COLLABORATIVE RESEARCH ON TROPICAL DISEASES (1985)  p. 6 of 12

E. THE INTERNATIONAL CENTER FOR DIARRHEAL DISEASE RESEARCH, BANGLADESH (ICDDR / B)

          We are familiar, from the early pages of this paper, with the advance of science and the discovery of an oral rehydration therapy for cholera which has allowed us to come to terms with, if not defeat, one of mankind’s most terrifying afflictions. Our main concerns in this section are to note the directions of continuing research at the Center and to make some judgment of the value of creating an international center as a device for concentrating research on a tropical problem.

          There are, superficially, parallels between two recent triumphs of modern science in Asia: ORT for diarrheal diseases and the short-strawed rice varieties that doubled or tripled yields per acre. Both involved work by Western and Asian scientists in internationally controlled laboratories in tropical areas where the plants and diseases of their interest thrive. Both international laboratories continue to enjoy a diversity of funding sources and widespread attention from the development community. Curiously, the creation of an international center as a device for ensuring research continuity, applicability, and excellence, largely insulated from the political or parochial concerns of any country, has been replicated a dozen times or more in agriculture, while in medicine the ICDDR/B remains the sole model.

          An extensive analysis of the parallels and divergences of the two fields would be rewarding, but would take us too far into the realm of agricultural research to be pursued here. Still, because the international center model is one serious alternative open to the United States if it decides to make a major commitment to attacking tropical diseases, the experience of the ICDDR/B deserves special scrutiny.

          As a model international center, ICDDR/B is flawed. In tracing its origins in the cholera story, we noted that after losing its SEATO affiliation at the time of Bangladesh’s independence, the Cholera Research Laboratory for several years existed as virtually a bilateral institution with its future status in doubt. Many in the new government favored turning CRL into a national institution, dealing as it did and does with some of the most serious health problems of the country. This alternative was found not to be feasible if a high level of international participation, particularly by NIH, was desired. The result was a compromise, an internationalized institution with continued responsibility for treating diarrheal diseases in Bangladesh. It is international and national at the same time.

          The Center’s role as a health-care provider is a boon to the country and probably has some scientific advantages in terms of access to a large patient population. The presence of the Center may, however, have inhibited the growth of a national capacity to deal with diarrheal diseases and distorted the pattern of development of the local medical profession through the lure of international salaries.

          The bilateral origins of the Center also account for a much higher ratio of local to scientific foreign staff, 40 to 18 in 1983, than would be the case for an international research institution begun from scratch. Marginal local scientists have been employed, with no solid research training program to improve their performance. Apart from distorting local career patterns, a heavy reliance on local appointments can have a stultifying effect on a center because such people tend to remain in their positions longer than staff members drawn from abroad.

          The Board has decided to follow WHO policies and establish a geographical distribution system for recruiting international staff. These positions will be filled by contracts up to three years, with tenure ordinarily not to exceed six years. These measures will in time lead to a more balanced distribution of nationalities among the staff, although they do not of themselves guarantee improved quality.

          Another perceived disadvantage of the ICCDR/B that may account for its being less emulated than its agricultural counterparts is that it was the child, rather than the parent, of success. When IRRI was set up in the Philippines, its scientists were aware that they could achieve major gains by dwarfing the rice plant so that it could use increasing amounts of fertilizer to produce a bigger head without toppling over. The trick had already been done for wheat, so it was only a matter of time for rice. In fact, within three years IR-8 was heralding the new high-yielding era called the Green Revolution.

          ICDDR/B is unlikely to produce a revolutionary product to rival what was already accomplished before the Center was internationalized, but its research program could still be at the frontiers of knowledge if quality were assured. Research on invasive diarrheas not alleviated by ORT; efforts to elucidate the interactions of diarrheal diseases, nutrition and fertility; and vaccine trials: all are of major potential significance. Top-quality research is less easy to ensure, however, now that the organic links enjoyed by the CRL with CDC and NIH are severed.

          The ICDDR/B record in its first five years is strongly positive, and we’ll get to the plus factors, but before leaving the subject of its disadvantages at birth, one must mention the curious liability of its dealing with human diseases. For agricultural research, the World Bank is able to assert confidently that up until 1975 the international centers produced an 80% annual return on investment. No such figures are available or calculable for curing or preventing human diseases. This is not merely a statistical mirage; it has real meaning to those who allocate research resources. It is notoriously easier to get funds for research on a disease that affects chickens than for one which afflicts millions of people who live in the tropics.

