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Smallpox—The Death of a Disease

By D. A. Henderson | Carnegie New Leaders | October 28, 2009

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DEVIN STEWART: I'm Devin Stewart, from the Carnegie Council.

For thousands of years, smallpox plagued humankind. In 1967, Dr. D.A. Henderson became director of a worldwide campaign to eliminate this disease from the face of the earth. About ten years later, the disease was wiped out. We are in the presence today of a true hero. Dr. Henderson is going to tell us about his epic story of wiping out smallpox from this planet.

He has been awarded the Presidential Medal of Freedom, as well as a knighthood from the Thai government and the Japan Prize. I could just sit here and tell you all the awards he has won. He helped found the Johns Hopkins Center on Bioterrorism and is an adviser to the U.S. government on numerous issues, swine flu being one of them, and bioterrorism—many, many very current topics that we can get into.

Dr. Henderson, it's a real honor to have you here. Thank you so much.


D.A. HENDERSON: Thank you very much for having me. It's a pleasure to have the opportunity to talk with all of you.

There are many, many challenges in the world today. Many of these involve cooperative efforts across nations, and that's where real progress is going to be made.

I think there has been a rediscovery of the smallpox program because, in a way, this was a very unique program, in that we really had, I think, 73 different nationalities at one time or another working with us on this. It was a task that involved different countries really taking the major role, because we never had more than 150 international staff in the field. So we were more catalytic than directive. This made it very challenging, as we were dealing with political and scientific and other problems all at once.

The question is, what is the importance of this event of eradicating smallpox? Until smallpox was eradicated, no disease had ever been eradicated. There were four major attempts to eradicate disease in the 20th century, but all of these failed. So there was a prevailing feeling, when it was raised—should we try to eradicate smallpox?—that this really was not possible. Many people felt that this occupied a special ecological niche in nature, and you can't take anything out of nature that has adapted for so long. So that was one of the elements of it.

It was 30 years ago—in fact, just December—that we had an international group, 25 people, who met for the final time in Nairobi, Kenya. We reviewed an enormous amount of data, studies that had been done in the different countries, the search for cases, special things that had been done, to determine whether or not they were satisfied that smallpox had been eradicated. And if any of them—quite prominent people—were not satisfied, then what is it that we should do that would make them satisfied?

Why was this important? Because in recognizing that smallpox was eradicated, at that time we would be advising that they stop vaccination. Vaccination causes a number of adverse reactions, which can be quite serious. So the implication that this is eradicated and now we can stop vaccination—this is a very important step indeed, and everyone has to feel pretty confident about it.

The question of how we could be sure that we didn't have it anywhere—somewhere in the tropical rainforests or somewhere in the slums of Calcutta or what have you—how could you really be sure? We can talk a little bit more about that, but we did develop the material and the approach, with searches and all sorts of things, that we were quite confident that it was eradicated.

The question of the importance of smallpox is, I think, for many now, somewhat forgotten, as to what it actually was as a concern.

Smallpox is a virus. It has to infect a human in order for it to survive. In other words, there's no animal reservoir. If it's going to survive, it has to infect one person after another and be transmitted one person after another.

We know that this chain of transmission, as we call it, has to go back at least 3,500 years, because there are four mummies that are preserved that actually have the lesions of smallpox. So it goes back a long way. It had been so prevalent in so many cultures and it was such a devastating disease that there were deities in a number of countries—in Japan, in China, India, Africa—specifically for smallpox. It is the only disease for which there are deities in these different cultures, which gives you an idea of how important it was to people, wherever they were.

Here's a disease that eventually pretty much everyone got at one time or another, and 30 percent died. That was a very horrific disease, with rash and what have you. This was a real problem.

How much of a problem has it been more recently? We did a calculation to try to estimate how many people must have died before our last case of smallpox in the 20th century. We conservatively estimated that it was about 300 million. Three hundred million—how do you measure that? What's a metric to measure that by? The New York Times published a statistic: One hundred and twenty million people died, directly or indirectly, as a result of armed conflict in the 20th century—120 million during the 20th century. Two and a half times that was the conservative estimate of the number of people who died of smallpox in the 20th century.

