The End of Smallpox

There are a lot of reasons why people believe Dr. D.A. Henderson was the best person to lead the successful effort to eradicate smallpox from the planet in the 1960s and 1970s. Usually they revolve around his intellect (unquestionably world class), his training (schooled in “shoe leather epidemiology” by his mentor) or his style of management (choose the right people, encourage them and let them make decisions on the ground).

What you don’t normally hear about is about his voice: a soothing, authoritative baritone that sounds more rural than his upbringing in suburban Cleveland would suggest; perhaps better suited to radio than  traipsing the world looking for smallpox outbreaks.

But once you read the recently released book by Henderson, founder of UPMC’s Center for Biosecurity in Baltimore, entitled “Smallpox: The Death of a Disease”—or hear the stories of how he rallied the    thousands of local people who were at the front line of the effort, you begin to understand how that voice, combined with his intellect, his experience and management style, combined to make him perhaps the only person for the job—even if he didn‘t want it at first.

“It’s not a hectoring voice,” said Dr. Sanjoy Bhattacharya, a fellow at the Wellcome Foundation in London who has studied and written about why the smallpox program worked in Asia, one of the last major battlegrounds with the disease. “In Bangladesh and India they see him as a father figure, someone who would sit on the floor with them, talk to them.

“They had time for him because he had time for them. He would go out into the field with the local workers, and he would put his hand on their shoulders and say, ‘We couldn’t do this without you.’ He has this wonderful way of making people feel they matter.”

The value of that human style often gets forgotten when people talk about Henderson and his landmark contribution. That perhaps is understandable when talking about leading what many call the greatest medical accomplishment in human history: the first time a disease—in this case, one of the worst ever known to mankind, responsible for hundreds of millions of deaths—was eradicated.

“One of the reasons that motivated me to write the book was to remind people it wasn’t easy, it was damn difficult,” said Henderson, also a professor of public health at the University of Pittsburgh.  “We had a lot of obstacles to overcome, but good people to overcome them.”

Finding the path

Donald Ainslie Henderson was born Sept. 7, 1928, in Lakewood, Ohio, a middle-class suburb of Cleveland, where   he was raised. His mother was a nurse,   and his father a mechanical engineer working at an Eveready battery factory, a job his father didn’t enjoy.

“He made it very clear that he was going to retire at the first moment he could,” Dr. Henderson says. “There was a life lesson there.”

Both of his parents were Scots-Canadian immigrants to the United States, and another life lesson came from his mother’s older brother, a physician and member of the Canadian parliament—an example of the combination of medical knowledge, politics and public service that would become crucial to Dr. Henderson‘s career.

“He was a remarkable individual,” Henderson said of his uncle. “And because of him, it was just sort of, ‘You’re going into medicine.’ ”

Raised in a Calvinist and Republican home, in 1946, Henderson went off to liberal Oberlin College in Oberlin, Ohio, gaining a deferment from the military draft. The racially and ethnically diverse student body—with few Republicans or Calvinists among them—was a revelation to Henderson, as was his decision to continue working on the yearbook, as he had in high school.

In addition to honing his journalism and publishing skills—which would become a crucial part of the worldwide effort to communicate with those working on smallpox—Henderson met his future wife, Nana (pronounced “Nay-nuh”) Bragg, a woman two years ahead of him at the school, and a top editor on Oberlin’s yearbook staff.

At first, “I would say there was a certain amount of antagonism,” Dr. Henderson says with a chuckle.

His wife of 57 years agrees. “I thought he was brash,” says Nana Henderson. “But I also thought he was very good looking.”  That brashness was buttressed by a healthy dose of confidence. “He was like the young people he writes about in the book: People who don’t know what can’t be done,” she said.

Henderson made a name for himself at Oberlin when he and his roommate started a radio station because one didn’t exist then—it’s still running today—and found a way around the campus rule that said students couldn’t drive cars by buying motor scooters instead.

“If he wanted something and was thwarted, he’d accept it gracefully, but you knew he was always working on Plan B,” Nana Henderson said.

They became friends but didn’t date until Memorial Day weekend, 1951, when Nana was working as a school teacher in Rochester, N.Y., and Henderson was attending the University of Rochester School of Medicine. It went well. They married three months later and have raised two sons and one daughter together.

Henderson was working in an internship at Bassett Hospital in Cooperstown, N.Y., in 1955 when he was told his draft deferment was up and physicians were needed in the military.

Fortunately for Henderson, just four years earlier the Communicable Disease Center in Atlanta had started an Epidemic Intelligence Service, an emergency group investigating epidemics wherever they occurred.

Public health had not been on Henderson’s radar, but because he wrote a paper as an undergraduate on the history of the 1833 cholera epidemic in Rochester, the CDC saw it as genuine interest. It hired him as assistant chief at EIS and promoted him two months later to acting chief when the prior chief left. A career was born.

