Q&A on: H1N1, a $200 prize and Romano & Engel

To see the extra questions referred to in the print version of Rochester Medicine, Click here.

D. A. Henderson, M.D. (M ’54), is professor of medicine and public health at the University of Pittsburgh and a distinguished scholar at the Center for Biosecurity in Baltimore. He is a former dean of the Johns Hopkins School of Public Health. From 1966 to 1977, he directed the World Health Organization’s global campaign against smallpox. His new book, Smallpox – The Death of a Disease, tells the story of how the only successful disease eradication program in history was accomplished. In 2002, Henderson received the Presidential Medal of Freedom, the nation’s highest civilian honor, for his work in public health. He also has received the National Medal of Science, the National Academy of Sciences’ Public Welfare Medal, shared the Japan Prize with two colleagues, and was knighted by the King of Thailand in 2008. In 2005, he was awarded the Hutchison Medal, the highest honor given to an alumnus by the University of Rochester. Henderson answered a few questions while he was in Rochester for his class reunion in October.

What are you working on?

My colleagues and I at the Center for Biosecurity are deeply concerned about the H1N1 pandemic influenza and how the government at the national level is responding and how local communities are reacting. Broadly-based preparedness plans and programs are needed at all levels of government, not only for influenza but also to counter the possible widespread dissemination of other agents. At the same time, we are concerned about international surveillance. How might we detect at an early time, new and unusual infectious disease agents that might eventually cause serious problems? As an illustration of the importance of this, I would note that AIDS was first diagnosed in 1982 in the U.S. The cases were then thought to be few in number, although serious and rapidly fatal.  Today, it is the fourth leading cause of death in the world and it is not yet under control.  However, we now know that the disease was prevalent in some areas of Africa decades before identification of the disease. With a better surveillance system we might well have detected it at a much earlier date and could have been in a position to take effective preventive measures. How do we as a country, and in a collective world response, establish better systems for detection of such diseases? This inevitably means helping Third World countries in the development of laboratories and fostering a network of fully cooperative and collaborative centers across the world. There are elements of such a network in place but they are scattered and incomplete. Are there investments the U.S. could make that would be productive in developing this?

What do you think of the handling of H1N1 so far?

I don’t think the government has done as well as it could in providing succinct, understandable, current and well-considered direction and information to local health departments and to citizens generally. A significant problem has been an inexplicable disconnect between government authorities and the manufacturers. Far less vaccine has been produced in a timely manner than the manufacturers had forecast.  Moreover, their regularly updated forecasts proved again and again to be overly optimistic. Health departments, on the advice of the federal government, made plans to distribute the vaccine as rapidly as it was distributed but to everyone’s frustration the promised supplies were not forthcoming. Frustrated citizens waited for hours in lines. A second problem was the flood of information from agencies and sub-agencies across government.

There seemed to be no single authoritative source. Some of the recommendations were contradictory, and some were poorly considered. Do we close schools or not? Should masks be worn or not? Will the virus abruptly change and become more virulent? Is the new vaccine likely to be associated with serious complications? Recently, key officials have suggested that we are in uncharted waters and have no idea what the future course of the pandemic might be. The lessons to be derived are that although we have made considerable progress as a nation in dealing with a major epidemic, much more must be done in the public health sphere in terms of resources, planning, and preparation. There will be other pandemics!

Fortunately, the current pandemic has proved to be far less serious than the one in 1918, albeit remarkably similar to the subsequent pandemic which began in 1957. If the present pandemic behaves as influenza in 1957, cases will begin to decrease sharply in November but an apparent lull in cases will be followed by smaller but significant outbreaks during the usual seasonal flu period of January to March. Thus, we are endeavoring to make the point to everyone that, even if vaccine arrives after the peak of the autumn epidemic, it would be prudent to be vaccinated to counter a January to March resurgence. 

What about your Rochester education helped you in your career?

My entire Rochester educational experience more than met my expectations. However, there were two experiences that proved to be especially meaningful. The first was my unexpected introduction to epidemiology and this eventually proved to be my career commitment. During my senior year, there was a prize offered (the George Corner Prize) to be given for the best treatise in the history of medicine. It was $200. My wife and I were poor struggling students and $200 was a substantial sum of money. I decided to win that prize.

