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Ralph H. Henderson*
Good Morning! We can look forward to an exciting week and, more importantly, through our deliberations and debates, to making contributions to public policy and political action which will improve the effectiveness of public health programmes. That is obviously a tall order, but certainly not out of proportion to the stature of this audience. The World Health Organization and the Pan American Health Organization are pleased to be sponsors of this conference and are glad to join with the many other sponsors who are such distinguished actors in the arena of public health.
I will not try to keep you in suspense about whether or not I think disease elimination and eradication are potentially effective public health strategies, in case any of you were wondering. I think they certainly can be effective. And while I think they have a number of especially attractive attributes as strategies, I see them as part of a continuum of strategies bounded on one side by global disease eradication -- that is, zero cases and zero risk of cases, and on the other by disease control -- that is, a reduction in cases by some defined amount. Intermediary strategies would include disease elimination (zero cases but with continuing risk) and our famous WHO term, elimination of the disease as a public health problem (reduction of cases below what is considered to be a public health risk).
So, given my general support, I would like to direct my remarks to some aspects of these strategies which can be summarized by three quotations:
For the first quote, I am indebted to Bill Foege, who called my attention to Certain Trumpets: the nature of leadership, a book by Gary Wills (New York, Simon & Schuster, 1994). Because leaders do not act in isolation, the book is also one about management, typically the management of attaining, or trying to attain, some great cause. And disease elimination and eradication are certainly great causes. Few would argue that we can achieve disease elimination or eradication with an "uncertain" trumpet. We need a clear call, and constituencies willing and able to heed it.
It was from Professor David Bradley of the London School of Tropical Medicine and Hygiene that I first heard the quote from William Blake that "He who would do good must do it in minute particulars . . .". And I find myself using it frequently, often in debates relating to such broad aspirations as the elimination of poverty, the prevention of violence, and even the attainment of "health for all". For, to be achieved, these aspirations must be dissected until one identifies specifically what can and must be done, the "minute particular" forming the building block of the larger cause. As a former colleague and friend used to say: "If you are going to eat a buffalo, do it one bite at a time."
Yet the act of blowing a "certain trumpet" for a "minute particular" sometimes leads some people, if not always the multitudes, to believe that the trumpet blower (like the hedgehog) only knows one thing, and does not (like the fox) know the many things that put each action into an appropriate overall context. That quote comes from the Greek poet Archilocus. A more modern quote comes from Lotfi Zadeh, the father of "fuzzy logic", who said "When the only tool you know is a hammer, everything begins to look like a nail."
This leads me to one aspect of our week's deliberations. When we choose a particular elimination or eradication goal, do we do so with the narrow understanding of the hedgehog or with the broader vision of the fox? Do we judiciously choose elimination or eradication because it is the best strategy or only because it is, like the hammer, the only tool we know? Even with a broad vision and judicious choice, however, circumstances inevitably arise in which one is unable to achieve an essential elimination or eradication objective without compromising a broader health services development goal. So part of our discussions will need to address what may or may not be appropriate trade-offs between the two, including the possible negative consequences of failure of a specific elimination or eradication initiative.
In his book, Gary Wills argues that, important as good leadership is, the goal selected and the followers are also essential for success and that the initiative in question must be right for the historical moment. Without quarrelling about these elements, I would like to argue that our "historical moment" is favouring a different kind of leadership than the examples described by Wills. What is that historical moment? I see it being characterized as a series of "-izations". They are, among others, globalization, decentralization, democratization and privatization. One result of these is a world in which there are more and more people and organizations involved in more and more aspects of life in all countries of the world.
In the "for-profit" sector, a result of these "-izations", or at least a desired result, is more competition. While this is generally regarded as a positive benefit for society as a whole by encouraging the more efficient use of resources, there is concern that such efficiency is eroding equity and widening the gaps in incomes and health between the rich and the poor and that it is leading to the increased promotion of unhealthy products, a notable example being tobacco in developing countries. In the public sector, however, it seems to me that these "-izations" emphasize the need for cooperation rather than competition. The cooperation of the increasing number of "stake-holders" involved in sectors such as health or education cannot be commanded or forced through economic pressures; it must be solicited. And more and more of these stake-holders are leaders in their own right. They have their own powerful trumpets.
So the public sector leader of today has the primary task of harmonizing many trumpets. The more resources that are required, the more the various trumpet players need to be empowered as partners in the endeavour. And the more the focus of all partners needs to be on outcomes rather than inputs. They must be able to rejoice in the results and be able to forego personal or organizational recognition for their efforts, if this is what is required for success. The best leadership then becomes that which is self-effacing and which ensures that the other partners get the credit they require to keep them and their various constituencies committed. This is the kind of leadership which was described some 200 years before Christ in the Tao Te Ching:
"A leader is best
The choice of highly specific goals is essential for success in such a "multi-leader" or "multi-partner" context. They must have two special features. First, they must be easily measurable in easily understood terms. This permits all partners to obtain clear feedback on progress and on their own participation in the effort. The broader the partnership, the more important that measurability and feedback become. Second, these goals must be narrow; they must be "minute particulars". This facilitates the measurement and feedback problem, but it is also important in achieving the type of consensus needed to make broad partnerships work. I suppose this is a paradox, as it would seem more logical that broad goals, e.g. the eradication of poverty, would be the most effective in achieving broad partnerships. But I think such partnerships have a high risk of being illusions.