          Turning now to the plus side of the ledger, the Center has in a remarkably short time succeeded in attracting a broad range of financial contributors. Initially, a core grant from USAID of $1.9 million per year for five years represented over 95% of the Center’s revenues. Within five years, the number of contributors has grown to 22, and the core grant is only 25% of the $7.1 million budget for 1984. The budget for 1985 is $9.1 million, which includes $1 million for extensive field trials of a new oral vaccine for cholera. USAID is in the process of determining whether its commitment of core funds for the next quinquennium will remain at the same or a higher level.

          The ability to raise large sums is not, unfortunately, an unmitigated blessing. Some veterans of the CRL days believe the quality of research at ICDDR/B has suffered, in part because the size of the institution makes it difficult to turn down large programs for which funding is available. Also, the availability of funds may permit initiation of activities not of the highest priority.  Nevertheless, the ability of ICDDR/B to diversify its sources of funding was an important objective of AID’s.

          When AID sought to internationalize the Center in the late l970s, it cited four general goals: to achieve permanence, to develop scientific potential, to attract high-quality staff, and to obtain broad-based support for operating and capital costs from multiple donors. The first and fourth of these objectives have been met, and progress has been made on the second and third. The Center continues to enjoy unique advantages in having the capacity to conduct high-quality research; to learn about the technical, managerial and socio-cultural problems of conducting health programs; and to adapt and field-test new products as they become available. No other institution can match the Center’s ability to conduct interdisciplinary research on the complex and important biological and social interrelationships of diarrheal diseases, human reproduction and nutrition.

          Recognition of the research value of the Matlab Demographic Surveillance System led to its designation, by the U.N. Population Division and WHO, as one of five areas of the world where extensive mortality studies will be done.

          Given the unusual importance of the institution, there remain scientific shortcomings and rising costs, which the trustees and staff of the institution are seeking to improve. An AID review of scientific work at the Center in 1982 concluded that the research was of excellent quality and great significance, but noted several weaknesses. Although it found the program to be generally balanced, it detected some lack of expertise in epidemiology and immunology. It thought training a bit overly structured rather than concentrated on field-based and laboratory bench experience. Equipment was not up to standard, the quality of publications less than first rate, and the dissemination of information limited by travel funds.

          More recent external reviews found shortcomings in laboratory equipment and in the research objectives pursued in some fields, weaknesses the staff and trustees are working to improve. The issue of rising costs stems in part from continuing pressures to increase the number of international posts, and salaries, at the institution. The adoption of United Nations pay scales for 42 staffers has added over $1 million to the budget, and 13 additional posts have been proposed for international status.

          Additional observations about the ICDDR/B can be made in the context of the comparative framework:

1. Scope of the Program

          This is one of the strongest characteristics of the international center organization model, as it assumes vertical responsibility for work on a disease from the laboratory to the village, generally on a worldwide basis. In the case of the ICDDR/B, village level research includes, as we have noted, interrelated work on nutrition and fertility in addition to diarrhea.

          Geographically, the Center has operated somewhat more narrowly than would normally be the case for an international center. This is due in part to the diversity of conditions that exist, making control programs too variable for ready replication. In addition, there is a WHO Control Program for Diarrheal Diseases (CDD), which performs much of the international monitoring and liaison required for keeping track of research developments concerning the diseases. WHO organized the CDD in about six months, just before the CRL was internationalized. Cooperation between the two organizations occurs, such as the testing of the oral cholera vaccine at Matlab this year, but relations have not been particularly close. This situation may improve because the CDD director joins the ICDDR/B Board in 1985.

          The ICDDR/B undertakes the important task of keeping scientists and health professionals aware of developments on the research scene. In 1982, with support from the International Development Research Center (IDRC) of Canada, the Center established DISC -- The International Diarrheal Disease Information Service and Documentation Center. Among the DISC activities is the quarterly publication of the Journal of Diarrheal Diseases Research, containing original papers and a comprehensive bibliography of available research papers.

2. Degree of Collaboration

          For an international center, collaboration implies forward linkages with national research institutions and health care providers, and backward linkages with basic biomedical laboratories in the advanced countries. In the rapidly moving field of medical research, scientists in international centers in the tropics can become isolated if vigorous interaction is not possible with scientists in other institutions. In the process of internationalizing the CRL, long established linkages with NIH, CDC and Johns Hopkins were ruptured. As a result, reliable sources of high-quality manpower were jeopardized.