I had read a book about a cholera epidemic in upstate New York in 1832 and wondered what impact this devastating disease might have had on the budding commercial center of Rochester. At that time, the first global pandemic of cholera was spreading across the United States. I searched through old Rochester newspapers, maps and books and drew curves and prepared maps showing the progress of the disease. I was fascinated by the actions being taken by the city and the health department in trying to stem this hitherto unknown disease. Preparation of the paper proved to be my first introduction to epidemiology and public health. I found the field to be fascinating and exciting and thus my career direction began to be shaped. I won the prize, although I suspect I may have been the only entrant. This award eventually played a role in my being selected for a position in the CDC’s Epidemic Intelligence Service.

A second important development in my learning curve derived from the teachings of John Romano and George Engel. They dwelt on the fact that in interviewing a new patient, one needed to question him carefully and to listen attentively. They made the point that if one listened carefully and the patient was given sufficient time, he would  more often than not make the diagnosis and give a clear indication as to the best possible course of therapy. I found the advice to be applicable in other puzzling situations. I remember on more than one occasion being sent on an emergency epidemic call and trying to anticipate what I should do and recommend. It was often supposed that because I came from CDC, I must be an expert when, in fact, I frequently knew little more than what I had been able to read en route to the scene of the epidemic. Inevitably on arrival, I was invited immediately to meet with government officials, local physicians and others. It proved useful to recall the Romano-Engel advice and to ask questions and to listen. What do you think is the trouble? How might the problem be handled? As I discovered, many people had both insight and good ideas but had been reluctant to offer them or they were ignored. As an outsider, I could ask questions and solicit answers that others could not. I routinely asked many questions and listened. Surprisingly often the problems were readily resolved and appropriate directions emerged.

As I moved on to other positions for which I had neither prior training nor experience—director of the global smallpox eradication program, dean of a school of public health, and presidential adviser in the White House—I followed the Romano-Engel advice in asking questions, listening, and learning. It was a pleasant and gratifying surprise in every setting to discover the many astute, creative, and helpful people I was working with but it was necessary to take the time to question and to listen.

Bonus Questions

What would you tell the vaccination skeptics who have raised so many strange issues during this flu season?

There are a certain number of skeptics about both the safety and efficacy of almost every vaccine.  Many efforts have been made to measure both of these factors -- the risks of an adverse reaction following vaccination and the protective values of each of the vaccines.  Independent expert committees of the Institute of Medicine and professional organizations have carefully weighed the evidence for each and have published their considered judgments. Whatever is presented, however, inevitably fails to persuade a few.

One argument that is frequently advanced is that any vaccine risk is unacceptable for certain of the diseases—polio and measles, for example—which have effectively disappeared from the U.S. What they ignore is the fact that importations of these diseases occur readily, but the diseases spreads poorly or not at all. Were vaccination levels to drop to lower levels, they could spread far more readily. Vaccination is a small inconvenience compared to life-time paralysis from polio or permanent brain damage due to measles. 

Do you know how many vaccinations you’ve had over your lifetime? Have you ever had a bad reaction?

I received all the vaccines recommended during childhood and have since received a number of other vaccines including those against yellow fever, hepatitis, and influenza (annually). I have probably been vaccinated against smallpox on at least 50 occasions. It was customary when visiting a village or region undertaking mass vaccination for the mayor or governor to be vaccinated as well as visiting officials from out of the country.  I have never had a bad reaction following any of the vaccinations.

Is there a disease that could be eradicated with methods similar to those used to rid the world of smallpox? If so, what is it? What would it take to accomplish the eradication?

Immediately after the announcement that smallpox eradication had been achieved in 1980, I was asked to speak to a national conference which was convened to address the question as to what disease should be eradicated next. I was only too cognizant of the difficulties that we had encountered in eradicating smallpox despite having had a highly effective vaccine and a disease that had epidemiological features that greatly facilitated eradication. No other disease came close to matching these characteristics. Accordingly, I asserted then and have continued to believe that we have neither the technology nor the international commitment to undertake the eradication of any other disease. It has seemed to me to be far preferable to invest our resources in large-scale programs of preventive vaccination for a variety of disease for which vaccines are available and to strengthen basic research programs to develop other new and better vaccines.