 Before we start a conversation, Dr. Fahey wants to give some remarks, so Dr. Fahey, welcome. Just a few. First of all, in 50 years of supervising people in global health, I've recognized that problem solvers are the people that get the most done. And Erica, thanks for bringing me here. Erica is a problem solver, and I keep looking for problem solvers. A few years ago I was invited to India to give a keynote talk for the 30th anniversary of smallpox freedom. On the way back, my wife and I changed planes in Paris. And as we were about to board the Paris Atlanta flight going through security, I noticed a man who was several people ahead of us who was very agitated. He could not believe that France would not allow a bottle of French wine to go through security. The security people said three ounces, that's the maximum and so forth. And he continued to argue with them, and he gave up and he looked around. He opened that bottle of wine, drank the entire thing down, slammed it into the waste basket, wiped his mouth, and he took that French wine right through security. I assume he had a good life too. The second thing, I wanted to tell you how the tools keep improving in global health. When I was born over 75 years ago, my mother bought a baby book. She left it for me. When I look at it, there are only two vaccines listed in that baby book. We now use 18 routinely, another dozen depending on your age and where you are in the world, and it keeps improving. The third thing, if I could, I would put on a panel of the key people, of the last 100 billion people who have lived in this world, to each give you one minute on their philosophy. And perhaps I'll do that tomorrow at the School of Engineering. Fourth and last thing, you will continue to hear over and over, do no harm. And yet when you find out what people are talking about and what the Institute of Medicine book is about, they're talking about errors of commission. Almost no one talks about errors of omission. And I can tell you, you will do far more harm in the world by the science not shared, the vaccines not used, the intellectual property not given to other people. And so do no harm should also involve errors of omission, thanks. And thanks everyone for joining us. I do recommend, highly recommend this book, House on Fire. And we'll talk about how the title came about because a very interesting story behind that. I wanted to begin by asking about your childhood. You grew up as a son of a minister. You grew up and you started, you were born in Iowa, but raised in Washington state. Four sisters and one brother. Tell us about your childhood and what about your childhood led to your becoming interested in global health? Four sisters, one brother, and one bathroom. When I was 15, I actually spent time in a body cast. And for three months, I could not roll over, do anything. And this was before television. And so I started reading a lot. And as part of the reading, I came across out of my life and thought by Albert Schweitzer. And then I had to read everything I could find on Albert Schweitzer. And it became very compelling, the idea of medicine, Africa. The idea that if you have been blessed, that you now have an obligation. You can't just accept this, you have obligations. Ten years ago, I made rounds at a hospital in Botswana. And almost every patient in that hospital had AIDS and they never used that word. They talked about this person having cancer and this person having a nutritional problem. This person having tuberculosis and so forth. When we finished rounds and went into a room, I asked the doctor, how do you face this every day? How do you get yourself to come to work? And what do you do for your own mental health? Having asked the question and he hit such silence, I worried that I had overstepped my authority because he just sat there and looked at me, and then suddenly tears started rolling down his cheeks. And he said, I've never told anyone this before. But he said, I was born one of four sons. My three brothers have died of AIDS, I don't have a choice. And in some ways, that's the way it is for everyone in this room. The blessings you have, the education that you have, you don't have a choice. You have to pay back. You also had a uncle who was a missionary in Papanugini. What did you come to learn about him and what did you come to learn about his work? He was more of a pioneer than he was and an explorer than he was a missionary. Because in 1933, some gold miners from Australia came down from the Highlands and they had seen smoke and no one thought anyone was living in the inner part of New Guinea. So my uncle got another person and they rented a plane and a pilot and they went into the Highlands. One person on each side of the plane drawing a map as they went with a clock in front of them and they put the time and what they were drawing and then they got back and put the map together. A year later, they went into the Highlands and sure enough, there were people all over. And so it was exploration that he was always at the edge of his knowledge, is the way I saw him. And I can remember his 16 millimeter movies from that trip into the Highlands. I want to go back to something you said and find out how many of you know the name Albert Schweitzer. Okay, great. That is very impressive because young people today by and large don't know that name. And I had wanted to meet him, he died the month I went to Africa, so I never did meet him. But his daughter married an internist