UNCOMMON PEOPLE
Science is the bedrock of public health, but people discover the truths of science and implement the knowledge to improve health. In the best of worlds, science would have the greatest role, and yet “tradition is the DNA of our beliefs,” and, at times, our beliefs run roughshod over scientific fact. Our painfully slow response to global warming serves as an example. When we do get it right, it is usually a team effort. However, certain people stand out as characters, leaders, mentors, and problem solvers. Or, as problems. (Fortunately, space and good taste restrict the numbers that I will mention in that last category.)
C. Everett Koop could play all of those positive roles. When he was first nominated as surgeon general, there was quite an outcry from the public health community because he was a surgeon (which to me seemed quite appropriate for the title of surgeon general) and not a public health professional. I have never sympathized with that view because I believe public health is more philosophy and common sense than a specialty. Through the years, I have seen contributions made by people like Jim Grant, a lawyer by background and director of UNICEF in the 1980s or, more recently, Mary Selecky, a historian and Washington State health officer. So I approached Dr. Koop without prejudice.
Dr. Koop told me some years after his appointment that he dreaded his first visit to the CDC. The pro-life community regarded him as a hero, and they regarded the CDC as pariahs because we did abortion surveillance. That community never understood the difference between doing abortions and doing surveillance on the morbidity and mortality resulting from legal and illegal abortions. We were simply trying to document the complications and deaths from the practice. Dr. Koop was under pressure from his backers to close down our abortion surveillance program. He arrived at my office, and without others involved, we closed the door and sat at the conference table.
After the formalities, I said, “Dr. Koop, no matter what we talk about today we are both going to wonder when we will get to abortion. Why don’t we start with that and get it out of the way?” When I finished my discussion of the topic, he was clearly overwhelmed by the logic of what we were doing, and he said, “If you weren’t doing this I would have to start it. We simply have to know about the health impact of both legal and illegal abortions. How can I help?”
I told him I received hate messages each time we published the surveillance report. I asked if I could send him our abortion reports in draft so he could search for factual or scientific errors and find words or phrases that were red flags to be avoided. He agreed and followed through. We continued our important work, and the hate mail from the pro-life community stopped.
Our ability, with different backgrounds, to come together on the science, blossomed into a friendship of easy conversation and discussions beyond public health. Dr. Koop had a white beard and was often depicted by the press as looking like Abraham. He once told me of a significant donor to the Republican Party, who had decided that he actually was Abraham, she was Sarah, and they were destined to be together. She had now said she would have a press conference to announce that fact. Dr. Koop’s question was whether I had any suggestions. I said perhaps, but first I must ask a delicate question. He asked, “What is that?” My reply, “Are you Abraham?”
Koop also taught me about delegating into the future. He called me one day when he was in his nineties and described a project that he could no longer attend to because of his age. He asked me whether I would carry it on for him, and I agreed. Koop taught me that careful delegation is a way to remain scientifically active after death.
Secretaries of HHS
In addition to Dr. Koop, I was fortunate in the people to whom I answered in the Public Health Service and the Department of Health and Human Services (HHS). I worked directly for four different secretaries. The secretary of HHS provides the ultimate political support for CDC programs. The assistant secretary for health and the surgeon general provide scientific support, but without the support of the HHS secretary, important access to both Congress and the White House can be blocked.
Secretary Joseph Califano, the first of these, was extremely interested in health issues. Because he was so intent on changing the image of swine flu, I received his extra scrutiny. He actually sponsored the first influenza meeting in the new administration, a prerogative of the CDC in the past, and held the meeting in the Humphrey Building in Washington, DC, rather than at the CDC. He was so concerned about that first meeting that he sent a senior assistant to Atlanta to help me write my speech. The assistant did prepare a text, but I felt it was not usable and prepared my own speech. The meeting went well, and Califano loosened the reins.
Secretary Califano was absolutely superb in supporting programs. He decided we would greatly increase our immunization efforts, and he personally sought funds for this program. Once again his approach was to be involved directly, in this case by establishing an immunization office in Washington, DC, but he relaxed his control when he gained confidence in the CDC.
Califano could be demanding of subordinates, but they accepted this because of the support he provided. He would at times call me in the morning and ask me to be in Washington, DC, in the afternoon. On one occasion, I had just returned from Washington to the Atlanta airport when he paged me and asked me to take the next flight back to Washington.
I appreciated his ability to listen, see through issues, and then make a decision. On one occasion, deaths were reported in a small number of young children shortly after they received the diphtheria-tetanus-pertussis (DTP) vaccine. A limited number of vaccine lots were involved. Deaths in small healthy children are wrenching experiences. On initial investigation, the vaccines had no defects or unusual events in manufacturing, so the statisticians concluded that this was a random cluster occurrence with no vaccine implications. The immunization experts were concerned that any action to withdraw DTP vaccine might have the undesired effect of scaring people away from getting vaccinations.
