D.A. Henderson: Acting Globally, Thinking Locally
They had said that it couldn’t be done—the worldwide eradication of smallpox. To hear D.A. Henderson tell it, the job of leading the World Health Organization’s initiative to conquer the disease in the 1960s and 1970s rather fell into his lap. In fact, he describes each of the posts that he has held with great modesty, beginning with his military service at the Centers for Disease Control and Prevention all the way through his assignments as Dean of Public Health at Johns Hopkins, Associate Director of the Office of Science and Technology Policy in the Executive Office of the President, and more recently as Director of the Office of Public Health Preparedness under Secretary Thompson at the Department of Health and Human Services. Confronted with enormous challenges in terms of public health initiatives, Henderson describes each assignment as a matter of communicating with the people he works with and the people that he serves, and drawing on their insights to devise strategies for accomplishing the task at hand. With bioterrorism posing one of the major public health concerns to face the United States and the world, it’s gratifying to know that someone with Henderson’s track record and wide-ranging expertise is paying attention and making sure that medical and government officials are preparing to respond to the threat. Again and again, Henderson appears to have the knack for showing up in the right place at the right time with just the right idea.
MI: Talk first about your time tackling smallpox globally for the World Health Organization. How did that begin for you?
DAH: I first started at the Centers for Disease Control in Atlanta. I had finished medical school and one year of internship, and I was facing two years of military duty. At that time, either you volunteered for service as a first lieutenant or you were drafted as a private. I was about ready to sign up for the air force when a recruiter from the Epidemic Intelligence Service of the Centers for Disease Control showed up and asked me to volunteer in the public health service. We talked about it, and there were no uniforms, no marching, and I wouldn’t have to conduct entry-level physical examinations, which would be very dull, and I thought the CDC would be an opportunity to learn something.
In fact, it turned out to be a very exciting time in epidemiology. It was a real challenge to solve problems of public health on a number of fronts—not only the clinical, but there was also the epidemiological, which brought in cultural aspects that you had to appreciate in order to understand how diseases behave. Most of the people who began in the Epidemic Intelligence Service in order to satisfy military duty did not arrive with a great interest in public health, but many of us who arrived during this period [around 1955] found the work very exciting and got hooked. After my two years, I left to do my residency and then I got a master’s degree in public health, and then I returned [in 1960] to the CDC and was soon made Head of the Surveillance Section when my boss unexpectedly left. And in a major way I was suddenly running a good part of the Epidemic Intelligence Service.
One of the initiatives that I inherited had to do with the Agency of International Development, which was proposing to make a measles vaccine available in western and central Africa. The intention was to make the vaccine available to these countries for four years, after which the countries themselves would have to pick up the financial burden. Now, the measles vaccine at that time cost $1.75 per dose—a cost that these countries would never be able to afford. I was anxious to keep in our good graces with AID, but the idea of ultimately throwing away a vaccine program after four years bothered me, and so, recognizing that the smallpox vaccine cost only a penny per dose, we came back with another plan. The plan was to piggyback the smallpox vaccine onto the AID’s proposed measles program. In this way, the package would at least include a vaccination program that could be financially sustained for the long term. Our proposal would cost 35 million dollars, and I knew that it would be turned down when it went to the Surgeon General—and it was—but at least the proposal was somewhat sensible.
At that time, President Johnson occupied the White House, and he was supporting something called International Cooperation Year, for which he wanted to announce that the U.S. was contributing. Somehow, our proposal surfaced in the State Department, who presented it to the President, and the President thought that it was a great idea. So, all of a sudden [November 1965], there was an announcement from the White House that they were going to do this big program in west and central Africa. And my boss—I was working with Alex Langmuir—was absolutely furious with me and wanted to have little to do with the program. I was on my own with it!
MI: Was that comfortable, to be suddenly in charge of such a big program?
DAH: No, I was very, very distressed. I hadn’t intended to spend all of my time doing this one program in west and central Africa. The thought of running a program of that size and in Africa and in eighteen different countries was daunting. And then in the following May, there was a discussion in the World Health Assembly about global smallpox eradication. The Russians had been pushing it. The U.S., on the other hand, had been supporting malaria eradication. There were about a billion people affected at the time with smallpox. The Assembly debated for about two days about this; it was an unusually contentious issue for the Assembly. They finally had a vote, and it passed by only two votes. Many people thought that it couldn’t be done; many countries thought that you couldn’t eradicate smallpox, and many others didn’t want to put any more money into the United Nations system. The Director General of the World Health Organization also felt that it could not succeed and that it would bring great disrepute to the organization. And he blamed the U.S. for having foisted the program on the organization, because he felt that if the U.S. hadn’t supported the initiative, it would have failed. He therefore wanted an American to head the program so that the Americans would be seen to be holding the bag when the program ultimately failed. The next thing I knew, I was summoned to Washington by the Surgeon General and told to pack for Geneva to head this program. I was basically ordered to go. The deal was, I would go for eighteen months, get it started, and if it became intolerable before then the Surgeon General would bail me out. I ultimately remained for eleven years.