In the United States we required all children to be vaccinated before they went to school. That continued up until 1972. Why? We were afraid smallpox might be imported. Our last case was in 1949, 23 years before. That is the only disease that we required every child to be vaccinated against. This was true around the world. Vaccination was continuing because of the fear of smallpox being introduced into the country from one of the developing countries and having it spread.

The thought that this disease might be eradicated was, for many people, a hard enough thing to accept, because of the fear that had been there for so long, so that its eradication was a remarkable event. Indeed, one of the comments made about this was by the man who won the Pulitzer Prize in science in 2006, a science historian, who said that one of the greatest achievements of the 20th century was the eradication of smallpox.

It was done by a very diverse group of people, from different countries, working together. A great many of them were under 40. It was a very diverse group, working through some really difficult bureaucracies and all the other elements. So it was after the end of the program—this was 1980—that we wrote a book called Smallpox and Its Eradication. It's 1,500 pages. It was really an archival history, intended to be put on the shelf. Nobody's going to read this, but we owed it to history at least to set down the data. It was a duty you have as an historian. They were distributed primarily to libraries.

Along came 2001, and September 11, and the realization that smallpox might again be released for bad reasons. So the books that still remained were sold immediately. You can get a copy of it. I have seen them on Amazon fairly recently. There's one at $400 and one at $600 and one at $1,900. Unfortunately, the editors weren't smart enough to have put away a few books. It really would have been a very good investment.

But at the time, I felt that the one part we didn't really dwell on was, how did it really work, and what problems did we really have? How was this really done? So this was the book that I decided to write about two and a half years ago, which was published in June of this year.

This is indeed a major disease. Let me describe it just a little bit more. The individual would be in contact with a case. He would get it from droplets expressed from the person he is talking with. Then he would inhale it and feel perfectly well for anywhere from a week to two weeks, seven to 14 days. Then he would come down with a high fever and be so sick and have head pain, chest pain, feeling absolutely miserable. At that point, after two or three days of this, a rash would begin. Until he developed the rash, he wouldn't be able to communicate it to anybody—until the rash began. Then the rash would gradually emerge. It was a very ugly-looking rash, very painful. It's like little pustules in the skin. They grew smaller and then they grew much larger.

This is a very mild case. This is a picture of the case. These lesions are inside the mouth, on the tongue, so the individual has trouble eating and he has trouble swallowing. It's a horrible disease.

What was interesting is that it was known, really, in every village, wherever you went. This disease they knew about.

In 1796, believe it or not, a vaccine for this was discovered. It's the first vaccine known to medicine. What happened was that there were milkmaids who took care of cows in England. They got a disease from the cows, which was called cowpox. It's a cousin of smallpox. They would have some pustules on their hands. But then, as the local people talked about it—local lore—they were protected from smallpox. They did not get the disease.

This is a disease that was so prevalent, and people, when they recovered, would be left with pockmarks on the skin, very deep, disfiguring pockmarks. But the dairymaids had beautiful complexions because they never got the smallpox.

Edward Jenner, who was a physician, decided to try to take material from one of these dairymaids and to take a little bit of the pustule material and inoculate another person. He was then able to show that this little boy that he inoculated—he could inoculate him with smallpox, and he was protected. These are not studies that we would do today. But he showed that he was protected.

So this was a vaccine which began back in the 18th century. But it was not widely used, because there were problems of spreading it and keeping it going, this arm-to-arm vaccination. It wasn't until later that they found they could grow it on the flanks of cows and so forth. It gradually became more available. It was very protective. But very few countries were able to vaccinate enough people and protect them, in order to stop the spread of it.

