Watch: Thinking Big in Public Health, Inspired by the End of Smallpox
One of humanity’s greatest triumphs is the eradication of smallpox. Many doctors and scientists thought it was impossible to eliminate a disease that had been around for millennia and killed nearly 1 in 3 people infected. Smallpox is the first and only human disease to be wiped out globally.
KFF Health News held a web event Thursday that discussed how the lessons from the victory over smallpox could be applied to public health challenges today. The online conversation was led by Céline Gounder, physician-epidemiologist and host of “Eradicating Smallpox,” Season 2 of the Epidemic podcast.
Gounder was joined by:
Helene Gayle, a physician and epidemiologist, is president of Spelman College. She is a board member of the Bill & Melinda Gates Foundation and past director of the foundation’s HIV, tuberculosis, and reproductive health program. She spent two decades with the Centers for Disease Control and Prevention focusing primarily on HIV/AIDS prevention and global health.
William “Bill” Foege was a leader in the campaign to end smallpox during the 1970s. An epidemiologist and physician, Foege led the CDC from 1977 to 1983. He appears in the virtual learning series “Becoming Better Ancestors: Applying the Lessons Learned from Smallpox Eradication.” Foege is featured in Episode 2 of the “Eradicating Smallpox” docuseries.
click to open the transcript Transcript: Thinking Big in Public Health, Inspired by the End of Smallpox
Note: This transcript was generated by a third-party site and may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the web event.
[The video trailer for season 2 of the Epidemic podcast, “Eradicating Smallpox,” begins to play]
Céline Gounder: Bangladesh 50 years ago, we were on the cusp of something big, something we had never done before. We were about to wipe smallpox off the planet. It’s one of humanity’s greatest triumphs. One public health has yet to repeat. I’m Dr. Celine Gounder. I’m a physician and epidemiologist.
This season of Epidemic, we’re going to India and Bangladesh, where smallpox made its last stand, to understand how health workers beat the virus. The question I’m asking, “How can we dream big in public health again?” From KFF Health News and just human productions, Epidemic, eradicating smallpox. Listen wherever you get your podcasts.
[Video trailer ends]
Céline Gounder: Good morning everyone, and thanks for joining us today. I’m Dr. Celine Gounder. I’m editor-at-large for Public Health at KFF Health News and I’m the host of the Epidemic Podcast. In today’s conversation, we’re going to talk about lessons to be learned from the eradication of smallpox and how those can be applied to public health challenges today. The eradication of smallpox is one of humanity’s greatest triumphs. Many doctors and scientists thought it was impossible to eliminate a disease that had lasted for millennia and killed nearly one in three people infected. Smallpox remains the first and only human disease to be wiped out globally.
Just a few logistical details before we get started. The briefing is being recorded and the link to the recorded version will be emailed to everyone later today. We also have ASL interpretation available. To access it, please click on the globe icon in your Zoom control panel and select ‘American Sign Language.’ A screen will appear and you will be able to view the interpreter. Questions should be entered using the Q&A function on Zoom and can be sent in during the discussion.
I’d like to move forward with introducing our panelists today. Dr. Bill Foege is an epidemiologist and physician and was a leader in the campaign to end smallpox during the 1970s. Foege is featured in episode two of the Eradicating Smallpox docuseries, and he’s also featured in the Nine Lessons series produced by the Becoming Better Ancestors Project. The Nine Lessons, available at ninelessons.org, is a virtual learning series about how the lessons from smallpox eradication could be applied to COVID and other public health and societal challenges.
Also, joining us today is Dr. Helene Gayle, who’s also an epidemiologist and physician. She’s the president of Spelman College. She’s also a board member of the Bill & Melinda Gates Foundation and past director of the Foundation’s program on HIV, Tuberculosis and reproductive health. She spent two decades with the Centers for Disease Control and Prevention, focusing primarily on HIV AIDS prevention and Global Health.
So welcome and thank you for joining us today, Bill and Helene. I’d like to start with talking about some of the challenges we face in science communication. And as we’ve seen during the COVID pandemic, one of the big challenges is balancing reassurance with uncertainty. And before I ask you my questions, I’m going to play a clip of Dr. Tony Fauci speaking about this as part of the Nine Lessons series. So let’s give that a listen.