A broad goal often simply permits the so-called partners to continue "business as usual", claiming they are an essential part of the overall effort whether or not they really are. A narrow goal may attract fewer partners, but those partners who are attracted are forced to confront the specifics of what they are being asked to do, and can be held accountable for their commitments. When the specific input needs are clearly defined, "turf" battles are minimized, as most partners easily see in what way they can best contribute -- where their particular comparative advantages shine. I champion the narrow goal as a more effective means of forging real consensus and collaboration than the broad goal. These characteristics of goals are, of course, generic to good management in any field, but are especially important in managing enterprises that rely on "multi-leader" coalitions. I cannot think of any goals that fit these characteristics better than disease elimination or eradication goals. This gives them a special utility in serving as rallying-points for coalitions of interested partners. This, in turn, helps to ensure that these goals can receive the support required to attain them.
There is another feature of disease elimination or eradication goals which makes them especially attractive: they bring direct and immediate benefits to those at risk of the diseases in question. By and large, those most at risk are those most socially and economically vulnerable. So the immediate benefits often go, not simply to the poor, but to the poorest of the poor. And they extend to all future generations as well, poor and rich.
In resource mobilization, of course, we do argue for support based on the benefits returned to the contributors. We will hear more in this meeting about the benefits to broader health systems which disease elimination and eradication initiatives can bring, and more about how sustained health benefits provide a powerful stimulus to broader social and economic development. Yet I have to confess that I think there is another major motivation for many partners engaged in disease elimination or eradication. It is simply the opportunity to achieve any concrete benefit whatsoever in the short-term! This is quite a rare event in international development.
Most of you are well aware of what a good example of multi-partner leadership is being provided by the eradication of poliomyelitis. Rotary International is one of the primary partners. Rotary's vision and goal have now become institutionalized and are being passionately supported by thousands of Rotary Clubs and by tens of thousands, if not hundreds of thousands, of individual Rotarians. Many seem only marginally aware that there are other major partners involved and have taken upon themselves the challenge of ensuring success! And the leadership they are exerting, from community to national to global level, is proving absolutely critical to that success.
Rotary is certainly not the only "polio partner", as most of you know well. Leadership is also coming from a broad array of others: from nongovernmental organizations, from national governments, from national institutions such as CDC and NIH, from international development agencies such as USAID, from the World Bank, the Inter-American Development Bank and the other Regional Banks, from other members of the United Nations family, including WHO and UNICEF, and from the private sector. This multiple-leadership pattern is also typical of our other initiatives, including guinea-worm disease eradication and the elimination of leprosy, onchocerciasis and lymphatic filariasis.
Yet, if poliomyelitis and several other diseases, which we will be considering, do provide us with attractive models of disease elimination and eradication which can be used as effective public health strategies, I think the Conference organizers may also be asking a further question. I interpret this as being whether disease elimination or eradication goals are so potentially powerful as rallying points for social action that one should intentionally search out candidate-diseases as an explicit mobilization strategy. In other words, might one intentionally single out a disease for elimination or eradication primarily because of its social-mobilization and more general development benefits rather than because of its more narrowly defined disease-reduction benefits? A related question, posed by one of our colleagues at this meeting, is whether an elimination/eradication orientation might not also imply giving priority to developing the tools required for elimination or eradication over tools that might be adequate for simple control.
While I think some caution in embracing a pervasive elimination/eradication orientation is warranted, I see the example of Jim Grant of UNICEF and his success in promoting narrow goals as an explicit strategy for social mobilization and broad development aims as a powerful argument for pursuing broad goals through narrow actions. He insisted that the key to mobilizing political leaders is to give them "do-able", if ambitious, packages to implement. Of course, Jim did not, in fact, primarily promote disease elimination or eradication, although he was certainly a member of the club with his support for the elimination of micronutrient deficiencies and for the eradication of poliomyelitis. His main focus, however, was on other areas where it seemed that rapid progress should be possible, such as growth monitoring, oral rehydration, breast-feeding and immunization. So, although disease elimination and eradication do provide quite special opportunities, they are certainly not the only "minute particulars" which can be elements of effective public health strategies.
I would like to conclude by summarizing my arguments. Leaders and "certain trumpets" are needed for success. Our "historical moment", however, is one in which many command certain, and often very loud, trumpets. The successful leader, and especially the successful public sector leader, is one who can persuade these various trumpet players to join in harmony to support a worthy goal. This requires that the players be empowered and be given credit for their contributions. This requires, in turn, that the leader or leaders involved be more orchestra leaders, intent on the results, than themselves trumpet-blowers. Such leadership is facilitated when the goal to be attained is easily understood, when progress is easily measurable, and when the goal itself is narrow -- a "minute particular". Disease elimination and eradication goals are especially effective in providing rallying points for coalitions of interested parties, although they are by no means the only rallying points. Finally, for maximum development benefits, support for "do-able", narrow goals must be obtained with the wisdom of the fox, as Jim Grant did, and not the narrow vision of the hedgehog.
Eleanor Roosevelt said: "The future belongs to those who believe in the beauty of their dreams." I am sure that if she were here with us today, she would agree that those who dream of disease elimination or eradication have a special claim on that future.
* Assistant Director-General, World Health Organization, 1211 Geneva 27, Switzerland.
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