Recently in my class, students come to me about issues that Ebola as an example, and saying, ''Well, we need the WHO to take care of this.'' Actually in some ways, that idea that you have there's one organization spearheading, controlling everything, that idea in the public imagination is actually dangerous in some way? Certainly today. I think that no doubt, there needs to be some order out of the chaos. Of course yes. I think it's unrealistic and unfair to think that WHO in its current format way of working financial situations can play that role. Right, technical advice is what they can provide. They had, they can give technical in some some areas. Sure. They have some very dedicated and very competent team. Sure. But to be an implementing agency? Right. With Ebola there's a call by the UN for $600 million. Yes, $600 million. We're pretty close to getting it. If you look at what the EU is giving the US, the Gates Foundation. My point from the beginning is not that we can get the money. Right. Now that we have the money how are we going to deliver the facilities that are needed, the hospital beds, the drugs, the protected gear and how are we going to find the health care workers to go out and do the work. Absolutely. Having money is great, but it's really how to organize the health care system and get the supplies and logistics and health care workers in place that matters. Sure, because there's a real difference between getting funding and planning and actual implementation and being effective. That's something I think that, sometimes in global health, periodically people get funding maybe the same thing again and again and it fails each time. Yes, we don't always learn from our mistakes. Unfortunately not, and with that in mind, I guess I'd want to ask you, what do you think are the keys to success for global health programs? What do programs really need to be effective? I think we have learned back to smallpox. To the eradication of smallpox, many people listening, I would expect none of the students listening to this have had smallpox vaccination. That's because we eradicated smallpox. What we learned in the eradication of smallpox was the importance of management in health. We can have all the technical details. Right. We can have all the science, and we should, the best science, but in the end what matters in global health programs is planning them, carrying them out and evaluating them in an organized systematic way. As we would run any program in any sector. Of course. Unfortunately, to be honest, most physicians don't have any training in management. Sure. It's getting better. Many more doctors today are getting MBA's or masters of science in Global Health or MPH, and they do learn some management there. But I think we learned in smallpox and let me expand the program of immunization back in the 1970's, 1980's, that you need to have, with any other program in any sector, you need to have good program management to set targets. You need to set priorities. You need to have timelines, you need to have specific metrics along each of the timelines, and then you need to periodically evaluate what you're doing, and change course where you need to change course. Very few diseases that have magic bullets. Smallpox was one, it did. Made it a little easier, but most of our problems today are not solved through magic bullets and even more importantly therefore, need to have sound program management. For me that's the most important aspect. Secondly, we can't compromise on science. Sure, agreed. We can't be unwilling to face reality. We have to really be frank about what's causing a problem, then we need to confront it heads on. For example, in the days when early days of working in AIDS, there was some reluctance to talk about sex, and then there was some reluctance to talk about condoms. Right. Because of the association with family planning and religious beliefs. Also when injecting drug use, there was harm reduction. Which means you actually give people who are injecting clean needles and syringes, so they don't infect themselves with hepatitis or AIDS. These were very controversial actions at the time. But after all, if you want to curb a problem that's spread through sexual intercourse and through injecting drug use, what's the choice? Exactly, right. I think when it comes to health we need to be evidence-based, we need to be willing to say what needs to be said and be able to work with many different partners. In the case of AIDS, with religious organizations in moving forward with the most effective and appropriate approaches and strategies. Sure. So sound management, good science, and then of course we need the resources, and we need to use those resources in the most efficient and effective way. Unfortunately, sometimes politics comes in. But I think even with politics, we really do need to be sure that we're making the wisest investment for the outcome that we can get. Absolutely. I like the way that you framed those issues. When I tie that back in something you said earlier, about students and people also going into communities and working. So we have both the idea of proper program, design management, implementation, surveillance, right? So that we have to be also brave enough, when we're not moving in the right direction or something we are doing is not working, to figure out why and change course. I think you make a really important point. We often say know your community. Right. I think even for students in junior high or high school, will get out and do community projects of different kinds. You learn early on that you need to understand and know your community and their beliefs, their culture, their religious predilections, their different preferences and lifestyle. Sure. All that is important in what we do in health. Understanding that is critical for you designing your interventions in your programs. I think that's a really important point. I'm so excited today that young people are getting those experiences. I can tell you that, when I first started in this field, the global health, let's just say 10 years ago and I would go into a classroom with freshmen from college. I would always ask how many had been abroad, before they come to college and maybe five or ten shot up. A 100 would raise their hand, they'd maybe they've gone to Europe. Today when you go in the classroom probably 60-70 percent raised their hand and probably two-thirds have been either to Africa or Latin America or Asia, many to Africa. Suddenly the student of today is thankfully quite sensitize. You know when I grew up it was a big deal to take the train to New York. So it's a whole different world today. That's wonderful. I would also say the students of today who are sensitive to communities, much more than perhaps the previous generation, that generation was interested more in wall street and we've learned that it's not necessarily the best place to go all the time. We see much more interest in a commitment