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Fighting disease

July 7, 2008

Leading the fight

Mark Twain once complained that everybody talks about the weather but nobody does anything about it. With apologies to Twain, I’d like to suggest that many people today are talking about global health but nobody seems to agree on what to do about it.

Increasingly, arguments are flaring in this burgeoning field that go to root principles. And if the basic concept itself is fuzzy, the core principles are also up for debate.

Just a decade ago, a precise definition of “global health” was perhaps not so critical. In the late 1990s, global health was largely defined, by default, as whatever was being done by the World Health Organization, UNICEF and the few other organizations working internationally on matters of public health.

Global health was about getting kids in poor countries vaccinated, educating mothers-to-be about safe birth practices, serving a stint in a remote clinic, responding to foreign medical emergencies and the like. It also was about often watching in frustration as many died from diseases that easily could have been prevented or treated in the United States or Europe.

Generally speaking, it was a poorly funded, neglected field handled by a relatively small cadre of dedicated folks working on shoestring budgets. The answer to the “Why does it matter?” question was that, back then, all this really didn’t much matter – at least when measured in terms of money, political will or media attention.

AIDS, of course, has been a big and highly visible part of the global health scene for the past quarter century. But the AIDS pandemic exists in its own category, with a unique set of political and social circumstances that have guaranteed this particular infectious disease a high level of public attention and concern. In a way, AIDS both helped educate people about the global nature of disease, while also overwhelming the story line.

Why wasn’t tuberculosis or malaria just as big a deal as AIDS? Together, they have been killing at least as many every year for centuries, perhaps millennia. Why isn’t the world outraged at a million deaths every year from something as mundane as diarrhea? Why do 27,000 children die each day – almost 10 million annually – from common diseases that could be prevented or treated for pennies per child? The list goes on and on.

There are no defensible answers here. The vicious circular explanation is that hardly anybody cared about these diseases because hardly anybody – in the industrialized world anyway – cared about these diseases. They afflicted the billions of invisible poor in Africa, Asia and the rest of the developing world.

What finally made the health of the developing world appear on our radar screen was not some new political movement or mass enlightenment. What happened, very simply, is that some powerful, high-profile people took an interest in these neglected diseases.

In the mid-to-late 1990s, Bill Gates, at the time the richest man in the world, his wife Melinda and his father Bill Gates Sr. were looking for something to do with all that extra money.

The Gates family had looked into supporting various philanthropic efforts in education, libraries and, on the global scale, population issues. But ultimately it was the simple vaccine – or more accurately, the lack of childhood immunizations across much of the world – that gave the Gates Foundation its primary mission.

And so the revolution in global health began.

Dr. William Foege ’57, former director of the U.S. Centers for Disease Control and Prevention and the man who developed the public health strategy that led to the global eradication of smallpox (and, it must be noted here, a PLU grad), had been an early adviser to the Gates family. One of the things Foege did was give to them a 1993 report by the World Bank that described the social and economic impact of disease in poor countries.

When Microsoft co-founder Bill Gates digested the numbers in that report, he was stunned. Among the many things going wrong, the report said millions of children die every year simply because they hadn’t received basic vaccines against garden-variety diseases like measles, pertussis, tetanus, polio, diphtheria or rubella.

“I didn’t believe it,” Gates recalled. “How come I hadn’t heard about this?”

One of the biggest revelations, he said, is that disease appears to be a bigger driver of poverty in poor nations than the other way around – poverty causing disease. Working with Foege and other public health experts, the newly formed Bill and Melinda Gates Foundation focused initially on trying to attack poverty by first solving a deceptively simple-sounding problem: How to get basic vaccines to the world’s poorest children.

Bill Gates Sr., as the point man for his son and daughter-in-law’s new philanthropy, had by then also learned of a small, Seattle-based organization called PATH, or the Program for Appropriate Technology in Health.

PATH, like most other such international public health organizations, had been working away since the 1970s trying to make a small dent in the massive health problems of the developing world. Dr. Gordon Perkin, then president of PATH, agreed with Foege that one place the Gateses could have a big impact was in children’s vaccines.

“Basically, we had gone backward since the early 1990s,” Perkin said.

Basic immunization rates for children in poor countries had fallen, he said, and new vaccines that protected against diseases like hepatitis B, pneumonia or rotavirus (which causes deadly diarrhea) were nowhere near getting distributed in the developing world.

