William Foege - World Health Assembly 2000

May 16, 2000
Remarks by William Foege, M.D., M.P.H., Gates fellow

My wife taught four-year-old children for many years so they have become a source of wisdom and stories over the years. One of my favorites is the teacher who talked to four-year-olds on their first day of school, explaining the rules. The last instruction was that if they needed to use the bathroom they should raise their hand. A very perplexed four-year-old boy asked, "But how does that help?" I ask today, "How does it help that we are all involved in global health?"

One year, I had completed my presentation on "How to stay healthy" to my wife's class. I asked if there were any questions and a four-year old girl asked, "Do doctors have bosses?" I wanted to follow her career. My response, after some thought, was, "The good ones do. Their patients are their bosses."

Do Ministers of Health have bosses? For the good ones, every person in their country is their boss. But it doesn't end there. Because you are building the foundation for the future, in a very real sense, every person who will ever be born in the future, in your country, is your boss.

Arnold Toynbee was wrong when he wrote, "The twentieth century will be remembered chiefly, not as an age of political conflicts and technical inventions, but as an age in which human society dared to think of the health of the whole human race as a practical objective."

It was instead, an age of political conflict and technical inventions, and in addition, we ended the 20th century with gaps and discrepancies and differences in health that make us embarrassed.

We meet this week not just to improve global health governance, not only to network, not simply to review the progress of our health programs…we gather to figure out how to close those gaps and to reaffirm the very essence of our philosophy as public health professionals. That essence rests on our obligation to use the knowledge and experience, gathered through the ages, to improve the quality of life for everyone. Our work foundation, our professional creed, our reason for holding the position of trust that brings us to this meeting, is to seek social justice in health.

And we come to dream…of a world we will never see…but a world that we will create.

The Road Traveled

Over a half-century ago your professional ancestors began these annual meetings. Could they have believed what was to happen over the next 53 years?

• Life expectancy has improved more during that time than in the previous 4000 years… in many places…but not all.
• One disease, smallpox, has disappeared.
• Infant mortality rates have declined by 50% in 90% of most countries...but not for all groups.
• The measles virus is no longer the most lethal agent in the world. And that simultaneously shows the power of an inexpensive vaccine, but at the same time the hesitancy of the public health establishment to fully use that power. How else can we explain almost 3000 people a day dying of diseases so readily prevented?
• Could those professionals have imagined children, by the millions, spared from death due to diarrhea? And their parents spared the grief of one less loss.
• Would they have believed that polio and guinea worm were about to join the ranks of historical footnotes?

We acknowledge those accomplishments while facing the inevitable truth. Which is that…

The Problems are Daunting

No Ministers of Health have ever faced a more difficult time. AIDS is a more formidable opponent than even the Black Death. That plague came and went, caused wholesale deaths and reorganized society. In 1348 and 1349, perhaps a quarter of the population of Europe died. Government workers, land-owners, merchants and church officials among them. For example, in one year over 50% of the bishops in the Catholic Church died. But then, as after an earthquake or other natural disaster, the population could regroup.

But not with AIDS. The problem goes on. Day after day.

There is never a chance to regroup, as health workers, teachers and government workers die faster than they can be replaced, weakening the social fabric. Grandmothers struggle to keep their grandchildren together, faced with the impossible task of providing food and clothes, and school fees.

Many of you have known for a long time that AIDS, in your country, is a national security issue. Now, that is being recognized globally.

If AIDS is not challenge enough, just add to the mix, tuberculosis, malaria, malnutrition, onchocerciasis, lymphatic filariasis, intestinal helminthes, the toll of injuries and violence, mental health problems, poverty and illiteracy…and if that is still not enough to make health officers surrender, add a problem causing more deaths than tuberculosis, not the work of nature, but of people willing to cause suffering in order to make a profit promoting tobacco…and you end up with a disease problem complex that few in the world can even comprehend.

You are the heroes of our time. Are you overwhelmed? Of course you are. But you are not defeated.

