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COMMENCEMENT SPEECH UC BERKELEY SCHOOLOF PUBLIC HEALTH MAY 12, 2001 AND UNIVERSITY OF ALABAMA, BIRMINGHAM SCHOOL OF PUBLIC HEALTH June 8, 2001 And Hunter College, New York City June 4, 2001
Laurie Garrett NEWSDAY MEDICAL AND SCIENCE WRITER 2 Park Avenue New York, NY 10016
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Greetings, to you: The first class of health professionals to graduate into the 21st Century. The world you are entering, in which you will work, is undergoing a paradigm shift as revolutionary as any previously seen in world history. Call it globalization, if you will: Or global consciousness and awareness. Regardless of the label, we are witnessing the first toddler steps in what will undoubtedly be the boldest leap in human history. When I was a graduate student here at Berkeley ---- an unsuccessful one, I might add, as I did not complete my PhD --- the Cold War was still very much in place, and the world was strictly divided: Communists and their proxy states over there, Capitalists and their proxies over here, and a handful of so-called nonaligned nations straddling the unstable middle ground. Borders were terribly significant, even within Western Europe, and the World Health Organization formed a fragile Public Health bridge between otherwise separated nations. If individual citizens of any nation tried to function in ignorance, or defiance, of these political and economic divisions there were ice buckets full of cold water to pour on their naïve faces: Gulags, ersatz mental asylums, House UnAmerican Activities Committee hearings, blacklists and, of course, the threat of thermonuclear war. And then came 1989: The fall of the Berlin Wall, followed in rapid succession by the Velvet Glove Revolution of Czechoslovakia, Solidarity’s toppling of communism in Poland and the collapse of the Soviet Union. The Cold War ended --- remarkably, without a nuclear holocaust --- leaving the United States the unrivaled superpower of the world. Simultaneously, the Internet insinuated itself into every culture, fueled by fantastic innovations in computer and telecommunications technologies.
2 At the close of the 20th Century the people of the world “globalized”, in two extremely significant ways: They cast off the atrocious boundaries imposed for half a century by the political struggle between adherents to the teachings of Karl Marx vs. Adam Smith; and they came to know each other as never before through the use of a cheap, new technology. Consider this Stage Two of a process which optimists forecast will ultimately drive the 21st Century closer to global governance and world consciousness. Nine years ago I had the pleasure of hearing the great Mexican writer, Carlos Fuentes, speak at Harvard University about Stage One of this Globalization process. The occasion was the 500th anniversary of Christopher Columbus’ landing on the shores of Santo Domingo. As the adventurous Italian placed his feet on that Caribbean island he, for the first time, linked the populated continents of the planet. Yes, other human beings had preceded Columbus to the Americas, but only he landed at the aegis of an Empire, officially linking this continent to Spain, and through her mighty Armada’s reach, to Africa, the Middle East and Asia. Under the flag of Isabella and Ferdinand the peoples of the world, for the first time in Homo sapiens existence, were conscious of living upon a round planet comprised of vast seas and distant lands, populated by incomprehensible strangers. You would have thought this phenomenal moment would have been heralded with decrees and trumpet blasts throughout Spain. But such was not the case. During his lifetime Columbus was barely known to the people of Spain, and today in Madrid no commemorative murals or steles erected during the late 15 th or early 16th Centuries can be found. Stage One was ignored. Europe was preoccupied. Spanish citizens hadn’t a minute to contemplate such grandiose ideas as the existence of far-off continents and a place called America. They were busy with the Inquisition, and worried about the growing threat of the English and Dutch fleets. Domestic politics, then, blinded most Europeans to the true significance of Stage One. According to Fuentes, however, there were a few noble monks, toiling in their Spanish monasteries, who questioned the wisdom of the Empire’s --- and, by mutual definition, Catholic Church’s --- activities in Stage One of Globalization. Nine years ago, when many Americans were struggling