Based on this, the Gates Foundation gave PATH $100 million to launch the Children’s Vaccine Program. In 1999, this led to an even more unprecedented Gates grant of $750 million to launch an even bigger initiative called the Global Alliance for Vaccines and Immunization (GAVI), first run by PATH but now based in Geneva, Switzerland.

To say that the Gates’ money and creation of GAVI stirred things up on the international health scene would be like saying the New York Yankees have done okay at baseball. Though there was, at this point, scant public attention to what the Seattle philanthropy was doing, it was basically remaking the field of global health.

As a reporter who had covered PATH in pre–Gates Foundation days, I stumbled onto this story early in its unfolding. Few in the media appeared to be paying it much attention at this stage. (As an example, a Google search of “global health” back then turned up mostly Seattle Post-Intelligencer stories. That’s certainly no longer the case.)

Since then, of course, the world has taken notice of the Gates Foundation’s rapidly expanding leadership on many fronts of global health.

It should be noted, however, that not everybody has been happy to ascribe to Gates the reinvigoration of this once-neglected field in human health. Many old-time public health warriors at the WHO, UNICEF and elsewhere resented this “billionaire geek” coming in to shake things up on their turf. Sure, the new money was nice. They just didn’t like the billionaire also telling them how best to spend it.

In any case, there’s little doubt now that this was transformative on a massive scale.

“Frankly, it would be difficult to even identify everything that has happened in this field due to the direct or indirect influence of the Gates Foundation,” said Dr. Jim Yong Kim, a Harvard University physician who, with his colleague Dr. Paul Farmer, has been a leading advocate on matters of health and global poverty.

As a result of this revolution in global health, not to mention the billions of dollars in new money, many are now jumping on this once-hobbled, broken-down bandwagon. Most major universities have created, or are creating, new global health departments. Governments, biomedical businesses and non-profit organizations are increasingly talking about what they are doing, or intend to do, to further global health.

Many of the problems in global health can, in fact, be solved by new, innovative technologies. An effective malaria vaccine would be an incredible achievement. But such technological solutions need to be pursued in a proper context, taking into account at every step what is really needed by the poorest of the poor.

If we had an effective malaria vaccine today, who would pay for it to be delivered to the billions of people who have nothing? Who would receive the vaccine in a country that has hardly any health care system at all? How would the vaccine be delivered to children if there are no clinics, doctors or nurses in the community?

The fact that global health is today a growth field, of high interest to economists and businessmen as well as do-gooders, is good news. It represents significant progress.

Millions of people, many of them young children, are almost certainly alive today who wouldn’t have been if the international community hadn’t made fighting disease a top priority for assistance to developing nations. We may soon, finally, eradicate polio from the planet. Malaria, not long ago just another ignored killer of poor people in poor countries, is now the target of hundreds of millions of dollars worth of research and prevention programs throughout the world. The list of such new “global health” projects goes on and on, with new ones coming on line all the time.

But success always brings with it the seeds of failure. There are lots of reasons why these attempts to improve the health of the world’s poorest might fail. There are just as many reasons to hope they succeed, if only because failure on this front would be to accept ongoing tragedy and disenfranchisement for one third of humanity.

If the moral implications here are not enough to persuade that failure to improve the lives of billions of people is intolerable, there is another argument – to be made in full elsewhere – that such massive inequity in this ever-interconnected world will not be sustainable anyway. It just cannot stand.

So, what will become increasingly necessary as the field of global health continues to expand in scope and popularity, I believe, is a much more precise definition of the enterprise. Much is at stake here and a general idea of what the goals are is no longer sufficient. Worse, a lack of definition opens the door to co-option and potential abuse.

Bill Foege, a key player in this story and one of the world’s pioneering leaders in global health, earlier this year gave a talk at the University of Washington on global health. He said many things worth quoting, but two statements stood out for me:

“Destiny is just an excuse for bad management,” Foege said in deploring those who believe the world’s current state of affairs is simply the consequence of some natural order. And after celebrating those who share in the excitement and optimism reflected in the new push for global health and development progress, he added a precautionary:

“We had better know where we are going.”

Tom Paulson ’81 has been a science and medical reporter at the Seattle Post-Intelligencer since 1987. Tom, a Seattle native and PLU graduate (B.S. chemistry), covers the physical sciences, biomedical research and public health issues for the P-I. He has reported on global health matters in Africa, Asia, India and Latin America. He is married and has two grown children