First off, I state my intense admiration and respect for the work that you have done. I'm sure that tens of millions of persons on our earth are alive because of what you have accomplished.
But what you have done is not what concerns me here. Now there is a new global challenge, one that is much more complex and untidy in its difficulty than the infectious diseases that you have been so brilliant in addressing.
As a geriatrician my attention is focused on lifestyle issues that are the primary roots of the chronic diseases now crowding our obituaries. I acknowledge that these lifestyle issues are much more complex and imprecise than bacteria, but this should not obviate your attention. Vaccines, mosquito nets, and clean water are magnificent foci of Gates attention. But it is the more elusive issues of dietary preferences and physical activity patterns that are now the new global determinants of health. Such a different transformative emphasis should not deter or distract you from your commitment. Yet almost all of the prestigious advisors of your organization are old school experts in areas that are no longer front and center.
John and Matilda Riley coined the term "structure lag" to elaborate the latent period between the occurrence of a new set of circumstances such as the Baby Boomers, or Global Warming, and the cultural and societal responses to the new challenges. John Gardner made prominent mention to the timing of this response. "He( she) who would effect social change cannot be of short wind." Our innate insistence on quick and easy solutions to complex problems cannot distract us from the zeal of pursuing first causes.
The central JAMA paper of McGinness and Foege, "Actual Causes of Death" (1), indicates that it is not heart or stroke or cancer that are the primary killers, but rather the antecedent adverse lifestyles, behavioral in nature, that are causative.
Some of our medical schools, largely through student enterprise are belatedly, starting lifestyle curricula. The medical profession, my own, needs to adopt prevention as its core mission. Mopping the floor is not the preferred strategy. Turning off the spigot is cheaper and more urgent.
I earnestly encourage you to facilitate and think deeply on this issue.
I cannot even imagine a more important mission.
Walter Bortz, M.D.
Reference: McGinnis JM, Foege W, 1993 Actual Causes of Death JAMA 270:2207-2212.
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