Conference Synthesis and Vision for the Future

W.H. Foege*

Eric Hofer once remarked, "When everything has already been said, be brief, repeat, exaggerate." I can't exaggerate about how good, how useful, how stimulating this meeting has been. Peter Drucker has said that everything must degenerate into work if anything is to happen. The amount of work done here in the last 52 hours predicts that much will happen in the future.

Last night, I gave a talk at Emory University entitled, "Protect the future, you may be living there." The two points that I hoped to make were, first, the immortality of all of our actions, and second, perspective. For perspective I started with a story: Abd-er-Rahman III (912-961 AD), a powerful ruler of a dynasty in Spain 1000 years ago, left behind a note at his death:

"I have now reigned above 50 years in victory or peace . . . Riches and honors, powers and pleasures, have waited on my call; nor does any earthly blessing appear to have been wanting to my felicity. In this situation I have diligently numbered the days of pure and genuine happiness which have fallen to my lot. They amount to fourteen."

What a sad commentary. For immortality, I spent some time making the case that we are not just tied to the past, but we are tied to every detail of the past. Likewise, it is not just the general actions, but every detail of today that has implications for the future. That is where Rafe Henderson started on Monday morning. If we are to do good, it will be in the details.

Many people will spend today, as they spent yesterday, and everyday, with all of their talent and energies devoted to making money -- trading stocks, trying to figure out how to sell more cigarettes, scheming to separate money from other people. Those actions are immortal with many ripples into the future . . . but they aren't necessarily important. Richard Hamming has said, "If you want to do important work, you have to work on important problems." What you have done in the past 3 days, which is possible because of what you have done over the years, is important work. To this end, I offer the following observations.

Observation 1. A PROCESS HAS BEEN BORN. This process builds on Dahlem and many things preceding, but it now has a secure life of its own.

• You have pushed for some order, some priority, some balance in deciding the specific eradication targets that make sense.
• You have developed a road map for organizing people and resources in the future.
• But most important, you have catalysed a process for refining, making corrections and promoting these ideas in the future. This process is very similar to the 1990 objectives: they started in 1978 with a meeting in Atlanta; some 220 objectives were selected for 1990, many so bad that they could not even be measured in 1990. But by setting targets the critics were able to have specific things to attack which gave us a chance to improve the targets and the definitions.

What we learned from the 1990 objectives is the power of the process. We don't have to have all of the answers. We don't even have to have all of the definitions right. What we have is a process that, just like science itself, is self correcting and keeps improving on the answers. Healthy people 2000 will be better than the 1990 objectives and the 2010 objectives will be even better.

We have only 50 years of experience in global organizations, and only 30 years of experience with successful eradication programmes. It is no wonder that we are still struggling to find the best way to organize, to implement, to cooperate. But struggle we must, because we cannot afford to waste resources, or time, or effort when the problems require the best we have to offer collectively. Rafe is right: the organizers need to edit the results, provide their own conclusions and plan the next steps.

Observation 2. A FRESH LOOK. You have tried to take a fresh look at disease eradication and control. There is power in doing that as a way of life; some examples:

• People used to ask: Why is a mirror reversed from left to right but not top to bottom? Richard Feynman, the physicist, took a fresh look. He says it is psychological rather than real. It is front and back that are reversed, as if you were squashed back to front. Since we cannot imagine that, we make it left to right.
• Another example. For centuries, people believed that Aristotle was right when he said that the heavier an object, the faster it would fall to earth. Aristotle was regarded as the greatest thinker of all times and surely he could not be wrong. All it would have taken was for one brave person to take two objects, one heavy and one light, and drop them from a great height to see whether or not the heavier object landed first. But no one stepped forward until nearly 2000 years after Aristotle's death. In 1589, Galileo summoned learned professors to the base of the Leaning Tower of Pisa. Then he went to the top and pushed off a ten-pound and a one-pound weight. Both landed at the same time. Case closed? No. The power of belief in the conventional wisdom was so strong that the professors denied what they had seen. They continued to say that Aristotle was right.
• A final example. In September 1942 a request was received from Guadalcanal for 100 gross of medical item #75-177, condoms. It made no sense; so the request went all the way up to Admiral Nimitz because no one could figure out why they would be wanted. He read the request and immediately said that General Vandegrift probably needs them to keep the rain out of the marines' rifles. He was right. Both of these leaders looked at things in a different way.

I have a hard time dropping beliefs just because they happen to be wrong. But here we have had the chance to revisit and test our beliefs, our approaches, our assumptions and our abilities. And we did. We pointed out where the survey was not helpful, and where definitions were confused. What would happen if we changed the question? What if we gave great rewards to the person who could develop a programme to save the world from the loss of 100 million DALYs each year? What would the programme look like: How much in control, how much in eradication? What is the maximum outcome we could buy for a billion dollars a year? How does that inform the debate about eradication and control?

