board.

CRAWFORD: I believe you were credited in the 1988 conference papers with the surveillance strategy. Could you talk about that?

HENDERSON: I don't remember it.

CRAWFORD: OK. Let me see. It was a thirty--

HENDERSON: Oh, no, not a surveillance strategy; it was the thirty-cluster survey.

CRAWFORD: I have it wrong. Thank you. Yes, that's it.

HENDERSON: Yes, that's right. OK, that comes back to smallpox. When I was in the regional office in Lagos, I was causing trouble. This is my story, that I was causing trouble with the Atlanta folks. That's a classic regional 01:07:00office-headquarters kind of tension. They said we think this, and I said, "No, no, but I'm out in the field. I know. Why don't you do this?" So I felt that I was causing some annoyance with them. My wife and I--well, I got sent to India, not because of that, but because India had a big outbreak of smallpox. This is another long story. But the U.S. Health attaché to the Indian government--no, it was to the U.S. Embassy in India, [Ernest S.] Ernie Tierkel [MD, MPH]--

CRAWFORD: Sorry to interrupt. Could you anchor us in time when was this?

HENDERSON: This would have been when I was in Lagos. We had to go through this 01:08:00then. We arrived in '66. I think this was the end of 1967, and it was the springtime. I got a telegram saying I should report to India to helped them do a vaccination campaign using jet injectors because I knew about jet injectors. I'd helped write the manual about how to repair them. I had a lot of experience in the field with them, so I was to lead the team.

Two other people came from CDC: [J.] Lyle Conrad [MD] was my classmate in EIS, and Gordon Reid [MD] was a year afterward. We three were to go to Delhi. The telegram arrived, and I was already a day late for the meeting because of the delays.

Ilze and I went there and tried to control this epidemic using the jet 01:09:00injectors, which the Indians didn't want to use. They had been using rotary lancets to apply the smallpox vaccine. The lancets would get contaminated. The vaccine was contaminated. It was a mess. Nobody wanted to get vaccinated. They had terrible immunization rates. They immunized the same people over and over again. The military, the schoolchildren, and they never went to the places where the smallpox was actually being transmitted. We found that out very quickly. It wasn't a surprise to anybody who'd looked at the program, but to change that was just impossible. The epidemic, as they do, they peaked, and then we arrived. The monsoons were there, and down came the epidemic, and we left, not having done very much.

Now, I'm trying to go back to see why India came up. I've lost the--oh, because 01:10:00I was sent from the regional office. Ilze and I went to India at that time the Biafran war broke out. Lo and behold, the embassy said, "No dependents who are outside of Nigeria can come back because of the Biafran war." I said, "I'm not going back without Ilze." I have to apologize because I've now--because that led me to be assigned in a roving capacity, and I had Ilze with me, all over the twenty-country area. I didn't go back to Lagos for another six months until they decided that things had settled down enough that dependents could come back. For 01:11:00that six months or so, I was traveling around with Ilze, firefighting in the different countries to look at problems, helping to do some epidemic control for smallpox.

Then when I got back to the regional office, they decided that, rather than being this troublesome person doing general epidemiology, I should do immunization coverage surveys. I should do program reviews in a number of countries to see how we'd done because we were now working for almost two years there. This was USAID, who was requiring the reports. They just said, "You go do that." I used my very brief EIS training to use a technique that had been developed here at CDC for immunization coverage surveys, and that was the 01:12:00thirty-cluster immunization cluster survey. Actually, Bill Foege and [Donald L.] Don Eddins, who was a statistician here at CDC, had gone to the Gambia to do an evaluation of the program in the Gambia, and they had already done some modifications of that [Robert E.] Serfling and [Ida L.] Sherman technique.

I took what they had done and further codified it, so I could teach it to teams that I needed. For Nigeria, Northern Nigeria, I think we had eight or ten different teams that were out doing these coverage surveys, and I needed to be able to teach them to do that. We had to say--this is exactly how you do this survey. In any case, we adopted the procedure and successfully applied it in five or six countries in West Africa. But nobody really cared about it.

It was good that we documented some impact to the program, a very substantial impact to the program, and then the technique died out. But when I came back to the EPI, I said, "Look, this is exactly what we need to do for our immunization coverage surveys." From the beginning, as we taught our management courses, the thirty-cluster survey was what we taught to do immunization coverage surveys. We taught doing that as a routine to check against the routine coverage statistics that were often reported and often useless. That thirty-cluster technique--I didn't invent it, but it was the EPI who really promoted it, and then it went gangbusters. People were using it for all sorts of things that they shouldn't have been using it for because it has some limitations.

