SERENDIPITY AND UNEXPECTED PATHS
It was like reading a novel, when you can’t read fast enough to satisfy your desire to know what is next. It was similar to the feeling I had when I read Albert Schweitzer’s book Out of My Life and Thought (1) as a teenager. This time, it was the New England Journal of Medicine, and I was reading a commencement address given by physician Tom Weller to Harvard Medical School graduates (2). He was making the case for using skills and knowledge to benefit poor countries and even poor areas of rich countries with a plethora of problems and a paucity of resources and medical services. He was talking about the desire for more global equity in the area of health.
Tom Weller
I shared Weller’s beliefs and assumed that I was being led away from the CDC to a new career in Africa. Little did I know that each step was actually and unexpectedly taking me back to the CDC.
Many years later, I would read lessons that a medical school classmate, Robert Eelkema, said that he had learned in life. The first one was “people in trouble do not need more trouble.” Translated into a public health message, this means that when we retain our medical skills and knowledge only for ourselves and our immediate community, we allow people in trouble in countries that lack that knowledge to have more trouble.
I had no idea at the time, in my naiveté, that Weller was a Nobel laureate. When I got to know him, I learned that his Nobel Prize was for growing poliovirus in tissue culture. He demonstrated the old saying that chance rewards the prepared mind. He freely admitted that he had been trying for a different outcome. He had been attempting to grow the varicella (chickenpox) virus in a new broth, and, because he had several extra containers of broth leftover and did not wish to throw them out, he included poliovirus in the remaining broth containers on the spur of the moment. But he also replaced the nutrient material daily in the event that chickenpox virus was a slow-growing virus. The chickenpox virus did not grow. But to his surprise, the poliovirus did, and that breakthrough permitted Jonas Salk to grow virus and prepare a vaccine. Serendipity can be a powerful accelerator, as I was to learn later in smallpox eradication.
I applied and was accepted to spend a year, from 1964 to 1965, concentrating in the Department of Tropical Public Health, chaired by Weller, at the Harvard School of Public Health.
The CDC had offered me a position in its career development program, in which the CDC would pay for training programs of my choosing and I would then pay back a number of years of service at the agency. But I was eager to get to Nigeria, and so instead applied for a government scholarship, which allowed me to spend the year with Weller and go to Africa without an obligation to remain in the Public Health Service. (As it turned out, a war in Nigeria would return me to the CDC within a few years, which meant the agency got my employment but did not have to pay for the training.)
Being in Harvard’s Department of Tropical Public Health was a wonderful experience. I got to be around a group who had dedicated their lives to the improvement of health in poor areas of the world. My faculty advisor, Frank Neva, was one of those rare people who could actually do research, pursue clinical medicine, teach, and be competent in all three endeavors.
But the faculty was only the beginning. Many of the students already had experience in developing countries. Charles Azu was a physician from Nigeria and would return to run a hospital with a public health perspective. Yemi Ademola was from a distinguished family in the former Western Region of Nigeria and had taken a year of leave from his position as head of prevention in the Nigerian Ministry of Health to get a master’s in public health degree. Ademola was eager to teach me everything he could about his country and its health problems, and I was just as eager to learn. When a wrist injury left him unable to take notes, I had the chance to attempt to repay him for his kindness by providing him with carbon copies of my notes. He would later be very supportive of the work we were starting at a medical center in the Eastern Region of Nigeria and later, with our work with the CDC Smallpox Eradication / Measles Control Program in all of Nigeria. It was a tragedy and a great loss for Nigeria when he was murdered several years after graduation.
Fellow students Connie Conrad and Lyle Conrad had spent two years in Nigeria as part of the Peace Corps. These physicians not only retained an interest in global health but also continued to be colleagues, Lyle when we both worked at the CDC and Connie when we both worked at Emory University.
