Global Health Equity Can Now Be Imagined

By:Jan Mazotti Issue: Collaborative Leadership Section: Community

An Interview with Dr. William Foege, Senior Fellow for the Gates Foundation Global Health Program

IF YOU WANT TO GO FAST, GO ALONE. IF YOU WANT TO GO FAR, GO TOGETHER. ~ AFRICAN PROVERB Foege Bill The progress that has been made over the last decade in global health was not possible a decade ago. Major health advances have occurred in wealthy countries, yet significant gaps in basic health tools and technologies still exist in the developing world. The approach at the Bill and Melinda Gates Foundation is that, “all lives have equal value and that all people deserve the chance to have healthy, productive lives.” Living the mission, the foundation has invested more than $13 billion in global health since 1994.

As a senior fellow for the Global Health Progam, Dr. William Foege, M.D., M.P.H. advises the foundation on strategies that could be usefully pursued in global health. He has served in a variety of executive positions at the Carter Center and is senior investigator on child development at the Task Force for Child Survival and Development as well as Presidential Distinguished Professor of International Health at the Rollins School of Public Health.

By writing and lecturing extensively, Foege works to broaden public awareness of the issues of child survival and development, population, preventive medicine, and public health leadership. In 1997, he was named fellow of the London School of Tropical Medicine and Hygiene. Foege helped form the Task Force for Child Survival in 1984 to accelerate childhood immunization. In the 1970s, he worked in the successful campaign to eradicate smallpox and served as director of the U.S. Center for Disease Control. He received his medical degree from the University of Washington and his M.P.H. from Harvard University.

Dr. Foege believes that collaborators must recognize the importance of respecting one another’s expertise and work together with a clear goal in mind. We had the distinct opportunity to visit with Dr. Foege to learn more about the successes and challenges of the foundation.
ICOSA: As a senior fellow with the Global Health Program at the Gates Foundation, discuss some of the major issues facing the U.S. and other countries regarding global health issues.

FOEGE: In both the U.S. and globally, there are a series of shared problems. First is the gap between the levels of unnecessary suffering and premature death experienced compared to what could be expected if we actually applied what we already know. In the U.S., for example, about two-thirds of deaths occur earlier than they should, largely as the result of self-inflicted problems—like tobacco, diet, alcohol, and intended and unintended injuries.

Even poor countries are caught in this trap, but they also face other problems like under-nutrition and infectious diseases. A second problem in both the U.S. and other countries is the terrible health toll inflicted by social determinants, especially poverty. The poor die earlier and experience more suffering in their shortened lives. Third, for many, the idea of being "brothers' or sisters' keepers" stops at the border of a country. We are only, in recent years, seeing a slow turn around in attitude where there is a feeling of responsibility to use our capacity in research, management and health knowledge for the world as a whole.
ICOSA: Does collaborative leadership play a role in addressing these issues? If so, how?

FOEGE: Yes. Collaborative leadership certainly plays a role. There are two lessons from the smallpox program as an example. First, improvements in health never happen by chance—they are the result of deliberate action with a decision to achieve some objective and then the development of a plan to achieve that objective. Second, objectives can only be reached through coalitions. In general, coalitions around health objectives are easier than in other areas, but they are still difficult. Important however, is that coalitions are more likely to occur if countries feel at some risk—this was the case for both smallpox and polio. Increasingly, we are seeing coalitions form around disease problems that constitute no risk to rich countries like guinea worm eradication, river blindness programs and trachoma control as examples. Important to note, the best coalitions include multiple organizations, such as global agencies, governments, non-governmental organizations and service agencies, bringing their strengths to bear.
ICOSA: When going into new communities, how does the Gates Foundation balance the needs and expectations of various stakeholder groups, both here and abroad?

FOEGE: The best collaborations form around the felt needs of communities and real needs that will improve health. All parents are interested in the well-being of their children, and this interest has no correlation with wealth. Vaccines are some of the best and most cost-effective tools available in global health as they often provide protection for a lifetime at a relatively small cost. An early program of the Gates Foundation involved the support of a global program for vaccines and immunization (GAVI). Over $1.5 billion have been provided by the foundation, which has encouraged others to provide support also. But the foundation does not try to actually deliver the vaccines. Instead, GAVI provides funding to countries with low to average incomes to support the country immunization programs—but the country must demonstrate that they are actually reaching children with the basic vaccine before they qualify for support for more recent and more expensive vaccines.
ICOSA In a relatively tumultuous political time, how does the Gates Foundation work collaboratively to ensure that “all lives have equal value”?

FOEGE: This is more than a mantra. The foundation works with global and government agencies around the world. Research funds are aimed at disease problems that inflict the poor and that have not received sufficient attention through the usual programs. The Gates Global Health prize was awarded to Brazil when the government of Brazil pledged to treat all persons with HIV/AIDS, regardless of their ability to pay.
ICOSA: What are the most critical/compelling leadership issues you have at the Gates Foundation-Health Program? How are you addressing them?

FOEGE: Over the past 10 years, we have witnessed a true transformation in global health. Research into the problems of poor countries is funded and thriving. Global health educational tracks have become so popular that over 150 schools of higher education now have global health programs. Global health is supported by politicians, service organizations, church groups and pharmaceutical companies. But two major barriers are still obvious. First, the delivery programs have not kept pace with the tools to be delivered. The world abounds with managerial talent, and we have to make the solving of management and delivery problems in global health a higher priority for gifted individuals and for countries.

Second, it is still difficult to get trained personnel to return to the countries from which they came. It is no mystery why this is true. None of us would acquire skills and knowledge and then move back to a situation where we cannot use those skills or that knowledge. So the second major barrier is to find ways to level the playing field so that people can return to their own culture, where they know the language, the people, and the needs. This means going beyond training to supporting. I like to refer to this as providing a warranty with every global health degree—computer support, laboratory support, research support, income support—as part of the formula to correcting this barrier.
ICOSA: How has the downturn in the economy, domestically and internationally, impacted your operations here and abroad?

FOEGE: No matter how many resources the Gates Foundation provides to global health, it is far too small to solve the problems directly. The entire annual investment in global health by the Gates Foundation is spent on health in this country every four to five hours, and yet major health inequities persist in the U.S. Global health activities are directly affected by the economic downturn and the reduction of health activities. At the same time, the greatest determinant of illness, namely poverty, increases the numbers of people at risk. The Gates Foundation investments attempt to fund the highest leverage programs possible.

When asked about his general thoughts on global health, Dr. Foege said, “While it is easy to become discouraged over the size of the health problems in the world, the real story is that determined efforts by many people and groups have had a major impact on disease and death. Many specific problems have improved—polio is almost eliminated and smallpox has not been seen for over 30 years; measles deaths have declined by over 90 percent; infant mortality rates have declined throughout the world; guinea worm disease is approaching eradication; river blindness no longer leaves people blind and fertile farm land unusable; diarrhea deaths are declining as the result of vaccines; and malaria deaths are going down because of bed nets and new approaches to treatment. In this country, lung cancer deaths are declining, stroke and heart attack rates have fallen over the past 30 years, and we have some logical arguments against fatalism. While it is only a beginning, global health equity can now be imagined.