The question of eradication was talked about a bit in the 1960s. In fact, the Soviet Union proposed, in 1959, why don't we undertake a global program to eradicate smallpox, and let's vaccinate everybody. That was the year before the Soviets had returned to the World Health Organization, the UN system. They had left the system for a while. I think the delegates who meet at the World Health Assembly—they are all ministers of health; they meet once a year—said, "Fine. We'll encourage this idea. The Russians have said, let's eradicate smallpox. We'll show them that it's a good idea, so we'll all say, yes, we'll eradicate smallpox."

But then nothing much happened. Things just drifted at that point in time. There wasn't a lot of money, and at that time the United States was very enthusiastically supporting a program to eradicate malaria. So, in fact, this was a Cold War political issue. The Americans had malaria and the Russians had smallpox. The Russians were angry because more money was not being put into the program. The Americans were putting a lot of money into malaria. So for a while, this was a Cold War phenomenon that went on.

Finally, a resolution was put to the World Health Assembly that said to the director-general, "Give us a plan to get rid of smallpox in ten years and give us an estimate of what it might cost and present it to the Assembly." This was done. They met in the May Assembly of 1966 to debate this plan.

It was very confrontational. There were a number of countries that wanted no part of this. They said, "It can't succeed. It's going to fail." Indeed, the director-general was against it, because he could see that the malaria program was failing at that time, and he could see that now he has another eradication program, and if this begins to fail, the World Health Organization is going to be held accountable and the credibility of public health people is at risk—"I don't want to see this eradication program."

The delegates usually decide things by consensus. Very rarely does it come to a real vote. This came to a vote. After three days, they could not resolve the problem.

There had to be 58 votes in order to pass it. It got 60 votes, so it just barely passed. By no means was there confidence that this was a good thing to do.

The director-general was furious. He felt the Americans, by having joined in on this, had really made the difference in the voting. Therefore, he wanted an American to run the program, be in charge of the program, so that, as he put it, "When it fails, the U.S. will be seen to be holding the bag, and we can blame the United States for this crazy idea."

This is where I got involved, because at that time our Agency for International Development had agreed to undertake a program and support West Africa in a vaccine program for smallpox and measles. I had been just starting to work on this, and I got a call to go to meet with the surgeon general of the United States in Washington.

He said, "You're assigned to go to Geneva to head the global program."

I pointed out to him that our Public Health Service is not a uniformed service, like the Army, Navy, and the Air Force. I said, "In the Army, Navy, and Air Force, you assign people like this, but in the Public Health Service, we discuss career options. We don't just order people to go one place or another."

He said, "Right. That's your career option."

I said, "Suppose I choose not to take my option."

He said, "You resign."

So I got the impression that maybe he was serious. So I packed up, with our family, and we went to Geneva, thinking that it would be very difficult to get this under way, and I would probably be back in 18 months or so. It was 11 years before I actually came back.

What were the problems? One was that the World Health Organization [WHO]—the director-general could see putting up $2.3 million. That was all. This wasn't enough to even buy the vaccine we needed. The rest of it, as he forecast, would be paid for by the countries—a large part of it would be paid for by the countries—and there would be a lot of contributions coming from other countries. Well, every year he had been asking for donations, and they weren't coming.

So here we were with $2.3 million. The headquarters office at WHO was to consist of four medical officers, two administrative officers, and three secretaries—nine people. We complain many times about overheard costs of running a program. This had very small overhead costs to run a global program which had to reach out to 50 countries and more than one billion people.

The important thing to know, of course, is that WHO has no authority to order a country to do anything. They can jolly well do what they want to do. It's a sovereign responsibility. They could go into the World Health Assembly and say, "Yes, we will support X or Y," or, "We'll do X or Y." But they don't have to go through with it.

Many times they approved many things in the World Health Assembly which they really had no intention of completing.

So here was a program to be run in 50 countries, $2.3 million and whatever we could raise in the way of funding, and a tiny office in Geneva. It was, shall we say, a bit of a challenge. I don't know how optimistic we really felt at that time. I think I was too numb to really estimate the likelihood that this could ever succeed.

