Global Health Science Technology
January 4, 2005
Prepared remarks by Dr. Richard Klausner, former executive director, Global Health
Improving global health is the essential challenge of the 21st century. As its name implies, it is a global challenge that must be met with a global response.
Before I begin I want to thank the organizers of the Indian Science Congress for inviting me here, as part of a larger visit this week to explore how India and the Bill & Melinda Gates Foundation together can participate in that great challenge.
Indeed, I suspect that without India we as a global community will fail to meet that challenge.
The stage for this 21st century challenge was set in the century we have just left—a century whose aspirations were summed up by the historian Arnold Toynbee, who said, “The 20th Century will be chiefly remembered by future generations…As an age in which human society dared to think of the welfare of the whole human race as a practical objective”.
A practical objective, not a utopian vision.
So let us talk of “Practical Ambitions,” and by that I don’t mean to imply that we lower our ambitions to that which is practical—quite the opposite. It is to embrace unprecedented ambitions for change, coupled with an equally unprecedented demand to achieve results.
Over the past 100 years, humanity has witnessed the capacity to improve health that dwarves all of the advances of the entire history of our species. This amazing progress was the result, quite simply, of science and technology:
- Science that gave us deep understanding of the causes of disease and the requirements of health, and
- Technology that gave us tools to turn that knowledge into actions that improved sanitation, food quality and quantity, vaccines, drugs, and strategies for their delivery to vast numbers of individuals.
Of course, science and technology only create the possibility for health. Actually achieving better health required the resources, commitment, and acceptance of the social responsibility to deliver. While it is science and technology that creates unprecedented opportunities for change, it is society that realizes them as “practical ambitions”.
Practical Ambitions for All
So let us return to the transformations of the 20th century.
Science and technology transformed the unimaginable into the practical. But a new moral transformation emerged in parallel that profoundly expanded the rights of individuals and, by extension, the responsibilities of society, including those who practice science and technology.
A just global community requires that all individuals have the right to the opportunity for basic health. All who can contribute must—not out of altruism, but out of moral responsibility.
While the stage was set in the last century, it is the opportunity and responsibility of this century to turn both the scientific and moral transformations into “Practical Ambitions”.
This talk is about the endless possibility of science and the tragically unfinished story of human health. The great question of global health is, in a way, obvious: How to bring the fruits of innovation to all? The answers are subtle, complex, and daunting.
The challenge of Global Health is the unacceptable fact of inequity. For 2-4 billion people with whom we share this planet, the most basic measures of health—neonatal, infant and child survival, maternal mortality, life expectancy, and others—provide statistics that are easy to recite but nearly impossible to comprehend. It is as if we are witness to a terrible time warp in which the great advances of the 20th century, advances taken for granted in the industrialized world, have simply left out the majority of people.
Too often, the gap between rich and poor has grown with advances in science and technology. Bridging that gap is, in part, an achievable goal of science and technology by solving the most demanding of scientific and technological design challenges—effective and appropriate technology—literally taking designed solutions to unprecedented levels. The gap between rich and poor will not be bridged without both the innovation of science and technology and the will and resources of society to deliver. Expecting the latter without the former may be just utopian visions. The former without the latter would be moral failure but the two together brings us to a global theme of the 21st century— “Practical Ambitions” for all.
Furthermore, the innovations required could revolutionize the science and technology of medicine, public health and life science; revitalize a global life sciences industry struggling with plummeting productivity and searching for social purpose; and inspire generations of young people to become problem-solvers through science and technology.
The Role of the Bill & Melinda Gates Foundation
The Gates Foundation is a relatively new institution whose mission in Global Health reflects the vision of the two remarkable individuals who founded it, Bill and Melinda Gates. The work of the foundation is motivated by their beliefs that:
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The value of a life everywhere is equal, regardless of the random circumstance of where one is born, and
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The enormous potential of science and technology, especially in the decades ahead, to improve people’s lives, all lives.
