Dr. William H. Foege

William Foege

MILLER: This is Dr. Bess Miller, and I'm here with Dr. William Foege. Today's date is August 26, 2016, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Dr. Foege as part of the oral history project, The Early Years of AIDS: CDC's Response to a Historic Epidemic. We are here to discuss your experience and reflections on the early years of CDC's work on what would become known as AIDS [acquired immune deficiency syndrome]. I must ask, Dr. Foege, do I have your permission to interview you and to record this interview?

FOEGE: You do.

MILLER: Thank you. Dr. Foege, I have known and admired you since I first came to CDC as an EIS [Epidemic Intelligence Service] officer in 1981, when you were Director of CDC. Your work in public health before and since is, of course, legendary. It includes playing a lead role in the global smallpox eradication campaign conducted during the late 1960s and 1970s, which led to the global 00:01:00eradication of smallpox in 1980. In the late 1970s and early 1980s, you were Director of CDC during both the Carter administration and into the first part of the Reagan administration, when AIDS emerged. And in the late 1990s and 2000s you have worked with the Bill and Melinda Gates Foundation to expand its global health mission, which has transformed the global fight against many diseases of poverty. In recognition of your achievements in international public health, President Obama awarded you the Presidential Medal of Freedom in 2012.

I must also note here that, according to many, and most recently [in] an online article entitled Profile of a Global Health Prankster: Bill Foege, written by Tom Paulson on June 3, 2014, in Humanosphere, there is a mischievous side to 00:02:00you, which we'll want to hear more about. Before we begin, I'd like to mention that this Oral History of AIDS with CDC was the idea of the late Dr. David Sencer, former CDC Director and, I know, a good friend and colleague of yours. I was fortunate to work with Dr. Sencer in 1982, when I conducted one of the early AIDS investigations, the so-called lymphadenopathy study in New York, when Dr. Sencer was Health Commissioner in New York, and I got a chance to appreciate his mischievous side as well.

Let's begin with your background. Can you tell us about your childhood and early years?

FOEGE: Sure. I grew up my first ten years in a small village in northeast Iowa, only 100 people and a one-room schoolhouse. We moved then to the state of Washington, and I graduated from high school in Colville, Washington, and then 00:03:00went to college in Tacoma at Pacific Lutheran University.

MILLER: It sounds like you moved a bit. How was that for you?

FOEGE: My father was a minister, and so he would get calls to different churches, and I think our moves were by and large exciting moves. We kept going to bigger and bigger places, which you almost have to do if you start out in a village of 100 people.

MILLER: Why did you go to college where you did? How did that come about?

FOEGE: Because they had a clergy discount, and so my siblings went there also. It turned out to be a very good liberal arts college with a good record of sending students to medical school at the University of Washington. There was one person at the school by the name of Bill Strunk, who was so well regarded at 00:04:00the medical school that if he recommended you, you had a good chance of being admitted.

MILLER: What inspired you to go to that school?

FOEGE: I think a number of things. When I was 15, I had a hip injury and was put in a body cast. This was before television in our town, so I was reduced to reading, and in reading I came across the works of Albert Schweitzer. His book Out of My Life and Thought was the first one that I read, but I gradually became interested in the idea of Africa and medicine. Then an older sister went to medical school, and so that was an inspiration to me because not very many women went to medical school in those days. I used to visit her on weekends at medical school and found it to be a very exciting environment.

MILLER: So you went to medical school, and when did you begin to do 00:05:00international work with respect to that?

FOEGE: In medical school I was already interested in what we now call global health, but you could not find people in the faculty that were interested, with a couple of exceptions. One was [Dr. Reimert T.] Rei Ravenholt, who had been an EIS officer at CDC, so he thought in public health terms, but he also thought in global terms. He told me, if you're really interested in global health, you should try to get into the EIS. And it was good advice, because there were not many tracks into global health at that time. Anyone that went into global health pretty much did this on their own. They created their own path. He said the EIS program would be one way to get in, and it turned out to be one of the best ways to get into global health.

MILLER: So those were the years of [Dr. Alexander D.] Alex Langmuir. What did 00:06:00you end up doing in the EIS?

FOEGE: I was assigned to the State of Colorado, and it was an assignment that I wanted, because I wanted sort of a broad look at public health. While I was there I was called one day because of a suspected case of smallpox in Farmington, New Mexico, in a Navajo child. The instructions I got from [Dr. Donald A.] D.A. Henderson and from [Dr. J. Donald] Don Millar [were], "Get a book by [Cyril W.] Dixon on smallpox and read as much as you can before you catch the plane tonight." So my problem was finding that book, because a medical student had checked it out in order to write a paper. I had to find the medical student. I did. But to talk him out of the book was somewhat harder, because he had a paper to write. I did, and it was interesting that I felt pretty confident in being able to distinguish between smallpox and chickenpox by the time I got 00:07:00off that plane, only to have a car come right to the plane to pick me up and take me to the hospital, because people were waiting for the outside expert. I walked into the room where this child was hospitalized, and as I walked in and looked at the child in bed, I knew immediately that I didn't know what that child had. I mean, it was sobering. So I took my time doing a history and physical, then went into a back room and called D.A. Henderson and Don Millar. Both of them were at a party here in Atlanta, and we went through everything I had found and concluded you can't rule out smallpox on the basis of this. So we called it a suspected smallpox case until we could rule it out.

Believe it or not, the specimens that we sent in that night to CDC constituted 00:08:00one of only two errors that I know of in smallpox diagnosis at CDC, and the error was not an absolute error. They said it was compatible with smallpox. So for the next three or four days, of course, we had to treat it as if it was smallpox; when the answer came back, it was herpes. But this was in a child just recovering from measles with a background rash, disseminated herpes with a different kind of rash, severe thrush so that you had trouble seeing the inside of the mouth of the child, and you can see why it was so confusing to the pediatricians. And then we got the answer back that it was herpes. But it interested me in smallpox, and the next year as part of my EIS training, I went to India for three months as a substitute Peace Corps physician. At that time I saw real smallpox in hospitals and realized what a terrible disease this really is.

MILLER: That's fascinating. Now, what role did D.A. Henderson and Don Millar have at that point? Were they at CDC heading up different parts of the organization?

