William "Bill" Foege



CRAWFORD: Today is Monday, September 25, 2017. My name is Hana Crawford, and I am the oral historian for the GPEI [Global Polio Eradication Initiative] History Project. I'm at the [United States] Centers for Disease Control and Prevention [CDC] in Atlanta, Georgia, with Dr. [William H.] Bill Foege [MD]. Thank you for being here. We are going to talk about intersections of your career and experience with polio eradication.

FOEGE: Thank you. I've had the chance to watch the entire polio program, from the pre-vaccine era until the point now where we're almost at eradication. I think the pre-vaccine era is something that most people will no longer relate to because they only know this by history.

We did not really have polio outbreaks until the late 1800s, when they started in Scandinavia and then Europe and then in the United States. People attribute this to the fact that with poor sanitation, a lot of children were exposed to polioviruses in their first year of life, when they were still protected by maternal antibody. Then, as sanitation improved, there was a delay in exposure to poliovirus, and so they no longer had the protection of maternal antibody. It became known as "infantile paralysis," although some people weren't exposed until they were adults, like FDR [United States President Franklin D. Roosevelt]. In the '40s and '50s, outbreaks became more and more significant in the United States. I recall this so vividly, the fear that people had every summer. While they closed swimming pools and movie theaters and so forth, they didn't really know why they were doing this because no one knew how the virus was spreading.

It was a great day in 1949. I was only thirteen years old. A person, who would turn out to be one of my mentors, working in the lab as a virologist, [Thomas H. "Tom" Weller, MD], was able to grow poliovirus for the first time. He wasn't trying to grow poliovirus; he was trying to grow chickenpox virus. He had come up with a new medium to try to grow this in, and he filled many vessels with different strains of chickenpox. He had three left over, and on the spur of the moment, instead of discarding them, he put poliovirus into those last three. Over the next weeks, he was surprised that chickenpox did not grow, but polio did grow.

CRAWFORD: Did he choose polio? Was that his plan?

FOEGE: No. There was no plan, and he was frank to say this in later years, that he was just a very fortunate person at the right place at the right time. Once they were able to grow it, then that set the stage for Salk [Jonas E. Salk, MD] and Sabin [Albert B. Sabin, MD] to grow large enough batches to try for a vaccine. Weller and his two coworkers then got the Nobel Prize. I didn't know him until years later. I was working for CDC as an EIS [Epidemic Intelligence Service] officer when I read an article. It was his commencement address to the Harvard Medical School. It was called "Questions of Priority," and the basis of this was, "You now have some of the best training in the world. How are you going to use those skills? Will you use them in the places where people really need them?" I liked this so much I applied to spend a year with him. I was so dumb I didn't know that he was a Nobel Laureate. And I did spend a year with him.

Within about four years--that was 1949--within four years, Salk had already developed a killed-virus vaccine. He took the virus, and he was able to inactivate it. He then made a vaccine that, when injected, produced antibodies. Salk did not want to do a field trial. He said he was so confident that his vaccine would work that it would be immoral to have a placebo group.

He had a mentor by the name of Tommy Francis [Thomas "Tommy" Francis, Jr., MD]. Tommy Francis was a virologist, the first person to ever isolate flu virus. He said to Salk, "That's not the way science works; you have to do a field trial." Tommy Francis went ahead and did the field trial, an incredible field trial. In two years' time, he employed hundreds of thousands of volunteers [and vaccinated] 1.8 million children, all before computers. He did this at the University of Michigan [School of Public Health]. I am told that there were file cabinets up and down the halls with these 1.8 million records. In less than two years, he had an answer.

Why did he need such a big study? Because when polio goes around, it infects a lot of people, but very few of them get paralysis. Some people say maybe only one in a thousand actually gets paralysis. You need a big trial to show a difference in paralytic rates: 1.8 million children.

Then on April 12, 1955, he [Salk] had a press conference at the University of Michigan. He had famous journalists there like [Ferdinand W.] Fred Friendly and Edward R. Murrow. He came out, and in [three] words he summarized what he was about to present: safe, something, and effective--oh, "safe, potent, and effective." With those [three] words, the journalists started jumping out of their seats trying to get to a phone. This was all before cell phones. It included Edward R. Murrow, and he, that night, took Salk to dinner. He said, "Young man, today you have lost your anonymity." Then he gave Salk a watch that Salk wore for the rest of his life, and he used to show it proudly--that he got this from Edward R. Murrow.

This was a high point, of course, scientifically. "Safe, potent and effective," those are the [three] words. The high point scientifically was that day. No one knew that there was going to be a higher point within a couple of weeks. The day after the announcement, people were so overjoyed, but then they started asking, "What's the government going to do about it?"

The Secretary of HEW [Department of Health, Education, and Welfare] was Oveta [C.] Hobby from Texas. She had come to Washington saying she would not do anything that assisted socialized medicine. She had no plan at all for the government to do anything. President [Dwight D.] Eisenhower told her to come up with a plan fast. She had a press conference and announced that she would seek an appropriation to buy polio vaccine for poor children. That sounded very good, except Senator [Joseph "J."] Lister Hill then had a press conference and said, "No American child should have to declare themselves poor in order to be protected. I will seek an appropriation for all children." That's what he did. Months later, it passed in the Senate.

This became the beginning of our immunization program as we have it today, that the Federal Government actually buys the vaccines for all children in this country. It was really quite a day because that day the vaccination status went from protecting individuals to protecting individuals and society. There was now a social contract implied in being covered by this vaccine.

As an aside, [United States President] Lyndon [B.] Johnson used the same reasoning ten years later to approve funding for the smallpox eradication program in the world: that no one should have to declare themselves poor; that we were going to get rid of this in the entire world.

CRAWFORD: Were there any objections to that approach?

FOEGE: There were many objections to the approach because some people did see this as socialized medicine, and it is. It's effective, and it's worked all of these years. It's one area of our medical practice where we actually have a single-payer system, and it works. People forget that.

I might say as an aside here that we also have a single-payer system for the military. People do not think about that, and yet the military is able--see, the people that are opposed to a single-payer system see it is as socialism and that the marketplace should be in charge. With the military, we have a single-payer system, and then they use the marketplace to provide everything they need. There's no reason we couldn't do the same thing in medicine.

In 1955, now we have a vaccine. Salk was so happy that we had a field trial because just weeks later, we suddenly had what's been called "the Cutter Incident," where children who had received the vaccine came down with polio. This began the reputation of the EIS in this country because [Alexander D.] Alex Langmuir [MD, MPH], who had started the EIS five years earlier, overnight, developed a polio surveillance system. [It was] only the second national surveillance [system] that we had for any disease in this country, the first being malaria in 1950 and now polio in 1955.

CRAWFORD: Can you describe that surveillance system?

FOEGE: The surveillance system consisted of every child with polio who had received polio vaccine being individually worked up by an EIS officer. These EIS officers were sent out, and they would do histories and physicals. They would find out when did the child get the vaccine, and they would trace the lot number and the maker. They very quickly were able to show this was due to the Cutter Laboratories in California. Three other manufacturers did not have this problem. If there had not been a field trial, I think you would have had to stop the entire program. You couldn't continue it with the other three manufacturers.

The surveillance system then made the reputation of the EIS program. But Langmuir went a step further: he predicted what the epidemic curve would look like based on how many doses of the vaccine had been given. Then he predicted what the secondary epidemic curve would look like, of people who got polio from those people. He was so close on both counts [that] it turned out to be an important part of the history of CDC, establishing themselves as being able to predict what might happen.

This was all in 1955. Within six years, Albert Sabin had developed his own vaccine. It was an oral vaccine, so you gave it on a sugar cube. The difference between the two vaccines is that the Salk vaccine produces antibodies. A new person will get the disease in their intestine, but the antibodies prevent that virus from going to the nervous system and causing paralysis. With Sabin's vaccine, the immunity was in the intestine itself, so you could not even have the infection. The Sabin vaccine by '61-'62 became widely used in this country.

I started the EIS [training] in July of 1962. I recall vividly just before we were sent to our assignments at the end of that month that Alex Langmuir called everybody in to brief them on where we were with polio. With the Sabin vaccine, he had news that bothered him. He said some people getting the Sabin vaccine have a reversion of the vaccine strain to wild polio, and they get polio. At the time, they didn't know what the risk was, but they were estimating about one case of paralytic polio per million or two million doses of vaccine. So [it was] a low risk, but it was there. We went off then to our assignments. Mine was in Colorado, and in Colorado, we started having "Sabin Oral Sundays"--"SOS Sundays"--where we would give Sabin vaccine on sugar cubes.

CRAWFORD: Who received that vaccine?

FOEGE: Children, but anyone could receive it. The vaccine was aimed at protecting children because they were the ones at highest risk. Yes, there were a few adults still getting polio, but it was [mainly] children. The theory was if you stopped the transmission of the poliovirus, you protect the adults also.

CRAWFORD: Do you recall where the children were from? Were they all drawn from certain geographic areas? Were they targeted socioeconomically?

FOEGE: Every state had their own program, but in Denver, we had so many sites on Sundays where you could get the Sabin vaccine that people were coming from everyplace. You had them so spread out that people did not have to travel far in order to get them.

An interesting thing happened: I was asked to present to their medical society, and they thought the risk of paralysis [with the Sabin vaccine] was so low it should not even be mentioned. I was arguing that it may be low, but they have to--parents have to know everything we know. We cannot have secrets because the first time you have a paralytic case in someone who got the vaccine, how do you answer that? But if they know in advance that there's a small risk, then you've already answered it.

I was getting no place in my talk to the medical society until a man by the name of Gordon Meiklejohn [MD], head of Internal Medicine at the University of Colorado Medical School, stood up. He just said, "He's right; we have to be transparent." He had such a good reputation in Colorado [that] there was no more argument, and that was part, then, of what happened. CRAWFORD: Did you know him?

FOEGE: I did not know him at that time. I certainly did appreciate him, but I got to know him quite well after that.

CRAWFORD: Could you talk about him a little bit?

FOEGE: Gordon Meiklejohn was an interesting, laid-back, quiet man who had such depth that when people got to know him, they absolutely trusted him. He was one of these people that did not stay in his office. He was not an ivory tower sort of academic. In fact, later on in the 1970s when I worked in India for smallpox eradication, Gordon Meiklejohn came as a volunteer for three months. Then he went as a volunteer to the smallpox program in Geneva [Switzerland]. He was very much involved in the fieldwork, not just teaching in an academic setting.

Now we're up to the early '60s and the Sabin vaccine. During the Salk years, polio decreased dramatically in this country. It was amazing, but then people switched over to oral vaccine because the advantage was seen as this intestinal immunity and stopping the spread of the virus, as well as stopping the paralysis. We later learned this is not all quite as simple as that, and I'll get to that in a moment. But people went then to using oral vaccine in this country.

This was the late '60s. We had our last outbreak of polio in this country in 1979 in an Amish community in Pennsylvania. It spread to other states [Iowa, Wisconsin, Missouri], but it always stayed in the Amish community. That showed that the immunization program had actually provided very good public prevention because it [polio] did not get out of the Amish community.