Formal classes were supplemented by spontaneous noontime debates on subjects I needed to understand but lacked the time to investigate, such as the efficacy of BCG (Bacille Calmette Guerin) or other vaccines not routinely used in the United States. A ten-day trip to the Public Health Service Leprosarium at Carville, Louisiana, provided training that would not be possible at Harvard. And, because this was the first time since fifth grade that I had not worked while going to school, I could also read for hours at a time—a luxury beyond belief.
During Weller’s class, I made lifelong connections with faculty and students. I continued to see Frank Neva and Tom Weller over the next decades, and Tom often attended when I spoke in Boston. His wife said he took credit for any good thing I ever did and ignored the rest. She said he particularly liked to hear me when I would pull out his article that had contributed so much to my decision to go to Harvard. I would tell audiences that they had no idea of the ripple effects of what they say, do, or write. The year Tom retired I read his words at the commencement address given for the Harvard School of Public Health graduates. He got a standing ovation in the middle of my speech. A cycle had been completed.
Medical Work in Nigeria
Most of the Harvard graduates returned to their home countries or to positions with global health agencies or domestic public health agencies. Paula and I left Boston at the end of the school year, in June 1965, for a six-week course in St. Louis, Missouri, given by our new employers, the Lutheran Church-Missouri Synod (LCMS). The course taught culture, linguistics, and the requirements for employees of a church program in other countries. Surprisingly, there were few restrictions. My intent was to pursue community health and preventive medicine, and the church program was giving us the freedom to do that. All the synod asked for was a plan of action, after we had spent some time in Nigeria studying the problems, on how we hoped to improve the community health.
Most church-sponsored medical work at that time was clinically oriented. People in Africa, Asia, or other places are no different than people in the United States: they value medical care when it is needed. During illness or after injury, competent medical aid is a great comfort. So it is understandable that churches sponsoring medical work around the world invest in clinical approaches. But it is also true that it is less expensive and less disruptive to prevent disease and injury.
But LCMS had made the additional, bold decision to invest in disease and injury prevention. To make the situation even more unusual, LCMS was known for its conservative approach to religion and society. Even today, women are not given an equal status to men and cannot become ministers. Despite this gender bias and one of its well-known seminary professor’s promoting racial bias at the time, this particular church body was willing to support work in prevention—work that, if optimally successful, would engender little gratitude, if any, on the part of those served and would therefore provide no benefit as a proselytizing tool. I found I could overlook a lot of things that made no sense for that kernel of goodwill that actually helped people.
While the organization sponsoring this prevention work was a surprise, an even greater one was that the genesis of this clear medical vision emanated from an unexpected person. Dr. Wolfgang Bulle had received his training in Germany during World War II. His training was interrupted by repeated terms of active duty. The atrocities of the war left him with what we would now undoubtedly diagnose as posttraumatic stress disorder. He always seemed to live his life at high speed to compensate for his involvement in that war.
Following surgical training, he spent ten years as a surgeon for LCMS in South India, a role for which he showed great creativity. For example, as a surgeon he needed a blood bank, but there was no possibility of developing one there. Instead, he identified a man who headed up a criminal network and made an arrangement. This man would send him dozens of people to have their blood typed. If Bulle needed blood from an O-positive donor, he would simply get a message to this man, telling him how many “volunteers” he needed and providing a list of the names of the people with that blood type. This walking blood bank was always available with no need for refrigeration facilities, outdated blood, and all the problems involved with blood banks. Bulle could reimburse the leader on the basis of the number of units drawn. The leader of the criminal network could keep part of the profits but also keep people eager to respond to the next call by providing donors with money.
Now, as head of LCMS’s medical missionary program, Bulle sought efficiency, and prevention is efficient. The person who does not succumb to illness remains productive and consumes no medical resources. Surgeons who become interested in prevention are some of the most passionate workers in public health, and Bulle provided exceptional support to the work Paula and I were doing in Nigeria.