His boss at the CDC was Dr. Alexander Langmuir, chief of the epidemiology branch, who would become Henderson’s mentor. Creative and demanding, Langmuir was a proponent of the shoe leather epidemiology that Henderson also promoted. He made sure that he and everyone else who worked for him spent significant time doing field work.

By 1965 Henderson had been chief of surveillance for the CDC for four years when he was named director of an effort to eradicate smallpox in 18 countries in West Africa, funded by the United State Agency for International Development.

A year later, the World Health Organization’s director, General Marcolino Candau, pushed the WHO assembly to approve a purposely underfunded effort to rid the entire world of smallpox. He did so, Henderson explains in his book, in the hope that it would be rejected because, WHO was already failing in an effort to eradicate malaria in 1966, and Candau didn’t want another eradication effort to fail.

Like many experts at the time, Candau also didn‘t think smallpox eradication was possible.

“He thought to the end that you’d have to vaccinate everyone in the world, and it was generally accepted that that was practically impossible,” Henderson said.

Candau also wanted an American—specifically Henderson—to be in charge of the Smallpox Eradication Unit, since it was the United States that had pushed so hard for it, and he wanted the U.S. to take the heat when it failed.

Initially, Henderson wanted to stay with the West African program, because he didn’t think worldwide eradication was possible either, given the scant $2.4 million a year WHO allocated for its own management of the program (millions more would be spent by each country). But being the good public servant, he took the post and moved himself and his family to WHO headquarters in Geneva, Switzerland. “And I really think if D.A. [Henderson] hadn’t gone to Geneva, eradication wouldn’t have happened,” said Dr. Donald T. Millar, who worked with Henderson at the CDC and later at the WHO in the smallpox program. “He’s got the kind of thing that, it was going to get done, or else—and the ‘or else’ wasn’t always clear.”

Millar is referring to Henderson’s hard-driving style of management, which was equal parts demanding and creative, like his mentor, Langmuir.

“He would tell me to go home at the end of the day, kiss the kids, help with dinner and come back and work some more with him,” said Millar, who considers Henderson his mentor.

Once he took the job, Henderson set a goal of eradicating smallpox in 10 years. Every hour of work was a step in that direction.

Given charge of the program, Henderson set out some essential rules that would become its guiding principles. One was that everyone who worked for the program, himself included, spend at least one-third of their time practicing the shoe leather epidemiology in the field—“Or they could find work elsewhere,” Henderson said.

Surveillance was also stepped up. Instead of simply counting how many people had been vaccinated against smallpox, as was the norm before the programbegan in 1967, he began asking for estimates of how many people contracted the disease (about 15 million in 1967), how many died (2 million that year), and where they lived. Another rule was open communication, with regular updates about new, local efforts that were successful fighting smallpox. This was collected in a newsletter that Henderson personally edited before sending it to more than 5,000 program affiliates around the world every three weeks.

Part of the rationale behind both of those rules was Henderson’s own personal style, but it was also in response to how WHO’s malaria program had been run. “The malaria program was very militaristic,” Henderson said, noting that the program even dictated how data should read on local bulletin boards. “It seemed to me inappropriate. We had to be more flexible.”

Looking for local solutions became the hallmark of the program, particularly after the CDC’s West African effort demonstrated that instead of immunizing everyone, the most efficient method for collaring the disease was an identification-and-containment method.

Relying on quick identification of carriers, local workers would then descend on a region and immunize in a ring around the area, cutting off the spread of the disease.

There were innumerable other barriers—cultural, political and geographical— that had to be overcome along the way, many with Henderson’s direct involvement. But it was the work and the solutions on the ground, in the villages, towns and regions where the hard work was done by local health care workers and volunteers that really got it done.

“The real work was done by local people in their countries,” he told a crowd of admirers during his book launch party in June at the University of Pittsburgh. “We in Geneva were serving more as catalysts than really operating the program.”

His 10-year goal would be missed by a mere nine months, with the last known case of smallpox occurring in 1977 in Somalia.  And although Candau never admitted it, his deputy director wrote a note to Henderson after eradication: “You were right and we were wrong.”

The implications of the world’s first eradication were monumental. “The fact that it has been done once, we believe it can be done again,” says Dr. John Sever, who as vice chair of the Rotary International’s Polio-Plus Committee, has been working on eradicating polio for 25 years.

Today, at 80 years old, Henderson is still a major player in worldwide debates on diseases, consulting on the flu epidemic and how to counter its spread, and still pushing to have the United States and Russia destroy their frozen samples of smallpox, for fear they could be turned into biological weapons in the wrong hands.

“He’s a giant in the field and one of America’s heroes,“ said Tommy A. Thompson, former U.S. secretary of Health and Human Services, who brought Henderson on as his chief science officer after the Sept. 11, 2001 attacks, when fears of bioterrorism abounded. “When he gets his mind set, he isn’t going to be stopped.”

Henderson says his ongoing drive, even at a time in his life when he could easily be retired to pruning his garden, comes from the most basic of motivations: “There are still real challenges where you have the arrogance to think you can make a difference.”

D.A. Henderson is a professor of public health at the University of Pittsburgh.