Authors: Adam Fifield
Joseph, who started at UNICEF in 1983 after resigning in protest from USAID over the US government’s failure to back a code curtailing infant formula marketing, was branded as an outsider. As a Grant hire, he felt the static crackling in the
corridors. Walking down the hall, he would sometimes pass a small cluster of people whispering, and when they saw him, the whispering would suddenly stop.
“It was organizational warfare,” says Joseph. “There was this stubborn, rearguard, step-by-step, hold-that-damn-bridge resistance to Grant … But he was not going to let that stop him.”
Despite its previous battles with Grant, the UNICEF board went along with GOBI—even though Grant had hatched the ambitious program before formally consulting with the governing body.
The fiercest opposition came from another member of the UN family: the World Health Organization (WHO), the UN’s health agency. Joseph was tasked with serving as the liaison between Grant and WHO’s director general, Halfdan Mahler.
“The two agencies absolutely despised each other,” says Joseph. “UNICEF people thought WHO was a bunch of old fogy physicians still living in the 1950s, and WHO saw UNICEF as a bunch of upstarts led by this guy who knew nothing about health care.”
Though Grant only spoke glowingly about WHO in public—he needed to secure its cooperation—he privately grumbled about the agency’s obstructionism. “He would tell me that a blockage point for public health was WHO,” says Grant’s son, Bill Grant, “because WHO was run by doctors, and many doctors felt that if a doctor wasn’t doing it, it wasn’t medicine.”
Elitism no doubt tinged WHO’s views, but it was not at all unreasonable to question what Grant and UNICEF were up to.
UNICEF was suddenly and brazenly traipsing around on its territory—health. WHO had every right to ask what the UN children’s agency was doing there. There were also legitimate concerns about the sustainability of the program Grant was proposing—if GOBI worked, if all these measures were put into place and reached hundreds of millions of kids—how do you maintain it all? And how do you make sure other health priorities aren’t shunted aside for what could be a grand, pyrotechnic, one-time performance?
Though WHO had earned a reputation as a stodgy know-it-all among UN agencies, it had recently presided over perhaps the greatest global health victory in history: the eradication of smallpox. Led by American epidemiologist D. A. Henderson, the campaign eliminated the cruel and often fatal disease once and for all (the only time a disease has ever been eradicated from the earth). The last reported case was in 1977 in Somalia. Grant would often hold up smallpox eradication as proof that amazing, seemingly impossible, triumphs in global health were worth pursuing.
Growing out of the smallpox initiative was the WHO’s Expanded Program on Immunization (EPI), first unveiled in 1974. The primary goal, set in 1977, was to achieve universal childhood immunization by 1990. Coverage did start to edge up in the late 1970s and early 1980s, but progress was sluggish, particularly in the developing world; it became clear that the target was patently out of reach. There was a saying at the UN—before Jim Grant came along—that goals were “ever set and never
met.” Many felt the EPI, perhaps overshadowed by the “health for all” summit in 1978, was a typical example.
The gap between the need and the available remedy—and between poor countries and rich ones—was chasmal. In 1982, according to World Health Organization estimates, coverage for the third dose of the diphtheria, pertussis, and tetanus vaccine (DPT3) in the United States was 96 percent; in Europe it was an average of 74 percent. In Africa, it was a mere 12 percent; in Southeast Asia, also 12 percent. Some countries, like Indonesia (1 percent) and Sudan (2 percent) barely registered any coverage at all.
One person determined to get immunization rates up was Jonas Salk. The famous American inventor of the injectable polio vaccine, which had ended widespread epidemics of the crippling disease in the United States during the 1950s, wanted to see it put to wider use. French epidemiologist Philippe Stoeckel had been working with Salk to enhance the production of inactivated polio vaccine to make it more available in Africa. But even with more production, it did not mean the vaccine would be used. “We could see WHO … was not really making much effort into pushing the agenda of immunization,” says Stoeckel.
