37. Nine Lessons for the Next Generation

Contagious Conversations  /  Episode 37: Nine Lessons for the Next Generation





Dr. Judy Monroe: Hello, and welcome to Contagious Conversations. I'm Dr. Judy Monroe, President and CEO of the CDC Foundation and host of today's conversation. Every episode, we hear from inspiring leaders and innovators, who make the world healthier and safer for all of us. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and prevention save and improve more lives.

Joining me today are Dr. Bill Foege and Dr. Mark Rosenberg. Dr. Foege is a renowned physician and epidemiologist, well known for his contributions to the eradication of smallpox in the late 1970s. A former director of the CDC, Dr. Foege has spent his career as a champion for science and management of vaccines and vaccination.

Dr. Mark Rosenberg is a physician scientist, trained in infectious diseases, psychiatry, and public health, who served as the founding director of CDC'S National Center for Injury Prevention and Control, and as the US assistant Surgeon General. Dr. Rosenberg was president and CEO of the Task Force for Global Health from 2000 to 2016. Under his leadership, the task force has been instrumental in providing people in the developing world with greater access to vaccines and critical medicines.

Through the Center for Global Health Innovation, Drs. Foege and Rosenberg co-developed a project called ‘Becoming Better Ancestors™: 9 Lessons to Change the World,’ dedicated to solving global health concerns and creating positive change for future generations.

Let me get started with a question for you, Bill. What are the nine lessons you have learned from the eradication of smallpox?

Bill Foege: Thanks, Judy, for having us. Of course, there are many lessons from smallpox eradication. I suppose we can name a hundred, but we selected nine that are so important, but also go beyond smallpox, beyond public health, to life in general. I put them in three categories.

The first category, basic lessons that everyone knows. Number one, it's a cause and effect world. This is not a world of magic. There are reasons why things happen. In infectious diseases, we try to figure out what those reasons are so we know how to prevent them in the future.

Number two, know the truth. It's related to the fact that it's a cause and effect world. There are so many times that I did not want to know the truth because it was so overwhelming. I can remember in India, the first search that we had of villages, we didn't expect to find many cases. It was a low point of transmission, but in six days, we found 10,000 new cases of smallpox that no one knew about.

Number three, then, is that coalitions are necessary. We can't do anything alone. It's an old lesson. Polymius taught us that 2000 years ago. It's an old lesson.

Then there are a category of three things that cause us pause. Number one is avoid certainty. It's Richard Feynman, the physicist who made that so clear. He said, ‘Physics is the most certain of sciences, and we're not certain.’ He said, ‘It's a shame that politicians and theologians may be so certain they try to prove that they're right’ but he said, ‘In science, we have to avoid certainty. It's the Achilles heel of science.’

The second thing is that if we're not certain, build an evaluation, and see what is really happening, rather than what we hoped would happen, and then continuously improve as we find out what is going on.

The third lesson in this category is respect the culture, that if you try to fight culture, you'll always lose. It's something we learn often in retrospect, I wish I hadn't done that, but respect the culture. Then when you've gone through these six lessons, we're sort of at a point of go for it. The last three lessons, number one, combine the science and the management. The science gives us the best answers. The management gives us the best results. How do you put those two together? The third lesson in this category is respect the culture, that if you try to fight culture, you'll always lose. It's something we learn often in retrospect; I wish I hadn't done that, but respect the culture. Then when you've gone through these six lessons, we're sort of at a point of go for it.

The last three lessons: number one, combine the science and the management. The science gives us the best answers. The management gives us the best results. How do you put those two together?

The next lesson though is get political support. Oftentimes, in public health, we are upset with a political decision. Well, we have to recognize we're totally dependent on politicians. They're the ones that provide us with the resources. We have to get them invested in the outcomes, so that they're not just funding us, they're funding an outcome that they have already bought into.

Finally, the last one is move to a global solution. Every place is both local and global. Therefore, any place you're doing public health, you're doing global public health. The objective is to get global health equity.

Judy Monroe: Those are such powerful lessons. I'd like actually to talk with both of you about with these powerful lessons, how did you see those lessons being applied, or maybe not applied, to the public health response during COVID-19? Bill, do you want to start with that? Then over to Mark?

