by Adam Fifield
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.”
UNICEF’s former director of programs, Nyi Nyi, says that he and Grant noticed that “there were lots of coups taking place in Africa” and that the newly installed leaders were “looking for ideas to make them popular.” He adds that “saving children’s lives naturally is a very popular thing” and then admits: “We took advantage of that.”
In the case of Duvalier, Kul Gautam, who was UNICEF’s representative in Haiti at the time, recalls that “some of us, after shaking hands with him, felt like washing our hands.”
Grant was candidly practical about the moral conundrum of dealing with thugs such as Duvalier. Gautam recalls his boss reminding staff that “we have to live with the leadership we’ve got and get the best out of them” and that “even the dictators want something good to happen in their image.”
Gautam recalls wondering whether Grant would even consider collaborating with the infamous Tonton Macoute terror squads. Named after a bogeyman that kidnapped children in the night, the Macoutes mutilated, hacked, burned, and viciously tortured their victims, killing whole families and reportedly hanging up the bodies for public display. Gautam shared this thought, in passing, with Deputy Executive Director Richard Jolly, who responded with impulsive alarm.
“Kul, don’t you ever mention that to Jim Grant!” Jolly admonished. “He might jump at it!”
Gautam did not mention it.
(Jolly says now that he doesn’t think Grant would have “actually made such a deal” and adds that his boss was willing to work with almost anyone, “but only if he had worked out beforehand what he thought he could get them to do.”)
During one visit to Haiti, when Jim and Ethel were staying at Jon Rohde’s friend’s beach house—they liked to snorkel there—Jim slipped in the bedroom. The floor may have been wet or he may have been in a mad rush, or both. Either way, he jammed a toe and broke it. The toe stuck out from his foot at a right angle, and the pain was searing, excruciating. Rohde tried to reset the toe, “but we could not get it fixed,” he says.
Grant was scheduled to meet Duvalier the next day. Getting proper medical attention meant he would miss the meeting. So he improvised by cutting a hole in a tennis shoe and wedging his toe through it. It protruded about an inch. On his other foot he wore a dress shoe. This is how he went to see Haiti’s president, jutting toe and all. “He would never give up the opportunity of meeting a head of state,” says Rohde with a chuckle, “whether he had to go barefoot or what not.”
Whether the vapid Duvalier took any notice of the toe or tennis shoe, he agreed to Grant’s request. He would team up with UNICEF (and other partners, including WHO and USAID) to kick off a major initiative to reduce diarrheal deaths by promoting oral rehydration salts and breast-feeding. (To avoid funneling all of its resources into the coffers of a corrupt government, UNICEF would also channel financial support for the program through a network of NGOs and the local private sector.) On July 22, 1983, Duvalier and first lady Michele Bennett Duvalier hosted a grand ceremony at the white-pillared, Mediterranean-style presidential palace with troupes of children singing and dancing.
Grant’s ultimate aim, says Gautam, was to bypass Duvalier and appeal directly to more enlightened government ministers and ordinary Haitians. “Duvalier was a pretty dumb fellow,” says Gautam. “Jim Grant knew what we needed from Duvalier was his kind of ‘yes, yes blessing.’ ” The head of UNICEF tried to empower others to “get Duvalier to do the right things.”
In his televised address at the palace, Grant said the new initiative could save ten thousand children’s lives each year if it received support from all secto
rs of society. “Let us not forget,” he said, “that mothers are the premier and potentially most effective health workers.” He reminded Duvalier, in front of the eyes of his nation, that he would ultimately determine the “difference between success and failure.”
To the probable consternation of some staff, Grant made another speech during that visit at Michele Bennett Duvalier’s pediatric center (the budget of which she apparently used as a personal checking account). An elegant and narcissistic woman with a penchant for lavish shopping sprees and corruption that rivaled her husband’s, Mrs. Duvalier was, in the words of Steve Joseph, an “archetypal dragon lady … a horrible woman.” But, according to his prepared remarks, Grant praised her profusely. “Nothing is more pleasing to an Executive Director of the United Nation’s Children’s Fund than to see a mother, and at that, the First Lady of the Republic, taking a keen personal interest in the well-being of children,” Grant said.