An interesting thing----CDC, at that time, for the first time was able to fingerprint that virus. They were able to show that it was the same virus that went to the other states. It was not two outbreaks or three outbreaks that you couldn't tell the difference; it was one outbreak. Then they were able to show it was a virus that came from a religious community in Canada. Then they were able to show it was a virus that came from a community in the Netherlands. Then they were able to show that that virus went back to the Middle East.

It was such an exciting time. I had no idea what that might mean at the time. If you can fingerprint a virus, are there legal implications if you can prove who you got your disease from? It's turned out not to be that kind of problem. But the classification and identification have become more and more sophisticated. It's been possible to track the families of viruses.

CRAWFORD: Has that had any political implications? Is that what you mean when you're saying it turned out not to be that kind of problem?

FOEGE: Yes, I worried about, "OK, if the Netherlands can say, we got this from such-and-such a country, and they should be paying for this." I wondered if that would happen, but it has not happened.

That takes us to the late '70s. A few years later, in the early '80s--I didn't look up the date of this--Dr. [Carlyle Guerra de] Macedo [MD, MPH, MPHA], who was head of the Pan American Health Organization [PAHO], called in a group. He gave us one day to go through every bit of information that he could gather on polio. He said, "At four o'clock, I want you to come back and tell me what I should be doing about polio in this hemisphere. The one thing I do not want: I do not want you to come back and tell me I should eradicate it from this hemisphere." He said, "I have no interest in talking about that. I want to know what I need to do to control it."

We went through the day, and what we found is, with this fingerprinting so sophisticated, we could follow each family of polioviruses and show when they were stopped and how infrequently they popped up someplace else. You knew you had a way of tracking and getting rid of an outbreak, and you knew where to put your resources to stop an outbreak. We concluded, one just has to try to eliminate this virus from the entire hemisphere.

CRAWFORD: When you say "we," who else was working with you that day?

FOEGE: It included Ciro [C.A.] de Quadros [MD, MPH], who is a famous vaccinologist from Brazil who worked on both smallpox and on polio and immunizations in general. It included D.A. [Donald Ainslie] Henderson [MD, MPH], who at that time was Dean of the School of Public Health at Johns Hopkins [University]. It included myself, and it included four or five other people, so it was a small group. We really worked hard that day going through the materials.

At four o'clock, we have our meeting, and we tell him we've concluded he should try to eliminate the virus from this hemisphere. He became very upset; he said, "That's the one thing I told you not to come back with." There was argument back and forth.

I then used an argument not to say we should do this, but to let him know how difficult it would be. I had no idea what that argument was going to do. I said to him, "If you decide to eliminate the virus from this hemisphere, you would have to know that you're in this alone. There is no other WHO [World Health Organization] regional office that will provide any support, not even moral support, and that WHO [headquarters in] Geneva will say that this is an atrocity; you should not have done that." He said, "How soon could I announce it?" I had no idea that's the reaction that that would have, but he wanted to go it alone.

CRAWFORD: Where do you think that reaction came from?

FOEGE: I do not know where that reaction came from, except that I think he was always thinking ahead. He wanted to do important things, and he was not afraid of standing up to power. The idea that he would be standing up to his own boss in Geneva somehow attracted him. But it worked.

He declared, "We're going to get rid of polio in this hemisphere," and he did. Much of the work was done by Ciro de Quadros, who was head of that program. That was in the early '80s.

CRAWFORD: Do you mind backing up for just a second?

FOEGE: Sure.

CRAWFORD: Do you remember any of the details of the back-and-forth?

FOEGE: The details are lost, in the sense that we were trying to convince him this was worth doing. He was saying, "I am not going to do that. That's the one thing I'm not going to do; it's too difficult." But then, this challenge, that he would have to do it alone, somehow attracted him in a way that I can't quite understand.

Dr. Macedo is still living in Brazil, and it would be worth trying to get an interview with him. His sister used to work at CDC, so it should be easy to track him down.

CRAWFORD: I wonder if he would--if he's ever in town visiting. I know that there are some travel plans, but I'm not sure what that will look like at this point.

FOEGE: It's worth trying. It's worth trying.

CRAWFORD: Yes.

FOEGE: That was in the early '80s. Then, in 1985 when Rotary [International] saw what had happened in this hemisphere, they made a decision to enter the polio eradication field. A man by the name of Herb [Herbert A.] Pigman was in charge of this for Rotary. I had numerous conversations with him.

Their aim was to raise $120 million dollars by the year 2005, which would be their centennial. I remember him calling me and saying, "It's going to be done in ten years." Then he called, and he said, "Money's coming in so fast we're going to do it in five years." Then he called and said, "We've done it." Rotary really got into this, and so they could be counted on, not just for money. They have Rotarians around the world, who are in positions of power. They are entrepreneurs; they are academics; they are in the sales force. These are people worth having on your side when you get to these countries.

Then, in 1988, March, we had a meeting in Talloires, France, sponsored by the Task Force for Child Survival [and Development], to look at what's the science that we now have behind polio eradication. We invited the ministers of health of the biggest countries--China, Nigeria, India, they were all there. Presentations were made over several days on the science, and the science was pretty convincing. You could see as we were getting close to the end of this meeting that these ministers thought it's worth doing.

Then Herb Pigman got up, and I remember his words that he said to the ministers of health: "You are going to meet Rotarians in your country, and they're going to be so invested in this program you will think that they actually produced the vaccine." He said, "Be nice to them because they're going to help you. They will help you with transport and with publicity and with extra support." He said, "They can help you eradicate this disease." This is March of 1988, and that meeting ended on a really high point with people excited. There's another aside to this, though--

CRAWFORD: In March of 1988?

FOEGE: Say it again?

CRAWFORD: March of 1988.

FOEGE: In March of 1988, another side to this and that is that nowadays, we talk about the millennial goals in health, and everyone takes this for granted. That idea started here in Atlanta, in 1978, a meeting at [Goodrich C.] White Hall in Emory [University], the second day at CDC, where experts from around the country came in to see if we could come up with objectives in health by 1990. We came up with 220 or so objectives, and then we tracked them over the next twelve years. In 1990, we had a big meeting to see how we have done. Amazingly, fifty percent of those objectives had been achieved, twenty-five percent had not been achieved, and twenty-five percent could not even be measured. It shows how far ahead people were thinking. Some people see that as a glass half full, and some see it as a glass half empty, but the fact is, it started a process so that every ten years this country sets new health objectives and tracks them. It doesn't matter who's in power, Republicans or Democrats, this continues every ten years.

It was at this March 1988 meeting in Talloires, France, that for the first time, objectives in health for children in the world--that this was presented. It was presented by [Ralph H.] Rafe Henderson [MD, MPH, MPA], a CDC person who is now head of the vaccine program [Expanded Programme on Immunization] for WHO. That led then to the UN [United Nations] setting millennial health goals [Millennium Development Goals] and now sustainable goals. All of that started here in Atlanta and then was fueled in March of 1988.

These ministers then went home, two months later, they assembled at the World Health Assembly in Geneva, and they voted to have a polio eradication program for the world. WHO had not been very keen on this because they did not think that they were at a point with immunization that they could take on one more thing, and yet they went along with it. Why did they go along with it? Because Halfdan [T.] Mahler [MD], who was a visionary leader of WHO for many years, was about to step down, and his replacement had now been chosen, Dr. [Hiroshi] Nakajima [MD, PhD] from Japan.

Now, Dr. Nakajima was not that interested in health. To tell you the truth, he was interested in his own CV [curriculum vitae] and wanted to be head of WHO. Japan spent heavily to get countries to vote for him. I never would have believed he was going to be elected, but he was. Halfdan Mahler, as head of WHO, talked to [James P.] Jim Grant [JD], who was head of UNICEF [United Nations Children's Fund], and they talked with Rafe Henderson: could we take this on? Because if it's to be taken on, it should be done before Nakajima becomes head of WHO because he will not push this at all. They went faster than they intended and made it part of the WHO agenda just to get around that problem. From May 1988 on, this was the goal, eradication of polio.

CRAWFORD: Looking back, I read maybe it was an obituary of Dr. Nakajima, something like that, but Margaret Chan [Fung Fu-chun, MD, DSc, FFPHM, MScPH] was quoted as having said that he was a real champion for polio eradication. Was that something that happened in retrospect? What's your opinion of that comment?

FOEGE: You know, Garrison Keillor said that such nice things are said about people when they die that he's sorry he's going to miss that by just a few days. That's what happens when people die: you end up putting a better perspective. But he [Nakajima] was not for polio eradication; he was not for cooperation with other groups, like UNICEF and the World Bank and so forth. WHO is not the program it should be, and part of it is due to that. I have to say at the same time, it's not all due to leadership.

We expect things out of WHO, and then you ask yourself, "What is it we did to set them up?" For one thing, we were trying to protect the Pan American Health Organization. Seventy years ago, the United States insisted on strong regional offices to protect PAHO. This led to regional offices so strong that they can undermine Geneva anytime they want. For example, with Ebola virus in West Africa, you may or may not know that initially the fight was between the African regional office and Geneva on who would be in charge, and that set things back. The one thing they could agree on was not to invite CDC because they wanted the glory of getting rid of Ebola on their own.

CRAWFORD: Would you say that that interfered in responses to Ebola?

FOEGE: It interfered tremendously. It delayed things. See, the difference is that when Ebola gets into an urban population, it becomes a different disease, much more difficult to control. All of the experience up until that time had been with Ebola in rural areas, in villages and so forth. It did delay things; there's no question about it. That's one thing, the strong regional offices.

The second thing is we made a board of directors of all ministers of health. Can you imagine any CEO [chief executive officer] accepting a job where the Board of Directors is 195 people? These are people who are in for two or three years. They don't have long-term loyalty to WHO. It's an impossible thing to govern when you have a board that big.

The third thing is we continued to say to WHO, every year, "Reduce your budget." The United States continued to say that, also. We always were putting them on starvation rations, and then we act surprised when they cannot respond to Ebola. We put them in an impossible situation.

Years ago, when I was president of the American Public Health Association--I think that's when it was--the United States was not actually paying its dues in full to WHO. I wrote an editorial, and I quoted Dolly [R.] Parton, who said, "You'd be surprised how much it costs to look this cheap." When Ebola came along, we found out how much it cost to be that cheap.

When I criticize WHO, it's for good reason, but we set up the plan that made that necessary for WHO. Now, in May of 1988, they've accepted the job of eradicating polio.

CRAWFORD: The resolution [WHA 41.28]?

FOEGE: The resolution, yes. In 1990 and 1991 and '92, CDC did studies in Sierra Leone, Africa, on polio. We found that, while the initial decision of WHO to use oral vaccine may have made some sense based on what we knew, that is, it made sense that you want intestinal immunity to try to slow down the spread of the virus. But they never considered using both vaccines simultaneously.

CRAWFORD: Why?

FOEGE: I don't know why, except that it had not come up as an idea at that point. People were thinking of cost, and they saw what happened with oral vaccine in the United States. Polio disappeared in this hemisphere. Polio disappeared, but we didn't know enough about why. With Sierra Leone, I think we found out why.

