Bill Foege shares his lessons on global health equity – and unscrambling eggs

Dr. Bill Foege, the renowned epidemiologist and former U.S. CDC Director, has had some exceptional achievements during his career, including helping eradicate smallpox by developing a global strategy to counter the disease that killed almost half a billion people. Smallpox is now the only disease that humans have successfully stamped out. Now retired, Dr. Foege has some lessons for the next generation of global health leaders. In a recent conversation with the Exemplars in Global Health team, he shared some of them in his own words, including on unscrambling eggs and writing your own obituary.

A surprising path into global health

"In high school, I was in a body cast and we did not have television at that time. So, I was forced to read, and came across Albert Schweitzer, and became interested in Africa, and in medicine. When I went to medical school, I was looking for people who could give me guidance on global health. But there was almost no one even interested. The one exception was Rei Ravenholt. I started working for him after school. He said to me, 'If you're really interested in global health, there is no path for you; you have to make your own way. The best way to do that would be to go to CDC and become part of EIS, the Epidemic Intelligence Service.' He said, 'You'll meet people who are interested in global health, and they'll end up being colleagues for the rest of your life,' and he was right.

While I was an EIS officer, I read an article in The New England Journal of Medicine written by Tom Weller. It was the commencement address for Harvard Medical School. He basically said, 'Now you've all had the advantage of getting skills and knowledge. Some of you are going to go out and make money, but some of you are going to ask where will I use these skills and this knowledge to the best advantage? And he said, 'That's the developing world.' I was so naive. I didn't know he was a Nobel Laureate, but I wrote and got an assignment there and spent a year with him. That's when I really developed my interest in smallpox. I tell people interested in global health today that you won't get rich, and you won't even be thanked, but if you can get beyond those two things, it's a very satisfying career."

Three words that define a career, and a three-legged stool that should support all projects

"For me, the philosophy of my career has been global health equity. Three words. If you take any of those three words away, it changes everything. You can add 200 words. It doesn't improve on that. Health equity is one of the easiest things to measure. All you have to do is take something you don't want, whether it's infant mortality or death, sudden early age disease, and so forth, and compare one state with another, one tribe with another, one nation with another. You can tell what's the global equity difference there.

When you're starting a new project, there are three things you should think about, like legs on a stool. The first one is science. So many people are afraid of science and think they can never understand science. They don't trust science. But as Thomas Huxley once said 'science is simply common sense at its best.'

Then, there’s art. The first scientist that we actually know by name is Imhotep from Egypt, who was a physician and an artist. He designed and built the step pyramid.

The third leg is the moral compass. I go back to Roger Bacon, who was born 801 years ago. He was asked to do a summary of science for the Pope. It's been over 50 years since I've looked at it, but I remember distinctly how enthusiastic he was about science. He predicted cars and submarines and airplanes and telescopes. Think of that, over 700 years ago! But he ends up saying to the Pope, 'but science has no moral compass.'

So, you have to develop scientists with a moral compass. If you put those three things together, what do we have? You have moral, creative, common sense at its best and that is worth looking at before you start any project."

The tragedy and triumph of COVID-19

"The coronavirus is really a combination of tragedy and triumph. The tragedy is every lesson that we have learned since the days of Louis Pasteur was ignored by the Trump administration. I go down the list: cause and effect, the need for truth, the need for a global approach, and every one of those things was violated by the Trump administration. That's a tragedy. The triumph is, how did we get a vaccine that’s so good? This virus, as scary as it is, cannot stand up to the science. Even if you're not talking about mRNA, you're talking about vaccines that hook onto a virus or protein vaccines, the virus cannot stand up to them."

On vaccine hesitancy, prevention, and unscrambling eggs

"I've dealt with the anti-vaxxers for years and years, but I never saw this coming, where it would be such a political argument. Some things you only have to do once, and coming up with a good vaccine is one of those things. The single biggest thing we have to offer in global health is the vaccine. We now have to figure out how do we get around this anti-vaccination movement, the anti-science movement.

Health is not valued by individuals, by citizens, by states, by nations, by the world… until you lose it. When I was getting my training, I was so unaware of what happened to people the day they got a lung cancer diagnosis. It didn't matter how much money they had, they would have given all of it up if they could go back 20 years and change what they had done. I knew a billionaire who got a lung cancer diagnosis and died three weeks later. He would have given up billions if he could have reversed that in some way.

Prevention is so important and so difficult to teach. Richard Feynman, the physicist, said that the biggest mistake he ever made as a physicist was to think that time could go in both directions. He came to realize that can't happen. Time goes in one direction and his description of this was scrambling an egg. It takes very little energy and all of science is incapable of reversing that process.

If we give iodized salt to pregnant women at a crucial time, we're talking about pennies worth of iodine. If you don't do that, their child can lose 30, 40 IQ points, and there's no way to reverse that, no matter how much money you put into it. Prevention turns out to be so important and epidemiology is the interface between that and how we decide what to do about it."

On multidisciplinary science and the value of non-medical disciplines

"When I first went to Africa, I found myself asking, 'What do I wish I had been taught? What do I wish I had sought after?' One thing was better management, because in medical school, it was always: if you had a heart attack and you could no longer practice, you could always go into public health or management. It was never the other way around, where you were in management and had a heart attack and now you became a cardiologist.

Management was denigrated. But I came to realize when I took courses from the American Management Association, which I really, really enjoyed, that medical school was actually a school about management. Here you have a patient with a problem, and you want to get them over here where they don't have a problem. What do you have to plan in order to make that transition? How do you monitor it? How did you make mid-course corrections?"

On social determinants of health

"I think the single most important social determinant of health is poverty. Many people over the years have said, 'We have to correct this,' and we haven't. We've had the war on poverty. Poverty is such a basic issue but what’s happened now is that all of us are guilty, and we end up with a lifestyle that's better because there are poor people subsidizing us.

That better be painful for all of us to think about, that poor people here and around the world are subsidizing us. What I tell the students is that we've become the plantation owners. We're so comfortable, it's hard to get us to say if we want to change this. The South in the U.S. was willing to get into a war because they didn't want to change it. What is it going to take to get us to change it? When it comes to equity, working on poverty seems to be well worth the time and effort."

On smallpox, aliens, and global collaboration

"There was a historian who said, 'You'll never really get the world to collaborate unless there’s an alien invasion.' Smallpox turned out to be a minor surrogate for an alien invasion because we could all see ourselves at risk. In our health programs we should deliberately ask: 'What could we use as a surrogate for an alien invasion?' We've done that with nuclear weapons. I think that we did that with HIV. That’s one example of trying to get some equity globally because we saw ourselves at risk. I think COVID-19 is a great opportunity to say, 'We're all at risk, so what do we do as a world to make this truly a surrogate for an alien invasion?'"

"Hod Ogden – who was head of health education at the CDC – was very quick. He could write a song, a story, or a speech at the drop of a hat. As he was dying, he asked one of his assistants to write his obituary. She agreed to do that. The word went out that he had hours to live. The next morning, he woke up and was feeling fine. And he went on to live for months. He said, what a great thing it was to renew conversations, but he said, 'Nothing was as good as the chance to edit his obituary.'

I like that story and I tell students, 'You're going to edit your own obituary every day, and you won't realize it, but if you wake up in the morning knowing that you're going to edit your obituary, it makes a difference what you will try to do that day.' Is there a unifying field theory in all this? Yes. We belong to a group of optimists who believe that we can change the future. So you wake up every morning knowing that you're changing the future."