[MUSIC]

This is a great story for many students to hear because all I can

say about working in international health is be prepared to expect the unexpected.

And nothing will ever work as it is planned.

You'll be really, really fortunate if it works out the way you thought it would.

So, I was quite a young faculty member at the time.

This was 1985, probably before most of you guys were born.

And I was involved in a study that was going to take place in

the Philippines where we were going to do a randomized trial looking

at vitamin A supplementation for preschool child survival,

and this was before we knew that it worked for survival of kids, and

so we're actually going to do the real thing that randomized trial.

And we did a lot of pre-prep work,

in sort of mostly through the 1985 visiting the plays.

We talked to all of Ministry of Health people.

We identified both international NGO and local NGO to work with.

The international group was Helen Keller International which did vitamin A and

other blindness prevention activities in the Philippines.

And then the local group was called the Nutrition Center of the Philippines.

And the person who ran it, his name was, Florentino Solon and he was a nutritionist

and good friend of Al Summers, and that's how we sort of made this connection.

He had very strong political connections.

He had been a mayor of Cebu city.

And so but his connections were to the regime of Ferdinand Marcos.

And Ferdinand Marcos was a dictator who had been in power for many, many years.

He had been supported by the United States for

many many years with his bad behavior, because he was anti-communist.

That was still the cold, the remnants of the cold war.

And so, but he was a really wonderful guy and

he was really influential in opening up and getting us connections to get all

the approvals we needed and connections with Ministry of Health people.

And we figured out where we were going to do the studies Southern Luzon which is

the main island.

It's about a eight hour drive from Manila.

This will become relevant later in the story.

And there was one flight a day that went from Manila to this place and back again.

And the name of the town was Legazpi City.

And it's actually beautiful if people want to look it up on the map,

it's a gorgeous place.

It's right at the southern end of the island and it's in

the shadow of this very beautiful volcano, Mt Maurya, which was an active volcano and

it did actually erupt at about two years before we started working there.

And then erupted subsequently like I think 1988 and again more recently.

And so we had all the permissions, we had all sorts of things ready to go,

and then in February of 1986, there was a revolution in the Philippines.

And the revolution was against Ferdinand Marcos.

And the US who had been supporting him all the time

sort of eventually realized this was it.

And they actually came and said you're outta here.

We're coming to get you.

You're going to Hawaii and that was the end of him.

And the government that came in was hated by

Cory Aquino who was also from a wealthy elite

family in the Philippines but was very much in favor of a democratic process.

So it was actually called the People's Revolution.

And so at that point we were sort of well, what do you do?

We had all these things in place.

We had all these agreements with a previous Ministry of Health, right?

And we talked with the new Ministry of Health people and

they were like, okay this is interesting we're willing to you know work with you on

this and, gave us all the new approvals and so on.

With the exception, it was interesting,

they said you can not work with Florentino Solon.

Because he was very much aligned with the previous regime.

And so they were happy with us to do things with Hellen Keller.

They said we'll even turn a blind eye.

You couldn't get advice from him.

All that sort of thing.

You cannot be officially seen to be working with him.

Great fine, okay.

He was totally understanding about it all etc.

The southern part of Luzon Island was interesting,

because during the insurgency that led up to that revolution there

was something called the New People's Army, they were very active in that area.

And when we were actually planning for the study we went and met with these people.

We knew who they were, we went and met with them,

we talked to them about what we're trying to do.

It's a health study, it's humanitarian stuff.

And they were fine with that.

And they were like the primary people that you needed to talk

to if you wanted to sort of make sure that things would go okay.

So then, so we felt like we had sort of covered our bases.

We got IRB approvals, all that sort of thing.

We actually trained up our field workers and we had a whole staff ready to go.

And then we had a week where we were going to do practice

interviews and giving out vitamin A in a set of villages for a week.

And that was sort of leading up to launching the exact study.

And we used the regular vitamin A capsules that UNICEF uses,

not the ones that were for our study.

Because we were going to give it to everybody.

It was just, they were not part of the study.

And we went into some villages that were not going to be study villages to do this.

And in that process we came across a group called The Medical Action Group.

This was a very local NGO.

[COUGH] Had been very much against the Marcos government but

was also against the new government.