The actual work of the Foundation is enabled by their generosity and their commitment to return their wealth to society. This year we will provide nearly 1.5 billion dollars in grants. Yet even with the resources of the largest foundation in the world, we recognize that we can only play a small part in achieving global health equity.
While governments and markets will have an enormous role to play, the capacity to achieve true global health will be driven by the international community of innovators—the community gathered here today.
While often driven by human curiosity, the role of science and technology in global health will be measured by its ability to improve people’s lives. The mutual responsibilities of science and society are:
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To create new knowledge
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To use that knowledge to create practicable solutions to real human problems
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To use those solutions to improve the lives of all people
It is easy to be cynical about the ability to affect health among the poor. Too often, efforts are presumed to be unworkable in the face of a multiplicity of constraints.
A recently published work carefully analyzed examples of large scale successful health programs in the developing world. Seventeen examples of success were examined and all share a number of attributes:
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They had a clear technical path with a technical consensus
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Adequate resources in time, people, and money
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Leadership and champions
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Political will
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Partnerships
In fact, success was not dependent upon the nature or functioning of the health system—too often taken as an excuse when, in fact, fragile health systems should be seen as creating additional challenges to be solved by innovation.
To achieve global health equity will require three types of innovations:
1. Innovation through the creation of technology.
New tools and strategies are needed to address diseases and health conditions that affect billions in the developing world that the scientific community has either ignored or has simply failed to find any solutions—such as vaccines for HIV and malaria.2. Innovation through the creative adaptation of appropriate technology.
Health tools must match the needs and requirements of all global communities. This is the aspect of global health innovation with the most profound implications for science, technology, and industry, a point I will return to later.3. Innovation through creative partnerships.
Innovative approaches to the financing, security, delivery, and measurement of health interventions to those who have been left out.
The mantra for responsible innovations is that we must become problem solvers. For science, for technology, for health delivery, problem-solving will require new ways of doing business.
Let me illustrate with three global programs that the Gates Foundation has been involved with:
1. Grand Challenges in Global Health
Over 100 years ago, the mathematician David Hilbert inspired generations of mathematical innovators with his famous speech laying out the Grand Challenges in Mathematics. Two years ago, we began a global process to attempt to define a set of scientific and technical grand challenges in global health.
We called for ideas from the world’s science, technology and health communities that posed the question:
“What specific scientific or technical breakthroughs would be required to overcome one or more roadblocks that stand in the way of solving a critical health problem of the developing world?”
We received thousands of pages of ideas from over 80 countries. Using this input, a 20-member international scientific board, of which Dr. Ganguly is an esteemed member, created 14 specific Grand Challenges in Global Health. We then called for proposals for solutions—radical, pragmatic, high risk—but aimed not at exploring a problem but solving it. For example:
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How to create vaccines in entirely new ways:
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To create life-long immunity at birth with a single dose of an antigen
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To solving the thermostability of vaccines
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To creating effective, needless delivery
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To making immunization predictable and not empiric
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To solving the classic antigenicity – immunogenicity paradox
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At least 10,000 scientists from over 70 counties were involved in proposing solutions. Over 400 full grants were submitted, unfortunately requesting over $4 billion, much more than we could fund. After extensive review, we will soon announce approximately 10 percent of these as recipients of Grand Challenge grants.
We had hoped to achieve four goals with this program:
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Raising the visibility, stature, and excitement of Global Health Science
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Inspiring the world’s scientific community and especially young scientists to think about what it takes to solve a problem
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Like Hilbert, creating a list of problems that have not been solved, that are worth solving and on which many would work on solving
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And finally, directing 100’s of millions of dollars to fund new communities of global health problem-solvers in science and technology
2. The Global HIV Vaccine Enterprise
There are few single medical technologies that would have as profound an impact on global health than an effective HIV vaccine. It is one of the most scientific and technically difficult problems ever faced. Progress has been painfully slow. This virus seems to have perfected the avoidance of the immune system, and with over 60 million people infected, not a single proven example of effective acquired immunity.
About two years ago, several dozen scientists began a conversation to ask whether we believed that our current approach to solving this problem was optimized. The universal answer was “No”.