FOEGE: Don Millar at that time was one year ahead of me in EIS and had already developed an interest in smallpox and some of the outbreaks in Europe. D.A. Henderson was head of surveillance, and so he was our overall supervisor. It was during those years that we first had the conversations on smallpox eradication. After EIS, I went to Harvard [University] for a master's degree in tropical public health with [Dr. Thomas H.] Tom Weller. Tom Weller was the Nobel Laureate for having grown the poliovirus and making polio vaccine possible. In one of his 00:10:00seminars, I did a seminar on the possibility of smallpox eradication. I had no intention of being involved in smallpox at that time. It was an academic exercise. But he questioned me with such detail that it put me off. I was actually somewhat frightened until afterwards, when one of his faculty colleagues said to me, he never embarrasses a student. When he questions like that, it's because he's so interested he cannot help himself. So I found that the idea of smallpox eradication had academic legitimacy also. I then went off to run a medical center in Nigeria and got a letter from D.A. asking if I would be a consultant, as they were starting a smallpox eradication program in 20 countries of West and Central Africa.

MILLER: What were some of the key aspects of smallpox at that time that inspired 00:11:00people to want to embark on eradication in those very early years?

FOEGE: Smallpox was a different disease in that we had a good vaccine. We had had the vaccine actually since 1796, but we hadn't exploited it. But it was a disease that if a person gets it, you know [it], because it's visible on the hands and the feet and on the face. There are very few, if any, cases that are subclinical, so you can do surveillance based on finding people that have lesions. Also the vaccine protected probably for life, but certainly two vaccinations protected for life. So it was easy even afterwards to know where smallpox had been, because of the scars of people. If you found scars, for instance, on people under the age of three, you knew there'd been an outbreak 00:12:00there within the last three years. So the disease had many things going for it. After eradication, people would often say in meetings at WHO [World Health Organization], if you mentioned a lesson from smallpox, they would say, oh but the smallpox eradication was easy. And that meant they hadn't actually been involved in it. It had some things going for it, but it was never easy.

MILLER: You ended up having a leadership role in the smallpox campaign for over a decade, working in a number of countries and especially, as you mentioned, Nigeria and India. For this interview, I'd like to ask you about the big lessons learned from this massive effort. Can you share some reflections on that?

FOEGE: I like to tell students that some of the lessons of smallpox eradication include the fact this is a cause-and-effect world. It's not a magic world. If 00:13:00you can figure out what is causing something, then perhaps you can intervene. It's also a world where you can collect facts. Epidemiology turned out to be the base science, of course, of public health, because you were looking for numerators and denominators. As Alex Langmuir used to say, it's so simple: you come up with a rate and then you interpret the rate. It's not all that simple, because you have to get the right numerators and the right denominators.

MILLER: Can you say more what you mean, for the viewer, about numerators and denominators?

FOEGE: When a person goes to see a physician, that physician is dealing with a numerator: a person who has some problem that they want advice on. But that physician does not see the rest of the population that did not come in to the physician's office. That's the denominator. That's everybody. And to get a rate, you have to know how many people are in the numerator. So if you want to know 00:14:00how much smallpox there is in an area, you have to know how many cases there are, and then what's the population. Then you can tell the difference between the rate of smallpox in India versus in Alabama, and it's quite different. So you can measure social justice through epidemiology by looking at rates and comparing people. One of the lessons is to find the truth, and you find the truth by collecting the right information. Sometimes you don't even want to know the truth, it's so overwhelming.

In October of 1973, we did our first major search for smallpox in India. I was so naïve that I wrote in the instructions, we won't find much smallpox because it's the low point of the season for transmission. But we will find out how to find smallpox. I was absolutely wrong. Six days later the searchers had found 00:15:0010,000 new cases of smallpox that we did not know about. Yet you have to know the truth if you're going to do anything about that. So finding the truth is absolutely important.

Then nothing is done without a coalition. None of us does anything alone. And so you ask the question, what's the difference between coalitions that are really exceptional and ones that are just average? It turns out that [for] the exceptional ones, everyone has agreed to the last mile before they start. You don't just get together because you're the same religious orientation or the same political philosophy. You get together in order to accomplish some last mile. If you've signed on for that, this can be a successful coalition. But it also requires leadership in the coalition willing to give up their ego, that you 00:16:00get your satisfaction from the output of the group rather than getting turf as an individual. It also turns out you need leadership that can do both executive leadership and congressional leadership. That is, sometimes you have to make a decision; sometimes you have to get the opinion of everybody before you make that decision. So those are some of the lessons.

MILLER: What part of that was easy for you, and what part was hard? Was it hard letting go of your own ego and getting to the group, or were the congressional discussions more fun for you or more difficult?

FOEGE: I did not find the mechanics of the coalitions that difficult, because once you got people to agree to smallpox eradication as the goal, then a lot of these other things just fell into place. The science in many ways was easy. If 00:17:00you didn't know the answer to something, you figured out how to get the answer. What always turns out to be hard, and this was not only in smallpox but at CDC, is politics and personnel. Personnel problems can just ruin your day. Political problems can ruin your day, and yet every public health decision is based on a political decision. If I have regrets, and I do, one of them is that I didn't learn how to operate politically early enough. Public health people tend to think if we do the right thing, everyone is going to understand, and they'll support it and they'll fund it. It's not true. You have to learn how to deal with politicians and give them satisfaction in achieving the outcome of a coalition. They are part of the coalition, and we're totally dependent, in public health on appropriations from politicians. So having the political 00:18:00parties involved just turns out to be absolutely crucial.

MILLER: So true. Let's turn now to your role as Director of CDC; this was from 1977 to 1983. You were instrumental in a major reorganization of CDC. Can you tell us a little bit about the motivation for this reorganization and describe the early years of this reorganization and some of the challenges?

FOEGE: The CDC reorganization was based on really two things. We started out at CDC as a communicable disease center, and so infectious diseases were the things we worked on. Public health was gradually enlarging to include chronic diseases, occupational diseases, environmental problems, and injuries, and we had to be 00:19:00ready to move into that area. The second thing is that management consultants that had come to CDC said, this is a great place, but it's still a mom and pop operation. You saw that with every outbreak we had to come up with matrix management, because you had to get the epidemiologists and the laboratorians somehow working together on this outbreak. We always succeeded in doing it, but it wasn't always the most efficient thing.

