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Rx for Survival: Why We Must Rise to the Global Health Challenge

November 29, 2005

Rx for Survival: Why We Must Rise to the Global Health Challenge by Philip Hilts

Introduction

JOANNE MYERS: Good morning. I'm Joanne Myers, Director of Public Affairs Programs at the Carnegie Council, and I'd like to thank for joining us this morning as we welcome Philip Hilts to our breakfast program.

He is going to be discussing his latest book, Rx for Survival: Why We Must Rise to the Global Health Challenge. This was a companion to a PBS series, which I don't know if many of you saw, but it was really terrific.

During the 20th century, the world witnessed a golden era in public health. As vaccines were discovered, diseases were cured, and the average life expectancy rose by many years. Yet, despite improvements in many developing countries in eradicating disease and providing cleaner drinking water and in lowering child mortality rates, in recent decades this stunning rate of progress has declined dramatically.

Challenges remain, as we learn almost daily about new diseases gaining ground or of old diseases, such as malaria and TB, reappearing as they become resistant to many modern drugs.

In this age of global travel, the increased level of contact between poor and wealthy nations makes it a near certainty that diseases will spread more rapidly than ever before, as we have witnessed recently with AIDS, SARS, but hopefully not with the avian flu.

Yet Mr. Hilts believes that if we continue to marshal the necessary resources, we can achieve an even more impressive defeat of disease than that of the late-19th and early-20th centuries.

In Rx for Survival, our speaker this morning tells the moving stories of a host of individuals who have been plagued by threat of disease yet have been able to make significant inroads. Whether fighting night blindness in Nepal, vaccinating against polio in India, or fighting against diarrhea in Bangladesh, Mr. Hilts tells the story of this crucial moment in world history and describes how low-cost efforts can attain incredible results. His aim is to highlight how major medical problems do not necessarily need the huge amount of resources most think are required.

Philip Hilts is a prize-winning health and science reporter for both The New York Times and the Washington Post. In more than twenty years' time, he has placed more than 300 stories on the front pages of those papers. As a man of science, his profound knowledge in the field of health has won him widespread recognition, including his winning the 2004 Los Angeles Times Book Prize for Science and Technology. This was for his previous book, Protecting America's Health: The FDA, Business, and 100 Years of Regulation. This book was also named a New York Times Notable Book of the Year.

Mr. Hilts has taught science journalism to graduate students at Boston University, and more recently taught journalism to undergraduates at the University of Botswana. Now to take us on a disease-fighting journey, please join me in giving a very warm welcome to our guest today, Philip Hilts. Thank you for coming down from Boston to be with us.

Remarks

PHILIP HILTS: Thank you.

Basically I am a reporter. I have spent about three years out in the field, starting in southern Africa, where I lived for a year and a half, and then traveling from spot to spot looking at health projects. When you go out, you see basically what you expect to see, which of course is suffering and disease and poverty. But in this last three-year round, I have to say that I came back considerably more hopeful than I had been before, and with a sense that we are on the edge of being able to do something much bigger than we have in the past.

I want to talk a little bit about how I developed that thought and some of the new pieces that are developing out there now. We have quite a bit of new knowledge across different fields that is not quite disseminated yet. I will start with the background of how we got here over the past couple of hundred years.

My first chart is "The Vital Revolution," which is to me, in a way, the most important piece, the controlling piece here. If you look at the chart, what you see is life expectancy at birth. The chart can go back all the way about 100,000 years. As far as we can tell, life expectancy has fluctuated at around twenty-five to thirty years throughout human history, until about 1850; and then it took off, almost straight up, first in England, then in other places. If you look at the chart, it is not just Europe; China and Japan and India are in there. They came on a little bit later, but went up faster.

So what we have now is a situation that is unlike anything we have had in human history.

Let me read a couple of quotes about this from the key economic writers on the topic.

Nobel Prize winner Robert Fogelsaid:

"A different kind of evolution in the past two-to-three hundred years, and mostly in the past century, has gone on. Human beings have gained an unprecedented control over their environment, a degree of control so great that it sets them apart, not only from all other species, but also from all previous generations of homo sapiens. This new degree of control has enabled homo sapiens to increase its average body size by over 50 percent and its longevity by more than 100 percent since 1800, and to greatly improve the robustness and capacity for work."

James Riley, who follows on Fogel, says in Demography:

"The attempt to control disease has evolved into one of three of the most elaborate structures that people have overtly built, along with polities and economies. Of the three, the health transition, the vital revolution, has been the most successful, delivering a larger quantity of long life to a larger share of the world population than polities have delivered good government or economies wealth. This is the crowning achievement of the modern era, surpassing wealth, military power, and political stability in import. Prior to the vital revolution, more than half of the people died before adulthood, and in some countries more than half died before age ten."