Bill Foege: Thank you. Yes. I'll be very blunt about this. I think that the Trump White House violated every one of those nine lessons. Right from the beginning in one press conference, you could hear two different truths, quotes, right to the last one, where they withdrew from WHO in the middle of a pandemic. It is just unconscionable. I think what the Trump White House actually did was add a 10th lesson, that lessons are useless if they're not used.

Mark Twain told us that the person who doesn't read has no advantage over the person who can't read. The country that doesn't use the lessons is no better off than a country before the [inaudible].

Judy Monroe: Well, thank you for that. Mark, what are your thoughts on these lessons being applied or not applied during COVID?

Mark Rosenberg: Well, thanks, Judy. I think one of the striking parts of the COVID pandemic was in terms of knowing the truth. We not only felt compelled to learn more about the virus, about its spread, about the epidemiology, but there were people who were actively fighting against learning the truth. We had human enemies to learning about this virus, people who spread falsehoods, and the people who got people stirred up with their mistruths. We had not been used to that big of a fight in one of our acute pandemics and epidemics. It touches on the next lesson, which is respect the culture.

I think one of the things that caught us by surprise were that so many people were vaccine-hesitant and were resistant to getting vaccinated. We did not know as a country how to deal with that. I think there's the third lesson now: coalitions. I think rather than mask together all the people who are in favor of vaccination to try and overwhelm the holdouts, we should have brought the holdouts in with us. We should have made them part of our coalition.

I think it's much better there. A simple statement about that and the culture is the idea that it's much better to have the camel inside the tent peeing out, than outside peeing in. I think that was such an important lesson from this COVID pandemic.

Judy Monroe: I agree completely on that. Mark, you've really had a public health career that's included leading the National Center for Injury Prevention and Control at CDC, leading the Task Force for Global Health, and serving as an assistant surgeon general. You've been a vocal advocate for global health collaboration. Can you unpack more about coalitions, the role that coalitions play in becoming a better ancestor?

Mark Rosenberg: I think coalitions are so important, and really the way that we go about collaborating with people is coming together to work together. Coalitions are like I would describe a marriage or a partnership. They're very easy to get into, but it's very hard to make them work. It takes a very clear approach to them and tenacity to stick with it. I think we learned that there are really five essential parts of forming an essential coalition.

The first is you have to identify a clear overriding goal that you all subscribe to. When the going gets tough, it's going to be having a common goal that keeps you together. Second, you need a strategy for how you're going to reach that goal. Third, you need to know the membership. Who's in? Who's out? Who do you need to be inside that tent? Who do you need to be in your coalition to make it effective? Next, you need the structure.

It doesn't need to be an elaborate organizational chart like a huge bureaucracy might have, but you need to know who's going to be responsible for different parts of what you do, and how you're going to run your meetings. The last part, in addition to the goal, the strategy, the structure, the membership, is the management. How are you going to manage your meetings, and how are you going to manage your projects? For successful coalitions, you really need all of these to be decided at the beginning.

Our tendency is to say, ‘Oh my gosh, it was hard enough getting those idiots here to sit at the table with us. Don't make me work with them to get agreement on these things.’ If you don't do it at the beginning, your coalition will probably fail. Coalitions are very important, and there are ways to make them work. I don't think we can get there without them.

Judy Monroe: Yeah, no, I completely agree. I love how both of you have emphasized the importance of management to actually get things done to be effective. Bill, you were an epidemiologist in Eastern Nigeria, and you pioneered a technique known as surveillance containment to combat the spread of smallpox despite vaccine shortages. Let's talk a bit about that approach. Is that an approach that can be applied to outbreaks today?

Bill Foege: I was called to an outbreak actually the month before the program was to start at the CDC program on smallpox eradication and measles control. We didn't have our supplies as yet, but I had been living in Eastern Nigeria. That's why I was there. We went to the outbreak and our ordinary response would have been just vaccinate everybody, put as wide a circle as we can around this outbreak. We didn't have enough vaccine.

We were faced with how to use a small amount of vaccine most efficiently. We actually sat around that night, asking what would we do if we were a smallpox virus bent on immortality. What would we do next? What we did was to get missionaries on the radio that night. We gave them each a geographic area, asked them if they would send runners to the villages to see if they had smallpox or not. 24 hours later, we got back on the radio with those same missionaries, and we knew exactly where smallpox was.

