Contagious Conversations / Episode 9: Celebrating the Invisible
A modern history of public health
Dr. Michael McGinnis looks back on his storied career to discuss how the focus of public health has evolved from treatment to prevention, what the actual root causes of death in America are, how those leading causes are changing... oh, and that one time his team had to commandeer an elephant.
Below left: Dr. McGinnis (left) in Bosnia, where he was Chair of the World Bank/European Commission Task Force for reconstruction in health and human services (1995-96). | Below right: Dr. McGinnis (center) chairs a field progress review while in India as state director for the WHO smallpox eradication program (1974-75).
Transcript
Claire Stinson: Hello, and welcome to Contagious Conversations. I'm your host, Claire Stinson. Every episode, we'll hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.
Joining me today is Dr. Michael McGinnis, an epidemiologist, health policy expert and Leonard D. Schaeffer executive officer at the National Academy of Medicine. Dr. McGinnis is well-regarded both for his program and policy leadership and his research and publications on population health and life expectancy. Dr. McGinnis was also the recipient of the 2018 Fries Prize for Improving Health.
In this episode, Dr. McGinnis shares background on his early career and explains how he created some of the world's most influential approaches for highlighting the importance of prevention and positive behavior change for addressing major health challenges. Welcome, Dr. McGinnis.
Dr. McGinnis: Thank you very much, Claire. It's a pleasure and a privilege to be able to chat with you today.
Claire Stinson: We really appreciate you being here with us today. Dr. McGinnis, you have served as assistant surgeon general, deputy assistant secretary for health, and founding director of the Office of Disease Prevention and Health Promotion at the U.S. Department of Health and Human Services. That's quite impressive. Can you tell us a bit about your early career that led you to these positions?
Dr. McGinnis: The common thread is that there's a fundamental focus on improving the human condition and in rational allocation of social resources, which in some ways stems back to my interests in political science, political theory as an undergraduate. Most of my training, if you just are counting the class hours, is in the field of, essentially, public service. I did a joint degree when I was in medical school in international relations and master's in public policy at the Kennedy School. So the training that I chose to undertake, with an anchor in public service, was very helpful to me both in giving me perspective as I went through medical school and as I began my career in international health.
I had the good fortune of being assigned the responsibility in the Department of Health Education and Welfare, at that point, to work with the secretary on International Health Affairs. And my responsibility was a quasi-diplomatic role of working to facilitate the programs that the U.S. had in bilateral cooperation during the Cold War actually, with Eastern European countries. And that was an interesting blend of science, policy, and diplomacy. It gave me a deeper appreciation for each of those three dimensions.
And it also, more importantly, gave me exposure to meeting D.A. Henderson. D.A., who was the former head of the Smallpox Eradication Program and the World Health Organization, dean of the School of Public Health at Hopkins, and really at a giant in every sense of the word in public health. D.A. said, "You know, you're doing this diplomatic stuff. You really ought to get your feet dirty and come over and work in the Smallpox Eradication Program."
Claire Stinson: That's so interesting.
Dr. McGinnis: Fortunately, I had a sympathetic boss at the time, and didn't hesitate to let me go for what was initially a three-month assignment but turned into a year until we actually finished the program in India. And that was a remarkably privileged experience to actually see a disease fall away before your eyes, and a disease that, really when you think about it, has been accountable for more human suffering and unnecessary deaths throughout history than probably any other.
Claire Stinson: That is quite an extensive background. So it sounds like you started with kind of an interest in political science that totally evolved and got you ready for all these amazing positions of leadership.
Dr. McGinnis: Well, that sounds a little too systematic, because life is serendipitous in almost every fashion, and there's no question that it was serendipitous in my case too. The notion of being prepared, I suppose it goes back to Boy Scout training – be prepared for whatever comes your way. And being prepared and keeping options open is a good watch word for anybody.