In response, what we proposed was a new approach called the Global HIV Vaccine Enterprise. Its premise is that “business as usual” is unlikely to solve this terribly refractory problem. In many ways taking its inspiration from the Human Genome Project, the “Enterprise” has created an ongoing process of producing, via the work of hundreds of scientists, a scientific strategic plan and a mechanism to continuously update that plan. The “Enterprise” itself is an alliance of funders who have agreed to align their HIV vaccine activities against this public, highly debated, and evolving global strategic plan. Enacting the Enterprise approach will require:
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The clear formulation of the questions that must be answered, the tools and technologies that must be created and the resources and structures needed to fulfill this scientific plan
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The responsibility of research funders is to assure that there is adequate funding to definitively answer those questions and to create the technical tools and data sets needed.
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The agreement of the participating scientists will be to share data, focus on the priorities laid out in the shared plan and set clear experimental standards that will enable all of us to have a scientific basis for what it means to be making progress towards an effective vaccine.
Let me illustrate the Enterprise principles with one example: No technical advance occurs without tools of measurement that are robust, relevant, reliable, and universally available.
Yet, in the arena of HIV vaccine development we lack any but the most rudimentary ways to measure the human immune response.
The “Enterprise” will change that, creating a global Human Immune Response Measurement Network that will replace the nearly random empiricism of current vaccine trials with a set of scientific guideposts to objectively direct real progress as we move from generation to generation of vaccine candidates. We have virtually abandoned the development of neutralizing antibodies because the problem has been too hard and because there has been no work to develop new technologies for isolating antibodies, and no mechanism to bring together immunologists, structural biologists, and synthetic chemists.
The Global HIV Vaccine Enterprise will be a massive experiment in change:
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A new way of both cooperating towards a common goal while maintaining the essential competition of ideas that compels scientific progress.
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A mechanism for holding ourselves accountable to a shared, global, and transparent plan – a plan that is alive and changes with new knowledge, to new tools and new ideas.
The oversight of this Enterprise is provided by an eminent international coordinating committee, and India is represented by Dr. Raj Bhan. We look forward to deeply engaging Indian science, government, industry, and the people of India in tackling one of the greatest technical challenges in the history of medicine.
3. Global Alliance for Vaccines and Immunization (GAVI) and the Vaccine Fund
The tragedy of unfulfilled promises in the delivery of spectacular advances in health technologies is no place better illustrated than in the failure to immunize every child in the world with vaccines of proven effectiveness. This is a failure responsible for the entirely preventable deaths of over two million children per year, virtually all in the developing world, and India is, unfortunately, no exception.
New vaccines take 20 or more years after their introduction in the industrialized world to begin to be adopted in the developing world. In 2000 a new global partnership called GAVI was created to fix this. It was coupled to a free-standing purchase fund, the Vaccine Fund, launched with a $750 million grant from the Gates Foundation. Its goal is to close the immunization gap between rich and poor. Its method is to bring order, reliability, accountability, and clear technical paths for the manufacturing, financing, and delivery of vaccines to the 75 poorest countries of the world.
In 2000, 30-35 million children out of a birth cohort of about 90 million children in these countries did not receive even the basic recommended immunizations. Newer vaccines, such as hepB, Hib, pneumococcus, and yellow fever, were unavailable to virtually all of these children.
In five short years of GAVI, nine million additional children have been immunized with basic vaccines, 42 million with hepB, six million with Hib and over three million with yellow fever – with an estimated 500,000 lives saved.
To make immunization safer through new technologies, almost ½ billion auto-disable syringes have been introduced, preventing over 600,000 infections from hepatitis B alone.
By making product demand and the market predictable and creating a new way of doing business in the public sector, in five years we have gone from only a single manufacturer of DTP-hepB combination vaccines to 10, accompanying a huge increase in demand and the price has dropped by 20 percent.
The public sector can neither shun nor replace the private sector but must creatively engage it – an emerging example of “Practical Ambitions” – to harness the power of markets where markets have failed.