Former CDC Director Dr. Bill Foege on why he stands behind Theranos, how to build an effective coalition & what presidential candidates must address this fall

The world's brightest minds work every day to untangle the complex issues that plague healthcare. And while many problems remain, occasionally someone succeeds.    

One of those breakthroughs was led by William H. Foege, MD, MPH, an epidemiologist and former director of the CDC. Dr. Foege is credited with developing a strategy to eradicate smallpox when vaccine supplies ran out in the late 1970s. His resourcefulness and advocacy became an integral part of the World Health Organization's global immunization campaign, helping wipe out an infectious disease for the first time ever.

Now, more than 35 years later, Dr. Foege has set his sights on another project with the capacity to change global health: miniaturized blood tests. Dr. Foege serves on the Board of Directors and Scientific and Medical Advisory Board for Palo Alto, Calif.-based Theranos, a startup developing affordable blood tests with smaller sample sizes. Though the company has faced significant challenges over the past several months — including class-action lawsuits, investigations and lab license revocation — Dr. Foege says he stands behind the Theranos' technology and promise.

We checked in with Dr. Foege to discuss why he is so excited about the global health potential behind Theranos' technology, what implications Zika could have on the U.S. and his advice for those leading change in healthcare today.

Editor's note: Responses have been edited lightly for length and style.

Question: In your May commencement speech at Emory University, you advised graduates to always question tradition. Are there any traditions in healthcare you think our readers should question?

Dr. William Foege: When I graduated from medical school 55 years ago, I was receiving a lot of warnings from the American Medical Association about the possibility of socialized medicine. They had all of us looking over our left shoulder to see if socialized medicine was gaining ground, and no one ever said, 'Look over your right shoulder to see if capitalism is gaining ground.' And of course, it did. Our tradition has been that the marketplace is the place to deliver medicine. We're now in the position of spending more money per person on healthcare than any country, but our outcomes don't reflect that. We are not in top five, 10, 15, or even 20 countries when it comes to health outcomes. It's time to challenge the tradition: Is the marketplace the best place to deliver medicine? I don't think it is because once profits become the bottom line, it skews everything.

Another tradition that's worth looking at is the concentration on process measurements. We put a lot of attention on process measurements rather than on health outcome measurements. In 1993, the World Bank came up with a new way of looking at this called disability-adjusted life years. It changed global health because you could combine illness, suffering and death into a single number. We should be clever enough in healthcare to figure out how to do a better job of measuring health outcomes, and at least part of reimbursement should be based on health outcomes.

Q: When you first came up with the "surveillance/containment" technique to eradicate smallpox, people felt it was a top-down approach. But, as William Watson Jr., then-deputy director of the CDC, said in Columns Magazine in 1994, "Bill has a great talent for coming up with creative ideas and presenting them in a way that doesn't threaten people."

How did you convince people to get on board with this technique — and based on your experience — what advice would you give hospital and health system leaders who want to lead innovation and change at their organizations?

WF: I have to admit coming up with that approach was largely by accident. We did not have enough vaccines to do what we had been trained to do, which was to mass vaccinate. We were looking for shortcuts. [The surveillance/containment strategy] worked so well, we [took it] from an individual outbreak [and applied it] to all of eastern Nigeria, from there to other places in Africa, and finally we tried it in India. That was the most difficult place because in 1974, in one state alone, there were 1,500 new cases of smallpox every day. That's a new case every minute. It was just massive and overwhelming.

The bottom line is we had the vision, and then we worked on managerial improvement. One thing that became clear to me is we don't do anything without a coalition. No one does anything on their own. So the question becomes: How can you better the coalition?

Leadership today is defined by the person who can make the coalition truly productive. The most effective coalitions are those built around an outcome — a definition of a last mile — rather than an interest. If you get people together because they are the same religion or the same political party, that's not nearly as good as getting them together against an outcome that is defined from the beginning. We also know leadership has to practice ego suppression for the coalition really to work. Success becomes group success, not a turf some person gets.

An example of all of this in healthcare would be if a health system decides we are not only going to have the best, state-of-the-art treatment for heart attacks, but we are also going to reduce the number of people who come in with heart attacks. That would force them to get prevention involved. That's the sort of last mile objective that could really change things.

