RESEARCH ON TROPICAL DISEASES (1985) p. 10 of 12
Before firm conclusions and recommendations are drawn about
preferred forms of collaborative research, this draft will be circulated
to members of the Project Steering Committee. In order to provoke comments and discussion, some tentative
conclusions are drawn and issues identified in the paragraphs below.
We may start by reflecting on our findings on the points in the
comparative framework we have tried to apply to each example in Section
1. The scope of the
program along the spectrum of research needed to deal with a disease
Only the international programs, ICDDR/B and TDR, and the
schistosomiasis program of the Clark Foundation seem to accept
responsibility for research across the spectrum. TDR and the Clark Foundation have mechanisms for establishing and
amending strategic plans, agendas of research topics that seem most
Of the U.S. Government-supported programs, the Department of
Defense laboratories operate along the widest bands of the spectrum,
from seeking to understand the biological nature of the pathogen to
devising methods of human protection from the disease. The military labs fall short of the international programs and
the Clark approach by having a limited concern for epidemiology, the
economics of protection, and the sociology and environment of the
village. In devising
protective strategies, the military scientists can assume standards of
sanitation, disciplined conduct, and financial resource availability for
the population at risk that do not prevail widely in the endemic
For the Government as a whole, there is no unit responsible for
monitoring the status, defining the research frontier and devising
research strategies, or formulating comprehensive policies for dealing
with tropical diseases, except within the mandates of individual
agencies. An explanation
for the absence of coherent, targeted efforts may be that the Government
does not consider tropical diseases to be of great concern to this
country, except as they endanger U.S. citizens abroad or threaten to
approach our shores. Another
explanation may be that a comprehensive approach to one or more of these
maladies would require more resources than the Government wishes to
supply. Two other views encountered in preparing this paper warrant
discussion by Steering Committee members.
One opinion is that the path of scientific discovery cannot be
charted; it is difficult to know what line of research will produce
knowledge of value in understanding or protecting against as disease. Hence, it may be unwise to attempt to formulate strategic plans
for attacking diseases.
The second view is that scientific advances are not required in
order to bring most tropical diseases under control. A hundred years ago, morbidity and mortality rates were as high
or higher in Europe and the United States as they are today in
developing countries. The
technologies and human behavioral changes needed to reduce Third World
rates to the level of the advanced countries are known: it is simply a
question of investing in sanitary infrastructure, clean water, and
education. From this point
of view, research expenditures on trypanosomiasis are justifiable in
order to advance our understanding of the immune system, without
implying commitment to the pursuit of protective substances against the
disease. Science should go
where the best scientific investigators want it to go, not where
administrators or politicians or development promoters try to push it.
2. The degree of
collaboration with scientists and institutions in developing countries
Scientifically, the most productive institutional collaboration
probably occurred between the Cholera Research Laboratory in Dacca, and
NIH and CDC in the United States. They
were all American institutions, basically, but the relationship was
productive because the quality of the work was outstanding, the
substance of the work was at the advancing research frontier, and each
institution brought something of value to the process. CRL gained from access to first class staff and CDC gained
valuable epidemiological field experience for a generation of young
workers. NIH also gained
field experience for its staff, but probably valued the relationship
less highly than did the other two institutions.
Currently, the GND program of the Rockefeller Foundation and the
ICIDR program of NIH include good models of collaboration on a limited
scale and on an abbreviated segment of the research spectrum.
Only three laboratories in rather advanced developing countries
were selected as GND grantees. Collaborative
relationships with institutions in the poorer countries are much more
difficult to sustain, although the Michigan State ICIDR in the Sudan
appears to be productive.