So Salk reached out to someone well known for making things happen: Robert McNamara. The US secretary of defense during the Vietnam War, who was widely vilified for escalating America’s involvement in a futile and catastrophic conflict, had since become known for his crusade against poverty. As the head of the World Bank for thirteen years, McNamara had completely transformed the institution, injecting it with progressive ideals. He had retired in 1981. The domineering, aggressively
confident political virtuoso cut a sharp contrast with the shy, reserved Salk. He took up the scientist’s challenge with alacrity. As for McNamara’s motivation, Stoeckel suggests he may have been still seeking redemption. “McNamara had a great guilt complex when I met him,” he says.
The two men had heard about Grant’s child survival revolution—here, it seemed, was a way to finally close the scandalous chasm in immunization coverage. McNamara knew Grant from Vietnam, when Grant ran the USAID program there. They had also both worked for the Kennedy administration in the early 1960s. At the World Bank, McNamara had also emerged as a champion of the “meeting basic needs” shift at USAID in the 1970s, also then advocated by Grant. The two men had even more in common: both had served in World War II and both were UC Berkeley alums.
Ever since reading Jon Rohde’s paper, Grant had thought the oral rehydration therapy would be the chief weapon in his revolution—the tip of the GOBI spear. Diarrhea was the biggest killer of kids, so why not go after it first and hardest? Ralph Henderson, who was involved in the WHO’s smallpox campaign and headed up the organization’s immunization efforts, remembers that Grant was “enthralled with ORS.” When Henderson met with Grant, the head of UNICEF seemed “unimpressed with the difficulties of immunization … it was seen as a dead end.”
Grant’s obsession with oral rehydration salts also stemmed from the measure’s “doability”: ORS packets were cheap (a few cents), easy to use, and, unlike vaccines, did not need to be injected or kept cool. If the packets weren’t on hand, you could
even make ORS yourself—all you needed was salt, sugar, and clean water.
ORS and immunization would eventually become the “twin engines” of child survival; the other elements of GOBI—growth monitoring and promotion and the advancement of breast-feeding—had already taken a backseat (though they were never entirely ignored; Grant would support the provision of growth charts in numerous countries as well as a “baby friendly hospital” initiative in 1991 that encouraged new mothers to breastfeed). And as GOBI gained ground, one engine roared far louder than the other—immunization soon emerged as the polestar.
Part of this was PR: it was easier to promote vaccines, if only because you didn’t have to talk about diarrhea to do so. But another part was likely Bob McNamara and Jonas Salk. The two men met with Grant numerous times, according to Stoeckel, and pressed him to make immunization a top priority. A proponent of rigorous analysis, McNamara may well have made the point that Grant should do something measurable, something that will show results. Whatever was said, Grant “embraced the idea,” says Stoeckel.
The UNICEF chief reportedly even accepted a hundreddollar bet from McNamara—the brusque, bespectacled former defense secretary wagered that immunization would become the leading tool in the fight to save children. Grant put his money on ORS—and lost. He told several UNICEF staff that he honored the deal and paid up.
The next step: win over WHO. Grant’s child survival revolution and a new global push on immunization wouldn’t get much
traction without the health heavyweight. WHO’s director general was a forceful, brilliant Danish doctor named Halfdan Mahler. The son of a preacher, he was one of the founders of “primary health care” and the “health for all” movement. Like Grant, he was often described as a visionary propelled by a missionary fervor.
In some ways, Mahler was even more of an idealist than Grant. His sweeping, radical dream of bringing quality and affordable health care to everyone on the planet—on their own terms—was courageous and laudable, though derided by some as hopelessly utopian. He believed in a world where “health is not manipulating people as objects but also making them subjects of their own kind of health development,” as he once said in a video interview. Many of Grant’s advisers and friends say he held a profound respect for Mahler, who was probably doing more than anyone at the time to carry out the legacy of his own father, John Grant.
Mahler’s views on GOBI became disquietingly clear in May 1983, when he addressed the World Health Assembly, the governing body of the World Health Organization. The stentorian director general said he was alarmed by “people outside the developing countries” who had selected “a few isolated elements of primary health care for implementation in these countries; or the parachuting of foreign agents into those countries to immunize them from above; or the concentration on only one aspect of diarrheal disease control without thought for the others.” He continued: “Initiatives such as these are the red herrings that can only divert us from the track that will lead us to our goal.”