CRAWFORD: Like what?

HENDERSON: They would use it for different programs where it seemed to me--all I 01:14:00can remember was saying, "Holy cow, they're using it, and it shouldn't be used there." The brain is gone. I'm sorry.

CRAWFORD: No, this is great. Thank you.

HENDERSON: By the way, the technique is now being phased out, because we can now use cell phones. The thirty-cluster technique, the way we simplified it was that you could go into the field. We often had no statistics at all. You'd go to a city that you knew existed, and then you had to figure out what cities or settlements or campsites were administratively linked to that city. You'd have 01:15:00to do a sample survey of those areas that you figured out were related or in the sample frame, and then use the technique where you would actually sample them, not really knowing how many were in the place and exactly where they were. We did a lot of very, very non-statistical things to get the job done. Even though it was a very crude technique, it worked extremely well.

CRAWFORD: Could you describe the basics of sampling so that we have it on tape?

HENDERSON: Of what it is.

CRAWFORD: Sampling and establishing the sampling frame?

HENDERSON: Yes, OK. Let's say that we've got people in an area, and you want to find out an immunization coverage survey: how many kids got immunized. What is 01:16:00the area you're interested in? Is it the United States? Is it Georgia? It is Atlanta? Is it the suburb of Decatur? What is it? Then you have your bound around that, and then you have to decide a way of taking people that is a random sample of people. If you take a random sample, you would number every individual in that set area that you've selected, and then from a random number table, you would select several numbers. Suppose you needed a hundred people. But in most cases, you'd need a thousand or fifteen hundred people. You would select a thousand or fifteen hundred random numbers, and then you would go to each person 01:17:00that had that random number assigned because you [had] already numbered everybody. Then you would actually ask them and get their immunization status. Now, that would be a simple, random survey, and it's impossible to do because you can't number everybody, and you don't have the time to go find these single individuals.

Instead of that, you decide to say, "OK, it'll work out pretty closely if I get a group of individuals here and a group of individuals there and another group there and another group here, and then I make the average of what their status is." That comes pretty close to what a simple random sample would do. It turns out that if you get a group here, a group there, a group here if you take the mean, the average immunization coverage in each group, those means, those 01:18:00averages, form what is called a normal curve.

A normal curve is something that statisticians love because they can, from that normal curve, assign an actual center portion of that, the mean, and they can calculate how wobbly that mean is. Is it within ten points? Is it within fifteen points? Is it within two points? Within how many points does ninety-five percent of the population fall? You've got a very precise statistical means of estimating a population statistic. It requires that you get a minimum number of these little groups, so that the group of means that you then plot on a thing, 01:19:00it forms this normal curve. It turns out that if you get thirty of these little groups, that your normal curve comes pretty close to being ideal. You can get a few fewer; it's better if you get more, but thirty turns out to be a magic number, and that's the number that we've [been] using. Thirty-clusters and then you have what's the size of the cluster. There's a lot of stuff that you can go in to do, but that's the basic idea because you can get the clusters. You can get thirty-clusters easily because you're getting all the people in the same area. That's logistically feasible. You can't go to every random person and assign random numbers.

CRAWFORD: I'm assuming that was applied in polio?

HENDERSON: Yes, they'd be the same for coverage surveys. But now I was going to say, this is much more sophisticated now. Now you can do a very precise 01:20:00selection of households because many countries now have census information that actually enumerates households. You have households with numbers on them, and you can select households with a random number table, although you would still want to select them in clusters of households. You can do that now with a cell phone because your cell phones can actually direct you with GPS [Global Positioning System] to where the households are that you want to find. Having done that, you can now apply a much more sophisticated sampling technique than we used. Within each cluster, you can do a much more sophisticated sampling technique than just grabbing people in a household. You can now actually take samples of the households in a much more rigorous statistical way.

Now, people are not using--it's still hard because you still need a lot of 01:21:00statistical power and sophistication to use the new techniques, which are very good. Some of the program managers who may not have that and don't have the resources can fall back on the EPI technique and still get a reasonably useful result from doing the old technique. There's a transition occurring between the old and the new, but the new ones are the ones that are recommended.

CRAWFORD: Were you involved in training at all for surveillance in polio? HENDERSON: No, I wasn't.

CRAWFORD: There are a few different directions we should go that I'm thinking of. One of them is into the politics around the meetings that started in Bellagio and where those meetings went and tensions within the conversations. I continue to circle back to those because those are so foundational to GPEI.

