 We come now to the highlight moment of the conference, which is the awarding of the McLean Center Prize. The McLean Center Prize will be awarded by Kenneth Polanski, the Dean of University of Chicago Medicine, dear old friend. He and I go back to the 70s. Our offices were across the hall from one another for two years. It's been a wonderful opportunity to know Ken. But Ken will introduce Dr. William Fagy. Well, thank you, Mark. It's always a great pleasure to come to these conferences and hear the really interesting and challenging discussions and robust discussions and see how many of the former trainees from the McLean Center are doing such extraordinary work across the country and making so many important contributions. So I'm delighted to be here today for the 30th annual Dorothy J. McLean Fellows Conference on Clinical Medical Ethics. And I think you know that Mrs. McLean was the matriarch of the McLean family and was a great supporter of educational programs both at the university and across the United States. Now, I'm particularly pleased to present the 2018 McLean Center Prize, which is a $50,000 award, and it is one of the largest bioethics prizes in the United States. It was established in 2010 by the McLean family to recognize physician scholars who have made transformative contributions to clinical ethics and healthcare. Previous winners of the prize are an elite group of scholars representing the best in medical ethics and include Dr. Paul Farmer, John Wenberg, Peter Singer, who is now the special advisor to the director of the World Health Organization, Dr. Susan Toll, the developer of the PULST model for the end of life care, Dr. Laura Roberts, chair of the Department of Psychiatry at Stanford and one of the world's leading psychiatric ethicists. The recipient of the 2018 McLean Center Prize in clinical ethics is Dr. William Fagy, an epidemiologist and infectious disease physician. Dr. Fagy is best known for his work to eradicate smallpox in the 1960s and 1970s when he served as an epidemiologist for the CDC and later as the chief of the CDC's smallpox eradication program. Dr. Fagy developed and applied a new strategy for delivering smallpox vaccination, the strategy that would eventually rid the world of this dreaded disease. Because of limited time and supplies during a smallpox outbreak in rural Nigeria, Dr. Fagy and his colleagues created the surveillance containment strategy of vaccination, an alternative to the then prevailing strategy of mass vaccination. The containment strategy enabled health workers to vaccinate a much more limited population than did the mass immunization programs. The smallpox vaccine was given only to those who were in the radius of the outbreak or at its periphery. At the time, the population of eastern Nigeria was 12 million, but Dr. Fagy and his colleagues stopped an outbreak in the region by vaccinating only 750,000 people. It was a remarkable achievement. Before it was eradicated, it is estimated that 300 million people died of smallpox in the 20th century alone. Since 1980, there have been zero deaths from this terrible disease, and it has begun to fade into history. The eradication of smallpox from the entire world is surely one of the most stunning achievements in the history of modern medicine and public health. After the successful eradication of smallpox, Dr. Fagy went on to serve as the director of the CDC in Atlanta from 1977 to 1983. There he oversaw the response to major health problems in the U.S. and abroad, including the beginning of the HIV AIDS crisis. In 1984, Dr. Fagy became the head of the Task Force for Child Survival, formed by the Rockefeller Foundation, UNICEF, the World Health Organization and the World Bank. There he helped raise the global immunization levels from approximately 20 percent in 1984 to 80 percent by 1991. Today the Task Force reaches populations in 157 countries. Jim Grant, the head of UNICEF, called the vaccination program success the greatest peace time achievement in history. From 1999 to 2011, Dr. Fagy worked as an advisor to the Bill and Melinda Gates Foundation, helping develop its childhood immunizations as part of its larger global health program. To learn more about the complex public health campaign to eradicate smallpox, I highly recommend Dr. Fagy's 2011 book, House on Fire, The Fight to Eradicate Smallpox. His most recent book published this year is Fears of the Rich, The Needs of the Poor, My Years at CDC. He was honored in 2001 with the Mary Laska Award for Public Service, in 2007 with the Jimmy and Roslyn Carter Award for Humanitarian Contributions to the Health of Humankind, and also received the Presidential Medal of Freedom from President Obama in 2012. Dr. Fagy's contributions to clinical medical ethics are extraordinary. He applied ethical standards to save lives, to eliminate health disparities, to give protective immunizations to many of the world's children, and to promote global health equity. As Dr. Fagy notes, the smallpox eradication program shows that humanity does not have to live in a world of plagues, conflict, and uncontrolled health risks. The coordinated action of a group of dedicated people can plan and bring about a better future. The fact of smallpox eradication remains a constant reminder that we should settle for nothing less. Today, Dr. Fagy will present his keynote lecture entitled Global Health Ethical Challenges. Please join me in congratulating Dr. William Fagy on this extraordinary career and in welcome him and his family to the University of Chicago. Dr. Fagy. First, let me thank the dean for that nice introduction, and second, let me apologize to the