A Pioneer for Public Health: Celebrating the Legacy of Former President Jimmy Carter

Mati Hlatshwayo Davis: [00:00:13] Hello and welcome to Let's Talk ID. I'm Dr. Mati Hlatshwayo Davis, director of health for the City of Saint Louis and member of the IDSA board of directors. Joining me today are Doctor Rochelle Walensky, former director of the centers for Disease Control and Prevention. She's also an executive fellow at the Harvard Kennedy School and the Harvard Business School, as well as a member of the board of trustees at the Carter Center. Welcome, Dr. Walensky.

Rochelle Walensky: [00:00:40] Thanks so much for having me.

Mati Hlatshwayo Davis: [00:00:41] I'm also so pleased to introduce Dr. Kashef Ijaz. He is a VP of Health Programs at the Carter Center and previously worked at the centers for Disease Control and Prevention. Welcome, Dr. Ijaz.

Kashef Ijaz: [00:00:55] Thank you, Dr. Davis.

Mati Hlatshwayo Davis: [00:00:56] So I want to start by saying that the original impetus for this episode was a supplement published by the Carter Center in the American Journal of Tropical Medicine and Hygiene on the impact of President Carter and Rosalynn Carter. His recent passing makes this episode quite timely and even more significant. We're all infectious diseases doctors on this call today. As infectious diseases doctors who focus much of our careers in public health, I think we can all attest to the important role that President Carter played in public health. I wonder if you could both talk about the role he played in addressing neglected tropical diseases. Rochelle?

Rochelle Walensky: [00:01:33] Great. Yeah. So one of the great benefits I had while I was CDC director was to understand what was going on in the local community. And through that, I really became very interested in what was happening at the Carter Center. And, and really President Carter's legacy in neglected tropical diseases. So maybe we should just rewind and say, what are neglected tropical diseases? They are a diverse set of conditions. They are caused by a diverse set of pathogens and can be anything from viral bacterial parasites and so on. The thing about neglected tropical diseases is they generally afflict impoverished communities, communities that are hard to reach, generally in tropical areas, and they affect more than a billion people. They are often vector borne. They are often water borne. There are often animal reservoirs, so they are notoriously hard to control. And while we now use the term neglected tropical diseases easily and smoothly, I think it's just interesting to note that even the journal PLoS NTDs didn't get started until 2007. So we're talking about sort of 20 years of talking about neglected tropical diseases. And now you rewind to what President Carter did. In 1986, President Carter decided that it was time to work on Guinea worm, to eradicate Guinea worm. And so, President Carter, 20 years before anybody was talking about neglected tropical diseases, was actually doing on the ground work in communities to try and address these diseases for impoverished communities in hard to reach communities. And maybe with that, I will pass it to Kashif to talk about the work that they have, you know, how he got involved in that work.

Kashef Ijaz: [00:03:11] Thank you very much, Rochelle. I love the word eradication elimination because as a public health physician working on infectious diseases during my career, both in nationally as well as globally, the disease eradication elimination is the holy grail, or what I call is the final frontier for public health. Dr. Foege, Dr. Bill Foege, who has been a champion for it. And he eradicated the only human disease which is smallpox. He was the CDC director and President Carter consulted with him when he was establishing the health component of the Carter Center. And at that time, as Michelle mentioned, you know, NTD name wasn't even coined as NTD. President Carter actually made enormous contribution towards highlighting the importance of entities, especially when it comes to diseases that impact the impoverished communities, as Rochelle said, and most vulnerable populations. And these are populations at the end of the road. You know, when you're talking about small communities. And President Carter, coming from a small community himself, knew the importance of community engagement and the importance of addressing these diseases, which can cause both physical and economic impact. And that's how we all got involved into the neglected tropical diseases. And President Carter wanted to just go ahead and eradicate and eliminate these diseases. Obviously, learning from Dr. Foege, that is how we all got involved in President Carter, got involved into disease eradication elimination work related to neglected tropical diseases.

Rochelle Walensky: [00:04:43] And maybe I'll just say one of his favorite lines. There are no neglected diseases, only neglected people.

Kashef Ijaz: [00:04:49] That is very true. That is very true indeed.

Mati Hlatshwayo Davis: [00:04:51] And so powerful. I mean, if I can't think of a better foundation for the work that we all do in public health then that quote, and thank you for giving us that perspective. I think there's a whole generation of young public health leaders who may not have that, and it's so important that both of you are able to give that to us. So, Dr. Walensky, given your leadership at CDC, could you talk about the importance of bridging the gaps between research and community-based interventions to create lasting change, and the example set by the Carters?