HENDERSON: Yes, the first Bellagio meeting was where this is really putting the EPI on the map and getting it recognized. There wasn't much controversy. Everybody said, "Wow, terrific idea." But the donors said, "Look, we're giving all this money to countries already. All they have to do is say that's how they want to use it." I mean, "We've got millions and millions that we are already contributing. We don't want a new thing at all."

Grant and Mahler got together--I don't know who else was in the meeting; Bill Foege would tell you--because they scratched their heads and said, "Gosh, we've got to have something coming out of this meeting. It can't just be a failure."

What came out of the meeting was the creation of the Task Force for Child Survival with Bill Foege as the director. I don't know what his title was at that point, executive director or--I don't remember what it was. Anyway, he was 01:23:00the head of the Task Force, and that was to be all the agencies that were involved, WHO, UNICEF, Rockefeller, the World Bank, UNDP [United Nations Development Programme]. 

CRAWFORD: Can you describe its purpose?

HENDERSON: The purpose was really to promote the EPI and to help partners get together. They did a magnificent job, with Jim Grant animating that with funds and pressure on ministers of health and using country staff--UNICEF staff--to get ministers of health to come to the meetings and all of that. Jim was the éminence grise behind it to get it done, but Bill and the Task Force staff really did all the gut work of setting up the specifics of the meetings.

CRAWFORD: Could you tell a few stories about how Jim Grant applied that pressure?

HENDERSON: If you had met Jim Grant, you would not have any question about it. He meets with the president of a country. He's very persuasive. He's a wonderful guy. He's got a lot of charisma, and if the president says, "We've got to go and get this done," then people fall in line.

CRAWFORD: Is there a story that you could share that would illustrate his personality or approach?

HENDERSON: I don't have any significant specific event. I mean, he was always Jim Grant. He was always bigger than life. He was always terrific. For example, he was unbureaucratic: [Michael H.] Mike Merson [MD] was the head of the Diarrheal Disease Control Programme promoting oral rehydration fluids, and I was 01:25:00head of the EPI. Jim invited both Mike and me to a retreat that UNICEF was having in Upper New York State, and there we were. I mean two WHO staff sitting along with senior UNICEF folks, just invited in as family. He was like that, but I don't remember any other specific--every time I saw him, he was just being Jim Grant in a very expansive way.

CRAWFORD: And later in Talloires, right? He really led the cause at that point?

HENDERSON: As I say, it was a very informal discussion. He and Halfdan came up and said, "Look, would you get this included in these goals because I'd like them for the World Summit on Children."

I didn't have any sense that this was a crisis or anything. They came up very loose, and I was pretty loose about it. I think everybody understood that we were heading in that direction, probably because of the success in PAHO. PAHO had already endorsed polio as a regional goal. They were pretty well convinced they had succeeded, so I think everybody understood that was in the works. So why not put it into the Children's Summit at this point? I don't remember any big discussion about it.

CRAWFORD: I'm wondering if this is a sensitive thing to bring up, but I'm wondering what some of the concerns were if there were any specifically about Nakajima?

HENDERSON: Oh, yes, lots. The director-general of WHO in those days was 01:27:00certainly very much elected on a political level. If you had a European director-general, you should have not a European director-general the next time.

Remember, WHO isn't that old, so that we had, I think, [George] Brock Chisholm [MD], our first director-general, who might have been Canadian. The second was a Brazilian [Marcolino G. Candau, MD, MPH, FRCP], whose name I will come up with, I hope. The third was Danish, and that was Halfdan. We hadn't had that much experience, but we were moving from time to time. The U.S. was not perceived to be an appropriate [source for a] director-general. It's just like the UN [United Nations]. The director-general of the UN is not from a major power. It's selected from one of the lesser countries.

Halfdan was really torn. I think he wanted to continue. There was no term limit at that time, but he wanted to continue with a really strong mandate. He felt that if people didn't come to ask him to continue that he wasn't going to go out and politic to continue. He didn't get the response that he wanted, and so the nomination went to somebody else because Halfdan really had not put himself forward.

It was not Europe's turn to have a DG [director-general]. It seemed to be Asia's turn. The Japanese had done a very strong lobbying effort, and in the Western 01:29:00Pacific, which is that region, there are many small island nations. It turns out each small island nation gets one vote, and so if you have somebody from that region who can collect all those votes, it's very powerful. They've changed the selection procedure now a bit. It's a lot more democratic. We've just had the Ethiopian guy [Tedros Adhanom Ghebreyesus, PhD, MSc] who has been--now director-general--a very good process, I think that went through, much more reasonable than the old days.

