Voices in My Head
We are the product of 1 million ancestors, since the Renaissance alone, and of countless associates who have encouraged us, helped us, worked beside us, and guided and nurtured us. Some are distinct voices in my head as I make decisions. Others, though they may be as important, are part of a chorus rather than soloists, so I may fail to point them out specifically.
To enlarge on each one of these mentors within this book might have been distracting, so here are more details on some of these voices in my head, for those who are interested. I know all but two of the people noted here—Jeanette Troup and Tommy Francis. I shared experiences with Jeanette, but never met her, and felt profoundly moved when she died of Lassa fever in Nigeria. Tommy Francis conducted a field study of inactivated polio vaccine so massive in its breadth and impact that I was moved to start a fund for students of global health, in his name, at the University of Washington.
This review highlights a major social change that continued after my departure from the CDC in 1984. Women were a distinct minority in medical and other scientific fields before that time. Female teachers in medical school were rare, and men constituted about 95 percent of the class. EIS officers at the CDC were usually men because the military draft did not include women. All of this changed during the second half of my career, which will greatly change the appendixes in my future books.
Personal Mentors
Of course, I will miss many as I start down this path but better to do that than miss the chance to mention any. This list is limited to those I knew personally, not those I knew only through their writings.
Family comes first: parents, brother, sisters, in-laws, and later my wife, Paula, and children, David, Michael, and Robert. I was later to learn how important my grandchildren, Max, Ella, Olyana, and Erika, can be in teaching and reteaching lessons on living.
Shirley and Jim Kohlstedt hired me at age 13 to work in their drugstore. They taught me, by example, how to treat people, the importance of passion in following professional pursuits or hobbies, and the necessity of meeting the public despite teenage shyness. (At this writing, Jim is in his 90s, and we continue to visit by phone.) Because of the Kohlstedts, I developed an interest in old cars, coin collecting, photography, and science.
Bill Strunk was a teacher of biology in college. He inspired fear in students and astonishment at the range and depth of his knowledge. He would begin lecturing before he entered the room and would go to the blackboard to write, using both hands simultaneously. I never got over my awe of him, but I became one of his lab assistants as well as a weekend gardener at his home. His bluster hid a kind and helpful core that provided support for my admission to medical school.
Medical school was exciting and demanding, but few faculty members had an interest in global health. The exception was Rei Ravenholt, Seattle King County epidemiologist and teacher in the medical school. He employed me after school and on weekends and shared his passions for many things. He advised me that, if I was interested in global health, I should seek entrance into the EIS. His letter of recommendation was crucial in my reaching that goal. (At this writing, he is in his 90s, and we continue to communicate by phone and periodic lunches.)
Alex Langmuir, the creator of the EIS, is a legend. He was feared by many but a supporter and advocate for those working for him. He taught respect for numbers and the need for rigor in interpreting them. He had incredible confidence in his abilities and the power of epidemiology and passed that confidence on to those working for him.
Tom Weller became my mentor by chance. Reading a commencement address he had given at the Harvard Medical School, published in the New England Journal of Medicine, I was struck by his ability to put into words concepts that I believed but had never seen written so clearly in regard to global health. He wrote about equity and the skills and knowledge we possess but don’t share in full measure with the parts of the world in great need of them. (See chapter 8.) I applied to spend a year studying with him, only then learning he was a Nobel laureate. We forged a bond that lasted until his death at age 93.
Charlie Houston, cardiologist, mountain climber, high-altitude physiologist, and professor, also came into my life by chance, when I volunteered as a Peace Corps physician in India in 1962. Charlie became an important contributor to my life philosophy. He was an icon in the climbing community, worked on the development of an artificial heart, continued high-altitude physiology work all of his life, and provided a daily example of tenacity in the most difficult situations, all without complaining. Again, I developed a lifetime bond with him and had an exhilarating phone conversation with him weeks before he died at age 96. (I have been fortunate to have long-term connections with my mentors—but also many have thrived into old age.)