Rochelle Walensky: [00:05:21] So much of the work that we did as we were working to vaccinate communities and understand what communities needed during the Covid pandemic, was community engagement. We could do research and we always talk about in clinical trials, you need to recruit people who floss their teeth twice a day and who will do everything that they need is supposed to do. And yet, people in communities have challenges that don't allow them to do all of the things that a clinical trial participant might be able to do. And so you really do need to go into communities to understand, well, this is what we believe is important for your public health and medical care, but what do you need? What is the most important thing? How can we talk about vaccination when you don't have food security, right? So those are the things that we really need to go into community and understand. And that is what President Carter knew so very well, being raised in one of those communities. He himself knew that community engagement was so very key. I think one of my favorite lines from from Jason Carter's eulogy at President Carter's funeral, Jason Carter is President Carter's grandson and chair of the board at the Carter Center, was, "Community is a place to find partnership and power. And it's a place to love thy neighbor." And so what he really, what President Carter did was he presented himself in these communities and really, as Jason said, left a whole community of Jimmy Carters who could carry out the task. It's one thing, as Kashef talks about in eradicating smallpox, we had a vaccine, but how do we talk about eradicating diseases when there is no medical countermeasure? Where there is no vaccine, there is no treatment and the countermeasure is education and water filtration. And how do you sort of educate a community at the end of the road to do those things and to make sure that they know those things are important and to create partnerships there, and that, I don't know, an organization that does it better than the Carter Center.

Mati Hlatshwayo Davis: [00:07:15] Powerful. So powerful. And now, shifting gears a little bit, I wanted to ask you to talk about a case study on Guinea worm eradication that was included in the journal supplement.

Kashef Ijaz: [00:07:27] So Guinea worm has been the flagship program for the Carter Center. So when President Carter started to work on it back in 1986, the Guinea worm actually had about estimated 3.5 million cases in 22 countries globally. Last year, at the end of 2024, so far, we have basically confirmed only 11 human cases on a planet of more than 8 billion people. Now, this is an enormous contribution towards Guinea worm eradication efforts because, as Rochelle was mentioning, Guinea worm is one of those diseases that does not actually have any vaccine. It does not actually have any therapeutic. It's all about behavior change. It's all about community engagement, health education, treating the sources of water and a lot of community volunteers. And there are hundreds and thousands of community volunteers, literally, who actually, you know, span these hundreds of villages in Africa. And they provide these health education. Now, building upon that, we are at the last mile, and the last mile is the toughest mile to run when you're trying to eradicate or eliminate a disease because you are you have just very few cases and you need to have very, very strong public health surveillance. In addition to that, we also need to have new tools and innovations built in too. So one of the things that which is published in the journal, is about the research agenda for Guinea worm. What are some of the things, in addition to what we have with our water filtration and how to drink safe water, we also are working on new diagnostics, new diagnostic tests.

Kashef Ijaz: [00:09:11] We are also working on genomics in order to ascertain the transmission dynamics of Dracunculiasis medinensis, which is the causative agent for for Guinea worm, and then also to look at the mathematical modeling as to if we actually get these new tools, how is that going to quickly help us reach the last mile and run the last mile so that we can be reaching the finish line? In addition to that, I mean, apart from Guinea worm, the Carter Center also works on other neglected tropical diseases like river blindness, lymphatic filariasis, schistosomiasis and trachoma, and a little bit of malaria work that we do in the island of Hispaniola. And when you look at all these other areas, we also do operational research related to many of these diseases in order to look at the frequency of mass drug administration with ivermectin, or how to go along with the safe strategy, which is the surgery antibiotic use, facial cleanliness and environmental cleanliness and sanitation for trachoma as well. A lot of this is already published in this supplement. And I would also mention that this supplement is available in the public domain. So if you Google the ASTMA journal, the American Society of Tropical Medicine and Hygiene Journal, it is available there and anybody can go in there and read the articles as well.

Mati Hlatshwayo Davis: [00:10:33] Thank you for highlighting that and how accessible it is. Because again, so much richness in the plethora of research that is covered here, but specifically the historical and current context on Guinea worm eradication is just not only historic, but extraordinarily significant. As someone who grew up in sub-Saharan Africa, this is something that is personal for me, something that we grew up even as children being made aware of. So thank you for laying that out so succinctly for everybody. Can you tell me more about the Carter Center's broader role in public health and in addressing neglected tropical diseases? I'll come to you first, Rochelle, and then Kashef, if you could add any comments.