3. Results:  Impact on Disease

          William B. Greenough III, director of the ICDDR/B, cited the following significant basic and applied research accomplishments in a letter to AID Administrator McPherson in November 1984:

·            Intravenous Solution:  One of the first safe and truly effective IV solutions, for both adults and children and for all types of diarrheal diseases, known as “Dhaka Solution,” was developed at the Center.

·            Oral Rehydration Solution and Home-based Treatment:  ICDDR/B has developed effective, safe and inexpensive methods for packaging and distributing oral rehydration solutions that can be given at home. Center scientists are working to refine a new type of solution based on rice or other cereals instead of sugar. Initial studies indicate greatly reduced diarrheal output, a better taste, and added calories --a critical factor for malnourished children.

·            Causes of Diarrhea:  Largely because of ICDDR/B efforts, almost 90% of acute diarrheal cases can be diagnosed and treated. (Other sources, such as the OTA study on tropical disease research, say only 65-70% of acute diarrheal cases can be diagnosed.)

·            Impact of Effective Health Service Delivery:  ICDDR/B provides health services to approximately 200,000 persons annually in the Matlab field area and has demonstrated that diarrhea treatment with ORT, together with a carefully planned package of selected maternal-child health and family planning interventions, can have significant positive impacts on increased contraceptive use, on lower overall fertility, and, simultaneously, on lower infant and maternal death rates.

          Over the next five years, the two major foci of the ICDDR/B will be expanded research and training on oral rehydration solutions, and field-testing and research on vaccines. The first vaccine trial will begin this year, in collaboration with the Government of Bangladesh and WHO. Both points of emphasis are controversial. Some feel strongly that research on ORT has gone beyond the point of diminishing returns. Others believe the candidate vaccines now available are not sufficiently promising to warrant elaborate field trials.

4. Results: Capacity Building

          Through extension activities, ICDDR/B has helped Maldives, Indonesia, China, Saudi Arabia, the Philippines, Sri Lanka and Pakistan to build up their manpower resources for research and training to control diarrheal diseases. The definition of the training role of the Center remains somewhat controversial. One knowledgeable observer commented as follows:

          “The international efforts of the ICDDR/B weakened their ability to meet priority research and service goals in Bangladesh, and almost broke the bank. Their training capacity is limited in physical resources, but moribund in terms of vision and professional ability. Simply put, they are not trainers and have exhibited no interest in becoming trainers. I’m not sure that training was a rational choice in the first place, but they should drop it or do it right. In the larger context, capacity building for a research laboratory should have focused on high-powered, post-doc or graduate-level training of laboratory and clinical investigators. The community service aspects of the eclectic ICDDR/B program commanded a great deal of attention of the training group.”

          In Bangladesh, the Center is assisting the Government to strengthen a comprehensive prevention, detection, surveillance and control system, and to introduce proven maternal and child health and family planning methods into the health services delivery system. The Center’s contribution to Bangladesh is mainly in strengthening the disease control program rather than the research capacity of the Government, except insofar as the Center functions as a national institution itself.

This differs from the experience of IRRI, for example, where the international center has made a special effort to cooperate with and strengthen national research systems. The difference may be explained by the fact that, whereas virtually every government recognizes the need for its own agricultural research system, few find it necessary to establish a medical research system. Medical research, where it exists, is likely to be found in the universities rather than the ministries of health. Conceptually, governments seem to be seriously lagging in defining their medical research requirements as compared with their agricultural research requirements. This would appear to accentuate the need for international medical research centers.

Conclusion

          The ICDDR/B has succeeded in gaining permanence and expanding both its program and its sources of support. Its origins as a bilateral institution and its continuing role as an integral part of the Government’s health care delivery system have affected its quality and perhaps its ability to respond to other countries in the region and the world. Opposition within WHO to the international center concept added to its difficulties, and its costs can be viewed with concern if contrasted to the level of expenditures for the TDR program, for example. Although the experience of the ICDDR/B to date is not likely to raise a demand for more international disease-oriented research centers, it has made solid progress on complex biological and sociological issues. The Center remains an important resource for research on diarrheal diseases, for research on diarrheal fertility/nutrition interaction, and for the adaptation and field-testing of new products.