in Proven Impact
The Institute of Preemptology is dedicated to transforming global health through preemption. These 9 lessons provide the intellectual foundation for our vision.
Introduction to the Nine Lessons
These nine lessons are adapted from Dr. Bill Foege’s latest book, Change is Possible: Reflections on the History of Global Health (2024) while the examples/anecdotes are taken from his first book: House on Fire (2011)
I. Causality Lessons
II. Collaboration Lessons
III. Conscience: The Capstone
CAUSALITY LESSONS (1-4)
Theme: How the world works and how we learn from it
Lesson 1. Causation: If we understand the causes, we can change the effects.
The Core Tenet
This is a cause-and-effect world. If we understand the causes, we can change the effects. This is not a world of magic. There are reasons why things happen. In global health, we try to figure out what those reasons are so we know how to prevent them in the future.
Case Studies
When faced with a vaccine shortage in Nigeria, Foege observed patterns of smallpox outbreaks and realized that by targeting vaccinations to villages actually experiencing infections—and those connected to them—he could interrupt the “fuel” for transmission, just as firefighters contain a blaze by cutting it off from fresh fuel (“surveillance and containment”), proving that understanding the true cause of transmission could change the effect.
During the first major outbreak in Ogoja, Nigeria, Foege’s team faced a vaccine shortage and could not vaccinate broadly:
“Forced to look for another solution, we raised the question: if we were smallpox viruses bent on immortality, what would we do to extend our family tree? The answer of course was to find the nearest susceptible person in which to continue reproduction. Our task, then, was not to vaccinate everyone within a certain range but rather to identify and protect the nearest susceptible people before the virus could reach them.” (p. 56)
Lesson 2. Candor: The Imperative of Transparent and Actionable Truth.
The Core Tenet
Know the truth. Share the truth. Act on the truth. This is obviously related to the fact that it’s a cause-and-effect world. There were so many times that I did not want to know the truth because it was so overwhelming.
Case Studies
Foege recounts the overwhelming reality of discovering far more smallpox cases in India than official records reflected, forcing teams to confront and act upon the uncomfortable truth—an honest case search revealed thousands of hidden cases, leading to a more effective containment strategy.
“In October 1973, during India’s first national smallpox search, we mobilized thousands of workers across Uttar Pradesh, expecting few cases due to the season’s low transmission. To our shock, in six days we found 5,989 new cases, far beyond the 1,000 reported by the passive system. We shared this with the Health Ministry immediately, and it forced a complete overhaul of our surveillance strategy.” This incident, detailed in the book, shows Foege’s team confronting the overwhelming truth of underreported cases, transparently reporting it, and acting to intensify containment efforts, saving countless lives.
Lesson 3. Curiosity: Question Dogma, Challenge Assumptions, and Avoid the Certainty Trap.
The Core Tenet
Avoid certainty. The physicist Richard Feynman made this principle so clear. “Physics is the most certain of sciences, and we’re not certain”, he wrote. In science, we have to avoid certainty. It is the Achilles heel of science.
Case Studies
At first, mass vaccination was considered the only solution, but Foege’s willingness to question this dogma led to the new approach of surveillance and containment—even in the face of skepticism, showing the danger of “certainty” in science and the necessity of continually challenging assumptions.
Foege recalls skepticism within the field team—even as their new approach took off:
“We were now confirming, through what amounted to additional field-testing, that the theory of vaccinating only those who were at immediate risk of exposure was sound. However, the strategy was new, and we were still unsure about how large an area of vaccination was required to contain an outbreak, so we tended to err on the side of excess. When smallpox cases were admitted to the Enugu hospital, we opted for a rapid mass vaccination program for the entire city. … lack of experience made us cautious.” (p. 66)
– Anecdote: “In early 1967, we were certain that Eastern Nigeria’s smallpox cases were under control based on reports from missionaries. But when we sent teams to verify, we found an unreported outbreak in a remote village near Abakaliki, with 15 deaths and 40 active cases hidden because locals feared quarantine. We had to rethink our assumptions and deploy immediate containment.” This story underscores Foege’s lesson to avoid overconfidence, as initial certainty was upended by field evidence, forcing adaptive measures to address the hidden outbreak.
