THE PLACE OF TROPICAL MEDICINE IN INTERNATIONAL HEALTH'

WILBUR A. SAWYER Director of Health, United Nations Relief and Rehabilitation Administration, Washington, D. C.

Received for publication November 22, 1944

The world crisis has already reached the stage dassed as tropical diseases. In a later period at which plans are being laid for the future inter tropical medicine contributed a large proportion national organization to preserve peace and ad of those brilliant discoveries and those successes vance human welfare. The completed plans will in their application, which have made quarantine undoubtedly give prominent place to provisions more scientific and effective and less burdensome, for effective collaboration between nations in and have also given hope that most diseases can promoting and protecting health, and will not be effectively controlled at their points of origin. overlook the outstanding problems of tropical It would be a poor outlook, however, if we should medicine. be satisfied with the application of these successes War, which might be regarded as a highly viru of the past and could expect only the application lent infectious disease of society, is now in the final of existing knowledge and methods. The very stages of its greatest pandemic. The best thought rapidity of the recent advance in tropical medicine of our statesmen is being concentrated on future is indication that a great body of useful knowledge prevention. It is dearly recognized that to pre still lies ahead and invites discovery. The mem vent war the causes of discontent and conflict bers of this Society should accept the challenge of must be diminished, while direct action wifi have the situation and should not fail to ward off the to be made possible for application as a last resort. slump which might come with the cessation of the Likewise in the field of international health it is special demands of the war. The narrowing of more important to remove conditions which give certain research fields now specially favored rise to disease, and to suppress it wherever it is should be more than offset by expansions in other first established, than to depend primarily on directions where there has been unavoidable tem keeping pestilences from moving about after they porary neglect. If we fail to spur the efforts to have developed somewhere under neglect. Quar accumulate new knowledge of tropical disease and antine measures will still be necessary to curb the to plan for its fullest application it may become results of the limitations and failures of the broader difficult to justify this scientific Society. I have international effort proposed, just as armed inter no fear, however, that tropical medicine in this vention may be needed at times to enforce peace part of the world will fail for lack of your interest. when the more fundamental measures have been Soon it will no longer be possible to excuse delay inadequately or belatedly applied. In the near in disease control on the familiar ground that future, however, we may expect to see the quaran “thereis a war on―. It will again be possible, tine principle yield its dominant position to the with reasonable support, to secure adequate per more adequate and more friendly concept of help sonnel and materials. With the world war com ful international collaboration in the suppression ing to an end, the war against disease will still of disease wherever it still flourishes. be building up. What will be most needed for Tropical disease has been prominent in the his success is wise central planning and the giving of tory of international quarantine. Plague, cholera, advice and assistance to countries with the greatest yellow fever, typhus fever, and smallpox were the health problems of international interest. Here diseases specifically dealt with in the International is where an effective and progressive international Sanitary Convention of 1926. They induded health organization comes into our picture. the pestilences which frightened nations into their Without it health progress is bound to be spotty early desperate efforts in health protection through in distribution, reaching high levels in some coun.. ship quarantine. At least four of the five are tries and leaving others quite unable to cope with ‘Presidential Address before the American Society disease problems which may be unusually difficult of Tropical Medicine, St. Louis, November 15, 1944. and of great international importance. In fact 1 2 WILBUR A. SAWYER disease itself may lower the power of the country dangerous species of anophelines from invading to cope with it. the malaria-free islands of the Pacific, or again There are many new factors which increase the crossing the Atlantic to re-establish themselves possibilities of rapid advance in the future control in South America. It could determine the order of tropical disease under adequate national and of preference, in relation to danger and need, of international organization. The now depleted projects for controlling malaria in the infected civilian forces against disease will have many new countries. recruits who have acquired experience and in The review of the world situation with regard terest in tropical diseases while in military service to typhus fever by an international health organ in foreign lands, or while engaged in subsidized ization or a special commission appointed by it, research related to the war effort. The present is overdue. The louse-infestation which permits assistance to the teaching of tropical medicine epidemics of typhus should be eliminated by in the medical schools should produce a succession methods now well understood. Living conditions of new doctors who already have interest and some and standards of hygiene should of course be fos fundamental knowledge in tropical medicine. The tered which would be incompatible with lousiness, war-time revelation of the inadequacy of the in but in addition the more rapid measures of de struction in tropical diseases has had a salutary lousing by simple powdering should be systema effect. There is also a growing interest in secur tically applied under the direction of the health ing greater facilities for post-graduate instruction authorities. The body louse should be easily and research in a few selected University Schools. exterminated in any threatened area, and then This whole movement for adequate education and there should be no fear of serious epidemics of research deserves the fullest support. typhus. Such a commission could also decide It might be profitable to speculate as to the the conditions under which vaccination against future of malaria control. This disease has al typhus should be utilized in addition. Certainly ready been openly threatened with a war of ex we should cease to regard certain regions as per termination in the United States after the world manent endemic centres of typhus, when there are war ends. The recent demonstration in Brazil effective methods for rendering communities non that under certain circumstances a dangerous infectible at low cost. What is needed is the species of anopheline can be exterminated through stimulation and guidance of a central agency in out a wide area by systematic measures, has led which each of the countries involved participates. to the commencement of similar attempts in South In the case of yellow fever, that most typical of America and North Africa even before the end of tropical diseases, there will be opportunity for the war. The war-time experience in West Africa still further advances toward complete control. has emphasized the need for thorough suppression The past decade has seen marked improvement in of anophelines throughout important malarious methods, but a comprehensive international sys areas and in vital ports by equally comprehensive tem of prevention is still to be devised. Only and vigorous methods. Success in these ventures through a common plan can all the interested