We had a surveillance system that exceeded anything I can imagine even doing in the United States in 24 hours. It was just remarkable. We used most of our vaccine in those villages with smallpox. We used the remainder of the vaccine where we thought smallpox might spread next. We found three areas where there were markets, and we vaccinated them. It turned out that smallpox was already incubating in two of the three areas, but by the time we got the first cases, everyone had been vaccinated right there.

That outbreak stopped so fast, it surprised us. We began asking, ‘Could we do this in a larger area?’ We did. We did it in an area of 12 million people, and then from there to other places in West Africa. We did not come up with a new strategy. I have to emphasize that, because we're credited with that sometimes. No, this was part of the WHO strategy. It was the second half of the WHO strategy. The first half was mass vaccination to bring down the incidents of smallpox, and then concentrate on the outbreaks.

What we found was you could eliminate that first part of the strategy totally, save a lot of money, save a lot of time. We finished the 20 countries of Western and Central Africa, where we had a goal of getting rid of smallpox in five years. We did it in three years and six months and under budget.

Judy Monroe: That's remarkable. I'm just envisioning you all sitting down saying, ‘Let's think like the smallpox, if we were a smallpox virus,’ which I think Mark also speaks to what you were saying about the camel under the tent, that we need to make sure that we're thinking like those that may hold different opinions than ourselves.

Mark, in December, the Center for Global Health Innovation announced the launch of Becoming Better Ancestors™, a project committed to solving global health challenges and creating positive change for future generations. Can you talk to us a little bit about the impetus for this project, and how it's being used, and what do you want to achieve with this project?

Mark Rosenberg: In 2020, it was the 40th anniversary of the eradication of smallpox. We decided we'd have a huge celebration, a big conference to celebrate that important event. We thought, this is so important. It's really the holy grail of global health. It was the most important, most spectacular achievement ever. It's worth commemorating. We planned the conference, bringing together a lot of the still-alive smallpox warriors who fought that original battle from all around the world.

Then came COVID, and we couldn't have the conference. We had to cancel the conference. We couldn't even just postpone it. We decided that these lessons are very important and we want to pass them on. We said, ‘Let's put them together, let's organize the lessons, and let's get them into the hands of the future leaders of global health.’ I will tell you two very short stories of why that was important to us.

The first is about the Vasa in Sweden. In the 1600s, they were fighting invaders from across the sea, and they decided that they would find a way to beat them. They would not only build a ship with cannons all around it, but they'd build a multi-decker ship with three layers of decks and cannons in each layer. It took three years of the treasury to invest in this, to build it, but finally, it was done. On a big celebratory day, the Vasa sailed out of the canal and into the sea, where it rapidly tipped over and sunk.

All the families were there to celebrate. They watched this happen. It was a horrific event. What was supposed to be a celebration was a tragedy. No one heard about the Vasa in my lifetime until the last century. A few fishermen were fishing along that canal and they pulled up some wood, some wooden railings. They went down and looked, and lo and behold, it was the Vasa. They didn't know what this was. Why didn't they know? People forgot. They forgot about the Vasa.

When I asked someone in the street, how could they have forgotten this thing that was so important? They said, ‘Whenever anything happens, there's only three generations that remember: the generation that did it, their sons and their daughters, and their grandchildren. After three generations, it's forgotten.’ We decided these lessons were too important to forget. Not only was there a risk of forgetting these lessons, but people, like after a terrorist bombing, for example, they tried to clean up as quickly as they can, so that the remains of the bombing are not there to terrorize people. They get rid of all traces of it.

This COVID pandemic, if you remember in the beginning, it was terrorizing. People were dying on respirators, isolated in their hospital rooms, short of breath and dying short of breath. It was a terrorist event. The risk is that people will try to clean up after that pandemic, not only clean up, but disassemble the very mechanisms that were put in place to protect us for the next time. We decided that the lessons are too important to forget.

Something I always remember that you told me, Bill, you were once on an airplane and you were riding next to the woman who had invented or developed the concept of hospice care. You asked her, as you were want to do, what was the one most important thing you learned from your experience? This really stuck with me. She said, ‘You don't have to be there at the very end when the person takes your last breath, but it's important that you've achieved closure. You could do that a day before, a week before, a year before. That's what's important, not that you're there at the very moment.’

