Recollections from the first decades of EPI

Cross posted from http://www.childsurvival.net with many thanks to Robert Davis NOTE FROM ROBERT DAVIS INVITING CONTRIBUTIONS The Expanded Programme on Immunization, now the world's largest public health programme, is approaching its fortieth birthday. It got started in a small suite of offices in Geneva, using the office equipment and super-stars of the then concluding smallpox eradication programme. The first global EPI director was recruited by the outgoing SEP director. We are slowly losing, from death and retirement, those who were there in the first decades of EPI, setting up the permanent structures which everyone, today, takes for granted. How many of my readers from those early decades would be able to set down, in a page or two, their recollections of EPI in the '70s and '80s? Dust off your memories, ladies and gents, and send me a few hundred words at [email protected]. If prospective contributors have trouble getting started, take as your model the contribution, below, kindly sent in by our colleague Robert Steinglass. For those who don't know him, Robert, who is now Washington based, started out in the smallpox programme in Ethiopia before working as WHO tech adviser for EPI to three governments in the Mideast and South Asia. RECOLLECTIONS OF ROBERT STEINGLASS In 1977, newly graduated from Hopkins with a masters degree in public health, I was in a restaurant in Washington, DC and chanced to see Dr. Ciro de Quadros walk past the window. He had been one of my supervisors on smallpox eradication in Ethiopia from 1973-75. He told me that WHO had just approved the creation of the Expanded Program on Immunization and they were looking for staff interested in overseas assignments. Soon after, I found myself in North Yemen. A year later, the process to certify smallpox eradication from North Yemen was nearly complete and my 12-month effort as a resident WHO officer to document that absence was coming to a close. Vaccination coverage in North Yemen against other diseases, as in most developing countries, was about 5%. WHO offered to extend my contract to help build MOH capacity to routinely provide all vaccinations included in the new global EPI, but there was little technical guidance available to do so. While it was exciting to be on the ground floor of this new initiative, all that I had to guide me was a two module WHO set in a distinctive blue cover. It provided guidance on such matters as flaming BCG needles between uses and boiling used syringes and needles. WHO in the EMR office and in Geneva were supportive when I raised questions from the field nearly every month. We were all learning together. The first task was to devour these modules and also test whether their advice was accurate. I found the statement that DTP vaccine, if ever frozen, would re-settle after shaking in just 5 minutes to be inaccurate and that a longer period of time was required. As a result of questions from the field, and as he did on so many other technical occasions later on, the late Dr. Artur Galazka set about studying the effect of freezing on different manufacturers’ DTP and DT products (citation Weekly Epidemiological Record, 1979 or 1980), which led to more precise guidelines on the shake test. We received Geneva’s guidance from James Cheyne, who was starting to produce training materials, and from John Lloyd, who advised on cold chain and logistics. One of the first region-wide learning activities was a visit to the Igloo ice cream factory in Karachi. We learned what it took for the private sector to keep their product continuously cold in a tropical environment. The early versions of the WHO/UNICEF Product Information Sheets started in about 1978 and appeared to have been produced using stencils. John was looking for a site to test the newly developed 3M cold chain monitors, so-called “silent supervisors,” and we jumped at the chance. Dr. Marc LaForce had produced excellent protocols to estimate the burden of polio and later tetanus, so we used them in the early 1980’s in North Yemen. (citation, Bulletin of the World Health Organization on polio). One of the first Senior-level Managers Training courses was held in Damascus in October 1979. Always encouraging, Dr. Robert Cook (first Regional Advisor for EPI in EMRO) appointed me as one of the facilitators. These were early days of EPI and I knew very little about vaccination. Dr. Cook had a box of the most important references on immunization in the developing world – 100 of them, hand-numbered and cross-referenced on a bibliography sheet dating back to the 1960’s - - which I proceeded to study, as there was so little available to inform WHO field workers at the time. These documents had been assembled by Dr. Galazka, who for many years was famous throughout WHO for his library in Geneva, his encyclopedic memory, and his kind mentoring of field staff. Everything was new and needed to be tested in the field and WHO at regional and global levels were themselves keen to learn. The early years of EPI in the field were devoted to building management capability, developing cold chain and logistics systems, preparing learning materials, training staff, etc. These were the years right after the Alma Ata declaration and WHO saw immunization as a means to jump start primary health care. Creating a functioning routine immunization system as an integral part of the overall health system was seen in those days as a developmental challenge. As such, WHO recognized the need to post field staff to focus on the required operational, programmatic and managerial tasks. Progress was slow and funding inadequate. Under James Grant’s leadership, UNICEF greatly expanded its financial involvement and entered the world of immunization in a big way in 1984. While we felt supported in the field and were eager to progress rapidly, our communications with WHO regional and HQ offices were mostly limited by “the pouch.” Once a week, official WHO correspondence would arrive by air in a sealed diplomatic bag from the regional office in Egypt. If there was an incoming item related to immunization, the WHO Representative (WR) to whom the letter had been addressed would call me in to advise him and request that I draft a letter to the MOH. A few days would pass and the MOH would call me in and ask for my help in replying to the WR. After a few more days, the WR would request that I draft a reply to the regional office. At times, I felt I was a post office; at other times, I felt I was having a stimulating correspondence with myself! In the best of times, the entire cycle took 2-3 weeks. Consequently, we learned to be rather self-sufficient in identifying the needs and locally addressing the barriers. Eventually in 1980, I passed through Geneva for the first time and got to meet the key thinkers and drivers of EPI at WHO. As Director of EPI, Dr. Rafe Henderson provided sound leadership and excellent management oversight to a team of talented staff. Highly disciplined, it was said that at the start of his assignment, he had sequestered himself in his office for a month and had read all there was to read on immunization in developing countries. Nearing the end of a long and illustrious career, Dr. Ko Keja was keen to meet visitors from the field and one thing he said has always stuck with me: a good health worker must provide all services and counseling possible on the day of the visit, because you can never assume that you will see the child again. It is as true today as it was then.