[Video clip from the Nine Lessons series begins to play]
Tony Fauci: If you have a static situation with nothing changing and you get one opinion one day, and then a week later you change, that’s flip-flopping. When you have a dynamic situation that’s evolving week to week and month to month, as a scientist, to be true to yourself and to be true to the discipline of science, you have to collect data as the situation evolves, which almost invariably will necessitate your changing policy, changing guidelines, changing opinion. And that’s exactly what happened with things like mask wearing. We didn’t know until weeks and weeks into the outbreak that a lot of the transmission was by people who were without symptoms. It was that that made the CDC and all of us say, “We really don’t need to be wearing masks.” As soon as we found out that, A, there was no shortage, B, we were getting good data, that outside of the hospital setting masks did work, and three, we found out that 50% of the infections were transmitted from someone who had no symptoms. When you put all those three things together, then the science tells us everybody should be wearing a mask.
[Video clip ends]
Céline Gounder: Bill, how did this play out in the smallpox eradication program, specifically this idea of scientific certainty, uncertainty, and science communication?
Bill Foege: This is actually a balance that goes far beyond public health and medicine and almost everything we do. And on the one hand, you have to have enough certainty in order to get other people to follow you. There’s a book by Gary Wills on Leadership, and it’s entitled Certain Trumpets. He takes this from the Bible verse that says, “If you hear an uncertain trumpet, who would gird for battle?”
So you have to have enough certainty. The other side of that though is Richard Feynman, the physicist who said, “Certainty is the Achilles heel of science.” If we believe something is true, we stop looking for other answers to why this is happening. And I think in smallpox, we always tried to present certainty in what we were doing. And all the time we worried about what could go wrong, what if we lose political support? I didn’t see HIV coming, but boy, if I had, that would’ve been a big problem to deal with.
Céline Gounder: Helene, don’t you think public health officials should still be confident in expressing, particularly in an emergency, what we know and their recommendations for managing a public health crisis, and how do you balance that confidence and reassurance with the lack of certainty?
Helene Gayle: So I think, and building on some of the things that Bill said, I think part of it is building the confidence in the communicator. And I think one of the things, and I point to Tony Fauci, is one of those people who I think Americans developed a sense of confidence with him because of his willingness and ability to say when we were wrong and what we know and when we knew it. And so I think recognizing that a lot of this is about building trust and building trust in the message as well as in the messenger. I think that’s where some of the ability to be confident, letting people know that you’re trying to give them the information as soon as you have it, but also being honest that this is evolving.
A message is just a slice in time. And I think it’s important that we remember that we’re creating a narrative every time we open our mouths and thinking about what’s the narrative that we’re creating and being consistent in that narrative. So I think the consistency, building that trust, being able to say what you know and what you don’t know is what really I think builds the confidence in the messages. I think what we saw through this pandemic as well, the COVID pandemic as well as past, are people who are unwilling to admit what they know and what they don’t know, unwilling to go back and explain why we said something when we said it and why we’re making that explanation of why we’re now changing, as I think Tony Fauci did very clearly about mask wearing.
So I think all of those things that really are about building trust and confidence are what can make us better in our communication as public health officials.
Céline Gounder: So it still amazes me that the global health community decided to take on smallpox eradication. We often hear about sustainability, cost-effectiveness, those kinds of economic concepts. What does it mean, Helene, for a program to be sustainable? And when we say sustainable, for whom?
Helene Gayle: Well, I think what we hope when we talk about sustainability is that efforts that are important for the short run can be sustained over the long run. And I think what we see so often in public health is that we have this massive surge of resources, personnel, effort, that then we let go of in between times.
So each time we have a pandemic, we have to create this big surge all over again. What we need in public health is to be able to have that kind of long-term, sustainable approach, understanding that there will be times when we have to have those surges, but not letting everything go in between time. When you say for whom, it’s really about how do we create a system and have a system that is in place that gets us not only at the times of great need and crisis, but is there for the public’s health for the long-term. And that’s what I hope we can move to as we think about public health in America and around the world.
Céline Gounder: Bill, does that sound like that’s a “sustainable goal” and should we be setting our public health goals based on what some think is sustainable or not?
Bill Foege: Well, sustainability is a problem that I often had because people require evidence of sustainability before they’ll fund something, but you don’t know what is sustainable until you try and do it. One of the lessons that I learned in the seventies was, in this country, the appropriations for measles would go up when there were lots of measles cases and they would go down when cases were reduced.