Frank Neva was my faculty advisor at Harvard. He was successful in three fields—research, teaching, and clinical medicine—simultaneously, a rarity. He was generous in his time as an advisor and a pleasure to converse with throughout his life until his death at age 89. His son-in-law, Peter Bell, was involved in my selection to direct the CDC in 1977.
Wolfgang Bulle was a surgeon educated in Germany during World War II. He was a gifted physician, who spent his life seeking redemption for his country’s role in that war. He could never work hard enough to ease his mind. I was grateful for his support in my work in Africa and for his continuing support when the CDC hired me to work on smallpox eradication. He provided an extreme example of tenacity.
Yemi Ademola headed preventive medicine in Nigeria. He came from a famous Yoruba family. Yemi was an example of compassion, competence, and absolute integrity. I met him as a classmate during the year I spent with Tom Weller at Harvard. Yemi became president of our class. In our yearbook, he wrote that no field of knowledge lies outside the interest of public health professionals. He was helpful in Paula’s and my early work with a medical center in Eastern Nigeria and with the launching of the Smallpox Eradication / Measles Control Program in Nigeria. With years of service still to be donated to his country, he was murdered by an intruder in his home a few years after graduation. The feeling of loss continues almost fifty years later.
Adetokunbo Lucas had just graduated from the Harvard School of Public Health in 1964 when I met him at the CDC. He provided an important intervention during a tense meeting in Lagos in 1967, crucial in my ability to pursue surveillance/containment strategies for the elimination of smallpox. We interacted constantly through the years as he worked at the WHO, Harvard, and Carnegie Corporation, including visits he made to the Carter Center and the Gates Foundation. Our friendship continues in his 84th year.
David Sencer directed the CDC for eleven years and was both a supervisor and a friend during that time and the years after. As a mentor, he both taught and caused concern. The teaching involved his ability to know everything, to prowl the halls of the CDC, dropping in to see people and to ask them to explain what they were doing. He had the pulse of the organization and was supportive and interested. The concern came from those same qualities; that is, he knew everything and had the kind of mind that could instinctively extract the relevant pieces of information important to the matter at hand. (I think it may be near impossible to learn this skill.) He invested domestic resources globally to eradicate smallpox, arguing that was the correct way to protect Americans. And his strategies fulfilled the demands of Congress that such global investments be shown to help Americans: the United States recoups its investment in smallpox eradication every three months.
Bill Watson, deputy director of the CDC during my time as director, was a superb manager, who combined great skills in finding ways to achieve objectives but always with the highest degree of integrity. He was a mentor not only for me but for everyone at the CDC. He also had an insatiable desire for knowledge and took a keen interest in politics. The day could not legally start at work until a discussion on current events was concluded. Few people have influenced me so continuously in work, had his understanding of the total environment in which we work, or had his ability to stay focused on outcomes.
As with Bill Watson, Stu Kingma—who was a unique combination of an intellectual, skilled craftsman, and philosopher—was a product of the group of investigators for the program on sexually transmitted diseases. The best of these public health advisors became great managers for other CDC programs. Stu was in that category. He was obsessive about doing the best job possible, but he was also philosophical and thoughtful. His answers to questions were always thought through. He worked in a variety of CDC programs, including smallpox eradication in India. We share a friendship in our ninth decade of life.
Stan Foster has been a friend and mentor since we shared our first days at the CDC in July 1962. We both worked in the EIS, on smallpox eradication in Nigeria, and on smallpox in Asia. We both had careers at the CDC and then both joined the faculty at the Rollins School of Public Health at Emory University. Stan worked in some of the most difficult places in the smallpox days and became a mentor not only for me but for countless students in other countries and at Emory.
Don Millar was the person who called me to say I had been accepted into the EIS. We switched roles at various times, as he supervised me and later I supervised him. He was bright, aggressive, and always a leader who could get things done. I learned from him for half a century.
M. I. D. Sharma was one of the calmest managers under pressure that I have seen. He was in charge of malaria eradication in India at one time but was in charge of smallpox eradication when I met him. He was wise in the way he handled people. He did not intimidate them so much as he made them want to serve him well. His stellar reputation made him a leader and a mentor for many of us.