Claire Stinson: That's a good thing to remember for anyone. I love that. So Dr. McGinnis, you are well-respected for your research on population health and the root causes of morbidity and mortality. Tell me more about your interest and work in these areas.
Dr. McGinnis: Well, if you're fundamentally interested in the rational allocation of social resources, and if you're fundamentally interested in the alleviation of human suffering, the first question you ask yourself is, "What is it that's giving rise to unnecessary disease and disability? And how are we as a society allocating our resources to address those challenges?" It's the essence of prevention in many ways. And as one who was both trained in prevention and interested in social change and appropriate use of social resources, the interest in population health and the root causes came very naturally.
It also, frankly, was an important fundamental mandate of the office that I had the privilege of holding, those positions as assistant surgeon general, and head of the Office of Disease Prevention, and deputy assistant secretary for health. My role in that respect was to provide policy guidance and insight for the nation's prevention strategy.
In the mid 70s, as it is today, unfortunately, the dominant focus of our investment strategy as a nation was on disease treatment. Over 90 cents out of every dollar in the health arena goes to treating disease. And that's not instinctively where the major opportunities lie for improving overall health.
There are many reasons of course that treatment has commanded so much of the health dollar in this nation, but not the least of which is that it evokes a kind of rescue mentality. That is, the perspective that, if we're going to be addressing human suffering, that we first need to reach out to those who are loudest and most obvious in their suffering. That's a perfectly reasonable human reaction, a human motivator. But we need to do everything we can, and still need to do everything we can, when the urgent is crowding out the important, to make it clear just how important it is to devote our attention to the root causes.
Claire Stinson: That would make sense that you would want to look at the root causes to understand the real issues that are going on in our country. That has to be a fascinating topic.
Dr. McGinnis: Well, it's not only fascinating, it certainly is, but it's extremely important for society to be able to – at the same time as addressing the most urgent and compelling pain and suffering that is present – to look at ways in which the pain and suffering itself can be prevented. So… it's interesting, it's important, and it's highly motivating for a whole cadre of people. It's highly motivating, for example, we're speaking under the auspices of the CDC Foundation – that's what the CDC was created for, and that's what every person in the Centers for Disease Control feels as the essence of their motivation, and the importance of understanding, discovering, and acting on of the root causes of the problems that they're confronting.
Claire Stinson: You're absolutely right. And it's the Centers for Disease Control and Prevention, and obviously so many people in America don't even see the effects of the prevention work, but it's equally as important.
Dr. McGinnis: Yes. Bill Foege who I worked with, whom I worked with directly in the Smallpox Eradication Program in India, later became the head of CDC, and at about the same time as I became the, in the Secretary's Office, the Assistant Surgeon General and head of disease prevention policy. So I remember very clearly working with him as he was re-crafting the CDC and adding the word “prevention” to the agency.
Claire Stinson: Oh, wow. Really?
Dr. McGinnis: Yes.
Claire Stinson: Well, that's an important part of their title. It's such an important part of what they do. And it certainly plays into your work as well. I understand you published a groundbreaking article in the 1990s on this topic. How have the main causes of morbidity and mortality changed since you published that article?
Dr. McGinnis: Well, they have changed. And again, the fundamental issue here is – that piece, which I actually co-authored with Bill Foege, was aimed at making it clear to people that what they had traditionally thought of as leading causes of death, heart disease, cancer, stroke, diabetes, and so forth, were not the actual causes, because the work of CDC and NIH and others had revealed that there were drivers that occurred much earlier in the course of any human life that increased susceptibility to those problems.
And so what Bill and I did in that article was take advantage of the epidemiologic data that had been developed and characterize the actual causes. So in 1990, the issues that we identified through our work of the, on the actual causes were, number one, tobacco; two, diet and activity patterns; number three, alcohol; number four, microbial agents; number five, toxic agents; number six, firearms; number seven, motor vehicles; number eight, sexual behavior, largely at that point because of the HIV epidemic; and number nine, illicit use of drugs.