The humanistic side of this was given to us by the late Stephen Gould. He said:

"It is a fallacy of human thought, a common one, to think of a golden age in the past, a simpler time of rustic bliss." He continued, "If anyone tells me he would rather have lived a century ago, I will simply remind him of the one irrefutable trump card for choosing right now as the best world we have ever known. Thanks to public health and medicine, people of adequate means in the industrial world will probably enjoy a privilege never before vouchsafed to any human group. Our children will grow up, we will not lose half or more of our offspring in infancy and childhood, we will not have to sing the songs on the death of children or hire the daguerreotypist to take the only image of a dead child as it lays before the funeral."

So this great rise is probably the single greatest of all human achievements. And it is worldwide, it is relatively new, it has gone on until the present time, and is still rolling to some degree. One of the questions about it is: How did we do this? What is driving this?

Economists, of course, have always loved the idea that the answer is putting the money in, putting it into roads and factories, putting it into technology, transport, these kind of things. They believed, until very recent times, that that is what drove it. It was called the industrial revolution, rather than the human revolution. But recent data shows that this is incorrect. The driver was the human engine.

Fogel, for example, talks about this and says that when you finally do the data, when you put together all the pieces, between 1790 and 1980 in England, 53 percent of all the wealth created was created by the human engine—not by the railroads, not by the technology, not by the factory plants. It was the human engine. The human engine was the longevity, the height, the robustness, the ability to work, real possible productivity. That drove it. That was 53 percent. All the rest of the stuff was 47 percent. Economists basically ignored this because they didn't really want to look at that piece. But that tells you a lot. This whole thing has been driven mainly by the human engine.

Again, we think industrial revolution, that it was started by the technologies, it was started by factory plants. And it was, in the sense that in England what you had was the plants getting started, people flocking to the cities, England becoming the center of this revolution in wealth.

But the first effect of that was life expectancy went down. The conditions in the city were terrible—open sewers in the streets, ten to a room in the buildings— so the trouble started when industry started. In the beginning it wasn't a solution; it was the problem. It led to revolution in Europe, a near-revolution in England.

Then it led finally, after a series of catastrophes, including two waves of epidemics, cholera and typhus, to the Public Health Act and the London sewers. Delivering clean water and taking away the filthy water was the single greatest public project of any kind that had been built. In current dollars it cost several hundred billion dollars, a huge public enterprise.

You can mark the beginning of this shoot upward from the Public Health Act and the London sewers, because then what happened is the concept of public health—sanitation—was created and exported. It went around the world. The great rise comes from that moment, from that public enterprise, from the delivery of health to the workers in England, and then on to us through a series of additional public investments.

We start with the germ theory, then we go to antisepsis, and then we go to vaccines, we go to the creation of modern drugs, antibiotics.

There is one story that I can't resist, the story of penicillin. There is a myth that penicillin was a project that was created by the drug companies. This is not true. It was created in public laboratories with government scientists. All the basic work was done in the public laboratories. Nine companies in a row were offered penicillin free and they turned it down. So that was a public enterprise.

This continued on up through the eradication of polio and the eradication of smallpox—polio in the United States and the Western world—and the rise kept continuing all the way up until the 1970s. This 200-year project goes up until the 1970s. Then it starts coming apart.

If you look at the data, there are a couple of pieces in here again.

The first piece is life expectancy. We had talked about life expectancy going up steadily around the world in all countries. This chart shows that some countries in Africa have now suddenly dropped, dropped not by a few years but by thirty years. There are actually more than twenty countries in Africa that had a steep drop in life expectancy, the first big drop downward over the last 200 years . People say, "This is, of course, related to HIV, and HIV is singular and different." But in fact it is not just HIV, it is not just Africa, and AIDS is not different. We will talk a little bit later about the connection between HIV and the other diseases. They are all coming as a piece.

The next chart is Eastern Europe and Russia. Eight countries have dropped life expectancy significantly there. It is not just Eastern Europe and not just Africa. It is Honduras, it is Azerbaijan, it is different places. The first time we've had a big drop downward, more than fifty countries' life expectancy. This is a big number. This is a number you don't move easily.

What we have had is a significant shift from the sense of public enterprise to the sense of private enterprise. If you jump to the next chart, it shows one of the reasons why we got to this place. This chart is "Federal Public Health Spending in the U.S." You see a collapse. It was high in the 1960s and 1970s, and in the 1970s it dropped down to the low level where we are now. This chart is from a paper by Senator Frist, who is advocating putting the money back, reinvesting in public health.

The next chart is foreign aid. Again it shows a large investment, a serious public effort, through the 1950s and 1960s, and then trickling along the bottom from the 1970s on.

So we've got ourselves in a position where we have stopped putting the effort and energy into the public enterprise. When the polio vaccine was first tested in the United States, the day the announcement came that it worked, all across the country we had bells ringing in churches, we had city councils passing resolutions congratulating themselves. It was a time that we don't have now, a time of public sensibility.