As we were trying to figure out how to solve that problem and to expand, we went through a series of steps that I'm really quite proud of now. We sent letters to hundreds of people and asked them, what do you think CDC should be doing? What priorities should it have? We then had an outside group that we ended up calling the Red Book Committee, because that was the color of their report. They were 00:20:00outsiders. The only exception was Don Millar, who was on the committee so that there would always be someone on the committee that could tap resources in CDC to answer questions. And these people really did get into their work. It's because of that group that we now talk about premature mortality, because they found that they couldn't actually compare mortality for infants versus for old people; if they're all the same they count as one.

MILLER: This was a scientific group of people.

FOEGE: It was not. It included, for instance, Betty Bumpers, the wife of Senator [Dale] Bumpers from Arkansas. It included some scientific people, but it was a cross section, trying to figure out what CDC should be doing. Because they asked that question, not every death is the same, we came up with the idea of premature mortality.

Then the question was, what [age] do you use as your cutoff? Well, there's an argument that could be made of median age of death. But then you have to change the equation every year, so then people said use 65 as the cutoff, deaths before 65. Other people said, yes, but 75 is closer. But then we stated 65, because most of the world had statistics [based] on under 65 and over 65. So that's how the premature death reports use 65. At any rate, this group came up with 12 priorities that they thought CDC should always be thinking about before appropriations. We then had two retreats at Berry College of the top management at CDC, to go over what this Red Book Committee had said and what other people were saying, to ask what can we agree on.

MILLER: I'm so curious to hear about that, because it was mom and pop and there 00:22:00were people that had very emotional feelings about their turf. How did that work?

FOEGE: Well, when this group met at Berry, we came up with 15 priorities, three more than the Red Book Committee. Our agreement was, we'll go through all 15 of these before appropriations or submission to appropriations, to be sure we've done right by them. Now we asked the question, how should we be organized to do it right? The decision was, we would have different centers, each one with all of the specialties that they needed. So we would have a center for infectious diseases that included statisticians, epidemiologists, and laboratorians. We would do the same for occupational health and environmental health, and this then would mean that if people went out on an outbreak, they didn't have to come up with matrix management. They had the specialties right there in their center.

Now, here's the problem. When we talked about a center for infectious diseases, the laboratorians immediately objected. They did not want epidemiologists heading up that center. They thought they would be marginalized if that happened. So I worried about this. I finally went to a laboratorian who had the respect of people in the lab and the epidemiologists, [Dr. Walter R.] Walt Dowdle. He had worked with the epidemiologists every year on trying to figure out what should be in the flu vaccines, so they knew him well, and he turned me down. I did not like to try to talk people into positions, but I went back to him a second time, and he turned me down. I went back a third time, and he said he would try it. And it turned out to be the solution, because those laboratorians had already put their CVs out on the street. They were looking for 00:24:00positions at universities, because they were not going to remain if an epidemiologist headed up the centers. I knew the first head of the infectious disease center would be the crucial one. After that you could choose anyone, because now you have a group of people that have worked together. That's exactly what happened. Walt made this thing work, and it worked so well it didn't actually matter what the specialty was of the next person.

MILLER: That's a great story.

FOEGE: So CDC got reorganized with relatively little trauma, and I think it was the right organization.

MILLER: Let's turn now to the early years of AIDS at CDC. In 1981 to 1983 you were still director of CDC. So the MMWR [Morbidity and Mortality Weekly Report] on five cases of Pneumocystis carinii pneumonia in homosexual men was published 00:25:00on June 5, 1981. What was the initial thinking about this disease at the highest level of the agency, and what was your response in terms of mobilizing a team?

FOEGE: We were absolutely bewildered by those first cases, and once the MMWR went out, suddenly we found there were many more cases. New York and Los Angeles and Miami and San Francisco all had cases, but they hadn't put this together that this was a new problem until that MMWR article. Yes, we were bewildered, and we were soon overwhelmed. One of the heroes in this story is [Dr.] Paul Wiesner, who immediately put people from the STD program, the Sexually Transmitted Diseases program, on the investigation. So he wasted no time in 00:26:00responding to this.

I think two of the other heroes turned out to be [Dr. James W.] Jim Curran and [Dr.] Harold Jaffe, who headed up the AIDS program. We put this in the front office when we realized how big this was, so that we could be sure to provide as much support as was possible from the front office. These people were exceptional. I look back at the things we did right, and getting the right people turned out to be one of the things. Harold Jaffe is unflappable, and as big as this problem became, he was able to contain his emotions and just keep working scientifically. Jim Curran had the ability to ingratiate himself with groups, for instance, the researchers. He soon learned the language. The clinicians, he already knew the language. He was able to get with the gay 00:27:00community and eventually be trusted. They didn't trust government. And Jim somehow was able to work in the most difficult situations and become believable, and CDC was well served by them.

But then we kept learning new things, every day. The first idea, that this is in gay men, turned out to be true. For all of the work we had done on STDs at CDC, I think most people were taken by surprise on the sex practices of gay men. It took a while for this to be understood, but eventually CDC did understand what were the risk factors in sex between men, and this was published in the MMWR. I was also so proud of the science work that was done, so that by March 4, 1983, less than two years after the first cases had been reported, the MMWR was able 00:28:00to provide an article on prevention of AIDS that is so good you can still use it today, and this was before we knew there was a virus. So this is work we should look back on and understand the power of epidemiology to define something even before the science can define it.

Then we had this odd Kaposi's sarcoma. It was understandable with the first diseases that these were diseases you saw with immune systems that were not working properly. But Kaposi's sarcoma was a cancer that we saw a lot of in Africa, rarely in the United States. What was the basis of this? Well, Jim Curran got a Kaposi group together, people around the world that have worked with this disease. As an aside, let me just mention the first day that they met. 00:29:00I welcomed them, but I used the pronunciation that I had learned in medical school, which was Kaposi's sarcoma. After welcoming them and thanking them for their services and so forth, one of the people said, we should start by getting the pronunciation correct. He said, it's actually Kaposi's. But then he added, but that's not the way Dr. Kaposi pronounced it. He pronounced his own name "Kaposhe," and he said it didn't really matter because that wasn't his name. His name was Cohen, and he changed his name. Now, according to the stories he changed his name so that he would not be seen as Jewish in trying to get into medical school. But Kaposi himself wrote, no, he changed his name because there were already four other Cohens on the faculty. He knew he was going to be great, 00:30:00and he did not want to be misunderstood as being the wrong Cohen.

