Finishing my account, in which I skipped lightly over Toby’s indiscretion in Charlio’s, I looked up at Michael as he reached over to fill my glass. ‘And, you know, I didn’t really believe any of it myself until it finally dawned on me that it could all have been done without you ever having the virus. That’s when the penny dropped. It was a bluff, a gamble. And it worked, didn’t it, Michael?’
‘Fascinating.’ Michael returned the bottle to the table. Seema would not look at me. Neither said anything, as if some impasse had been reached.
I sighed with elaborate forbearance at having to ask the question outright. ‘So, what I would like to know, my friends, is … is that how it happened?’
Seema’s look appealed to Michael, who allowed himself a smile. And. though the smile was more assured these days, it was still the same slow smile of the seventeen-year-old I had known at Amherst more than fifty years ago.
‘If I may paraphrase, Tom, never has so much been built on so little.’ He looked out, still smiling, over the yard towards the Musketaquid Pond and the distant hills. ‘But, then again, you only have to go to Europe and see all those medieval cathedrals like we did last fall to realize how much can be built on very shallow foundations.’
I smiled back indulgently. But of course I would not be satisfied. ‘But my little story is plausible, on the whole, wouldn’t you say, Michael? Seema?’
A breeze stirred the lavender, bringing its perfume on the warm air. Over the pond, an emerald dragonfly held itself motion less. Michael took Seema’s hand and raised his glass towards me. ‘It’s a great story, Tom. Wish I’d thought of it myself.’
Thomas Keeley
New Canaan, Connecticut
2017
POSTSCRIPT
The real story
The dramatic rise in immunization across the poor world during the 1980s is a matter of public record. Many millions of children’s lives were – and continue to be – saved by a decade-long effort which saw immunization coverage climb from below twenty per cent to almost eighty per cent across the developing world. Many more millions of children were also protected from lifelong disability.
The Kennedy Moment gives an entirely fictional account of how and why this great advance came about.
The real story is perhaps more extraordinary.
Mission impossible
In 1977, smallpox was declared eradicated following a ten-year effort led by a small World Health Organization team under the leadership of the American epidemiologist Donald ‘DA’ Henderson. The strategy which made it possible – the ‘surround and contain’ technique described in the pages of The Kennedy Moment – was developed by William Foege, subsequently director of the US Centers for Disease Control.
Following this achievement, WHO established the Expanded Programme of Immunization (EPI) with the aim of protecting children against measles, diphtheria, whooping cough, neonatal tetanus and poliomyelitis. Together, these five vaccine-preventable diseases were claiming an estimated five million young lives a year and condemning hundreds of thousands more to a lifetime of disability.
To many at the time, the task seemed hopeless. Bringing such diseases under control would require much more than a one-off campaign to ‘surround and contain’. It would require the routine, annual vaccination of all newborn children and pregnant women in all countries, most of which would need help with sourcing vaccines, disease surveillance, training immunization teams, developing infrastructure and logistical systems, and deploying cold-chain technologies. To lead such a massive undertaking, the EPI team in Geneva under another American epidemiologist, Ralph ‘Rafe’ Henderson, numbered eight professionals and four support staff with a budget of one million dollars a year.
At that same time, at the beginning of the 1980s, something was about to happen on the other side of the Atlantic that would transform the chances of success.
The scarcest resource
In one of his last acts as US President, Jimmy Carter nominated James P Grant, the head of the Washington-based Overseas Development Council, to be the new Executive Director of UNICEF. Within months, Grant announced that UNICEF would be devoting most of its efforts and resources, including several thousand staff in offices throughout the developing world, to the task of bringing about a ‘child survival revolution’. Its main engine would be a campaign to lift immunization coverage from twenty per cent to forty per cent of the world’s children within five years, and to eighty per cent by the end of the decade.
The audacity of such an announcement is, today, difficult to recapture. At the time, projects being run by UN agencies and NGOs would typically reach out to a few hundred, or at most a few thousand, children in villages and neighbourhoods here and there in the developing world. Grant’s plan would require reaching out to all children – over 100 million newborns every year – with the right vaccines at the right times in the right hands and at the right temperatures.
No one doubted that this was technically possible; improved and more heat-stable vaccines had become available at a cost of a few cents per child. The problem was one of scale – of putting a known solution into action on the same scale as the known problem. And no matter how many partners could be enlisted, and no matter how many individual projects could be launched, sustained action on the scale required was impossible without the commitment of national governments. In other words, what was required was ‘political will’.
Grant’s response was to switch UNICEF’s emphasis from programmes to advocacy. ‘If the problem is political will,’ he argued, ‘then the job is to create the political will.’
Backed by UNICEF staff in country offices throughout the world, he set about the task of meeting personally with presidents, prime ministers and other influential figures in a great majority of the world’s countries. At each meeting, he would ask if he or she knew the country’s current immunization rate, or the number of children dying from vaccine-preventable disease, or the relatively low cost of preventing death and disability on this scale. Shamelessly, he would inform them that neighbouring countries were racing ahead with immunization, or point out that the country’s child death rate was much higher than in other nations, or appeal to a head of government to set an example to the world. At the same time, he also met with the political leaders of most of the world’s developed nations, hammering home the message that five million children a year were dying unnecessarily from diseases that five cents’ worth of vaccines could prevent.
