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.