audience, because it's all downhill from here on. What a golden standard program you have here. I was wondering yesterday and today what would happen to American medicine if we had a McLean Center in every medical center, and what would happen if Mark was asked to train all of those directors of those programs? It's really very, very overwhelming. I'm impressed with so many of the things that I've heard over the last day and a half, stimulating things. Creativity, we know from the studies that creativity usually involves two different fields of knowledge coming together that were not put together before. And I kept thinking of that as I heard about surgery and prevention. Those two words are not heard very often, they were heard yesterday. I thought about that with clinical medicine and philosophy. I thought about that with every discipline plus ethics, and when I heard they talk on violence this morning, I realized how violence is one of the things that over the centuries has detracted from happiness. Violence combined with depression, addiction, fatalism, poverty have been problems forever. So many good points when Valerie talked about the informed consent yesterday, and the fact that we have to think about how do we protect patients as well as physicians. In the area of immunization, we spent so much time on informed consent, but it eventually led to a program with a surge charge on vaccines put into a program run by the government so that people who have adverse reactions from immunizations now have recourse to be able to get compensation. When I heard the malaria program, I was reminded of the fact that malaria is the first disease that we've ever had a national surveillance program for in this country, 1950 and 1951. The second one happened to be in 1955 because of the cutter incident with polio vaccine. The third in 1957 with influenza, and now we have dozens and dozens of national surveillance programs. Yesterday when I heard the question of why do we underfund WHO and then expect them to do more, I thought back to when WHO was formed about 70 years ago and the role of the United States and other countries in making that organization such a difficult organization to run. We insisted on strong regional offices because we were trying to protect the Pan American Health Organization. We made them so strong that regional directors could always undermine the director in Geneva and that continues to happen. So it makes it very difficult to have a global program. Second we insisted on having a board of governors, all the ministers of health in the world. 195 ministers of health on the board, many of them in place for only two or three years at a time. They're not really invested in WHO, but they love going to Geneva every May for the World Health Assembly. And then third, every year we ask them to reduce their budget. There were some years ago when the US was not providing its fair share, its dues. And I should tell you that we save more money each year in this country because of smallpox eradication than our dues to WHO and still we were not paying our dues. I wrote an editorial for the American Public Health Association and I quoted Dolly Parton. She once said you'd be surprised how much it cost to look this cheap. And 2014 Ebola in West Africa showed us how much it cost to look that cheap. Yesterday I heard the term optimistic bias and I love that term because there was a political scientist by the name of Harlan Cleveland who late in life became interested in global health and he said the fuel for global health turns out to be unwarranted optimism. I love that phrase unwarranted optimism. And let me one last item, an ethical item that I've tried to promote unsuccessfully but you might be able to, which is when medical students do those elaborate write-ups of the patients that they see in the hospital, why not have the last question be, how could this hospitalization have been avoided? That will get them immediately into prevention. When I heard Alex talk about transparency in the operating room, it brought me back immediately to what a change over a short period of time. As the book on Halstead, the surgeon who started the surgery program at Johns Hopkins, a book called Genius on the Edge tells about when he was a young surgeon in New York and he received a request to go to upstate New York for someone in trouble. He packed his bag, he got on the train, he got there I think like seven or so in the evening and he examined the woman, an older woman and he diagnosed gallstones. No surgeon had ever taken out gallstones up till that time. He put her on the kitchen table and gave her ether, removed the gallstones she recovered. And so as the book says, he not only did the first gallstone operation in the world, he also saved his mother's life. Think how things have changed. Twenty-four years ago I was having a hip replacement and my training was 60 years ago. Sixty years ago, general anesthesia was still a pretty big risk factor and I had trouble in my psyche accepting how fast the improvements had come. So I told the surgeon I would like to have a spinal instead of general anesthesia. That's what I got. He kept going back and forth looking at the x-ray and coming to me and then finally he said it's decision time. He said your good side is totally numb and we could replace your good hip but if you want me to replace your bad hip I have to give you general anesthesia. One of the stories I've liked over the years was about James Thurber, the humorist when I was young who would have both cartoons and articles in the New Yorker. And an American woman confronted him at a reception and she said she was now living in Paris and she said you know they do your articles now in French. And she said I think they're funnier in French. Thurber said Riley they do lose something in the original. Ethics loses something in the original as a body of knowledge. It has to be practiced. It's like science in general. It's very interesting but in order to have power it has to be applied. So my plan is just to express several thoughts on ethics. Some experiences that I've had and some challenges that I see. Some thoughts. First of all I found ethics to be a quandary, a mystery when I was young. I kept hearing the phrase when in doubt do the right thing. And I kept pondering in that and I thought doing the right thing would be easy and would be obvious. And then I found out that I was very wrong. I kept breaking my own resolutions. 