The strategy we had was very simple. It was two things. One was, we wanted to vaccinate 80 percent of the population of the countries, but with a vaccine which was of assured potency—that is, that we were sure that they were using good vaccine. This would seem like a pretty logical thing to have. We began testing the vaccine not too long after this began, and we found that there were some 40 different countries producing vaccine and less than 10 percent of the vaccine met standards. A lot of it was just plain diluent that you use. It was just liquid without any virus in it. To vaccinate, you have to insert the virus under the skin. It grows for seven days. If it doesn't grow, then you don't get protected. It is an infection that protects you against smallpox.

They were giving vaccine to a lot of places—they were using inferior vaccine.

The question is, what to do? I talked with laboratories, one in the Netherlands and one in Canada: Would they be able to run specimens from the different laboratories?

They agreed to do that.

Then we had to persuade the governments to make the vaccine available. As the director-general said, "We can't do this. WHO has never approved any product. We have no authority to do it. We have nothing we can do if they choose not to turn out a good vaccine."

We did it anyway. We basically said to the countries, "We really can't support you in your program in any way unless you're using a satisfactory vaccine." That seemed to be enough to persuade them. Eventually we got everybody checking the vaccine.

Again, there was no authority, but working with them, we could get this accomplished.

The idea was to vaccinate 80 percent and to be sure that the spread of smallpox would be not so rapid.

The second thing, which was a new idea, was that we felt it would be helpful if we could find cases very early. Then we could vaccinate all the people around those cases and protect them, so that the virus would have no place to go; you would be able to break the chain of transmission of the virus. The question was, how do we find out about the cases quickly?

So we set out to have every health center and every hospital report every week the number of cases they had. They had never done this before. They sometimes produced monthly reports, but the idea of sending in a report every week—and in many cases, there was only one way to bring it, and that was by messenger or by military people or travelers, so that we could get the reports. What was so surprising was, when we started doing this, it took roughly 18 months before we were getting about 90 percent of the reports from the field, which was incredible.

We then had teams of two people—we called them the firefighting teams. When a report came in for a case, they would go out and vaccinate around that to produce what we call ring vaccination around the case. It was surveillance and containment.

What we quickly found out was that smallpox did not spread so rapidly as the medical textbooks said, that you could stop it this way, and that it was far more effective than anything that had been done before. In fact, we stopped the spread of transmission in some areas which had only 50 percent, 60 percent vaccinated. It was really quite a dramatic change.

So the surveillance and containment and a good vaccine—then there was another piece to this, which I won't go into, but it is the development of the device which is on the cover of the book, which is a little bifurcated needle. I could tell the story about that. It was, again, a piece of technology that was quite remarkable, quite simple, and just changed dramatically what was going on.

It was surprising. As we got into this, we got rid of, quickly, smallpox in Latin America, Indonesia. Within three years, I think about 15 or 16 countries of Africa were free. Within six years, we had only one country really left in Africa and five countries in Asia. So within six years, it was so dramatic that we were really excited about it.

At that point—it was 1973—we were feeling very optimistic indeed.

There was only one trouble. One of the problem areas was India, Pakistan, Nepal, Bangladesh, and Afghanistan. But there, there were more than one billion people.

What we were doing with the surveillance and containment was not working. What was surprising to us all was how much travel there was on the part of people in India and Pakistan, on railroads, in little jitney buses. Rarely were they paying much, if any, fare. They kept moving around in ways that we just could not keep up with them. A whole family would come into the city. One of the family would get sick. They would all go back to their village and spread in the village before we could even get to it. So it wasn't working.

I remember the spring of 1973. We were sitting there figuring out, what in heaven's name do we do? At that point, the suggestion was made, why don't we mobilize the health staff and visit every village in India—this was in India that this was proposed—and try to do that within a week or ten days? Ten days, we finally decided. So we mobilized 120,000 people and visited every house in India. Then we did the same thing in Bangladesh and also went in Pakistan.

It was amazing. We turned up cases like—oh, my gosh. What was being reported was, let's say, 500 cases from this one state, and the search turned up 10,000 cases. It was everywhere—smallpox like we couldn't believe.