who began working at CDC. So I got to know the family and his daughter just died two years ago here in California. You mentioned the word smoke, you used the word smoke, so I want to go back to your childhood also. During two summers, you worked at the US Forest Fire. What did that experience of fighting fires, what did you learn about fighting fires that you could extrapolate about fighting disease? One of the things I learned is that you often don't know what you've learned until long after the fact. And so with, for instance, I spent a summer as a bum. And it took me a long time to understand what that was worth. What it was worth is- What do you mean by bum? I just went, two of us went around the country and we had no itinerary. We worked when we had to, we didn't work when we didn't have to and spent a summer doing that. And what I'd learned was I had grown up poor and I lost my fear of being poor. And you don't know how liberating that is because now you can do anything you want. You don't have to be planning for. I should say you should marry a spouse that has the same experience, but because that does cause some problems. Now, with back to the question of firefighting. I fought fires in Washington and in Oregon. And you are given very clear instructions that what you're trying to do is get rid of the fuel or get rid of the oxygen. And so when you do a fire line, you do it right down to the dirt so there's no fuel. The fire cannot cross that. Now, of course, sometimes it crosses by the wind putting sparks over and so forth. Or you take dirt on the fire, which you're separating the oxygen from the fire. Well, it was many years later that I realized that's what we were doing with smallpox. That smallpox does not spread that quickly and that easily. And in general, if you can have a six foot barrier between a case and a susceptible person, that susceptible person won't get smallpox. Now, sometimes through clothing and other things, it goes over that fire line. But that got us thinking that the way to control smallpox was to figure out where the virus was. And find the people around that virus and protect them and do a fire line. About the strategies in smallpox at a minute. And before we get to that, I'd like to talk about one other thing that's critical in your life and that was mentors. And I'm sure this room full of people often is searching for their own mentors. What mentors were important to you and how did you go about securing the right mentors? The first one, it turned out to be a person I worked with, the pharmacist. My family was not into science. There was something about working in the pharmacy using the metric system that introduced you to a whole new way of thinking. But then these magic drugs that actually did save people's lives. So that science was introduced by this couple who ran the drug store. I then, in college, had a biology teacher who was absolutely amazing. And I didn't realize how amazing until I got further along in life. This guy would walk into the room and he was lecturing before he came through the door. He would go to the blackboard and he would write on the blackboard as he was talking with both hands. And different things. And I've often said, I think I went into biology because I wanted to be able to do that. And then I found out it has nothing to do with biology. This guy was just different. And he became such a mentor, everyone was afraid of him. I started working for him on Saturdays and saw a totally different person. Pretty soon his wife and Dr. Strunk were competing with each other to give me food without the other one knowing it. So one of them would come out with a piece of cake, don't tell my wife. And then she would come out with something else, don't tell my husband. So I saw a far different person than what he was in the lab. He was the person who became the mentor for me to go to medical school. And he required, if you were going to go to medical school, you had to do all kinds of testing. IQ test, Minnesota multiphase, and so forth. And only then would he recommend you because he had such a good record. He didn't want to ruin it. And so he became a mentor. But then, over the years, I went to Harvard because of one article in the literature written by Tom Weller. And I didn't even know Tom Weller was a Nobel Laureate. I just read this article, it was called Questions of Priority. And it was given to the medical school at Harvard saying, now you have all of these skills and all of this knowledge, and how are you going to use it? And he said, you should be looking for efficiency and use it where it's needed most. And I thought, this is someone I would like to know. And so I apply, and only later find out he's a Nobel Laureate, but spend a year with him. So Tom Weller turned out to be a mentor. But over and over, that sort of thing. But in 1963, you took a position as a physician at the Peace Corps, a temporary physician, as a physician at the Peace Corps in India. And you talked about how that changed your life. So how did it change your life? What about that experience led to and connected the dots to later life? It was the next chapter in having read about Schweitzer. I mean, now to have the idea of health in a developing country and now see what the problems were, that had quite an impact on me. But also my supervisor turned out to be such an incredible person. Well known in mountain climbing circles, his name was Charlie Houston. So if any of you are mountain climbers, you'll