So let's, let’s just do a quick run-through of the state of play now. By the way, the total of those accounted for about 60% of unnecessary deaths in 1990. And so those factors were substantial determinants of the health of the nation at that point. They still are substantial determinants of the health of the nation at this point, but there are some changes, to get to your question. We haven't done a thorough analysis of the changes since that time, but I have done an approximate assessment using the same methodology. And I can give you some general changes that have occurred between 1990 and where we are today, more than a quarter-century later.
Instead of the number two cause being diet and activity patterns, that is likely the number one preventable cause of unnecessary morbidity and mortality at this point. Tobacco is still an issue, because its ill effects are – attack so many organ systems and it's such a powerful, addictive substance. But the fact is, overall, as we've seen the obesity epidemic increase, even now among children, the problems of poor diet and physical inactivity together represent the leading cause of unnecessary morbidity and mortality in the nation.
Alcohol has dropped slightly as a leading killer. It's still up there near the top, but the efforts in particular to reduce drunk driving and to raise awareness of the problems of alcoholism have made a slight impact.
Something that's on the list now that wasn't on the list in 1990, because we really didn't have a keen sight on it, was medical errors. Medical errors now are – despite the awareness that was stimulated by the Institute of Medicine's report in 1999-2000 about the health and mortality challenges of medical errors, the results of that increased awareness have improved quality control programs, but at the same time, the complexity of medical care has introduced additional opportunities for errors. And the, the fact is we're still a substantial distance from getting solid traction on the impact of that as a cause of death. And as I say, it wasn't on the radar screen in 1990.
Firearms have increased, unfortunately. I don't have to explain that. But both due to suicides and due to these increasingly larger scale violent events, they're higher on the list.
The issue of sexual behavior is as a cause of mortality has seen a decline, substantially because of the very impressive societal response to the HIV epidemic. I was actually in the room when Bill Foege, who was then, as I mentioned earlier, the director of CDC, at an agency head meeting, we had the heads of NIH and CDC and FDA come up to Washington to – for our bi-weekly meetings to talk about the current events. And Bill took his turn at the table to say that CDC was going to be releasing in the MMWR the following week this report of a strange cluster of seven cases of Kaposi sarcoma and Pneumocystis carinii in Los Angeles. This was the first report of the syndrome. And I can recall that, even though it was only seven cases, and we – this was an agency head meeting in which we were primarily focused on broad policy issues of the day – we actually spent a fair amount of time trying to understand what was behind those seven cases. There was, there was very little insight.
The fact is that, from that day, in June of 1981, until a very rapid sequence of events occurred: One, the cluster was identified, the means of transmission was identified, the active agent, a retrovirus, the HIV virus was identified. A test was developed to test for it. A series of public health programs was mounted. There were some antiretroviral agents which were identified to be able to combat the problem in those who were ill. And all that occurred in a period of, of less than a decade, and in the early parts of it, in just two or three years. Substantial public health progress and again, CDC was at the heart of the effort. I realize that I've wandered away from going down the list by going off on the HIV tangent, but I think it's a very important insight as to how these challenges are not immutable they can be affected.
On the other hand, the next one on the list I'm going to have to say, with the illicit use of drugs, has now climbed tragically with the opioid epidemic. So while there haven't been dramatic shifts in the order of these problems, there have been important changes in their impact, and most importantly, important understandings about what we as a society can do and need to do to address them.
Claire Stinson: Right. No, absolutely. And it sounds like we've made a lot of progress, and certainly a lot of those topics are familiar to people today in 2019, but – it sounds like we still have a lot of work to do.
Dr. McGinnis: No question about that. In fact, it's become even more complex when you add in the realization – which has taken a while to get traction, but it certainly is now beginning to, and that is the impact of social determinants and social factors in cutting across susceptibility for these various root causes of suffering.
Claire Stinson: We'll be right back with Dr. McGinnis.