1965, 53 years ago we went to Nigeria and I told myself I would never pay a bribe or a dash to have something done. Within two weeks, within two weeks we were in line to get on a ferry to cross the Niger River and it was a very hot day. We had our three-year-old son in the car. And I noticed that cars were going around us. And I tried to figure out what was happening and I went to talk to someone and he said oh yes they're paying a tensioning surcharge. And I asked how long we'll be in this line if we do not pay a surcharge and he said probably a day or a day and a half. Now I justified very quickly paying that surcharge because of my wife and child. But you know if I had been alone I would have done the same thing. And so ethics is difficult. Some work experiences. You've heard about Eastern Nigeria and smallpox. So here we were one month before the program was to start. We were working in a medical center in West Africa and CDC contacted me because I'd worked for them previously and asked if I would be a consultant starting in January of 1967. One month earlier, December 4th, 1966, a missionary sent me a radio message that he thought he had a case of smallpox. It took me almost all day to get to the remote village and sure enough it was smallpox. But our supplies did not arrive. We did not have enough vaccine. So it wasn't that we were so smart. We were desperate. And we got on to the radio system with the missionaries that night. They did that every night at 7 o'clock to make sure no one had an emergency. And we divided up the country so that they would send runners the next day to see in each village whether they had smallpox. 24 hours later we knew exactly where the smallpox was. I don't think we could have replicated this in the United States. And here we were in a remote part of Nigeria and we knew where the smallpox was. So we used our small amounts of vaccine on those villages. And the remainder of the vaccine we used to go to three places where we thought it might spread. We were right. It was already incubating in those places but by the time the cases appeared everyone around the cases had been vaccinated. And that outbreak stopped so fast that we began wondering what could we do this on a larger basis. And we did. The Eastern Nigerian Ministry of Health allowed us to change our strategy. We thought everyone would be so happy with the fact that we could now reduce what was going to be a five-year program to an estimated six months in Eastern Nigeria. We were so wrong. The federal government immediately felt threatened because they had issues with the east that would lead to civil war within months and they stopped the flow of vaccine to Eastern Nigeria. They said this is a national program and until the rest of Nigeria catches up with you you can have no more vaccine. So they were saying it was more important for people to have smallpox in Eastern Nigeria than for them to lose face. Two of us drove to Lagos an all-day trip in those days and we had a plan. I had in my mind decided that that vaccine belonged to the Nigerian people and not the Nigerian government. And so we went to the warehouse and one of us kept the person involved in trying to find small parts for jet injectors. While the other person stole all the vaccine where we were going to need, all the dilliant, the syringes, put them out into the pickup and we started driving back all the time looking in our rearview mirror thinking we were going to get caught. We made it back and six months after we started that program the civil war broke out and we were working on the last outbreak. And so I sometimes think back to from December 4th the first case that I saw to the time when the last case was reported. It had to be demonstrated someplace that this new strategy worked or you couldn't sell it. So Eastern Nigeria became so crucial and it came to me that stealing that vaccine may have been the single most important one in that entire smallpox eradication scheme and think of the ethical dilemma. Then we went to India where the problem was even worse. It was almost overwhelming. We did our first search, our first surveillance in October of 1973. And I think of how naive I was. I wrote out the instructions for the searchers and I said we will not find much smallpox because it's the low season of transmission but we're going to learn how to do this. To our surprise six days later in only two states they had found 10,000 new cases of smallpox that no one knew existed. We were overwhelmed. Our surveillance system kept getting better and better and so it appeared that the cases of smallpox were increasing and again if we thought people were going to be happy we were wrong. The Indian government felt embarrassed that it appeared that smallpox was out of control. And so the minister of health of the state of Bihar called me in and