with collective guilt over the Columbus Quintennial, Mexicano Fuentes chose, instead, to praise those rebellious Spanish monks. Why, the monks asked, is it right for Spain and the Holy Church to enslave the native peoples of the Americas? Look at how they die in droves before our Conquistadors, supplicate in diseased states to our ministering Jesuits and cry out for mercy! Historian William McNeill tells us that the Spanish Army, led by Cortez, was able to capture the capital of the Aztec Empire with a tiny rag tag band of hooligan soldiers. It was an achievable conquest because Monteczuma and his vast army had fallen to European diseases, against which they had no natural immunity. During the first `years of Spanish conquest of the Americas measles, influenza, smallpox, tuberculosis and other European microbial diseases claimed an estimated 56 million Amerindians. Within 200 years of Columbus’ landing the Amerindian population had declined by 90%, mostly due to wave after wave of European and African microbes. Stage One Globalization was financed by spices, whaling, cotton, gunpowder, tobacco, rum, silk and slavery. The trade routes took European ships along Africa’s coasts, where ivory and human captives were stacked below and hauled to distant lands. A century and a half after Columbus’ landing the English were trying to manage a belligerent lot of some 10,000 Europeans who had settled on the swampy, fetid tip of an island they called Manhattan, in a town they dubbed New York. The colony’s survival hinged on its vast natural harbor, and its willingness to accept all comers, regardless of which European nation they called home. Key to New York’s thriving economy was the global trade in human slaves, with the colony serving as a connection between Europe, Africa and the Caribbean.
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More than any other city in the Americas, and perhaps in the entire world, New York thrived under Stage One of Globalization. But it also paid a price, for on those slave ships, living off the bodies of that human cargo and in the contaminated casks of water that gave them sustenance, were Africa’s Anopheles and Aedes mosquitoes, smallpox and yellow fever viruses. And from Asia aboard those ships came cholera vibrio. During the sweltering summers of New York’s 17th and 18th Centuries these vectors and microbes killed 5, 10 even in one year 12% of the city’s population. Consider it the downside of Globlization, Stage One. Microbes that had co-evolved with Homo sapiens in our species’ primary ecologies, hitch hiked aboard clipper ships to fresh, naïve ecospheres. And there they flourished, caused massive epidemics and, eventually, reached stages of endemic stasis. The noted British health expert Thomas McKeown spent years analyzing the excellent morbidity and mortality records of England, Wales and Sweden for the period 1700 – 1971. McKeown was able to surmise that average life expectancy for a man in the three areas in 1700 was a mere 27 years. By 1971 male life expectancy in those areas reached 75 years, and it is I still climbing. Obviously, that constitutes striking improvement. And it has been mirrored, to varying degrees, throughout Western Europe, the United States, Canada and Japan. It has always been an assumption at the United Nations, World Bank, IMF and within successive administrations of the U.S. government, that the rest of the world’s populations would follow a similar course --- eventually --- if given enough time and economic development. Life expectancy and development have always been viewed hand-in-hand: One would simply follow the other. So in 1990 the World Health Organization and World Bank issued cheery forecasts: Average global life expectancy --male and female combined --- in 1955 was just 48 years; but by 2025, the agencies predicted, it would reach 73 years. Today we must collectively admit to an enormous hubris problem. Not only will the world fail to meet its rosy life expectancy projections, but many parts of the global community are now witnessing life expectancy reversals, notably countries in subSaharan Africa, central Asia, and the NIS. During the 1990s the former Soviet nations experienced the sharpest life expectancy reversals seen in the region during peacetime since the Black Death of the 14th Century. Why? First, why did male life expectancy increase by 48 years among Northern Europeans between 1700-1971? Many microbial diseases, introduced to Europe in Stage One of Globalization, were peaking in 1700, with wave after wave of