The TDR program of WHO, although attuned to the interests of
developing country scientists and intended to build Third World research
capacity, falls short of the collaborative ideal because mechanisms for
supporting long-term relationships between laboratories in advanced
countries and those in endemic countries have not been established. However, it is worth noting that training and grant support from
TDR has facilitated much collaborative work resulting in joint
The military labs abroad and Gorgas, although not completely
devoid of collaborative relationships, are the poorest examples among
As a general point, the investigator-initiated, peer-reviewed,
competitive grants programs that constitute the bulk of the funding for
medical research are unlikely to spawn many collaborative projects. Communications problems, language factors, and differing research
traditions are likely to complicate efforts to win highly competitive
awards. Programs such as
ICIDR which require collaborative relationships would need to be
expanded if the collaborative process were to be encouraged.
in terms of the impact on our understanding or controlling a disease
American medical research seems to operate on a version of the
laissez-faire principles that govern our economic thinking: each
investigator, in pursuing his or her individual research interests, will
maximize in social terms the value of the research funds available. In the search for unique research topics, the theory might go,
proposals will emerge to fill every perceivable gap in the advancing
research frontier. Overly
structured or narrowly targeted research designs, on the other hand,
would distort the allocation of brainpower, channeling research along
beaten paths into the unknown, but leaving large wilderness areas in
The quality and productivity of the American medical research
establishment makes it difficult to dispute this approach, if it is a
fair approximation of guiding principles, but perhaps the system depends
for success on a large number of active investigators. Where resources are scarce and investigators few, the targeted
approach may be a more efficient strategy.
Some types of experiment, which may be vital to linking different
segments of the research spectrum, donít fit well into the existing
array of programs and institutions. For example, the Rockefeller Foundation for some years
carried out experiments in St. Lucia, carefully costing out various
approaches to reducing infection rates from schistosomiasis on the
island. Out of these
experiments came valuable information that allows policy-makers to
choose among alternative strategies for controlling the disease, taking
into account environmental factors and resource availability.
That type of experiment would be unlikely to be funded in
military laboratories, where marginal costs of control alternatives are
of minor significance, or in Gorgas, which concentrates mainly on the
diseases of Panama. Nor
would an ICIDR grantee be likely to undertake such an experiment, given
their biomedical orientation. Possibly
AID would fund such a program, although no parallel example comes to
The point is that our present federally-funded programs and
institutions are not designed to track a tropical disease problem from
its biomedical origins through to the point of choosing among
alternative protective practices. There
are gaps in the spectrum, and no agency has responsibility to identify
or fill them.
in terms of enhancing individual and institutional capacities in the U.S
The creation of American capacity for tropical disease research
warrants separate treatment from creating Third World capacity. The military medical research system seems by far the most
successful U.S. program for building and retaining U.S. capacity for
work on tropical diseases. The
ability to offer extended field laboratory experience to career
employees permits the Army and Navy to develop reservoirs of trained
manpower, and to deploy the manpower wherever the needs of the service
The Cholera Research Laboratory, before it was internationalized,
deserves second ranking in terms of U.S. capacity-building, and first
rank among U.S. efforts to build Third World capacity. The remarkable CRL success in offering field experience to so
many people who remained in the tropical medicine field may be
attributable to the organic links between CRL, NIH, and CDC, and to the
fact that research at the lab was recognized at the time to be focused
on an important and rapidly advancing set of issues.
The ICMR, ICIDR and GND programs all offer or offered excellent
field experience for American researchers, although in limited numbers
and without strong career opportunities.
Gorgas, situated in a tropical area, itself represents an
institutional capacity for work on tropical diseases, although its value
could be substantially advanced had it an assured supply of bright young
researchers for residencies at the lab. This could perhaps be accomplished through links with more
American universities, although Gorgas would require additional funding.
Turning to American efforts to develop Third World capacity for
research on tropical diseases, the CRL is the most notable example. CRL was built largely with foreign assistance funds, with a hefty
assist from blocked local currency under the PL-480 program. For several reasons, the experience is unlikely to be
repeated. Blocked currencies have for the most part been exhausted, and
long-range institution-building efforts at AID have largely given way to
activities with more immediate and direct pay-offs, at least in theory.
The GND program does not attempt to build new institutional
capacity as such, but in Bangkok it is benefiting a research institution
built years earlier, with assistance from a previous Rockefeller
Foundation program designed to strengthen medical faculties in selected
Third World universities. That
same program helped shape the medical faculty at Universidad del Valle
in Cali, where the Tulane ICMR was initially based. Institution-building programs like the earlier Rockefeller effort
are very long-range and expensive undertakings, no longer popular in
foundation or government circles. Whether
there are shorter, less costly, ways of building the same level of local
competence remains as yet unclear.