The writer F. Scott Fitzgerald once wrote, "The mark of a first class intellect is the ability to keep two conflicting ideas in mind at the same time…such as:

• This is an impossible situation, and
• Here is how we are going to solve it."

And so, in the midst of this impossible situation, you evaluate the assets and tools at your disposal, and conclude that never has this Assembly, as a group, faced such an impossible problem and at the same time, never have you had so much power to change forever the future health of the world.

As we look at…

The Road Ahead – What Gives You Hope?
The positive signs are very positive.

#1 - Better Tools

• Could we have believed when we started our professional careers, that we would have an inexpensive vaccine against polio and the chance to spare every future generation? Some of us still remember that day, 45 years ago last month, when it was announced that the Salk vaccine protected against polio.
• Or measles vaccine…saving children by the millions every year.
• Hepatitis B vaccine – the first of what will be a group of anti-cancer vaccines.
• Haemophilis Influenza B – A magical vaccine in removing meningitis and pneumonia from the lives of children. And now soon, through the Global Alliance for Vaccines and Immunization (GAVI), it can be made available to countries that were excluded, in the past, because of the price.
• Did we envision simple effective impregnated bednets?
• Or an integrated management system for childhood illnesses?
• Could we have understood that we would now be dealing with powerful and inexpensive micronutrients to decrease infant mortality, improve strength and improve IQs?
• Did we dream of a time when pharmaceutical companies would join the battle of diseases in developing countries by making some tools available free?
  • Did we envision Merck Drug Co., over the past 12 years, giving $400 million worth of Mectizan for onchocerciasis?
  • Or Glaxo-Wellcome providing up to $30 million per year of Malarone, a new anti-malarial, to discover how to most effectively use it to get to those in need, regardless of their ability to pay?
  • Or Smith Kline Beecham providing Albendazole in an effort to finally do something about lymphatic filariasis?
  • Or Pfizer providing Zithromax in the fight against trachoma?
  • And now the agreement of five pharmaceutical companies to provide major discounts for drugs useful against AIDS?

#2 - Better Organization

We are here because we know we can do better together than we can do separately. We help our own countries by being globalists. Einstein reminded us that Nationalism is an infantile disease. He called it the measles of mankind. We have learned, that strengthening our ability to solve disease problems, involves the paradox involved in strengthening ourselves… that is… our independence as both people and countries, is achieved through consenting to interdependence.

As Gandhi said, if we understand that, we will pursue interdependence with the same zeal that we show when pursuing self-reliance.

And after 50 years, we are beginning to understand how to organize globally to increase our collective ability to improve health. For example, the last time WHO organized to contain malaria, most of Africa was excluded because it seemed too hard. This time, Dr. Brundtland and Dr. Nabarro did not take the position that any place was too difficult, and indeed "Roll Back Malaria" was launched in Africa, with the heads of State meeting in Nigeria, and declaring, "We are committed."

Which leads us to the third positive sign…

#3 – Increased Political Interest

It is not just "Roll Back Malaria." Heads of State have demonstrated interest and commitment to AIDS, guinea worm eradication, child health, onchocerciasis and a host of health problems. Former heads of state are actually working for guinea worm eradication in Mali and Nigeria. This is a new resource. Use that power.

A former Head of State, President Jimmy Carter, has spent countless hours pursuing health improvements in Africa, raising funds, visiting programs, and hiring workers for guinea worm eradication, river blindness, lymphatic filariasis, nutrition and polio eradication.

Around the world, political leaders are demonstrating a new interest in health. This, in turn, gives us new power.

We are also seeing…

#4 – A New Understanding of the Role of Health in Development

• The World Development Report, issued by the World Bank in 1993, outlined the role of health in development.
• Now we see repeated articles on that theme. This in turn will put a new challenge on us to show what outcomes are resulting for every dollar invested.
• Ministers of Finance are beginning to speak up about the value of investing in health. And in the US, the Secretary of Health and the Secretary of the Treasury have been working together to promote global immunization efforts.
• As health workers we have made this point for some time…but we lacked an authoritative voice. Now the economic world has discovered the relationship. Use their voice.