Following on this withdrawal from public enterprise, simultaneously we have globalization. Globalization has a number of different meanings, but one of them is that you have a billion trips a day between countries, and between the countries with very high burden of disease and very low burden of disease we have a million trips a week.

At the same time, you have forests being razed. What's in the forest? Unfamiliar bugs. We drive the roads in, we bring the animals in; we bring the diseases out.

So we have this storm developing of people traveling and bugs traveling and everybody mixing. And, of course, this is what bugs do, is they mix, they change genes back and forth. And so what do we see? We see what you would expect: forty-one new diseases since the 1970s. This is a human record as far as we know. Forty-one new diseases, many of them quite serious.

In addition, we have twenty old ones that have resurged and have become different. Here are some of the the new diseases, for example: The Ebola hemorrhagic fever is a new disease; E. coli syndrome is new; hantavirus is new; HIV/AIDS is new. This is one we could have caught if we had public surveillance before 1980, if we were watching in St. Louis when it arrived. But we were not. Then there's Lassa fever, Legionnaire's disease, Lyme disease, mad cow disease, Marburg, Nipah,SARS, West Nile Virus.

The ones that are coming back are malaria, dengue, yellow fever. And, of course, we have another new one, avian flu.

We have to get used to this condition. This is not going away. This is going to continue. We are not prepared for it. We have let down our guard on these things. We don't have the epidemiologists and we don't have the structures in place, because we had pulled back from that. But we have to expect that this is going to be the condition in the future.

So all of that is the bad news. Now for a little bit of the good news. There have been other things going on out in the world that have been quite positive.

There isn't much time to talk about what is going on in the different countries, so let me just talk a little bit about Bangladesh and the BRAC, the Bangladesh Rural Advancement Committee. The story started November 12, 1970, with a huge hurricane coming up the Bay of Bengal, smashing into Bangladesh in the middle of the night, when the tide was high, creating twenty to twenty-five-foot storm surges, 17-mile-an-hour winds. Bangladesh, like New Orleans, is a very low-lying place. The people were not warned, so we had 500,000 people killed in that event. In the records, it is the worst natural disaster in history.

The President of East Pakistan at the time was not in the country. He was on vacation. When the storm happened, he didn't bother coming back. There are always tensions with the President anyway. So the next thing we had was revolt, and then civil war, and eventually Bangladesh broke free. Out of this double catastrophe was born Bangladesh.

In the country at the time, the people at the top end of society felt they should come back from their big jobs. One of them was Faisal Ahmed, who was a Shell Oil executive, with a house in London. He said, "Well, if we are going to build a country, we have to go back, we have to do it on the ground." So he dropped his job, he thought for a couple of years. He went back and he started hauling bamboo and setting up medical clinics and trying to rebuild Bangladesh.

He and a few others realized pretty quickly that doing emergency aid isn't going to get you anywhere except back to where you were, which was no place. So they decided, "Let's start an organization that can have a significant impact on the actual situation in Bangladesh."

They had many options, but they decided to start with diarrheal disease. It was the number one childhood killer at the time. In Dakka there was a hospital that has this cure, which is essentially an I.V. bag with water and salt and sugar, and a sterile tube and a sterile needle, and a doctor and a nurse. Right around the hospital you had kids who got severe diarrheal disease. Normally, 50 percent of them die from this disease. You bring them into the hospital, fewer than 1 percent die. So right around the hospital you had one neighborhood that was doing fine, and the rest of Bangladesh was not getting it.

Their plan was: "Let's take what's in the bag and deliver it to the villages. We can't do the needles and we can't do the doctors, but we can take what's in the bag." So the plan was to deliver the oral rehydration solution to the village women and let them give it to their babies when they get sick.

The doctors and WHO and others said, "No, you can't do this. These women can't handle it. They'll mess it up. It won't work. It will be a complete waste."

But Faisal Ahmed was an accountant, who was very used to the idea of going back and back until you get it right. They started out with 58,000 women and they taught them how to do it. They took each sample to the lab to make sure the women were mixing it properly. The formula turned out to be a pinch, that is, a three-finger pinch in Bangladesh; a fist, which is you fold your thumb over and you scoop sugar; and then half a cup. You mix them together and you give it to the baby out of the cup a sip at a time over several hours.

The crisis goes by. Instead of the body collapsing for lack of water, you carry on until the bug goes away. You save the child. They were able to do this with 58,000 women, and they were congratulating themselves.

Then Faisal Ahmed went back and did a little study quickly to find out how it was going after they trained them. They found that only 6 percent of the women who knew how to do this were using it. They said, "What is going on here?"

Faisal had a friend who was an anthropologist, and he told him, "Go out into the villages and ask what's going on."