Rochelle Walensky: [00:11:14] The secret sauce of the work that President Carter has laid the groundwork for is really, as we've talked about, community driven approaches, innovative approaches. But I also think that President Carter challenged all of us. And I look to his legacy, even personally, to say, how did he use his platform to go on and do bigger, greater things? So if you think about, like, the power of a former president and what they can do, President Carter, I think this is my favorite example. In 1995, negotiated what they called the Guinea worm peace fire. So civil war in War in Sudan. Access to populations was nearly impossible because of the civil war, and a former president can actually negotiate a health related ceasefire. It was intended to be for two months to address the neglected tropical disease of Guinea worm. And it turned out it lasted for six months so that they could do both polio vaccination as well as ivermectin for river blindness. And when you think about the power of the platform that he had and how he always really used it for good, it was, who would have thought that we could, you know, in the middle of a war, deliver all of this help? But you see how you actually can and how you can work creatively and use the leverage that we have. I'll pass it to Kashif to talk about all the other innovative ways that the Carter Center is currently working.

Kashef Ijaz: [00:12:37] Yeah. Building upon what Rochelle just said about the power of the political support that President Carter actually had, when you look at these medications like ivermectin as well as Zithromax for trachoma for mastering administration. He actually persuaded both Pfizer and Merck to donate these drugs for free for eradication or elimination of these diseases. And they basically committed to it and said that you will have these drugs for free as long as you need and where you need it. Now, this is hundreds and millions and billions of doses and money that these pharmaceuticals were persuaded to donate for free for elimination of these diseases. Building upon the work of the Carter Center, I mean, our commitments right now are, as we talked about, are to disease eradication, elimination of these neglected tropical diseases that we talked about earlier during the podcast. But in addition to that, we should not forget Mrs. Carter's passion for mental health and reducing stigma around mental illness. When I became the vice president for health programs, we looked at our strategic plan for health for the next ten years with a five-year implementation plan. So we are going to continue on with our existing commitments of disease eradication elimination for these neglected tropical diseases because the work is not finished yet. However, building up on this work, on these vertical programs, we are looking at how mental health can work in a cross-cutting way with our work in neglected tropical diseases. For example, we have done a pilot on lymphatic filariasis, people who actually suffer from lymphatic filariasis in Haiti and still have hydrocele and elephantiasis with swollen legs, because there's a lot of stigma associated with that for these communities.

Kashef Ijaz: [00:14:25] And we have created this working with these communities and providing them with psychosocial support through mental health programming to create these Hope clubs. And we are now replicating this work in Africa, in places like Nigeria as well. So trying to see how the mental health can work and help on this from a psychosocial standpoint with some of the impacts of these neglected tropical diseases that we work on. In addition to that, you know, we are working on health system strengthening and how these vertical programs can contribute towards health system strengthening and public health system strengthening in the countries where we work. Because every vertical program builds systems around themselves, which is like on diagnostics with diagnostic platforms that can be used for other diseases as well, as well as the workforce or the volunteers that are working on mass drug administration and so on and so forth. And once we are done with eliminating a disease, how do we transfer these skills, and they can be used in a cross-cutting way through cross training, on other public health efforts in those communities as well? Lastly, that I would say, which is really important, building up on Rochelle's point about Guinea worm ceasefire, we're also looking at how peace and health programs can work together. And we have recently worked and published in Health Security Journal about our work in Mali, where our conflict resolution program has actually helped us get the Guinea worm workers in some of the insecure areas in the Mopti region in Mali to do the Guinea worm eradication work.

Mati Hlatshwayo Davis: [00:15:47] You said so many things that resonate with me as a public health director for a city. It is inspiring to hear that the Carter Center is really in the forefront of understanding a few things. Number one, that we deal in a world of syndemics, right? We don't just operate in a monolith. So to understand that we can talk about neglected tropical diseases, but this work doesn't get done, if we don't address building infrastructure, if we don't address mental and behavioral health, right, that impacts communities and impacts our ability to be successful in these endeavors. But for you to specifically to really understand the countries and the cultures they're within and even say, let's empower ourselves and empower those countries to be able to deal with conflict resolution is truly inspiring, um, such an important global health approach, but honestly, just local public health. I completely resonated with the way that you are addressing this, because this is what we have to do on the ground right here in St. Louis. So thank you so much for your work, for your leadership, but for being intentional in understanding that there is a 360 degree approach to how we deal with these topics. And most of us ID nerds may historically have thought about them as a monolith, but it's not. You don't do this work without committing yourself to mental health and behavioral health. You don't do this work if you don't really have leaders who understand infrastructure development. So truly excites me to hear you talk about that.

