Jon Andrus (M.D., ’79) has spent three decades working to extend lifesaving vaccinations to millions. We asked him about his immunization campaigns in some of the world’s most impoverished regions – and about the reemergence of preventable diseases in one of its wealthiest.
From Peace Corps service to deputy directorship of the United Nations’ Pan American Health Organization, Jon Andrus (M.D., ’79) has worked at every level in his journey to advance global health.
The physician, epidemiologist and immunization specialist has treated individual patients in hospitals without electricity or running water, and met with foreign presidents to rescue vaccination campaigns targeting hundreds of thousands.
Along the way, he’s earned the federal government’s highest public health distinction, the U.S. Public Health Service Distinguished Service Medal, as well as honors from nations across Central and South America. The latest came this summer with an honorary induction into the Mexican National Academy of Medicine.
Andrus currently serves as an adjoint professor and senior investigator at Colorado School of Public Health’s Center for Global Health, where his work complements vaccine- and immunization-related efforts. He is adjunct professor of global health at George Washington University and also holds a faculty appointment at UCSF.
Q. This must be a fascinating time for you. For decades, you’ve been part of an international effort to eliminate vaccine-preventable diseases in developing countries. Yet now we’re at threat of losing measles eradication here due to burgeoning vaccine hesitancy. What runs through your head?
As you frame the potential threat, I am constantly struck how the current situation in many ways is absolutely mindboggling. To put it into context, in 1993 the World Bank concluded that vaccination was one the most cost-effective public health interventions medical science has to offer. Its power to save lives had been realized with the eradication of smallpox.
Fast-forward to 2010 and measles vaccination in Africa, supported by the elimination initiative, had adverted more than 7 million measles-related deaths in less than 10 years. No other public health program in the history of mankind even comes close.
Yet today we see measles resurging in places like the U.S., Brazil, and Venezuela, and it is indeed very sad and disconcerting.
Q. As a CDC medical epidemiologist, you were a member of a specialized team that worked to reduce measles mortality by 60 percent over five years, as a result of vaccinating 200 million children. What does it take to make such a major real-world impact?
Several factors contribute, first and foremost a political commitment to get the job done. In Africa, Ministers of Health understood that measles was a killer of their children, and more importantly, that such deaths were totally preventable with vaccination. What political leader doesn’t want to be viewed by constituents as saving the lives of their children?
Resource allocation is another factor. By tackling multiple diseases where they overlap – such as we did with measles, rubella and congenital rubella syndrome in the Americas – you can galvanize more buy-in.
Q. You’ve served in Africa, Asia and the Americas. How do you work across different cultures?
I was very fortunate to grow up in a small farming community in California’s Salinas Valley. My dad Hughes was a local doctor, as was his father Len before him. I remember Mom gathering all four kids into the station wagon on summer nights to accompany my dad while he made house calls to farmers. We were happy to go because that’s how we learned to drive, and there was always a “milk nickel” ice cream bar waiting for us in some country store.
One thing my dad believed in was hard work, hence the after-hours house calls. He insisted that we all did farm labor growing up. I saw firsthand how the migrant families from Mexico – the Braceros, as they were called – worked in the fields. They were hardworking, very caring people. My dad was also passionate about serving the underserved – at the time, he was the nation’s first private doctor to receive a Rural Health Project grant to provide primary care to migrant farm workers.
The point is that through my childhood experience, largely with my dad’s commitment to the underserved, I strove to emulate such values. In a sense, I’ve always been inspired and motivated to expand what he did to more of a global level. The people I’ve been fortunate to meet and work with along the way motivate me more than ever.
Q. What kind of resistance to vaccination did you encounter overseas, and how did you adjust?
I recall several examples where we met resistance. The one that upsets the most was a situation in Peru around 2005 or so. I was chief of PAHO’s immunization program. Peru’s Ministry of Health was planning a mass vaccination campaign to eliminate measles, rubella, and congenital rubella syndrome. Just before launch, a parliamentarian from the minority party (and a pediatrician by trade!) declared in Parliament the campaign would cause autism. It hit the papers, and the campaign halted.
On urgent notice, I flew to Lima to meet with the authorities. The “doubters” needed to understand that an in-utero infection of rubella virus actually caused autism – NOT the vaccine. The whole misunderstanding was a result of Andrew Wakefield’s egregious claims in the The Lancet a few years before – the damage had been done. We had a chance to meet with President Garcia, and thankfully he was convinced the campaign should go forward.
Q. You were quoted in an NPR piece about challenges to eradicating polio in Africa. In Nigeria for example, at times communities actively fought immunization campaigns. Religious leaders denounced vaccination drops as a Western plot to sterilize Muslim children. Vaccinators were shot and killed. How do you deal with these situations?
There is no easy answer. The bottom line is to work incredibly hard in each and every neighborhood to involve all the community leaders, including religious leaders. Do this at the beginning – don’t wait. The focus must be on communicating effectively, and providing them opportunities to participate and to “own” their program.
There’s a great story about a rural slum of Uttar Pradesh, India. After achieving polio eradication, community leaders actually erected a beautiful shrine to commemorate the remarkable achievement. That kind of result takes a lot of work and commitment, by all partners.
Q. You worked on vaccination in Southeast Asia in the 1990s, not too long after the end of the Vietnam War. Did the legacy affect your efforts, and how did you adjust?
In India – the country which always reported annually half the world’s polio cases – the legacy of the Vietnam War and the Cold War had a huge impact on our efforts. When I arrived in 1993, western corporations had been kicked out. There was a lot of tension. Being an American, I was put under the microscope.