he said we are going to stop surveillance containment and go back to mass vaccination. I talked to him for three days in a row, Friday, Saturday, Sunday and pointed out for 175 years this had not worked and why would he think it would work now? He said it was political that he was being embarrassed by other parts of India and so on Monday he said when you have your supervisors come in from the field I'm going to meet with them and tell them that surveillance containment will stop and mass vaccination will be renewed. So that morning as people gathered I told them the news the minister is going to come and change our strategy. Then the minister came and went in front of everybody. He was so complimentary in all the work they had done but he said the facts are we have 31 districts in Bihar, every one of them is showing an increase in smallpox. We knew of course that the increase in smallpox was because we now knew how to find it. But he said at the end of this meeting we will stop surveillance containment and we will go back to mass vaccination. And once again an ethical person, a young person who risked his reputation, a young Indian physician so then and so vulnerable that the silence in the room was broken when he stood up and shaking he said to the minister I don't know much. I'm just a village man but I do know when I grew up in the village if someone's house caught on fire we poured water on their house that's surveillance containment. We didn't pour water all over the village that's mass vaccination. The minister appeared to have been slapped across the face he sat there and he stared out for the longest time and then he said I'll give you one more month. A month later we were able to show the first reductions in smallpox in three of the 31 districts and he gave us one more month and then the question never came up again. At that time we were discovering 1500 new cases of smallpox a day in Bihar alone and we went from that level of smallpox to zero in all of India in 12 months. It's one of the most exciting 12 month periods I think in global health. When I wrote about this you may think I have a lot of problems with the cane and so forth. Fact is I can't see much and so when I wrote the book because I've typed for all of my life I'm able to type fine but I have trouble reading and so I would type a chapter. I would email it to my wife. She would sit across the room, read it back to me making suggestions and I would then retype on my computer. Frequently she would say this is really really boring and she said you shouldn't have a book of statistics include the stories which I did and then halfway through the book when we came to this point of that young Indian physician standing up to the Minister of Health of Bihar she said you ought to call this book House on Fire which I did. So this is my way of thanking you Paul. In medical school we heard repeatedly do no harm and all of you have heard that but it came to me finally it always referred to errors of commission. As we left for Africa in 1965 my supervisor a surgeon his last words to me were oh by the way you'll never forget the people you kill. Think of going off with those words in your mind. It took me some time to realize of course I forget the people I kill because the errors of omission kill far more people than the errors of commission. The vaccines not used the science not shared the science not used this. These are errors of omission hidden errors of omission as we heard this morning. Yet we pretend we don't see them. Margaret Halsey has written the stress laid on upward social mobility in the United States has tended to obscure the fact that there can be more than one kind of mobility and more than one direction in which it can go. There can be ethical mobility as well as financial and it can go down as well as up. And so in medicine prevention has not been valued and it's oftentimes not compensated and therefore it's so easy for us to short change smoke enders and diet programs and exercise programs because doctors don't have the time to practice prevention if they're not being reimbursed. And I think if this is not an ethical problem think of the fact that what we were really being told in medical school was do no harm unless money is involved. Another problem that prevention has that Robert Wood Johnson pointed out is when the Congressional Budget Office is asked to do a cost-benefit evaluation of some procedure they are by law limited to looking at benefits over the next 10 years. In much of what we do in immunization and so forth and pediatricians know this the benefits gone for an entire lifetime but they can't count beyond 10 years. And they do this because of discounting of money in the future. So what have they done instead? They discounted people in the future. Some of the public health ethical problems that I've been involved in soon after becoming director of CDC several dozen women died who were taking liquid protein diet. We investigated and we found there was a cardiac abnormality associated with this diet and the diet was taken off the market. But then Senator Percy's office asked me for the names of the women who had died. They wanted to investigate themselves to be sure that this was true. My consideration was we're not going to do that but I said to them we'll give the names to another group such as NIH and let them do a separate study. Senator Percy's office said no we want the names and I said I'm not going to share them. Then our CDC lawyers told me you will lose. People lose their privacy when they die and Congress has exempted itself from the privacy rules. So they said I had no leg to stand on. So I called