MI: With so many people predicting that an eradication program would fail, did you yourself think that it could succeed?
DAH: Well, I think technically, the answer was yes. We could do it, because there were large areas that were free of the disease. The real question was whether a program could succeed despite the many administrative barriers that were there. I was not at all certain that one could work through this very complicated big bureaucracy and manage to pull it off, particularly with only two-and-a-half million dollars and fifty countries to do programs in. And the whole staff in Geneva at that time consisted of four professionals and two secretaries. We finally got up to five professionals, three secretaries, and an administrative officer. The total group!
MI: So how did you get it to work?
DAH: Well it was interesting. We had a goal, and in this bureaucracy as in other bureaucracies, there was a lot of dead wood and that sort of thing. But the goal seemed to appeal to so many people as we began to work with them, and they responded to the determination of our small group. We made it a rule that for anything that came in the way of a query or concern, we would respond within forty-eight hours. So, everyone who became involved, in the field and elsewhere, came to know that they were listened to. I also put out a surveillance report every three weeks, and an overall global summary about two times per year, with maps and charts documenting our progress and focusing on specific regions. I think we counted seventy-three different nationalities that participated, and that means within the WHO. We did have a lot of young people, and they saw achievement and accomplishment. And the ministries in the developing countries, often so in shambles administratively that it was normally hard for them to demonstrate progress, became really energized when they saw themselves conquering a disease that was so fearful.
MI: Did you discover particular traits in yourself that came to play in directing a program that was so obviously confronting a huge problem?
DAH: One important element came from the two people who taught a course in physical diagnosis during my first year of medical school training. They kept stressing, “You take a good history from the patient. Keep asking questions and listen carefully. The patient will tell you your diagnosis; all you have to do is listen carefully.” And actually it has been very good advice. I don’t know how many instances that I wound up facing problems—political problems, medical problems, all sorts of things—that could be solved by listening to the views of the people affected. It was just like talking with a patient and getting a diagnosis. It’s surprising how often the people actually do know what to do, but sometimes it takes somebody from the outside to ask the question and bring their insights to the surface.
The second element that was very important was what I had learned from Alex Langmuir at the CDC. He was a can-do spirit, very determined, and he lived by the code of the good civil servant: very conscious about integrity. When I worked with him, there were not many medical professions who had much regard for the press. But Alex said again and again, “We are paid by the citizens of the country. We have a responsibility to communicate. And so we will see every press person who wants an interview.” That concept of public service, that concept of doing a good job with great integrity, made him a great teacher, and he made epidemiology an adventure.
MI: Was there a point where you became convinced that smallpox was on its way to eradication?
DAH: Well, the real hurdle was India. We had used a search and containment strategy that was very effective in Africa, Indonesia, and Brazil. But it wasn’t happening that way in India at all. We had to identify the cases of smallpox in India more quickly, because families that were afflicted would travel among remote villages. And we decided to try to visit every village in India in a period of ten days. On our first such search, we found so many cases it was just unbelievable. We had around 500 cases a week coming in from one particular state alone. I’ll never forget that. By the third search we had a system going so that we could go to every house in India within ten days. And we practiced tight quality control. We had really good people working at the national level in India. We had excellent reporting on every case and the quality control was there. The last case occurred in May 1975. And in Bangladesh it stayed until October that year. And then the big push was Ethiopia and Somalia.
MI: When you were working at the WHO to eradicate smallpox, did you ever imagine that the disease might one day return through bioterrorism?
DAH: Not really. I think the issue was raised once or twice, but we all tended to dismiss it. Biological weapons were not high on anybody’s radar screen at that time. In fact, until the defection of Vladimir Pasechnik to Great Britain in 1989, we had no idea that the Soviet Union even had a program. In the U.S., we stopped our program in 1973 in accordance with the Biological Weapons Convention. Pasechnik brought word that he’d been working on a new plague organism that would be antibiotic-resistant. And he had knowledge that there was a bigger program going on in the USSR. Later, in 1992, when Ken Alibek defected, we learned a lot about the Soviet program.
MI: And is that when your own thoughts turned toward developing the Center for Civilian Biodefense Studies at Johns Hopkins?
