COLLABORATIVE RESEARCH ON TROPICAL DISEASES (1985)  p. 4 of 12

C.  THE GORGAS MEMORIAL LABORATORY, PANAMA

          This laboratory for the study of tropical diseases was founded in 1928 by the Gorgas Memorial Institute, an American private, nonprofit organization, in memory of Major General William Crawford Gorgas.  The Government of Panama donated the land and original buildings, and the U.S. Congress authorized an annual contribution for operating funds.

          This contribution continues today in amounts up to $2 million.  Panama contributes a modest research fund and grants tax advantages.  Additional contracts and grants for research are received from U.S. agencies and international programs for specific projects.

          Originally, the core support for operating expenses passed through the Department of State.  In the mid-1950s, NIAID administered the award, and this responsibility was passed to the Fogarty International Center of NIH in 1971.  Administration of the grant does not carry with it the power to govern or control the laboratory.  It remains in private hands, governed by a 47-member Board of Directors based in Washington, D.C.

          In 1983, NIH responded to pressures on its budget by including no funds for the laboratory in its budgetary request.  NIH cited the fact that funds provided to the laboratory were not subject to the same peer review process as were other NIH programs, and proposed to use the savings to fund additional investigator-initiated projects.

          There can be no doubt that NIH does not welcome the role of conduit for funds over which it can exercise no control for quality or process.  The decision to omit funds for the laboratory altogether from the budget may, however, have reflected an awareness that neither the Congress nor the Department of State was likely to permit the laboratory to founder at a time of heightened political tension in Central America.

          In any event, the U.S. Senate requested that the General Accounting Office (GAO) report on the scientific review procedures applied to work at the laboratory, the similarity of research at Gorgas to other federally-funded research, and the extent of efforts to broaden the base of financial support for the laboratory.  At the same time, the Senate requested the Office of Technology Assessment (OTA) to examine the quality and relevance of research at the Laboratory.  The two ensuing reports, of August 1983, provide most of the information for this section.

          The Gorgas Laboratory began, and achieved distinction, as a research institute concentrating on malaria, trypanosomiasis, and leishmaniasis.  It has always played a role in surveillance of yellow fever.  More recently, increased attention has been given to other insect-borne diseases and their vectors.  In addition, current projects concern sexually-transmitted diseases, specific cancers, and ecological studies.  Some projects involve clinical work; about 1000 patients are treated yearly, as a service to the community and as a source of learning about the natural history and treatment of disease invasions of the isthmus from South America.  The Laboratory also offers access to a supply of Aotus monkeys, an animal useful for malaria studies.  A six-week course on tropical medicine sponsored by the Navy is the principal training activity; but the Laboratory also hosts predoctoral and postdoctoral students and scientists.

          The scientific staff of the Laboratory in 1983 consisted of six Americans, nine Panamanians and one Peruvian, under the direction of Raymond H. Watten, Phillip’s colleague in Bangkok and later commander of NAMRU-3 in Cairo.

          The budget of the Laboratory over the last several years has run about $2.5 million, of which about $1.8 million consisted of core support.  In fiscal year 1985 the budget was over $3 million, with $2 million in core support.

          The OTA review of the scientific facility and the relevance of work at Gorgas gave the Laboratory high marks.  OTA noted the special value to American science of a laboratory located in the tropics, and found overall scientific quality at the laboratory to be high, if a bit uneven.  Similarly, with some exceptions found almost entirely in the core-funded activities, OTA found the research relevant to the various parties at interest.  OTA did make several suggestions for improvement, including the proposal that Gorgas make more of an effort to seek out associations with universities and collaboration with groups from other countries and international organizations.  The report also recommended that better use be made of the Advisory Scientific Board, in planning research and as part of an improved peer review process.  Also, the Laboratory should plan to move more fully into modern scientific technologies, such as the use of monoclonal antibodies and other immunological diagnostics, and biotechnology approaches to vaccine research and development.  The overall conclusion of OTA was that the positive attributes of the Gorgas Laboratory far outweighed its costs, and that defunding would be a mistake.