should be possible when the manpower and mate countries protect each other and themselves. rials and trained leadership become available; Even our present knowledge should make it pos especially as larvicidal substances more effective sible to devise and carry out a yellow fever pro than paris green will probably be at hand. gram which would be a model for international The planning of the critical first demonstrations disease control. of complete control in difficult situations should be With yellow fever firmly entrenched in animals thoroughly done and preferably with central and mosquitoes of the tropical forest in South guidance, perhaps by a commission created by the America and Africa complete extermination of the future international health organization. We disease from the world has had to be indefinitely need a central strategy board which can map the postponed. It must at least await new dis places of danger, measure the risks, and make a coveries not yet foreseen. In the meanwhile time schedule for the campaign. It could also local extermination of the urban disease through estimate the costs in terms of personnel and mate elimination of the vector Aedes aegypti, and the rials, and propose ways of allocating them. confinement of the infection to the endemic areas Such a commission could decide what quarantine of jungle yellow fever by barrier vaccination can and control measures are necessary to prevent most certainly be accomplished. Moreover, in TROPICAL MEDICINE IN INTERNATIONAL HEALTH 3 ternational quarantine regulations relating to providing for their administration for the time yellow fever can be modernized and liberalized being by UNRRA, but without prejudice to the so that threatened countries will receive all pos return of the functions to the Office international sible protection while restrictions on infected coun d'Hygiêne publique. As .soon as the new con tries can be safely reduced if they keep their sea ventions carrying the amendments have been ports and airports and surrounding regions signed or acceded to on behalf of ten or more noninfectible. governments, they will come into force. For the It would seem that an adequate international immediate administration of the conventions and system of yellow fever control would indude five particularly for the determination of endemic areas essential parts which I shall enumerate: for purposes of quarantine, UNRRA's Technical 1) Thereshouldbefrequentandadequatesur Committee on Health has set up an Expert Corn.- veys of all endemic and suspected regions, with mission on Quarantine which will cooperate closely immunity tests of men and animals on a sampling with the Pan-American Sanitary Bureau. basis and with adequate mapping and statistical 5) International facilities for promoting edu analysis. Only by constant vigilance can we as cation and research in the health field and for certain where precautions are needed and avoid exchanging knowledge and experience, is the fifth being taken by surprise from an unexpected quar of the essential parts of the program for the con ter. An international organization is necessary trol of yellow fever, and it would apply equally to for the even exercise of such a function for the any other important disease problem. Means benefit of all nations. must be found to encourage and enable health 2) Barriers should be erected around endemic officials and medical scientists of the interested areas of jungle yellow fever through vaccination countries to study and confer wherever the oppor of the inhabitants and the extermination of Ae4es tunities are most favorable. They should meet aegypti if present in neighboring towns. The and investigate where disease is active in its nat object would be twofold—to protect the local ural environment and also at centers where med people themselves and to keep the disease from ical science is reaching its highest development. wandering out in infected persons and starting Only when research is promoted and knowledge widespread epidemics. freely exchanged shall we acquire a body of par 3) Infected or threatened cities, and particu ticipating health administrators and scientists larly seaports and airports, should be made com able to make a success of the international health pletely non-infectible by the extermination of organization we envisage. Aedes aegypti. If this is done and there is con Classic typhus, cholera, and yellow fever are stant vigilance to prevent the return of this insect, among those diseases dependent for survival on it would be impossible for yellow fever to spread correctible conditions. In fact these diseases if introduced from the jungle. have disappeared completely from many coun 4) Adequate international quarantineprovisions tries which have become practically non-infectible, would be needed as a third line of defense to pre although once ravaged. We know what would vent the conveyance of yellow fever from port to have to be done to eliminate any one of these port or country to country in case it should pass disease@from the people of any locality. It fol the barrier around the jungle area and find a port lows that if we are really interested in having in which Aedes aegypli has not been fully sup a healthier world, as well as one safer from war, pressed. Yellow fever quarantine measures are we should begin thinking in global terms. We receiving special attention in the revision of the should organize our forces to strike wherever International Sanitary Convention of 1926 and preventable disease is prevalent, and to apply by the International Sanitary Convention for Aerial preference those measures which lead steadily Navigation of 1933. Convinced that the Office to conditions incompatible with its persistence. international d'Hygiêne publique, on account of Sometimes this means providing pure water for the war situation, is not now in a position effec twenty-four hours in the day; sometimes more soap tively to carry out the duties assigned to it under is needed and better housing and improved eco these conventions, the Council of the United nomic conditions for the groups hardest hit. Nations Relief and Rehabilitation Administration There are always, however, additional scientific recently approved in principle proposed amend methods of direct attack to hasten victory. It is ments bringing the conventions up to date and obvious that the best effort of each nation as well 4 WILBUR A. SAWYER as of the whole group will be required under ideal of the lands plagued by the diseases of his domi cooperation. If the vulnerable diseases, including nant interest and contribute to the thought and especially infectious and nutritional diseases, statesmanship which will be needed for setting among which many are classed as tropical, are to up a suitable and acceptable world health organ be thoroughly suppressed in our time, there must ization. We can then hope soon to reach a situa soon be established an effective cooperative world tion in which every country, no matter how small health organization. The Health Organization or how poor, can handle its own problems with of the League of Nations made a good beginning such central help as may be necessary and can after the last World War. UNRRA should add cease passing pestilences to its neighbors. valuable experience in its developing war-emer No country can live to itself in disease preven gency health work. The time is surely ripe for tion any more than in political relations and corn setting up the ideal permanent international health organization. merce. We must reach a state of knowledge, a My message to the Society, as its retiring presi state of organization and a state of mind which dent, is to urge that each member look beyond his permit our recognizing that all nations are allies own specialty within the broad field of tropical in the fight against disease, and that the failure medicine and beyond the geographical boundaries of one is the failure of all.