They found out exactly what you'd expect, once you hear it, and that is the women were not the ones who were making the decisions all the time. It was the brothers and the husbands and the local healers who were saying, "Nah. This is a crude method. We know what's good. You go down to the little pharmacy and you get the Western drugs and you take those drugs. Or if you can make it to the hospital, try to do that. Do not do this crude home thing that the women are doing."

After that, they changed their program. They went out the villages and didn't talk only to the women, but they got the men in the meetings, they got the healers in the meetings, and they changed their approach, bit by bit. From that program, after many iterations, they built it up to 13 million women in Bangladesh knowing how to do this. The rate of death from cholera and diarrheal diseases dropped enormously in Bangladesh, even though other conditions were quite bad.

They moved on to other projects, such as vaccination. At the time they started, 2 percent of the kids were being vaccinated in Bangladesh. The government wasn't able to do it; the clinics were nonfunctional. After BRAC went out and worked in each province, going back and working with the local people as volunteers, they got from 2 percent up to 80 percent. BRAC is now probably the largest NGO in the world and sort of a shadow government in Bangladesh.

Along with Grameen Bank, they also created micro-finance, so that down at the bottom level the poorest people now have some hope of catching hold and moving up.

They went on to prenatal, and to TB, helping village women in how to recognize and how to deal with these things, one after the other. Over time, what you saw was Bangladesh rising from zero growth rate up to over 5 percent, from the 2 percent vaccination up to 80 percent.

Ninety percent of the children in school were boys. Now it is 50 percent boys, 50 percent girls in the village schools in Bangladesh. In the beginning the rate of death among children under age five was that 270 per 1,000 were dying. After BRAC and the follow-on programs, it is now down to 68 per 1,000.

And, a key point, the rate of having children was seven children per woman, and now it is down to three. They had worked on previous family planning programs, but mainly when you have healthy children and you have the access to family planning, the families themselves do not want the seven children. So that has dropped.

In the end, what you see is the country pulling itself up from the bottom, from the villages, with the villagers doing the work.

A small amount of aid money was there in the beginning. It started out 80 percent aid money and 20 percent local, and now it is the other way around. They pay for 80 percent of their own programs and have only 20 percent donation.

So this is Bangladesh and BRAC, the center of the possible rise of Bangladesh.

There are many other cases like BRAC. I saw myself seven or eight projects in different countries that are nationwide in scale, delivering health in a crucial way—not how many people do you vaccinate alone, but what is the death rate, does it change.

The Center for Global Development made a list recently of seventeen additional national-scale programs that have an effect on mortality rates. So what you can see is this growth in the ability to do health aid. There was a time when we didn't understand it, we didn't know how to do it. Now we have many examples of doing it successfully. It is almost a formula. It is not just an individual here and an individual there. There are clearly guidelines of how to do it. And we can deliver it.

The Global Fund to Fight AIDS, TB, and Malaria is a good example of an organization that is using the formula now, which can deliver it successfully and can prevent money from being used in corrupt ways. As soon as they see it straying, they pull the grant, which they have done several times. So we see the hope that these programs can grow.

With the new information we have from Jeffrey Sachs and some of the other economists who are working on the issues of health as a driver, as we saw with the drive of the 200-year rise of life expectancy, they are saying—and they have done the data—if you want a country to develop, you don't start with the roads and the factories; you start with the delivery of vaccines, of antibiotics, of bed nets. These are the things that will make a country rise up from nothing.

When you have the workers working, they will start getting ideas, they will start getting hope, they will start growing, which we saw in Bangladesh and we are seeing elsewhere. So the hope now is to deliver the very basics, the cheap stuff, the stuff that is very easy. We know how to do it, plus now we have knowledge of how to deliver it through the people in a country, going with what they need, rather than what we need, to build, say, twenty to thirty countries up from zero to the first rung of development.

The hopeful part for me was seeing this go on in country after country—seeing BRAC spread, for example, which was first in Bangladesh but now is in Afghanistan and in Africa as well. Oral rehydration is a great story of globalization.

When they started, there were 5 million childhood diarrheal disease deaths per year around the world. Oral rehydration treatment (ORT) took off from Bangladesh and went everywhere. It went from 5 million deaths a year down to 2 million deaths a year now, due directly to the ORT from Bangladesh, from one of these small programs. So I came back looking at this and feeling very hopeful about what we can do.

Now the issue is our choices. There is a line from Samuel Clemens. He said, "History doesn't repeat itself, but it rhymes."

We had a couple of other moments in history like this that were interesting. In 1915, globalization was rising like crazy and people thought there was no way it was going to go away. But of course it collapsed, with two events. We had a terrorist attack and we had a preemptive war—World War I—Germany against Russia, things we are familiar with now.