“Ick” factor aside, Grant would say whatever he had to say to advance his cause. If he felt nauseated by gushing about such a notoriously awful person, he kept it to himself. (At Gautam’s insistence, Grant agreed that UNICEF would not provide any financial support to Mrs. Duvalier’s hospital, “because that would be abused.”)
The end result of the oral rehydration campaign was striking. The use of the life-saving salts by Haitian mothers whose children had diarrhea rose from 2 percent to 34 percent within the first six months of the program and continued to increase over the next several years. Thousands of children’s lives were likely saved. Which showed, Gautam says, “that even in Haiti, you could get things done.”
The tussle with WHO came to a head one night in October 1983. Grant had invited a small, distinguished group of about ten guests to dinner. Among them: Jonas Salk, Philippe Stoeckel, the Rockefeller Foundation’s Ken Warren, revered Australian immunologist Gustav Nossal, and Halfdan Mahler. They gathered at Grant’s sprawling new house perched atop a Manhattan high-rise on Thirty-eighth Street, a few blocks south of the United Nations. It cost about five hundred thousand dollars to build and was a financial strain, putting Jim and Ethel heavily in debt to family members. The “roof house”—Grant studiously avoided calling it a penthouse—featured floor-to-ceiling windows, sun-soaked rooms, rambling decks, and panoramic views. On a clear day you could even see the twin towers in Lower Manhattan. From a distance, the large, modern, blocky house looked like an elaborate Lego structure.
The guests gathered around a long table, Grant at one end and Mahler at another. Everyone else sat on the sides. Ethel served them cucumber soup, leg of lamb, bulgur, and salad. For dessert they had chocolate mousse. Many UNICEF staff have extolled Ethel’s cooking, but Philippe Stoeckel doesn’t remember the food that night. The conversation grew so tense so quickly that the meal became an afterthought.
Sharp-faced, somewhat gaunt, with high cheek bones marked by deep-grooved parentheses, Mahler radiated an imposing magnetism. Early on, the conversation veered into immunization and quickly escalated into a one-way shouting match. It began, according to Stoeckel, when Mahler dismissed immunization as a practical way forward. The discussion went something like this:
“I don’t believe in these vaccines,” Mahler said. “I have seen the BCG vaccine [for tuberculosis].” It was problematic, he explained.
Attention snapped onto the WHO director general.
“I would rather have barefoot doctors doing primary health care with affordable means at the community level,” he said. The reference to “barefoot doctors” may have been a subtle dig, an allusion to Jim’s father.
Grant replied, likely flashing a wide, thin-lipped grin: “Yes, why not?… But why don’t you add a few tools? Like oral rehydration, education, and immunization. Immunization has had fantastic results in our country. Why not use it elsewhere? Why deprive children in developing countries of immunization?”
“No,” Mahler said, his voice growing taut. “This is just a way to keep these countries in our control, in the control of the developed world. Because they will have no money to buy your vaccine!”
At one point, Mahler exploded and began banging his fists on the table. “I am the one responsible for health!” he yelled. “And you are not! WHO is the one!”
He was venting what, until now, seems to have been an unspoken grievance: How dare you try to take over my turf?
Grant was “very cool.” He didn’t raise his voice. He just listened as his dinner guest raged at him.
Says Stoeckel now: “Never, ever would I have thought that dialogue on such a topic could become so heated.”
It was clear, says Stoeckel, that Grant would not budge. Others at the table intervened, trying to deflate the tension and talk Mahler down.
Salk kept quiet. Part of his reticence, says Stoeckel, stemmed from a horrific fiasco in the 1950s that left him rattled decades later. Soon after the launch of his polio vaccine, one of the manufacturers, Cutter Laboratories, had released several contaminated lots. The virus had not been fully inactivated. The tragedy resulted in thousands of polio cases, up to two hundred instances of child paralysis, and ten deaths. It was a devastating scandal and stirred allegations that the Salk vaccine had been hastily rushed onto the market. His image as a national hero took a big dent. Ever since, he avoided the limelight. (Vaccine manufacturing has traveled light-years since then. Today, polio and other vaccines are highly regulated and safe.)
