Mary Woodward Lasker Award
for Public Service

An Interview with William Foege
Interview by Allan Rosenfield

Allan Rosenfield, Dean of the Mailman School of Public Health at Columbia University, interviews William Foege, whose courageous leadership improved global health and led to the eradication of smallpox.

Date of interview: September 20, 2001

Rosenfield: Hi. I'm Alan Rosenfield, Dean of the Mailman School of Public Health at Columbia University. With me today is William Foege. Bill, it's an honor to be with you on this occasion. I wonder, as we start, whether you'd like to say something about the horrific events of the past week and the public health implications.

Foege: Well, I'm impressed that even ten days later, there's such a depression in any group that one meets with. And it's a time where you really need optimists. But it strikes me that this is a little bit like what global health is about. That if you concentrate on it, you absolutely get depressed. I often times tell students that every day, 30,000 children die before the age of five. I've never had a real mental concept of what that was. Suddenly on September 11th, you get the feeling of what that means. The problem with the 30,000 children, they're so diffused geographically that there's no way to put them on a television screen. And therefore it's very difficult to get the kind of response that's needed. And the question is, when you look at ten days and the response of, not just New York and Washington, but the entire United States, and the millions of acts, of good acts—how could you get that kind of response in global health?

Rosenfield: That's very interesting. Let's go back in your career. You started with the Epidemiologic Intelligence Service at CDC. Could you tell us how you got started there after medical school?

Foege: In medical school, I worked after school and on Saturdays for Ray Ravenholt. Ray Ravenholt was the epidemiologist for Seattle, King County Health Department. One of these people who is energetic, interested in everything, makes things exciting. And I had never even thought of public health and epidemiology until I worked for him. But he was working on everything, staph infections, what happens at swimming pools. Recently he published an article on what was the real cause of death of Merriweather Lewis. I mean, he's just interested in everything. So he kept telling me about the Epidemic Intelligence Service at CDC. When I finished my internship, he continued to push me in that direction. So I went to CDC and I've never been sorry.

Rosenfield: You, early on, after your first couple of years at the Intelligence Service, you went to Nigeria as part of the smallpox eradication program. Tell us a little bit about that.

Foege: I actually went to Nigeria to run a medical center. I went there just after a year at Harvard with Tom Weller, and in tropical public health. In Nigeria, I got a letter asking would I be willing to do some work on smallpox eradication for CDC. I'd actually done a paper for Tom Weller on what are the chances of global eradication of smallpox. So I was interested in it. And for several years, I worked both at the medical center and for CDC on smallpox eradication.

Rosenfield: Where was the medical center?

Foege: It in the eastern part of Nigeria. At that time, there were four provinces, or four states. And this was in the eastern part, which became Biafra during the civil war.

Rosenfield: Tell us a little bit about being left in Biafra during that civil war as one of the few white Americans as war broke out.

Foege: Well, that was a horrendous war. You recall the pictures of the children who were starving, the attempts to get food in at night by air lifts. It was a very difficult time. But with smallpox, they never had a case of smallpox in the area of Biafra during the war, because we were working on the last outbreak the week the war broke out. We didn't know for some time whether we'd actually gotten rid of that last outbreak. There were two reported cases of smallpox during the war. In both instances, they were able to get specimens out of Biafra. They turned out to be vaccinia, due to the vaccine, not the disease. So the disease was eliminated just before the war started.

Rosenfield: That's remarkable. You might want to tell us in just a few sentences being there during the civil war as a rather unusually tall American in that country when you weren't supposed to be there any longer.

Foege: Actually, I think Africa was a much friendlier place 35 years ago, even in the midst of civil war. There was a great protection of people from the outside. So I didn't feel in danger just because I was not African.

Rosenfield: Right. You returned eventually to the United States and did a number of things. But perhaps you are particularly well remembered here for your years at CDC as the Director of CDC. Can you tell us a little bit about those years?

Foege: Being at CDC as Director, I always said was like having test week in medical school every week. The amount of information that kept coming in was overwhelming. And I recall during test week in medical school I was always surprised how things fit together that I hadn't quite understood before that. But now you look at it a second time. It fits together. Well, it was this sort of thing that there were lots of people tutoring me. So I didn't have to become a specialist in anything. There were also experts who could do that. But it was always a changing boundary that when I started, in public health, infectious diseases in public health were almost synonymous. And then gradually, CDC got into the population area, got into the environmental health, occupational health and then finally into violence and injury control. So it kept expanding.