The war, worldwide depression, a second war, and then we come up to the end of World War II, when we have George Marshall saying to Churchill: Let us not make the mistake again that we made after the first war—lack of cooperation, failure to build a UN, failure to build a WHO—these organizations got started in their earlier forms and did not get support: failure tocooperate, high trade restrictions all over the world, failure to understand how to do this.

So they built the Marshall Plan, which we count as the most successful aid project in history. Again, we are talking huge investment, something the United States hasn't done since then, hundreds of billions over several years into Europe, which was looking at the time as though it was going to be a Third World area. After three years of pumping aid in and nothing happening, they really thought they were not going to be able to deal with it. So they put the Marshall Plan into effect, very large amounts of aid, and built up the European renaissance that we see now.

So at the moment, what we are facing is this same kind of large choice, in which we have the technology, we have the money—we have never had the money like we have it now—and we also have relatively fewer poor people around the world to deliver it to. We have the means. We have been working on it for years, so we know how to make these aid projects work.

We even have plans on the books: the Millennium Development Goals, which the countries have agreed to—even the United States reluctantly agreed to this. They have worked out the details of it. They've got the mechanism, with the Global Fund and a few others, that can deliver it. So we are right at the edge. And they've even got the basic number, 0.7 percent: that is 0.7 percent of the the U.S. GDP and that of all the other wealthy countries. That's the goal. If we can deliver 0.7 percent, we can make it happen. That 0.7 percent is clearly peanuts. It is about one-twentieth of what we were doing during the Marshall Plan.

There is a funny displacement, though. There are polls of Americans asking, "How much are we spending on these things?" They say, "Well, it must be 20 or 25 percent of our whole federal budget on foreign aid, and it's not working." The number is less than 1 percent, but they think it is 20 or 25 percent.

So then you say, "Okay, here's the actual number." The response in these polls—and there have been six or seven of these polls over recent years—is, "That's not enough. We're willing to put in more. We'll put in 3 percent, 5 percent." We don't need 3 or 5 percent, but they are willing to do it.

So the willingness is there, the plans are there. The only question is: Are we going forward in this direction? We had a meeting in Washington with the Rx for Survival group—that is, the people who were doing this TV program—to present to Congress what the show was, kind of hyping the show and so on. Only a few congressmen were invited, but actually the room filled up. The number of congressmen and senators interested in doing something in this area is enormous, starting with Senator Frist of course. There is serious interest in this. There are bills being written now in Congress.

In the White House they are split. The Administration has people on both sides of this. Interestingly enough, this is natural for the strong Christians— this is missionary work; they know what this is and they want to do it. Sam Brownback is one of those. He has other problems, but this one he wants to do.

Because of the split in the Administration, we are not clear where it is going. But the Bush Administration has put in more money than the previous three administrations. So there is a start. That's where we are now—"The Rx for Survival," TV program, the book, this movement growing up of people like Sachs and like Bono, out there saying, "Let's do this." This is a positive thing. This is a positive policy for the world, of sharing globalization, so that we all move up together, instead of saying, "We're going to keep it and you're not and let's see what happens next."

I am going to close by repeating something that Churchill said in 1948, when he was looking ahead to the Marshal Plan and saying let's do it. He said,

"If we allow ourselves to be rent by pettiness or disputes, if we fail in clarity of view or courage in action, a priceless occasion may be cast away forever. But if we pull together and firmly grasp the larger hopes of humanity, then it may be that we will move into a happier, sunlit age, when the children who are growing up in this tormented world may find themselves not the victims nor the vanquished in the fleeting triumphs of one country over another, but the heirs of all the treasures of the past and the masters of all the science, the abundance, the glories of the future."

Thank you.

JOANNE MYERS: Thank you very much. I'd like to open the floor to questions.

Questions and Answers

QUESTION: It seems to me that the thrust of your argument is an appeal to altruism. I'm wondering whether there isn't a more selfish, self-interested, and perhaps more compelling argument to be made, that with all these new diseases and with the resurgence of some old diseases, this poses a threat to us. After all, the Marshall Plan occurred in the context of a major threat, a perceived threat anyway. I'm wondering whether raising this issue as an important threat to us might be a way of persuading, let's say, some of those of us who are not missionaries.

PHILIP HILTS: In the Marshall Plan they had the same situation, where there was a reluctance to go along and a lack of vision; and then Czechoslovakia fell. Their terrorism, the Soviet Union happened, and instantly the Marshall Plan was passed in the face of the threat. They realized they had to do something positive to counteract it. I think we are in a similar position.

The same thing in England in the second half of the 19th century. It was the threat that got them moving. They weren't going to move until they had the disease at their door, and they had people in the streets, in the Chartism movement, threatening the palace. So yes, I think threat matters.

And you are looking at the threat, the avian flu and the fact that we are going to have new diseases one after the other, along with the terrorism that is going on, so there is the hope that people will pay attention.