The best decisions are based on the best science, but the best results are based on the best management. It's this combination of science and management that can make a coalition really work.

Q: What are one or two healthcare issues you feel are absolutely essential for the presidential candidates to address in the coming months?

WF: I would sure like to see them address the issue of prevention. Each day, life expectancy for the average American increases by 6-7 hours. That's just an incredible figure, and a big share of that is prevention. Yet prevention is always the last thing funded. We don't seem to learn the lesson. This is true for individuals, cities, states and the nation: We don't truly value health until we lose it. It's hard to get people to speak about prevention ahead of time.

The other thing I would like to see them discuss is global health. When I started at the CDC, I was told over and over we had to justify everything we did on the basis of what it meant for the health of an American, and not the health of the world. All you have to do is look at Ebola and Zika and you realize how short-sighted that is. It's the same with smallpox eradication. The U.S. saves as much money every 3 months because of smallpox eradication as its total investment in smallpox eradication. Every year we get four times return on our total investment, and that will continue forever. It becomes almost an infinite figure.

We should have more discussion on how related we all are in this world and how important it is to be investing in global health. It's especially important when you see the political discussions now becoming very nationalistic. Einstein said nationalism is an infantile disease. He called it the "measles of mankind." When it comes to health, we have to talk globally.

Q: Do you expect the Zika virus to be a major challenge for U.S. healthcare providers this summer? Why or why not?

WF: I don't know what's going to happen with Zika. This virus has been known about for decades. It was recovered in Africa and other places, and the vector was in the Americas for a long time, but for some reason it didn't spread. When it did spread, it spread fast. I would expect that's what will happen in part of the U.S., but I can't be sure. I know we have to be ready for the worst-case scenario. One of the good things that Zika has done — it's caused people to do a better job of conveying their research findings. Just [recently] The New York Times talked about how people are putting their findings online before they even publish them. That's a nice step in medical research.

Q: You mentioned we have to be ready for the worst-case scenario with Zika. What is that?

WF: The worst case would be massive spread wherever we have Aedes aegypti mosquitoes, and we pretty much know where that is. Then, it's pregnant women becoming infected and having infected children. One of the hard things about Zika is this is the first virus we've ever known about that is spread by a mosquito that causes birth defects. It isn't as if we have a track record of knowing how this will play out.

Q: You recently were named to Theranos' Board of Directors and its Scientific and Medical Advisory Board and previously served on the company's Board of Counselors. What first attracted you to this company and what made you decide to stick with it through its recent troubles?

WF: My interest initially was very much around global health. What they have done is what the computer industry has done. That the industry has gone from computers that take up an entire room to desktop computers, to laptops, to smartphones. This miniaturization is now being done by Theranos in technologies and equipment. This means it is possible to consider using this technology in developing countries, even without electricity. You could hook up this technology to a car battery.

Why is that so important in global health? One example: You see a person with tuberculosis in a clinic in Nigeria. You take a sample and it takes three weeks to see if that person has tuberculosis or not. By the time you get the result back, you may or may not be able to find that person again. But with Theranos and this miniaturization, you can actually make a diagnosis in the clinic the day you see a patient and you can tell whether that organism is resistant to antibiotics. It's a huge leap forward. That's what originally attracted my attention.

Having had the opportunity to look at their technology, it's very robust. The problems they have been vilified for have to do with lab operations and the fact that they have not published in peer reviewed journals. They are correcting the operational problems, and changes are being made. As for the science, they are preparing to send articles to peer reviewed journals. For me, the bottom line is that global health needs this sort of technology and Theranos is going to solve the problems to provide it. That's what has me excited.  

Q: Why didn't they initially choose to publish in peer review journals?

WF: Theranos was trying to get to a point of development where they had the entire package before they released the specifics of it. Now they realize that did not work so well, and they are going to share their technologies with the scientific community.

Q: Are they at the stage now where they have the whole package or are they still working on it?

WF: They have tests now for many entities, but the number of things to be tested continues to increase. In one sense, [Theranos has] a platform in which they will be working on new technologies forever. Not only are there so many organisms we don't know about, but one new problem organism emerges every year, like Ebola and Lassa fever, and the other hemorrhagic fevers of the past.

 

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