At any rate, Kaposi's sarcoma was another one of these bewildering things. Fourteen years later we understood it, when a virus was isolated that is responsible for this condition. So now you can see, again, it was an altered immune system.

Then I can tell you one of the darkest moments was when we realized that people with hemophilia were getting AIDS. We had one case, as I recall, from Colorado, where the person had died before being interviewed, so we didn't know whether this person had a problem because of hemophilia or he was gay. But then a second case, I think from Florida as I recall, we had information the person was not gay, and now it was a strong suspicion this came from Factor VIII. Now, Factor 00:31:00VIII is something that you get in the blood by pooling plasma from literally hundreds or even thousands of people. The idea that we might have the virus in that pool, I tell you, was sickening. But we then immediately that day said to ourselves, now we're going to get cases in people who have blood transfusions, and, of course, this was true.

But one more thing. We went to a meeting at Mt. Sinai [Medical Center], and at this meeting we knew that there were people who felt this was not a virus, it was due to drugs that gay people were using as part of the sex experience. So Jim Curran talks about this being a turning point, because when we presented the CDC material both on a case from Los Angeles that had resulted in many cases and 00:32:00you could trace them over space and time, and the hemophilia problem, it was clear this was a virus. Suddenly it changed the whole meeting. Then after this meeting, we had the problem of how do you test the plasma for hemophilia. This is such a heartbreaking decision, because these people cannot live without Factor VIII and now they're going to get AIDS from Factor VIII.

But then the same thing [happened] with transfusions. How do you screen the blood? For blood transfusions our screening was really on the basis [of] if you're in a [high-risk] group. That turned out to be gays or people from Haiti, because they had a higher risk or rate of AIDS at that time. No one was happy with that because it excludes a lot of people who could be giving blood, but we had no alternative. I can remember [Dr. Donald P.] Don Francis from CDC becoming 00:33:00so angry at the blood bank industry because they did not want to really deal with this.

Well, just a few months after we published the article on prevention, we had the first article from France of a virus, and now things started to fit into place. But in early 1984, a virologist from CDC came to me, and he said, "I think the virus isolated by [Dr. Robert C.] Bob Gallo is actually the French virus; I don't think this is a new virus." So what do you do about that? I went to my boss, Ed Brandt, who was Assistant Secretary for Health, and told him about what I had been told. He said, let me check into this, but he said, don't worry about it. If it turns out to be true, science takes care of these sorts of problems. 00:34:00Well, it took a while for science to take care of that, because only months after that Margaret Heckler, the Secretary [Health and Human Services], had a press conference with Bob Gallo and Ed Brandt to announce that they had isolated the virus for AIDS and that they would soon have a test for that virus. In two years, she said, we will have a vaccine. It took some time until the Nobel Prize was awarded to the French scientists, so in that case Ed Brandt was right. Science did eventually take care of this problem.

If I can say a few things about what this meant globally, in Africa this turned out to be an even bigger problem than here. I can remember the absolute discouragement that I felt in Africa as young professionals were dying, doctors 00:35:00were dying, church workers were dying, teachers were dying. They were dying faster than they could be replaced, and it brought out several points of AIDS in Africa. It was a heterosexual rather than homosexual disease in Africa. And in Africa when people were successful enough to be making money, the men ended up with more sexual partners, and as with the U.S. the number of sexual partners did make a difference in this disease. So it was spreading rapidly among the educated and rich in Africa. What to do about that? Well, the African leaders tried to pretend it wasn't happening. They were afraid it would hurt tourism and markets and so forth.

But in the late '80s, 1987, [Dr.] Seth Berkley, who had been an EIS officer at 00:36:00CDC, was now working in Uganda for the Task Force for Child Survival. He was there on Rockefeller [Foundation] money to do child survival work. He sent me a letter saying he had just evaluated what was happening in a prenatal clinic. He was seeing a rapid increase in HIV [human immunodeficiency virus] positivity in young pregnant women. He asked, is it possible for me to switch and work on this problem rather than child survival? We got the agreement of Rockefeller, and he did.

A year later, which would be 1988, President [Jimmy] Carter was going to make a visit to Uganda. The President of Uganda, President [Yoweri Kaguta] Museveni, had many people brief him before Carter's visit. He was a man who liked to get his facts correct. Seth Berkley briefed him on a number of things, but included 00:37:00the histogram or the graph on what was happening to HIV positivity rates in prenatal clinics. Museveni was actually shocked, because you could see this increasing month by month. His remark to Seth Berkley was, if I know this, everyone should know it, and he started spreading the story and actually published that graph. This was the beginning of leaders in Africa acknowledging the problems that they were having.

If I can skip forward to another episode that involved CDC people, the Merck Drug Company had from the '80s been giving Mectizan for river blindness in Africa and in Central America, and they had given this free. At the Task Force for Child Survival we were running a program to distribute Mectizan. Merck 00:38:00became so pleased with their Mectizan program that they called a small group of us, including myself and Jim Curran, and said, we're so pleased with this, is there something similar we could do for AIDS? Our suggestion was, don't just send one more person to Africa to study this and publish a paper and Africa doesn't benefit. Try to figure out what would it take to actually control AIDS in Africa under current conditions, so you don't have to wait for development.

Well, it was in maybe November of 1999 that [Raymond] Gilmartin, who is now the CEO of Merck, called us back and showed us a plan that a man by the name of Guy Macdonald had put together on what could be done about AIDS in Africa. We became 00:39:00very excited about it, and in January of 2000, we had a meeting in Seattle of six foundations. Everything looked so bleak in Africa with AIDS [that] the question of the meeting [was], is there any light at the end of the tunnel? What should we be suggesting to our funders? We met for two days. But before the meeting I told the group that I was inviting Guy Macdonald from Merck to present on his plan for Africa. The people were aghast. They said, we don't need someone from a company that makes a profit telling us what to do about AIDS; they're going to try to promote some product of theirs. We actually discussed this for two or three hours and they said, absolutely not. Well, I knew he was already on the plane heading for Seattle, and finally after three hours one person said, I'm going to remove my objections as a favor to Bill Foege. He must have some 00:40:00reason why he's promoting this. The next day Guy Macdonald reported on his plan, and it was the hit of the meeting. It gave some hope. People became very excited. We came up with six ideas, and everyone was to go back to their foundation to promote these ideas.