Gradually, the funds available for the immunization effort began to rise.
There were many critics. Some were shocked by the narrowness of the approach. And many were alarmed that Grant risked lending UNICEF’s good name to leaders with appalling human rights records just because they had been persuaded to make a public commitment to immunization. Grant’s answer was always the same: You think we should wait to immunize children until all governments are respectable?
No hiding place
Reaching out to entire populations – not only to ensure supply but to create demand – was often too big a task for health services alone. Grant’s answer was ‘social mobilization’. In practice this meant attempting to enlist every possible outreach resource in the society – the media, the teachers, the religious leaders, the business community, the trades unions, the non-governmental organizations, the youth movements and the women’s groups – in a ‘grand alliance’ for immunizing children.
The strain of all this on UNICEF offices and their counterparts across the world was enormous. And there was no hiding place. Grant demanded regular reports detailing the progress of immunization coverage in each country. If the rate was not rising, or not rising fast enough, he wanted to know what the bottlenecks were and what outside help was needed to bypass them. On one memorable occasion, he refused to accept civil war as an excuse for El Salvador’s low-performing immunization programme: flying to San Salvador, he enlisted the help of the Catholic Church, met with both government and guerrilla leaders, and
negotiated a series of ‘days of tranquillity’ – suspending the war for three days every year so that the nation’s children could be immunized.
UNICEF provided most of the vaccines. Meanwhile the World Health Organization (WHO), other UN agencies and national health services were working to translate high-level political commitments into action on the ground. WHO, in particular, trained thousands of immunization managers and advised on every aspect of immunization programmes from quality control to cold-chain technologies and the use of improved syringes, needles and sterilizing equipment. In many countries, non-governmental organizations also took up the cause: Rotary International, for example, raised over three hundred million dollars and mobilized its membership in more than one hundred countries in support of the immunization effort.
Endgame
Few believed that the intensity of all this could be sustained over a decade. Yet, as the immunization numbers began to climb in country after country, Grant used news of the progress being made to add to the momentum. As the forty per cent mark was passed, more governments and organizations were persuaded to believe that the eighty-per-cent target could be achieved.
By the end of the 1980s, when it was clear that the eighty per cent target was going to be reached in the great majority of countries, Grant proposed a World Summit for Children, bringing together the world’s Heads of Government to consider what more could done. His aim was to set new targets for the deployment of other low-cost methods for saving the lives and protecting the normal health and growth of millions of the world’s poorest children. And, by the time the World Summit convened in September 1990, he was able to confirm that the eighty per cent immunization target had indeed been achieved in almost all countries and to use this announcement to give credibility to new targets being set for the mid-1990s.
But as the new decade got under way, Grant himself was diagnosed with cancer. Operations, radiotherapy and chemotherapy followed. Yet in his last year of life, though visibly failing, he travelled tens of thousands of miles and held face-toface meetings with over forty presidents and prime ministers, urging them to commit to the new targets for protecting their nations’ children. By 1995, many of those targets had also been achieved.
Each and every child
James Grant died in a small hospital in upstate New York towards the end of February 1995. Around him were letters and cards from almost every country in the world, including many from the political leaders he had pushed so hard and for so long.
A card from President Clinton read: ‘I am writing to thank you from the bottom of my heart for your service to America, to UNICEF, and most of all to the children of the world.’ Chinese Premier Li Peng wrote that Grant’s death ‘was an irretrievable loss to the children of the world’. Nelson Mandela commented that ‘his death is a great loss to each and every needy child in this world’. Former President Carter said that his nomination of Jim Grant to head UNICEF was ‘one of the greatest and most lasting achievements of my Presidency’. And the New York Times mourned the passing of ‘one of the great Americans of this century’.
The ‘real story’ continues to inspire. ‘Jim Grant’s achievement,’ said Microsoft founder Bill Gates in committing the Gates Foundation to the eradication of polio, ‘is the greatest miracle of saving children’s lives ever’.
The progress that Grant inspired in his sixteen years as head of UNICEF went beyond the expansion of immunization coverage. Other low-cost, life- and health-saving interventions, from oral rehydration salts to Vitamin A and iron supplements, were subjected to the same ‘going to scale’ treatment. Over and above the successes in reaching individual targets, the whole notion of promoting progress by means of measurable, internationally agreed goals was rescued from disrepute, contributing directly to the setting of the Millennium Development Goals that guided the international development effort into the twenty-first century. And behind all of the achievements of the Jim Grant years was the message that he had repeated endlessly to world leaders throughout his tenure as head of UNICEF – ‘morality must march with capacity’.
The Kennedy Moment is dedicated to the memory of James P Grant, with whom I had the privilege of working for his sixteen years as Executive Director of UNICEF. The full story of Jim Grant and the child-survival revolution is told in Adam Fifield’s magnificent 2015 biography – A Mighty Purpose: How UNICEF’s James P Grant Sold the World on Saving Its Children (Other Press, New York, 2015).