The oral vaccine does well in the U.S. and Europe, but when you get into tropical areas, you have other viruses competing in the intestine. You give the oral vaccine, and you don't get as high a take rate under those circumstances as you get here. The CDC studies in Sierra Leone, in fact, showed you would probably have to visit a child ten times with oral vaccine to get ninety percent protection against type 3 polio. It's difficult to get a child ten times in the United States, but it's impossible to get there ten times in Africa. Ciro de Quadros was such a driver that he was able to get the Americas to come close to that and get rid of polio in this hemisphere, but now in Africa, it's a different question.

Most of the cost of vaccination is in reaching a child, not in the cost of the vaccine itself. If you're going to go more times, it's going to cost more money. But the argument kept being that it cost too much to buy Salk vaccine.

CRAWFORD: And to administer the Salk vaccine.

FOEGE: It costs nothing to administer it because if you put it in the DTP [diphtheria, tetanus, pertussis vaccine]. Now you need no additional storage; you need no additional vials. You need no additional needles and syringes, no additional vaccinators. It's hidden, so the cost is just the vaccine. Yet, even at that, people did not want to do that. Part of it was that it looked like too much work to add one more thing. It was hard enough to keep a polio program going. I--

CRAWFORD: What was your evaluation of that?

FOEGE: My evaluation is pretty clear. At the beginning, I can understand why oral vaccine was the decision, and based on the example of the United States, that worked. But in retrospect, when you see what happens in developing countries and the vaccine does not work as well--

Then we found out from Dr. [T.] Jacob John [MBBS, PhD] in South India, a pediatrician, a virologist trained in this country who was so good [that] many places were trying to capture him. No, he wanted to go back to India, and he did. He did studies that showed even with Salk vaccine, you get a certain amount of intestinal immunity. He did big studies where he used only Salk vaccine, and the transmission of the virus went down. The intestinal immunity was not a hundred percent versus zero percent. The take rates were not as great in developing countries, but there is a third thing here that turned out to be very interesting.

We make a big thing out of herd immunity, and when I went to India, herd immunity was talked about for smallpox all the time. If you got eighty percent coverage with vaccine, you could reduce the spread of smallpox. Study after study in India showed that when they said they were at eighty percent and you actually tested, they were probably at fifty percent or sixty percent because the vaccinators kept going back to the same places that were easy: schools. They would get big numbers on immunization, but they weren't covering more people. The other part of that is I realized in Bihar, if we got eighty percent coverage with the vaccine, we would still have more susceptibles per square mile than we would have in Atlanta if we vaccinated no one. This is what's misleading about herd immunity. Now we have polio, and in parts of the world where you have high population density, many children, and poor take rates from the vaccine, it's no wonder we were having problems.

In 1991 or '92, there was a meeting in India on polio eradication, and I decided to present the CDC material and suggest that we use both Salk and Sabin vaccine. My approach to this was, "Why would you tie one hand behind your back when you have a big job to do? Why not use both vaccines simultaneously?" Because CDC found in Sierra Leone that instead of ten trips to get ninety percent immunity, you could do this in four trips if you used both vaccines together. It just made so much sense.

The night before I presented that, Ciro de Quadros told me, "If you actually say that tomorrow you will set polio eradication back by ten years." The head of the polio program for WHO, [Nicholas A.] Nick Ward [MBChB], told me they would not change what they were doing. He said, "How can the world trust WHO if we change strategies?" I said, "How can they trust you if you have the wrong strategy?" I made it very clear in that speech [that] this is what we had to do. WHO made the decision not to change. Only a small number of people were in on that decision, but it was rigid. Ciro de Quadros was one of them. Ciro told me before he died. Privately, he said to me, "You were right all the time about using inactivated Salk vaccine and Sabin vaccine." But he said, "I never could say that publicly because I would be letting down the people who had made that decision," and he was one of them. CRAWFORD: Who were the other people who made that decision?

FOEGE: Nick Ward, who was head of the polio program, and D.A. Henderson. They were the three key people. There were other people involved, but they would all bend to the will of those three, they were so strong. It was a good decision originally. This is all in answer to your question of how did I feel: [it was a] good decision originally, and then as we got more information, it just did not hold up. In 2001 or 2002, I was working for the [Bill & Melinda] Gates Foundation--

CRAWFORD: Can you talk about how you got there? Like what happened between CDC and Gates?

FOEGE: When I left CDC, it was to become the executive director of the Task Force for Child Survival. This was an interesting group because both UNICEF and WHO were doing immunization programs, and WHO had started the EPI, with Rafe Henderson in charge. They were really doing a great job of all the technical things; getting vaccine that was good, getting a cold chain that worked, but the coverage was increasing so slowly it was discouraging.

In WHO, there was a feeling of the old horizontal-vertical debate, where WHO was taking the horizontal approach, that you have to improve the health care systems, and Halfdan Mahler was a great believer in that. There was a meeting in Alma-Ata in the Soviet Union [1978], and "Health for All by the Year 2000" was the motto that came out of that. Mahler was behind that, so he was not for vertical programs. One of the greatest vertical programs was of course smallpox, and he supported that completely. I spoke recently in an honorary lecture for D.A. Henderson, who died, to show why he was so successful at WHO. Part of the reason was that D.A. was on CDC's payroll for all eleven years. Halfdan Mahler wanted CDC's support, so he gave D.A. great latitude, and D.A. used that latitude. He was able to pull off a program that I don't think anyone else could have. I mean, he really did a superb job at that.

Now we have the WHO still, despite smallpox, wanting to have the horizontal programs. Then at UNICEF, we get Jim Grant, who is a firebrand. He's a lawyer, and he's so good. He says, "Let's pick out the three or four most important things and put our money there." He's coming up with vertical programs--that's right. He came up with what's called "GOBI": growth monitoring, oral rehydration, breastfeeding, immunization--those four things. He and Mahler had problems reconciling this.

CRAWFORD: What did that look like? Were you in the rooms consistently with both of them together as they were having these discussions?

FOEGE: Yes, and now I'll tell you the next part of this story. Jonas Salk and [Former United States Secretary of Defense] Robert [S.] McNamara have watched what's happened to immunization in this country under President [James E. "Jimmy"] Carter and [Joseph A.] Califano [Jr., Secretary of Health, Education and Welfare] and Alan [R.] Hinman [MD, MPH], Walter A.] Walt Orenstein [MD, DSc (Hon)], and [J. Donald] Don Millar [MD, MPH]. Our immunization program improved so fast, and they were asking, "Why can't we do this globally?" So they went to [Kenneth S.] Ken Warren [MD] at the Rockefeller Foundation, and they decided what they would do is have a meeting at Bellagio, Italy, at the Rockefeller Center, to figure out what to do to speed up immunization in the world.

CRAWFORD: This was before Talloires, correct?

FOEGE: This what?

CRAWFORD: This was before France?

FOEGE: This is March of 1984, so it's four years before France. At this meeting, the convening power is so great that they've got the head of WHO, head of UNICEF, head of the World Bank, head of UNDP [United Nations Development Programme], head of USAID [United States Agency for International Development], McNamara, and Jonas Salk. See, this is a meeting [room] that can only hold twenty-four people, and they really got some of the best people you could imagine. Rafe Henderson was there, and D.A. Henderson was there, to ask, what could we do about immunization?

Before that meeting, Jim Grant and Halfdan Mahler came to see me alone, just the three of us in the room. What they said to me was, "We have such big egos; we sometimes have trouble getting along. It's no wonder that our programs have trouble getting along. We go into countries, and we compete with each other when we don't want to because we have the interest of immunizing children at heart. Yet, we compete." They said, "If this Bellagio meeting ends up as we hope it will, with a task force, would you be the head of that task force? And would you never use the word 'coordinate,' because no organization wants to be 'coordinated.'"

CRAWFORD: Because it's not important enough?

FOEGE: They see themselves as the head. We started using the word "facilitate." We found out that there was really quite a lot of antagonism between those two organizations, even though they had the same objectives. With meetings every three months for ten years, we were able to bring up the immunization levels in the world from about fifteen percent to [the point that on] September 30, 1990, at the World Summit for Children at the UN, Jim Grant got up and announced that eighty percent of children in this world have now received at least one vaccine. He said, "This is the biggest peacetime endeavor the world has ever seen." You see what happened in six years' time because the heads of agencies decided they wanted it to happen.

CRAWFORD: Can you discuss that in fuller detail? I've heard that one of the things that you bring to this work, to global health, is your amazing ability to connect with people, work with people. How did you work with that dynamic of competition?

FOEGE: It would not have worked if the immunization people in UNICEF and WHO had [not] come to say, "Can you help us work this out?" It has to be the heads of the agencies. I mean, that's absolutely crucial because then everyone below has their marching orders. Those two men really did change the way they worked.

Jim Grant came to me one day and said, "We need to have some sort of publication that goes to all immunization workers, regardless of who they are working for. [It will] let them know what are the problems, what's the accomplishment." He said, "If we did this at UNICEF, it would just be one more problem with WHO people." He said, "I'll give you $60,000 dollars a year if you do this out of the Task Force." The Task Force never had much money, but people were always trying to give us money to do things, and so we never had to go out to solicit.

At that meeting in March of 1984, Robert McNamara said if we could raise $100 million new dollars for immunization, everything would change. Everyone said to him, "There's no way to raise $100 million new dollars because the world would say, 'You have to take it out of something else in health. You can't just add it to what we're doing in health.'" Two years later, we would not have settled for $100 million new dollars. Italy alone gave $100 million dollars for immunization in Africa. Think of that. What happened with the Task Force was that people thought there was now a global plan, and there wasn't. I mean, we were just barely hanging on, trying to figure out what to do next. But with people now giving money, $100 million dollars from Italy, we had to come up with a plan.

We continued every three months, working at what needs to be solved in order to improve immunizations. Then people wanted to join this small group that met every three months, which included WHO, UNICEF, World Bank, UNDP and the Rockefeller Foundation, five people. We knew USAID desperately wanted to be in that.

CRAWFORD: Why were they not?

FOEGE: Because if you let one bilateral in, how can you keep the other bilaterals out? And so DANIDA [Danish International Development Agency] would want to join, CIDA [Canadian International Development Agency] Canada, SIDA [Swedish International Development Cooperation Agency] Sweden, they would want to. We had to just draw the line at the people that had started this. But what we did was, every eighteen months we had a big meeting where we invited all those people. We'd have 150-200 people, and we would meet at different places. We'd always call it a Bellagio meeting, even though the next one was in Cartagena and--

CRAWFORD: Colombia, yes?

FOEGE: In Colombia. And the president of Colombia--boy, I'm getting off the track here, but--

CRAWFORD: This is great. This is great.

FOEGE: The president of Colombia was President [Belisario Betancur Cuartas] Betancur. He made such a big thing out of the program, the immunization program, that they had immunization days. Rotary was helping to introduce it, and then Betancur himself would give the signal to open the clinics by giving oral polio vaccine to a child on TV [television], and this was the opening.