terrible epidemics of syphilis and tuberculosis yet to come. McKeown tells us --- and records in the USA and Canada bear him out --- that more than half that improvement in life expectancy occurred prior to 1900. And nearly 90% of it occurred prior to the invention of a single antibiotic. Even tuberculosis, which we always think of as a classically antibioticdependent control problem, declined by 87% in the UK between 1838-1949 --- again, before streptomycin was proven efficacious for treatment of TB. In the wealthy world modern medicine --- CT scans, MRIs, open heart surgery, anti-psychotic drugs and intensive care units --- has been responsible for only incremental improvements in average life expectancies. In the U.S., experts estimate fewer than 8 years of total increased 20 th century life expectancy can be credited to medical interventions. So what made the difference? Those 48 years of additional life were largely won through combination of essential public health efforts, improved housing and quality of life, construction of water and sewer systems, soap, drainage of mosquito-
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infested swamps and transportation that allowed delivery of fresh and highly varied food options at affordable prices to the general populations and iceboxes in which to safely store fresh foods. The most dramatic improvements in life expectancy were realized when scientists in Europe and North America 110 years ago applied basic germ theory to large scale interventions aimed at protecting children from typhus, typhoid fever, scarlet fever, measles, chicken pox, dysentery, vitamin deficiencies and so on. By reducing child mortality from New York City’s abominable 40% rate in 1870 to a current less than 1% rate health officials pushed statistical life expectancies through the roof. As New York’s pioneering public health leader Dr. Hermann Biggs said in 1914, “Public health is purchasable. Within natural limitations a population can determine its own life expectancy.” That was then. This is now. The US Centers for Disease Control recently determined that between 1980-2000 the numbers of Americans who died of infectious diseases annually DOUBLED, now topping 170,000 a year. When the upswing was first noted a decade ago officials blamed the US AIDS epidemic --- and at the time HIV was, indeed, the number one cause of premature death in America. But since 1996, when Highly Active AntiRetroviral Therapy, or HAART, came into widespread use death rates among people infected with HIV have plummeted in this country. Nevertheless, overall infectious disease rates have climbed. Most industrialized nations now report similar trends. What’s going on? It’s the down side of Stage Two Globalization. It’s payback, if you will, for decades of shunning the desperate health needs of the poor world. It’s the boomerang from a 20th century in which 20 percent of the world population stopped having to worry about measles, malaria, yellow fever, TB and so on….. But the remaining 80% struggled for access to the most basic antibiotics, clean water, waste disposal, safe syringes and anti-malarial drugs. The world is now a fluid place in which borders and territorial expanses have ever less significance. This global fluidity may make sense economically, politically, even culturally and socially. But, as was the case in Stage One of Globalization, it has its risks, particularly in the form of spread of microbial disease. Malaria --- introduced in the 17th Century via slave ships --- was virtually eradicated from North America by 1950. But the numbers of malaria cases in the US have risen steadily since 1985. Between 1996-1997 --- IN A SINGLE YEAR --- the number of malaria cases increased 11%. This merely reflects what is happening globally. Last year, according to WHO, more people died of malaria than ever before in human history: 3,000 children EVERY DAY in 2000, more than 1 ½ million people. The mosquitoes have become resistant to our pesticides, and the parasites are resistant to our drugs. Hepatitis C, virtually unheard of by any moniker before 1985, is now a global catastrophe. Here in the USA 90% of all intravenous drug users are infected with the cancer-causing virus, which it is estimated will kill 25% of those who are now infected. This, too, merely reflects what is going on globally, thanks largely to medicinal use of NONSTERILE syringes. It is now estimated that 170 million people are infected with the virus ---- 42 MILLION of who will die, as a result, of liver failure or cancer.