Observation 3. DEFINITIONS. Bjorn Melgaard pointed out that it is not useful to polarize the debate. Some of you have heard me say that before speaking at the 1986 American Public Health Association meeting where I reviewed the materials from the programme 100 years earlier. To my great surprise, I found that public health people in this country were debating vertical versus horizontal programmes. I wondered if we were wasting time and asked what had actually happened in the USA during those 100 years. The answer won't surprise you. We actually implemented things whenever we had the tools, often in very vertical ways, with the result that we kept enlarging the infrastructure which was able to constantly take on new challenges.

The CDC infrastructure was forged from work on a single disease. In the early 1940s, the first task of what would become CDC was to provide a 1-mile mosquito-free barrier around every military installation in the south so that recruits being trained for the Second World War would not get malaria. After the war, with the addition of each new vertical programme, the general capacity for public health developed. But even now, CDC has trouble getting appropriations for infrastructure. Congress wants to fund AIDS or diabetes or immunization programmes. The challenge for CDC leadership is to see a big picture and then capitalize on the individual skills and interests of its employees and the single-issue fanaticism of its funders. I have frequently said that we have to tie the needs of the poor to the fears of the rich if we are to get anyplace.

The bottom line? As eradication efforts improve the credibility, power, and attention to public health, the infrastructure improves. As the infrastructure improves we have greater opportunities, skills and tools to consider eradication. The mix is so important that we must beware of using words that may divide our effort. Kipling said that "Words are the most powerful drug in the world." We must use words with care, to bind and promote public health rather than to divide our efforts. Petrarch, the father of the Renaissance, distrusted philosophers because he said they became too clever with words -- great debaters, but hardly wise. We want to be wise rather than great debaters. Unifiers, healers. To be wise, let's use the words as now defined, but challenge everyone to come up with better ideas on a continuing basis. As Don Hopkins suggested, don't cheapen the word eradication when you mean control.

And we need to figure out how to communicate to others. Godfrey Oakley mentioned one difficulty this morning with the terms eradication and elimination. On Sunday, I talked to a politician, very influential in the funding of public health programmes in this country. I talked about DALYs and return on investment and the need to tie resources to the size of the health problem. Basically, the politician's message was: this will not work; you must go back to the drawing board if you want to have an impact on politicians; get us emotionally involved in specifics; and target your efforts.

As we debated definitions I found myself thinking about our efforts over the years to attack measles in the USA. The problem was to avoid an objective that would cause us to stop short of what was actually possible. I recall the pleas not to choose interruption of transmission as a goal because if we failed, that would certainly set back public health. But we knew that anything less would not reveal the ultimate barriers. We set the objective of interrupting indigenous transmission and we reviewed our efforts once a week. It was indeed like peeling an onion and finding new layers of problems: school outbreaks led to changes in school entry requirements; measles in military recruits caused the military to change procedures; measles in day-care centres prompted entry requirements; and different solutions were required for other situations, including special groups, such as drum and bugle corps members, and wrestlers, college students, and people attending social functions such as weddings. Each new problem required a new solution. But without the goal of interrupting transmission, that would not have been found. Finally we came to the ultimate barrier . . . importation, forcing us to look at the global picture. My point is, we must balance a line of not raising expectations by using the wrong words, but not settle for anything short of what might actually be possible.

Observation 4. This follows from the preceding observation. Rick Goodman raised the question of "synergy". It may be hard to measure, but it is a message I get from this discussion. Denis Broun pointed out the tension between eradication and other things. Of course, it is the balancing of tension that produces new molecules, compounds and products. For example, many speakers mentioned the key ingredients required for both eradication and infrastructure: surveillance, epidemiology, analysis, implementation, logistics, evaluation, etc. These ingredients are not only necessary for both, but are refined in different ways by both and then reinforce each other.

We heard convincing evidence that eradication contributes to infrastructure. This contribution is reflected through factors, including political involvement, the power of success, techniques and tools, and mobilization of resources, as shown by the role of Rotary International in poliomyelitis eradication. This effort brings new money for health programmes, not a diversion of health money. Don Hopkins pointed out that guinea-worm eradication is taking primary health care to places that never had it before. What are the other possibilities? What does the Rotary involvement teach us about broadening our base of public support?

It made me think back to several years ago in the Congo when I visited a health centre without prior notice. On the wall they had an impressive chart showing immunization status. I asked them how they checked to make sure it was really that good. They said, "We use the Henderson method." I said, "Tell me about that." They then described the 30-cluster technique that we all know. The Henderson method was developed 30 years ago when Rafe Henderson was conducting an evaluation of the smallpox programme in West Africa. He enlisted the help of Don Eddins who used techniques developed by Sherman and Serfling in the USA and figured out how to make them applicable to a developing country. So the infrastructure of U.S. public health provided techniques for an eradication programme which in turn have become part of the infrastructure of primary health care. There in one story is the lesson we should be taking away.

There are other lessons. Eradication contributed to the progress of surveillance -- the ease of use of the concept; since smallpox eradication, surveillance is used with a familiarity that wasn't possible before -- to the CDC/WHO relationship, a relationship that was forged in the smallpox eradication campaign but is now part of the infrastructure; to laboratory techniques, upgrading, and standards, and to standardization of vaccines.