I was with him in his house as he did that, and afterwards, I said to him, "You know, that's pretty dramatic. In the United States we've only had one president ever give a vaccine." He was a historian, so he said, "Let me guess. It was Gerald [R.] Ford with flu vaccine?" I said, "No, it was [United States President] Thomas Jefferson," who in 1804 was able to get vaccine from England through a fellow by the name of [Harvard professor, Benjamin] Waterhouse [MD] in Boston. He went back to Monticello [Virginia] and vaccinated his family, his slaves, neighbors, and so he was the first one. Then President Carter went to Colombia and also gave vaccines, to become the second U.S. president to give vaccines.

CRAWFORD: For polio?

FOEGE: For polio, yes. You can see how this whole thing started mushrooming. Country after country now was competing with each other. Jumping ahead, it was a lot of hard work, every three months, trying to figure out what needs to be done next and then holding these meetings.

But then, on September 30, 1990, the Summit for Children, seventy-one heads of state gathered at the UN, the largest number of heads of state who had ever gathered up until that time, and it was for children. Each head of state was taken to their seat by a child in national dress. Each head of state was given five minutes to describe what they had done to improve child health and what they planned to do. Now if you can imagine heads of state, you have more ego in that room than you'll ever see again. All but one actually held to the five minutes. I was in the room and I watched that. It was dramatic. People started upping the ante as they would hear other people, "This is what we're going to do, OK." We're going to do this and this and this. By the end of the day, you know, it was really a success for child health in the world. They held their egos in check in order to have a global answer to things. When McNamara asked for $100 million dollars, suddenly money started flowing in. I tell you, up until September of 1990, this was one of the most exciting programs that you can imagine in global health.

CRAWFORD: What was the impact of suddenly having all this funding, having resources?

FOEGE: The impact--we could not have gone from fifteen percent up to seventy percent or eighty percent [vaccine coverage] without--that becomes crucial because in many of the developing countries they simply don't have the resources. We can say, "It's their responsibility. They should do it," but they can't do it. It's an example of putting the world first rather than your nation first.

I'm very bothered by this idea of "America first." It's the world first. If it's good for the world, it's going to be good for America. I think of [Albert] Einstein saying, "Nationalism is an infantile disease," he said, "It's the measles of mankind." We've got to think globally and what makes sense for everyone.

Now we're up to--we have this program, I have advocated that they use both vaccines; I have been overruled clearly, time and time again, by WHO. Then in 2001 or 2002--oh, you asked me how I got to the Gates Foundation.

I went from CDC to this Task Force [for Child Survival and Development]. CDC agreed to pay my salary for the first months at the Task Force, so it didn't cost the Task Force any money. I went to the president of Emory, [James T.] Jim Laney, and I told him about the Task Force: we're small. Three of us have now formed a 501(c)(3) [nonprofit]. We have a few other people, but it's very small. Our budget is $500,000 dollars. I said, "We're so small that we simply can't do things like retirement plans and travel regulations and so forth. Could we purchase this from Emory?" Jim Laney saw the value of this immediately, and he said that he thought we could work it out. But he said, "You know, there's the question of overhead." You know about overhead: if you get a grant, sometimes fifty percent of that goes to overhead.

I tightened up as he said "overhead." He said, "We'll have to charge you overhead." I asked him how much, and he said, "Would eight percent sound right?" I said yes so fast, so he couldn't change his mind. Then what he said was, "You'll have to answer to someone at Emory." He said, "How would it be if you answered to the dean of the Medical School?"

Jim Laney had no idea that I had many years of experience with this dean [Richard M. Krause, MD] because he had worked at NIH [National Institutes of Health]. He did not like public health. He always said no first before anything else, and I knew this would be a problem. But I said to Jim Laney, "Yes, I guess that could work," but I said, "Let me give you one other idea first to see whether it would work for you." I said, "What would you think if I answered to you, if I promise never to bother you?" He looked startled, and then he said, "OK."

"Now I'm answering to the president of Emory; we have eight percent overhead to do all of our support, and I have access to everybody at Emory because I'm answering to the president. Then, at CDC, the head of CDC has now said he would pay my salary, and I have access to everyone at CDC. I mean, it was a perfect situation. We got a lot of borrowed help, but we also found out that we could do things that other people couldn't. People were always coming to us, saying, "We'll give you money if you'll do this."

One example: CDC wanted to assign an epidemiologist for polio to Vietnam at a time when the U.S. did not have diplomatic relationships with Vietnam and couldn't assign someone. They came to the Task Force and asked, "Is there a way you could do that?" My deputy, [William C.] Bill Watson [Jr.], loved those kinds of questions because he just liked to solve problems. What we did was, we hired a French man on money we got from WHO, and we assigned him from the Task Force to Vietnam on the condition that he answer to CDC for supervision. You know, it worked perfectly; we were able to solve so many problems like that. We had no trouble getting support. So, by 1990 we've reached that level of immunization.

But then, in the 1990s two things happened: Halfdan Mahler retired from WHO, and Jim Grant died. Their replacements had no interest in this kind of cooperation, Nakajima at WHO and Carol Bellamy [JD] at UNICEF. She told her staff that immunization is a Jim Grant thing, and she reduced the budget. The 1990s turned out to be very difficult for immunization in the world.

Then in the late 1990s, the president of the World Bank [James D. Wolfensohn] said, "We've got to solve this," and so he called people together again. This time, Bill [William H. Gates, III] and Melinda [A.] Gates got involved, and they agreed to put up $750 million dollars for five years to support GAVI, the Global Alliance for Vaccines and Immunization [Gavi, The Vaccine Alliance]. The rules were, it would be chaired one year by the head of WHO and then the next year by the head of UNICEF, and it would go back and forth. Suddenly, UNICEF had to get back into immunizations. I mean, you can't turn down $750 million dollars from the Gates Foundation. This brought things back, but now in a way that I think will continue forever. They put up $750 million dollars and expected others would join in, and they did not.

CRAWFORD: Why not?

FOEGE: I was at the Gates Foundation by then, and I worried. After four years, Bill & Melinda Gates said, "We're going to put up another $750 million dollars for an additional five years." Within a day, Norway said, we'll add $250 million dollars, and the UK [United Kingdom] said, "We'll add over $1 billion dollars." All of a sudden, the matches [came] because people were not sure the Gates Foundation would stay with this. Once they showed they were in this for the long haul, suddenly they got coverage. Then it was possible to come up with rules on how would countries get vaccines. They have to meet certain criteria; they have to show that they can deliver vaccine. Then, under Bill and Melinda Gates, they've now put more expensive vaccines under GAVI, so that poor countries now have access to even the expensive vaccines. See, we have two vaccines against cancer. One is hepatitis against liver cancer, and this is a big cause of death around the world. The other is against human papillomavirus, which leads to carcinoma of the cervix.

I tell you, I am so proud of what they did. I often say to students, "When the history of global health is written, we're going to look back and we're going to realize the tipping point was about the year 2000, and [it was] due to the Gates family." They now made global health accessible. [It's] important, [because] you could have a track that led to global health, you could have research in global health. This has just been one of the best things that has happened. I'm so proud of what they have done.

Then I went from the Task Force to the Carter Center. President Carter asked me to be the executive director of the Carter Center, and I told him that my experience was all in global health. What do I know about other things? And should I be diluting what I'm doing by getting into other things? He came back the next day and asked, "Would it make a difference if I became interested in global health?" Of course, it would. That's why he's done all of these things in global health: Guinea worm eradication, lymphatic filariasis. We actually moved the Task Force office into the Carter Center. There was no daylight between the Task Force and the Carter Center in those days because I was head of both of them, and we just continued to do one thing after another.

Then the Gates Foundation was developed, and in the late '90s, Bill Gates and Melinda Gates asked if I would become a consultant to them. I drove down to Plains [Georgia] and talked to the Carters and asked them, "Is this a reasonable thing to do?" and they said yes. They said, "They're really going to make a difference in the world, and so be part of it."

President Carter did suggest he might be cutting his resources away because I would be afraid to give money to the Carter Center or suggest it for the Carter Center. It's all worked out.

CRAWFORD: Did you have any reservations about making that transition?

FOEGE: I was so--see, if you're in global health, you think like a poor person. You never have the resources you need, and it's always trying to figure out how do you get by, and how do you let all these things go because you don't have money for them? It never occurred to me that a rich person would become interested in global health. Rich people become interested in cancer, in heart disease and mental illness because someone in their family gets it. Global health--why would they get interested in global health? It never dawned on me that that would happen. Then to have the richest person in the world become interested and then have him get the second richest person, Warren [E.] Buffett, involved--this is just beyond comprehension. It truly is the tipping point for global health. In my day in school, I could not find three people in my medical school with an interest in global health. Now global health turns out to be one of the most attractive tracks in schools of public health, but also in universities in general. This I think is because the Gates had made it important.

CRAWFORD: I'm assuming that you had conversations about this because you talked to lots of people. What is it as you're rallying this support what is it that is compelling and makes people care about global health?

FOEGE: I think the compelling thing about global health is [that] in the long run we truly are in this together. With smallpox eradication, when I was at CDC, you had to justify everything to [United States] Congress on the basis of direct health benefits for America. [David J.] Dave Sencer [MD, MPH] said the direct health benefit in smallpox is to get rid of it in the world. He was willing to put domestic funds into smallpox eradication; that's not something that Congress would approve. It's unbelievable that Congress did not have the insight to see that global health benefits the United States. You can make the case economically, that if you have healthy people in other countries, you have better markets. If you have healthy people in other countries, they produce goods at a lower cost that they can sell to you. There are economic reasons for this, but Congress had trouble seeing it.

I remember one hearing where a congressman was giving me a bad time because of what we were doing with flu and the Soviet Union. You could tell he was opposed to the Soviet Union specifically, but he was opposed to doing anything internationally in health in general. He was asking for justification, "Why would you do this?" I asked him if he had his flu vaccine, and he said, yes, he had. I said, "One of the ingredients of the vaccine you received was the Leningrad strain of flu, which the Soviet Union provided to us during the low period of flu in this country. We were able to incorporate it in the vaccine for the next flu season." I could have left it at that, but I decided to twist the knife just a little bit, and I said, "So it means you now have anti-Soviet antibodies running through your bloodstream because of the fact that we worked with the Soviet Union."

CRAWFORD: What did he say?

FOEGE: He just went off to something else. The case for global health has become much stronger--

Let me go fast forward to this last summer, when Rotary had their convention here in Atlanta. Bill Gates came, and he spoke to them. He asked me to meet him at the Georgia State library in the afternoon, after he gave his talk, which I did. He had a film crew there and a table with just the two of us to talk about the early days of the Gates Foundation, without any format, just talking about it.