We did the containment. Then, two months later, we went back to do another search. This time we didn't find so many cases. About this time, I must say, the health staff was getting very good at this. The third time around, they decided, "We're going to visit every house in India." So they did. How do we know they visited every house? We had a quality-control team that followed afterwards and checked that. If they didn't reach 90 percent of the houses, they had to repeat the search.

Amazingly—I just couldn't get over this—here I am, flying back to the United States and thinking—I think there were 600 million people in India at that time—could I organize something in a little country like the United States and visit every house in the United States in ten days? No way. There's no way you could do this. But it was being done in India and, as I say, in Bangladesh and Pakistan.

Along about January of 1974, we thought, "By gosh, it's working. This is our third search. We're finding the cases. The number of cases seems to be under control."

We were really feeling pretty good in January of 1974.

At that point, we ran into the gasoline shortage. If you remember, the big problem was that they blocked the shipment of gasoline. So we couldn't get gasoline for the vehicles. The airlines went on strike, so we couldn't move our staff around. Then the health staff started to go on strike, groups of them.

That was pretty bad, but then Northern India, which was where most of the cases were in India, had the worst floods in 30 years. We had several hundred thousand refugees moving out of this, infected and spreading smallpox at the same time. It was probably the worst five or six months that I have ever experienced. At the same time, things were falling apart in Bangladesh and they were similarly falling apart in Ethiopia.

About that time, India exploded an atomic device. That was in May of that year. The world press was there covering this. What went out everywhere was, here is this sophisticated science in which they are able to detonate an atomic bomb, but they can't get rid of a simple disease like smallpox, which they have already gotten rid of in Africa.

Prime Minister Indira Gandhi was quite distressed by all of this publicity. This generated a considerable interest on the part of the Indian government. There was no doubt about it. By August of 1975—August 15, 1975 was a telling moment for all of us. It's Indian Independence Day, and the prime minister normally makes a speech from the Red Fort in New Delhi. She did, congratulating India on its 28th anniversary as a free country—and its freedom from smallpox for the first time in recorded history. For us, it was a very dramatic moment, and for her.

We went on to Pakistan and Bangladesh. They came along. There were many adventures in Bangladesh which were just disasters, but by November that year, they were finished. It left us only Ethiopia at that time. At that point, it's only 25 million people there, but there are almost no roads. You are doing everything by foot and on donkey. There was smallpox in a lot of places. They had a revolution. They assassinated the king, Haile Selassie. They had a Marxist revolution. Two additional civil wars broke out, independent of the Marxist revolution. It was really an incredible time.

Most of the embassies evacuated their people. None were allowed to leave Addis Ababa, the capital, except we negotiated for the smallpox people to be able to leave Addis Ababa. They were the only people traveling around the country at that time, trying to stop smallpox.

Talk about heroism. It was really something. Nine times the teams got kidnapped and wound up in Mogadishu and Somalia. We had to use the United Nations' good offices to spring them loose. What would they do? They'd go right back to work again—go across the border and go back to work.

Then we had two helicopters, finally. The helicopter got captured. They wanted ransom. That was negotiated over some period of time. But the pilot, who was a Canadian pilot, was a pretty capable guy, and he managed to vaccinate all the rebels while we were waiting to get people ransomed.

The last chapter was in Somalia, where the smallpox went across to Somalia. The president of Somalia suppressed the reports. They were embarrassed because they were the last country with smallpox. The smallpox started to spread. This is very near to Mecca, and November was the period of the Hajj that year. We could just imagine, smallpox is continuing in Somalia and people go on the Hajj, and my goodness, it gets into Mecca. It will be like a centrifuge; it will spin out everywhere.

So there was another heroic eight or ten months getting rid of it in Somalia. But, finally, on October 26, 1977, the last case of smallpox occurred.