Since this is a show about contagious conversations, we want to hear from you. Each episode, we ask you a question, and this episode's question is: What are you most proud of in your career? Just email us at info@cdcfoundation.org to answer. That's info@cdcfoundation.org. And if you share your thoughts with us, you'll have the chance to win some CDC Foundation merchandise.
And now back to our conversation with Dr. McGinnis. Dr. McGinnis, I understand you established the Healthy People Process for creating and tracking national health goals in 1979. Can you tell us a little bit about the main goal of this program?
Dr. McGinnis: The Healthy People Process actually in some ways had its origins on the Ganges Plain in India. And I say that because the way that we ran the Smallpox Eradication Program in India was... without going into all the details, essentially became a focus of identifying targets for reducing the disease in certain geographic areas, and then shifting resources to address those targets, and then holding monthly meetings to see how we were doing against the targets. And that systematic strategy was very successful obviously, with the disease being eliminated fairly quickly after that set of strategies was implemented. I say quickly in relative terms, in not decades, but years. And it couldn't help but impress – me, and I'm sure a few others, that something of that sort, the quantitative targeting of progress ought to be able to be applied in the world's wealthiest nation if it could be that successful in one of the least developed nations at that point in time.
I found myself in a position, relatively shortly thereafter in a position of responsibility to be able to take action on that observation and belief. And so it seemed to me that we had, as leaders of prevention policy at the national level, the obligation to be clear about what was possible to achieve in the prevention arena if we as a society set ourselves to it.
So the first goal was to really underscore the sense of the possible and the fact that we as a nation could achieve a great deal, and a great deal more, frankly, by investing in prevention than in only investing in the treatment side.
So the second motivation was clearly related to that, and it was to give us a sense of benchmarks that we could then either claim credit for achieving or hold ourselves accountable for – for failing. In prevention, what we're celebrating, when we can celebrate, is the absence of a disease. So it's not really the number of people who have died tragically, but it's trying to be more appreciative of the successes that we have which are silent: the absence of pain and suffering. That's one of the most important issues and barriers to increasing emphasis on prevention, is the fact that it's just not as loud as the obvious suffering that occurs when people are acutely ill.
So by laying out specific goals that were thought to be achievable, the fact, for example, that from 1980 to 1990, we ought to be able to reduce infant mortality by 35% if we as a society set ourselves to it, or that we could reduce adolescent and young adult mortality by 20%, or that we could reduce adult mortality by 25% in that decade, or even that we can reduce sick days, not deaths, but sick days among older people by 20%, was an important opportunity to draw to the attention of the American people. It also gave us a means of celebrating when we actually achieved those targets. Or of saying, "We need to do better," when we're not achieving them.
And then there's a third goal that was also clearly in mind at the outset of the program's development, and that was improving our data system. The ability to mount programs effectively and to assess progress effectively is dependent upon data systems. And data systems at that point, and still to some extent, are not well-focused on some of the priority issues. And so we were very hopeful that, by identifying through the Healthy People Process some of the most important opportunities that had to be tracked with improved data systems, that we would help enhance data infrastructure.
Claire Stinson: Well, it sounds like quite a process. And it's had a lot of success, and it's still used today, correct?
Dr. McGinnis: Yes. In fact I’m, I'm not involved in it, but I've watched appreciatively as the Healthy People 2030 Committee has been hard at work. I don't know exactly when the release date is, but Healthy People 2030 will be issued likely sometime in the next several months as we enter the decade of the 20s.
Claire Stinson: And the CDC Foundation is actually involved in a project related to Healthy People, funded by the Robert Wood Johnson Foundation. So we are involved as well.
Dr. McGinnis: Oh, I'm delighted to hear that. Thank you for your service, as they say.
Claire Stinson: Yes. So you also served as director of the World Health Organization's Smallpox Eradication Program in India, which you mentioned. Are there stories that stand out to you from your time in India?
