COMING INTO THE UNITED STATES
New Americans
Most people in this country descend from New Americans. The reasons are multiple and complex. Some New Americans came here for adventure, but most came seeking a better life.
In weather systems, low-pressure areas determine where the wind will go next. In a sense, certain areas at certain times in history become low-pressure areas, attracting the winds of change and with them, new immigrants in search of perceived opportunities. The same dynamic operates within a country. In this country, better opportunities pulled people westward, and when the opportunities were perceived to be exceptional, the barometer reading in that area plunged, and people flocked in. The California Gold Rush and the Oklahoma land grants are examples. As the playing field levels, migration patterns subside or even reverse. Once Norwegians flocked to Minnesota and Seattle, for example, but with a level playing field, where skills and knowledge can be applied as easily in one place as in another, people prefer to be with family and familiarity. Someday, that may be the case globally.
But for now, immigration is still robust to the United States. Health officials have attempted over the years to dictate certain conditions that need to be treated in order to allow a person into the country. (Author afternote: When this was written, I could not have even imagined attempts to reduce immigration on the basis of religious beliefs. Civilization is indeed a thin veneer.) At times health officials have even attempted to exclude people with certain conditions. That usually turns out to be counterproductive because people attempt to enter without having the condition detected. Attempts to exclude HIV-positive persons demonstrate this problem.
I write this on April 30, 2013, exactly thirty-eight years after the fall of Saigon. In April 1975, my family returned to Atlanta after working for several years on smallpox eradication in India. I was anticipating a period of decompression, but history intervened. America withdrew from the Vietnam War that April 30 and provided a destination for many who had helped the United States during the war. Dave Sencer asked me to oversee the public health aspects of the refugee influx.
Thousands left Vietnam for an uncertain future. The fear and anxiety that they felt are not possible for us to understand. Some were separated from other family members and so faced the unknown without those who could have given the most support. They were destined for weeks of new locations, uncertainty, health inspections, and often little input into their ultimate destination in the United States.
By May 3, 1975, more than 77,000 refugees had passed through two staging areas, the largest in Guam, the other on Wake Island. CDC assignees were assisting military medical personnel in the health screening at each staging area. The routine became for them to call Atlanta each day to report on the number of refugees in residence, the number arriving in the previous twenty-four hours, the number departing to the US mainland, and the health status of those screened. As with the Nigeria/Biafra relief program, a surveillance system was developed to characterize the size of the health problems and to provide assistance in resolving those problems.
About 30,000 of the 77,000 had already arrived in the United States at one of three military bases—Camp Pendleton in California, Fort Chaffee in Arkansas, and Eglin Air Force Base in Florida. About 9,000 of the 30,000 had been discharged to relatives or sponsors and had left for their final destinations.
Health problems were less significant than many had feared. About 3 percent of persons arriving at the staging areas were hospitalized, most for pneumonia, gastroenteritis, or obstetric reasons. In the first 77,000 screened, no diseases required quarantine, and only two cases of malaria, one case of typhoid fever, and a dozen cases of tuberculosis were found. Because of cases of measles, an active immunization program was initiated in the staging areas and in the US military camps.
When a destination was established for a refugee family, the state health department was provided with the chest X-rays, serologic results for syphilis, immunization records, and a record of health problems detected, especially those that required follow-up. An attempt was made to minimize time in camps to avoid communicable diseases and to facilitate refugees in obtaining the stability of a final location. For some refugees, departure to their final destination could be accomplished in days once they reached mainland camps. For many, their time in camps would be measured in weeks, but others remained for months before they reached a final destination. If the health screenings on the US military bases would cause undue delay, the Immigration and Naturalization Service arranged for the exams to be conducted at the refugees’ final destination.
The MMWR, the CDC’s weekly newsletter, provided frequent summaries of the findings during the health screenings. It also provided information on recommended treatment, for example, of malaria if it should be detected after a refugee’s arrival in a state.
By May 14, more than 111,000 persons had reached the staging areas. Of this number, 56,000 had already arrived on the mainland; 16,000 of these had been released to sponsors. Health problems remained small: 20 cases of malaria and 215 cases of suspected tuberculosis. In retrospect, the flow of individuals was quite efficient.
