― International Cooperation of the Medical Science Mr. Inamori, Ladies and Gentlemen: The commemorative prize given to the Nobel Foundation is in honor of the many hundreds of Swedish scientists who have been involved in the work of the Nobel Foundation and of the prize committees since the beginning of this century. I have chosen to give a lecture of a more personal nature, relating to the biggest international cooperation ever undertaken in the field of health research, with which I have been connected during the last fifteen years. Health is certainly a primary concern of every individual, and I will start by giving a little survey of the health situation in the world. I realize that a large part of the audience is not very familiar with this field, as you are looking forward to the “real” prize winners, but I will make it as easily understandable as possible. There is a drastic difference in the health situation in developing and developed countries. Considering the demographic patterns of death, for example, we find that in the developing countries up to 50% of deaths are of children aged less than five years, and once they have survived this critical period, people die more or less remarkably. In a typical industrialized, developed country nowadays, death in early childhood is almost eliminated, and people live a long life, and those who die are at a very mature age, for both males and females. Sweden has long had a very good system for recording deaths and births, and this allows us to say that, tragically, more than half of the population in the world are living under conditions where the situation is similar to Sweden in the year 1750. It is generally the tropical countries that have the worst situation, with more than 30 percent of the children dying before five years of age. In the industrialized nations including Japan this figure is very low. So that is basically the situation. How has this changed through time? If we again look at Sweden, we find that the death rate and the birth rate have become almost the same, which means that Sweden has zero growth, we have practically a stable population. This is a trend which took a long time, during which the death rate and then the birth rate went slowly downhill. In a country like Sri Lanka these changes are taking place at a much quicker rate. The death rate drops quickly, but the birth rate stays high, and that is the background of the rapid population increase. Often the death rate goes down before the birth rate, and the rate of increase is very high. For many developing countries, it will take until the latter part of the next century until they can reach zero growth. This of course is a very serious situation in many of these countries. In some of them there is more than two and a half percent increase every year, and many of these countries have great difficulties already today in managing their population, their health and their food situations. In the short term, from the year 1980 to 2000, there is also a clear pattern of difference. The industrialized countries of Europe, North America and Japan will remain very nearly stable with a modest increase from 1.1 to 1.3 billion expected in these 20 years. Whereas in the developing world the population is estimated to increase from 3.3 to 4.8 billion. Where will this end? There have been many predictions that the population of developing countries might end up someplace around eight or nine billion, and on top of that we will have one or two in the developed world, so anyplace between eight and twelve billion might be the final outcome. What is the health situation of this population? We all saw the hunger catastrophe in Africa this spring, spread around the world on television, but there is a silent and even worse situation in the health field. It is estimated that about 100 million people get malaria every year. New leprosy cases number only 11 million, but you know that is a chronic and very difficult disease. And the problem is that for many of these diseases there is no good therapy available. In many parts of the world malaria is rapidly becoming resistant to the commonly used drugs, that is chloroquine resistant, and this is In this situation at the beginning of the 1970s, the World Health Organization, which until then had had a small advisory committee on medical research in Geneva, suddenly decided to have such research committees in six regions, including Europe, Africa, Southeast Asia, and the Western Pacific. These committees consist of scientific representatives from most of the countries involved, and they were interested to look into the question of what type of research is needed to attack these health problems I mentioned. They agreed that the most urgent need was population, and it was the tropical diseases such as malaria and diarrheal diseases that are causing most of the early childhood death. In each field special groups were organized for improving chemotherapy, immunology, vaccine development, and application in the field. So a very large organization took form. This program undertook to do research and development to improve the tools needed, and at the same time see to it that training and strengthening of biomedical research capabilities took place. It was tragic in many developing countries when the colonial power left, as many of the hospitals and research institutions that they had organized and were running were left, and in many cases closed down. Now I’ll just give a few examples of what has happened under this very large program. Scientific projects on malaria are now being pursued in a great many locations in many nations, often by people going there and collaborating locally. Through this network the progress of the new resistant strains of malaria is followed, and new approaches to control are tried out. I might mention a very interesting development, an unexpected one. That is a Chinese drug called “quing hao su”, derived 2000 years ago from a plant that was known to decrease fever. From this Chinese scientists have isolated a compound in pure form, a very unique structure. They are making analogues, and through the cooperation of the World Health Organization, clinical trials are now going on in many countries. This is very exciting because it is effective against chloroquine-resistant malaria, and it especially seems to be very active against the dangerous malaria of the brain. Thus traditional medicine is already contributing an unexpected and interesting thing. Otherwise the main focus in the malaria field is on vaccine to attack the malaria parasite during its various stages of development, and progress there is unexpectedly successful. Various projects are under way on African sleeping sickness, which is one of the diseases where there is really no good therapy, so hopefully that will change the situation in a number of years. Another group are the so-called philaria, which are diseases that are spread by mosquitos and develop various sized worms in different parts of the body. In West Africa a common variety of these worms settle in the eyes, and up to 20 percent of the population in a village may be blind. Large areas cannot be populated because of these diseases. Again there are no good drugs available. And there a very large cooperative effort is now being made between scientists and the pharmaceutical industry. Here you see how synthesis and screening on new drugs, and their metabolism is studied. The screening is mainly done in Australia, the synthesis mainly in Europe and the U.S.A., and then clinical trials are going on. So this is a completely coordinated worldwide activity that can proceed much more quickly than a single laboratory or a single pharmaceutical industry can proceed, because clinical trials in developing countries are very difficult and there the World Health Organization has an enormous advantage. Leprosy, as you