Dr. McGinnis: Of course, one can't live in India for any time, much less a year of intensive activity, without coming out of the experience with stories. I'll mention two things as I think about this. First was the… success of the effort was the product of generous decisions and spirits of stakeholders from around the world. D.A. Henderson, when he orchestrated this effort, enlisted epidemiologists from many countries, he enlisted donations from many countries. And so the team that we had on the ground was generally multinational and bound by a spirit of commitment. So I think the most important impression that is not a single story, but it's a fundamental reference point – for me and I think anybody else who was involved in that program – is the bond that is developed by working with colleagues who are so dedicated toward a common purpose.
But I can tell you, as an example of how that bond and how those, how those individuals worked as individuals, when they were working individually, I'll tell you a story about Mary Guinan. Mary was a CDC career person at the time who later became the director of the health department in Nevada and so forth, but she was on a three-month assignment within my purview in Uttar Pradesh, and she was the head of I think a major program in Khanpur, which was a large metropolitan area.
And I mentioned those monthly meetings that we had to take stock of the progress, well, when Mary came in for those monthly meetings, she, like everybody else, went to accounting in order to assure that they had the resources necessary and they were filing all the initial necessary financial reports.
And she came to me in this process, and said, "I have a voucher for an elephant." And of course I see you have a voucher for an elephant, which you want me to get cleared in New Delhi. And she explained that it was the monsoon season, and there had been a reported case in a rural area, and everything was flooded. The roads were flooded. The only way she could get there was by commandeering an elephant to go to the village, through the flooded plains, to check on the case. And so she rented this elephant and well, we got her voucher approved.
Claire Stinson: Oh my gosh. Well, I'm sure you will always remember that.
Dr. McGinnis: Absolutely.
Claire Stinson: That's an amazing story. And it sounds like you had quite an impact in India as well as the impact you've had here in America.
Dr. McGinnis: Oh, I wouldn't say I had a dramatic impact in India at all. I was a small cog in a very big and important team. And the impact there was entirely the work of of all those folks involved, and especially D.A. Henderson and Bill Foege.
Claire Stinson: Well, we're a big fan of Bill Foege as well here at CDC Foundation. So Dr. McGinnis, you have experienced a long and fascinating career for over four decades in protecting the public's health. Can you tell me how the practice of public health protection has evolved during this time?
Dr. McGinnis: The practice of public health protection has evolved in various ways from a focus on communicable diseases: the first name of CDC was the Communicable Disease Center, then to the Centers for Disease Control, and then to the Centers for Disease Control and Prevention. And that's reflective of a growing, and in some cases rapidly growing awareness of the different factors involved in shaping health, disease and disability in the nation.
So at the time that I started out in the 70s working in this area, while we were still dominantly focused in many ways on communicable diseases in the prevention arena, the Surgeon General's Report of 1964 on tobacco and health had already been issued, and CDC was beginning to move substantially more into chronic disease control, taking leadership in the tobacco arena. And then with the later addition of injuries as a focus, and the change of the name, and the change of the structure to provide the capacity to deal much more broadly with challenges that were, that were not only focused on ways in which medical services – let's say vaccines for example – the preventative medical services might be engaged, but on ways in which the physical environment challenges could be better engaged, the ways in which the challenges of health and behavior, the ways in which genetic predispositions interfaced with susceptibility to disease, and the ways in which social circumstances played a role in the course of disease and diseases.
So the major change that has occurred I think over those times with respect to public health has been the evolution to the point that we now look at prevention in a much more holistic fashion, so that it's not enough just to think about medical treatment and the preventive, preventive services part of medical treatment, but to the other four arenas as the determinants of health: the issue of physical environments, of social circumstances, of behavioral choices, and the genetic predispositions. And that's where we are now.
But the common denominator throughout all of the changes that have occurred is the fact that the public health field has been, continues to be populated by those professionals who are more committed than any group of professionals that I know, and more bound by their determination to improve the human condition, and more inclined to reach out across sectors to recruit allies to the work. And I think that those changes are all fundamentally positive and absolutely necessary.