Mati Hlatshwayo Davis: [00:17:10] Dr. Walensky, having had a front row seat in your role as the director of the CDC, and I have to embarrass you a little bit. This was a director who was so passionate about community. I remember you coming to St. Louis. I remember you taking time. You know, you only had two hours and you stretched it to six hours. You were in North St. Louis meeting with FQHC CEOs, right, in the hood. You were right here in my health department, meeting individually with members of my team, talking to them, making them feel seen. And I mean, for them, it was like the biggest celebrity day. That was the kind of CDC director you were. Because of you and your support, I was able to establish the first behavioral health bureau for the City of St. Louis. That came out of a commitment you made to this health department. So I will always give you your flowers when I'm around you. So having had a front row seat to your role as a very present and active director of CDC, can you talk about the importance of political support in addressing public health and health equity issues?

Rochelle Walensky: [00:18:09] Oh, thank you so much. That was so kind. And in fact, it only works if we do it together. It only works in partnership. I think that that is what we just learned. And it only works if when I pass the baton, you pick it up, right? And then you pass it to someone else so that we're all working together. I think that what we sort of demonstrated, or what even you just spoke about, speaks that political support drives funding. It fuels innovation. It influences health equity policies. It motivates people to work together. And I think if we learned something in the last five years, it's almost been five years, right, if we've learned something, it is that all of these things are related to health security, that a disease anywhere is a potential for disease everywhere. That health security actually very much is related to economic security. And that when you have a disease that affects a billion people or in this country, 330 million people, that you're talking about years of productive life that are lost, years of education that are lost, years of potential that are lost. If you just think about the Guinea worm, the mathematical models that Kashif was speaking to estimate that we've averted, the Carter Center has averted, tens of millions of Guinea worm infections. What we know is that kids are in too much pain. They can't be educated when they have Guinea worm. Adults cannot work when they have Guinea worm. So when you talk about tens of millions of people and what that has the potential to do in terms of children being educated, jobs being filled, people being able to put food on the table, economic security around countries. That is what we're talking about. And so the political motivation, I think fuels everything that comes forward. And to talk about this only being a health security issue, it is a health security and an economic security and a family security and a community security issue.

Mati Hlatshwayo Davis: [00:20:01] So powerful and so true. It is so important for me, for us to talk about the next generation of leaders. And one of the unfortunate impacts of Covid-19 is we've seen a little bit of a drop off in people going into careers in medicine and certainly in public health. Public health is not the most lucrative area of medicine to go into. But we can all, the three of us, speak to how rewarding and how impactful it is. So what advice would each of you give to young people interested in medicine and global and public health? And of course, I'm going to be biased in saying and careers in infectious diseases to that point as well. But Kashif, what are your thoughts here? What would you say to young people interested in this in this field?

Kashef Ijaz: [00:20:41] Infectious diseases is a broad area. I mean, there are many, many infectious diseases. It basically enables the young generation to choose this career and offers a diverse set of opportunities to make an impact. They can work in academia, they can work in public health, like I did, and then Dr, Walensky did as well. And you can go into global health, which is very exciting. And of course, you can do private practice. So it is a broader area. And it actually gives you a lot more broader opportunities to work on various fields. Of course, I mean, like yourself, I am also biased and would say that, uh, public health is the way to go because, you know, you're not treating one person at a time. You are actually treating the populations. And you can have a much greater impact by working in infectious diseases, in public health. And it's actually very rewarding to see when you eliminate a disease or when you eradicate a disease, or you or the populations are no longer at risk for a certain neglected tropical disease, for instance. This is definitely an area for the young generation to look into. I also think that professionals also have the opportunity to work on research, clinical trials, and various other roles that they can actually work on and development of policy and advocacy, serving on the various groups that provide recommendations, which CDC basically always relies on experts in infectious diseases to provide them with recommendations on how that's how the recommendations come out from CDC for immunizations and so on and so forth. Of course, Rochelle knows much more about, from a CDC standpoint, being the former CDC director, so I'll turn it over to Rochelle.

Rochelle Walensky: [00:22:18] Yeah. You know, my father used to have a line. And I think that this is very true in careers, which is, "You can't have everything you want, but you can have anything you want." And what I wanted was impact. I wanted to make a difference. I want to make a difference at the bedside. I wanted to make a difference at the policy level. And Infectious Diseases Society of America, IDSA, I'll just put in a plug for them, was the place that I that I could meet with people who were making impacts in all sorts of different ways. And part of the motivation, I think, for this podcast is because I didn't actually recognize the work of the Carter Center when I was sitting from my perch at IDSA or my perch as an infectious disease clinician. And I think it just opens your eyes to all the different potential ways that you can have impact. Whether it be at the bedside in research, in policy, at the last mile. There are so many different inspiring ways to make a difference in people's lives, and then to meet your colleagues who are making those differences as well.