P. Diesh, a gruff, experienced career medical officer, who answered to the minister of health of India, was initially an enigma to me. I was put off by his apparent low regard for women or workers under his supervision. It was some time before I realized his approach was based on a fear of not being respected if he did not display power. In truth, he was very concerned about those under him and became increasingly comfortable in dealing with women. And he was so effective. Give him any problem and he would pick up the phone and badger someone until the problem was solved. Nothing stood in his way. In retirement, he told me how meaningful smallpox eradication had become for him and that he would come out of retirement if we could find another such challenge.
Mahendra Dutta, another career medical officer in the upper echelons of India’s Ministry of Health, was similar to Sharma in his calm approach to disastrous problems. He was unafraid to express opinions, even to a minister of health. The second of a three-generation public health family, inspired by a Rockefeller Foundation fellowship to his father in the 1940s, he traveled constantly to the field. With his measured tones, he was able to get work out of everyone. Forty-one years after the last case of smallpox in India, we continue to communicate and be friends.
Jacob John received his medical training in the United States and turned down many offers to stay in this country. He returned to India to become head of pediatrics at Vellore Medical School. His scientific acumen, research abilities, clear thinking, writing, and speaking—plus his extraordinary compassion—have made him an important mentor for decades.
Nicole Grasset was in a league of her own. A fearless physician who drove alone from Delhi to Paris at the completion of smallpox eradication in Southeast Asia, she accepted no bureaucratic obstacles. She once wrote a letter to Prime Minister Indira Gandhi when she was unable to get the system to respond to her requests. She mixed scientific abilities with compassion, graciousness, and fashion to become an example to all.
Julius Richmond took pediatric training before World War II and became a flight surgeon during the war. He made his mark in medicine, eventually becoming surgeon general of the United States. But his interests were broad, and he cofounded the Head Start program. He was tireless in his pursuit of better health for everyone until his death at age 92.
Ed Brandt combined medicine, a degree in biostatistics, and a background in theology to become the assistant secretary of health in the Reagan administration. He was as solid in that position as anyone could be. Low key but intense and always learning, he welcomed advice, rewarded good ideas, and brought an ethical framework to his decisions.
Everett Koop, a pediatric surgeon, became surgeon general with the backing of the religious right. He continued to surprise his base by looking at the science, supporting abortion surveillance programs, and speaking out on the need for humane responses to the AIDS epidemic. He was a delight to work with and became an important health symbol in conveying information to the public.
Richard Schweiker went from senator in Pennsylvania to the secretary of Health and Human Services under President Reagan. He was very able and would give proper attention to scientific evidence. He was comfortable in asking agencies for information when layers of government obscured the message. His interest in global health was an important signal and demonstrated his ability to provide leadership in difficult times.
So many political leaders provided leadership to the CDC. Senator Mark Hatfield was interested in global health and in making sure that the CDC was getting proper budgetary attention. Senator Paul Simon traveled to Africa and was interested in health and education on that continent. He was a strong supporter of nutrition programs in low-income countries and always voted his conscience. Senator Edward Kennedy not only took public health seriously but also would call frequent hearings to be sure the CDC was being heard. He even held a hearing on Legionnaires’ disease at the CDC in Atlanta. Congressman Henry Waxman never missed an opportunity to promote public health. Congressman Paul Rogers was one of the kindest people in Congress. He was always fair to witnesses, and his courtesy was legendary. At his memorial service, one person asked for a show of hands from anyone who had ever followed him through a door. Not a hand went up because he always insisted on the other person going first. Congressman Bill Lehman provided money for three years to expand the CDC program on injury control. Finally, he could not be ignored by the Department of Health and Human Services, and it included the money directly into the CDC budget.
I need to mention the only man who was so interested in health that he asked for a private tutorial. Senator Bob Graham from Florida was so committed to improving his health legislative skills that he asked us to arrange a tutorial for him. We planned for a series of the top people from various branches of medicine to instruct him, and he set aside an hour a week, over a period of many months, for the project.
Colleagues
Even more numerous than mentors are the many colleagues, in and out of the workplace, who helped in achieving health objectives. Their influence goes far beyond any stories in this book.