There is one piece of wisdom from Bill Clinton. The other day he was here in New York talking at the Time Global Health Summit, and he was saying that you have to do it for humanitarian reasons, but that there was another thing that happened in Aceh, Indonesia, when we delivered aid. The troops were not there with their guns; they were there with antibiotics and vaccines; they were helping to build.

They did a poll. This is the largest Muslim country in the world. The positive feeling toward Americans was about 36 percent. After Aceh, it went up to 60 percent. And Osama bin Laden's poll numbers dropped from 58 percent to 28 percent. He didn't show up. He can't show up. This is where we can show up

So this is the positive message. This is a potent foreign policy, even if you don't think of it that way.

There is the threat and there is the possibility of having a positive effect and having people change their attitudes toward you because they can see your hands are not dirty, you are there to do something useful on the ground. I think this is what happened with each case in the past.

It's partially self-interest. Right now people are not paying attention to the food imports. Food imports have gone up five times, 500 percent. If you grow the foods here, you can watch what pesticides are put on them, you can check for the bacteria. The stuff coming in from outside is not being tested. Food-borne illness is rocketing up now.

I talked to the guy at the FDA who is in charge of this program. He said, "Well, we actually have the power to go to these places in the countries, work with the farmers, clear this up. We have no money. We have no inspectors."

So this is the kind of thing you have to do if you want it to work. And I think you are right, this is the kind of thing where you can start with the humanitarian argument, and Americans buy that, but it needs a little more oomph.

QUESTION: I found that your presentation covered a little bit too much territory. It was hard to focus on it, for a lot of different reasons. I think that you have brought up several public health issues, but they are not the same. Those that are plaguing us in this country are not the same as those in Africa.

You talked about the resurgence of some of the simple diseases. Well, there are some public health practices that people are forgetting. Surveys have shown, for instance, that even doctors and nurses are failing to wash their hands in the restrooms at the hospitals and in their offices. That is going to lead to other kinds of diseases, basic ones, just from lack of personal hygiene. Years ago in Hungary Semmelweis found that by the simple washing of the hands you can eliminate a lot of infections, including during childbirth and so on. They lost very few women once they started doing those kinds of basic things.

The other thing is that viruses tend to mutate anyway, so the more that you eliminate the weaker ones, you are going to have more complex ones.

In terms of Africa and some of those other countries, you have failed states where the personal and public hygiene has gone completely by the board, so that the infusion of a lot of public money for simple programs—whether basic inoculations, or even trying to clean up the water or anything else—may be wasted because the governments—

PHILIP HILTS: That happened in the 1870s.

QUESTIONER: Well, it's still happening now.

PHILIP HILTS: It's wrong.

QUESTIONER: They're taking issue with Jeffrey Sachs. Giving the money is not happening.

PHILIP HILTS: In Bangladesh, the government is still corrupt, the clinics still don't work. They drove right around it with the NGO and delivered. That is what is happening in the other countries now. So the old model is gone, the idea that you waste the money. The Global Fund brought some money into Ukraine, found that they were having a problem, and pulled it back immediately. The same thing in Uganda. People who were out there in the 1970s saw it failing. But that's not the way it works anymore.

QUESTIONER: But the argument was being made in the 1920s too. It is not only in the 1970s.

PHILIP HILTS: It's no longer valid. These things can be done, they are being done, and if you need the evidence, just get on a plane. I can give you the list of places to go.

QUESTION: There has been a lot in the press about the weakness of the public health infrastructure in a number of countries, and also the magnet effect of doctors, nurses, and health professionals moving to the West. You must have seen some of this in Africa. Can you comment on what kind of response there could be to that?

PHILIP HILTS: Yes. This is a particularly hard one, because you want to leave the possibility open so that you don't command doctors and nurses to stay. Botswana is a particularly bad place for that, because they have a nursing school that is quite good, and the nurses get out and leave immediately for London. They have a class of 200-and-some nurses every year, and about 90 percent of them leave.

There is now a problem. There are some possible solutions. The first one, of course, is raise the amount of money that you pay—not up to international levels, but up to the level where in Botswana you can have a car, you can have a house, and you are okay. For most people who are nurses, that is enough, if you can get it up to that level, if you can add some respect, and if you give some additional incentive: "If you stay, we will do such and such for you"—free schools, free this, free that—just simple incentives. There are a lot of solutions being explored now to try to stop that. It has not happened yet.

Fortunately, what has gone on in Botswana is that, even with the nurses leaving, they have trained more. In addition to the ones who are leaving, they had to train many more to deal with HIV. They now have clinics all over the country delivering ARVs (anti-retroviral drugs) through people who are para-nurses, para-doctors. They are in the villages, they are in the clinics, they are going to the huts, delivering ARVs, even with the nurses gone. So in an emergency you just have to take whoever is on the ground and train them, and you can do it.