But he had a pile of books there. That was the one thing on his agenda because early on--and I went with the Gates Foundation in 1999--early on he asked for some books on global health. I asked his staff, "Should I choose the two best books or the four best books?" They said, "We don't know, but don't underestimate him." I went to his office with other people helping me, and we carried in eighty-three books. Weeks later when I saw him, I asked him, "Have you had a chance to look at any of those books?" He said, "I've read seventeen of them." I asked him," Which one is your favorite at this point?" He said, "The 1993 World Bank Report on Health." It's one that I had studied carefully, at that time. When he talked about disability-adjusted life years, I knew he had actually read that because in 1993, the World Bank was able to put suffering and death together in a single number. Now you could actually compare diseases and what it cost to do something about them. You can compare geographic areas and age groups because you can put suffering and death in a single number. There's still a ways to go to make that more perfect, but it is such a step forward. With that you can prove the importance of global health for the United States because you can see what it returns.

One example: our investment in smallpox eradication is recouped in this country every three months because we don't have to vaccinate, we don't have a person every two months dying because of the vaccine, we don't have the hospitalizations of the people who have reactions to the vaccine, and we don't have to do the same sort of foreign quarantine screening. We save that money every three months, which means we have just ten and twenty and thirty times recouped our investment. That's what would happen if we really did the job on global health.

You can't imagine how much global health has improved. When I started, the world was losing fifty thousand children a day under the age of five. That's down now to a fraction of that. It's still thirty thousand, twenty-five thousand, and so you can be unhappy that we still have a long way to go, but you can be very happy that in one lifetime it's gone down that fast. We've gotten rid of smallpox. We've gotten rid of most of polio. We're now seeing a way to get rid of river blindness or onchocerciasis from West Africa; lymphatic filariasis is going down. These are ugly diseases, you know, it changes how people see themselves. But this is all off the track. I ended up at the Gates Foundation

In 2001, 2002, to get back to polio, they asked me if I would revisit this question of Salk and Sabin vaccines. I came to CDC, and people here were in accord that we should still be adding Salk vaccine to the program. It's late, it will cost more to get started again with producing the vaccine, but here in the United States, that's all we use, is Salk vaccine. We don't use Sabin anymore, and we don't use it because of that risk. We do have a template for how to make it and produce it at a certain level. Everyone here said, "We still have to do that."

Plus, you need this at the end of the polio program because there comes a day when you have no more wild poliovirus. You can't continue giving oral or some of them will revert. You've got to stop. But then how do you keep this from coming back in? If you were giving Salk vaccine in the DTP, you have an insurance policy. You don't have to do anything. You just drop the oral vaccine in. Everyone here agreed.

I went to WHO, and I had lunch with JW Lee [Lee Jong-Wook, MD, MPH], who was head of WHO at that time. He's from South Korea. He had worked in immunization in Asia, so he knew the problems. He just immediately agreed, that's the thing to do, immediately. But he said, "How do I do it?" I said, "You become a dictator, and you say the new norm for the world is we're going to put Salk vaccine in the DTP, and we're going to continue the oral vaccine as long as we have polio. As the dictator, you go around and ask rich countries if they will subsidize the poor countries until the poor countries can get this into their budget." He was so excited about it, and by the time I left, we had a plan for how he was going to get his own scientific committees to back him up. The polio people were not that happy because it's one more thing that they have to worry about. I tell you, they were working so hard. I left very happy, and what happened was JW Lee had a stroke and died, and we were back to ground zero.

CRAWFORD: What did you do?

FOEGE: Now we're at a point where the science has become so clear that they are adding the Salk vaccine.

I should step back just a moment to say, though, that ten years ago there was a question of whether we had a different virus in India than elsewhere because they simply couldn't get rid of it. In two places particularly, Uttar Pradesh and Bihar, two states that I worked in for smallpox eradication. They turned out to be the last problems with smallpox, and now here they are the last problems with polio. People were worried: "This must be a different virus because we cannot stop it." I said, "It's not a different virus." We have all of the problems of crowding, and therefore, the herd immunity level has to get so much higher. Number two, you have these children interacting at early ages, spreading that virus. Number three, the take rate is not as great with oral vaccine, so you have to keep going back. People argued that the public health infrastructure isn't good enough, and I pointed out how often they were actually getting to children by two years of age. I said, "There's no state in the United States that could do that well. This isn't a problem of infrastructure. This is a problem [showing that] we should be adding the Salk vaccine to DTP. But we'll get rid of it," I said, "even if we don't do that," but it becomes much more difficult. Now, India is free of poliovirus. You know, one thing after another has happened.

Where are we at the moment? I went then to WHO, JW Lee has a stroke, but little by little, people realized that we have to add the Salk vaccine, and that's what we're doing.

The science has changed. We no longer have type 2 polio in the world, so that was taken out of the vaccine, and that's an assist. We have two big problems, Pakistan and Afghanistan. Both of them are war areas where the sociology is turning out to be the problem that hinders this. In Pakistan, it's more than sociology. As you probably know, our CIA [Central Intelligence Agency] was involved in trying to get DNA [deoxyribonucleic acid], using the polio program as a cover, to see whether Osama Bin Laden was in that house. The Taliban has now succeeded in killing, I don't know, sixty or more polio vaccinators. That's something I never would have seen fifteen years ago. I would not have even thought about it, and it's a tragedy of our time.

CRAWFORD: Do you remember where you were when you heard the news about vaccinators being killed in Pakistan?

FOEGE: I don't remember. I just remember it was such a letdown feeling that--see, and this is the other thing, if WHO had in the '90s decided to put IPV [inactivated polio vaccine] in the DTP and give both vaccines, we would be finished with polio before any of these problems had happened. That's part of what drags me down is to see these problems that we shouldn't have had to face, and we do. We're still going to get rid of polio. It's just that it's much, much harder under these conditions.

When we get rid of it, then the question will be, "Do we keep the Salk vaccine in the DTP?" My guess is we will because it's a relatively cheap insurance policy. This poliovirus is in many labs around the world. At some point, the poliovirus is going to get out again. When it does, if we have not kept IPV or the Salk vaccine in the DTP, then we have a population susceptible, and we've got to start over again. But if we just keep this in, it's a cheap insurance policy that we wouldn't have to do that. It's not going to be able to spread. We will get rid of polio because there is no real alternative. We can't go back to control; it's too difficult. We have to keep going until we actually get rid of the virus.

CRAWFORD: Dr. Foege, there are a couple--I wanted to ask you for a little contextual information, and there's actually a lot already out there about your beginnings. But I wanted to see if you would introduce yourself, state where and when you were born, and just share a little bit about your early life?

FOEGE: OK. I was born in Decorah, Iowa and lived my first ten years in Iowa, in a town of a hundred people. [It was] so small that when my family moved, the population went down eight percent. We moved to the state of Washington.

I have just been so fortunate over the years with mentors.

Everyone needs mentors, and there are studies now that show the best predictor of how people will do after college and university is number one: do they have a mentor? And number two: do they have an experience that's equivalent to an internship where they could use their new knowledge, but under supervision?

What surprised me is the majority of people graduating from universities and colleges have not had a mentor. I tell them it's their job to find a mentor because the people they want to emulate are usually quite busy; they're not looking for mentees. I tell them to find someone they really want as a mentor and then ask that person something in that person's field. Go back after several weeks with a follow-up question that shows you really paid attention to what they were saying. By the time you've gone three times with a question, you have a mentor, whether they want to be or not. They are going to be interested in you. I just fell into this of having good mentors. At the age of thirteen, I went to a drugstore in a town we had moved to, Colville, Washington, and applied for a job. I had no idea that the pharmacist had only been in business for a month or so. He was very young and poor, and he was living above the store with his wife and a child. I walked in and asked if he would have a job. He later said he had no interest in having another employee because he couldn't afford one. He had no interest in a teenager, but he thought I was handicapped because I had a long leg cast on. I had broken my leg, and I didn't even think of telling him about that. He said he could not turn down a handicapped teenager, and he hired me. Weeks later I walked in the store, my cast is off, and I'm walking normally, and he realizes he's been taken.

But it turned out to be such a good relationship that all five of my siblings ended up working for him. What was important was--this was not a town that put great value in education, but here I was introduced to science because you use a metric system in the drugstore. I was introduced to magic--of things that actually worked to cure people. Then, one of the people that came into the fountain every day for coffee was a scientist who did assays from the mines. He became interested in talking to me and invited me to his house at night to learn logarithms. Suddenly, this is a whole new world for me, and I go to school thinking, no one in my class knows powers of ten, and isn't that something that here I have the opportunity.

I became interested in science. I went off to college, and my biology teacher was a forbidding Germanic person, tall, with white hair. He looked like Einstein, and he would walk into the class, lecturing as he walked in. I mean, you had to be listening down the hall to hear him start his lecture. He was no nonsense; he would come in, and he would start writing on the board with both hands simultaneously, families and phyla and things like that. I think I went into biology thinking I'd be able to do that, and of course, it didn't work that way. But he turned out to be so important because he was well regarded by the medical school at the University of Washington. When I went in my junior year to say, "I think I would like to go into medicine," he said, "I'm willing to recommend you if you are willing to take a series of tests." He gives me IQ [intelligence quotient] tests, the Minnesota Multiphasic, things like that. Then when I go back, he said, "OK, I'll support you, and here's what you've got to do." You get someone like that.

He was so overwhelming in some ways, but I ended up working as a lab assistant for him. Then pretty soon, I'm working on the weekends on his yard. He and his wife were competing to see if they could bring me food without the other knowing about it, cake and ice cream and things; "Don't tell Bill," that sort of thing.

I went from there to medical school, and I said there were only three people interested in global health. One of them was [Reimert T.] Rei Ravenholt [MD, MPH]. I should say that the pharmacist that hired me at thirteen, I kept up with him until some months ago when he died in his nineties, but we would have phone conversations. Then I went off to medical school and [met] Rei Ravenholt. He's in his nineties and I keep up with him by phone.

CRAWFORD: Could you talk about him, tell a few stories about Rei Ravenholt?

FOEGE: Rei Ravenholt was part of a large Danish family in Wisconsin, and they lost their farm during the Depression. He talks about that winter of 1935, 1936, when they lived in the basement of a Danish Lutheran Church that had no heat. The newspapers, if you go back now, you find it was one of the worst winters that the Midwest ever had, you know, temperatures of thirty below and thirty-five below zero, and they were in this church basement without heat.

CRAWFORD: How did they survive?

FOEGE: You wore a lot of clothes, is what you did. His family turned out to be really a very productive family. One of his brothers ended up as the chief aide to Hubert [H.] Humphrey [Jr., former vice president of the U.S.]; one of them was health officer for Reno [Nevada]; Rei Ravenholt ended up becoming head of population for USAID [United States Agency for International Development].

In medical school, I worked for him after school and on Saturdays because he was also the epidemiologist for Seattle-King County. He was in the second class of EIS officers at CDC. He said to me, "If you're really interested in global health, you're going to find that there are no good tracks. Everyone has to make it on their own. But the EIS Program is the best track because," he said, "you'll be surrounded by people that are interested in global health, not just domestic health, and you'll make contacts for the rest of your life." That's what I did, and he was absolutely right.