Connie and Lyle Conrad, both physicians, were in the Peace Corps in Nigeria before their time at the Harvard School of Public Health. Lyle went on to head the program for EIS field staff at the CDC. He spent long hours on the phone providing guidance, always taking copious notes. He was in an ideal position to suggest people for short-term work in smallpox eradication and disaster relief. Connie went on to head a program at Emory University. It started as a master’s program in community health and then grew to a master’s in public health. Eventually, Emory developed a school of public health, now in the top half-dozen schools in the country.
Jeanette Troup, known to me only by reputation as mentioned earlier, was the only doctor at the Jos, Nigeria, hospital that admitted the first known Lassa fever patient. She was well trained and exceedingly well liked by the staff and patients at the hospital. Coworkers described her singing as professional, and indeed she often entertained the staff with music. After medical school, she took residencies in both pediatrics and pathology so she was well equipped to do an autopsy on a Lassa fever patient in 1970. And yet she slipped, cut her finger, and died of Lassa fever. Her tragic story is told in the book Fever: The Hunt for a New Killer Virus, by John G. Fuller.
Karl Johnson was head of the Special Pathogens Laboratory at the CDC, investigating the most deadly viral diseases. While highly regarded for his calm ability to confront hemorrhagic viral diseases, he describes himself as being absolutely scared in dealing with the first known Ebola outbreak in Zaire in 1976. Until he was convinced the virus was not spreading through the air, he said the investigators could not relax. In retirement, he continues to respond to many requests for consultation.
Joel Breman was a veteran of the smallpox program in West Africa. He was also part of the initial team to investigate Ebola in Zaire in 1976. He continued his career in global health at the National Institutes of Health and served on assessment teams to verify that smallpox had truly disappeared from the world. He is doing comparable work on verifying the elimination of Guinea worm.
Joe McCormick also became a career global health worker. He originally went to Zaire as a science teacher, became interested in medicine, and returned to the United States to go to medical school. He became interested in virology and participated in the first Ebola outbreaks. He later went to Sierra Leone to study Lassa fever and was able to determine its epidemiology from rodents to people and worked on approaches to treatment.
Peter Piot worked on the original Zaire Ebola outbreak before becoming deeply immersed in the problem of AIDS in the 1980s. He was named the first director of the Joint United Nations Programme on HIV and AIDS (UNAIDS), traveling around the world to secure resources and to help countries develop national programs. He is now the dean of the London School of Tropical Medicine.
Don Francis, in a career devoted to global health problems, has worked in Africa, South America, and Asia. He joined a WHO team to control an Ebola outbreak in southern Sudan, one that actually preceded the first recognized outbreak of that disease, in Zaire in 1976. The outbreaks were found to be caused by slightly different strains. Don went on to work on smallpox eradication in India and Bangladesh. He later conducted the first human trials with an AIDS vaccine in Thailand and the United States.
David Fraser’s work with Legionnaires’ disease is recounted in this book. Fraser went on to have a varied career, which included the presidency of Swarthmore from 1982 to 1991. At that time, he left to become the head of the Social Welfare Department at the Aga Khan Secretariat, where he directed health, education, and housing activities in Asia and Africa. Moreover, he has been named by the Pennsylvania Guild of Craftsmen as a Master Artisan, using ancient arts to make contemporary baskets.
Mark Rosenberg worked in enteric diseases as an EIS officer and spent time in India for smallpox eradication. He started the program on injury control at the CDC, work that was highly praised and included state health department programs and academic centers for injury control research. Mark went on to great success at the Task Force for Global Health, including serving as director for seventeen years. That group focuses on neglected diseases in poor countries.
Joseph McDade described himself as a “back bencher,” out of the limelight in a small lab at the CDC, at the time of the Legionnaires’ disease outbreak. His lab was asked to rule out Q fever in that investigation. This infection with Coxiella burnetii, a bacterium, didn’t really fit the clinical pattern being seen with Legionnaires’ disease, as it causes a flulike illness that can progress to atypical pneumonia. Nonetheless, the CDC’s plan was to exclude any infectious disease known to science. Six months after the outbreak, Joe McDade discovered the problem, both because he was compulsive and returned to the lab between Christmas and New Year’s to sort through the past year, but also because he was disturbed by a man at a holiday party who said that he expected better of the CDC. Joe repeated the process originally used to rule out Q fever and found a small clue that led to the unraveling of the mystery of Legionnaires’ disease.