And inevitably, when they would go down, then the numbers had come up again. And so we had these variations. And we made a decision in the 1970s what would happen if we could interrupt transmission once, and that changes everything. Now the norm would be no transmission, and you could sustain the appropriations and it worked. We finally did that. So sustainability is something that bothers me. The pragmatists demand this, and I understand where they’re coming from, but there was a fellow by the name of Harlan Cleveland who was an American diplomat. He was our ambassador to NATO for many years. And late in his life, he became interested in global health and he was astonished at what happened with so few resources. And he came to the conclusion that global health workers are fueled on unwarranted optimism. And I like that phrase, because that is in fact what we do, is we become very optimistic and we make something happen that could not have been foreseen, that it would happen.
Céline Gounder: So this also reminds me about a conversation we had on the podcast with, believe it or not, a science fiction writer. Her name is adrienne maree brown, and we spoke with her about how she imagines world’s, possibilities different from our own. So let’s hear a short clip of that now.
Where do you find the inspiration to think up, to dream up the world’s that are so wildly different from our present reality?
[Audio clip from episode 1 of the “Eradicating Smallpox” begins to play]
adrienne maree brown: Saying that stuff is just the way it is. That’s one of the greatest ways that those who currently benefit from the way things are keep us from even imagining that things could be different. For centuries in this country, we were told that slavery was just the way things are and that it could never be any different. And yet there are people in those systems who said, “This isn’t right, this isn’t fair. Something else is actually possible.”
So a lot of the work of radical imagination, for me, is the work of saying, can we imagine a world in which our lives actually matter and we structure our society around the care that we can give to each other, the care that we need.
[Audio clip ends]
Céline Gounder: Bill, you just talked about unwarranted optimism and you told me once, in fact, I think more than once to bet on the optimist. But to go back to what you were saying about the pragmatist, doesn’t it make more sense on some level to be pragmatic and realistic if you want to get things done? And how would realism have gotten in the way of efforts to eradicate smallpox?
Bill Foege: Well, I think realism would have kept us from trying many things that we’ve tried. And the clip you just showed about an imagination that goes beyond realism is so important. If I would be director of CDC again, if I had a problem, I would try to get six comedians to come to CDC and I present them with the problem because they think in a different world than realism. And so I think it just makes sense to be unrealistic that we can do these things.
Céline Gounder: Helene, what about you? How did you balance thinking big versus being pragmatic when you were leading public health programs over the course of your career?
Helene Gayle: Well, I didn’t bring in comedians, but I think maybe I missed the boat on that. I love that idea. I like to think that I was able to combine the two. I think if you don’t think big, you will only achieve small progress. So I think you have to have big goals, but big goals can also be chunked into bite-sized pieces. So I think mixing the practical of what are the short-term games that are necessary to get to those big goals, both, give you a sense of what’s pragmatic and possible, but also keeps you inspired towards the bigger goal.
I think it’s also the case in public health where oftentimes we are operating with very difficult political situations. And again, sometimes you have to be the realist and understand what the limits are, but at the same time not give up on what’s your ultimate goal, what’s your ultimate vision, and keeping that front and center, it’s incredibly important, particularly as we think about how we inspire, back to the unwarranted optimism, how we inspire public health workers to keep going. People don’t get inspired by the short term, “Did I get my stock in today?” They get inspired by, “I’m part of eradicating a disease or stopping a pandemic.” So I think we have to combine the two.
Bill Foege: I might say that in India, we would have a meeting every month in the endemic states and go over what we had learned that month, and we would end the meeting by setting goals for the next month. We never once reached those goals until the last month. They were always beyond what we could do, but they gave us a vision of what we hoped we could do.
Céline Gounder: So this also reminds me of another aspect of goal setting. In another episode of the podcast, we spoke with a global health expert, Dr. Madhu Pai at McGill University, and he pointed out that historically it’s been white men in Europe and in the United States who’ve really driven the agenda in global health. Here’s just a short clip from Madhu.
[Audio clip from episode 2 of the “Eradicating Smallpox” begins to play]
Madhukar Pai: We need to flip the switch and recenter global health away from this, what I call default settings in global health, to the front lines. People on the ground, people who are Black, indigenous, people who are in communities, people who are actually dealing with the disease burden, people who are dying off it, people who have actually lived experience of these diseases that we’re talking about, having them run it is the most radical way of re imagining and shifting power and global health.
[Audio clip ends]
Céline Gounder: So Bill, who set the smallpox eradication goals? Was this local or global experts or both? Was it local communities and how were those different perspectives weighed and balanced in the program?