Then in the midst of all this, as people thought infectious diseases would decrease, we kept finding new infectious diseases. It started with lots of fever and then toxic shock syndrome, Legionnaire's disease, and now it's about one new emerging infection a year that this country and this world faces. So it's always changing. You can't get tired of it because it's never the same thing.

Rosenfield: Is there any single accomplishment during your ten years as CDC Director that you particularly would like to remark about?

Foege: Well, there are a number of things that I was very pleased with. I mean, toxic shock syndrome, the speed with which this was actually solved. But I suppose one of the things that strikes me as feeling very good about was the CDC solving the problem of Reye's syndrome and aspirin. And the reason is this was before what we now call meta analysis, where you put together the findings from a lot of studies and your able to come with, what does all of this indicate? We weren't able to do that in those days. We had three or four small studies, each one indicating there's a problem with aspirin in children if children have flu or chicken pox. But not a single study got to the point of being statistically significant. So, what do you do? We know that you can cause great harm if you end up saying something is a problem when it isn't. And if you say there's a problem with aspirin and it turns out there isn't, you've done great harm to an industry.

So you have to be very careful about this. We went to the American Academy of Pediatrics. And everyone had the feeling, "There is a problem here, even though it's not statistically significant." And the question was, should we publish this or not? As soon as the aspirin manufacturers found out that we were going to publish it, you can't imagine the pressure that they put on. And they continued to say to me, "It would be a shame if you ruined the reputation of CDC by making a big mistake." We decided to publish it anyway. It was going to be a joint publication of CDC and FDA.

The night before it was to come out, FDA called me at home to say they'd come in with more information and we can't publish it tomorrow. We decided over night that we wouldn't change anything. We went ahead and published it just with CDC's name on it the next day. It took the aspirin manufacturers by surprise. They went to my boss, Ed Brandt, and he backed us up totally. They then went to the Secretary of HHS, Richard Schweiker, and he backed us up totally. They then went to the White House, and the White House ordered to stop, to cease and desist, and to do a new study. But you see, it didn't matter. We'd already published it. It was now in the public domain. So I think that's one of the things I feel best about—that we did not bow to political pressure and we were able to get the scientific truth out.

Rosenfield: Based on your years at CDC and coming back to our initial talk about last week, we've been talking for the last year or two about concerns about bio-terrorism. But all of a sudden, bio-terrorism has taken on a new appearance. What are your comments? What do you think the New York City Department of Health should be doing, the country be doing, CDC should be doing, with the threat that now appears to be more possible than perhaps we thought just ten days ago?

Foege: I think one has to take the approach that anything that you can actually imagine happening, there are some people willing to carry it out. And therefore, we can't take the position, this is so horrendous, no one would ever do it. I think what we need is to relook at all the possibilities and figure out what has to be done, even if it means going back to immunizing people for smallpox, for instance, and taking the risk of vaccine, if that's what it takes to reduce the risk of bio-terrorism. I really worry about, is science going to turn on us? Is it possible for someone to develop a virus that is as bad as AIDS, in its implications, but it spreads as easily as influenza? And if someone would be able to develop that in a lab, then there's someone that's willing to use it. I think we have to be much more attentive to what people are doing in order to alter organisms. But what do we do to protect a population? Not just the population of this country, but of the world?

Rosenfield: You mentioned smallpox. And since we know that smallpox was misused during the Soviet era and it may well be in the hands of people that it should not be in the hands of, you mentioned immunizing. That's a question many people ask right now. But I don't believe there's enough vaccine around. How would you recommend our government act in relationship to immunizing the population against smallpox now?

Foege: Well, it's true. We don't have the vaccine to do that. But I think we should be open to all possibilities, which means we should be buying sufficient vaccine to at least stockpile. But that we should ask the question again: Could we product a smallpox vaccine that does not have the implications of the old vaccine? The reason we stopped vaccinating is because we were losing eight to ten Americans a year due to the vaccine itself. But that's been decades ago. We now are at a point where it's possible, I think, to take out the adverse effects of the vaccine. And if we could produce a vaccine that had no adverse effects, then why not use it?

Rosenfield: After you left CDC, you were quite helpful in the beginning years of Jimmy Carter's Center. Can you tell us about your role working with the former president? Many people describe his work there as among the most effective of any former president.

Foege: The Carter Center is a real joy to talk about. It was a joy to have worked there, because I think what happened is you were able to bring together activism, the ability to get academic input, and access. President Carter having access to heads of state made all the difference of being to do things in Africa. Working on guinea worm eradication, on river blindness—these are things that happen much more quickly because of his ability to get access.