#5 - The New Coalitions

WHO is becoming stronger by participating in, and sometimes sponsoring, coalitions outside its usual structure.

• Mectizan distribution has brought dozens of non-governmental organizations, medical mission groups, foundations, ministries of health, WHO, UNICEF, the World Bank and Merck Drug Co., together in a new coalition, held together by a common goal…to treat those infected with onchocerciasis. This coalition provided Mectizan to 33 million people last year.
• Lymphatic filariasis is inspiring a similar organization, involving both Merck and Smith Kline Beecham.
• GAVI is an ambitious attempt to get public and private groups organized around yet another goal, the immunization of children.
• The Global Alliance for Tuberculosis Drug Development is forming to develop new drugs for an old disease problem.
• The list goes on, with Medicines for Malaria.

The point is that the future of public health will no longer be based just on the usual organizational lines of WHO. WHO is becoming stronger by supporting those who can put together coalitions around a shared goal.

There is a sculpture at the WHO building, of a boy leading a blind man by means of a stick. This sculpture is rich in symbolism. The symbolism of a disease, onchocerciasis, but also the symbolism of the social fabric that gives hope.

That man, of course, shows the impairment of blindness, but for those who have worked with river blindness, it takes little imagination to see the thickened and altered skin and you can feel the itching that is his first thought in the morning and the last thought at night. The boy, at the front of the stick, is demonstrating the social fabric that holds that community together. He is investing in the future of that community but also in his own future. Because he already has microfilaria coursing through his body. He already has the itching of this miserable condition. He already knows that some day, he will be on the other end of that stick. But because of this remarkable coalition, he will not end up at the other end of the stick.

That sculpture is not limited to WHO. There is also one at the Carter Center, making clear that the coalition involves, and is dependent on, the non-governmental community.

A third one is in the lobby at the World Bank. Of all the things that could be put in the lobby of the World Bank, they chose this symbol of their investment in health, their investment in a coalition.

But it doesn't stop there. The fourth and last copy of the sculpture is in the lobby at the headquarters of Merck. It was actually the first to be erected. Visitors to Merck are greeted in the lobby with a sculpture to commemorate a drug for which they make no money in its use for humans. This symbol acknowledges a new way of doing things in global health.

#6 - The Successes

• Not just the global successes of disease eradication or child survival, but the national successes of Uganda and Thailand, for example, as they turned the tide in HIV transmission rates. Giving hope to their countries but also hope to the world.
• These successes make the point that every global program that we have is the outgrowth of something that has worked nationally or locally. This is true of smallpox eradication, polio eradication, malaria control, river blindness control, immunization and diarrheal disease control.

#7 - The Increased Resources

• We have become accustomed to the traditional sources.
  • National contributions to WHO and UNICEF.
  • Bilateral health programs.
  • The Rockefeller Foundation.
  • Medical mission groups.
  • Service organizations…such as CARE, Plan International, Save the Children, World Vision etc.

For that we are continually grateful.

• But the traditional sources now have new and welcomed company…
  • Countless Non-Governmental Organizations.
  • Rotary International, with over $400 million raised to date for polio eradication.
  • George Soros and hundreds of millions of dollars for health improvement.
  • The UN Foundation providing $100 million per year for a decade.
  • Merck, Glaxo-Wellcome, SmithKline Beecham and Pfizer and other pharmaceutical companies now providing major resources for the benefit of global health.
  • And now…Bill and Melinda Gates. Providing something that none of us in global health had ever dared to hope for. A foundation of significant size, dedicated to "Global Health Equity." Prepared to invest over $500 million a year to make sure children everywhere have the benefit of the science now protecting children in developed countries and, in addition, to stimulate research into health tools and solutions for the problems of poor people in poor countries.

This combination of resources from public and private sources is unprecedented in global health.

"How has the world used accumulated wealth in the past?"

Several millennia ago, Alexander the Great used accumulated resources to increase military might.

Then we saw, throughout the world, great fortunes invested in forts and fortresses.