You have to have some help from the developed countries, to say, "Well, we don't need to accept everybody. We can have a cooperative agreement that we take so many and we send them back," so that at least there is circulation. Circulation is good. You get both ends.

QUESTION: Thank you. I'm going to read every page of that book of yours. One of the big points that I would like to have you address is the question of monitoring and surveillance. Now, this needs troops on the ground. One of the great stories this year is that there was no cholera after the tsunami because of the organization and the cooperation between governments and parts of the UN. The result was terrific in this respect.

Monitoring and surveillance is so important when it comes to rural areas. There is a big divide between rural health and urban health. Would you talk about that a little?

PHILIP HILTS: In the places I went, it was common to see government clinics that opened late, quit early, and tended to have bad attitudes towards the local villagers, and the villagers just didn't use them. They were really ineffective in the rural areas. So you have to build around that again.

For example, in Nepal they wanted to deliver vitamin A, because you could reduce the mortality rate significantly just by delivering two drops of vitamin A twice a year to kids between one and five. They did that by going into the villages and recruiting folks who had a little bit of time. It turned out to be grandmothers. There are 49,000 grandmothers in Nepal who are now delivering vitamin A. The rate of mortality among kids has dropped by 30 percent, even in a bad situation in Nepal, because they picked out a woman who was going to be the village health person.

From vitamin A they moved on to deworming, and on to iodized salt. The same grandmothers are now being trained to recognize TB. And, of course, their social status rises immediately, once they become the ones who help out the children. These 49,000 grandmothers are substituting for the clinics. So it's the manpower on the ground.

The polio program did this as well. In Uttar Pradesh they had this problem with polio, and in the neighborhoods they were not getting there. So when they went in the second time, after some failure, they said, "Okay, let's go house to house, let's take people from the neighborhood, people who are the same religion, the Muslims go to the Muslim households, and talk to the people one by one." That, again, is the troops on the ground in the neighborhoods who know what is going on. This is part of the formula now that we have to deliver aid, by doing it through the people.

QUESTIONER: We treat polio with vitamin A. It's so simple.

PHILIP HILTS: Right. So it's that kind of troop movement, regardless of the clinics, regardless of the degree to which the government is cooperating. Usually, they stand by, at least. Once in a while they interfere, like in Nigeria, when they stepped in. But for the most part you can get this done, even if you have additional troubles.

QUESTION: Being in New York, we are very conscious of the UN and the effectiveness of the UN here. I wonder if you could comment on WHO, how effective it is in terms of determining the needs of X country, and how effective they are in terms of coordinating the solutions to these problems.

PHILIP HILTS: I think some of the projects have been quite effective. Vaccination rates are up around the world, and that is their job and they have done that quite effectively. Other things don't work so well. They do a good job of setting standards, listing medicines that work, giving people an idea of what to work with. But when it comes to in-country decisions about what it is you need to tackle—if you are only going to tackle four things, what are they?—you don't want WHO to make that decision. In the past, they have, and it hasn't worked very well.

The new model is, inside the country you have an organization, the country-coordinating mechanism. You have somebody from the government in the group, you have local ministers in the group, you have the NGOs in the group, you have the whole civil society sitting at the table saying, "Pick this, pick this, and these are the things we are going to do." Let them decide what to attack and then present a proposal, such as "We are going to go after TB." So then you say, "Okay, what's the goal? How many are you going to save over the next five years? We will give you the money as long as you are on your way to your goal. As soon as you stop, we'll pull it back." That's the plan.

WHO has key roles in various places. They have done some of them quite well, some of them less effectively. You can't take WHO away. You need to have them do many things. They are part of this country-coordinating mechanism because they have people on the ground in every country working with them, people who are professionals. So they are very helpful.

They can even lead these groups—but not by themselves, because part of it has to be ownership. It has to be the people in the country who make some of the decisions, who are responsible for the funds, and run the mechanism, take the money, and either do it or don't do it. So I think mixing them, doing both together, is a good idea. It's something we hadn't thought of before. We don't have to have a big international organization driving everything. That's a bad idea. We need both.

QUESTION: Life expectancy in our country is several years less than that of other leading industrialized nations. Is that because throughout our whole population we have poor diet, not enough exercise, and so on? Low-income Americans have significantly lower life expectancy.

A second question, are there public health measures in the United States that you would recommend?

PHILIP HILTS: There is a big gradient. I was reading a book on the train down, The Impact of Inequality: How to Make Sick Societies Healthier, which is a pretty brilliant book. It goes through, detail by detail, what is happening. The range from the top to the bottom is enormous in income and in death rates. The average doesn't get you there; you have to look at the full range.

We do have a problem with the bottom of society, and we are doing less well than the other developed countries. We are paying more and getting less. That needs a political solution, I think. You have to deal with a health system at large, and then figure out how to make one that works.