Dysentery and parasitic diseases are on the upswing in many parts of the world ---- ailments that can be COMPETELY PREVENTED through simple water filtration and purification methods. In March of this year the World Health Organization estimated that 1 BILLION people drink unsafe water every day and 2.4 BILLION lack proper sanitation and sewage capacity. Water-borne disease last year killed 3.4 million people, most of them children. We reached another landmark last year with tuberculosis, which killed a record number of our species in 2000: more than 2 million of us. And 8.5 million people had active TB last year. Recently WHO and the
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US CDC released the hair-raising results of a 58-nation survey of drug resistance. Comparing rates of multi-drug resistance ---- which is to say the prevalence of infections caused by forms of the bacteria that can resist treatment with two or more of the 10 anti-TB drugs ----between 1995 and 1999 the agencies saw dramatic increases everywhere in the world. In the rich world, for example, MDR-TB rates more than tripled in just four years. Here in the US they went from 1.2% of all TB cases to 5.6%. In Germany --- from less than 1% to 6.3%. In Switzerland ----from NO detectable multi-drug resistance in 1995 to 12.5% in 1999. BUT, of course the trends in the poorer world are more disturbing. Mexico jumped from 2.5% to 22.4. Tomsk, Russia from 6.5% to 25.9%. India from 8% to an absolutely astonishing 48.2%. WE COULD WELL ASK JUST HOW LONG DO WE HAVE BEFORE TB WILL BE INCURABLE. IF THE TRENDS CONTINUE ON CURRENT TRAJECTORIES MANY NATIONS IN THE WORLD WILLHAVE FULLY INCURABLE TB IN CIRCULATION BEFORE THEN END OF THIS DECADE. Drug resistance now threatens treatments for all bacterial diseases, especially Staphylococcus aureous, Streptococcus pneumonia, Enterococcal infections, Klebsiella and E. Coli infections. We have watched this trend for five decades --- seen penicillin and tetracycline rendered useless against one disease after another. And we have, as a global community, done very little about it. We simply waited for drug companies to invent an alternative drug, paid more for it, and assumed that new drug option would always be there. But each new class of antibiotics is far more expensive than its predecessor, and for most of the world’s population drug resistant Strep or Staph is financially incurable disease. Further, of the roughly 250 anti-bacterials now on the market all use just one of 6 ways of attacking the microbes. If the microbes manage to mutate around those 6 basic modes of attack, they are incurable. And that has now happened with an alarming number of diseases. Finally, death rates are far higher, and hospitalization costs average 50% greater, for victims of even mildly drug resistant forms of bacterial disease. WE SHOULD BE ASKING, AS WITH MALARIA AND TB, JUST HOW LONG DO WE HAVE BEFORE OUR VITAL ARMAMENTARIUM OF ANTIBIOTICS WILL BE RENDERED USELESS. As a corollary of that, we should be asking what could be done to curb the massive black market in antibiotics, and limit their use in livestock. Because of these bacterial threats, hospitals are becoming more dangerous environments, especially in the wealthy world. During the 1990s in the US, for example, some 40 million people EVERY YEAR acquired infections inside hospitals, about 2 million of which were drug resistant. Those infections killed nearly 100,000 of them and increased treatment costs overall by $4.5 BILLION. As disease spreads in American hospitals, driving up costs and killing our citizens, managed care is doing exactly the opposite of what it ought: It is restricting lab tests and reducing nursing staffs. Over the last five years we have witnessed two outbreaks of the dreaded Ebola virus --- in Kikwit, Zaire and Gulu, Uganda. I was in the Kikwit outbreak. And it is obvious that the sorts of failures in clinical infection control that are permitting spread of bacterial infections inside American hospitals are driving FAR more dangerous epidemics and outbreaks in resource-scarce poor countries. Ebola, like so many feared microbes, takes advantage of ecologies in which contagious patients come in contact with health providers who lack protective gloves, masks, and clothing. Who have no fuel for their generators and so cannot run their autoclaves to sterilize their equipment. Who have no water filters with which to provide patients safe fluids. And who must BY NECESSITY reuse contaminated syringes on one patient after another after another after another. The CDC estimates that last year 12 BILLION injections were given worldwide for medicinal purposes --90% of which were medically unnecessary. Most alarming, 70% of those injections delivered in hospitals and clinics of the NIS and CIS were NONSTERILE. 79% of the medicinal injections in ssAfrica were nonsterile. And a whopping 80% in SE Asia were nonsterile. PHYSICIANS, DO NO HARM: how is it possible, in an age of hepatitis C and HIV, that doctors, nurses, marketplace injectionists and other health providers are routinely reusing nonsterilizable needles and syringes?