Lesson 4. Calibration: Prioritizing Consequential Evaluation and Relentless Improvement.
The Core Tenet
Continuous Improvement: Build in consequential evaluation and continuous improvement. Given that we’re not certain, we need to evaluate to learn what is really happening rather than what we hoped would happen, and then continuously improve as we find out what is going on.
Case Studies
Monthly program meetings were held in India to review what worked and what didn’t, constantly refining strategy to respond to evolving outbreaks and realities on the ground, embodying the principle of ongoing evaluation and improvement.
“In the final three months of 1973, the team learned a lot about what needed to be done to scale up the surveillance/containment strategy so that it would be adequate to confront the reality of smallpox in India. Each month saw changes in how the searches were conducted, the addition of new and complementary search techniques, and better approaches to record keeping and containment. The year ended with a system of smallpox detection that seemed to work.” (p. 120)
COLLABORATION LESSONS (5-8)
Theme: How we work with others and systems
Lesson 5. Coalitions: The Imperative of Forging Diverse and Essential Alliances.
The Core Tenet
Coalitions are essential. We can’t do anything alone. This is an old lesson. Polybius taught us this 2,000 years ago.
Case Studies
Foege describes how the success of smallpox eradication depended on building diverse coalitions—local health workers, WHO, CDC, missionaries, and governments across countries and continents—all united by the common goal of eradicating smallpox, proving it was impossible to do alone.
On coalition-building for eradication:
“The difference in timing was partly due to political and logistical problems, since USAID negotiated and signed a separate agreement with each of the twenty countries. In some cases, these negotiations required many months. For some attendees, our change in strategy was of little importance because they were not yet far enough along to consider the program in depth. Others, such as Don Millar and Henry Gelfand, who had flown in from Atlanta, instantly saw the advantage and provided support and motivation to those pursuing the new approach. New friendships and alliances were formed, and a kind of smallpox coalition was forged.” (p. 69)
– Anecdote: “In Bihar, India, in 1974, we faced a massive outbreak with 8,000 cases. We formed a coalition of WHO advisors, Indian health workers, local police, and village headmen to conduct door-to-door searches. In one week, 12,000 volunteers vaccinated 100,000 contacts, stopping the epidemic’s spread.” This story highlights the necessity of diverse alliances—uniting global experts, local authorities, and community leaders—to achieve rapid, large-scale containment, showcasing the “gorgeous coalition” Foege celebrates.
Lesson 6. Culture: Respecting Local Norms to Achieve Unstoppable Buy-In.
The Core Tenet
Respect the culture. This is the final lesson in this category. Culture matters. If you try to fight culture, you will always lose. Unfortunately, it’s something we often learn in retrospect. I wish I hadn’t done that.
Case Studies
Anecdote: “In a village in Uttar Pradesh, we met resistance because smallpox was revered as the goddess Sheetla Mata. Mothers hid sick children, fearing vaccination would anger the deity. We worked with priests to offer sweets as a ritual post-vaccination, and within days, 80% of the village accepted the vaccine.” This incident, recounted by Foege, shows how respecting cultural beliefs—integrating vaccination with religious practices—overcame resistance, aligning with the lesson that fighting culture leads to failure.
Negotiating with local authorities and respecting “juju” beliefs:
“A crowd began to gather around us, and soon the area chief arrived. Once he had sized up the predicament, he spoke through an interpreter, telling a story in the powerful oratorical style prized in Africa. … The story went on for some time, but the bottom line was that our truck had hit a sacred juju tree. This had offended the juju gods and would require the sacrifice of a chicken, which cost 10 shillings. My initial emotion was relief. Ten shillings was a small price to pay, and we could be on our way. However, something perverse invaded my thinking, and before I had thought it through, I began to respond. … I explained that in my culture, the van had some of the characteristics of a juju god, and the truck was offended that the tree was in its way. I would now have to sacrifice a goat, which cost 20 shillings.” (p. 62-63)
When we’ve learned these six lessons, we need to summon the courage to go to scale.
