The Fears of the Rich, the Needs of the Poor: My Years at the CDC By William H. Foege
Baltimore, MD: Johns Hopkins University Press; 2018 280 pp.; $24.95 ISBN: 9781421425290
William Foege, in his preface, claims that this book is not a history of Centers for Disease Control and Prevention (CDC), public health, or the breadth of CDC activities, but is a collection of stories. This statement is incorrect—the book is all of the above. Our storyteller, a renowned international leader in public health for half a century, is a fine historian. He is also an acute observer; extremely smart, compassionate, and dedicated; and his account is enriched by delightful flashes of humor.
A THREE-PART AUTOBIOGRAPHY
This is the second installment of his autobiography; the first deals with the fight against smallpox.1 This volume offers narrative, stories, and analysis of Foege’s career at the CDC: as an officer of the Epidemiological Intelligence Service, a senior official in episodes of disease control in the United States as well as low-income countries, and its director from 1977 to 1983. He promises a third volume, a history of the Task Force for Child Survival, which he helped to found and develop as an adviser to President Carter and the Bill and Melinda Gates Foundation in the 1980s and 1990s. (Disclosure: One of us, D. M. F., has read several draft chapters of this manuscript.)
Here, Foege offers 26 chapters summarizing the history of public health crises and interventions since the late 18th century; of the CDC since its founding as a malaria program during the Second World War; and of the science, policies, and politics of significant CDC programs and interventions since the 1960s. A gifted storyteller, he writes engaging prose describing how he acquired the knowledge and experience that informed his career in public health, globally and in this country.
This book and its companions will likely become classics in the public health literature—analogous to publications by such 19th century giants of the field as Farr, Semmelweis, Snow, and Virchow. We base this prediction on Foege’s disciplined focus—throughout this book and in his earlier autobiographical volume on the smallpox campaign—on what he calls “three essentials for good public health programs.”(p18)
ESSENTIALS FOR GOOD PUBLIC HEALTH PROGRAMS
These essentials have been fundamental to much public health practice, research, and education since the middle decades of the 19th century. But they have rarely been articulated as forcefully as Foege does here. The first essential is his conviction that the “basis for public health is to achieve health equity . . . the bottom line is social justice in health.”(p18) Second “is the understanding that the science base of public health action is epidemiology,”(p18) the discipline that “determines the gaps in social justice, identifies the groups with poor health outcomes, discovers the details of disease causation, and provides clues to how corrective action might improve health.”(p18) Foege’s third “essential” is “good management for efficient implementation of corrective actions.”(p18)
The title of this book also encapsulates a key insight (he calls it a “bias”) that the way to improve health equity is to figure out how to link the fears of the rich to the needs of the poor.(p30) The rich will respond to the needs of the poor when they understand that they can benefit because they, too, are at risk. The rich will thus respond to Ebola, AIDS, and bioterrorism with more alacrity and enthusiasm than they will to river blindness or intestinal worms.
FOEGE’S APHORISMS
Foege inserts remarks in his stories and analysis that will linger in the minds of many readers who have studied and practiced public health. Following are some examples:
The job of public health is to try and rewrite history before it happens.(p32)
Every public health decision is ultimately based on a political decision.(p48)
While the best decisions are based on the best science, the best results are based on the best management.(p77)
Why prevention? To save money? . . . Yes, but it is far more than that. It is simply better to be alive than dead, and healthy than disabled.(p169)
. . . government is the only place that can provide actual social justice for all. It is a revelation for social activists when they finally discover that.(p112)
Politicians, says Foege, “may often be harmful to the health of people (as when they reduce support for immunization programs, refuse to expand Medicaid, or do not fund prevention in health care delivery programs).”(p166) They may also, when properly motivated, be a powerful force for positive change in health.
Foege often uses the freedom of the conventions of autobiography to assert strong opinions on controversial issues. He is a proponent of universal coverage of health services under a single payer. Moreover, he despises the commercialization of health care: “When profit became the bottom line, quality, equity and outcomes all suffered.”(p168)
The financing of public health programs should be based on two new principles, he argues. The first is that “programs with proven positive benefit–cost ratios should become entitlements and no longer compete with other public health programs.”(p167) The second is that “public health expenditures should be indexed to total health expenditures.”(p167)
INTRODUCTION TO THE WORLD OF PUBLIC HEALTH
In summary, we commend this book without reservations to our colleagues in public health disciplines and, no less strongly, to all interested in reading about persons who have had brilliantly effective careers—and who write about them with vigorous attention to detail. This is a wonderful introduction to the world of public health for the newcomer and will likely be a source of proud reflection for the well-seasoned. We make no criticisms. We look forward to Foege’s third volume of stories, history, analysis, and inspiration.
REFERENCES
- 1.Foege WH. House on Fire: The Fight to Eradicate Smallpox. Berkeley, CA: University of California Press and the Milbank Memorial Fund; 2011. [Google Scholar]