Dr. William H. Foege

The Babe Ruth of public health

Dr. Bill Foege was the Babe Ruth of public health – he accomplished so much more than any other public health figure that he stands in a league of his own; his accomplishments changed the field forever

Foege’s philosophy of rigorous epidemiology that combined with commitment to global health equity will endure

Foege’s innovations were key to smallpox eradication: He established the ring vaccination strategy and partnered with WHO and country leaders in Nigeria and India to end the two largest smallpox epidemics. The goal of smallpox eradication inspired more than 200,000 health care workers in more than 70 countries to find and vaccinate more than 10 million contacts of smallpox patients within 5 days of exposure. Smallpox eradication has averted more than 200 million deaths in the past half century. And, as Foege wrote, “The U.S. recoups its entire investment in smallpox eradication every three months, and will forever, saving more each year than our dues to WHO. We have recouped our investment over 140 times.”

Foege was a wonderful CDC director, overseeing a strategic reorganization and supporting goals for a healthy United States. He imbued CDC with an even stronger commitment to rigorous epidemiology, global engagement, and health protection at scale.

He then became the first director of the Carter Center, and his partnership with President Carter led to programs that have prevented more than 80 million people from dreadful suffering. He then helped start the Gates Foundation; he was a driving force behind Gavi, the vaccine alliance, which has supported vaccination programs that have prevented more than 20 million childhood deaths.

Any one of these four accomplishments – smallpox eradication, CDC leadership, Carter Center programs, and Gavi – would be extraordinary. With all four, Foege has no peer in public health – although he would have been the first to insist that all were collective efforts.

He wrote, “Progress requires a coalition. Nothing is done by a single individual.”

Bill’s humor and humility were as impressive as his accomplishments. He liked to tell the story of an airplane ride: When he sat down, he noticed an elderly man next to him and had the uncharitable thought that the man was quite homely. A woman then sat next to them and exclaimed, “Are you two brothers?! You look so much alike!” He told of Richard Doll traveling by train; a woman was smoking and Doll told her there was no smoking on trains. She was outraged: “I’m one of the directors’ wives and will file a report.” Doll replied: “I don’t care if you’re the only wife of the director, there’s no smoking here.”

Bill showed that you can focus on saving lives and have fun at the same time. He liked to reminisce about the practical jokes he and others played in his time at CDC. He quoted George Bernard Shaw, “Life does not cease to be funny when people die, any more than it ceases to be serious when people laugh.”

In one of our last conversations, Bill said that “stories never end, they just get interrupted”. He observed that knowledge is fleeting, skills last a lifetime, and philosophy is forever. Despite today’s challenges, Foege’s philosophy of rigorous epidemiology combined with a fundamental commitment to global health equity as our North Star will endure.

With that commitment to health equity as the foundation, his moral compass was unerring, and he spoke truth to power.

He wrote: “We will not know most of the people we kill. Far more people die and suffer because of our errors of omission. The science not used, the science not shared, the vaccines not given, the prevention not practiced, the Medicaid not expanded, the millions without health insurance – all cause harm but are rarely mentioned or even recognized in the context of ‘First do no harm’…. The primary biomedical ethics battleground of today concerns budgets. ‘Do no harm’ is a powerful statement that we have degraded to mean, in reality, ‘Do no harm...unless there is money involved.’”

He understood that every public health decision requires a political decision. For that reason, “public health practitioners must enter the world of politics. They should take it as part of their job description to provide politicians with the information needed for good policy decisions.”

He advised us to wake up every morning as if we’re editing our obituary – and that is how he lived his life.

Bill’s life came to a peaceful end after 89 years. But, as he said, stories never end, they are just interrupted. The stories Bill Foege shared, the people he inspired, the millions of lives his work saved, and the history he created will endure.

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Excerpts from Bill Foege’s writings and conversations

Dr. Foege distilled wisdom from his career, available at Becoming Better Ancestors: 9 Lessons to Change the World

The best solutions move us closer to global health equity

“Global health equity means that people everywhere have access to what they need to be healthy. Smallpox eradication is the ultimate in equity – for everyone and forever. How we implement programs and the outcomes of our programs should be equitable. Every program should be designed to measure and reduce inequities. Nobody is safe until everyone is safe….

The core value of public health is social justice.”

Know, share, and act on the truth – it’s the only way to improve

“The purpose of surveillance systems is to discover the truth. Knowledge is power, and even a little knowledge of the truth goes a long way. Each particular disease and its context must be studied in order to understand its vulnerabilities. Public health is at its best when we see, and help others see, the faces and the lives behind the numbers.”

Systematically improve tools, organization, and techniques

“Spend the time and attention needed to systematically improve tools as well as the techniques to deliver them. Smallpox eradication workers were learning and improving every month while the smallpox virus could not respond with the same agility. The virus continued in the way of its ancestors, unaware that its strategy for survival, adequate for millennia, would soon no longer suffice.”

Management is the key skill in public health

“Whether knowledge changes health is a matter of management. Public health solutions rest on good science, but the implementation of those decisions depends on good management. Find deficiencies and correct them. Tactical flexibility is crucial. Allocate resources where they are needed. Implementation is always local; only the specific locality can provide information on how to secure the cooperation of the community. In all cultures, an approach of respect for local customs is needed.”

Effective evaluation is key to success

“Evaluation makes it possible to predict where resources are needed in advance rather than simply react to the information of the day. It is not an add-on; evaluation is a priority management tool to make effective use of scarce resources. Successful efforts combine implementation and research so that programs lead to better knowledge and knowledge leads to better programs.”

Effective leadership is precious

“Effective leaders focus on the program’s objectives, are willing to use new information to improve the strategy, and build coalitions.”

Coalitions are powerful

“Effective coalitions start with a clear vision of the last mile of the journey. Unwavering focus on the desired outcome obscures bounds between organizations. Trust is the glue that holds coalitions together, and it is earned, not purchased. Communication functions as the nervous system of successful coalitions. The single most important reason for the successful eradication of smallpox was the seamless coalition of national program leaders and international participants.”

Social will and political will are both crucial

“Social will drives individuals to provide resources and opportunities for others and must be transformed into political will. Every public health decision ultimately requires a political decision. Therefore, public health practitioners must provide politicians with the information needed before they make public policy decisions.

How people treat each other is the metric of a civilized nation, political party, society, university, or program.”

Be optimistic!

“There is a place for pessimism, but don’t put those people on your payroll – they will ruin your day. Smallpox eradication proved that it’s possible to choose a global objective and bring global resources to bear on it.”

Never give up: Settle for nothing less than a rational future

“Tenacity and optimism are of the highest value. Tenacity won’t always bring success, but without it, success is impossible. Think long-term. Our bosses are really the people to be born in the future, and they are totally dependent on the decisions we make now. They don’t know that they have given us their proxy vote to create the world in which they will live.

“This is a cause-and-effect world. Smallpox disappeared because of a plan, conceived and implemented on purpose, by people. Humanity does not have to live in a world of plagues, disastrous governments, conflict, and uncontrolled health risks. The fact of smallpox eradication remains a constant reminder that we should settle for nothing less. Coordinated action by dedicated people can succeed.”

Resources:

Becoming Better Ancestors: 9 Lessons to Change the World

House on Fire: The Fight to Eradicate Smallpox

The Fears of the Rich, the Needs of the Poor

The Task Force for Child Survival: Secrets of Successful Coalitions

William H. Foege: Global Health Chronicles