          The GAO report was somewhat more critical in tone, but found no evidence which would support termination of U.S. funding on grounds that the Laboratory’s research was not needed, duplicative, or of a poor quality.

          GAO was particularly critical of the fact that Gorgas had made little effort to expand the financial base of its activities.  In recent years, only Panama has made financial contributions, in addition to those of U.S. agencies, in amounts under 4% of total cost.  The Institute did contact 150 foundations and other private funding organizations without encouraging results.  Other countries in Central America were not solicited because they were thought to be too poor to contribute.  WHO and PAHO, contacted by GAO, indicated they could not provide additional funding.

          Among the alternatives for funding the laboratory suggested to GAO in the course of the study was the internationalization or regionalization of Gorgas.  Internationalization could be modeled on the experience of the ICDDR/B, which will be discussed in more detail later.  Regionalization might be modeled on INCAP, which it will be recalled was the model for the original SEATO cholera laboratory in Dacca.

          The Panamanian Minister of Health formally proposed internationalization in 1982, suggesting that his country and other states of the region would be more willing to contribute if they were invited to play a greater role in the decision-making process, and received greater benefits from the research.  The Minister later had reservations about his own idea because the Laboratory could end up like INCAP, where some member countries are far in arrears in their payments, but still participate in decision-making.  A State Department official also was negative about internationalization because some of the purposes of the Laboratory, such as improving environmental and health quality in Panama, training military physicians, and offering a means of applying political leverage in dealing with the Government of Panama, would not be well served.

          Another set of critical GAO findings concerned the processes of planning and administering research at the Laboratory.  GAO could identify no formal long-range program plan or planning process for the work of the Laboratory.  The shape of the program is said to be set by the recruitment process.  Scientists appointed to staff positions are free to determine their own research directions, subject to an internal review.  The review process is informal, and given the small number of scientists at the institution and the diversity of their interests, cannot approximate the quality of the internal review process at NIH.  External reviews are conducted approximately every three years by the Fogarty Center.  The 24-member Advisory Scientific Board has been rarely utilized, and has never met as an entity.

          All this does not necessarily reflect adversely on the quality or productivity of the Laboratory.  Both OTA and GAO found the publication record of Gorgas scientists to be good, and the Fogarty external review team in 1980 concluded that the Laboratory’s studies were of scientific importance to the United States, Panama, and the region.  The overall research quality was of a high standard; and the scientific value and benefits derived from the Laboratory were a worthwhile investment of U.S. funds.

          The two reports offered ample grounds for the Congress to insist that funding be restored to the endangered Laboratory, and within the Executive Branch, the Secretary of State took the unusual action of addressing a letter to the Secretary of Health and Human Services urging that the matter be reconsidered.  The Secretary felt defunding to be inconsistent with our posture of constructive engagement with Panama and other countries in the region.  This action by the Secretary of State, while admirable in itself, reveals a serious shortcoming in the budgetary decision-making processes of our Government.  There is no mechanism for the consideration of diverse elements of the national interest in assigning budgetary priority to a project other than intervention at the Secretary level.  Each agency defines its priorities under its own terms of reference and authorizations, taking no formal notice of the multiple benefits that an activity may produce.  It is difficult to see how this system could produce optimal results in terms of the national interest.

          Turning to the comparative framework, the following observations can be made about the Gorgas Memorial Laboratory:

1.  Scope of the Program

          The Laboratory is an unusual resource, able to conduct basic and applied research in a tropical setting with an extraordinary diversity of endemic problems.  The range of activities, including some clinical research and drug and vaccine testing, is very broad, but it is not broad along the spectrum of a particular disease.  That is to say, the Gorgas Laboratory is not focused, as was the Pakistan-SEATO lab, on a single family of diseases.  Nor is it part of a coherent targeted effort against a disease, as are the military labs, except for those parts of its work that are contracted for by the armed forces or other agencies.  The result is not a wide range of activities along a single spectrum, but a wide variety of activities along disjointed segments of different disease spectra.