the Percy's office and I asked would they be willing to issue a subpoena for the names and they said of course. But then they added and then you'll give us the names and I said no. I said we'll go to court I'll lose. The court will tell me I have to give you the names. They said why would you do that if you know you're going to lose in advance and I said I want the whole world to know I did everything I could to protect their privacy. And with that Senator Percy's office decided they did not want the bad publicity and so they withdrew their request. One hospital reported an infection in a person who got a new heart valve. We investigated this and found it was not a hospital infection. It was an inherent infection that came from the manufacturers of that heart valve. And we said other places need to know this. And so we put the story into the morbidity mortality weekly report and we identified the hospital as hospital A. Under freedom of information a lawyer got the name of the hospital took a $1 million lawsuit against them and they said to me we will never report to CDC again. This is an ethical problem. A last domestic one that I'll mention is Congressman Weiss from New York asked to see our records on HIV Aids and I told him that he was he could. But I said we have to redact the names of AIDS patients and he said no you don't understand I want the whole record and I said we will not give out the names of patients. He then had a press conference and said that we were refusing to cooperate with him and he knew we had something in our records on AIDS that we were not willing to tell the public. He sent a staffer down who repeated the request to see the records and again I said we'll do this but we have to take off the names the identifiers of people with AIDS. He had a second press conference and then he sent me a letter saying you don't seem to understand I want to see your records all of your records including the names of patients. And when I still did not allow this he then called a hearing. I did not tell my supervisors what I was going to do but at the hearing he started out by condemning the government health workers me in particular for not being transparent about what we had in our records and then when he was finally through castigating me he said you can give your opening statement. And I said with your permission Mr. Chairman I would like to introduce your letter of such and such a date asking me for the names of AIDS patients. This took him totally by surprise and now he has a committee around him. If he says no they already know there's such a letter and they'll ask for it and so he had to say yes but it changed the entire tenor. Ethical problems are difficult. Two final examples globally. I had a very fine scientist by the name of John Bennett working with the task force and he looked at the problem of neonatal tetanus in Pakistan and he discovered something that no one had reported before and that is that the use of ghee or clarified butter on the umbilical cord of a newborn baby led to an increased risk of tetanus. And it turns out later that we find that ghee is very similar to the medium used in the lab to grow tetanus and so you can see why it was a problem. He then went on to see if the same thing was happening in Bangladesh and in Bangladesh he was totally surprised to find children with neonatal tetanus where their mothers had actually received tetanus vaccine during pregnancy and we know that if mothers received tetanus vaccine the antibodies go across the placenta to the child and protect the child from neonatal tetanus. So he was mystified and he continued the investigation, found these mothers had no antibodies to tetanus then went back to the vaccine and found that it was totally inert. It was produced by the Bangladesh government and there was nothing in it. We said this is a public health emergency and our suggestion was that they take all of the tetanus vaccine and replace it with emergency supplies from WHO. Can you imagine what they did? They decided that that would hurt their reputation and instead they would continue to use this worthless vaccine until they ran out and then they would replace behind it with good vaccine. It's one of the most egregious ethical errors I've ever seen in global health and we were totally unable to stop it. The last one that I will mention is what happened with Ebola virus 2014 in West Africa. I mentioned that regional offices were so strong that they could undercut Geneva. The first battle in the Ebola outbreak was between WHO Geneva and WHO regional office in Africa. Who would be in control? The only thing they could agree on was they would not ask CDC for help because they knew they could control Ebola and they could get the credit. Well as you know it got out of control very fast because it was the first time Ebola virus had actually gone to an urban area and it became a much more difficult problem. And so they finally had to ask CDC to come in and the US government provided treatment facilities and so forth. But you see the problem with underfunding WHO and then we expect them to do things that they simply cannot do. Some challenges. We often when we're dealing with ethical problems look at beginning of life and end of life. I think one of the great battle grounds in ethics turns out to be resource allocation. Budget people do not regard themselves as ethicists and not enough ethicists are interested in budgets. But we should have an ethical review of federal, state, county, city budgets to see where we are letting people down. Second, our science is ahead of everything. It's ahead of our ethics and our sociology, our