Mati Hlatshwayo Davis: [00:23:13] So, so powerful from both of you could not have said it better. And I will say to any young people listening to this, whether you are in high school, a medical student, a resident, a fellow, if you sometimes didn't feel like you had a home, if you are struggling with where to go for resources, I remember the most impactful period as a medical student was I got a CAS award to go to my first Infectious Diseases Society of America meeting, and I got to present on my research on tuberculosis in Boston. I will never forget that meeting. And so. And what I wanted to do in this world, I didn't really see a lot of people doing. But I'll tell you who helped ground me and find me spaces and mentors and resources is the Infectious Diseases Society of America. Check out the website. Sign up to volunteer and then you will see a plethora of different areas that fit for you. You don't have to do things that don't fit, but they have critical resources. They can get you a mentor. They give you opportunities for advocacy. We have young people on Capitol Hill advocating for policy, right along with leaders in ID, and so there's a lot of support at all career stages for you all right here at IDSA.

Mati Hlatshwayo Davis: [00:24:25] You all this has been such an impactful, such an important conversation. I'm a little bit of a history nerd, and it's this is the first podcast that I think has done such a great job of giving us some really powerful history of medicine and public health. You taught us. You gave us example of research. I mean, you guys knocked it out the park. I'm not surprised, but I have to say it on record. So I want to give you both an opportunity for any final words, things that we didn't get to talk about before we wrap up. So, Kashif, what's on your mind as we bring this to a close?

Kashef Ijaz: [00:24:55] I would go back to the founder of the Carter Center and the type of person he was. I mean, President Carter has certainly, and Mrs. Carter, too, has certainly left us an incredible legacy that we all have to carry on in global health. They were true humanitarians, incredible leaders. They were people who taught us persistence, how to remain focused. They also taught us how to listen to people and listen carefully as to what the needs are for the communities, as well as when working with the ministries of health in various countries. And President Carter, being the former president of United States, was also competitive. He would also give us tough love in terms of challenging situations. And for those who are residents, I mean, it's just like going to a morning report with a tough attending. And that's how he was.

Mati Hlatshwayo Davis: [00:25:50] [laughs] That's right.

Kashef Ijaz: [00:25:51] So he took us to task, you know, when he was active and wanted to know about how many cases of Guinea worm are there. And he always said, "I would want the last worm to die before I leave Earth." So we are almost there and we have an incredible legacy. Now, if you want to learn more about the Carter Center, I would encourage you to go to our website, which is www.CarterCenter.org. And thank you very much, Dr. Davis.

Mati Hlatshwayo Davis: [00:26:15] So important. I love that you talked about the tough love approach. We don't get work done if we don't buckle down. And for young people it's not always easy, right? But if you surround yourself with mentors who care about people, who care about impact, even when it's hard, it will still be worth it. Kashif, you're such an important example of that in your leadership is so important. Rochelle, final words for us today?

Rochelle Walensky: [00:26:35] I didn't get to know President Carter as well, given my participation in the Carter Center later in my, just recently, as he was getting older or as he was approaching 100, shall I say. But this is so much of what I've just said has resonated with me. There is so much that we need to project in terms of humility and leadership. So many of his examples that we can follow. And yet we also need the chief resident, the tough love, the stick to the task. When people say, how do you figure out a research topic? I say, it's the ones that piss me off.

Mati Hlatshwayo Davis: [00:27:07] [laughs]

Rochelle Walensky: [00:27:07] It's the ones that that at 11:00 at night I'd rather research than go to bed, right? So those are the ones we have to stick to and be tenacious about to make the world a better place. I do invite people to go to the Carter Center website. I've learned so much. It's been really inspiring for me to be working there, and so many other good things that IDSA is doing for our infectious disease community. There is a reason, after my CDC tenure that I'm still back at IDSA.

Mati Hlatshwayo Davis: [00:27:36] Ah, I'm so inspired. I'm so happy on this chilly Monday. It's been an honor and a privilege to be in conversation with you both. We hope that we have done a small part to continue to honor the legacy, the leadership, the innovation and the impact of the late and great President Carter. We thank him and his wife for their commitment, their tenacity, and their love for humanity that was personified through this incredible work. And we are thankful for the leadership of both of you and the Carter Center in continuing his and their work. This has been Let's Talk ID. Thank you so much for joining us.

Mati Hlatshwayo Davis: [00:28:17] Thank you so much. 

Kashef Ijaz: [00:28:22] Thank you very much.