Nakajima had been the regional director in the Western Pacific and [was] very known to be not an easy guy. He was somebody who did not take advice easily. He would not respect [or] acknowledge other people in his environment. He was the 01:30:00person, and so I think very clearly not the individual that Halfdan Mahler was. Just from the stature alone, he was not very well thought of.

CRAWFORD: What happened when he did become director-general? Was he in support of polio? [Fung Fu-chun] Margaret Chan [MD, MSc, PMD], I read, maybe on the occasion of his death, said that one of his passions was seeing polio eradicated?

HENDERSON: I don't remember that.

CRAWFORD: Could you say more?

HENDERSON: He didn't block it. That was a surprise. He was, I think, one of the worst managers I've ever met.

CRAWFORD: In what ways?

HENDERSON: He didn't consult his staff. He constantly denigrated staff by 01:31:00saying, "You don't know that?" He said that to me many times [laughs], and I didn't know that, it was true. It didn't bother me; I wasn't worried about it.

He would have staff meetings in which there was no direction. A couple of occasions--I can't remember the policy he came out with--and he said, "This is our new policy." He hadn't consulted anybody. Very much like our President [Donald J.] Trump today. He was going off really on his own to do things. But he didn't generally interfere with people. He let the programs run--at least the ones I was associated with--more or less run as they needed to do.

He didn't get in the way of polio. He did get in the way of collaboration. He didn't want me to go to meetings. He didn't want to collaborate with the Task 01:32:00Force. He didn't want to collaborate with UNICEF. He wanted WHO front and center, to get the credit, to be seen as doing and being the important thing. So that posed some problems. But I think the other partners understood that and overlooked that to an extent, and we were able to work under the radar to a great extent.

CRAWFORD: I'm wondering if you were addressing some of these points in your keynote in 1998. I remember you, in my reading, this is the conference.

HENDERSON: I'm going to have to read that again. [Laughs]

CRAWFORD: I keep referencing it, right? It was the Global Conference or conference--

HENDERSON: Yes, yes. I remember the conference.

CRAWFORD: But you talk about the approaches to management--"minute particulars"--and being willing to collaborate. HENDERSON: Yes, indeed. It was the quote, "He who would do good (to another) must do it in Minute Particulars: 01:33:00General Good is the plea of the flatterer," the something, "and the scoundrel."

CRAWFORD: The hypocrite?

HENDERSON: "--the hypocrite, and the scoundrel." It comes from "Tyger, Tyger, Burning Bright." Who is the poet? Who is the originator of that saying? Who was the poet who wrote "Tyger, Tyger, burning bright"?

CRAWFORD: William Blake?

HENDERSON: Blake. William Blake was the originator of that quote, and I first heard that quote made at the London School of Public Health, and I thought it was right on. That's the issue about primary healthcare. That's the issue of so many programs. "Fight poverty"--OK, great. "Love your neighbor," fine. But what 01:34:00is the minute particular? What is the issue? What do you want to do about it?

Immunization was a minute particular. Within immunization, the length of the needle that you use for immunizing [by the] intramuscular or subcutaneous [route] or whatever is a minute particular. The composition of the syringe that doesn't melt when you boil it is a minute particular. It is getting down to those minute particulars that are required really to move things practically forward. If you forget about that and you only deal with the larger issues, you can get lost in the cloud and not get much done.

CRAWFORD: Did Nakajima take an approach of minute particulars?

HENDERSON: I don't think Nakajima had much sense of management. Nakajima was about himself. No, he was a clever guy. His mind was like flypaper. I mean, he 01:35:00would remember everything. If he didn't remember it, he actually had staff members from Japan that came over to be his--they weren't called that, but he would call on them to find out the background on this or the background on that, so he was well-informed about what he wanted to know. And he would remember those things. I do not have that kind of a mind. It comes, and it goes.

CRAWFORD: This is kind of a jump--do you feel like it's a good time to do that? All of this was happening [in the] late '70s, early' 80s, which is around the time that AIDS emerged.

HENDERSON: Yes.

CRAWFORD: I'm wondering if in conversations about resource allocation if that was considered. What was the climate?

HENDERSON: AIDS hadn't really taken the stage.