DAH: No. I didn’t really become concerned about it until 1995, when we had the Sarin gas attack in Japan. Also in that year we had the Iraqis make their Full, Final and Complete Disclosure. And Alibek’s information about what had gone on in the Soviet Union, because there were a great many people who simply didn’t believe him when he defected in late 1992, didn’t really surface until about 1995. All of this was occurring around the time [i.e., 1992–1993] that I was transitioning from [the position of Associate Director of the Office of Science and Technology Policy at] the White House to go over to the Department of Health and Human Services to be Principal Science Adviser, and so I wasn’t deeply involved in these events before I returned to Johns Hopkins in September of 1995. But I was very definitely becoming concerned about the potential for bioterrorism and the lack of preparedness in the federal structure.
There was also very little going on in any of the academic institutions—the National Institutes of Health had no program, and the Centers for Disease Control had nobody working in this area. I tried to get funds for a Center at Johns Hopkins, but initially, each foundation that I approached expressed discomfort in funding any sort of bioterrorist program [e.g., a program of studies of bioterrorist threats]. Even after the formal establishment of the Center at Johns Hopkins, I got turned down again and again, until finally I met with the President of the Sloan Foundation, Ralph Gomory. He encouraged me to send in a proposal to the Sloan Foundation, and literally within a few weeks—in 2000—money became available.
MI: After you founded the Center in 1998—well before the attacks in New York and Washington on September 11, 2001—what kind of responses were you getting?
DAH: Well, before 9/11, a number of people were gradually coming to appreciate the problem. The Center hosted two national meetings, the first of which was early 1999. Although we had been told by many people that we wouldn’t be able to attract a sizable audience, the registrations came pouring in—although not until about four or five days before the meeting—and we finally ended up with about a thousand attendees. It really established the Center, I think, as being important. We had many people from Congress and from the federal agencies. We had a second, equally successful meeting about eighteen months later, and these two national meetings really helped bring attention to the subject of bioterrorism to the country and the whole profession. We also prepared papers to cover a list of five agents and a group of biological agents (i.e., smallpox, Anthrax, plague, tularemia, botulinum toxin, and the hemorrhagic fevers) that could potentially compromise the functioning of civil authority; they were published in the Journal of the American Medical Association and so they got very wide circulation and also helped establish the Center.
The final important event that involved the Center before 9/11 was a tabletop exercise on smallpox at Andrews Air Force Base with the Center for Strategic and International Studies [see, for example, http://www.hopkins-biodefense.org/lessons.html]. From that exercise, Sam Nunn [who played the role of US President in the exercise] went to the Congress and testified about the seriousness of the potential for bioterrorist attack. The testimony in the Senate was on the fifth of September, so by the time we were into 9/11, there were a great many in Congress, and many colleagues in medicine and public health, who were sensitive to the same concerns we were raising at the Center at Hopkins. After the attacks at the World Trade Center and the Pentagon, there was concern that a second event would follow, and as we thought about it at the Center, we speculated that increased security would make it difficult for any terrorist to do anything involving airplanes, and we were concerned that a second event might involve biological weapons. September 11 was a Tuesday, and then on Sunday afternoon the Secretary called me to come down to the Department of Health and Human Services.
MI: This was the beginning of your appointment as Principal Science Advisor to Secretary Thompson?
DAH: Yes. I began coming down to the Department more and more frequently to do some planning and consulting. And then finally in October the Secretary asked if I would assume direction of the new Office of Public Health Preparedness that he was creating. He had decided that he wanted an office responding directly to him, which would be responsible for all of public health preparedness, that is, for everything from bioterrorism to chemical and nuclear threats. So I became Director of the Office, but I had commuted to Washington DC from Baltimore when I had been at the White House, and I said I was not very thrilled about doing this again and I asked to direct the Office on an interim basis only. My days at the Office have really been very long and I’m moving now to what I’m hoping will be 20% time to help the incoming Director. We were really a very small office, trying to start a variety of programs that are quite unprecedented. And there’s been a certain amount of tension to prepare the country under the circumstances we now face—always the question of how prepared are we.
MI: How do you answer that question? How prepared are we?
DAH: Well, you’re never fully prepared. We gradually have become better prepared. A response to a bioterrorist event is a very complicated thing to organize. There is probably no other event that you could think of in America where you would have to bring together such a diverse group of people on an emergency basis, who have to talk to each other and devise a plan—and they better have a plan before the event to work together under very intense circumstances. Each state is required to designate a director and a committee for overall public health preparedness. We’ve indicated the sort of medical people, hospitals, police, emergency medical and volunteer agencies, the blend of laboratory competence and communications needs that must be at hand. There has to be coordination between state and federal professionals at a level that is truly unprecedented. We’ve made funds available to the states and from the states to the municipalities, and it’s absolutely astonishing to see what the many, many states and local areas have accomplished. Just incredible. We put a real premium on speed because we felt that the country really had not been prepared.