I was to present these to Bill Gates, and so a few days later we went to Bill Gates's office at Microsoft. It could not have started worse, because as we entered the meeting, he began chewing us out about a grant proposal that we had sent. He said, I've told you before I never want to see a proposal like this. It's a bottomless pit. He said, if I fund it today, I have to fund it next year. As he went through the list of things he never wanted to see again, I realized 00:41:00these were exactly the things I was about to propose. So I tried to think of some other reason for being there but couldn't, and I decided I have to go ahead with the proposal. So I told him about the meeting. We came up with six ideas. I wanted him to at least hear them. As I went through the first five, he stopped me and said, wait a minute, how much money are you talking about? I said, well, from the Gates Foundation I was hoping for 50 million a year for 10 years. Now, that's a half a billion dollars. That's not a small ask, and he said, oh, it's going to take more than that. And all of a sudden I had the ability to go to number six, orphans in Africa. I presented our ideas on orphans, and he said, you can't worry about AIDS in Africa without worrying about those orphans. In 20 00:42:00minutes he told us to do all six things.

On the way back from the meeting I rode with his father, just the two of us, and I asked his father, can you explain to me what just happened? And he said, my son knows business. He wants a return on his investment. He doesn't want to put money down the drain. But when faced with the human condition, he'll try to make the right decision.

Now, I think that's the best story that I have out of the Gates Foundation. What it led to is we did try those six things, but we also hired [Dr.] Helene Gayle from CDC. I told her she could give up her billion-dollar budget and hundreds of employees and have one employee and no budget at all, but she could influence the person who could make the biggest difference. So she came to the Gates Foundation.

One of the first things we did was a project in Botswana where Merck put in $50 00:43:00million, and the Gates Foundation put in $50 million. I tell you in that first visit to Botswana 35% of people were HIV positive and 45% of newborns were HIV positive. It was the most dreary, dreary look at things. I went on rounds at a hospital in north Botswana where no one ever mentioned the word AIDS, and yet you know every patient we were seeing had AIDS. But they called it cancer, they called it malnutrition, they called it all kinds of things, tuberculosis--and often it was tuberculosis. We finished. We went to a room, and I asked the head of the medical department, how in the world can you come in here every day, what do you do for your mental health? He stared at me for so long that I worried 00:44:00about what I had asked. And then suddenly tears started rolling down his face, and he said, I've never told anyone this before, but he said I was born one of four sons; my three brothers have died of AIDS. I don't have a choice. Four years later we went back to Botswana, and the rate of HIV in newborns had dropped from 45% to 4%. I mean, this was a combination of Merck and a foundation and a government and Harvard University, all with a coalition that actually worked.

MILLER: And also a result of some of your authority and power of persuasion. Can you talk a little bit more about coming to people, to leaders, and having an 00:45:00idea, wanting to persuade them. What goes through your mind? How do you make things happen like that? Do you listen a lot?

FOEGE: There's a book by Gary Wills called Certain Trumpets, and the title of the book comes from a Bible verse that says, if you hear an uncertain trumpet, would you gird for battle? Gary Wills shows that there are all kinds of leaderships. Oftentimes people think if you're a leader, you're a leader, and he said, no, that isn't true. There are all kinds of leadership. He gives examples of different kinds and people that exemplify that and then people that didn't. He uses only two living people in his examples. One is Andrew Young, and not because of being the U.N. Ambassador, but how he could bridge the black-white 00:46:00community in the early days of civil rights. The other person he uses is Ross Perot, who he said was a good business leader but not a good political leader. These are different things. But the basic point is, if you want leadership, you have to know some endgame that you actually want, and you explain it to other people who want it also. Then they become followers, and suddenly, he says, you're the leader. So Gary Wills talks about the different kinds of leadership and how they're not all the same. But the point they have in common is, someone defines an outcome that they want and then they talk other people into wanting that same outcome. Once that happens you've got followers, and if you have 00:47:00followers, it makes you the leader. So he said that's what leadership is about: defining that last mile and then being able to picture it so other people can see it and they want it also.

So with smallpox eradication it was easy to define the last mile. It was harder to get people to believe that that was possible. I mean we'd had the vaccine since 1796, and smallpox continued on. In India they had countless smallpox eradication efforts and still the disease existed. Each time that they looked at this, they would set a goal of getting 80% of people vaccinated. Every time when they would evaluate afterwards, they found that people had used vaccine that should have covered 80% of people, but they had taken easy populations and given them two and three and four vaccinations, so the real coverage was about 50%. So 00:48:00in the '70s they had their last evaluation, including people from CDC, WHO, from around the world, and again they said, it's not working. Their conclusion was [that] you must raise the 80% to 100%. That makes no logic whatsoever. If you can't make 80%, you're not going to make 100%. So that's why it required coming up with an endgame where it was not 80% or 100% coverage, it was zero virus. Now you could concentrate on the virus rather than on mass vaccination.

MILLER: What about your personal style? Can you talk a little bit about that? I'm going off the grid here, but it's been so successful. I'm wondering if you can speak a little bit about just the art of persuasion or discussions, 00:49:00certainly in international settings but in the U.S. settings as well. Can you point to any things that have worked well that you've done?

FOEGE: I'm not sure that I have a personal style. If I do, I don't know what it is. I do know that I enjoy learning things and that I learn many of these things from people telling me, and so I enjoy talking to people. Even today if I get into a taxi, I enjoy finding out who this person is that's driving the car: where are they from and why are they here and are they enjoying it here. You wouldn't believe how often--in fact, I would say almost always I can come up with someone that we know in common. One of the most interesting ones was in 00:50:00Washington, D.C., when the driver was from Nigeria. I try to guess before I ask them where they're from, and sometimes I actually can hit the actual town, but this person was from Enugu, Nigeria. So I told him that I had lived there once, and he wanted to know where. I described the Abakaliki Road and the soccer field, and he knew where the fire station was and he understood which flat I lived in. He pulled the car over to the side of the road, he was so excited, and he turned around and he said, I used to steal mangos from your yard. So I enjoy finding out about people, and I think that this helps in negotiation.