He did not name UNICEF, but everyone knew who and what he was talking about. The “red herrings” were the components of GOBI. The “parachuting of foreign agents” were presumably UNICEF staff (though UNICEF does not actually perform immunizations; this is usually done by government health workers). It was a jolting public rebuke.
How could they possibly convince Mahler to get on board now? McNamara, Salk, Grant, Stoeckel, and the Rockefeller Foundation’s medical director Ken Warren met to discuss their options. Recalls Stoeckel: “There was a plan to corner Halfdan Mahler into agreeing to join UNICEF to do a WHO-UNICEF campaign to push immunization.” Former Overseas Development Council analyst and Grant ally Dave Gwatkin said Grant and others “thought we were saving Mahler from himself.” His ideas were seen as even more grandiose than Grant’s. Those in Grant’s camp believed GOBI was specific enough, narrow enough, that it could actually make a tangible difference.
But Mahler reportedly saw GOBI through the tarnished prism of the large antidisease campaigns carried out in the 1950s and 1960s. Before the triumph over smallpox in the 1970s, the model of big, frontal assaults on particular diseases had seen mixed results. The much-heralded battle against malaria, which began in 1955, had failed to stop the disease (in part, some believe, because it was imposed on local communities without much consultation). Mahler himself had led antituberculosis efforts in Ecuador and India in the 1950s, experiences that had apparently left him saturated in doubt.
But his concerns were graver than that. Mahler believed Grant’s revolution reeked of the top-town paternalism that had dominated much of international development over the last few decades; people should not be told what to do—they should decide for themselves. GOBI would also fail without a robust primary health care infrastructure in place. That was the elementary first step, and without it, no health advances would be viable. Worse, he apparently saw GOBI as a fatal threat to his “health for all” movement. These mere “medical fixes” could shift resources and attention away from the basic mission of building a more equitable health system for all.
The qualms with GOBI, some of which were erroneous, nonetheless accrued into an abstract philosophical tangle that threatened to immobilize the whole endeavor. To Grant, Rohde, Adamson, and the growing army of GOBI adherents, the matter was now starkly simple: If you have the tools to save children’s lives, you use them. You don’t wait for an ideal environment that may never come. You do what you can do now. Plus, GOBI could actually help advance Mahler’s vision of health for all by hewing a health path in remote places that could eventually be built into a road. It didn’t preclude community participation; it encouraged it. How could people make decisions about their own health if they had no options to begin with? GOBI was a starting point.
As the confrontation with WHO intensified, Grant looked for places where he could bring GOBI to life. One was Haiti, the
most destitute country in the western hemisphere, with high rates of malnutrition and diarrhea. It was “the poorest country closest to UNICEF headquarters,” as he pointed out, and should receive more attention. The Caribbean nation had been branded a hopeless case, impervious to progress or international aid. It was also then ruled by one of the world’s worst dictators, Jean-Claude “Baby Doc” Duvalier. Duvalier and his father, François “Papa Doc” Duvalier (who died in 1971), would reportedly pillage Haiti of a half billion dollars and, according to Human Rights Watch, order the deaths of as many as thirty thousand civilians. Hundreds of thousands of Haitians fled during their merciless rule. The pudgy thug with boot-shaped sideburns kept Haiti in a constant state of fear through the cruel, machetewielding militia his father had started, the Tonton Macoutes. None of this fazed Grant. He wanted to show that change could happen, even in Haiti. He opened UNICEF’s first full office there and decided he would persuade “Baby Doc” Duvalier to do something for children.
Recruiting despots became a Grant trademark, a practice that would rattle the scruples of many at UNICEF and elsewhere. He remarked to several staff members that he wouldn’t hesitate to “make a deal with the Devil … if it helps kids.” There was also a tactical consideration. “I asked him once, ‘Why is it you seem to focus so much on dictatorships?’ ” recalls Urban Jonsson, a Swede who served as UNICEF’s Tanzania representative during the Grant era. “He said, ‘Dictators are dictators. We don’t like them, but they’re bloody good at scaling up programs. Because
if you get them—it’s just one, two, three, and the country’s covered.’ ” Jonsson found Grant’s assessment to be true in his own dealings with various leaders. “It is much easier to work through a dictatorship. Things just get done. In a democracy, there must be a committee and a committee to supervise the committee.”