Bill Foege: Well, the global goal was set by WHO. It was originally conceived by the Soviet Union and presented to WHO, and it got only three votes the first time. Later, when the Soviet Union and the United States combined their efforts, they were able to convince the World Health Assembly and WHO took this on. So the global goal was set by WHO, but countries had the ability to say no. And Ethiopia went for a long time not becoming part of the program, they had other priorities. And these are legitimate priorities that World Bank once had a discussion on whether we should get into polio eradication or not. And I agreed to be part of the debate, even though I hate debates. I agreed to be part because I wanted to know what were the strongest arguments against polio eradication. And for me, there were two of them.
One was that this would distract from other global health efforts. People would focus on this. But the other one came from an African leader who said, “This is neocolonialism. You’re telling us how to spend our money on a disease problem and not allowing us to make that decision.” My counter to that was, “I understand that, but I also understand when Gandhi said his idea of the golden rule was that he should not be able to enjoy what other people could not enjoy.” And so I said, “If I can enjoy the fact that my children, my grandchildren, and now my great-grandchildren are free of polio, I have an obligation as a parent to share that with everyone.”
Céline Gounder: Helene, very often it’s scientific experts, physicians, epidemiologists who really lead the goal setting. Is there anything wrong with this technocratic approach to public health goal setting, and isn’t that just “following the science?”
Helene Gayle: Well, it’s obviously following the science at a macro level, but I think, while it’s important to set these global goals and these big overarching goals, it’s also very important to listen to the people whose health we’re actually trying to have an impact on. And I can remember, during the HIV pandemic, where once people realized how important it was to mobilize resources, there was an unprecedented amount of resources available for HIV, and we got from several countries around the world, the pushback just as Bill was talking about, because they said, “Malaria is a bigger problem for me. We have more people who die from malaria, from measles, from other infectious diseases. So where are our resources for the things that are making the biggest difference for our people?”
So I think it’s great to set the global goals and to be able to have these big overarching goals, but we can’t do that in the absence of also listening to the national and local needs and making sure that we’re thinking flexibly about how we use our resources so that what we do really meets the greatest needs of people on the ground.
Céline Gounder: Bill, you once quoted Einstein to me who said, “Perfection of means and confusion of goals seem, in my opinion, to characterize our age.” So are government officials and public health leaders somehow confused about public health goals while being overly focused on perfecting public health tools?
Bill Foege: I think so. You can’t stop scientists from trying to enlarge their area of knowledge. This is what scientists do. They try to figure out what is right and what is wrong. And so yes, we do confuse this. And it doesn’t matter whether you’re talking about a person, a state, a nation or the world, we devalue health until the day we lose it, and then suddenly it becomes so important. And so this idea of conveying what should happen ahead of time so we don’t lose health is problematic. But yes, it’s much easier to concentrate on the specifics and lose our sight of where we’re actually going with this.
Céline Gounder: Can you just give an example of this attempt to perfect a public health tool?
Bill Foege: Well, with vaccines, you see that people keep improving the vaccines, but don’t improve how to get them to everyone. The clip you showed on white people, mainly white men, making the decisions on global health in the past, is so true. And I’ve just finished reviewing the history of global health, and I think the one thing that was most destructive of global health was colonialism. Some people try to justify it on the basis of it brought new science and so forth, but just think of this country and the fact that colonialism killed off so many people that the slave trade became so important.
And so today, we’re still operating with the effects of colonialism in this hemisphere. Not seeing the vision of the big goal and concentrating on small things, it’s easier for all of us to do.
Céline Gounder: Helene, do you agree that public health officials are confused about the goals? And if so, why and how?
Helene Gayle: Well, I think it’s hard to talk about public health officials as a monolith, and it’s part of the challenge, particularly in this country, is that we have such a disjointed public health system. And I think we would benefit from having a much different public health system, such that people can individualize their roles, what they want to focus on, et cetera. But at a national level, and I would argue even at the global level, that there is a system that is consistent about what’s most important and what’s most important to deliver on.
So I do think that there’s a lot of inconsistency in our system. I think we have a fragmented public health system, and we would really benefit by having something that really had a much more of a network that is coordinated than what we have today.
Céline Gounder: I just got back actually from vacation in Morocco and I happened to be staying in the Medina in Marrakesh the night of the earthquake. And it’s now been estimated that nearly 3,000 people have died in that earthquake or from that earthquake, to date. I felt it, but the building where I was staying sustained hardly any damage. And to date, I haven’t heard of any tourists or expats having been reported dead or seriously injured. Now, this was not an infectious disease outbreak, but it is a public health crisis of a kind, and some are more likely to be hurt and die than others. What does this tell us about, Bill, how..