Well, two changes that occurred: at the time that we're talking about--EPI--AIDS had not really been recognized to an extent. It was just being discovered in the U.S. By the late '80s, when the EPI was going strong, there was still not much happening internationally. Jonathan [M.] Mann [MD, MPH] had only come into WHO a little before that time. He had been a CDC assignee in Zaire, and he had come to WHO in the later '80s.

There really wasn't much happening, and the issue with AIDS at that time was prevention. There was no hope of doing treatment, which came later only as the drug prices began to come down and people began to realize how much of 01:37:00importance the treatment was to prevention of AIDS, that you had to go in with treatment; that the treatment itself was preventing the spread of AIDS. That was a much later development.

At the same time as that was happening, you had Bill & Melinda Gates and then other big donors and private philanthropies beginning to come in and transforming the way that international aid is being developed and funded. We never would have dreamed that the finances would be available and became available. At the same time as you had this enormous challenge of AIDS and now treatment of AIDS, you also had this enormous growth of funds and resources, so I didn't see that as a tension.

CRAWFORD: So polio was eradication?

HENDERSON: I didn't see that as a problem.

CRAWFORD: OK. It wasn't challenged?

HENDERSON: I've been out of it since I became assistant director-general in 1989. That's right. There was a transition time that I had, where I was nominated as [assistant] director-general. I hadn't quite left the EPI, and it was in 1989 or '90 that I would have been formally ADG [assistant director-general]. And now I've forgotten what we were talking about.

CRAWFORD: AIDS and whether it was a challenge to GPEI. HENDERSON: Lost it, again.

CRAWFORD: No, it was wonderful.

HENDERSON: Chalk it up to age, not AIDS.

CRAWFORD: Never. You are incredibly sharp.

HENDERSON: Because I said, when I became ADG, I would have gone crazy as the 01:39:00director of EPI had my ADG come around and tried to interfere with what I was doing. I felt the same way about my becoming ADG. I then said, "Look, you guys are doing this. Get it done. I'll come to help with problems. Tell me how I can help you get done what you're doing, but I'm not in here. I'm not going to be on your tail with every detail about it. You're the guys in charge."

CRAWFORD: EPI is in charge. HENDERSON: I just left it, yes. I did not--

CRAWFORD: And when did they seek out your counsel?

HENDERSON: They never did. [Laughs]

CRAWFORD: After 1989, they did not?

HENDERSON: No. There were various things. We had staff meetings and talked about things. They never, as far as I know, got into any real trouble, so I was never consulted about going this way or that way. They were doing fine.

What I regretted, though, was that I think had Ko Keja not died at about that 01:40:00time--he was the great consolidator and [kept] the various folks in EPI working together. When he died, then the polio guys, [Nicholas A.] Nick Ward [MBChB] and Harry [F.] Hull [MD], who was from CDC originally--Nick and Harry split off and then became much more isolated. Then, really, I think [they moved] much more vertically outside the EPI than I think would have been the case had Ko still been there. I think he would have kept it a bit longer together.

It's inevitable, if you have an eradication program, you've got to do specific 01:41:00stuff. You can't do eradication at the same time and be comprehensive, all at the same time. Those are tradeoffs, but I would have liked to see the EPI a bit more cohesive a bit longer than what happened. But I wasn't consulted on that. That was just the way it went. CRAWFORD: I was going to ask you about any involvement in GPEI when it became a formal initiative?

HENDERSON: Nope. No, no.

CRAWFORD: OK. So where would you say was the end for you in polio eradication? Would you say 1989?

HENDERSON: Pretty much. I mean, yes, as soon as the resolution was there and then moved on to be ADG, I pretty well left that.

CRAWFORD: Which actually makes me wonder: in 1998 at the Global Disease Elimination and Eradication conference--

HENDERSON: Why was I there? [Laughs]

CRAWFORD: Why you were there? I mean, clearly you're an expert.

HENDERSON: Well, I was willing to talk. I might not have known much about it, but I talked.

CRAWFORD: But I wonder what had changed from early conversations about eradication up until that point in 1998, in retrospect?

HENDERSON: Nothing is coming to mind.

CRAWFORD: OK.

HENDERSON: It'd be nice if you'd read that speech into this thing [microphone]. [Laughs] It was one--it was my last and best speech.

CRAWFORD: Sure, I have it. I can actually give you the copy of your keynote. It was quite good. And you really do address management.

HENDERSON: Good.

CRAWFORD: Managing eradication and collaboration.

HENDERSON: That's what public health is. I think a lot of it is management. You can say anything is management. Everything is management, but that is 01:43:00certainly--if you take management in a broad sense, which includes collaboration, it includes everything. [Laughs]