theology, our application, head of everything. And there are two ways that we could solve this gap. We could slow down science and that's never gonna happen. Or we can do what you're doing here is to get clinicians and medical people involved in the ethics of their profession. Roger Bacon 700 years ago was asked for a report on science by the Pope. And one of the three things he said was science has no moral compass. It still has no moral compass and that's why you need places like the McLean Center in order to provide that moral compass. Number three, keep focusing on application. The power of science, as I said, is in its application. Ernest Boyer was asked to do a paper on what the future university would look like. And he said it would involve tenure based on the development of new knowledge or research. It would also look at the scholarship of knowledge transmission, teaching, writing papers. But it would also third look at the problem of knowledge coming together with other knowledge in order to be integrated. And that's what you're doing here is integrating knowledge and fourth, it would give tenure on the basis of knowledge application. We've learned how to do that pretty much in medicine with university hospitals. We haven't learned how to do that in the rest of the university to make ethics a basis for what happens in application. We need to remind ourselves that information is not learning. It isn't common sense. It isn't kindness or trustworthiness or good judgment or imagination or courage. It doesn't tell us right from wrong. Knowledge and information are only tools, which if not used are wasted. Ethics is the glue and it's a complicated glue. Number four, another challenge is to focus ethics laser-like on poverty. Poverty we know is one of the big reasons for poor health. And it's been a problem for so long, but now it's the new slavery. It's the new slavery. Every one of us in this room gets our food and our clothes and our travel and other things subsidized by poor people. People who are in poverty producing things at a lower price in order to subsidize us. And I keep thinking we should feel ashamed of ourselves, but we don't because we benefit because every one of us has now become a plantation owner and we don't want to change this system, which is benefiting us. A final ethical challenge seems to be to involve us in ultimate questions. How do we get people and resources focused on these ultimate questions? And I'll give only one example. What could cause extinction of the human race? That is the ultimate challenge. There are at least four things now that Steve Luby from Stanford lists as very likely to cause extinction of the human race. And we should be asking how do we put more resources into those? Number one, of course, nuclear weapons. And some of us that are older were involved very much in the IPPNW, international physicians for the prevention of nuclear war. This has to be revived and strengthened because this is one of the things that could destroy us. The second thing he puts on his list is climate change and the difficulty in getting people to even look at the science. It's easier to get middle school students to understand climate change than it is politicians. And I don't understand why it should be that difficult, but it is. A third thing that he talks about is synthetic biology. We've heard about some of this yesterday. As you have the ability to move DNA fragments around, he said someday there's going to be a combination that's lethal. And we need to figure out in advance how to handle such a situation. And his last example is artificial intelligence because he shows in his graphs how long it took before computers could do as many computations per second as a rat. And then how long it took to be able to do as many computations as a human. And then how long it will take before it can do as many computations as all humans put together. And so he said we will get to a point where computers will program themselves. And they will develop robots to do all the work that they need to have done. And there will be no use for humans. And he suggests that they will keep a few of them in a zoo so people will know what it was like in the past, but that they won't be needed anymore. Ethics is not abstract. It should drive us to solutions, to benefit our ultimate bosses. Who are our ultimate bosses? Everyone who will be born in the future. Because they have given their proxy to us. And they're depending on us to make the right decisions. Will Durant said immortality, in his view, was the absorption of one's soul in deathless acts. You're all involved in deathless acts. And I thank you for that. I almost got away. So Dr. Fagy, thank you very much for an absolutely spectacular lecture. I think also for demonstrating to all of us by your career that advances in science take not just outstanding intellect and rigorous thinking but great courage and courage to oppose conventional ways of thinking about things. And I think what was particularly meaningful for this morning was the ethical compass that you've had throughout all of this. So thank you for being such a wonderful role model and for being here today. So we now have some sort of tangible elements of this prize. There's a very nice award. It says the University of Chicago McLean Center for Clinical Medical Ethics awards William H. Fagy, the McLean Center Prize in Clinical Ethics for contributions to eradicating smallpox, increasing childhood immunizations worldwide, and practicing clinical ethics globally. So there's the end. This is an even more tangible award. Thank you very much. Thank you. We will now take a break. Thank you.