From the moment that I arrived, I realized that I must earn and build respect and trust with my counterparts. I had the knowledge and experience, having been through the polio battles in the Americas, but I just needed to earn their faith in me as an advisor.
It may sound trite, but I really made a great effort to always place values (in the form of reducing inequities) and vision (a strategic plan) first. For seven years I worked weekends and was always available after hours. I attempted to follow the credo of never asking anyone to do anything that I wouldn’t do myself.
The program was committed to reaching the unreached, regardless of race, religion or socioeconomic status. It was all about reducing inequities. Little by little, I think I earned that trust and commitment of colleagues, and eventually governments, to believe and commit. By the time I left in 2000, Bangladesh, Nepal, Myanmar, Thailand and Indonesia had eradicated polio. Cases in India had declined to an all-time low, in only two states.
Q. Do you think today’s vaccine debate in the U.S. has affected international advocacy?
Definitely, and the Peru example highlights this point. The parliamentarian would have never made his false claim if he hadn’t been exposed to it elsewhere, in particular the U.S. Latin countries look to us in many ways, right or wrong, as an example or standard to live by.
Q. What can be done about attitudinal resistance here?
There’s no simple answer, here or in any country for that matter. In my opinion, we shouldn’t overlook the role of childhood education, especially for girls. Compulsory immunization for school entry has a definite role. Make immunization a child’s right. And role models in sports and theater also have a place.
At a provider level, learn effective methods for communicating with patients. People have faith in the advice their family physician or pediatrician provides. Research shows that presumptive communication methods work. “Glad you came in for your child’s vaccinations! Let’s get started.”
When parents express concerns, providers should always be empathetic and caring, but also try to avoid dwelling on “myths” presented by parents and instead bridge back to benefits. There will always be recalcitrant non-believers here, but fortunately they remain a small minority, perhaps one to three percent of the population. Unfortunately, the social media tools they use amplify misinformation in egregious ways.
In our culture, a sad thing is also that people often only see what they believe, rather than believe what they see. People react to their emotions, not to information. Science and evidence are not always the answer in America. So framing communication from the perspective of the parent is useful. A message a colleague likes to use is something like, “You provide a helmet for your child when she gets on the bike. You don’t wait for the moment just before the accident to put it on and prevent the injury. That would be impossible. The same applies for vaccines.”
Q. During your Peace Corps service in Malawi, you were the only doctor for a district of more than 210,000 people. Can you tell us more?
After fulfilling my National Health Service Corps obligation in Lassen County, I joined the Peace Corps. My wife, a nurse, and I were assigned to the Mchinji District of Malawi.
As the District Medical Officer, I was responsible for all curative and preventive services. The first year I spent most of my time in the operating room doing complicated obstetrics – a large proportion of medical emergencies in Africa requiring hospital care are obstetrical.
It wasn’t uncommon to operate on a woman with a ruptured uterus because of the long distance she had to travel in an ox cart with a transverse lie of the baby. We also did our share of ruptured ectopic pregnancies. We knew all the blood types of the school children in the surrounding area, because the hospital didn’t have a blood bank. Or electricity, or running water.
A bad day was to hear women wailing their grief over the death of a child during the night. I would hear them when I arrived in the early morning – my walk to work was almost a mile, and I could hear them from far away. The feeling was awful. There was this gut-wrenching appeal to how terrible it must be to lose a child. And most of these deaths were preventable.
Q. How did that experience shape your interest in global health and in vaccination?
1986 was the African Year of Immunization, and a bolus of funds from WHO and UNICEF reached the districts to train vaccination teams. District Medical Officers were tasked to ensure efficient trainings, microplanning, vaccination and outreach. It was really a defining moment for me.
The hospital staff became incredibly enthusiastic to get involved with activities that would prevent diseases killing their children on a daily basis. That enthusiasm and excitement, combined with a lifesaving technology like vaccines, was all it took for me to decide then and there that this was what I wanted to do for the rest of my life.
I came to realize the potential contribution of the team was greater than the sum of the parts, and greater than anything I’d ever been a part of.
For me, the call transitioned from care of individual patients to care for the community. I had the amazing opportunity to work with dedicated people in need of a little support, all with a tremendous sense of how to save more lives more quickly.
Q. How has working in international health changed over three decades?
Health conditions respect no national borders, and especially infectious diseases. Measles, tuberculosis, dengue, Zika are now truly only a plane ride away. Prevention and control require both regional and global coordination.
Another often overlooked factor is the need for country ownership. We must get away from the paternal relationship some donors have with countries. Nations must find ways to resource and own their own immunization.
Q. Can you share some memories of UC Davis School of Medicine in the 1970s?
Professor Gibb Parsons was a mentor. He had a great sense of professionalism, but also a great sense of humor. I remember as a first-year student, I nervously presented my findings after completing my first complete history and physical exam on a patient. In my anxiousness, I reversed the order of results for respiratory rate and pulse. He immediately injected, “Jon, that is incompatible with life!”
Terry Smith, a classmate, almost fell out of his chair laughing. Terry, John Shepherd, Carolyn Shelby (later Carolyn Shepherd), Ann Searcy, and I were part of a wonderful study group. Terry never failed to mention in front of them every chance he got, “Jon, that is incompatible with life.” Boy, did we get some laughs out of that one! We still try to keep in touch.
Q. What advice would you give today’s students, especially those interested in global health?
The short answer is that experience is golden. Go overseas and work. Get firsthand field experience. Also, get knowledgeable in the fundamentals of epidemiology, the language of public health.
Then, mentor younger colleagues every chance you get. We are students for the rest of our lives, and we should always be looking to build the next generation of professionals and leaders.