to service and to society and making a difference in the world. There's no better place to do that in global health. Absolutely. I think that it's also shows why the future in global health are intimately related. There is no future without health. No way. In terms of the future what do you think the future holds for global health? Both in terms of problems and solutions. I think the future's bright. Every time we get complacent we face something new. It's Ebola today, but who knows what'll bring tomorrow. Exactly. I think the fact that the chronic diseases are being prominent everywhere. Sure. The real challenge of aging around the world. In our country in the United States the change in the growth of the average age of death let's say. Has been relatively fast. But not as fast as a country like China where in one or two generations the average lifespan goes from from 50 to 70. The hope, I work a lot in Singapore where we have a med school. Same thing is that's happening there. A tremendous increase in people over 70 and the challenge that that is going to bring to global health is remarkable. Both in terms of diseases, the care, the ethical questions about dying, palliative care. All of these issues are coming to the fore. So and also I think we're fortunate that the resources seem to be there. Students that go into this field. Most of them I know either go on to second or third degrees or they get a job somewhere. So it's a field that for young people it's very promising. I would add one really exciting development is this whole innovation area. Innovation in technology, the innovation in health systems. This is a fascinating development. I think it's going to spur this field even further. You can now diagnose malaria and diabetes in ten seconds. You can now use your smartphone first for diagnosis for treatment. There are so many new devices and approaches to prevention and treatment in our new era. Absolutely. That I think the field is going to really take off as our innovations become evaluated and shown to be effective. I agree with you and that's very exciting. Sometimes I know that we've talked a lot about how global health is also a combination of altruism and self interests. Sometimes I tease the students that the real reason there're interested in global health is because they learn about the demographic transition. Then soon they realized that when there were about 40, it's going to be a lot of us old guys with dementia. So they'd better get it to work. Well I will tell you another thing that's interesting to me. This debate that you alluded to just now is global health. Do we care about global health for humanitarian reasons? Or do we care about it for other reasons? The one reason I just think it's important to mention is the security angle. Absolutely. I think what gave Aids the big boost in political support and funding was the fear of having political implications and countries causing security concerns. Absolutely. We know that in Rwanda Burundi conflict Aids played a role in a lot of the way migration took place. There are many examples where we know that terrorist organizations try to use healthcare, as a way of getting support from people. So and that's led to this interest in global diplomacy and global health being used as a tool for security. Absolutely. That's another reason why I think health, global health has a long future that it it's now seen as a critical role in defense, critical role in security and in the health of the nation from a much broader perspective. And diplomacy. And diplomacy. As well. Yes. As well. You know I know that you've got two more meetings to go to. Yeah. That's the life of a director. It's fine talking to you and the students they don't have to go to me. That's true or they will eventually when you're old and gray. Or they will have to be with you maybe. Maybe so. But you know before you leave, I don't want to embarrass you and you don't have to answer this if you don't want but, is the students know from my recommended readings you are the author of an acclaimed textbook on Global Health actually the top textbook in the field. Thank you. But infact I have look over there it's right underneath that [inaudible] I've got two more over there too. To good. Okay. But rumor has it that you right now are completing another book. Would you just give her a little preview of what that book is? Sure, the you mentioned one of my earlier responsibilities was to run the Aids program in WHO this was called the Global program on Aids. This was the first UN response, for UN Aids. Actually the global program on aids existed from 1987 to 1995. I was the Director from 1990 and 95 and helped devolving it into what is now called Human Aids, right. So the book basically tells the story of what happened between 1981 when HIV was discovered and the global program on aids came to an end in 1995. Talks about the long delay in the global response. The how the response then was had its setbacks and its ability to move forward. It was a tough period. We didn't have any retrovirals leading to the creation of UN Aids, discovery of anti-retrovirals. That's really where the book comes to an end. It's trying to inform us all how the world responded to aids and what have we learned for the future. Of course I touch on what's happening now but it's much more a history of what happened during that 20 year that 15 year period from 1981 to 1995. Sure, well I think that both from, we've learned the importance of history and not repeating our mistakes and what we can learn from? That is a period that actually for younger students or for people who are in their twenties and below not only did they not remember. But so they may not actually have thought about those questions that we want. So I think that's going to be an insightful book. Many of their students weren't even born. That's true. When HIV was first was on the scene and there was few cases in Los Angeles. In 1981 and I think that it's interesting hopefully for them to know what it was like. Both how the disease affected people but how the activist groups work so hard to get whatever discoveries were available and available quickly. Which we now are going to see again with Ebola. Same thing. Yeah I still have active fight back by days in my head. I remember these days and it's crucial. I also think it also is important in that as we talked about looking at things from both whether from an individual level or from a structural level. In global health do you have to think about both. That's why we focus on both individual level medicine and population-based strategies. From what you're saying I think this book is going to give the example and keep both of those [inaudible]. Yes very much so. You know. Well Mike as always thank you so much. Thank you and I look forward to seeing all of these students either at Duke or some other university. I agree yes, many places. All right Dr. Boyd, Doctor Merson signing out. Bye bye.
