Thinking Globally - 'Do No Harm': Time to Turn a Phrase on Its Head

January-February 2009


Dr. Schaeffer is editor, Health Progress, Catholic Health Association, St. Louis.

Take three words well known to anyone immersed in the world of medicine: "Do no harm." Revisit those words, and from them, craft a vision.

Form coalitions. Focus on the end point, not on present realities. Take persistent, measured steps toward the goal.

And the result?

Eventually, maybe 200 years from now, or 300, we could have not only global health but also world peace.

Vision, and where it can take an individual and a society, is something Dr. William H. Foege, epidemiologist and global health leader, talks about a lot — as recently as mid-November, in Scottsdale, Ariz., where he addressed participants in the annual conference of the American Academy of Nursing.

But those familiar with Foege know that vision isn't just a word in his lecture notes. It's a theme that runs through his life. It has shaped his thoughts and acts for decades.

As a young man, inspired by Albert Schweitzer and educated at the University of Washington and at Harvard, Foege was working in the 1960s as a medical missionary in Africa — the fulfillment of a childhood dream — and was sent to eastern Nigeria to check out reports of smallpox. When he and his colleagues arrived, the disease was rampant, far exceeding their supply of vaccine. So Foege, working with others in the region, developed a bold but risky plan: scout out the hot spots and immunize just those living within them.

It turned out well. With a limited amount of vaccine, the outbreak was stemmed — and a global health leader was born.

Foege was named head of a smallpox eradication program at the U.S. Centers for Disease Control and Prevention, and in 1973, was sent to India, where again, seemingly against all odds, his targeted vaccination approach ended a raging smallpox epidemic. Just six years later, thanks to Foege's work, the World Health Organization declared a major milestone: a world free of smallpox and the first such success for a global health initiative.

For Foege, titles followed: director of the Centers for Disease Control and executive director of the Carter Center among others, including the two titles he holds now — distinguished professor of international health at Emory University, and senior fellow in global health at the Bill and Melinda Gates Foundation. (See biographical information.)

Titles don't impress him, though, as having much to do with the future of global health or what he believes could be its handmaiden, world peace. Leadership in global health will be based not in titles, but in committed individuals who think big (that vision thing) and, who working through coalitions, take persistent steps toward the goal.

The most important starting point, he believes, is to get the vision right.

He likes to talk about individuals who did that (other than himself, that is). In his talk to the nursing academy, he cited William Wilberforce, the British politician who, through vision and persistence over decades, brought slavery in most of the British Empire to an end. He cited Molly Melching, founder of Tostan, who has empowered women in Africa to unite against female genital mutilation, ending the practice in thousands of villages. He cited Sheila Dinotshe Tlou, professor, activist and former minister of health in Botswana, and her work in Africa — in concert with Merck & Co. and the Gates Foundation — to reduce the incidence of children born HIV-positive to an "unbelievable" 3.5 percent — down from nearly one-third of all births in 2001. (Tlou was also a speaker at the conference.)

Foege thinks Americans, as they look back to forebears in quest of a more perfect union, are in a good spot to understand the significance of vision and the steps it takes to achieve it.

The Founding Fathers had a vision of a society based on equality. When they wrote the Constitution, the document they hoped would make it real, they created structures not only for the moment, but also for the future, and they refused to be limited by present ironies, Foege said. It took another 89 years to get rid of slavery, 134 years for women to get the right to vote — and well over two centuries for the nation to elect its first black president, an event the Founding Fathers certainly could not foresee.

In terms of realizing a vision for global health, and even world peace, the starting point would be first to change the way we measure the success our civilization, Foege said. A successful civilization, he believes, should be measured not by wealth or wisdom, not by happiness or control of the environment (the Nazis were masters at that, he noted), but "by the way people treat one another."

This, he said, is what we as a society should be willing to be judged on — not just on how we treat people today, but how we secure their welfare into the future.

The determined steps toward that vision would require eliminating poverty and constructing a society — and a world — in which the physical, psychological and spiritual well-being of everyone is assured. Poverty, he noted, is the biggest obstacle to global health.

For health professionals, "poverty should be as untenable in this world as slavery," Foege said, because "every reduction of income in a society leads to a reduced level of health for individuals and for a society as a whole."

"What are the real cases of early death in the world? Lack of resources, lack of education, social discrimination, lack of empowerment." Changing that means "putting our influence and prestige behind global health programs."

And how does all of this relate to "do no harm"?

Health professionals have learned to think of "do no harm" in a negative sense — in terms of sins of commission, things to avoid, Foege said. And he thinks it's time to turn that on its head.

"Far more people are brought to harm by our errors of omission — by the things we don't do rather than by the things we do: by the vaccines not given, the science not shared."

If we want to do no harm in terms of global health, we have to focus not only on our errors of commission "but also look at inequalities that highlight our errors of omission," he said.

The right vision, the right coalitions, persistence and a commitment to measuring success by the way we treat one another … "if we put it all together, what would it mean for world peace?"

By reaching higher, for a more perfect world we can't yet see, by working together to assure the well-being of all people, "it is possible to plan a future where world peace becomes the norm."   

Dr. William H. Foege, Epidemiologist and Global Health Expert

Dr. William H. Foege was born in Decorah, Iowa, in 1936. His father was a Lutheran pastor; his uncle a missionary to New Guinea. He graduated from Pacific Lutheran University and earned his medical degree at the University of Washington School of Medicine in 1961. After serving an internship at the U.S. Public Health Service Hospital, Staten Island, N.Y., he earned a master's degree in public health at Harvard University in 1965. He helped eradicate smallpox in Nigeria and directed the smallpox eradication program at the U.S. Centers for Disease Control and Prevention. He was appointed director of that agency in 1977 and expanded its mission beyond infectious diseases to include injury, violence and chronic disease.

Dr. Foege helped found the Task Force for Child Survival and Development, under the auspices of the World Health Organization, UNICEF and others, and served as its director for 16 years. He was named executive director, Fellow for Health Policy, of the Carter Center in 1986; was appointed Presidential Distinguished Professor of International Health at Emory University in 1997; and joined the Bill & Melinda Gates Foundation in 1999, where he remains as Senior Fellow in the Global Health Program.

Dr. Foege has been instrumental for decades in developing vaccine and prevention programs worldwide, targeting numerous virulent diseases, including HIV/AIDS. His awards include the Mary Woodard Lasker Public Service Award, the World Health Organization's Health for All Medal, and Columbia University's Calderone Prize. He was elected to the Institute of Medicine in 1979 and named a fellow of the London School of Tropical Medicine and Hygiene in 1997. He received the Public Welfare Medal from the National Academy of Sciences in 2005. His alma mater, the University of Washington, named a building after him in 2006.


Copyright © 2009 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Thinking Globally - Do No Harm-Time to Turn a Phrase on Its Head

Copyright © 2009 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.