An example: It was 1989 and I was walking one afternoon with Norman Borlaug. Norman Borlaug won the Nobel Peace Prize in 1970 for the green revolution in India and Pakistan. Borlaug said to me, "I'm an old man. And there's one more thing I'd like to do. I would like to introduce a strain of corn into Africa that has all of the essential amino acids." Now regular corn lacks enough lysine and tryptophan to be a complete food, which is why children can be malnourished even if they get plenty of corn. But his group in Mexico had developed a strain of corn with high lysine and high tryptophan. He said it could be a complete food, like milk. And if you introduced it to places like Ghana, where it's used as a weaning food, you could change the malnutrition rates. But he said it takes years and years to convince people. So he said, "I'm depressed."

I mentioned it to President Carter that afternoon. And he said, "I'm having dinner tonight with the head of state, Jerry Rawlings. Why don't the two of you come along?" We did. And President Carter started in immediately talking about this miracle corn. He asked Borlaug what the implications were for agriculture. He asked me, what were the implications for nutrition? And I indicated to Jerry Rawlings that the word "kwashiorkor" had come from Ghana in 1933, when a woman working there used the word in print for the first time. I said it would be nice if the solution would come from Ghana. And it would be nice if that happened in the lifetime of the woman who first used that word in print.

He looked surprised, and he asked, "Is she still alive?" And I said, "Yes." "How old is she?" And I said, "95." He said, "We don't have much time. Could you have a plan by tomorrow morning?" Now something that would ordinarily have taken years was implemented within months. And within two years, this high protein, this high-quality protein corn was being sold in the market as a weaning food. That's something a former president can do. You and I can't do that at all.

Rosenfield: That's remarkable. Currently you are doing two things. You're, if you will, a guru to several foundations. And you're a professor at the Rawlings School at Emory, School of Public Health at Emory. Tell us a little bit about those two roles and particularly your role with what many people consider a wholly new paradigm for foundation giving. That is the approach that the Bill and Melinda Gates Foundation has taken.

Foege: First the Emory role. I truly enjoy working with students. And when you see these altruistic students coming to learn about global health, they know they'll never get rich. And yet they're so enthusiastic about learning how to do this. So I find that a very rewarding thing. And you understand that, having spent so much time at a school of public health.

With the Gates Foundation, this is very rewarding because it has totally changed the field of global health. They've been giving money for only a few years. And yet you see in every part of global health, it's not just the money, it's the hope that's been engendered. As people who have worked their lifetimes on a shoestring and never expected that there would be more than that, all of a sudden see that there are the possibilities of resources. I think it's almost the placebo effect that you see in clinical medicine that people get well beyond what you can explain by the medicine. In global health, people getting well beyond what you can explain with the resources.

So I think this is a wonderful time in global health. The tools are improving. The vaccines that are possible are improving. And the Gates Foundation, of course, has been putting money into vaccine development, and 125 million into AIDS vaccine development. Money into malaria vaccine development, which looks very promising. Money into tuberculosis vaccine. So, new tools.

But its the resources and not just from the Gates Foundation. I look at Rotary International and the fact that 16 years ago they decided to raise money for polio eradication. And they've now raised about 500 million dollars. It's new money. It's not coming from some other place in global health. Then you look at Ted Turner, his billion dollars. You look at the corporations with Merck having put in hundreds of millions of dollars now for Mectizan, a drug that prevents blindness from a disease called river blindness.

And then the Gates Foundation—which first gave 22 billion, and now they've added to that with half of the money going to global health—which means about 600 million dollars a year. I think when Toynbee said that the 20th century would be the time we saw some equity in global health, he was wrong. But now, the 21st century will be that time. And I think we're going to look back in 100 years and see that it was basically due to two people, Bill and Melinda Gates, that they have changed the entire field.

Rosenfield: I agree that what they've done has been exciting. Tell us, if you will, about the AIDS pandemic—or the worst pandemic of our life to certainly and maybe since plague—what are your thoughts, particularly about AIDS now in Africa, about treatment, the importance of prevention? But now, activists talking about we can't just write off the 33 million people worldwide and 26 million in Africa. Can you comment on your thoughts on this?

Foege: Well, going back to where we started, with the World Trade Center, and the depression that has settled over people, it's appropriate depression. You look at AIDS in Africa, and that depression that has settled over Africa and the people working on AIDS—it's been appropriate depression. I mean this truly is a horrendous problem. And when you look at what is happening in many parts of Africa, where school teachers are dying faster than they can be replaced, medical workers dying faster than they can be replaced, church workers dying faster than they can be replaced. You can see how society is pulling apart.