know, is a disease that has been described for thousands of years. It has been eradicated in the northern and industrialized countries. I think the last leprous patient in Scandinavia died in the early thirties. Leprosy is being spread by the many refugees now being distributed over the world, so there are many hundreds of lepers in the U.S. now, for example, although they didn’t have any before. Now various new therapeutic drug trials are being organized around the world. Planning takes place in Geneva at WHO headquarters. Drugs are manufactured in various places, and then the trials are coordinated, the same trials in different places. As you know leprosy is a very drawn-out disease, and it is very important to follow the patient during many years. The most exciting development in leprosy depends on a little animal which lives in Central America, and is cold-blooded. It is called the armadillo. What has hampered research on leprosy is that the bacteria multiplies so slowly, that it has been very difficult to get pure bacteria to work with if you want to make vaccines, for example, and growing it in vitro has been virtually impossible. By chance it was discovered about 10 years ago that if an armadillo is infected with leprosy bacillae they grow madly, and in one year the liver and internal organs are packed with leprosy bacillae. So this program proceeded to organize farms with many armadillos. They are infected with leprosy bacilla, the tissues are brought to England and purified and there is now a depot of pure bacillae there that scientists around the world can use. In a few years time they have now got the first vaccine of heat-killed bacillae. It has been safety tested in Norway last winter and they will start clinical trials in India probably this winter. If this is successful it will be an enormous boost for eradicating leprosy. The program for tropical disease research has branched out dramatically during the last ten years. Almost three thousand scientists have been directly involved, located in 122 countries, and there have been meetings and workshops, and the important thing is the projects. There have been almost 2000 projects funded in 95 countries. Now, how is this large program organized? Well it is something completely unique for the UN system. For each special field ― for example, malaria chemotherapy, malaria vaccine or leprosy vaccine ― there is what is called a scientific working group. That in effect is a small research council of about eight or ten people who make the plans, who invite people, who invite applications and who also decide who should get how much money. So it’s a classical type of research council, but an international one, and they fund the projects. The whole program is supervised by something called a joint coordinating board, which has 30 seats, one each for WHO, the World Bank and the United Nations Development Programme, and then there are 27 representatives appointed by the governments of 27 countries, most of them developing. So they are really supervising the research done on their behalf. It is formally known as the Scientific Subcommitee for Tropical Diseases Research of the WHO in the UN system, but it is run entirely by scientists and not by UN bureaucrats. They only help as secretaries and arranging transportation of drugs around the world and so on. So it takes advantage both of the UN system and of the scientific expertise of the world. In addition there is an annual review by independent scientists of how things are progressing, and they recommend how the available money should be distributed. The point is that the UN system doesn’t have money for this type of thing. They don’t do research. Therefore it was important that the World Bank joined, and also the United Nations Development Programme. And then this group of agencies invited the member countries to make voluntary contributions and that was very successful. During the first six years, for example, the largest contributor was Denmark and the other Scandinavian countries were also rather high on the list, and various other countries and even the World Bank, WHO and UNDP are contributing. The annual budget now is about 25 million dollars. Japan has recently joined symbolically, but I’m sure will increase its support. The other area I mentioned was the diarrheal diseases. That is not a simple disease item. It is different in different countries and different areas. In some areas most of the diarrhea is caused by viruses, in some by amoebas, some by bacteria. Therefore there must be wide-ranging studies by various expert groups, and they should first of all further develop the oral rehydration, which you might have heard about, the sugar-salt solution that has been improved greatly. They should define what types of diarrhea are the most common in the different countries, and they should also try to develop vaccines for the viral diseases and continue the testing of new anti-diarrheal drugs which is going on now. All these fields are not very actively pursued by industry because you can’t have much hope to regain money by selling drugs in the developing world. But with this government support, industry has now heavily entered the field. Again the support of this program, which started only three years ago, is already rather high, up to 12 million dollars, and again Denmark and the Scandinavian countries are high on the list. There is also a program for human reproduction research which was started a little earlier and that is done with the same mechanism as the programs I have just described for tropical diseases and diarrheal diseases. In this field Japan is one of the biggest contributors. Of course population research recently has taken on additional political overtones, but hopefully that will quiet down slowly. Apart from the research on these diseases of various kinds, these programs should try to help on training and technology transfer to the developing world. In many places all three programs are doing that, and at many locations a clinic or an institute has been selected that is strategically located and has some possibilities already, and a five-year plan is usually formed for equipping and training of additional people there. But a prerequisite is that a government should be prepared to take it over, possibly gradually over five or ten years, otherwise nothing will happen. There is a long and sad history of institutes being started and then abandoned. With time this is, I think, the most efficient way of technology and knowledge transition between the industrialized and the developing worlds, but of course one has to be patient, and it will take decades until Now these three programs, on reproduction, tropical diseases and diarrheal diseases, have started and rapidly grown and are now stably funded, and the main concern now is to have these continue growing because many good results will require further development and further clinical trials and it would be sad if that could not be efficiently developed. Many billions of dollars are now used in bilateral aid by the big countries. They prefer bilateral aid for political reasons, which in natural for they can hook it up with political and business deals, but the amount needed for increasing this type of cooperation is really very small, and hopefully that will grow soon. This type of activity under the umbrella of the UN system hopefully will develop for many other fields of science, agriculture and so on. I think it’s a model that should be utilized much more. This way of building up cooperation and trust between nations is a long-term thing, but I think it’s even more important than disarmament in the short term. And so I leave you with the hope that this is an example of a development of international cooperation that The Inamori Foundation in also committed to pursue.



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