recognize that name. Because he started climbing on K2 in the 1930s, took a group up in 1953 and they had every chance of getting to the top of K2 in 1953 when a storm came up. They got into their tents and they were near the top. But one of the people developed deep vein thrombosis. Charlie Houston was the leader of the group. And when he developed symptoms in the other leg, he said, we've got to get him down. It's his only chance. And the rest of the team said, we can't get him down. I mean, there's a storm, we're on K2. And he said, only chance, and so they pack up and they start down. And as they go down, this just very steep incline, one of them loses his balance. And he pulls the other person on the rope down with him. They run into the second group on ropes. The ropes get intertwined, and now four people are going down. The whole group runs into Charlie Houston, knocks him unconscious. He's holding on to the sick person who's in a sleeping bag. They're all saved by a man by the name of Peter Shoning, who has his ice axe in and he saves the entire group. And this is one of the great stories in mountain climbing. And so then they put the sick person in the sleeping bag with an ice axe. And they try to find someplace to put up the tent and get reorganized. They do that, and when they come back, he's gone. And at first they thought an avalanche would take him. They later concluded, he realized he was putting everybody's life in jeopardy. And that he climbed up the rope and pulled out the ice axe. When Charlie Houston was 93, he received an honorary degree from the University of Colorado. And I went there to see him receive it. They had a half day seminar in his honor at which I spoke. And all the surviving people of that 1953 K2 were still there. Bob Bates, age 95, came back, it was an amazing thing. And when I saw these people in their 90s, who are very careful in the way they go up steps. And I think back to, these people were three standard deviations above the mean in athleticism, in balance, in everything. And here they are like us. We are now having the same sort of problems. This is what age does. And I said, statisticians have a term, regression to the mean. And with elite mountain climbers, the regression to the mean is a mean regression. 1963, actually 10 years before the WHO declared their war on smallpox. You were at Harvard and you wrote a paper. And in the paper, you deliberately used the word eradication. And most people probably thought you were nuts or using the word eradication. But I'm curious of how did you come to have this grand vision that smallpox, a persistent virulent disease in many parts of the world could be eradicated? Part of what you say is true, but it wasn't because I used the word that they thought I was nuts. It was just an academic paper at that time. And looking at what would be possible, people didn't talk about eradication because there had been an attempt to eradicate malaria and it had failed. There had been an attempt to eradicate yellow fever before people knew that the virus actually was in primates. And there was no way actually to get rid of the virus or stop transmission. And so to use eradication was now out of favor. But when you look at smallpox, no non-human host. And when you think of what a smallpox virus has to go through just to ensure their immortality, they have to find another susceptible person within days or weeks of infecting someone. That must be very difficult, even though it had gone on for thousands of years. It just seemed if you could break transmission, you could one chain at a time get rid of smallpox. And once you get rid of it, it would never come back unless of course you keep it in the lab and there's some reason to let it come back. And you began that work in 1966 in Africa and you settled into a small village. And that's where your work really began on smallpox. What happened, what was the life like then and what were you attempting to do? Was this part of a larger effort in Central and West Africa? Well, I went there not for smallpox, but to run a medical center and to see if we couldn't make it a community health center that we would be going beyond the hospital and the clinic. So we were working on things like immunization programs and water supply and so forth. When CDC, where I had worked before, got hold of me and said we're starting a smallpox eradication program, would you on a temporary basis be a consultant in eastern Nigeria? So that's how I got into that. And before the program actually started, we had our first outbreak in a remote area and we had not at that time received enough vaccine. So here we were faced with a problem and not enough vaccine. We sat around that night trying to figure out what to do. How do you optimize the little vaccine that you have? And it turned out that the missionaries in this area would get on the radio every night at seven o'clock at shortwave radio, just to be sure everyone was okay. So we got on the radio with them and with maps in front of us, we divided up the area and asked the missionaries to send runners to every village to find out if they had smallpox. But you couldn't do this in the United States at that time with as good as our communications were. But 24 hours later, we actually were able to pinpoint every village with smallpox. And so we used most of our vaccine on the villages with smallpox. We used the remainder of it, trying to figure out where smallpox might go and prepare for it and