Califano assembled the heads of all Public Health Service agencies as well as others in his office and had each person give his or her appraisal of the situation and recommendation. Every person said that Califano should explain to the public that this was a random grouping of sudden infant deaths, unrelated to vaccines. I was the second to the last person to speak and the first to give a contrary opinion. I worried that calling a cluster of deaths a statistical occurrence would not be understood and could even appear to be callous. I said that the conclusions were correct, as far as we could tell at the CDC, but that I would take a different approach. I suggested that he make the announcement as recommended but add that because of an abundance of caution an additional step would be taken. All lots of DTP vaccine that had been given to any infant who had suddenly died would be replaced with other vaccine lots; moreover, the Public Health Service would thoroughly review the records to make sure there had not been a manufacturing error overlooked in the initial investigation. My argument was that it gives the public more confidence to go overboard with caution than to appear cavalier. The last person to speak was Surgeon General Richmond, and the only thing he said was that he totally supported the last statement. Califano said he would consider all of our recommendations and ended the meeting. The next day he announced the department’s approach—the recommendation that Richmond and I had made. That he would do this when only two people in the entire room supported it was gratifying. No vaccine problems were discovered even after an in-depth investigation.
Califano’s support of the Public Health Service’s antismoking activism was a decisive move that has resulted in major reductions in the shameful toll of death and disease due to tobacco.
Califano had asked me about my views regarding the role of the assistant secretary of health versus the surgeon general. I saw the assistant secretary of health as the line officer in charge of making policy and supervising the agencies. The surgeon general, on the other hand, was the senior officer of the Commissioned Corps—although not all public health service workers are in the corps. Indeed, the majority are civil servants. The surgeon general has a great bully pulpit but lacks the authority to direct or change programs. My suggestion was to have Richmond occupy both positions. It was a great solution and simplified life for many. But for obscure reasons, the practice was not followed in the future.
Richmond was a wonderful supervisor. A pediatrician by training, he had been a flight officer during World War II. He was cofounder of Head Start and a champion of mental health issues. The country was fortunate to have had Califano and Richmond during those years.
Secretary Patricia Harris moved from the US Department for Housing and Urban Development (HUD) to succeed Califano and brought an inquisitive mind to every problem. On my first meeting with her, I was asked to give a review of the CDC’s activities. Things were going fine until I mentioned the number of children with elevated lead levels and the implications for mental impairment. I mentioned that lead in gasoline and lead in paint, particularly in urban dwellings, were the two largest sources for children’s elevated lead levels. She stopped me, and said that her advisors at HUD had assured her that lead paint was not a hazard in city buildings. She threw up her hands dramatically and asked, “Who am I to believe?” I told her it might not always be the case, but in this instance, if I were her, I would believe me. She was taken aback for only a few seconds and then said, “I will do that, and you will bring me the proof.”
It was the way she continued to operate. Give her the proof, and she would defend us to the end. As proof is the cornerstone of public health, this was a fantastic arrangement.
When President Reagan came to office, agency heads in the Public Health Service were fired. I received calls from other heads saying that they had received notice to be out of their offices by that afternoon. I began packing my office for the call that never came. Why wasn’t I fired, too? Once again, I learned that we simply cannot see the future.
The reason I was spared actually went back to my first weeks as director of the CDC. At that time, I was told I had to meet with the senator from Pennsylvania, Richard Schweiker, to explain why his state had not been selected for a diabetes demonstration project. Senator Schweiker had engineered an appropriation for ten state demonstration programs to see what could be done to improve diabetes control. Now I had to explain why his state would not be in that number.
There are many gut-wrenching moments in public service. This was one of them. I made the appointment and told him the results. He asked how the selection had been made, and I walked him through the steps, including the use of outside reviewers, who had made the recommendations on which states should receive the money. He was unbelievably kind, and said he could find no fault with our approach, but he was sure that this would not happen to Pennsylvania again because he would personally be after them to provide a credible plan.
Periodically, after that meeting, I went to his office to brief him on the latest diabetes activities. On one occasion, he called to ask whether I could take his place in speaking to a diabetes dinner group as he had been asked to go to the White House that night. I now realized he trusted me, and trust is the glue for partnerships and coalitions. I did give the talk for him, but it is not pleasant to be the substitute speaker when people are expecting a senator. In later years, I would experience the same disappointment when I would substitute for President Carter. I would tell the audience that it is like being the brother of Jesus with people saying to me, “Why can’t you be more like your brother?”