For the first time, I see some light at the end of the tunnel. We have the example of Uganda having not just stopped the increase in AIDS transmission, but actually turning it around. Doing that before we even have a vaccine. We have the example of Senegal, keeping the rates very low, one percent or two percent in Senegal. We have the example of Thailand turning around a horrendous increase in AIDS and doing it very quickly. So we know it can be done.

But in addition to that, we now see some tools. There was a meeting just two week ago on an AIDS vaccine that attracted 1,000 people. And people were now excited that there are three or four truly good vaccines potentially, that protect in primates, and now have to be tried in humans. There are three vaccines that are now undergoing human trials, phase three trials. And the goal is to get up to 15 or 20 candidate vaccines so that you have parallel research. You don't wait to see what happens with one study before you do the next one. You do a whole lot of them, knowing a few of them will work. Most of them won't. But you don't know which ones will work. And so you do them all at one time.

Then I look at what is happening with drugs. Not only the drugs that are available in this country, but the new ones, easier ones to use. I think that the tools are improving. But now, the last thing is, the interest that is suddenly developed. The political interest, the scientific interest, because people are coming to a point where they're saying, "We don't have to put up with this. This could be solved." And it's a matter of will—can the world respond to AIDS in Africa the way we're responding to the World Trade Center crisis here?

Rosenfield: What do you think of the groups that are proposing to focus on women as an entry point for treatment?

Foege: Obviously we're going to have problems treating everybody at one time. And so you have to ask, "What is a good entry point?" The problem I think with treating AIDS in Africa is the delivery system, rather than getting the drugs themselves. I think that can be managed. It's the delivery system. Well, the delivery system has to be built up. You don't start overnight delivering to everybody. I think it makes sense to try to do this with women who have just given birth, who are positive and now you ask the question, "How do we keep that woman alive to be a mother, rather than simply produce an orphan?" Then I think it's very logical to ask, how do we keep the fathers alive? I think that one goes step by step until you have a delivery system that provides antiretroviral drugs for every target that needs them.

Rosenfield: If you were to look back on a 30-plus year career, are there one of two things that you haven't talked about that stand out as areas in which you personally took a prime interest and were involved?

Foege: I don't think that I would concentrate on an area. I which concentrate on the process of what's happened, that it's very easy to get discouraged because of AIDS in Africa. But I think what we have learned over this period of time is that there's real reason for optimism. Infant mortality rates have decreased by about 50 percent in only 40 years time. Except for AIDS, life expectancy rates have been increasing for lots of reasons. We're getting rid of some diseases, such as smallpox, and now we'll get rid of polio. And there's a concentration on which diseases could we get rid of all the time, so that we make an investment now and the benefits accrue forever.

I think that we're starting to act now as a world, rather than as a lot of nations when it comes to health. And if there's one lesson from the World Trade Center, I think what it is, we have to figure out how to be global citizens, rather than be national citizens. We have to figure out, how do you break down these walls between ethnic groups and religious groups and national groups? There's nothing in the DNA that determines whether you should be a Muslim versus a Christian. All of the behavior that you see in these groups is learned behavior. Therefore an optimist has to say, "this can be unlearned, or relearned." And so I think what I've taken from 35 years is that there is reason for optimism that the lessons of the last 35 years are "this is a cause and effect world, and if we're smart enough to figure out the causes, we can intervene to change the effects."

Rosenfield: Last question. You deal with a lot of students. When they come to you for advice about careers and international global health, how do you counsel them, physicians and non-physicians?

Foege: They often want to know, "What should I specialize in? What kind of career track?" And I tell them that there's a more general answer to this. And that is to figure out how to be a generalist and a specialist simultaneously. If you're going to be the best specialist, it's because you had the big picture. And having the big picture, now you know this is where I should be putting my time and attention and resources. But it also makes you a better specialist because you know where you fit in. I think this idea of trying to see the whole as you specialize in a part is the best advice I can give.

I often quote a professor by the name of Peligan from Yale, who says, "The difference between average and good scholarship is undoubtedly the program that you train in. But the difference between good and great scholarship is undoubtedly due to how much you know outside your field." So I tell them to learn everything they can outside the field, become generalists, have curiosity, which is, I think, an addiction that you learn. It's like coffee. You don't necessarily start with it. But you can work on it until you're curious about everything and them figure out where you want to specialize.

Rosenfield: Thank you. And again, congratulations on the Award.

Foege: Thank you very much.