Your quest to find the most important thing that people know, you asked lots of people that question, what's the most important thing? I think it strikes me, this is your way of saying, ‘This is the most important thing I've learned.’ It strikes me that this framework, Becoming Better Ancestors™, is the most important thing you've learned after an unbelievable career in global health. To me, these lessons are so important. It's the way that we're going to not just pass something onto future generations, but save future generations.

That's why Becoming Better Ancestors™, Judy, is so important. I think for us and for the whole team working on this to make sure it doesn't get swept away with the most recent pandemic, but gets kept and used to protect future generations.

Judy Monroe: We'll be right back with Dr. Bill Foege and Dr. Mark Rosenberg.

Becoming Better Ancestors™ is premiering a free original virtual series and curriculum, called Nine Lessons to Change the World. Based on lessons learned from the successful effort to eradicate smallpox, the curriculum focuses on nine simple, proven and reliable ways to approach global health threats. The complete virtual learning series and curriculum are now live at Ninelessons.org

Now, back to our conversation with Bill and Mark.

You both are such amazing storytellers and we learned over the centuries, we've learned from storytelling, as you talk about the families passing down the stories, but if those stories are buried and not lifted and carried forward, yeah, we've lost so much. Bill, just to build on this, what does it mean to you to become a better ancestor? Can you paint a picture for us? What's in your mind about that?

Bill Foege: Well, Mark points out that that was Dame Cicely Saunders who started hospice, and what a lesson that she taught. It was really Jonas Salk that introduced me to this idea of Becoming Better Ancestors™. That's the title of his talk that he gave in the Nehru lecture decades ago. He said, ‘It's important to be a good citizen. We all should try to do that, but it's even more important to be a good ancestor.’

When I think of becoming a good ancestor, what I see in my mind are faces of children 300 years from now, trying to get my attention, because they've given me their proxy. They're pleading, ‘Please make the best decisions you can for us.’ It's easy for us to make a good decision for ourselves and for our family, for our loved ones, but it's very difficult. Time and space put us in a difficult position to make good decisions for a child 300 years from now.

That's what we have to think of, that we have their proxy. We have so much power because of that proxy, but we have to use it well.

Judy Monroe: That's so well, so well stated. I'd like to end with a question for both of you. What do you believe it will take for global public health to stay ahead of future public health threats? Bill, I'll let you take this one first, and then to Mark.

Bill Foege: Number one, it requires everyone in my master of public health class, our president was from Nigeria, Yemi Ademola, and he wrote in the yearbook, ‘There's no area of knowledge beyond the interest of public health people.’ I thought that really captures what we should be thinking about, but it also means there's no specialty beyond the interest of public health, that we're all contributing to the improvement.

Number two, it requires better surveillance than we have now. If we look at the last 30 emerging infections, 75% of them involved an animal, or a vector, or both. Our surveillance systems at CDC and at WHO do not generally include animals. It's an ad hoc thing. When we have a problem, we add specific animal surveillance. This one world concept is something that we should take very seriously. How do we get surveillance that really covers animals and humans?

Third, we need resources. The last time I appeared in an appropriation hearing, I was asked the question, ‘What would you do about resources if you could, for public health?’ I said, ‘Number one, I would index them to healthcare expenditures, because healthcare expenditures keep going up every year.’ Public health is always a struggle. I said, ‘I don't even care what the present percentage is. Leave it at that and keep it there, because it keeps going down,’ so that if we're indexed to health expenditures, this would improve public health.

It also shows the importance of politicians. They have to be invested in this. A fourth lesson would be to balance numerators and denominators. In simple terms, people often say that the numerator includes the people who go to the hospital or clinic, but not others. The denominator is the rest, and public health deals with the denominator. In truth, the denominator includes both the numerator and the denominator. Public health is actually responsible for dealing with both.

Fifth, use the technology that we have. We know that one of the best outcomes for students falls back to, did they have a mentor? In the United States, when you do surveys, you find only about 25% of college graduates think they had a mentor. That's just a tragedy. It's the mentor that inspires you to a philosophy, helps you with your skills and so forth. Every graduate of a school of public health should have a mentor. I like to say, schools should be doing what refrigerator manufacturers do. They provide a product with a warranty.

If every school felt that they had a warranty, that they have to have a mentor, so those students can come back to contact someone that has contact with the entire field to help answer their questions. I think that this is a very important thing. We all share the objective of global health equity. Three words. If you take any of the three words away, it doesn't mean the same thing. You can add 200 words and you don't improve it. Global health equity is our objective.