Another example: if you have worked in smallpox eradication and you run into anyone in the world that worked in smallpox eradication, you immediately have a rapport. After I returned to CDC, I went to India once as the American chair for a science delegation. The Indian chair was Dr. Ramalingaswami, whom I'd known for years. USAID [United States Agency for International Development] asked me if I would stay for a week after the meeting, because they had a problem with a program they were trying to get approved by India. So after the meeting, I went into USAID, they showed me what the program was and who had it at the ministry of health, and I went over to see the person. We immediately recognized each other from the smallpox days, and so we talked for 45 minutes about our experiences in smallpox. Then he asked what I was there for, and I told him 00:52:00about this USAID program. Yes, he had it on his shelf and he just had held it for months, but he signed it right there. I went back to USAID three hours after I'd left them, with a signed document. See, there was nothing special about that. It was that he and I had shared an experience and part of a coalition. The thing that holds a coalition together is trust, and we already had a trust relationship. I didn't even have to talk about the document they wanted signed. He was willing to sign it because he trusted me. So I think it comes down to personal relationships.

MILLER: How about one or two aspects of the political side, going back to AIDS. 00:53:00During those first years there was dramatic increase in cases and very high mortality rate, as you mentioned. Can you tell us about some of your efforts to draw the federal government's attention to this disease and to get funding to address it?

FOEGE: There's often a question of the political environment at the beginning of AIDS, and there's no question that it was pretty negative, that there were difficulties with the White House even wanting to talk about AIDS. They didn't want to talk about it, but they got to a point where everything we put out from CDC had to be approved by the White House. But I find myself not wanting to blame politics for any of the things we did wrong in AIDS, because I think that we did a lot of things right. We did some things wrong, and we had some favorable people in the administration. Ed Brandt was the Assistant Secretary 00:54:00for Health. He had a medical degree and he had a Ph.D. in biostatistics, and so you didn't ever try to fool him on statistics. He had a theology degree, and he was a person trying to do the right thing, and so we could rely on him to convey the science of AIDS. Then we had Dr. [C. Everett] Koop, who came in with the religious community believing he would always support them. But he was a scientist and he listened to the facts, and he became one of the strongest supporters of AIDS in the Reagan Administration. So it's not as if it was a total wasteland that we couldn't penetrate. There were good people trying to do it. So if there were problems, I think that we have to take responsibility for them.

This is something I learned from [William C.] Bill Watson, who was Deputy Director of CDC. I used to become so upset about political decisions that hurt public health. One day he said to me, well, it's probably your fault. I said, what do you mean? He said, if you had anticipated the information they needed before making that decision, they wouldn't have made that decision. So I got to a second step in my evolution: we've got to try to incorporate politicians, let them feel some of the successes, give them the information. But I can tell you that is so labor intensive, because politicians keep turning over. So then I went to the third step, which is trying to talk public health people into going into politics. I continue to do that all the time, because if we have public health people in politics, you don't have to do this kind of training. They understand immediately what the implications are. So, yes, there were political problems.

Now, I think the PEPFAR [President's Emergency Plan For AIDS Relief] program is where politics came and benefited us. I think this is a lasting legacy of George W. Bush: the PEPFAR program and what this has done. I have several problems with it. One, we all believed that treatment was going to lead to better prevention. Instead what it did, it led to better treatment, but we still didn't use that for prevention. The other thing, I resented how the religious community was able to use the idea of abstinence, the delay of sex, but no condoms. This message really became very important. I was in Seattle when the head of PEPFAR came to give a talk and I went to listen. I was very taken by his grasp of management 00:57:00and understanding of the problem, but he was very strict on abstinence, no premarital sex or extramarital sex and no condoms. There was no give on his part. Then it took me by surprise when he stepped down, and I realized only days later he stepped down because his name was on the Madam's list in Washington, D.C. So this idea of abstinence and no extramarital sex he wasn't listening to at all, and I hope he didn't listen to the third message of no condoms.

MILLER: I remember that well. Going back and pushing just a little bit more on the climate in Washington in the early '80s, I think there was a huge outcry 00:58:00from the marginalized populations, mostly gay men at that time, but certainly drug users were marginalized. Some claim that because of this thousands, perhaps ten thousands of lives were lost. Can you say a little bit more about specific meetings you might have been at or conversations you were a part of? I recently just watched a program on the history of Ronald Reagan's presidency, two programs that were fascinating. Can you say any more about that? It was a time of great change in the country, so what was your take at that time?

FOEGE: It's interesting how we forget the details. Recently when Nancy Reagan died, Hillary Clinton talked about how she was such a supporter of work in AIDS. 00:59:00That was totally untrue, but that's the way she remembered her or she wouldn't have said it. But in those early months of the Reagan administration, I went to the World Health Assembly as the U.S. delegate. Koop had already been nominated but not approved, so he was there but could not go in an official capacity. He was there to learn. One of the big issues was infant formula. Infant formula was a problem because it was being promoted by the infant formula companies in developing areas, and when mothers used this, they often used contaminated water. So these children were getting sick because of the infant formula, while if they had been breastfed for the first six months, they would have been protected during that period of time. The World Health Assembly was voting on 01:00:00whether the infant formula manufacturers should be able to promote this in hospitals in the developing world or not. The vote was going to be very lopsided against the manufacturers, except the U.S. sent word that we had to vote for the manufacturers. I objected and said we could at least abstain. We're going to be the only country voting in favor of giving infant formula to children in developing countries. And the White House ruled that the U.S. had to vote against the resolution. That just made us look bad--look bad scientifically, politically, and in every way. So that was the atmosphere early on.