Lesson 7. Coordination: The Synergy of Uniting Science and Executive Management.
The Core Tenet
Seek strong leadership and management. This means combining science and management. Science gives us the best answers. Management gives us the best results. How do we put those two together?
Case Studies
During the Biafran Civil War, Foege and his team demonstrated courageous leadership—they returned to dangerous regions despite armed conflict to keep immunization programs running, showing that effective public health requires both scientific judgment and practical, brave management.
On-the-ground improvisation and risk:
“It was not unusual for him to place himself in physical jeopardy for the sake of the program. For example, he would carry millions of rupees in his briefcase to make sure that payrolls were met.” (Foreword, xvii)
– Anecdote: “In 1967, during a Nigerian civil war, we coordinated a smallpox ceasefire in Ogoja. Our team used shortwave radios to direct mobile units to a village with 20 cases. Scientists mapped the outbreak, and managers deployed 10 vaccinators with jet injectors, ring-vaccinating 1,000 contacts in 48 hours, halting the spread.” This story illustrates how combining scientific precision (mapping cases) with managerial logistics (rapid deployment) under strong leadership stopped an outbreak, embodying the science-management synergy Foege advocates.
Lesson 8. Civic Commitment: Strategically Mobilizing Sustainable Political Will.
The Core Tenet
Mobilize political will. With political will, anything is possible. Without it, nothing is. Oftentimes in public health, we are upset with a political decision. But we need to recognize that we’re totally dependent on politicians. They’re the ones who 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.
Case Studies
The eradication depended on persistent advocacy—Foege had to convince political leaders, including India’s Minister of Health and the US Ambassador, to continue contentious or misunderstood strategies even during setbacks and accusations, securing the political will essential for success.
This anecdote shows Foege leveraging political support by framing eradication as a national priority, securing resources and commitment to scale up efforts during a crisis.
– Anecdote: “In 1974, Bihar’s floods worsened smallpox, with 11,000 cases reported. I met India’s Health Minister, convincing him that eradication could be a national triumph. He mobilized 50,000 workers and army units, vaccinating 2 million people in two weeks, turning political will into action.”
A pivotal crisis with an Indian Health Minister:
“We begged the minister to give us another month to prove our strategy. … He kept returning to a single, worn argument: he had allowed us to pursue this new course, unproved in India, for seven months. … At meeting’s end, he declared, we would return to the strategy of mass vaccination in Bihar. … One of the field-workers, a young Indian physician, raised his hand. He looked too young even to be a medical school graduate, and he was very thin, the epitome of a dedicated field-worker. … with great deference, addressed the minister. … ‘But, he said, when he was growing up, there were …’” (p. 170-171)
LESSON 9: COMPASSIONATE EQUITY
The Core Tenet
The best solutions move us closer to global health equity. 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. At the Institute of Preemptology, we strive to close the equity gap for the poorest communities, guiding our global health advocacy throughout our career.
Case Studies
Reflecting on his time living in rural Africa, Foege realized his own privileged access to health, and that poverty divided realities—emphasizing that the ultimate measure of public health is whether it closes the equity gap for the poorest communities, an insight that guided his global health advocacy throughout his career.
A visit to devastated families and the social tragedy of smallpox:
“In one house I might find a baby, face swollen, eyes closed, breathing hard, with exposed surfaces thick with raised, pus-filled blisters. In such cases I would have to admit that there was nothing to be done. The devastated parents were about to lose the child. … Each patient was part of a family and a community, yet others could do little to help. There was — and is — no cure for smallpox, and in this sense each patient faced the disease largely unaided.” (p. 5)
The best solutions move us closer to global health equity.
– Anecdote: “In a Nigerian village in 1966, I met a mother blinded by smallpox, holding her vaccinated toddler who would never face the disease. She said, ‘You saved my child, but who will save me?’ Her words stayed with me, driving our push to vaccinate every last village.” This poignant encounter, shared by Foege, underscores compassion as the moral core of eradication, ensuring no community—however remote—was left behind, advancing global health equity.