The next day, I heard that President Reagan had asked Senator Schweiker to be the new secretary of HHS, and the call to step down as the CDC director did not come.
The final secretary during my time was Secretary Margaret Heckler. I had less contact with her than with my other supervisors. She did not seem deeply interested in the CDC or in health.
Ed Brandt
During the Reagan years, the assistant secretary for health (my immediate boss) was Dr. Ed Brandt. In the mold of Richmond, it would be hard to imagine a better informed and involved supervisor. He had a medical degree and a PhD in biostatistics. He also had a theology degree and straddled the worlds of science and ethics with comfort.
It would have been a mistake to try and fool Brandt with probabilities or standard deviations. On one occasion, he interrupted a talk I was giving to protest a statement that I had just made, the first time I had ever cited that particular fact. I had said that the life expectancy of the average American had increased by seven hours a day since January 1, 1900. He said that could not possibly be true. At the end of my presentation, he apologized to the audience for interrupting but said that the figure had stunned him and while I was speaking he had done his own calculations. His conclusion was that I was in fact wrong. It was not an increase of seven hours a day but an increase of seven hours and six minutes a day!
Art Buchwald
He wasn’t a politician or a public servant, but this famous American humorist was a stinging political satirist in his syndicated column for the Washington Post. I met Buchwald by chance alone. One day, I boarded the plane for the return trip from Washington, DC, to Atlanta and recognized Buchwald, already seated. His newspaper columns were always entertaining in a Mark Twain sort of way. I recall a column in which he was making fun of the executive branch. The next day, he had an irate call from the State Department complaining that the Soviets had found it so amusing that they had reprinted it in Pravda. The State Department said they did not want that sort of publicity. Buchwald’s response was, “Stop them.”
Art Buchwald. Photo by Mark Lovewell, courtesy of the Vineyard Gazette
I ignore celebrities so as not to invade their privacy but was surprised when Buchwald moved to an empty seat next to me after the plane door closed. He was sociable and wanted to talk. He asked about my family and related funny stories to tie into each piece of information. He was going on to Texas but got off in Atlanta, simply to keep talking until his plane was ready to depart.
I asked him whether he ever gave pro bono speeches, and soon he agreed to come to the CDC and entertain us free of charge. On the day selected, he had a family medical problem to deal with but still arrived, as he said he would, and provided an absolutely riveting and funny evening of entertainment.
A year later the Journal of the American Medical Association asked whether I could convince Buchwald to write an editorial on the role of humor in healing. I called his office, and his secretary said he was at the hospital with his wife, who was in serious condition. But his secretary relayed the request, and in the midst of his own grieving process he wrote the editorial.
The final story concerns an invitation we both had to be on a panel at the University of Minnesota. After I had agreed to go, President Carter asked me to go to Sudan, where we were seeking an extension of a peace interlude to do medical work. I told President Carter I would do that if he would explain to Art Buchwald why I couldn’t join him for the dinner and panel. President Carter did that, and Art Buchwald said, “All things considered, I suppose I would prefer a call from a president to dinner with Bill Foege!” But then, to my complete surprise, he donated his $30,000 speaking fee for a scholarship in my name. It provides support of about $1,500 each year for a public health student, and I receive information on the recipient.
Other Gifted People
Now I recognize my inability to do justice to dozens, even hundreds, of gifted people who impressed me during the CDC years, and so I surrender in my hope of describing a few who inspired me.
Jim Grant, a lawyer, became an exceptional director of UNICEF and pulled people and resources into the attempt to make life better for children around the world.
Halfdan Mahler, a minister’s son from Denmark, brought compassion and soaring rhetoric to the almost impossible job of coordinating a global approach to the improvement of health, with special attention to the poor.
Peter Bell, another lawyer, was passionate about improving the lives of the disenfranchised and left Califano’s staff to work with NGOs and eventually became head of CARE.
Andrew Young, a minister, went from being the voice of reason who could bridge the racial divide during the civil rights revolution to becoming our UN ambassador. He could also be counted on to bridge nationalities, becoming the ambassador of the developing world to the United States.
Maynard Jackson, a lawyer and brother of a public health worker, became mayor of Atlanta and a constant supporter of the CDC.
John Lewis, the symbol of nonviolence in action during marches and riots in the South in the 1960s, would become involved in various civil rights efforts. President Carter named him as associate head of ACTION, a government program responsible for running the Vista program, the Retired Senior Volunteer Program, and the Foster Grandparent Program, before he was elected to Congress. He responded to every request for help in public health over decades.
And it was during the CDC years that I met President and Mrs. Carter. They are both persons of such quality and accomplishment that justice to their contributions is only possible in a future book.
This is an impoverished list, knowing as I do how many uncommon people have influenced my life. Please see the appendix for a fuller list.