After that, we spent two years searching and documenting in all the countries, sending independent groups out. For three weeks, they would go into the country, review what was going on, go to areas to see what they could find. They weren't finding anything. With smallpox, remember that you can't just have cases going on silently.

Every individual who gets infected is going to have a rash. So even if you don't get every last case of smallpox, eventually that chain is going to become apparent. So we weren't that good to be able to detect every case, but eventually you detect the chain and are able to stop it. You can also confirm that there was no more there.

Finally, the meeting of the expert committee in December of 1979. We didn't have any more cases. This went to the World Health Assembly. In May of 1980, they announced that smallpox was eradicated and advised that smallpox vaccination stop around the world, which indeed it did.

That was not the end of smallpox, for two reasons. One, we had been so impressed by how many people could be vaccinated, particularly in Africa, with the type of organization that had been created and the way the teams worked, that we counted on, in Africa, the vaccinator to average 500 vaccinations a day. Remember, that's going village to village. And that was readily able to be achieved.

Earlier, in 1970, I was asking the question, why can't we give more than just smallpox vaccine? We found that in the countries almost no other vaccine was being used.

We had diphtheria, whooping cough, tetanus, what we call the DPT vaccine. We had measles. We had polio. These were widely used in the industrialized countries.

Why couldn't we expand the program in smallpox to include these other vaccines?

Finally, in 1974, that was approved by the World Health Assembly. After that, UNICEF made this a major effort. The Rotary International decided that they would raise $100 million for their 100th anniversary, and they set out to do that. They eventually raised, I think, somewhere between $600 million and $700 million. By 1990, 80 percent of the children in the developing countries were being vaccinated against DPT, measles, and polio. Polio right now is down to just four countries. It is eradicated in the Americas. The mortality rate worldwide has sunk to very low levels.

What has happened is that we have had the Expanded Program on Immunization, because vaccination is clearly the most efficient, least cost-per-capita intervention you can use to control a disease. So vaccine is very powerful.

The idea of using EPI, the Expanded Program on Immunization, more broadly was very important. In the Americas, this has gone extremely well. They are now using regularly 11 different vaccines in the Americas. With the exception, I think, of two countries, they are reaching between 85 and 90 percent of children every year. With this, the under-five mortality rate has fallen dramatically. At the same time, for reasons that are still being discussed, the fertility rates dropped off. So they are having fewer children and they are having many fewer deaths because of the diseases. So it has been a marvelous synchrony.

The last part, which is the unhappy part, is the discovery, only in the early 1990s, that the Soviet Union had been very active in developing biological weapons. In 1972, there had been the International Biological and Toxin Weapons Convention, in which all countries said, "We will destroy any biological weapons we have. We'll stop all research." It seemed like there was no mechanism made to verify this. But countries throughout the world did stop. It was assumed that the Soviet Union had stopped, but, as we were later to learn, they actually began in 1972 to develop their biological weapons program. By the early 1990s, it was at a level which, in funding and in personnel, was about equivalent with the nuclear program. It was big—about 500 laboratories and 60,000 people.

We met in the National Academy of Sciences, in the mid-1990s, with their four principal people who were running that program, the scientists. They explained to us the different diseases that they had looked at and what characteristics each one had. Then they rated each disease, from 1 down to X.

Right at the top of the list was smallpox, anthrax, plague. Those were the top three. As we were later to learn, they developed a very large smallpox production facility north of Moscow, which could produce in excess of 20 tons of smallpox virus a year. They had an extensive research program in Siberia, Novosibirsk, which indeed, during some of the, let's say, Gorbachev era, we learned a great deal about, because we have had many meetings with people from that laboratory. They indeed have developed this.

That was less the concern—and at this point, I would say is still less the concern—than what happened at that point. As you know, the Soviet Union collapsed. There were huge financial problems. They cut way back on the laboratories. Many of the people in the laboratories left and went to all sorts of different places—where they went and where they might be today we really don't have a very good idea, although we do know a number are here in the United States and a number in Europe—obviously carrying with them a lot of knowledge about biological weapons, how you produce them and so forth.

