1 Constructing International Health: The Communicable Disease Center, Field Epidemiologists and the Politics of Foreign Assistance (1948-1972) Etienne Gosselin Department of History, Faculty of Arts McGill University, Montreal December, 2011 A thesis submitted to McGill University in partial fulfillment of the requirements of the degree of Doctorate of Philosophy in History ©Etienne Gosselin, 2011 2 Abstract Following World War II, new institutions were created to manage international health issues and assist developing nations in addressing their public health problems. Bilateral aid agencies and multilateral organizations designed, promoted, financed and implemented various programs to alleviate the burden of disease in the Third World, but also pursued political goals. In this dissertation, I analyze the development of international health activities of the Communicable Disease Center (CDC) from 1948 to 1972, from the first overseas assignment of a CDC officer until the end of major global public health campaigns at the beginning of the 1970s. My focus is on the role and motivations of CDC leaders and field epidemiologists who aimed and worked to transform the public health agency from a marginal international player into an important actor in the institutional constellation. In extending activities from the U.S. to the international arena, the CDC, as a national health agency, faced legal and political obstacles which limited its access to foreign localities where international health programs were being implemented. I argue that if expertise in field epidemiology existed in Atlanta and CDC leaders expressed a desire to see their agency take a more prominent role, the deployment of CDC personnel overseas remained problematic. To circumvent these obstacles, the CDC utilized development agencies, public health technologies and multilateral health organization as conduits to get access to foreign environments, procure international field experience to its epidemiologists and make an impact on the control of infectious diseases. As I show, it was especially during the 1960s that these three trajectories coalesced to ensure CDC’s place as a public health actor of international reach and contributed in establishing its credibility. The exploration of the CDC’s relationships with these international health actors and technologies also demonstrates the tensions deriving from the arrival of a new actor of 3 international health, the limits of expertise when opposed by political considerations and the various tactics employed to secure a role in the design, implementation and management of public health programs abroad. Key words: Communicable Disease Center; Centers for Disease Control; international health; bilateral assistance; field epidemiology; malaria; smallpox; surveillance; history of public health; history of U.S. foreign relations. 4 Résumé Après la Deuxième guerre mondiale, de nouvelles institutions sont créées afin de gérer les dossiers de la santé internationale et d’assister les nations en voie de développement dans la prise en charge de leurs problèmes de santé publique. Les agences d’aide bilatérale et les organisations multilatérales ont imaginé, promu, financé et implanté plusieurs programmes dans le but d’alléger le poids des maladies dans le Tiers monde, mais aussi à des fins de politique étrangère. Dans cette thèse, j’analyse la construction des activités de santé internationale du Communicable Disease Center (CDC) de 1948 à 1972, période correspondant à sa première mission outremer jusqu’à la fin d’importants programmes de santé internationale au début des années 1970. Je me concentre sur le rôle et les motivations des dirigeants du CDC et des épidémiologistes de terrain, qui visaient à transformer leur agence de santé publique, d’abord un acteur marginal, en un joueur important dans la constellation institutionnelle de la santé internationale. Dans l’expansion de leurs activités de la scène nationale à l’échelle internationale, le CDC, en tant qu’agence de santé nationale, a été confronté à des obstacles légaux et politiques limitant leur accès aux territoires étrangers où les programmes de santé internationale sont implantés. Je démontre que si le CDC disposait d’une expertise en épidémiologie de terrain et même si leurs dirigeants désiraient jouer un rôle international important, le déploiement des officiers du CDC à l’étranger demeurait problématique. Afin de contourner ces obstacles, le CDC utilisa les agences de développement international, les technologies de santé publique ainsi que les organisations multilatérales comme conduits afin d’accéder aux territoires d’outremer, donner une expérience internationale à ses épidémiologistes de terrain et modifier profondément les conventions sur