To speed up processing, a fourth mainland camp was opened on May 28 at Indian Town Gap, Pennsylvania. The entire screening operation had overcome the early problems and was now running with smooth efficiency. The first cases of tuberculosis or leprosy, for example, required a review of how best to handle care and follow-up. Each subsequent case would benefit from the procedures developed. By the end of August, 130,000 persons had arrived, and 75,000 had already been placed with sponsors. Disease counts, although relatively low, continued to increase; 39 cases of Hansen’s disease (leprosy) had been diagnosed by the end of the year, and 2,000 persons were diagnosed with possible tuberculosis. But the real news continued to be a relatively healthy population that had entered the country, the efficiency of the operation in general, the openness of the US population in providing sponsorship, and the gratitude expressed by the refugee population. (In 2011, I met a doctor in military uniform who informed me she had been one of those child refugees, and she was now trying to pay her debt to this country.)
Jimmy Carter Becomes President … and There Are Consequences
In November 1976, Jimmy Carter became president and selected Joseph Califano, a lawyer who had been an aide to President Lyndon Johnson, as the secretary of the Department of Health, Education and Welfare. One of Califano’s first actions as secretary was to ask Dave Sencer to come to Washington, DC. Califano was not happy with the Swine Flu Vaccination Program and put the blame at Sencer’s doorstep. My own feelings were that Sencer had acted in the best interest of public health, but that the public health community had been fooled by a virus: for the first time in history, a new strain of influenza that had been shown to be capable of spreading from person to person in a population devoid of antibodies to the strain had not resulted in a pandemic.
In any case, Hale Champion, Califano’s deputy, informed Sencer that he would have to leave the position. A petition signed by hundreds at the CDC, including me, asked for the department to reconsider, but it did not.
I did not know it at the time, but Dave Sencer had requested that the department include my name in the list of candidates to replace him. My interests were so focused on global health that I had never even contemplated the position of the CDC director until I was asked to submit my résumé. I was not eager to do that as I saw it as a diversion from my real interests in global health. Dave asked me to at least go for the interview as a favor to him, pointing out the potential for promoting global health in that position and reminding me of what he had been able to do in that position for smallpox eradication.
Dr. David Sencer, director of the Centers for Disease Control and Prevention from 1966 to 1977, in 2008. Courtesy of Emory Photo/Video
I went to Washington for the interview. My ambivalence prevented me from being nervous. For example, when I entered Secretary Califano’s office, he was emptying an ashtray, and he apologized. He said that the last guest in his office was a smoker, and he was sorry for the smell. I replied that I was surprised because I had assumed that the secretary had sufficient authority to designate his own office as a smoke-free zone. He looked startled, and when I returned for a second interview, there was a No Smoking sign in his office.
The author in 1976, posing for an official CDC photo. Photo from the CDC
He called me some time later to say he would like me to be the director of the CDC and that he would personally come to the CDC on Friday to talk to the staff and announce his decision. In the meantime, I was to tell no one but my wife.
Minutes later, even before I had time to call my wife, Don Berreth, director of the Information Office at the CDC, entered my office to say that the information office in HEW had called him, requesting that he prepare a résumé on me and get a photograph. Don told me that he did not want to share this information with anyone else at the CDC and therefore he would take the photo in his office.
I reached for my suit coat, but he said that everyone knew I wore my coat only for guests or special occasions, so to carry the coat to his office might alert someone. So we went to his office, and I put on his suit coat. It was far too short, with six inches of shirt showing at the end of the sleeves. Don said it was no problem since he was only getting a head shot.
After taking the picture, Don suggested that, since it was a special occasion, I should get a standing shot to show how ridiculous the jacket looked. He said that he and I would be the only ones to ever see it. I agreed and can only marvel at my naïveté.
On Friday, Secretary Califano came to the CDC and made the announcement. By the end of the day, everyone seemed to have a copy of me standing with Don’s suit coat on. His explanation was that of course he meant it when he said that he would not share the picture. But the moment Califano announced my appointment I had become a public figure, and I had lost my privacy. After all, this was the official picture. It was a wonderful joke at my expense and might as well be shared.