One thousand years ago, as tools improved, as building materials improved, we saw new creativity in architecture. At that point resources from churches, royal families and communities, were invested to build cathedrals, some taking hundreds of years to complete. Artisans were assembled who knew they would never see the completed cathedral and yet there is no evidence that it decreased the quality of their work. Likewise you and I are investing in a work for the future.

Over the centuries, we have seen the use of resources to build the great universities of the world.

And then, accumulated resources helped to fuel the age of commerce – With ships, trading companies, and the multinational companies.

More recently, wealth has built the modern cathedrals…the medical centers of the industrialized countries.

But now, for the first time we see significant resources being invested in global health. We have the chance to build a new kind of cathedral…a virtual cathedral…dedicated to global health. The tools, organization and resources are improving. Will the architects and builders, and managers, and laborers, in this room, be equal to the task?

Will you provide such leadership that it becomes logical for others to follow the example of Bill and Melinda Gates? Will you form a movement so strong, will you rally around Dr. Brundtland with a WHO so capable, a health structure so powerful, that the story of this collective health movement will be recounted in schools of medicine and schools of public health through the coming centuries?

Repeatedly, people say it is the Ministers of Finance that we should talk to – They are the key. But it is you, the Ministers of Health, who turn that key. For public health to improve it is up to you.

"The world cannot be allowed to exist half healthy and half sick."

There is a point in every movement, where a line is crossed. There is a drop of water that finally causes a glass to overflow, a moment when a friendship becomes permanent, a minute when a vaccine actually provides protection.

There will be a moment when the phrase, "The world cannot be allowed to exist half healthy and half sick," goes from being a nice statement to an actual commitment. Where there is no turning back and the world, in the words of Toynbee, "dares to think of the health of the whole human race as a practical objective." That moment could come at any time in the future, but it might just as well come today…with the World Health Assembly of 2000. It will require us to give new attention to measurement, identifying gaps, evaluating interventions, and always emphasizing outcomes.

I tell students about a man who was told by a fortune teller that he would be very poor and very unhappy until he was 45. Grasping at that straw he asked, "What will happen when I am 45?" The fortune teller said, "You will get used to it." Your job, as a health leader, is to be sure that no one ever gets used to the gap in health. Never gets used to unnecessary suffering, premature death, poverty or illiteracy. That Heads of State, Ministers of Finance, those in leadership positions, and those who are trusting you to make things better have no chance to get used to pessimism, cynicism, or fatalism. Be professional health workers, but also be professional optimists.

In 1932, Lincoln Steffens said, "What is true of business and politics is gloriously true of the professions, the arts and crafts, the sciences…the best picture has not yet been painted, the greatest poem is still unsung, the mightiest novel remains to be written." And we echo today that the most spectacular health contributions are still unimagined this day, the finest solutions are still before us.

In closing, let me ask you:

Would you have preferred being one of the health ministers starting this organization 53 years ago, without polio vaccine, measles vaccine, or oral re-hydration therapy? Or, even with all of our problems, would you prefer being here today?

Would you even have preferred being part of the World Health Assembly of 1980, so pleased as it announced eradication of smallpox and yet lacking mectizan for onchocerciasis, an integrated approach to childhood illnesses and having achieved less than 10% immunization coverage? Or would you prefer being here today?

Would you even have preferred being part of the World Health Assembly of 1990, about to participate in the Children's summit, but without widespread use of Hepatitis B vaccine, fragmentary approaches to micronutrients and no example, as yet, of a reversal of the AIDS transmission rate in any African country, no promising treatment for lymphatic filariasis, no major involvement of pharmaceutical companies in solving these public health problems, and no UN Foundation or Bill and Melinda Gates Foundation? Or would you prefer being here today?

There has never been a better time. The ingredients are in place. Coalitions, leadership, inspiration, optimism are required. Hard work will be the order of the day, but if you are willing, your bosses…the people you serve…most of them as yet unborn, will judge you as great cathedral builders...and great ancestors.

Thank you.