get everyone vaccinated. We were so fortunate we guessed right on everything. They were guesses, we weren't that smart, it was guesses. But smallpox stopped within weeks and we had only vaccinated about 7% of the population. And now we knew we had something that was different. And so we tried it next in an area of 12 million people. And again, we were so fortunate. We didn't know that six months later this entire area was going to be involved in a civil war and it would be impossible to work there. This was the Biafran Nigerian Civil War. We got rid of our last outbreak the week the war started. I mean, that's how close it was. But now we had an example that we could go to other places in West Africa and gradually we extended the area trying this. War, the Biafran War, and I want to go back to something you said in the book. And that was the analogy that the anthropologist Laura Bohannon said. The closest thing to smallpox in the West is war. What does that mean? She said there was such fear in the population when the news came that smallpox was coming through. They called it in the Teeve tribe water because it just seemed to flow every place. And she said, we have no idea what this kind of fear is like. And the closest thing we have today is war. That people become very stricken with what's going on. That's the way smallpox was. It would totally, totally confuse society. So many people would die. Others would be left with pock marks and not become marriageable and so forth. Talk about smallpox. And the other thing I found interesting is that you wrote you can smell smallpox before you even enter a patient's room. What is the smell and how would you describe it? It's very hard in retrospect to describe, but a smallpox worker just a month ago came up to me and said, I'm glad you wrote that. Because he said, I had never seen it written before and I knew exactly what you were talking about. But you know the smell you get when there's a dead animal in the area and you immediately recognize it's something similar to that. And I think it's because of the pustules and the decaying flesh that that's what we're smelling. And I've said in the book that no one thought of it at the time. But today I would try training dogs to find smallpox because I think you could go through a village and immediately know whether or not there was smallpox. But we weren't sophisticated enough to even think of that plus I think the whole business with dogs and drugs and cancer and so forth is pretty recent. But there is a smell and twice I think I found smallpox outbreaks just because of the smell. One was I was walking down a hospital corridor in India and suddenly I was stopped. And I started looking room by room and sure enough there was a smallpox case. And the other time was walking through a slum in Pakistan. And if you're walking through a slum there are a number of competing smells. And yet, I suddenly had that feeling that I was smelling smallpox. And we stopped and we started knocking on doors and we found an outbreak of smallpox. Can you talk about the life of the virus? How contagious is it? And in one descriptive part of the book you talked about a mother I think leaving a child's room. I think the child had died of smallpox, came outside. Other children were sitting outside. She shook his bedclothes, she shook his whatever clothing that had been removed from him. And all of those children ended up getting smallpox. Can you talk about the virus? And that particular story is one that Don Francis tells. Don Francis, some of you will meet, he's the person who did the first AIDS trial in humans in the US and in Thailand. And we're still not clear whether there's protection of some degree from that. But Don Francis observed this and wrote up this particular story. The virus spreads not easily, but it's tenacious. And so oftentimes in a compound in Africa, the virus might stay in that compound for four or five generations until finally it exhausted susceptibles. But unlike measles, where if you put, if you have a child walk into this room with measles, and we're all susceptible, I can tell you that two weeks later 80% of us will have measles. That's how contagious it is. With smallpox, even if you're in the same house with a smallpox case, only about a third of people come down a generation later. And then another third and then another, it's tenacious, it sticks around. But it's not as transmissible as people think it is. And so the other nice thing about smallpox that's not shared by other diseases, you can actually vaccinate a person the day after they've been exposed, or two days or even three days later and still prevent the infection. Why? Because vaccinia, which you use for vaccinating, has a shorter incubation period than smallpox. I mean, it's just incredibly nice if you're after trying to get rid of smallpox to have these things happen. In Africa and later in India, there has always been, it seems, a fight versus a strategic fight, versus mass vaccinations and containment and surveillance. I wondered if you could explain to everyone why this persistent fight, why mass vaccination, which one would think would work. Why didn't it work specifically for smallpox? And how did you convince, and how did others convince the world that, essentially the world that mass vaccination was not the route to go? For most diseases, mass vaccination is the way to go. You simply have to improve the immunity of everybody. Sorry, I keep dropping this. Can you