by Adam Fifield
The announcement and stated goal were intentionally audacious—Grant’s aim was to snag people’s attention, make them do a double take. Cut child deaths in half? How the hell is he going to do that? Grant would show them how.
“At the start of one of the bleakest holiday seasons in a generation, this is one of the most powerfully hopeful news stories of a decade,” he told the reporters, according to a United Press International account. His words often came out in quick staccato bursts, punctuated by swollen pauses, especially when he spoke publicly. When concluding an emphatic point, he would clamp down hard on his final syllable, his mouth snapping shut like a trap. After describing the four tools in the GOBI arsenal, as reported by United Press International, Grant hoisted a wineglass filled with oral rehydration solution—as he would do at many future press events—and gleefully gulped it down.
Everything needed to make this happen, he went on, was already in hand. Just as important as vaccines and oral rehydration salts and recent medical advances, Grant claimed, was a technological item that had become ubiquitous in recent years: the radio. Even in the poorest, most remote places—even where there were no health centers or wells or schools—you could find radios. Combined with rising literacy rates, they enabled communities to connect with one another and created a critical conduit for lifesaving information. The burgeoning capacity to communicate in even the most isolated pockets of the world made great gains in child health possible.
The main obstacles, he would repeatedly explain, were a lack of awareness and commitment and resistance from the medical establishment. Opposition had also already sprouted out of ugly Malthusian reasoning—saving kids’ lives in Africa and Asia could exacerbate population growth. These fears, Grant insisted, were unfounded—the more you can assure parents their children will live, the fewer children they will have. (He probably did not say that such fears, which essentially justified the death of African and Asian children, were also patently racist.) When making such points, he emanated a visceral elation and a certainty that all of these impediments could be overcome, knocked aside like balsa wood bowling pins.
He enticed the reporters, but he also chastened them. “Forty thousand small children in developing countries die every day,” he said, according to the Associated Press. Likely hammering each syllable, he repeated: “Ev-a-ree day!” And then added: “And it goes unreported in the press.”
The jibe worked. For a few weeks, the mass, preventable deaths of poor children were widely reported. Grant’s “revolution” drew considerable coverage, landing in the pages of the New York Times, Newsweek, the Associated Press, the Washington Post, and a slew of other publications and outlets. UNICEF was not used to such intense media attention.
This was owed not just to Grant but also to Peter Adamson. Unlike most dry, dense, acronym-laden UN documents, The State of the World’s Children pulsed with emotional fervor. Adamson’s crisp, kinetic prose took the reader by the collar and would not release its grip. At the core was a searing moral question: How can a child be allowed to die of malnutrition or preventable infection when the means to save him readily exist? Adamson described such a tragedy in chilling detail:
No statistic can express what it is to see even one child die in such a way, to see a mother sitting hour after anxious hour, leaning her child’s body against her own; to see the child’s head turn on limbs which are unnaturally still, stiller than in sleep, to want to stop even that small movement because it is obvious that there is so little energy left inside the child’s life; to see the living pink at the roof of the child’s mouth in shocking contrast to the already dead-looking greyness of the skin, the colours of its life and death; to see the uncomprehending panic in eyes which are still the clear and lucid eyes of a child; and then to know, in one endless moment, that life has gone.
Adamson had witnessed this child’s death himself in Upper Volta (now Burkina Faso). He was in a remote village, with a small group of people, none of them doctors. A woman nonetheless brought her limp baby to them, hoping someone could do something. The infant boy, maybe eight months old, was probably malnourished and badly dehydrated. “We didn’t have anybody who could do anything for this child,” Adamson says. “The child was almost dead.”
For this child, it had been too late. But for hundreds of millions of others, it was not. Echoing Jon Rohde’s paper, which had sparked all of this, Adamson wrote that making children’s survival and health a worldwide priority required even more than technological know-how and community organization—it required political commitment. To pry the world free of its inertia, the wielders of power had to be mobilized.
And so Grant, a veteran government operative and former Kennedy administration official, wooed another class of people, even more important than journalists: heads of state. Grant quickly secured endorsements from prime ministers Indira Gandhi of India, Olof Palme of Sweden, and Pierre Mauroy of France. The day of the report’s release, he snared a meeting with British prime minister Margaret Thatcher in London (where he had presided over a second press conference). She pronounced the findings “very exciting.” Grant proudly later told people that after he had shown the Iron Lady one of his props, a growth chart in Haitian Creole, she had been so impressed with it she had asked to keep it. Soon, he would win the blessing of Pope John Paul II; Grant painstakingly cultivated the Vatican’s support over the next several years. He even managed to coax a morsel of endorsement out of US president Ronald Reagan, despite Reagan’s open antagonism toward the United Nations. “Literally hundreds of millions of young lives would be healthier,” Reagan said in a statement, urging Americans to back the new UNICEF program.
Those within UNICEF who thought Grant naive or bombastic or profoundly irritating could not help but be dazzled by his marketing and political acumen. No previous executive director had so easily toured the corridors of power or so readily hobnobbed with presidents and prime ministers. Like him or not, he had propelled UNICEF’s profile to a new level of notoriety.
Grant’s whiplash-inducing marketing blitz signaled a monumental shift in UNICEF’s approach: the role of advocacy and communications became central to everything the agency did. After all, this “handful of people with a pocketful of coins” had more than just money and manpower at its disposal—it had influence. It could pressure other entities to spend their money for children. It could prod governments forward. And it could shame those that lagged behind. It could be a potent catalyst, a peerless PR machine. But if Jim Grant had begun to bolster UNICEF, it bolstered him, too. It was his pulpit—from perhaps no other perch could his voice carry so soundly and so far.
For a while, that voice still came to a thudding halt in the halls of UNICEF itself. The enthusiasm wafting from the press and prime ministers’ offices had still not done much to thaw the cynicism at his own agency. Grant’s senior health adviser, Stephen Joseph, recalled sitting with a group of high-ranking old-timers one night during a staff retreat at Mohonk Mountain House in New Paltz, New York. At the time, he says, senior leadership at UNICEF comprised “a white men’s club.” Headquarters was an insular place dominated by a small group that had held power for a long time. They did not appreciate Grant’s upheaval. That night they were playing poker—and trashtalking the executive director. Joseph, an incisive, principled American pediatrician who would go on to become New York City’s health commissioner, just sat back and listened to the contempt clatter out amongst the cards:
What a ridiculous idea—a child survival revolution!
What kind of political bullshit is that?
We know what we’re doing! We’re plugging down wells! We’re doing emergency feeding programs! We’re handing out midwifery kits!
In other words, we’re practical, clear-headed veterans, and this guy is a dangerous dreamer.
Says Joseph: “It was a dislike of the person, because he was disparaging of what they had accomplished” (or so they perceived). The old-timers also “disliked his methods.”
&
nbsp; 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.