MI: And the states responded quickly because the public health issues are so concretely real now to everyone?
DAH: This has made a big difference. And then of course the Anthrax events that occurred after 9/11 actually affected states across the country. Even in Alaska and Hawaii they were processing all sorts of swabs for Anthrax and were deeply concerned about the mail and all. And when you come down to it, it was really only twenty-two cases and five deaths, all regrettable and tragic, but in terms of the magnitude of a serious event it was nothing like the Trade Towers going down. And yet the amount of publicity, the amount of anxiety across the country, it was incredible. So, there was a real motivation to do things.
MI: Are there indications that the mechanisms for preparedness that have been implemented across the country will be effective?
DAH: Well, in terms of the West Nile virus, for example, I’ve talked with officials from Chicago, Mississippi, and Louisiana, and they have said how much easier this summer has been in dealing with West Nile because they now know how to work toward effective surveillance and laboratory diagnosis. We had asked all the states and local municipalities to have a plan to accommodate 500 patients per million people in the population. To prepare themselves, hospitals had to get together and decide how they would handle 500 patients on an emergency basis and house them in negative-pressure rooms in the event of a smallpox outbreak, for instance. Secondly, we had asked that each hospital have one or more rooms under negative pressure where patients with rash and fever could be examined. Thirdly, we asked each municipal area to develop a plan whereby they could, in a ten-day period, provide vaccines or antibiotics to their entire population. And then as we approached the SARS problem, we found a level of preparedness that was very gratifying. The cases of SARS that we’ve seen in the country were handled very well because of the level of preparedness that had been attained. We had also been meeting with the WHO and others about preparations against bioterrorism, so the concept of working together instead of in isolation and the fact that many of the people now know each other have made quite a difference compared to the level of preparedness that we started with.
MI: Right now, what are the biggest issues facing the Office of Public Health Preparedness?
DAH: Oh, there are a number of things. Right now, we’ve had a major thrust on smallpox vaccination and we still believe that it is important that a reasonable number of people in the medical community and public health arena get vaccinated. We feel that this is going to be a problem with us for a long time. So, we’ve got a priority program going to develop a more attenuated smallpox vaccine that would cause fewer reactions. A second priority is to try to get a second-generation Anthrax vaccine that would have really few or no reactions and that could be effective with no more than two or three doses. In addition, the further development of everything that’s going on in the state and local governments is critical.
On the research side, there’s another very important problem we face. Back in the 1960s and 1970s, we heard a lot about how we had licked infectious diseases and could move on to chronic diseases. With this attitude, we’ve let our research base decline; our training base has declined, although we’ve seen some improvement with the work in AIDS. But we are still far from what we need, and the idea of developing centers of excellence in basic research is going to be very important to prepare for emerging infectious threats. We must expand basic work in vaccines and antiviral drugs, particularly for bioterrorism, but also for SARS or any such emerging diseases. We do not have anywhere near enough trained people to deal with infectious diseases, epidemiology, and the management of the whole public health network.
MI: And in terms of this last issue, of training people—is this something you hoped to address when you started the Center for Civilian Biodefense Studies at Johns Hopkins?
DAH: Oh, yes. Particularly in the bioterrorism area, all of the different diseases that we’re concerned about are really—you might say—exotic. We’ve had almost no base of people working in the research of plague, Anthrax, tularemia, or smallpox. In addition, we’ve allowed the whole public health infrastructure to deteriorate over the years. The reporting of diseases has in some cases been substandard.
MI: What do you think accounts for your success in recognizing and then tackling big problems of public health?
DAH: Well, certainly, I always feel that whatever I’ve done I could have done better.
MI: So part of your success comes from being a perfectionist?
DAH: Well, I would say that my own style is that I don’t consider myself a genius in any particular field, and I think I’ve been very fortunate in identifying people who knew a lot more than I did and getting them to be part of a team. In my experience, when I’ve encountered very serious problems and have wondered how I’m going to handle them, more often than not the people I’m working with have the necessary ideas and it’s simply a matter of asking them for advice. I have found it crucial to delegate authority and give team members responsibility and authority and accountability. That makes a huge difference.
- © American Society for Pharmacology and Experimental Theraputics 2003