Claire Stinson: So it sounds like it has evolved quite a bit, but there's so much more important work to be done.
Dr. McGinnis: Oh, yes. Our realization of how much more work there is to be done grows with every moment of the growth in the science space as we develop different understandings of what makes people well, or keeps people well, or makes them ill. And what's important I think to also bear in mind is that, as the science has improved, we see a blurring of the, what has been in the past, occasionally described as a dichotomy between treatment and prevention. So the fact that the relationship between the two, the need for those who are primarily working in treatment arenas to deal with the social circumstances that their patients are encountering, to understand the behavioral choices that they're making, and to understand their genetic predispositions, has become clearer and clearer. And similarly, those in the public health arena understand the fundamentally important levers and access points that those in the treatment arena have.
And so, the combining of the common interest in improving the human condition for an individual and for a population, whether from the perspective of treatment or from the perspective of public health, and the combining of strategies, and – coordination is probably a better word – of strategies and tools as a necessity for progress is a reality today, which makes it a more complex challenge, but it also makes it more likely that we'll ultimately be successful.
Claire Stinson: Right. No, absolutely. So you've had this fascinating career. What are you most proud of?
Dr. McGinnis: Pride is not the word. It's grateful. I'm really, I'm most grateful for the opportunity to deal with challenges which are very important to people, to work with leaders who have been vitally important leaders in the nation. Working with these people who have, by virtue of their leadership and providing both the support for and the broad encouragement around, and the air cover that's needed, for public health progress has been a tremendous privilege. And so I'm very grateful for that privilege.
And I'm, and I’m grateful for having had the opportunity to essentially live out the conviction that I fundamentally started out with, and that I think most people start out with in many ways, and that is – none of us, or very few of us live in a command and control world where we can declare something to be some way and then it will. Each of us can only hope to try to make it a little easier for the right thing to happen. And I've been very grateful and privileged to be able to see, with the assistance of many others, what kinds of things do make it easier for the right thing to happen in the various circumstances I’ve found myself. So that's a major source of gratitude for me.
Claire Stinson: Well, you're very humble about it, but it sounds like you've made so many important contributions to the field of public health over the last four decades.
Dr. McGinnis: I've been lucky.
Claire Stinson: So you sound like a good person to ask this next question. What advice do you have for future public health leaders of America?
Dr. McGinnis: For future public health leaders of America, if I had to pick two words to use as guideposts for what we do, they would be evidence and partnerships. We are stewards of bringing the best evidence to bear for the most progress. And we have to be faithful stewards to that mandate. We are also uniquely in a position to forge partnerships and bonds and motivate activity from multiple sectors that are necessary to make a difference.
I'm not worried about the commitment, the motivation, the determination, and the drive of public health leaders of the future; that's part of the DNA of an individual who decides to take on the field. And I'm actually not worried about the focus on evidence or the focus on partnerships, but I think it's, given your question, a nice opportunity to emphasize those two dimensions.
Claire Stinson: I love that, evidence and partnerships. And we certainly believe in partnerships here at the CDC Foundation.
Dr. McGinnis: That's right, and that's why you're doing such wonderful work.
Claire Stinson: Dr. McGinnis, thank you so much for sharing your perspective on the state of health in the U.S. and how it has evolved over the years. We really appreciate it. And thank you for being a guest on Contagious Conversations.
Dr. McGinnis: I appreciate the opportunity.
Claire Stinson: Thanks for listening to Contagious Conversations, produced by the CDC Foundation and available wherever you get your podcasts. Be sure to visit cdcfoundation.org/conversations for show notes and bonus content. And if you like what you just heard, please pass it along to your colleagues and friends, rate the show, leave a review, and tell others. It helps us get the word out. Thanks again for tuning in, and join us next time for another episode of Contagious Conversations.