Another lesson. Infrastructure contributes to eradication. The components of the system -- vaccinators, health education, logistics, etc. -- were invaluable to the smallpox campaign. Experiences in surveillance help us define the problem, define the possible, find the truth, the real, and the authentic. (I sometimes think of a true story of a man taking a picture at the wax museum in Washington, DC. He asked a woman with two grandchildren if they would kindly move for him to get a picture of the wax dummy of Lady Bird Johnson. He never realized that he asked Lady Bird Johnson and her two granddaughters to move so he could get a picture of a wax figure.) Infrastructure also contributes to evaluation and logistics systems. Indeed, every experience we have ever had in public health becomes part of the response we can muster for eradication.

Observation 5. MAKING THE CASE. I believe the burden lies with those interested in eradication to make a very persuasive case. Accept a high burden of proof that includes the points below.

• Make the case for reductions in suffering and death in individual countries and in the world. To be worth the effort of eradication, the problem to be solved must be significant.
• There must be an adequate return on investment as compared to other investments in health activities. Eradication does not get special consideration unless you can show a return on investment by DALYs or other similar measures.
• Demonstrate the benefits in terms of development. Those engaged in development activities tend to devalue the importance of health. We must be careful not to do the same thing in reverse. It is important to show that disease eradication is an important ingredient in improving development.
• Demonstrate the benefits in terms of strengthening the health infrastructure. As already stated, I believe the way to strengthen infrastructure is by solving health problems. But we need to be explicit. We need strategies that make it clear that infrastructure is being helped.
• Understand the risks incurred. And show that the benefits make this risk-taking appropriate (we took risks giving smallpox vaccine but we tried to calculate them). Think it through. Know the downside. Know it better than anyone who is trying to argue against the programme.
• Demonstrate in a geographical area, as D.A. Henderson was emphasizing, that it is possible. Again, there is a delicate balance. We must be able to see what is possible to believe. On the other hand, we have to believe some things if they are to be seen. There is no question that some risk-taking is required.

In summary, know the problems: acknowledge the real and potential problems of eradication, including the diversion of resources. Make the case for each eradication proposal with real care: What is the return on investment? What are the returns in terms of development? What are the returns in terms of stronger infrastructure?

We need better ways of calculating the value. Discounting may be fair in figuring the value of money now as compared to the future, but the bottom line is that it gives a different value to future people. Public health teaches us that the value of a person in Burundi is the same as one in Atlanta. That concept of social justice should place the same value on a person born next year or in 10 years or in 50 years. How do we avoid discounting the value of people?

I should add that public health does not always value economists appropriately. We quote Ezra Solomon, the economist; "The only function of economic forecasting is to make astrology look respectable." The fact is, just as lawyers have done a better job on tobacco than public health people, so have economists developed metrics for measuring the burden of disease that we were not able to develop on our own. I especially appreciated Dean Jamison's observation that the war on poverty may be through public health.

When we have done all of these things, and when the case is convincing, we must -- yes, must -- then proceed to eradication of guinea-worm disease and poliomyelitis with conviction, with energy, with purpose, with leadership, and with a shared vision -- as we did with samllpox. Because the benefits are impressive, some things need be done but once in the history of the world. Therefore, eradication is the ultimate in sustainability. Long term, it is also the ultimate in efficiency . . . and long term is the way that public health people should think. Eradication then, at its best, becomes a tugboat to pull other health programmes -- it energizes health workers and builds social capital and social efficacy.

But the bottom line is that eradication attacks inequities and provides the ultimate in social justice. We say that is the base of public health philosophy, but only once has it been achieved in public health. In the last 20 years there has not been one case of smallpox because everyone in the world, and all of those yet to come, benefit from the experience and the knowledge acquired about that particular disease problem. Some make the argument that we have no right to impose poliomyelitis eradication on Africa. I understand that concern, but I am plagued by the opposite. Gandhi said his idea of the golden rule was that he couldn't have what was denied to others. If my children are protected from poliomyelitis I feel an obligation to share that with other parents. As Primo Levi has said, when we know how to prevent torment and don't, then we become the tormentors.

So the hurdle is high. We must meet high standards for eradication. But when these conditions are met, then we should make no mistake . . .eradication is the thing to pursue. Norman Cousins in a 1976 editorial asked what is the major gift that the United States has given the world. His answer was that the major gift has been that it is possible to plan a rational future. The Constitution is the incarnation of that idea. We fully believe it is not only possible, but mandatory, to plan a rational health future. We will be judged by how well we do for those separated by both geography and time. It is a challenge and a responsibility to "harmonize the trumpets".

Finally, to return to the idea of immortality. Abraham Lincoln, 133 years after his death, has left no biological DNA evidence that he lived. But every day we are influenced by the fact that he was here. He has left the social equivalent of DNA. The future may have your DNA, if telomerase works, or it may have parts of your DNA in your descendants, but it will for sure contain the fingerprints of your social DNA, the impact of all the decisions you make and the actions you take, the details accomplished. Your immortality is assured. Thanks for being part of this immortal work.

* Rollins School of Public Health, Emory University, Atlanta, GA, USA.

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