          This may be a problem of “critical mass.”  If Gorgas had a single disease concentration, or if it were an integral part of the research program of a major laboratory such as NIAID or WRAIR, it could perhaps have a more focused impact on one or more diseases.

          At one time, Gorgas appears to have had a somewhat greater concentration on a single disease: malaria.  Over the years, investigators have worked on vector biology, vector control, response of the parasites to drugs, drug resistance, epidemiology, monkey hosts and other aspects of malaria. 

2.  Degree of Collaboration

          Naturally Gorgas has established good working relationships with the Panamanian Ministry of Health and hospital authorities, without whose cooperation field and clinical studies could not be carried out.  Relationships outside Panama have occurred with the Medical Entomology Research and Training Unit in Guatemala, the Centers for Disease Control, NIH, Louisiana State University, the University of Alabama at Birmingham, Johns Hopkins University, and other academic and scientific institutions.  It has undertaken a number of activities, such as conducting environmental assessments of major project proposals, which are of service to the Government of Panama.  It has not, in general, sought to establish collaborative relationships with other institutions in the region, nor to expand its training programs to accommodate very many scientists from the region.

3.  Results: Impact on disease

          OTA sought to determine the value of the research done at the Gorgas Laboratory by examining the quality of its output and the relevance of the topics studied to the health concerns of the United States, Panama and the region, and to biomedical research generally, with positive conclusions as noted above.  The major accomplishments of the Laboratory from 1970 to 1983 were the following:

·            Continued yellow fever surveillance and monitoring of vectors of St. Louis encephalitis and Venezuelan equine encephalitis vectors and reservoirs

·            Insect genetic studies using isozyme markers

·            Transovarial transmission of yellow fever virus in mosquitoes

·            Use of Aotus monkey model for testing of therapeutic agents for malaria

·            Several new viral isolates in area

·            WHO regional center for bloodmeal analysis of triatomids

·            Improved identification of insect vectors: sandflies, triatomids, blackflies, etc.

·            Development of cancer registry in the Republic of Panama

·            Discovery of high incidence of cervical and penile cancer in Herrera Province (Republic of Panama)

·            Studies of sexually transmitted diseases in the Republic of Panama (the first such studies in Latin America)

·            Rapid identification of viral agent in recent epidemics of conjunctivitis and encephalitis in the Republic of Panama

·            Discovery of high prevalence of HTLV antibodies in the Republic of Panama

·            Environmental impact assessment of Tabasara hydroelectric project

(Source:  Gorgas Memorial Laboratory, Office of the Director.)

4.  Results:  Capacity Building

          The Laboratory helps to expand the U.S. capacity for research and disease control through its training course and its facilities, which offer access to a useful primate population and to areas in which many insect-borne diseases are endemic.  A substantial number of Panamanian researchers are trained and employed at Gorgas, frequently moving on to university or public health positions in which their Gorgas experience is invaluable.

          In general, however, the Gorgas Laboratory has not had, as part of its mission in its fifty-six year history, the building of local and regional research capacities.  This would appear to be a major shortcoming of the present operation, one that could probably not be remedied with existing resources.

Conclusion

          It is worth noting that the Department of State, while able to exercise influence at the highest level to head off a budget cut that would damage our diplomatic posture in the region, is unable, in terms of budgetary authorities or scientific expertise, to stimulate an expanded course of action that would positively benefit U.S. standing in the region.  NIH has no mandate to initiate medical activities for diplomatic purposes.  The State Department lacks the expertise as well as the mandate.  No agency is in a position to, or expected to, define the optimal use of U.S. resources for medical research in the Caribbean, weighing in the balance scientific, diplomatic, military, developmental and humanitarian considerations, all of which are elements of the national interest.