The magazine of the UW School of Public Health

Viewpoint: A Global Perspective

Our Place in the World, by William Foege

In 1950, the United States developed a surveillance program for malaria, its first national surveillance program for any disease. The program revealed that malaria had quietly disappeared in this country in the 1940s but no one knew it. People had continued to get fevers, and they recovered after malaria treatment, as most people do even in the absence of malaria. This reinforced the idea that the disease was still around. Not until each case was investigated, bloods were drawn to determine the type of malaria, and a series of negative lab tests resulted, did the reality become obvious. Malaria was gone. It was the accumulation of local reports that permitted a national picture. And that is the lesson. No national or global interpretation is possible, separate from many local images.

But the opposite is also true. Local interpretations require national or global information. In the spring of 2002, a Lutheran bishop attended a meeting in West Africa. He returned to the United States, was seen for fever in Chicago, and died of malaria. The local response was adequate for most local problems, but not for the actual problem, because it drew diagnostic conclusions without a global view.

The detection, analysis, and response to disease problems require balancing local and global information. The bumper sticker "Think Globally, Act Locally" is catchy but inadequate, because every place is simultaneously local and global, depending only on perspective. The phrase should be, "Think and Act, Globally and Locally." It is akin to the question of whether one should strive to be a generalist or a specialist. The answer is that we must strive to be both simultaneously, to understand as much as we can about the world in order to know where our special skills, knowledge, and experience fit in.

The world improvement in health depends on the highest quality response in every locality and often becomes victim to the weakest links. In 1975, health workers were ready to celebrate the demise of smallpox as the last outbreaks in the world were being contained in Ethiopia. But somehow, in what should have been the final week of global smallpox, the virus escaped to Somalia. It required an additional two years to finally interrupt transmission. Global containment was held hostage to local containment.

The Yale theologian, Jaroslav Pelikan, has said that although good scholarship is often traced to the place of training and the mentors a person has had, great scholarship is often traced to how much a person knows beyond his or her field of study. Great local public health is often traced to how much is known beyond the geographic locality and how much is known beyond health.

The Pacific Northwest has rapidly gained a deserved reputation for contributions to the health of the world. These contributions include research aimed at the disease problems of poor people in other countries, people involved in programs of global scope, nongovernmental agencies directing operations in every country of the world, foundations supporting programs for all people now and in the future, and a corporate community actively working to make responsible contributions to a rational global future.

At the same time, we are also blessed with unsurpassed clinical facilities and competent state and local health departments staffed by people who are working on approaches to quickly detect and diagnose unusual episodes, share information with national and global authorities, and respond to contain infectious agents. It is a great public health example of thinking and acting both locally and globally.

William Foege, MD, MPH, has been the director of CDC and the Carter Center and is currently a fellow at the Bill and Melinda Gates Foundation.