I think part of what changed it, though, was having Koop not only approved but 01:01:00being able to become his own person. When he came to Atlanta, he and I talked, just the two of us. Koop told me later this was the meeting he dreaded the most on becoming Surgeon General: coming to CDC, because the religious right had been accusing CDC of doing abortions, and Koop was assigned the job of getting us to stop. So he came to my office, the two of us went in, we closed the door, we sat down, and I said, Dr. Koop, no matter what we talk about, we will both wonder when will abortion come up. Why don't we talk about that first and get it out of the way. I explained what we did on surveillance, of what's the morbidity and the mortality from legal and illegal abortions, and that CDC isn't involved in 01:02:00[performing] abortions at all. When I finished, he said, if you weren't doing that, I would have to start it because we need to know what the risk is. He said, how could I help you? And I said, every time we put out a report I get hate mail. I said, would you be willing to look at the reports in draft form and let us know if something is scientifically incorrect or if we're using a word that's a flag. And he agreed to do that, and the word went out that he was doing that, and the hate mail stopped. See, that's how reasonable he was.

So there were times when they could change things, but in truth, the environment was very difficult. It became, for me, the most difficult when it came to Reye syndrome, where we had now three studies that all showed aspirin given to 01:03:00children with flu can lead to Reye syndrome. But none of the studies individually came up to statistical significance. What do you do with that? Well, we didn't know in those days how to aggregate studies. So we went to the Academy of Pediatrics and others, and we all agreed that we don't know exactly how to approach this, but everyone should know what we know. So we decided to put this out. The aspirin manufacturers were so clever in the way they attacked everything. They would call me at home and say, it'll be a shame if you ruin CDC's scientific reputation by putting something out that has not reached statistical significance. Now, why they would do this I don't understand. It can't help them in the long run if it's true, but they even called me at my 01:04:00parent's place at Christmas time. At any rate, we reached a day when we were going to put it in the MMWR with the FDA [Food and Drug Administration]. The night before, the FDA called me, and they said the aspirin manufacturers have brought in new information, and we're going to have to examine it before we sign on. So everyone thought we would delay publishing it. I went to CDC the next morning and did not tell anyone about the phone call. The MMWR went out, and it took everybody by surprise. The aspirin manufacturers went to Ed Brandt, and he supported us. The aspirin manufacturers then went to Richard Schweiker, the Secretary of HHS [Health and Human Services], and he supported us. They then went to the Reagan White House, and we were told to cease and desist and say nothing more about this and to start a new study. And I said, okay, because the 01:05:00word was already out. You can't stop it. So we started a new study. Walt Dowdle was in charge of keeping track of the figures as they came in. He stopped the study in the preliminary phases because it was so clear that this was true. But once again, that was the Reagan White House trying to control public health.

So public health needs the politicians, but public health has to be very clear about not caving in to politicians. I'm so happy about so many things we did with the science. I'm less happy and I feel concerned that we did not always stand up to the politicians or to the religious community. I mean this idea of not using condoms, we should not have been willing to even listen to them on that.

MILLER: A couple of thoughts just as we're getting towards the end.

FOEGE: You mean the end of the interview? I just wanted to be sure you didn't have information I didn't.

MILLER: What are your insights now about how CDC approached the AIDS epidemic? What did we do best, and what could we have done better?

FOEGE: Science was the best. I look at every step of that, and I come back thinking how fortunate we were to get the right people working on the science. What could we have done better? You know, we didn't understand the kind of backlash we would get from the gay community. We didn't understand the problems 01:07:00we would have between the gay community and the black community when it came to AIDS. I'm reminded over and over that when you tangle with culture, culture always wins. It was AIDS that finally changed the EIS applicants to include anthropologists and everyone else, sociologists and so forth, rather than sticking to MDs, veterinarians, and statisticians. We needed this sort of insight into culture, but we weren't forced to get it until AIDS. AIDS forced us into it.

MILLER: Certainly very true in Africa. Just as the global eradication of smallpox was a watershed moment for public health globally, in many ways the AIDS epidemic has been the turning point for public health globally and for CDC 01:08:00as well. Can you comment on the historical significance of the AIDS epidemic on CDC? You've already mentioned several things in terms of getting more social scientists at CDC, but any more on the significance of the AIDS epidemic on global public health?

FOEGE: I think the AIDS epidemic took everyone by such complete surprise, not only by the size of the outbreak, not only by the speed of the spread and not only by the length of the incubation period. Everything about it was different than we had expected from our past experience. It's been sobering that our science has not been good enough to develop a vaccine, but it's also been a watershed in other ways.

I think it was so difficult to get other countries to develop EIS programs. 01:09:00Canada was the first one, then Thailand with [Dr.] David Brandling-Bennett, and now what do we have, 80 countries that have EIS programs. I think AIDS has speeded that up. I think it has changed our mindset on we're all in this together. Even with smallpox, while we use those words, I don't think Americans felt vulnerable to smallpox, certainly not to guinea worm, certainly not to river blindness and so on. But AIDS, we understood it when we said, we're all in this together. The problems were somewhat different.

I think it's also made us more conscious, as I mentioned, of some of the cultural things. I think the basic bottom-line problem with AIDS in Africa is that women have no power. If you look at what happens in Africa, you think they 01:10:00do, because you see them doing the marketing, you see them doing the agricultural work, providing for children, getting them off to school. That tells us who does the work. It doesn't tell us who has the power. And women have an absence of power. They cannot even control their sex lives, and now we know that. I think it changes how we feel about what does development mean in Africa.

Then this whole idea of going into treatment for the poorest people in the world, and that's what PEPFAR allowed us to do. Before that we always assumed, oh, these countries are too poor to do treatment, but we'll try to do prevention. So it's changed the playing field a little bit in terms of 01:11:00treatment. We still have a long ways to go on that.

I think it's changed the world in terms of how we bring coalitions together. I'll give you one example. When the Rockefeller Foundation decided the answer to AIDS was a vaccine, they started something called IAVI [International AIDS Vaccine Initiative], which was a vaccine initiative and they made Seth Berkley the head of that. They put $10 million into it. Then the Gates Foundation put $100 million into IAVI, and at first Rockefeller was concerned that they're outbidding us. I kept saying to Rockefeller, no, they're following you. You have such credibility that if you've decided to do this, they've decided they want to support it. Then people worried about, well, if Gates puts in that much money, 01:12:00other money will dry up, and we won't have government money going to NIH [National Institutes of Health] for AIDS vaccine.

