shipment under specified conditions, to assem-
ble people for the vaccination process, to de-
velop a mechanism for reporting any cases,
and to carry out other steps in the public
health process leading to eradication of the
smallpox virus. For each individual affected,
this was a relatively inexpensive technology,
whereas for certain technologies -- such as
renal dialysis or lithotriptic dissolution of kid-
ney stones -- the costs must be measured in
thousands of dollars per case. A rich country
such as the United States can, with govern-
ment funds, finance the dialysis treatment of
thousands of patients with end-stage kidney
disease, whereas in developing countries most
patients with such disease must simply be left
to die. In summary, the discovery of new knowl-
edge through research is usually a long and
costly process, and yet it is only the first step in
a sequence leading to the application of a use-
ful technology. Vast amounts of knowledge,
on which health services are based, of course,
have been conveyed from the past -- the result
of both observation and experimentation. The
production of new knowledge usually requires
research, although sometimes it comes from
clarifying relationships between ideas not pre-
viously recognized. Second, the new fact or
theory must be reported, so that others can test
it and hopefully confirm it. Third, when
knowledge is firmly established it must be
communicated widely, if it is to bring benefits.
Fourth, human and physical resources must be
available, to be used for practical implemen-
tation of the new idea. Fifth must be an ade-
quate flow of economic support to convert re-
sources into the appropriate services. Sixth is
the crucial step of application of the knowledge
to derive an expected effect. Seventh is evalu-
ation of the outcome, to determine if the whole
new technology has been worthwhile. In a world of nation-states, with very differ-
ent levels of capability, this entire process usu-
ally requires many years. The speed and out-
reach of a new idea, embodied for example in
an immunizing agent, are bound to be much
greater than for an idea requiring changes in
human behavior, such as smoking cigarettes.
Assuring clean water proved to be a much
more effective way of eliminating cholera than
a policy of convincing everyone to boil the
water they drank. A comparable policy on cig-
arettes would call for eliminating all growth of
tobacco by crop substitution, but the political
and economic obstacles to this would be enor-
mous. The excellent health record of Sweden, for
example, reflected in its low infant mortality
rate, is not the result of any fund of knowledge
lacking in, say, India. The knowledge of nutri-
tion, sanitation, immunization, childbirth, and
infant care is essentially equal in both coun-
tries. The difference lies in the application of
this knowledge in the daily lives of the people,
their environment, and their health systems.
Knowledge is indispensable in every national
health system, but it is sterile unless it is ap-
plied. The application of available knowledge
is the task of society in every country and the
mission of its health system.
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