Then, as part of the EIS, I read this paper by Tom Weller, and I go to Harvard, and Weller becomes a mentor. I just kept getting good people. Alex Langmuir at CDC, he really was an unusual person. All of these people had very strong personalities. I remember once with Langmuir, where we're talking about a subject, and he's presenting his view on it. I said to him, "Yes, but you know, you have to listen to the other side." He slammed his fist down on his desk, and he said, "There is no other side!" These were people of strong opinions. I often wondered because I was not the kind to argue with that kind of person, how I was so lucky to get them. They all turned out to be very important. I've ended up with mentors that are very unusual.

When I wanted to get into global health, one of my mentors was a man by the name of Wolfgang Bulle [MD]. He was in the Nazi military, and he was in medical school. He would spend a quarter in medical school, and then he'd be in the Armed Services. He became a surgeon and went to India. He spent ten years as a surgeon for a church group. I see him now, in retrospect, as suffering from post-traumatic stress disorder [PTSD], spending his life seeking redemption for having been a German in the Second World War. But he was so important to me because he was willing to support me in global health.

I tell students now that I was told to develop a life plan. I said, "Don't waste your time." You have no idea what life is going to present, what opportunities will exist. Spend your time on a life philosophy, and then you'll know with each fork in the road what's important to you and which direction you could take. I would never--I went to Africa expecting to spend my life running a medical center there. I didn't expect that the civil war in Nigeria would drive me out. I didn't expect that during that time I would become so obsessed by smallpox eradication that I couldn't go back to that when the war ended. The war lasted from '67 to '70. I thought it would be a few weeks, but it went on--and I couldn't go back now that I was in smallpox eradication. If I had not done smallpox eradication, I would not have been asked by [Joseph A.] Califano [Jr.] to head up CDC. Each time it was a new opportunity that I could not have predicted. If I had had a life plan, I would have been left far behind in opportunities. I never would have had President and Mrs. [E. Rosalynn] Carter as mentors. I never would have had Bill and Melinda Gates as mentors.

I've just been very fortunate, and part of this fortune is that I started at the county level in Seattle-King County. I ended up going to a state, Colorado [for the EIS assignment], and then working in national and then in global health. I've worked for NGOs [non-governmental organizations]--I've worked for global health institutions; I've had an opportunity for experience in a lot of different things. As I tell people, here I am in my eighties, and I can't retire because it's still so exciting. That's what you want to do is get in a profession that you simply don't want to retire. Was that enough?

CRAWFORD: That's great. I have a follow-up question, though. In addition to mentors in your career, who were some of the people that you spent time with growing up?

FOEGE: It's an interesting question. I grew up in a very small town. I often tell people, before they know I was in a small town, that one of the interesting things, one day I realized that I was first in my class in the slow group. What's funny about that is that there were only three in my class.

There's something nice, though, about a one-room schoolhouse. We all got ahead of our grade level because the teacher would do math for second grade and then give you problems and then do third and fourth and fifth, all the way up through eighth, but you listened to all the rest of it. By the time you were in third grade, you knew math all the way through eighth grade, that type--that was important.

I think some of the really important people in growing up---- my oldest sister married a West Point [United States Military Academy] graduate, and they were both in high school at the time that they met each other. He was an absolutely straight arrow. Here was a person that fit in so well, but he did not participate in a lot of things. He would be the person that would drive people home after a party because he wouldn't drink, that sort of thing. His discipline and his approach to life turned out to be very important.

The pharmacist that hired me at thirteen, his family became so important. I started babysitting for them. I started spending my evenings at their place after work. I'd go to school, I'd work, go home and eat and then go back to their place. When his wife Shirley [Kohlstadt] died, I went to her memorial service, to her funeral, and I said that I didn't realize until later how much I had absorbed from them. It wasn't until I got to college that I realized I wasn't supposed to like Lawrence Welk, but I did because that's what they would be watching. We didn't have television. They did, and so I would watch that. I became interested in old cars because of them, and I still have a car that I bought when I was sixteen years old, a 1928 Model A Ford, and it's restored. I didn't know I would become interested in photography and in coin collecting. These turned out to be very important contacts. Then, in my work, for example, for the Task Force for Child Survival, I recently did a eulogy for one of the people that worked there. She repeatedly said after her retirement, that she had never worked in a group as inspiring as that one. Everyone had--they shared an objective, and they were just good people. I see people who are unhappy with their work, and I understand--you get trapped in that sort of thing, but in global health, you find so many people who are just first class. They have a different view of life, and I just feel fortunate about the people I've been able to work with. CDC people, you know.

This last week, I had a luncheon at my place because Bill Watson, who was the deputy director at CDC, was a public health advisor. He was so good that they named their group the Watsonian Society when they decided to get together. When he was in his final years, some of us used to go to have lunch with him. It became more and more difficult, and he couldn't actually keep up his side of the conversation. I suggested one day, "Why don't the seven of us that were doing that go as a group? Then he's just part of the group and he doesn't have to participate if he doesn't want to."

It turned out to be so good. After he died, which is three and a half years ago, we decided that it's been so much fun to get together and talk about the old days, so we continue doing that every two months. We get together and reminisce. The CDC people, the CDC family, turned out to be very important to me.

CRAWFORD: This is a skip to a whole new bag of questions, I guess, but I'm interested in smallpox and the transition to polio. Smallpox was the first eradication, and now we're on the brink of the second in history. I wondered if you could talk a little bit about how smallpox is different from polio, but also what has been transferable from smallpox.

FOEGE: It's interesting to me that many of the polio people actually worked in the smallpox eradication program--D.A. Henderson and Nick Ward and Ciro de Quadros--they were all smallpox people. You have probably put Walt Orenstein on your list--

CRAWFORD: Yes.

FOEGE: Walt Orenstein reminded me in an email this week that he was intending to be a nephrologist, a pediatric nephrologist in San Francisco, until he came to India and worked in smallpox eradication. Then he spent the rest of his life on vaccines. Smallpox turned out to be a very important program for getting people into public health and keeping them in public health.

The diseases are different. With smallpox, you can easily diagnose a person that's sick because the rash tends to be on their face and on their extremities, and they are often very sick also. With polio, 999 out of 1,000 [infections] you don't know that they have polio. It's only the one that's paralyzed that you know of. Those are differences.

CRAWFORD: And that makes surveillance different.

FOEGE: Surveillance becomes different, but in both cases, it's the surveillance that drives the work. With smallpox, surveillance allowed us to know where to spend our time on vaccinating, so that we didn't waste all this time with mass vaccination, vaccinating people who would never be exposed or who weren't going to be exposed for a year or two. This worked in Africa when we first tried it in December of 1966, and it took us a while to realize it's not just this one outbreak, maybe we could do more. Over six months, we identified every outbreak in Eastern Nigeria and got rid of it, and that's where the war took place, the Biafra and Nigerian Civil War. There was never any smallpox in the war area. Then that gradually went to other countries--finally to India, where it almost met its match because in India there was so much smallpox, you wondered if this could work. It made a certain amount of sense; do mass vaccinations because there's just too much smallpox. It took us about three or four months to perfect the surveillance part of this; we started out just going to villages and asking questions.

We were so surprised in two states alone, where we did this in October of 1973, during the low period of transmission. I was so naïve that in the instructions I said, "We won't find much smallpox, but we're going to learn how to do this." In six days' time, we found ten thousand new cases that no one knew existed. We were just totally overwhelmed. It was the surveillance that allowed you to know where to go for your execution of the program, and so containment then was the second thing.

Surveillance with polio is more difficult, but it still is possible. Do you know how we used to do surveillance early on in polio? We would put Kotex [feminine hygiene product] into sewer systems and then try to detect the virus. Then you would just keep going upstream from the positives until you find the case, but you see how laborious that was and how much work. Surveillance was still possible. It's absolutely essential now to know where to put your attention with polio.

Those are two differences. In both cases, the sociology turns out to be so important. If you go in with just the science and try to implement that--with smallpox you had goddesses in both Africa and in India. For some people, they saw the visitation of smallpox as a positive visitation of the goddess, so how do you get around that? In both cases, we had to learn a lot more about the culture. I have said in a book that I wrote about smallpox eradication [House on Fire: The Fight to Eradicate Smallpox, 2011], if you tangle with culture, culture always wins. You have to figure out what to do specifically, there.

In both cases, you need constant motivation because we wear down. It becomes so difficult to keep doing the things you have to do every day. You need people that motivate you, to let you know that this is the right thing to do and times will change. There was a time in India when it was hard to get people from New Delhi to actually go to the monthly meetings in the state because things just kept getting worse every month. You're always faced with people who are blaming headquarters for not doing this or that. I continued going because I said, "There's going to be a day when this turns, and everyone is going to forget their complaints. It's all downhill." And that's exactly what happened.

CRAWFORD: When? When was that day?

FOEGE: The day was May of 1974, when the Minister of Health in Bihar had declared that we were going to go back to mass vaccinations because smallpox was not disappearing in Bihar. There were thirty-one districts, and he was able to show it was getting worse every month. Of course, the figures were getting worse every month because we were becoming more efficient at finding the cases. But our containment was getting more efficient, and I could already see where the turning point was going to be.

Then the bottom drops out when he says, "We're going to go back to mass vaccination." I argued with him at his home on Saturday and on Sunday, and he was very polite about everything, but he said, "I'm coming to your meeting on Monday to declare this." All the workers came in on Monday for our monthly meeting, and they began reporting on what they were finding in their districts. I told them, "The Minister is going to come today and say we're going back to mass vaccination, and I've been unable to change his mind."

About then, he came in with his entourage, up to the head table, and he began talking. He thanked people. He said that the work that they've been doing is incredibly good and hard, but for political reasons he had to go back to mass vaccination. He said, "Think of all these young babies that have been born in the last few months who are not protected. They're going to become more and more of the population, and when smallpox then reaches them, you won't be able to stop it at all."

He said at the end of this meeting, "We're going back to mass vaccination," and there was absolute silence in the room. We knew it was coming, but once he said it, it just took all the wind out of the room. Then a young man stood up, and he was so thin and so unsure of himself as he stood in front of the Minister, he was absolutely shaking. He said to the Minister, "I don't know much, I'm just a village man--"He was a doctor at this point, but he said, "I know one thing: when I grew up in the village, if someone's house caught on fire, we all poured water on their house. We didn't run around the village pouring water just every place." He said, "If we had done that, pouring water everywhere, that would be the equivalent of mass vaccination." By concentrating the water on the house that was burning, that is surveillance containment The Minister sat there and looked as if he had been slapped, and he just stared and stared and stared. I had no idea what was going to come next. Then he said, "I'll give you one more month." A month later, we were able to show improvement in three of the thirty-one districts. It's not a lot, but it was enough for him to give us another month, and then the question never came up again. Between May of '74, when we had that meeting, and May of '75, twelve months later, smallpox totally disappeared from India, totally. I don't think there's ever been a more intense time in public health than those twelve months.

That was the tipping point, and then it improved. We learned a lot about how you have to--the local culture has to be involved. It was that young, shaking man that made all the difference in the world, not us.