The ICMRs in Cali and Kuala Lumpur seem to have left lasting
legacies in the institutions where they were based. The ICIDR grants may have similar results, although it is too
early to tell.
Gorgas has not seen local or regional capacity building as a
major part of its mission, although that could in future be a valuable
role for it to play. Again,
additional funding and a new outlook would be required.
The U.S. record in developing institutional and individual
capacities for tropical disease research thus seems sporadic and not one
in which the nation can take pride. No agency has a clear mandate for Third World capacity creation,
and there may not even be agreement that building research capacity
should have priority over other activities, such as conducting research
programs or carrying out disease control projects, if additional funds
Even if a pool of funds were earmarked for building tropical
disease research capacity, it is not clear that there is an agreed
course of action to follow. Unlike agriculture, the medical research community does not
seem to have thought through the pattern of national and international
research establishments that would be most effective in dealing with
tropical disease problems. To
someone coming fresh to the scene, it appears that the tropical medicine
community is 20 years behind its agricultural counterpart in conception,
planning, organization, and funding.
Going beyond the comparative framework, some additional issues
come to mind, some of which the Steering Committee may wish to address:
there tasks to be done requiring collaborative efforts in developing
countries for which U.S. institutions or manpower are uniquely or best
able to accomplish?
national interests would be served by additional efforts?
prospects unusually good for rapid progress in developing new
technologies or applying them in the field if more funds become
available? Are some
research technologies underemployed on tropical diseases because of lack
present levels of funding, is there an appropriate balance among
expenditures for biomedical research in the laboratory, vaccine and drug
development, epidemiologic research, field-testing of products, and
clinical research? If 25%
additional funds were available, where on the spectrum should they be
DoD and AID each fund tropical disease research in pursuit of its own
mandate. We have found no
suggestion of wasteful duplication of effort, but there is some doubt
that the sum of the fragments adds up to complete coverage of the uses
of tropical disease research in the national interest. Are we missing medical, humanitarian, foreign policy or other
gains by not having a comprehensive policy on tropical disease research? Do the legislative authorizations for each agency encompass
the range of our national interests?
international medical research budget needed, or would it become an
early target for congressional or executive budget cutting?
the present distribution of American overseas laboratories and
collaborative research programs offer adequate access to American
scientists for field research on tropical medicine?
Is the geographic distribution of existing facilities
appropriate? Are there
adequate opportunities to use existing facilities?
additional U.S. resources for tropical disease research become
available, should they be used to bolster existing international
research programs (TDR, DCC, EPI), increase research grant availability
through NIH for tropical and parasitic diseases, increase contract
research on specific diseases through AID or DoD, strengthen the
military overseas laboratories, build Third World research capacity
through AID, or mount some new programs or institutions?
there ways in which international research programs and U.S. research
efforts can be designed to give greater benefit to institutions in
developing countries? Are
there useful models or lessons to be drawn from international research
programs sponsored by other industrialized countries?
networking approach employed by WHO in TDR and CDD the best use of
existing international resources, as compared with an international
centers approach? If
significant new resources were to become available internationally,
should they be used to expand existing programs, add new networking
programs, or establish disease- or problem-focused international
U.S. military labs abroad likely to remain viable in political terms
over the next 10-20 years?
military purposes served by the overseas labs require military control
over them? Could they serve
as well if linked to NIH? If internationalized?
under military control, could the overseas labs serve a wider range of
U.S. interests by giving greater access to American researchers?
By undertaking local capacity-building projects?
By increasing clinical research?
the Gorgas Memorial Laboratory be strengthened by better linkages with
one or more U.S. labs, based either within a university or a federal
agency? Could or should it
balance, has the narrowing of focus on infectious diseases strengthened
the overall value of the ICMR/ICIDR programs?
In what ways?
NIH set up its own overseas laboratories?
Should CDC have overseas facilities and an international mandate?
private foundations generate new large-scale national or international
research efforts on tropical diseases?
ICDDR/B be seen as a model for other international medical centers?
Should it be seen as more of a local or regional institution?
should the smallpox eradication campaign be used as a model for other
vertical international campaigns? For
an expanded immunization program?