Judy Monroe: Wow. So well stated. Every student across the world should listen to this podcast and listen to your wisdom. Mark, over to you on the question of what's it going to take for global public health?

Mark Rosenberg: I think there's some important things in looking to the future. I think Bill was talking about the importance of mentors. I want to take this chance to thank Bill. He's been an extraordinary mentor for me for more than 40 years. Bill, I love you for all the things you've done, for what you've taught me, and for who you are. I think I also want to point out that it was when Bill was at the Task Force for Child Survival, that the CDC Foundation had its roots.

I want to thank CDC where I learned so much, but also the CDC Foundation. I think you, Judy, have done an extraordinary job in leading this foundation, way beyond what Bill and his colleagues thought it could ever become. You bring an extraordinary set of experiences and passion to this job. Thank you for everything you do. I want to talk about, I guess the lessons, three points that I would make.

The first is that these lessons, although this is called contagious podcasts or Contagious Conversations, these lessons apply to non-infectious disease problems. I have worked for a long time in the area of violence prevention. We've seen, in the last three days, three mass shootings in one state, the state of California. While some people think that this violence is imitated and there are copycat killings, it is not an infectious disease problem, but it's something that these lessons absolutely apply to. Many non-infectious disease problems could benefit by applying these lessons.

Second, I want to say that it's very important, one value of coalitions is it brings us together with people who may start out as our opponents. We have so much to learn from people we start out on opposite sides of the table from. I learned a lot about gun violence prevention from someone who started out as my arch enemy, the Congressman, Jay Dickey. We came to talk to each other, to learn from each other, to trust from each other, and in the end, to love each other. It was extraordinary.

He really taught me what I think are the secrets of being able to move forward in this area together to prevent gun violence. We can learn from our opponents if we bring them into the tent, into our coalition, and give up on the notion of certainty. As Bill said, it's the Achilles heel of science. It's also the Achilles heel of public health. When we think we know absolutely the right thing and we have the right answer, we really cut ourselves off from progress and the truth.

Third, I think that equity means we have compassion for those who are the least well off, the poorest people, and the most distant, and poorest places, and that we don't just take public health measures to protect our country from threats over there. The reason we care about what's going on in the Congo or in China is not just to protect ourselves from those threats of Ebola or COVID, but it's because we care about those people. When things happen to them, when they suffer, it diminishes us. That part of equity is compassion for the people that we think it's important to help.

I think these lessons that we talk about, global health equity being the cornerstone, we also include the idea of compassion and caring about those people, wherever they might be. Again, I think these lessons carry a tremendous amount of value and truth, and not just scientific, quantitative value, but moral value and ethical values that are embedded in this. Bill always says that the best science is science with a moral compass.

I think these lessons, in addition to guiding us how to proceed and solve problems, also give us a moral compass. That can be so important.

Judy Monroe: Thanks for sharing that. I have to tell you, both of you have been mentors to so many people, role models, and have inspired so many. On a personal note, I was a brand new state health officer in Indiana, and Bill, I read one of your speeches. I remember reading that and being so inspired. I thought, who is this Bill Foege? I didn't know you until I had gotten into public health and started following your wisdom. You're just so inspiring.

Mark, I have to tell you, the story about your relationship with Congressman Jay Dickey, that just so powerful that. Folks should read more about that, the relationship that you all had, the way you started as arch enemies, as you said, and ended up you gave his eulogy at his funeral. Both of you just have so many powerful stories. I just want to thank you so much for inspiring me and inspiring generations, and I can't think of anything more powerful than becoming a better ancestor.

Thank you for the project. Here at the CDC Foundation, we're going to do all we can to help advance, advance the project, make sure folks know about it. Thank you very, very much.

Mark Rosenberg: Thanks, Judy.

Bill Foege: Thank you, Judy.

Mark Rosenberg: Thanks for the chance to talk about these things and be with you.

Judy Monroe: Thanks for listening to Contagious Conversations, produced by the CDC Foundation, and available wherever you get your podcasts. Be sure to visit CDCfoundation.org/conversations for show notes. If you like what you just heard, please pass it along to your colleagues and friends. Rate the show, leave a review and tell others. It helps us get the word out.

Thanks again for tuning in, and join us next time for another episode of Contagious Conversations.