Paula and I experienced Africa by living in the village of Okpoma, in Ogoja Province in Eastern Nigeria. Although we did not have electricity, running water, or an indoor bathroom, life was easier for us than for the villagers, as we did not have to grow our own food, spend the day carrying water from distant locations, or secure firewood. Several nurses were already working in the area for the same church group, and they provided valuable insights into the problems of highest importance. Our plans for medical work matured as we experienced village life, observed the daily toil, and studied Yala, the local language. Our hopes were to expand child health services, especially immunization, diarrheal disease control, malaria control, water and sanitation programs, nutrition programs, and clinic services for all but especially children and pregnant women.
Jim and Gordon Hirabayashi
An unexpected boost to our efforts in Nigeria came from the chance meeting with anthropologist James Hirabayashi at a reception in Enugu, the capital of Eastern Nigeria. He was on leave from San Francisco State University for a one-year fellowship. Seeking interesting experiences, he asked whether he could visit our medical program to gather material on the culture of the Yala people with whom we were working. He was intrigued by what we were doing and asked to stay awhile. We provided him with an interpreter and transport, and he practiced his craft. During the day, he interviewed people living in Yala villages; at night, he typed up his notes and make entries on three-by-five cards, organizing his material by topic. Within weeks, he had discovered information about the culture unknown to LCMS missionaries who had been working in Ogoja Province for years. For example, there were social rules that governed who could marry into families. Illness was often understood in magical terms, and some illnesses actually resulted from curses that had been placed on individuals. Fatalism was at times the response to an illness if a person felt it was due to a curse. Hirabayashi also documented mechanisms that had developed to cope with death, illness, and unhappiness. For example, death was frequently followed by rituals that continued to celebrate a person even months and years later. Hirabayashi’s work was intriguing and had direct relevance to a program hoping to improve health.
Unfortunately, the Nigerian (Biafran) Civil War interrupted his—and our—work.
A sidebar to this story: Back in Atlanta, some years later, I was reading about the internment of Japanese Americans when I encountered the legal case Hirabayashi v. the United States. Gordon Hirabayashi was a student at the University of Washington who resisted internment on the grounds that he could not be arrested without a reason. But he was arrested anyway and jailed in Seattle, while others were moved to an internment camp.
I called information in San Francisco and got a number for Jim Hirabayashi, my associate in Nigeria. He answered the phone, and I asked whether the legal case involved anyone in his family. It was his brother, Gordon, now a sociologist, who taught in Canada because he was not comfortable teaching in the United States. Jim said, “He happens to be visiting me tonight. Would you like to talk to him?” Gordon then related the story of how he resisted internment and was jailed. His case eventually went to the Supreme Court, where he lost unanimously. (A reminder that the Court is made up of fallible humans, and they have made some very un-supreme decisions.) After his loss at the Supreme Court, he learned that the government lacked the money to send him from jail in Seattle to the internment camp. So with great dignity, he hitchhiked and was admitted to the camp.
Gordon did not expect that the decision would ever be reversed. But years later, it was, and Gordon issued a statement about what a great country it is that can admit to that kind of mistake. In 2010, the University of Washington gave degrees to students who had been removed to the internment camps. I was pleased for Gordon—only to learn that he had Alzheimer’s and was not aware of this second correction.
Gordon’s final triumph came in 2012, when he was awarded the Presidential Medal of Freedom. Unfortunately, both Gordon and Jim died before the White House presentation.
If the Nigerian Civil War had been short, as I anticipated, we would have returned to renew our efforts to use a church medical program as a community health program. But the war became brutal and long, from July 1967 to early 1970. While I was able to work in the relief program during the war, my main job involved smallpox eradication, working from the CDC in Atlanta. When the war was over, I had become so obsessed with smallpox eradication that I could not return to Nigeria, at least at that time.
Dr. Gordon Hirabayashi. Courtesy of University of Alberta
But the African experience was crucial in guiding the rest of my professional life. The needs of people living in poor countries could not be unlearned. The success with smallpox in Eastern Nigeria became a template for smallpox eradication in other countries. And the work of Jim Hirabayashi on the social determinants of health continued to resonate. The AIDS epidemic reinforced the need for anthropologists, sociologists, ethicists, theologians, and workers committed to social justice.
All of these experiences were totally unplanned by me. Beware of a life plan.