still hear it? Okay. With smallpox, the mass vaccination just gives some clarity to that. That is essentially having a huge nationwide program. That's right. And generally, people would go from one place to the next place to the next place until you had everybody covered. But there are so many reasons why you miss people. In India, for instance, if you went into a village, there are enough people who don't trust government. Oh, I said India. In the United States, if you go into a, so that people disappear. And you have, so you have trouble getting the last percentage. Then you have children being born all the time, diluting the population with unprotected people. So it's hard if you plan to take two years or three years to do an entire country to actually get ahead. You always have these pockets that are not vaccinated. India had, I don't know how many mass vaccination efforts where they would have three year plans and they would actually work hard at those three year plans and they could not bring down the number of cases. With this surveillance containment, the whole idea was to do mass vaccination and then use surveillance and containment to finish it off. But it was hard to get to that point because you just could not bring down the intensity of spread. In Bihar, India, during May of 1974, we were having a thousand new cases of, we were having a new case of smallpox every minute and all over the state. I mean, it wasn't just in one place. So the intensity of spread was so great, no one thought you could use surveillance containment under those circumstances. They thought you had to do a mass vaccination, get down the fire to a reasonable level. But what we found was, if we put our attention on actually finding that virus and each time responding to that virus, we could. And India went from the highest rates of smallpox that they had had in decades in May of 1974 to absolute zero 12 months later. I mean, there's never been anything quite like this in public health so we had to pass from such intense infection to zero. And by 1975, smallpox had been eradicated around the globe. Well, it still was in Bangladesh and it was still in Ethiopia. And in Ethiopia, they were on their last week of smallpox. They were going to be the last country in the world. And they actually announced smallpox had stopped. So we don't need to find out that it had spread during those last weeks from Ethiopia to Somalia. And Somalia is not an easy place to work. And so it took two more years to get rid of it in Somalia. Now here's the irony of the whole thing. Somalia did have the last case and it was an interesting thing because a family came with two small children with smallpox. They asked one of the workers at the hospital how to get to the infectious disease ward. He said, I'll take you there. He was a good person. He did. And in that short period of time, they transmitted smallpox from one of these children to that worker. The worker thought he was vaccinated. He'd been vaccinated, but he didn't get a take. And so now this worker came down with smallpox. But it was the last case because he didn't pass it on to anyone. The chain of transmission that had gone on for thousands of years was finally broken. And you would think that's the end of the story, but it's not. Two years later, in England, the place that gave us smallpox vaccine, where Edward Jenner in 1796 used the cowpox from the hand of Sarah Nelms and inoculated it into a small boy, James Phipps, gave him a sore with cowpox. Then several weeks later, tried to give him smallpox and couldn't. And this, as you may recognize, was before we had committees. But he had observed this for 12 years in milk maids and he had concluded the reason they had nice complexions was because they didn't get smallpox. And they didn't get smallpox because they were being infected by cowpox and that was protecting them. And he tried to duplicate nature and he did. And so that vaccine went from 1796 around the world. Smallpox was eliminated and then, two years after that, in a lab in England, someone was working on smallpox virus. That virus left the lab, went out the window, up to the floor above, and a medical photographer got smallpox. She was admitted to the hospital with smallpox. Her mother then came down, an incubation period later with smallpox. Her father came to visit at the hospital and had a heart attack in the hospital and died and the director of the lab committed suicide. I mean, the whole thing was just ended in absolute tragedy, unexpected ending. I want to ask you some other questions before we, other than smallpox before we take questions from the audience. Let me start with, do you worry about the anti-vaccine movement in the United States? Do you think that this movement, this grass-first movement out there, that is interestingly sort of a left movement, not a right movement when you're politically speaking? Do you worry about that movement? Do you think that it's going to have some impact in this country? It's already had great impact and I worry a lot about it because it's going to have impact globally at some point. And these parents are doing what they think is the right thing for their child. I mean, these aren't bad people. They simply don't have the right information. And then you have people like Andrew Wakefield, position from England, who published the paper that related autism to MMR vaccine. And he's lost his license. It's been shown that he made up some of the information. It's also