“[Salk] didn’t want to find himself on the frontline,” Stoeckel explains. “Even though he had been instrumental in setting up this dinner and this momentum for immunization with McNamara … he was happy to have Gus Nossal and Ken Warren [intervene] between Grant and Mahler.”
The next morning, to wrap up matters, the group reconvened at the Harvard Club in Manhattan. The meeting in the dark, mahogany-paneled sanctum of power and privilege was subdued and focused on bookkeeping matters. Everyone, including Mahler, apparently concurred on the next step: a major conference in Bellagio, Italy, to discuss plans for a global immunization drive. They agreed to form a “child survival task force” to coordinate the work of different agencies. This was done perhaps to appease Mahler, show him some deference, but it was clear he really had no choice. (Mahler did not return a request for comment.)
The argument at Grant’s house was, of course, not a fair fight. It was essentially five against one, though the irascible Dane does not seem to have been intimidated. In any event, the consensus on GOBI was mounting—if Mahler resisted, he would be cast as a colossal spoilsport. So he offered his imprimatur, however begrudgingly. He would become one of Grant’s most crucial allies.
The two men eventually formed a collegial bond, says Steve Joseph, who acted as their go-between. They had a lot in common, not least that they were both at odds with their own agencies (Mahler was also viewed as wildly quixotic by many of his staff). Each was unshakably confident and stubbornly riveted to his convictions, but they were able to influence one another. Getting their agencies to work together required delicate synchronization, says Joseph, “like porcupines making love—very carefully.”
Chapter 5
THE FAMINE AND THE CRUSADE
The blunt question startled him: “So how are you doing with your immunizations?”
Though Alan Court had seen Jim Grant from afar, speaking at a staff meeting, he had not met him until now. The tall, candid, velvet-voiced Briton had started with UNICEF in Bangladesh in 1975 and was now working in Ethiopia as a program officer. He had come to New York for meetings.
It was late 1984, at the height of a grisly famine that would kill as many as one million people in Ethiopia. In just one refugee camp, Korem, a hundred people were dying every day. Each morning, bodies were wrapped in burlap sacks—many of them babies and little kids—and taken to the camp’s perimeter, where parents and relatives wailed in piercing grief. A harrowing BBC news report, aired on October 23, 1984, offered an intimate window on the unfathomable suffering. The correspondent, Michael Buerk, told viewers of
a “biblical famine, now, in the twentieth century.” The video triggered a widespread international reaction that culminated in singer Bob Geldof’s Live Aid concerts. But the famine had been quietly spreading long before BBC cameras were turned on.
Like so many famines in the 1970s and 1980s, this “biblical” crisis had many authors other than drought and the shortage of food. Ethiopia’s Stalinist government was fighting a ferocious civil war with rebels in the north. According to numerous accounts, the Soviet-backed regime had stoked the flames of famine by collectivizing agriculture, launching ruthless counterinsurgency offensives, diverting crucial relief to its militias, and forcibly relocating hundreds of thousands of people from the north to austere, and sometimes disease-ridden, camps in the south. Human rights abuses were rampant. The government’s Relief and Rehabilitation Commission had made some efforts to provide relief, says Court, and had alerted aid agencies to the severity of the crisis before the BBC report.
As in Cambodia, UNICEF found itself in a political minefield. It faced the ugly prospect of partnering with a murderous and vengeful regime. The head of state—a cold, mustachioed former army major named Mengistu Haile Mariam—had presided over a reign of intimidation and political executions in the 1970s called the Red Terror. He was manipulative and merciless; working with him could legitimize his repressive and, some said, genocidal policies.
The aid group Doctors Without Borders had, in fact, been ejected from Ethiopia after openly criticizing Mengistu’s resettlement program. The NGO also slammed UNICEF and other agencies for failing to speak up against Mengistu and for, in effect, abetting his crimes.
But what was UNICEF supposed to do? The most righteous position was not always the most effective. What if UNICEF had heeded the call to condemn Mengistu? It might have suffered a loss of access, and its programs—including immunization and other GOBI initiatives—could have been curtailed or shut down. The consequences could have been catastrophic.