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One could especially ask the wisdom of this continued practice in countries where the HIV prevalence exceeds 5% of the population. I have witnessed it with my own eyes: children in African villages lined up and vaccinated, all with the same syringe. Health providers in Ukraine using one syringe on a room full of pregnant women. I have seen it. The United Nations, US AID and American humanitarian organizations should ask themselves just how much longer they intend to support global child vaccination efforts that may actually be spreading HIV. There is a simple solution, of course: Package all injectable drugs and vaccines with autodestruct, single use syringes. The increase in cost associated with this is trivial; less than 2 cents per syringe. A trivial sum, compared to the social, human and economic costs of spreading HIV/AIDS. I won’t review the numbers --- you have heard them before, and you know that AIDS has now eclipsed the 1918 influenza pandemic’s death toll. Within less than 4 years it will also have killed more people than it is estimated perished in the 14 th century Black Death plague. The United Nations, the G-8, heads-of-state in the wealthy world and some of the planet’s most powerful political figures have, at last, awakened to the reality of the catastrophe unfolding before our eyes. This month the leaders of Africa gathered in Abuja for their annual OAU summit --- AIDS was the top item on their agenda. Secretary-General Kofu Anan in Abuja called for creation of a $7-$10 billion war chest --- annually replenished by the wealthy nations and used to combat AIDS in Africa. Some very smart people from all over the world have in recent weeks thrown out ideas --MULTIBILLION DOLLAR IDEAS --- for how to solve, slow or treat the global crisis, particularly in Africa. A group of 138 Harvard faculty, led by economist Jeffrey Sachs, has calculated that an annual $8$12 billion expenditure from the U.S., Europe and Japan could offer a treatment and prevention package for AIDS, malaria and TB in Africa. All these ideas merit close attention, and will undoubtedly be discussed at the upcoming Special Session on AIDS of the General Assembly. Missing in the discussion, I fear, is a sense of what is really happening in the hardest hit countries of the world. I have been chronicling this epidemic since it began 20 years ago, devoting much of my life to its impact in Africa. The numbers --- horrific as they are ---- cannot capture the public health reality. It is a reality in which an 81-year-old grandmother in the village of Kyebe, Uganda takes me on a stroll of her tiny banana grove, pointing out mounds of stones under which lie the AIDS victims that once were her husband, 10 out of 12 of her children and 10 out of 33 of her grandchildren. With nothing to trade or eat but bananas she is raising 23 orphaned grandchildren. And she is no exception. From house to house in her village, and in hundreds of villages like it, the carnage is the same. Africa --- which NEVER BEFORE had trouble absorbing its occasional orphans into larger clans or coping with the dire straits of individuals in its midst --- is falling apart. Today orphan girls of 9 or 10 years of age in Bunazi, Tanzania are raising four or five younger orphans, some of whom aren’t even distantly related to them. These girls cannot pay for schools --- they are themselves, illiterate. They cannot pay to transport the youngsters to clinics for their immunizations, nor do they fully understand when and why those injections are necessary. Most important: They cannot explain to the young ones who are the Buhaya people. The Ndebele people. The Shona people. They cannot tell them the stories of their ancestors, the spiritual meanings of things, the hopes and legacies of a people. It’s more than just individuals who are dying. It is entire CULTURES, perishing – POOF! --- Before our eyes. It is without a doubt the singularly most devastating event in human history. The forecast? No, there will not be a cure or vaccine anytime soon --- unless one of you, or a bright innovative young scientist just like you, dreams up something quickly that is so far out of the box of current biological thinking as to constitute a fundamental paradigm shift in immunology.