been shown that he was receiving money from a lawyer who was suing a vaccine company. And when you think of the damage that he's caused, and even though he's lost his license, he continues to tour the United States and he gives lectures. And I tell you, parents turn out for these lectures because autism is a problem. And people want an explanation for autism and why is it increasing? And it sounds logical that something that has increased may be related. Vaccines have increased. There have now been many studies, but big studies that show no relationship between vaccines and autism. It seems to me parents have so much to worry about. They shouldn't have to worry about things that aren't true. And how to counter this, I tell you, it is a real problem. Now, I've suggested two things to CDC. One would be that every pregnant woman should be told during her pregnancy, your child does not have congenital rebella syndrome. And do you know why? Because so many children have taken the vaccine that they've stopped transmission of rebella virus. And so they have protected you. This is a social contract. They've protected you. What will happen if your children are not able to protect them in return? Number two, just point out to these parents something that most of them have not thought about, which is they have limited their children's mobility in the future. Because those children are now more susceptible if they go to another country and have not been vaccinated. So that they're not really doing them a long-term favor. But third and last thing on, believe it or not, I live on an island in Puget Sound that has some of the worst vaccination levels in the whole country. It's been featured front page New York Times, Vashon Island, 16% of children are not immunized. And what is happening on Vashon now, some parents are organizing to educate all of Vashon. So it's not the government, not the medical profession. Parents themselves saying, I want my children protected, which means you have to protect your children to protect mine. One question for me, you participated in a conference at the Carter Center, where you were the head of the Carter Center, on compassion in global health. And compassion in global health seems obvious. So why would you need a conference to talk about that? You're right, you're right. And my conclusion was, we want compassion every place in society. That it's compassion that is really the glue that holds us together, that we can understand how other people are feeling. And this is something that we should be deliberately teaching. I think you can teach the ability to feel for others. My wife for many, many years had preschool. And one year for Martin Luther King Day, she had a peace table. And what happened, whenever two children had problems, they had to sit down at the peace table. And they had to come to a conclusion without the teachers helping them before they could get back into the mainstream of what was happening. They thought that this would take a lot of time to teach some methods and so forth. Those kids, they want to get back into things, and they would very quickly, the whole question was, how do you think the other child is feeling about this? How does that child think you're feeling about it? And so they were sharing empathy. And it worked so well, she kept having it. It wasn't just a Martin Luther King Day thing. So I think you can teach empathy. And that's the basis for compassion, of actually sharing how someone is suffering. But it's not something limited to global health and shouldn't be. It's something you want for all of society. Thank you. And I'll take questions from the audience. You're talking about smallpox specifically. You don't need smallpox anymore because there's not been a case of smallpox for 30 years in the world, and so no country actually requires it. Now, to get into the military, you have to be vaccinated. And so there are some requirements there. But yeah, there's been nothing in Africa, nothing anyplace in the world. The last case was this one in England, which was over 30 years ago. Well, with smallpox, people recommended getting a booster about every 10 years. I think that, in fact, immunity was even better than that. And when we had the scare in the United States, I say scare. You remember there was this talk about vaccinating the United States because people feared that Iraq had weaponized the smallpox virus. And so there was a fear of this. It turns out that this was based on one CIA report of a person saying, he thought there was a 50-50 chance that they had done that. And then there was an article in the New York Times that talked about Iraq had received a special strain from the Soviet Union that did not respond to the vaccine we were using, and people worried about that. I was actually asked if I would be on a committee to oversee what the government was doing with that, but I was told I couldn't criticize the government. And so I flatly refused. I said, I'm not going to be part of a committee and then can't say what I, so then they came back and said, okay, if we allowed you to be a consultant at no pay and you can say anything you want, and I said yes. And so I immediately wrote an article published in The Washington Post about what was wrong with what they were trying to do. Within hours, I had an email from someone in government saying, I agree with you completely and we're not going to change the thing we're doing. I mean, just think of that. So there was this attempt