And then we have to have individual health projects. If I were going to recommend one thing, and only one thing, it would be difficult, but I think building up the public health funding, which we had very high in the 1950s and 1960s and then went down flat. We don't have people watching for disease in every state now. We don't have the labs. If we have a disease and we want to take a sample and bring it to a lab, they can only test one sample; they can't test 300. So as soon as we have a problem, it fails.

So this kind of thing has to be built up, I think. And just raising the level of public health funding, putting it on the agenda, making it an issue, I would think is a key item.

One of the things that will come out of that is when you have surveillance and people in the cities looking at what's causing infant mortality to go up in some places, then you would have some epidemiologist looking at where they are, what are they doing; let's watch that and figure out if we can pull the plug somewhere. So that would be my suggestion. There are many possibilities.

QUESTION: My question is this: China is planning to inoculate all chickens against avian flu. However, if those participating in this process don't decontaminate after leaving each area, won't this really spread the virus throughout the country and the rest of the world?

PHILIP HILTS: I'm not very hopeful about what is going to happen with the vaccination. And also Tamiflu as a drug is not a very good drug, it doesn't work very well. The vaccination is spotty. In China you can probably do a better job of getting everybody together.

But then you go right over the border into Cambodia and places like that, and there is no hope. Right now we do not have the system in place. You can contain it in some areas of China. You can't contain it in Indonesia or Cambodia. So what have you got? You've got a system with holes. Where does the virus go? It goes straight out through Indonesia, which is where it is going now.

I think probably we are looking at a situation with avian flu where we are going to have a worldwide pandemic among chickens. I don't think it is going to break to humans. I think this one has been out there long enough. We have seen human cases, but it doesn't go human-to-human, and it looks like there may be some biological barriers. So I think we are lucky on this one, that it probably will not be a big human pandemic. It will create a lot of problems for chicken farmers though.

But what we should take from it is the message: Now is the time to build it up. Let's have epidemiologists in Cambodia. Let's work with the farmers there. Let's compensate the folks who are losing their chickens when the virus appears.

In this country the state health departments are the ones in charge of spotting the disease. They did a survey, of course, and found out that of the fifty states, twenty-eight cannot spot a disease within two weeks. It's because they don't have the people. So we have to build that back up.

Now is the time, because avian flu should give us a clue that these things are possible, they are coming regularly. We have the means, we have the money, and we should go ahead and do it.

QUESTION: I was just thinking about your point about building nongovernmental organizations as a sort of barrier for public health. Well, one of the things you will find in many of the lesser-developed countries is that the most effective public health delivery system is often the organizations which we are not happy with, the jihadi organizations, the Maoists in Sri Lanka, the Liberation Tigers. Groups that are either terrorist or may be politically sympathetic to terrorists are the ones that are actually the nongovernmental organizations that are delivering public health. The most bizarre example of that is currently in Kashmir where relief is really being delivered to jihadi organizations, the same terrorists as the al-Qaeda groups.

So if you are to go along with your solution, you will probably find that you have people who are interchangeably moving between aid organizations, relief organizations, and also card-carrying members of terrorist groups. How will you deal with that? There is a strong political element in response to aid, in addition to one of the points made earlier. There is a political element here which we need to resolve.

PHILIP HILTS: There is, yes. There are a couple interesting examples from history. In Nepal, for example, that is one of the problems. When they started delivering the vitamin A program, the rebels at first were upset. Then they talked to the folks who were on the ground, and those people said, "Listen, we're not government; we're just delivering vitamin A." So they talked with them, and now they work with both sides. So you do have people in the rebel groups who are helping, who, when the roadblocks come along, say, "Oh yeah, you're the vitamin A guys; you go through."

In Bangladesh, what we had was a situation where the BRAC offices were bombed. This is the group I was talking about, which was raising the level of the whole country. There was an assassination attempt on the head of the group. But the Muslim community suppressed it very quickly, saying, "Listen, these people are building up our towns and our people, and we are not going to tolerate this kind of thing." So there was a reaction within the community. I think you have to depend on that.

In the Marshall Plan, what they said was, "We're going to deliver money to Europe." That included the Soviet Union and the Eastern European countries, and that was a big risk. Everybody said, "You can't include those people. Those are the enemy." They said, "Forget about it. This is going to be open. Anybody who can deliver this, we're going to deliver it." It was a big risk, but they did it. Of course, in the end, the Soviets decided not to show up.

I think that's an interesting case now, the same sort of thing. You have to be open, you have to assume they will be there, and try not to think in political terms but think in direct health terms. That's my guess. We could be wrong.

QUESTIONER: That's very radical.

PHILIP HILTS: Yes. It was radical when it was proposed before in the Marshall Plan. They said, "If the Soviet Union comes in when we deliver aid, the answer is yes."

JOANNE MYERS: Thank you very much for opening our eyes to many of the challenges that we face in the field of global health and what we can begin to do about them.

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