Charlie Shepard was chief of the Leprosy and Rickettsia Branch at the CDC for more than thirty years. He had a reputation for being a superb scientist, who advanced the understanding of leprosy. At one time, that organism could not be grown in the laboratory. Shepard pioneered ways of growing it in the footpads of mice. Later he worked with the nine-banded armadillo, which provided abundant opportunities for growing and studying leprosy. He supervised Joe McDade, and he helped to isolate Legionella organisms (chapter 9). He was approachable and acted as a mentor for many CDC scientists.
Walter Dowdle was another revered scientist at the CDC. He had wide and varied experiences with laboratory techniques but especially concentrated on the baffling role of the influenza virus as it mutated to essentially become a new threat every few years. His wide-ranging interests and leadership abilities led him to head the Center for Infectious Diseases at the CDC in 1977. He later became deputy director of the CDC and provided oversight for the Morbidity and Mortality Weekly Report (MMWR). On his retirement from the CDC in 1994, he became involved in polio eradication and helped to establish diagnostic laboratories around the world to support that effort.
Don Berreth directed the Office of Public Affairs at the CDC. Raised in South Dakota, he spent five years as a press officer for the FDA. He spent the rest of his career at the CDC. He had exceptional judgment and was called on repeatedly to advise on developments both within and outside of the CDC. He was trusted by journalists and had a reputation for making the people working on a particular problem available to the press, rather than using the Office of Public Affairs as a filter. He died at age 57 of a virulent staphylococcal infection.
Gene Matthews spent twenty-five years as the CDC’s counsel. He was also an advisor on many situations beyond his immediate responsibility and a leader in using the law to improve the health of the public. In his early years, he served as attorney-advisor to the Micronesian Claims Commission, stationed in the Mariana Islands. On retirement from the CDC, he went to the North Carolina School of Public Health and has concentrated on making the law a potent tool to improve health throughout the world.
David Thompson worked on smallpox eradication in Eastern Nigeria during the first year of that program. He later became a missionary in Chad and had great success in developing village health programs that were staffed by local workers provided with basic training to treat the most common conditions they encountered. He was part of the global health successes in transferring skills and knowledge to poor areas of the world.
Mike Lane played a major role in the eradication of smallpox with oversight responsibilities for many countries in the CDC’s West Africa program. He played a leading role in determining the risks of smallpox vaccine and in ending the use of that vaccine in the United States even before smallpox was eradicated from the rest of the world. He taught public health at the University of California, Berkeley, and at the Emory University Rollins School of Public Health.
Don Hopkins is a gifted pediatrician and global health worker, who demonstrated the surveillance/containment smallpox strategy in Sierra Leone. He headed the CDC global health efforts before joining the Carter Center, where he became the director of health activities and the major force behind Guinea worm eradication. He documented the history of smallpox in a popular book, The Greatest Killer: Smallpox in History, and is doing the same for Guinea worm.
George Lythcott was a pediatrician working in Ghana on pulmonary disease research when the CDC hired him to head up the new regional office in Lagos for smallpox eradication and measles control. He was an intuitive politician, who could negotiate easily with African governments. The same skills were useful when he later served as a dean at the City University Medical School in New York, as associate dean at Columbia University, associate vice chancellor at the University of Wisconsin, and administrator of the Health Services Administration for the Department of Health and Human Services. I was in awe of his ability to talk himself out of any dilemma we encountered during our many years of working together.
Rafe Henderson combined a strong academic background in medicine and public health plus a degree from the Kennedy School at Harvard, with communication skills in both English and French that allowed for superb leadership first in smallpox eradication and later as head of the WHO program to expand childhood immunizations to all children. He was able to persuade others to share his vision and then methodically plan strategies to achieve that vision. He continues to inspire.