Thus, the concern today: Is it possible that this could be released, maybe by some other person? Rather than a nation-state, it might be a rogue group of some sort or a rogue nation. Thus, the concern, both here and in other countries, that we be prepared to respond with protection of people by vaccine, if indeed it was released. We at this time have about 300 million doses in storage, for that reason—very well preserved in cold storage. There are smaller reserves in a number of other countries.

So smallpox is finished. We haven't seen this in the wild since 1977. It's gone. But we are still concerned about smallpox as a disease.

That's what is covered in the book. But I think more important in the book is the lesson that we felt came from this. There are a lot of opportunities here for our younger staff, who were working here, who really didn't know you couldn't do what we did and were ready to tackle big problems. Many of these people have gone on, in their own countries and elsewhere, to tackle a lot of the problems of the Expanded Program on Immunization.

I think that and working as an international program—because this really was an international program—was very critical. We didn't have enough people to do much, other than to help stimulate countries. One hundred fifty people were all we ever had in the field. So it was mostly done by the countries themselves, with personnel in the field. So this is a great tribute to the health services and what they could do. What we provided was a stimulus and a sense of practices which would be helpful.

Let me stop there. That's a quick once-over as to what happened.

Questions and Answers

DEVIN STEWART: Wonderful. Thank you very much, Dr. Henderson.

I kept on bubbling up questions in my head, and you just answered them.

One, before we pass the microphone out, is what happened after 9/11/2001. You were called to Washington. Do you want to tell just a brief story about meeting with the U.S. government on the war on terrorism?

D.A. HENDERSON: I met with the secretary of Health and Human Services, 7:00 p.m., Sunday night, an emergency meeting. They had gotten an indication that there was going to be a second attack and it was going to be biologic. We assumed it would be smallpox, as the very probable one. And we found that we had almost no vaccine. We had about 90,000 doses, and that was produced in 1978.

We talked with manufacturers, and they said they could produce it in five years. That was as fast as we could get going. There were no manufacturing capabilities at all.

This was a great adventure of bringing in what I thought was one of the best people in the country that I knew. I called him up and asked him to come in. What can we do? Between the two of us, I would say we broke more bureaucratic barriers than you can possibly imagine. In 18 months, we had 200 million doses of vaccine coming in.

At the time we had it—this is a story that's not in the book—we actually went to see the secretary. We said, "Mr. Secretary, realize that we are producing it a different way and the strains are a little bit different. We haven't put it in people yet, but we are about to do that. But, remember—we talked about this—if it doesn't work, we have a lot of answering to do, because we've committed more than $500 million."

I must say, he got very pale. He said, "Yes, you said that, but you said it would work."

We said, "No. We said it was 95 percent certain that it would work. But I just want to remind you"—well, he was on the telephone every day, "How are the studies going?" The studies worked all right.

DEVIN STEWART: Before the talk, you made a link between that episode and the swine flu, which is going around the world right now—that things end up arriving too late. Did you want to make a brief comment about that?

D.A. HENDERSON: Yes. In 1957, we had the pandemic of influenza, which was very much like what we have with this one, with when it started and everything else.

At that time there was a heroic effort made to produce some vaccine, which was done in only a few countries. At that time, we met with European manufacturers, and they just said, "We probably can't handle it at all." We had some going in the U.S.

We looked at the course of the epidemic. It did exactly what this one has done. It hit a peak along about October, late October, and then gradually vanished. About that time was when the vaccine came along. It obviously had nothing to do with the end of the epidemic at all. We were out vaccinating a lot of people, but the epidemic was at an end.

I can't imagine that 52 years later, with all the efforts we have put into it, all the advances in technology, here we are again. The vaccine is coming in. We are peaking in the epidemic at this point. Guess what? We are going to get the vaccine just in time to say the epidemic is over.

DEVIN STEWART: I'll take that as reassuring.

Let's get a couple of questions.