Peter Adamson
ENDNOTES
2 | I would know her by heart
1 yard of ale A trumpet-shaped beer glass, about a yard long (0.9 metres) with a closed bulb at one end and a wide opening at the other. The ‘yard’ contains about two and a half pints (1.4 litres) of beer. The future Prime Minister of Australia, Bob Hawke (who, like the future US President Bill Clinton, was a Rhodes Scholar at Oxford), broke the then record by drinking his yard of ale in approximately eleven seconds. Hawke later admitted that this feat had probably done more to advance his political career than any speech he ever made.
3 | Life and times
1 two years at the International Centre for Diarrhoeal Disease Research in Bangladesh The ICDDRB played a major role in the discovery and development of oral rehydration therapy (ORT) for the treatment of diarrhoea and cholera (see Postscript).
2 Wasn’t there a rumour about Jefferson In 1980, the allegation of a long-term sexual relationship between Thomas Jefferson and Sarah (‘Sally’) Hemings, one of his slaves at Monticello, was still unproven. In 1998 DNA tests established beyond reasonable doubt that Thomas Jefferson was the father of all six of Sally Hemings’ children.
5 | Not really cricket
1 It’s been rumoured the North Koreans might have hung on to it, and maybe even the French, the Iraqis, the Israelis This was certainly the suspicion of Lev Sandakhchiev, long-time Director of Vector, the Soviet Union’s State Research Center of Virology and Biotechnology in Koltsovo, Siberia. In the 1970s and 1980s, Vector carried out secret research leading to the development of biological weapons. When the programme was later dismantled, in the late 1980s, Sandakhchiev helped to engineer the peaceful transformation of the Soviet germ-warfare programme.
6 | Next year in New York
1 Just heard he might be going to the New School The New School for Social Research was founded in Greenwich Village, New York, in 1919 by a group of university professors whose vision was of a modern, progressive, free school where adult students could ‘seek an unbiased understanding of the existing order, its genesis, growth and present working’. In 1933, it established the University in Exile as a graduate school for scholars fleeing fascism in Italy and Germany. Today’s Graduate Faculty remains a home for left-leaning American political analysis.
2 not even basic EOC Emergency Obstetric Care, the availability of which is the key to steep and sustained reductions in maternal death rates.
3 follow-up to Alma Ata Alma Ata, in the former USSR (now Almaty, Kazakhstan), hosted the first International Conference on Primary Health Care (PHC) in September 1978.
10 | Filer à l’anglaise
1 Les amis In French-speaking West Africa, ‘les amis’ was used as compound slang for ‘friends’ and ‘Americans’.
11 | Can we take a walk?
1 interview with Shriver Sargent Shriver, brother-in-law of President John F Kennedy, was the first Director of the US Peace Corps.
2 Some very odd PCP clusters Pneumocystis pneumonia, a severe infection of one or both lungs, is most often seen in people who have a very weak immune system and is a common opportunistic infection for people living with HIV/AIDS.
3 Not even going to be in the MMWR The Morbidity and Mortality Weekly Report has been published by the US Centers for Disease Control since 1952 and is the official source of US public-health information, including current recommendations.
4 a ‘Welcome Home’ banner across the street On January 20th, 1981, fifty two US hostages were released from Iran after 444 days in c
aptivity. Five days later, they arrived home aboard ‘Freedom One.’
5 AMRIID will for sure have the final say The U.S. Army Medical Research Institute of Infectious Diseases is based at Fort Detrick, Maryland and was responsible for U.S. bio-weapons research.
13 | Flies on a summer day
1 Billy’s Bar on First Avenue at 52nd Street Long an East Side institution, Billy’s Bar closed its doors in 2004 after a hundred and thirty years of serving Manhattanites. Located on First Avenue at 52nd Street, a cause of its demise was the ‘social depression’ that hit many New York businesses in the months following the September 2001 attack on the twin towers of the World Trade Center.
15 | Forget it ever happened
1 The FBI break-in On March 8th, 1971, while much of America was preoccupied by the ‘fight of the century’ between Muhammad Ali and Joe Frazier in Madison Square Garden, two members of a citizen-activist group broke into an FBI office in a suburb of Philadelphia. The documents stolen revealed an extensive FBI ‘dirty tricks’ programme of illegal surveillance, entrapment and intimidation directed towards dissident groups, civil-rights activists and anti-war protesters. Copies were mailed anonymously to several newspapers, leading to the setting up of the Church Committee and the eventual reining in of the FBI. The burglars were never traced despite the deployment of more than two hundred agents by FBI Director J Edgar Hoover. The hunt lasted five years before finally being called off in March 1976. More than forty years later, in January 2014, the burglars revealed themselves in an interview for a book by Betty Medsger, a Washington Post reporter who had been one of the first to receive copies of the stolen papers. One of the conspirators, John Raines, is quoted as saying ‘It looks like we’re terribly reckless people. But there was absolutely no one in Washington – senators, congressmen, even the President – who dared hold J Edgar Hoover to accountability.’ After the break-in, the eight seldom communicated with each other and never met again as a group.
The Kennedy Moment Page 31