Perspectives — A Forum for RAND Guest Voices

Heart and Soul

For Global Health, Prescriptions of Medicine and Morality

While the world faces daunting challenges in reining in such diseases as malaria, river blindness, guinea worm, HIV/AIDS, and tuberculosis, often overlooked is the fact that progress is being made on multiple fronts. This progress also holds clues to making further gains.

Epidemiologist William Foege.
PHOTO BY DIANE BALDWIN
Epidemiologist William Foege points out the good news in global health.

That was the uplifting message delivered at RAND by William Foege, a world-renowned epidemiologist who helped devise and implement the successful strategy for eradicating smallpox in the 1970s and who continues to serve in international health policy leadership positions. Foege shared his decades-long perspective on what has been accomplished to improve global health and some personal lessons he has drawn from his work over the years.

Silver Linings

Foege finds hope amid some of the direst of the world’s circumstances. “Today, we celebrate getting down to less than 10 million deaths per year for children under the age of five. That’s almost obscene, but I can remember a time when it was 15 million such deaths a year.”

Another reason for encouragement is what has happened in Botswana in terms of HIV/AIDS, he said. “Ten years ago, 40 percent of all newborns were HIV-positive. But now, with the combined efforts of the Gates Foundation, Merck, Harvard, and the government of Botswana, the rate has dropped to less than 4 percent.” This progress among newborns is a sign of progress among adults as well, of course. “AIDS used to be a “ radio disease’ — something to talk about on the radio but never in person; now, people are talking about AIDS on the street.”

Signs of promise have also emerged in treating tuberculosis. “The current vaccine — known as BCG — has not been that effective over the years,” he said. “But new strategies to improve on or replace BCG have been developed over nearly the past 20 years, and there are now six new vaccines in human trials, which means the treatment of tuberculosis is going to change.”

Collaboration as Cure

One driver of such improvements, according to Foege, is the willingness of key stakeholders to work together. He applauded the efforts of the Global Alliance for Vaccines and Immunizations (GAVI), also known as the GAVI Alliance, which grew out of a 1984 task force sponsored by the World Health Organization, UNICEF, the World Bank, the United Nations Development Programme, and the Rockefeller Foundation.

A health worker extracts a guinea worm from a child's foot.
AP IMAGES/OLIVIER ASSELIN
A health worker extracts a guinea worm from a child's foot in Savelugu, Ghana, in 2007. On July 28, 2011, after 23 years of work, Ghana declared victory in eradicating guinea worm disease, or dracunculiasis. Guinea worm could be the first parasitic disease eradicated, and only the second disease to be eradicated in the world, since smallpox in 1979.

“In 1984, former Secretary of Defense Robert McNamara said that if you could raise $100 million for immunizations, it would change everything, but people said it couldn’t be done,” Foege recalled. “In 1984, Italy alone put in $100 million for vaccines in Africa. Today, even in the midst of the global economic recession, GAVI has raised $4.3 billion for new vaccines. If people believe there is a global plan, money becomes available.”

Another story of exemplary cooperation is that of Mectizan, a drug developed by Merck to treat dogs for heartworm. As it turned out, Mectizan could also be used to treat humans for river blindness — a debilitating disease that infects 37 million people, threatens to infect 100 million, and renders people blind by the age of 50 or 60. “The drug has to be used only once a year.”

Merck approached the Atlanta-based Task Force for Child Survival and Development, “offered to give the drug away forever for this use, and asked if the task force would help distribute it,” Foege recounted. “Since 1987, over 530 million treatments have been approved, and the drug is now being given to more than 60 million people a year in Africa, Latin America, and Yemen.”

Science with a Moral Compass

Ironically for someone who has marshaled the global forces of modern medicine, Foege said that one of the most important lessons he has learned in his career has to do with the limits of science. “Even in physics, where we think we have facts, those facts are within a margin of error. I was shocked to see that the Periodic Table now has atomic weights plus or minus some number.”

“We should love science but not worship it. Science lacks a moral compass, which means scientists must cultivate it. Science with a moral compass is science that contributes to social equity, science in the service of humanity, science aimed at health for all, science that says you can’t take shortcuts.”

— William Foege, senior fellow, Global Health Program, Bill & Melinda Gates Foundation

He reflected on the role of science in the context of improving global health: “We should love science but not worship it. Science lacks a moral compass, which means scientists must cultivate it. Science with a moral compass is science that contributes to social equity, science in the service of humanity, science aimed at health for all, science that says you can’t take shortcuts.”

Foege has come to interpret the Hippocratic oath, “do no harm,” differently than it is typically meant. “We hear this often in almost every profession, but when we hear about it we are usually talking about errors of commission,” he said. “We can also do harm by committing errors of omission — by not using science, by not sharing science, by not using vaccines when we have them. Science needs to be applied to be useful.”

Two final lessons he has learned are the needs for tenacity and optimism. As for tenacity, he offered the example of Colonel Thomas Allen, who led the 5th Wisconsin Infantry in the battle of Chancellorsville in the Civil War. In rallying his troops, Allen said: “When the signal ‘forward’ is given, you will advance at double-quick . . . and you will not stop until you get the order to halt. You will never get that order.” After a pause, Foege observed: “That’s the situation we’re in now in trying to improve global health. We will never get the order to halt.”

As for optimism, he stressed the importance of not hiring pessimists: “It will ruin your day and ruin the office. When you need pessimism, contract out for it.” square

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