River Blindness Life Cycle from PATH
David: What inspired you to join the field of global health?
Bruce: It was accidental. I’m an economist by training, but for various reasons World Bank management thought I would be suitable to spearhead the Bank’s Oncho control / elimination effort in Africa. I knew then that global health was going to be important both for African development and in my own career path.
When I first heard about river blindness (Oncho), I had little idea of what it was. It was not a big-name disease like malaria or HIV/AIDS so I questioned its importance. But when I started investigating the disease and the suffering it caused, I realized it was extremely important particularly for the rural poor in Africa and became enthusiastic about doing the work. In fact, I got to the point where I became less concerned about advancing my career than by deriving personal fulfillment from the work.
To advance at the Word Bank, you needed to keep a job for about five years and then move on, and up, to another position. If you had been working on African issues they wanted you to work on Asian or Latin American issues. By frequently changing positions, you might become an expert in how to operate effectively in that large institution, but was that the best way to maximize one’s impact on Africa and the poor? I wasn’t so sure. I wanted to stay where I was as Manager of the Oncho Programs because I thought I was making a difference and felt fulfilled. Eventually I was pressured by one of my Directors to rotate to a different office to meet the rotational requirement expected of professionals working in Bank “operations.” At the time, I confided in former World Bank President, Robert McNamara, about my dilemma. I got to know Bob McNamara because he had launched the Oncho program in 1974. He gave me strong moral support in my preference for remaining as the Oncho Manager. He said to me, “Development is a long-term process and requires the continuity of good staff. Resist the pressure to move if you can and stick with the Oncho program.” So I did – for 21 years.
David: It sounds like your early childhood experience predisposed you to wanting to relieve suffering.
Bruce: Absolutely. There’s also something about health work that is very direct and has an almost immediate impact on alleviating pain and misery. When I was young and returned from the Peace Corps I wanted to do development work. I realized after a while that “economic development” by itself did not have the same meaning or personal impact that health work does. With development, it’s not always clear whether societies understand or want to become “developed.” We presume they do because we can’t imagine any other way for ourselves to live, and we think they must want our way of life, too. Global health, on the other hand, means, for me, helping the poor and disadvantaged lead satisfying, pain-free, and disability-free lives – even if they don’t become “developed.” But, of course, if they can lead disability-free lives, they have a greater chance of pursuing their own development opportunities.
My passion for this work has been passed on. My daughter, Brooke, who is about to receive her Master’s degree in Public Health, feels pretty much the same way. She has entered the field of global health and is focusing on children and women who are the most disadvantaged, as well as indigenous population groups who don’t receive equal treatment when it comes to health care. However, I don’t think she and I have talked much about compassion being a part of this. Maybe I should do that. I think we just take for granted that compassion is what it’s all about. It would be better to be more explicit about our motives with respect to our involvement in global health.
David: Yes, that would be a great conversation. Was influencing your daughter in this way intentional?
Bruce: No, not at all. As a family, we had a great trip to Africa when I was working on the Oncho programs. A program annual meeting was held in Accra. The program provided us with two Land Rovers for the six of us to drive up-country for a week. We drove all the way to the top of Ghana to the border of Burkina Faso. We witnessed the impact of river blindness, guinea worm, and lymphatic filariasis on rural Ghanaians. My kids became fascinated with these diseases. I thought my daughter was too young to be influenced much, but it looks like global health work rubbed off the most on her. She still talks about that trip and includes this story when she is filling out applications for grad-school fellowships and work. I was just doing my job and they were picking up on it. I have two kids, out of four, who are now working in health.
David: What it is that you’ve found most meaningful about your work at the World Bank and particularly with APOC (African Program for Onchocerciasis Control)?
Bruce: It was making a difference in a lot of people’s lives. In this work, I could quantify what making a difference meant; a distinction between living a life of misery or a life of relative normalcy, such as getting married, raising children, and the like. Tens of millions of people would not have been able to have a regular life without this program. It also alleviated real suffering and pain, which I witnessed in the field. I couldn’t directly experience what they were experiencing – millions of microscopic worms migrating through their skin causing incessant, unbearable itching. People were scratching their skin nearly 24 hours a day often with stones to somehow get relief. I saw them sitting around with their heads in their hands. They were not smiling, or talking with each other, or experiencing joy of any kind. It was pretty clear these people were suffering and feeling hopeless. Mectizan alleviated the itching in a day or two, and had an immediate pick-up effect on them. Even those who had already gone blind took the drug to alleviate the itching and felt better as a result.
David: What were the most challenging aspects for you while trying to alleviate that level of suffering, and scale up and manage the program?
Bruce: I got a lot of satisfaction out of making sure that the program received funding. This was difficult and often stressful. It was my job to meet with 27 donors around the world every year and help them understand how their donations would lead to successful control of the disease. It was vital to keep them engaged over the long-term because both of the Oncho programs would last more than 20 years.
There were a couple of times when it looked like the first Oncho program – The West African Onchocerciasis Control Program (OCP) – might fail. At one point, there were infective blackflies capable of transmitting the disease coming into the program area from neighboring countries. The only way to salvage the program was to double its size to control the blackflies at their source by bringing four new countries into the program. At another point, the flies became resistant to the least expensive insecticide that we were spraying on the blackfly breeding sites to prevent ongoing transmission of the disease. To combat this, we had to use more expensive insecticides in rotation and the costs and the need for donor funding increased enormously.
In another case, a depreciating US dollar threatened to financially undermine the program effort. Most of the contributions were coming in dollars into the Trust Fund that I managed at the World Bank, but the expenses for the program were paid out in French francs for program staff and Japanese yen for all of the program’s vehicles. When the dollar value declined, the program’s costs increased 35% in dollar terms. We thought all of these factors taken together – blackfly reinvasion, blackfly resistance, and a depreciating dollar – would bring an end to the program. And, they almost did. The only way to surmount these challenges was to secure substantial increases in contributions from every donor while bringing in a sizable number of new donors. This whole situation was extremely stressful; we experienced a lot of pressure, and had a very real concern about the possible failure of this first major effort by the World Bank to get involved in health. Then, there was the travel. I had four children and was traveling 40% of my time. That was hard and, in turn, placed a great deal of stress on my wife, Patricia.
David: On the one hand, I hear a deep compassionate desire to alleviate suffering. Your efforts were motivated and sustained by witnessing the relief that you saw in the field. On the other hand, much of your time was spent educating donors, working within big systems, and balancing budgets. When you were traveling, jet-lagged, and caught up in administrative details, what did you do to keep the faces of those you were trying to serve in front of you?