Other differences and similarities [were] the idea of having teams that actually focus on places. [For] the STOP [Stop Transmission of Polio] Program, this has turned out to be very valuable, and the ability to move resources into areas that are still having problems. For instance, now that they're adding IPV, obviously you add it to where you still have polio rather than across the board because they can't make it fast enough for every place. You add it to where you have polio.

I think this is one of the lessons: you don't come up with a strategy and just hang onto it. While we kept the strategy, we changed the tactics every month with smallpox eradication, every month. That's what we're doing with polio.

It won't be the second disease. The second disease eradicated was rinderpest. It wasn't a human disease, but a disease of cows. It's similar to our measles virus, but it kills cows. [For] the Fulani tribes in West Africa and the Masai in East Africa, this was a big thing to them, and rinderpest has been eradicated. I think that Guinea worm may be the third disease, and it doesn't use a vaccine. The fourth will be polio. I think the fifth could be measles. The sixth may be onchocerciasis, and the seventh may be lymphatic filariasis. I had always hoped that I would live long enough to see six diseases disappear; I've seen two, and we're getting close with some of the others.

Here's another interesting thing, though: there is not a single pattern that works for disease eradication. Smallpox disappeared because two countries, the U.S. and the USSR [Union of Soviet Socialist Republics], combined forces to drive this through WHO. It was the USSR that started it, not the U.S., and we finally got together to make that happen. With polio, it's going to be a service club, Rotary, that turns out to be the important driver. I see the advantage now of an outside group forcing WHO into something. That's what happened. With Guinea worm, it's an NGO, the Carter Center, that has driven this. With onchocerciasis, it's a corporation, Merck [Merck & Company, Inc.], that has driven this. With measles, it's going to be the American Red Cross. Each time we use a different pattern.

What's similar is we gather a coalition around an outcome, and that's what makes it work. That's what we're learning about leadership; leadership doesn't come with a title, head of CDC or head of WHO. It comes with the person that can make a coalition effectively work.

CRAWFORD: And then does that person disappear?

FOEGE: That person oftentimes disappears because they are so focused on this one problem. Sometimes, I mean, when you see how many people went from smallpox to polio and then from there into onchocerciasis, there is a certain continuity with a certain group of people.

CRAWFORD: I'm very interested in how these partners have worked together. Everyone has entered at a different time. UNICEF and WHO were very close together in timing, I believe. I'm interested in your personal experience working with--when you have encountered Rotary and maybe other points of contact, maybe with Gates would be a good place to go, too. Or anything that you think is relevant.

FOEGE: See, these things turn out to be coalitions. With the Task Force, that was a coalition that actually worked because heads of programs wanted it to work.

With polio eradication, the leadership has shifted a little bit. It's still a coalition, but I think that Rotary was the impetus to really force this. I think the Gates Foundation rescued it because it was turning out to be more and more expensive. It's only when the Gates Foundation got involved and said to Rotary, "We'll put up this amount of money if you match it." Rotary got into this bigger and bigger, $120 million dollars was their original goal, and pretty soon they are up to $200 and $300 and $400 and $500 million. It's really miraculous what has happened with them. Getting Gates involved turned out to be very important, and now you have this coalition that really runs the polio program.

There's another lesson here. WHO, for its faults, is necessary, and if it didn't exist, we'd always say we'd have to form it. You do need that sort of place. What is the problem is that WHO has often not been willing to include other people in things, as with Ebola. There was a time when Nakajima became worried that the World Bank was doing too much in health, and he tried to undercut them instead of trying to incorporate them into his coalition. I don't understand that, how you help yourself by undercutting, but that's what happened. It's the coalitions that end up working in this.

CRAWFORD: I have a question about banks, and I'm surprised actually that banks have not become or are not considered part of GPEI. Can you speak to that?

FOEGE: Why the bank is not?

CRAWFORD: Yes, World Bank or regional banks or--

FOEGE: Actually, they have been so important. I can remember the American banks [Inter-American Development Bank, IDB], when I went with Ciro de Quadros to see whether they would provide a loan for polio eradication when he was cranking this up in this hemisphere. We went and had a luncheon with them, and they kept saying, "We don't give grants." Then someone said, "You know, we have this category of non-reimbursable loans," which sounds like a grant to me.

That's what they gave Ciro, a non-reimbursable grant, and so the bank did get involved in that. With Jim [Y.] Kim, as president of the World Bank, they have gotten into health programs, but they weren't into polio early on. That's why historically they weren't part of this.

But you raise another interesting point. When the Merck Mectizan [Donation] Program started and the Task Force and Carter Center got involved in this, John [J.] Moores, who was the owner of the San Diego Padres, became interested in river blindness. As part of what he did, he commissioned a sculpture of a young boy leading an old man with a stick, a blind man because this is what would happen in Africa in villages close to fast-moving streams. This is where the Simulium [vittatum] fly would reproduce, on a fast-moving stream, and then it would transfer Onchocerca [volvulus] from one person to another. People would go blind by their forties and fifties in these villages. Many of them had to be abandoned because people would go blind so early.

He commissioned this sculpture, and the first one was placed at the Merck headquarters. I went there for the dedication and spoke, and I said, "You know, isn't this interesting? It's the first thing people will see as they come to the headquarters," a sculpture for a drug where Merck is making no money on the human use. They are giving it away free. They made money, of course, on the use for dogs and animals, the Heartgard [heartworm medication] that you give dogs once a month. That's what they used to support the human program. By this time, Merck has given over a billion free treatments of Mectizan.

I pointed that out, but I also pointed out how rough the man's feet were and that this was part of the disease, the roughening of the skin and so forth. It turned out that the person that made this sculpture was from Alaska, and he was there. He came and said, "I had no idea about that." He said, "I did this from a photograph." But sure enough, he had made it so that it looked real.

Anyway, John Moores then commissioned a second one, which is at the Carter Center here in Atlanta. He then commissioned a third one, which is in the lobby of the World Bank, a place that said they were not a health program, and here they have that in their lobby. Then he did a fourth one, which is now at WHO headquarters in Geneva.

The coalition was very interesting, but it's one program that is not led by a global agency because Merck gave the drug and set up a Mectizan expert committee to decide who would get the drug, and I chaired that for twelve years. He had gone originally to WHO, and he walked away because the bureaucracy became so great. He then went to USAID and asked, "If we give you the drug free, would you figure out how to distribute it?" They just said they weren't interested, which is--I had a chance to ask [Melville] Peter McPherson years later, who was head of USAID at the time, "Why didn't you do it?" He said, "We were too busy." Then Merck came to the Task Force, and they asked me, "If we gave you the drug free, would you figure out how to distribute it?" The first thing I asked them was, "How long will you give it free?" Well, they decided they would--they didn't know what else the drug would be good for, but for onchocerciasis, they would give it free for as long as needed, which is as much as you can ask. I was very excited about that. Then I told them about two other problems I had: what are the side effects when you get into millions of people taking this drug, and how do you convince people to take it if they don't see the result for twenty years? These are difficult questions. But I said, "We'll do it."

What we found was that it is probably the safest drug I know of. There are side problems, but they are so minor that you can handle them. Number two, how do you get people to do this if they don't see the result for twenty years? I ended up feeling so dumb because I had lived in West Africa. I lived in a village, and I sat around talking to men at night and watched how they scratched. They were scratching because of onchocerciasis. This microfilariae crossing the eye that causes blindness also goes all through the body, causing itching. For some of these people, the day after they took Mectizan they had their first itch-free day ever. Marketing is easy when that happens.

This very quickly spread. We had set a goal of reaching six million people in six years, and we did it in four years. I went back for the 250 millionth treatment in Africa. Now they are over a billion, and all of this not run by a global agency. It doesn't come under WHO or UNICEF or the World Bank; it's all private and ad hoc in a way. It worked so well, as did the Task Force for Child Survival, that it makes me wonder, "Why can't we do more of this?" CRAWFORD: I guess GPEI--do you place GPEI in the same class of coalitions?

FOEGE: It's a coalition, absolutely. It's still WHO [that] is seen as leading the coalition, but it now includes the Gates Foundation and UNICEF and others, yes. Rotary continues to be a big part of it.

CRAWFORD: One question I have about GPEI is why there has never been a legal agreement or entity put in place. I like to think that it's not necessary to do that, that you can do it on good faith and common interests.

FOEGE: You can be sure there would be one if it were required. Rafe Henderson has often said about the Task Force that the WHO lawyers continued to try to find a way to write this up legally, what we were doing, and they couldn't, so they dropped the idea. Rafe said that's what allowed this to work because we could be a little bit loose.

The best coalitions, I think, are based on faith that you actually have faith in the other people in the coalition. In that Talloires meeting in March of 1988, we came up with a statement about things that needed to be done. Each one of the agencies, UNICEF, WHO, UNDP, World Bank, said there is no way we can get this approved by our agency in less than a year. That does no good if you have to wait a year to put that out. We put it out as a Task Force statement, and the rest of the world assumed WHO and UNICEF had cleared it. We knew they hadn't, but we had enough faith in each other that we put it out and didn't say anything. It became sort of globally legal. If you don't need a legal statement, be careful about doing it. It reminds me of [Samuel] Johnson, the famous fellow from the UK, who once was in a group. They were drinking, and someone left the room. He said, "I don't like to speak poorly about someone behind their back, but I suspect he's a lawyer."

The president of Mercedes has just given a talk on what's happening because of computers. He said, "If you're in law school, drop out; there's no future for you." He said, "We're going to have a ninety-five percent reduction in lawyers because computers are going to be able to provide what most people need, whether it's wills or a contract for a house, and you won't need a lawyer." That's an interesting--if you don't need to have a legal document, avoid it. I never had a legal document with Emory on their eight percent overhead and who I answered to. It was all on just good faith.

CRAWFORD: I think we're coming [to a close], at least, I don't know how much time you have today.

FOEGE: I don't either, but I live day to day, hoping I have more time.

CRAWFORD: That's a good policy. In terms of polio, do you feel like there are things that we--there's no way to cover everything, especially in one session, but is there anything major that you feel like we have left out? In the pre-interview, you referred me to a list of notes you had made. I'm just stating this for the recording, so that we know it's here, also. I think that we've covered--

FOEGE: I think I covered most of them, having drawn up this list. I had a chronological list, but what happens is then I get off on a side tangent and--

CRAWFORD: Which is great. That's what we want, yes.

FOEGE: --and then forget where I am, so I could have missed some things because of that. But you know, this turned out to be a far bigger challenge than any of us could have imagined at the beginning. Part of that is based on our decisions rather than on what nature did. Nature was tough enough in this, but then, I think we made some bad decisions along the way. We just could not figure out how to get those reversed.

CRAWFORD: Not including--IPV earlier would be one of them?

FOEGE: Absolutely. At one point, someone raised the question of whether I had a financial interest in Salk vaccine, and it bothered me so much that I dropped out of the discussion for a while. I thought, "I've got enough things to do; I'm not going to get into that." But then I kept coming back because I could not understand why WHO would not reverse their decision. Part of it was this feeling that if they did, they would be saying to the world, "We were wrong at the beginning." You know, that leads you into doubling down rather than correcting.