They were sort of more to the left than even that regime.

And we had never heard of them.

There was a small group, and they did medical work in these villages.

They were like, what's going on?

Who are these people?

Who are the Americans?

What are these Americans doing here?

And somehow, and I don't know how they did this actually, it's interesting.

They got hold of the protocol, the scientific protocol of the study.

And they, I don't

know to this day whether they really believed the rhetoric that they had.

But they basically were sort of,

there was also a political agenda and motive in their actions.

And they took the protocol that said, we're going to look for

a mortality difference between a high and a low dose vitamin A capsule.

And they said, they interpreted this as you're trying to look for

the highest dose of vitamin A that won't kill a kid.

So it's sort of interesting, I've always thought about this afterwards.

It's interesting to make sure you appreciate the language,

the scientific language that's in a protocol.

Because it can very easily be misunderstood or misinterpreted.

And they went on the radio, so radio was the primary form of media at that time,

and said, what are these Americans doing mapping our villages,

and cold they be the CIA?

Why are they giving these vitamin A capsules to children?

And they actually went and they found,

because the trial was not just to give capsules to kids, but also to moms,

pregnant women in lower doses than to the kids.

And they went and they found women who said, I took this capsule and

the next day I had a miscarriage.

Or kids where they got sick after they had got it.

And there's a certain amount of that that's going to happen,

just serendipitously.

And they really sort of capitalized on this.

And they got these people to come on the radio and say these Americans came, and

they gave me this stuff.

And then I got sick, and lost my infant, and things like that.

And this then, so then we were sort of well what do we do now?

And our workers actually were quite up in arms, and

they challenged this group to a debate on the radio.

And in the meantime, these guys,

these medical action group people, had actually posted people at the airport.

And they were sort of watching to see if we going to leave, and

they said they were going to sue us for harming Filipino

babies, and the one thing that we had that was actually valuable,

and this was an era before laptop computers, and

we had portable computers that we were going to do our data entry on.

And they actually were worth something, and we had about ten of them.

And they said we're going to impound those and

That'll be a settlement with them and for our lawsuit and so on and so forth.

And so, the people who were there at the time was Keith West,

myself, and there was a woman, Kate Burns,

who was a nurse-midwife who was going to live there and run this study.

And the three of us went into town and we called Elsa.

We were in a telephone booth, because there was no Internet,

or any of that sort of stuff.

And we were in a telephone booth, and we were, here's what's going on.

We don't know what to do, and what should we do?

And should we start the study, not start the study?

Should we leave?

Should we stay?

And I remember him saying, you should do, you're on the ground,

you should figure out what's comfortable, what you think is safe.

Do what you thinks safe.

We were in some disagreement about what to do, and Kate was very much,

she was a very experienced person working overseas.

She had worked in refugee camps in Somalia, she had worked in

Brazilian Amazon and, she was, we're staying.

We're not changing anything.

And I was very cautious having grown up in South Africa,

but, and Keith was sort of somewhere in between.

And we had various conversations, and then when we heard that

there was going to be this radio debate on a Saturday morning,

we're, while those guys are all down there at this radio station,

I think we should just pick up and leave.

So, we decided that we should probably leave town,

and do it while all these other people were at the debate, so

that they wouldn't be people sort of watching out for what we were doing,

having seen that they were watching at the airport for us.

So, we had a vehicle, and we packed up all these computers,

and we just hit it out of town.

And we were actually listening to the debate while we were driving out of town.

And actually, the funny part of this story was while we were packing up,

I had a mother-in-law who was very on top of things, and she and

Marie Diener-West had gotten together to try to figure out what was

happening to her daughter-in-law and to Marie's husband.

And she kept trying to call, she was trying to get in touch with us.

That was a time period where there were no cell phones, there was no, and

you had to actually go through a telephone exchange to contact people.

She just kept at it with this telephone exchange people in the Philippines, and

eventually, the phone rang while we were [INAUDIBLE] the office and

picked it up and said, it's your mother-in-law.

I was hiding under the desk sort of saying, I'm going to Manila.

I'll be there in eight hours, I'll contact you then.

And then we sort of headed out.

And it was an interesting experience, because we never went back.

And we realized we were unable to continue the study.