to vaccinate. And the medical profession didn't go along with it. And so they finally had to give up on it. And I kept asking questions. If Iraq has a strain that is not prevented by this vaccine, why would you do a vaccination program? I mean, it made no sense to me at all, but that's where, yeah. So people thought we should do this every 10 years. I think the immunity was much better than what I think they were trying to scare us into no one has any immunity and we have to do this. I'm not sure that any is absolutely comparable, but I think the lesson that one learns from this is these things do not happen by chance. You don't see improvement just by chance. And that each problem requires understanding the details of it. Now, guinea worm comes very close to this. Guinea worm is a disease that we see in West Africa. It used to be in India and Pakistan. That people get by drinking contaminated water that has a larval form of draconculiasis. It's in a water flea. The water flea is just barely at a size that you can see it with the naked eye. And when they step into the water to get drinking water, the guinea worm lays eggs and it starts through the cycle. And then people who drink the water end up keeping the cycle going. The cycle involves 12 months incubation period and then people get a worm that's maybe two or three feet long. It's in the lymph system and usually comes out in the ankle. That's where the eggs are laid. But I've seen these come out any place in the body, including the face. And one of the most interesting was a picture of a nine month old child with a guinea worm. And you say to yourself, wait, if there's a 12 month incubation period, how can a nine month old child, well, this was inter-uteral. And so it's a bad disease and it was pretty much ignored because it's an end of the road disease. It's not something you see in the capital cities that the ministers of health know about. In Nigeria, they were reporting about four or five or 6,000 cases a year. We did a one-time survey in Nigeria and at one point in time, we found 700,000 cases of guinea worm. The government of Nigeria that day put up a million dollars for a guinea worm eradication program. It's now been eliminated, 99.8% eliminated. And the remaining problem is in Sudan. But it follows very much the smallpox model. Find the disease and then do something around it. And Jimmy Carter is largely responsible for that. Absolutely responsible for it. Some years ago I was pointing out that there isn't a one way that we do these things, even when you look at disease eradication. Smallpox eradication was accepted by WHO because of two countries. The Soviet Union and the United States. And it was a Soviet Union that was promoting that. Guinea worm eradication is an NGO, the Carter Center, that pushes that. River blindness, it's a corporation, Merck, that has promoted that. Polio eradication rotary was really the spark plug for that that got the World Health Assembly in May of 1988 to adopt that. So each one has been a slightly different approach. But the Carter Center has been responsible for Guinea worm. Can I tell you one quick story about that Carter Center? When the Gates Foundation was asked to put up money for Guinea worm eradication, they got requests from WHO, from UNICEF, from the Carter Center, from various places. And each place was looking for money for itself. What do you do? I had a dinner in Washington, DC with representatives from each place. And I said, tomorrow I'm going to Seattle. I'm going to present one Guinea worm project to Bill Gates. It can either be a project that you've all agreed on or I'm going to choose one of these. And these organizations that had not been able to get together for months on this within two hours had a plan for how they all get together. Part of the plan was, WHO was very jealous of its reputation. And so, they asked if when a country gets down to 200 cases of Guinea worm, could this go from the Carter Center to WHO so that we get to finish it off? The Carter Center representative, Don Hopkins, said yes. A week later, I get a call from WHO saying, but we don't know how to do that. And I said, it's very easy, contract with the Carter Center to do it for you. So that's what happened. Okay. So, smallpox virus is held in two places. And it's been a standoff over the years. You don't need that virus to protect people from smallpox, because we use vaccinia virus or COMPOX virus for the protection. But there's been this fear of once we get rid of it, we'll never have it again. And so each time it comes up for, we're going to destroy it. People on both sides end up with reservations and they keep it for a little bit longer. I have always thought the easiest thing would be if they would give up the virus to a WHO group. But that any research done on the virus would have to be approved by an international group of scientists that say, yes, this is really important, it needs to be done. And then you know how it's going to be controlled and so forth. So I think there is an answer around this. But I must also say, I don't worry about it like I used to, because I think the real worry is about smallpox virus we don't know about. There are tons of virus supposedly that were made in the Soviet Union that can't be accounted for. And I think that's the risk, not what's in those two reservoirs. The preceding program is copyrighted by the Board of Trustees of the Leland-Stanford Junior University. Please visit us at med.stanford.edu.