QUESTION: I have a question about your perspective on reaching the most marginalized populations. The program of immunization was very broad, covering all populations. But were there specific instances where you had ethnic minorities or certain populations that were really hard to reach? How did you motivate and do the outreach with the governments in-country to motivate that?

D.A. HENDERSON: That's a very good question. We were working in some areas where they had never had vaccine at all.

What was very key, as we found out, was that we used in most areas what we called an advance team of one or two people, who would go into a village area and sit down with the elders. You usually did the elders and the schoolteachers and whatever health help there was and perhaps police or military. You would sit down with them and spend some time, drink some tea, and talk with them about the program. It was surprising to us, what a good response we got.

When we got into some rebel areas, which we did extensively in Ethiopia—we had a lot of problems—we always found that there were people that were on our staff or whom we knew who knew the rebels and who could go and sit down with the rebel groups and explain what you were doing and work their way through it. We found a lot more cooperation and receptivity than we would ever imagine. Very rarely did we come to a point where we had people who just said no.

One occasion was in southern Africa, where there was a religious group. They were migratory, quite large. There the president of Botswana said, "Everybody in my country gets vaccinated, and if you don't, you leave." So they decided that they would get vaccinated.

That was not a good way to go about it most of the time, but occasionally one had to lean on them a bit. But it was not extensive.

QUESTION: I think, obviously, it's generally recognized that governments are primarily responsible for dealing with public health issues—pandemics, et cetera. My question is, what is the role of private-sector organizations, given the fact that there are some 60,000-odd multinational corporations in the world?

They are well capitalized. They are extremely sophisticated organizations—in certain cases, more so than certain governments. Simultaneously, these multinational corporations are obligated to certain corporate social responsibility procedures and operating standards—for example, protecting their workforce and protecting the environment and respecting the environment and the community in which they are operating.

Are companies obligated to or can they participate in the global surveillance effort in the host countries in which they operate? I understand that maybe this is something that they could do tacitly.

D.A. HENDERSON: It's a good question. The smallpox vaccine was all produced in government laboratories in the first place, so it really didn't come up there, the production of vaccine.

We did have a major problem in India. Again, the same approach was used that we used going into a village. That was to sit down with people at the head of government, the head of the industry and talk with them. J.R.D. Tata, of Tata Industries, was one individual. We had a lot of problems in one state. That was a major manufacturer headquarters. We sat down and talked with him about it, and when he learned what this had in the way of implications for his company, they took over half of the state, with the approval of the government of India, and put their best management people in and ran the show.

What has also been interesting to me to see is the number of companies now who are giving very large quantities of antibiotics. I think Merck was one of the earlier ones that got involved here. They found that in making known to their employees what they were doing, they got a huge boost from the employees. It was good for the employees. They thought this was wonderful. It had an effect on the employees that they had never thought about.

Since that time, there have been several companies that are giving large amounts of antibiotics for treatment in trachoma and some of the parasitic diseases. This has been a motivation that is new. We never saw this before, until, I think, the late 1990s, when we began to see the companies doing this.

As we moved into the influenza in this country, and, in fact, in our preparedness operations we find, as we sit down with the company leadership—what assets do they have, and how can they contribute? We have been very surprised at how many of them are ready to contribute assets, but nobody has asked them. Once you sit down and do this—after we had this catastrophe, Hurricane Katrina—there had been a lot of planning with very large companies, whether it's Wal-Mart or various of the food distributors. Many of these companies have large reserves in their warehouses. They are ready to make them available rapidly. So they become very important in the mobilization.

I have been surprised, as I have heard the stories around the country, about how effective they have been. But they have never been asked before and have never been included in the planning before, or very seldom.

I think it's a lesson here. Like in the villages, if you sit down and talk it through and get them aboard, there is a receptivity here that we have not tapped, I think, as well as we might.

DEVIN STEWART: Dr. Henderson, thank you again.

I just want to say, Dr. Henderson, you are an example of moral leadership for this group, the Carnegie New Leaders. If you want some inspiration, just listen to the podcast.

Thank you so much, Dr. Henderson.

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