le contrôle des maladies infectieuses. Tel que je le démontre, 5 ces trois trajectoires fusionnent dans les années 1960 afin de confirmer le statut du CDC en tant qu’acteur de la santé internationale et contribuent à établir la crédibilité de l’institution. L’exploration des relations du CDC avec ces institutions et les technologies de santé publique permettent également de mettre en relief plusieurs éléments : les tensions découlant de l’arrivée d’un nouvel acteur institutionnel de la santé internationale, les limites de l’expertise qui est parfois en opposition avec des considérations politiques et les diverses tactiques utilisées pour s’assurer une place dans la mise sur pied, l’implantation et l’administration des programmes de santé publique à l’étranger. Mots clés : Communicable Disease Center; Centers for Disease Control; santé internationale, aide bilatérale; épidémiologie de terrain; malaria; variole; veille sanitaire; histoire de la santé publique; histoire des relations étrangères américaine 6 Dedication To my father (1951-2008) and my children: my links to the past and the future 7 Acknowledgements My first words of thanks go my family and friends who supported me through this long process. Their patience and understanding were invaluable. Tania pushed me and comforted me in times of doubt. Without her, this dissertation would never have seen the light of day and I would not have escaped with my sanity intact. To Florent and Charles Vincent: the time spent playing with them was my daily reward. Frédéric Jean remained interested in learning about my research and rekindled my flame about my own work. Igor, Jean-Frédéric, and Jonathan offered much needed breaks and showed me it was possible to be done. Very special thanks to Melissa for the hospitality and to Mireille who really came through at the last minute. My father passed away as I was starting my dissertation but he was an inspiration in doing good work. To my mother: she never questioned my choice and encouraged me in going as far as I can. Guy and Diane believed in me and were sources of motivation. Their help with everything cannot be overstated. My supervisor Thomas Schlich was always there for all kinds of support and gave me the freedom to explore this fascinating subject. He was unwavering in his belief that this could be done even during difficult times. His patience and comments were ingredients that allowed me to sit down and get to work. I wish every graduate student to find as good a supervisor as Thomas was to me. I would also like to thank George Weisz who first believed in this project and offered precious advice to further my research. Andrea Tone and Lorenz Lüthi were always there in case of need and contributed greatly in expanding my knowledge in new directions. George Dehner and Randall Packard graciously provided me with documents and comments to improve the quality of my work. Thank you to Gilberto Hochman, 8 Ted Brown Bob Reinhardt, Michael Bresalier for taking the time to read parts of this dissertation and generously offering their insights. This work would not have been possible without the financial support of the Social Sciences and Humanities Research Council of Canada, the Fonds de recherche du Québec - Société et culture, the Tomlinson Fellowship and other grants from McGill University. I received much help from archivists and librarians in finding documents. Rob Richards at the NARA facilities in Morrow, Georgia and Tab Lewis in College Park went out of their way to find boxes and obscure documents and offered continual support throughout the years. Mary Hilpertshauser and Joel Hewett assisted in finding and assembling sources from the David J. Sencer Museum at the CDC. Thanks to Jessica Murphy of the Countway Library of Medicine, Marjorie Kehoe of the Alan Mason Chesney Medical Archives, Doug Atkins of the National Library of Medicine, Charles Florey and Eman Hamman of the International Epidemiological Association, and Romain Ledauphin of the UN Archives. This extends to the staff of the Health Sciences and Osler Libraries at McGill University, especially Christopher Lyons who was available to answer my many questions. My research has greatly benefited from participation of former CDC members who graciously accepted to be interviewed: Teeb Al-Samarrai, Philip S. Brachman, William H. Foege, Donald A. Henderson, Joan Millar, Robert G. Scholtens and an anonymous informant. A very special thanks to Don Millar, who accepted to read and comment part of this work and accepted to share some of his personal papers, and to David J. Sencer (1924-2011) who was very generous with his time and also provided me with documents from his collection. 9 Finally my thanks go to friends, faculty, professors and staff who assisted me in