And part of that was, we waited about six months and we,

the Helen Keller people actually went back to this area, and

asked moms whether they knew about vitamin A, and would they allow their children

to receive vitamin A, and about 60% said no.

And so that was the point in which we realized this is not going to be the place

to do this work.

And the interesting thing about it was those people from that

medical action group.

They took us all the way to the Ministry of Health.

And there's quite a lot written, even in Time Magazine and various things about it.

And they firmly sort of said they

think that Filipino children, they sort of withdrew from its killing children,

but they said they thought that Filipino children had many more side

effects than other children in the world from getting vitamin A.

And they actually conducted a randomized trial of different doses of vitamin

A to kind of show what was, quote unquote, the safe dose for Filipino children.

And you know there's no biological plausibility to any of this,

but they sort of went through this whole process and found that it was safe, and

all that sort of thing.

But that was already seven or eight years later.

And I feel, I felt very badly about it, because I feel at the time,

we damaged the Helen Keller vitamin A program that was ongoing.

Because people didn't, now had a bad thought, had bad thoughts about vitamin A.

But I also feel, I mean I've thought a lot about what could we

have done differently and there clearly are certain things.

I mean, for one, I think it's difficult to do this kind of work in a very politically

fraught environment, and we didn't start it out that way, but it ended up that way.

And it was just difficult to kind of recover from.

All the little political perturbations that were ongoing and

we just couldn't have known about every little splinter group.

And we thought we had covered the bases of the big players but

even a small group can do you a lot of harm in these situations.

I think I would, I think and I still do think to this day think

differently about how to write scientific protocols to,

with a view in mind that somebody non-scientific might view it, and

how would they interpret it, et cetera.

The other things I would say, I think we

did all the things we were supposed to in terms of interacting with local people,

the Ministry of Health, getting all the approvals, those sorts of things.

I can't think that that was something we could have done differently.

Sometimes you're just in the wrong place at the wrong time, and

you have to realize that and you have to sort of assess what to do next and

whether to keep going or not.

And so that's what we did and we realize we couldn't do it there.

The positive end to the story is Al Summer had an ophthalmology colleague from

Nepal and he invited us to go to Nepal and do this work there.

And we'd been working in Nepal for the last 25 years.

We actually took those computers to Nepal.

And used them for many, many years there interestingly.

And Nepal had its issues too, its political issues as well.

There was a revolution in 1989 and we survived that.

There was a civil war in Nepal for ten years, we survived that.

So every circumstance is just a little bit different and

you never know what you're going to come across.

But the best part of the story and I have to,

I'm going to leave you with this part of the story, is many years later,

there was a faculty member here, actually, no, it wasn't him.

It was a woman from the development office who was doing a journalism course.

And Debbie Peron was her name and Debbie was writing,

she wanted to write a book about the story of Vitamin A.

And she did interviews with various people and she came and

talked to me about this story in the Philippines.

And I told her about this group of people, this medical action group, and

I remembered the name of the main guy [COUGH].

And she said, I'm going to see if I can track him down and interview him.

And, anyway, she finally did.

She tracked him down.

He was so anti-American at the time, it's so interesting, and she tracked him down.

He was in private practice, a physician, private practice in Brooklyn, New York.

And she interviewed him, now she didn't see him in person,

she interviewed him on the telephone.

And she said that, at least in the interview with him, that he swore that it

was, he really believed that what we were doing was harmful to Filipino children.

But I think that was, frankly my view is that was disingenuous and

that he was sort of using this for political reasons.

I mean he got enormous press out of it.

And press for his group and so on by, from this.

But it was sort of funny that he ended up in Brooklyn,

New York in private practice after all this very kind

of left-wing stuff and anti-American stuff that he spouted.

So you never know where you're going to meet somebody all around the world.

But so I mean, I think this is not a story to put anybody off.

I've had a very long career in international health and

it's been a fantastic career and

you just have to sort of have a little bit of caution,

a little bit of thought process and planning when you go over seas.

And be willing to be very flexible in your plans, in both your travel plans and

your work plans, because things do change, things get moved around.

It's all part of the fun.

So go out there and enjoy it.

Tales from the Field: Joanne Katz

International Travel Preparation, Safety, & Wellness

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