Don Eddins was a Texan with a soft approach. He was able to develop statistical techniques and polling approaches useful to programs working in poor areas of the world that lacked addresses or census information. He was methodical and prized order in his approach to record keeping and distribution of information.
Seth Leibler brought a refreshing approach to training at the CDC. He had been trained in criterion-referenced instruction, in which training is graded by previously determined criteria that indicate success. The approach was highly relevant to the CDC, and this concept was taken to ongoing tasks, such as how to provide a system for responding to a smallpox importation into this country. He developed his own consulting firm to teach his approach to business clients.
Olen Kew is a virologist with a PhD from the University of Washington and a creative mind, put to good use in combatting the frustrating disease of polio. Polio can infect hundreds of people before the first clinical signs are apparent in a person with muscle weakness. It has been known since 1962 that oral polio vaccine can revert to a dangerous virus that can circulate and cause polio disease. Kew has been involved in tracing such reversions and is in the forefront of developing scientific tests and approaches to eliminate polio from the world.
Tommy Francis was the first scientist to isolate influenza virus. He became the mentor to many virologists, including Jonas Salk. It was Francis who convinced Salk that a field trial was needed for his new inactivated polio vaccine. Francis then ran a study of 1.8 million children, plus hundreds of thousands of volunteers, to determine the efficacy of the vaccine. It is because paralysis is so rare with polio—only a single case may occur in hundreds of children with the disease—that the study had to be so large. The study was completed in less than two years, before the advent of computers, and is the largest field study ever undertaken in the field of vaccines. His son-in-law, Russ Alexander, was a teacher of mine in medical school, and his daughter became a minister. They were both retired in Seattle at the time of the fiftieth anniversary of the Francis field trial.
Paul Wiesner is mentioned for his role in beginning the first CDC investigation of AIDS. He was head of the venereal disease program at that time. Paul also went on to head the DeKalb County Board of Health, where he was honored for providing extraordinary leadership. He was president of the National Association of County and City Health Officials (NACCHO), a group numbering about 3,000 health leaders. Paul is a solid scientist and mentor to many.
Alan Hinman has fifty years of involvement in global health. He directed the Immunization Division at the CDC during the expansion of that program to cover all children in the United States. He retired from the CDC in 1996 and continued to work in global immunization programs with the Task Force for Global Health. He still provides global leadership, especially in the areas of polio and measles eradication.
Walter Orenstein had intended to become a pediatric nephrologist. A field assignment in India for smallpox eradication became a life-changing event for him, however, and he returned to the CDC to devote his life to vaccine-preventable diseases. He headed the national program when the United States hit the lowest level of vaccine-preventable diseases in history. He played a major role in advising other countries and the WHO on their immunization activities. He now works at Emory University on the continuing improvement of vaccine programs for the world.
Joan Davenport was the nerve center for the early smallpox program in West and Central Africa. She not only supported the Atlanta headquarters but also became the go-to person for those in the field. She was unflappable, organized, and cheerful, making a host of new incoming workers comfortable at the CDC.
Carol Walters, my assistant at the CDC and later a cofounder of the Task Force for Child Survival, spent many years in global health activities. Well-organized, perceptive, and friendly, she provided a welcoming environment to the many visitors seeking advice. She demonstrated the role of good management in making programs work and was able to reduce the stress level of those of us working in her team.
Anne Mather has her master’s degree in journalism and spent years as the managing editor of the MMWR at the CDC. She is the author or coauthor of ten books, most recently one with Mary Guinan, Adventures of a Female Medical Detective: In Pursuit of Smallpox and AIDS, on Guinan’s career as an epidemiologist. Anne has been involved for years in rug hooking and has published books on that craft, advising hookers (that is indeed what they call themselves) to infuse their personality into the rugs they create. She has made writing accessible for me, saved me from many bad ideas, and made the process fun.
And More to Come …
I was to have even more mentors as I aged. A subsequent book will pay tribute to Jim Curran, Norman Borlaug, President Jimmy Carter and Mrs. Rosalynn Carter, Jim Laney (president of Emory University), Melinda Gates, Bill Gates Sr., Bill Gates Jr., and Patty Stonesifer.