So someone at NIH always told me that you can tell this story, but I will deny it. He said they had a meeting at NIH when Gates gave that hundred million. The meeting said, we can't really afford to have an outside group come up with the vaccine; what does NIH have to do to be the one to develop the vaccine? They came up with a new plan calling for more resources and more people, and this increased the amount of research everyone was doing. We're going to break that conundrum at some point and come up with a vaccine. I absolutely believe this. But it shows how difficult is the science. So AIDS has changed the kind of research that we do and how we're working together and outside forces getting 01:13:00into research, and it's certainly changed public health in Africa. I mean, the fact that it's bouncing back now able to do things that it couldn't do before. I really thought we'd lost a lot in the early 2000s when people were dying so fast.

MILLER: Coalitions are kind of messy. It sounds like you're okay with messy. Are you? Or can you comment at all about that?

FOEGE: First of all, non-coalitions are pretty messy. I mean even CDC. WHO is pretty messy and UNICEF [United Nations International Children's Emergency Fund], and one of my conclusions from the Task Force for Child Survival is, we need those groups. If we didn't have WHO, we would have to develop WHO. But it's 01:14:00not good enough by itself, and when you have a Task Force that follows different rules, they're able to make WHO even stronger.

The original Task Force was looking at immunization. WHO had a program of immunization, and they now had achieved 15% or so coverage of children. They weren't satisfied with it. [Dr.] Rafe Henderson, formerly of CDC, was head of the program, and I tell you, this man was working his heart out, and he was not satisfied with how slow it was going. UNICEF was not satisfied. It was the head of UNICEF, Jim Grant, and the head of WHO, [Dr.] Halfdan Mahler, who came to me separately and said, we each have such a big ego that we sometimes have trouble getting along. You can imagine what it's like for our organizations. We both go 01:15:00into a country saying we want immunization, and then we fight with each other for turf. What we need is someone that can bring us together.

So they said they would like a Task Force, but with certain rules. They said, you will never try to get a bigger silhouette than we have, and you will never use the word coordinate because no one in our organizations will agree to be coordinated. So we used the word facilitate. But here's the point. Immunization went from 20% to 80% in six years, and it showed what could happen when you took these big organizations, UNICEF and WHO, and had a way of facilitating what they were doing with UNDP [United Nations Development Program] and the World Bank and with the Rockefeller Foundation, with Ministries of Health. So these coalitions turn out to be important in order to grease the wheels, to get the organizations 01:16:00to do what they can't do alone, because the organizations have rules.

As an example, March 1988, we had a meeting in Taillebois, France, on polio, and the people at the meeting included UNICEF and WHO and so forth. We came to the conclusion that polio eradication should be pursued, but if we came out with a proclamation from that meeting, each of those organizations would have to approve it, which would take months. So instead, the Task Force put out that statement and the world assumed the organizations had approved it, because they were the ones that were sponsoring the Task Force. Two months later the Ministers of Health of the countries that had met went to the World Health Assembly and passed a resolution for polio eradication. That could not have 01:17:00happened without the Task Force and Rotary [International] and others from the outside making it happen.

Inside there were reasons why WHO wanted this. Dr. [Hiroshi] Nakajima had just been approved as the new director, and everyone knew he was not actually interested in health and so he would not pursue polio. Even though Halfdan Mahler was afraid WHO was not ready for polio eradication, Rafe Henderson was afraid of the same thing. They both agreed to this, because they said it has to be fixed before Nakajima comes onboard. So you see, they had their problems internally. An outside group pushed it, made it happen. So coalitions are messy, and sometimes they provide an avenue that the organizations can't find themselves.

MILLER: Finally, in other presentations you've talked about the politicization of public health. Can you comment on that with respect to the AIDS epidemic in the U.S. and globally? We've touched on that.

FOEGE: We can see originally how the politics impeded the science, and then the interesting thing was, things turned around and the politics helped the science with PEPFAR. Who would have ever believed [Senator] Jesse Helms was going to vote in favor of funds for AIDS globally? Jesse Helms was such an opponent of all of that. Now, it's unclear to me why he changed, although one of his staff members said he was a very religious person, and he saw how old he was. He 01:19:00believed he was going to see Jesus, and he wanted to change his image before that happened. I thought to myself, you know, maybe I don't even care why he changed; it's helping everybody. I can't judge whether he's going to see Jesus or not. I'm going to stay out of that. But you see how the politics that ended up helping.

Over and over politics has helped. I remember once when someone from Dale Bumpers' office called and said, here's the problem with CDC being in Atlanta. If you were in Washington and you could have a letter here tomorrow morning with your signature, saying you need $6 million for polio, we could get it for you tomorrow morning, but being in Atlanta we can't. I said, don't be so sure. And 01:20:00the next morning they had that letter. You see how politics then helped us with the immunization program. To me it's never been a problem that we're 600 miles away from the politicians. This [distance] has always been an asset. Yet we need the politicians, and we have to figure out how to make them part of the coalition so that they get rewarded when that last mile is achieved.

You know, it was politics that actually gave us our public immunization system in this country. It was April 1955 when [Dr. Thomas] Tommy Francis announced that the polio vaccine worked at the University of Michigan. The secretary of HEW [Department of Health, Education and Welfare], Mrs.[Oveta Culp] Hobby from Texas, had come to Washington saying she will have no part of socialized medicine, she was going to do everything she could to stop it. Now, a vaccine 01:21:00works, and the public was absolutely ecstatic. The question was, okay, what's the government going to do? And she was inundated suddenly with questions on this, and [Dwight D.] Eisenhower said to her, you're going to have a program for polio vaccine. So she had a press conference, and she announced that she was going to seek an appropriation to buy vaccine for poor children. And you know what happened? A senator--it's all politics--Lister Hill then had a press conference, and in essence what he said is, over my dead body. No American child will ever have to declare themselves poor in order to be protected. I will seek an appropriation to cover all American children. And that was the beginning of the Public Vaccine Act in this country. Look what it's led to, because it said 01:22:00in that one statement that this vaccine is not just for personal protection, it's for the protection of the entire public. And we've maintained that to the present time. Ten years later Lyndon Johnson used the same argument for why the U.S. got into the smallpox program, when we didn't have any smallpox here. We're all in this together.

MILLER: Thank you so much, Dr. Foege.

FOEGE: No, thank you.

MILLER: I really appreciate it.

1