CRAWFORD: Another kind of stray question that I have, too, is what it was--just to provide context to immunization in the late '70s, early '80s, during part of which time you were director of CDC--what the picture looked like in terms of priorities, especially as AIDS [acquired immunodeficiency syndrome] emerges--whether or not that impacted approaches to immunization, resource allocation?

FOEGE: The immunization program in the United States began improving in 1977 because President and Mrs. Carter, when they got to the White House, invited the former Governor of--[phone rings] oh my goodness, I'm sorry.

CRAWFORD: That's OK. Do you want to take it?

FOEGE: No, no.

CRAWFORD: We can pause.

FOEGE: I didn't even know I had it on. I'm sorry about that.

CRAWFORD: No worries, no worries.

FOEGE: They invited the Bumpers, he was now a Senator [Dale L. Bumpers]. Betty [L.F.] Bumpers and Rosalynn Carter had become friends as governor's wives, and they had worked on immunization. They had dinner, and the question came up, what could they do about immunization in the country? President Carter called Califano the next morning. Califano called me, and he said, "Let's set a ninety percent goal of immunization by school entry."

CRAWFORD: When you heard ninety percent, did that sound like a really high number to you?

FOEGE: It sounded like a very high number. I went to Don Millar, who was head of immunization [at CDC], and he immediately said, "I would not want to see that in my job description." The next day we put it in his job description, and he rose to the occasion and got to ninety percent and ninety-one [percent], ninety-two [percent], all the way up to ninety-five percent. Then we found that you actually have to do this by age two for some of the diseases rather than school entry, but we kept improving.

Then we asked, "Could we interrupt measles transmission in this country?" The answer from most people was no. It spreads too rapidly that it's just unbelievable, that virus. If you take a child into a doctor's office with measles, that child leaves, and two hours later another child comes in, they'll get measles. They've never even seen the case of measles. It spreads so--it's just like a laser beam. It picks out people who are susceptible. But we decided we're going to see if we can get rid of it, and so every week I devoted thirty minutes where the measles people came in and said, "This is what we've found this week."

Every week, there was a new problem. Every week we corrected that problem, and we got to a point finally where we had the first week with no cases of measles. But the last barrier--and this is what I insisted on--was [that] we won't know what the final barriers are unless we choose this as an objective.

The last barrier turned out to be that we were having about two importations a week of measles from other countries, and we didn't even know it. It was all hidden in what was just happening domestically. With that, PAHO improved its program, so we had fewer importations. Now we know that every case of measles is due to an importation from some place. We were able to do that, so immunization became a very important part.

What happened with AIDS was--some people have said the government did not respond well to AIDS. I have a different opinion. I think that the government responded as well to AIDS as it ever did to the Cutter incident or anything else we had. People who make that accusation are following budget lines, and it takes a few years for something to get into a budget line. I can tell you immediately after that MMWR [Morbidity and Mortality Weekly Report] article in 1981, Paul [J.] Wiesner [MD], who was head of [the Division of] Sexually Transmitted Diseases, already had put people out under his money to investigate this. We continued to draw money from epidemiology from other places. There was never any slacking, but--

CRAWFORD: Or competition.

FOEGE: Yes, that's right, or competition with other programs. We put in what needed to be done.

There was a great controversy at first, whether this was due to a virus or whether this was due to using drugs. What finally clinched this was our second case of AIDS in a hemophiliac. The first one we couldn't quite be sure because the person had died, and so we weren't able to tell whether this was a gay man or not. The second one was clearly due to Factor VIII. We knew that day we were going to have problems now with blood transfusions. We kept pouring money into trying to answer these questions.

In 1984, before a virus had ever been isolated, the MMWR came up with what we know and how to avoid getting AIDS. I look back at that, and just on epidemiologic grounds, we knew everything. We were able to give all of the recommendations that we would give now, even with the virus.

CRAWFORD: Even with the knowledge now?

FOEGE: Yes, yes. But I tell you, it was a very worrisome time. I can remember that in January of 2000, I was now at the Gates Foundation, and we had a meeting in Seattle to ask, "Is there any light at the end of the tunnel in Africa?" People were dying so fast that teachers were dying faster than you could replace them. Health workers were dying faster than you could replace them, church workers, and so forth. It looked so unapproachable. We came up with six, what we call "lights at the end of the tunnel," and we were each asked to go back and try to encourage our foundation to get involved.

The Gates Foundation had not been involved in AIDS up until then, so I was delegated to present this to Bill Gates. We went to his office, and as I've said before, it couldn't have started worse because he was angry about a grant request sent to him. He said, "I've told you before, I never want to see something like this again. It's a bottomless pit. If I invest this year, I have to invest for years to come. You've committed me to something that I cannot withdraw from." I was thinking, "That's what I'm about to ask him," and I was desperately trying to figure out, how do I get away with this? I decided all I can do is tell him.

I told him we had this meeting, and we came up with six ideas. I started through them. I got through five of them, and he said, "How much money are you talking about?" I said, "Maybe $50 million a year for ten years." That's a half a billion dollars; that's a fair request. He said, "Oh, it's going to take a lot more than that." That gave me courage to go to number six, which is orphans in Africa. His response was, "You can't worry about AIDS in Africa and not worry about those orphans."

In twenty minutes, when he had started out saying, I never want to see anything like this again, in twenty minutes he approved all six. On the way home with his father, I asked his father, "Can you tell me what happened?" He said, "Well, we all have our inconsistencies." He said, "He knows what he wants, which is a return on his investment, but when faced with the human condition, he'll try to make the right decision." I've always thought that was one of the best things I ever heard at the Gates Foundation, and it came from [William H.] Bill Gates, Sr. [II].

CRAWFORD: That's great. We're seventeen years behind, is something that Alan [R.] Hinman [MD, MPH] said on Friday in the oral history interview. I wanted to get a little bit of your perspective on what it means to set these target dates and then for things to continue after that. How do you view that?

FOEGE: I often say that with smallpox in India, we had these monthly meetings in the endemic states. Each month we would review what the people had found on the ground, and then we would set targets for where we wanted to be a month later. We never once reached our targets until the last month. You have to have targets that would expand what you think might happen, in order to keep you inspired to try to do that. You're much better off failing in a target than not having the target. As one physicist said, "It's much more fun to not catch a big fish than to not catch a small fish."

That's what we do with those targets. These are big fish, and if you don't make it, say you don't make it. Don't come up with excuses; come up with reasons why you didn't make it and how will we correct this for the next time around.

CRAWFORD: Have you felt that there has been a range of responses? Has anyone responded with disappointment? I'm getting at this other question of how you keep people going for this long. It's been such a feat.

FOEGE: Yes, and the question you asked yourself: what would it take to keep people going if you did not do polio eradication? If you every year gave polio vaccine and every year had kids getting polio and every year have iron lungs, then how do you keep people going? This is what I mean by a big fish versus a small fish. You have to be convinced this is worth doing. Garry [Wills] wrote a book called Certain Trumpets [Simon & Schuster, 1995], and it's a book on leadership.

CRAWFORD: Rafe Henderson, I think, mentioned this.

FOEGE: Yes, I referred that book to him. Garry Wills ends up showing that there are lots of different kinds of leadership. Basically, he said you become a leader by having an objective. Then you have followers that say, "Oh, yes, that's what I want to do," and suddenly, you're a leader. It takes different kinds of leaders to inspire in certain conditions. In his book, for each kind of leadership he gives two examples of people who are really good at that and an example of someone that wasn't. He gives only two living people as examples: one is Andrew [J.] Young-- who he sees not because he was a UN Ambassador, but because of the way he provided leadership to the black and white community during the Civil Rights time--and [Henry] Ross Perot, who he said was a good business leader, but not a good political leader. Part of leadership is to continue showing what the objective is and sometimes putting it in new ways that people say, "Yes, it's still possible." In some ways, the feat will be even greater because the problem was greater than anyone realized at the time that they started.

CRAWFORD: Observing polio eradication, can you think of times when the language around polio eradication has changed to keep people going? In terms of communication strategy, or I don't know--wherever else you have seen it.

FOEGE: I think [it's] this idea of making it a global problem rather than a country problem. If we give up now in Pakistan, we have essentially decided we will in the future sometime have problems again in the United States. That's the inevitable result of giving up now. There was a time, I think, when we were focused totally on eradication. Now, we have to be focused on what happens if we don't get eradication, and that's just not tenable. It's just not tenable.

CRAWFORD: The only way out is through.

FOEGE: Yes, yes.

CRAWFORD: I'm thinking of my follow-up questions. Another question, I think we spoke about this in the pre-interview a little bit, was the role in Cuba in establishing for PAHO this kind of base, that eradication is possible or elimination in one country is possible. I wanted to ask if you recall Cuba coming into the conversation about eradication, even if not specific to polio?

FOEGE: I do recall, but I don't know enough of the details. I have been to Cuba, and I have seen their vaccine production and their ability to do things that we were unable to do. You were mentioning AIDS. Before I went to Cuba I was told over and over, they incarcerate people with AIDS, and that's the way they treat it.

I got there and found out that wasn't true at all. People with AIDS were, in fact, put into a health facility while they were worked up, and then they were discharged to their local physician. I went to a reception [where] there was a person in the Rockefeller family. She married a Cuban, went through medical school, and she had patients in her own practice with AIDS. Somehow, we were getting the wrong impression in this country about what they were doing. I ended up very impressed by how Cuba was able to focus on prevention; that they were able to focus on things like vaccines and that they had a medical care system that covered everybody.

CRAWFORD: What have we left out?

FOEGE: I can tell you one of my fears in all these years has been, what if we get a mutation in one of those polioviruses where the vaccine no longer protects. That is my fear every time we have a setback, that it's going to take a little bit longer and a little bit longer, and do we have a risk of a mutation? That's something that we have to keep following. Of course, people are doing that because with every virus that they actually are able to get, they do a full exploration of the nucleic acid.

CRAWFORD: Meaning how long would it take for a mutation to occur?

FOEGE: What if it just occurred overnight, and now it no longer--the vaccine no longer protects against it. How long would it take us to have to get a new vaccine? That's been one of my worries.

CRAWFORD: But it is being addressed?

FOEGE: People are watching for that all the time, yes.

CRAWFORD: Do the chances of a mutation occurring--I guess that you say it could happen overnight--

FOEGE: [Yes.]

CRAWFORD: Really, it's--is there anything that would increase that chance?

FOEGE: It's been so stable. I think that's the positive news. I mean, we have viruses like flu that change all the time. We have parasites like trypanosomiasis that change just all the time. It's hard to get a reading on the antigens because they are able to--but polio has stayed pretty true for as long as people have been able to study it.

CRAWFORD: I guess that has been to the advantage of the eradication efforts. Yes. Is there anything else you would like to include today? This is like a snapshot of--

FOEGE: I'm sure this was more than you expected as it is. But no, I don't think of anything else.

CRAWFORD: OK, that's wonderful. If there were to be an opportunity, would you consider a second interview?

FOEGE: Oh sure, of course.

CRAWFORD: Great, great. Thank you, and we'll close there. Thank you so much.

FOEGE: OK, thank you.