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Baring some dramatic interventions, we can see a grim, terrifying future. In Africa half the subSaharan nations now have HIV prevalence that exceed 8% of their populations, and at least 10 countries have rates above 20%. There are even in areas of Africa where IN EXCESS OF 40% OF THE POPULATION IS NOW INFECTED. Could this actually continue to grow? Could some African nation experience a 60% infection rate two or three decades from now? Perhaps no worse is the alternative: Endemic stasis. Some epidemiologists believe that several African nations have now reached that state in which HIV has become endemic, and infection rates will now remain stable for decades to come, at unthinkable levels of 20% or more of the adult populations. India and China, with their billion-plus populations, could well outnumber Africa’s carnage within a decade, though prevalence rates in those Asian nations might well remain below 5%. The Russian Ministry of Health has forecast that between 2005-2010 some 10 MILLION Russian will dies of AIDS, most of them under 29 years of age. And the prevalence in Russia, they say, by 2015 will exceed 12% of the total population. That’s equivalent to Uganda’s current estimated prevalence. Earlier this year the Central Intelligence Agency released its forecast for 2015. AIDS, the CIA says, will decrease the GDPs of most African nations by 30%. For countries that will have HIV prevalence rates in 2015 that exceed 10% of their populations AIDS care and control costs will eat up in excess of half of their national health budgets. And life expectancy will, in hardest hit countries, fall by some 30 to even 40 years compared to 1988 levels. It won’t just be the virus that will shorten those lives, the CIA says. It will be the complete collapse of all public health systems, starvation due to destruction of the agricultural sector and secondary epidemics of tuberculosis and childhood preventable diseases. History shows that public health prospers when class disparities are lowest, when there is a large, selfinterested middle-class. Today, however, globally and in the United States specifically, we are witnessing a record wealth gap. A worrisome wealth gap is swelling in the United States. From 1989 to 1998 the poorest fifth of American society lost an average of $587 in real annual income while the richest 5 percent of the country gained $29,533. The number of American families classified as “very poor” --- those living on less than $8,018 per year --- increased, and as the Children’s Defense Fund put it, “We have five times more billionaires but four million more poor children.” On a global scale, according to the World Bank, wealth disparity grew sharply during the 1990s, as a direct outcome of Globalization, Stage Two. The bottom ten percent of the planet --- its poorest citizens --- lost about a third of their wealth during the decade. The richest ten percent of the planet’s population got richer, still, gaining an additional 9 percent of global wealth. If these trends continue you, the first new health professionals of the 21 st Century, will be sorely needed, and sorely challenged.
To be effective, a twenty-first-century public health infrastructure can no longer be confined to New York City, or Los Angeles, or the United States of America: it has to be global in scale. The measures that ensured longer lives for New Yorkers at the dawn of the twentieth century must be implemented planetwide a century later if disease in one earthly ecosphere can be held at bay. Such a global public health infrastructure must embrace not just the essential elements of disease prevention and surveillance that were present in wealthy pockets of the planet during the twentieth century, but also new strategies and tactics capable of adjusting to global changes. We --- the world citizenry --- are counting on you and your peers to discover those innovative strategies, tactics and technologies.
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And please remember this: Public health is not an ideology, religion, or political perspective. History demonstrates that whenever such forces interfere with or influence public health activities a general worsening of the populace’s well being usually follow. As envisioned by its American pioneers public health is a practical system, or infrastructure, rooted in two fundamental scientific tenets: the germ theory of disease and the understanding that preventing disease in the weakest elements of society ensured protection for the strongest (and richest) in the larger community. I believe that public health is a bond --- a trust --- between a government and its people. Citizens entrust government to oversee and protect the collective good health. Individuals agree to cooperate by providing tax monies, accepting vaccinations and abiding by rules and guidelines set by government public health leaders. If either side betrays that trust, the system collapses like a house of cards. Go forward now, graduates of the University of California School of Public Health, and rebuild that precious trust. Thank you.