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First, I want to thank the American Society of Tropical Medicine and Hygiene (ASTMH) membership for having the courage and/or folly to elect a woman clinician to the Presidency. It has been an honor and a privilege to represent the Society in this somewhat tumultuous year post September 11th. I want to share this podium and acknowledge my coworkers of the executive committee; Peter Weller, Stephen Hoffman, Ed Ryan, William Petri, Kevin Hacke, and Judy DeAcetis.
As Dr. Stansfield mentioned, it was 21 years ago that I attended the Puerto Rico ASTMH meeting; I have been a faithful attendee ever since. In preparing for this special occasion I have tried to reflect upon why I have been so faithful to this Society, rather than to one of the infectious disease, public health, bioethics, or even rheumatology societies, since I have interests in those areas too. I believe the reason is that the ASTMH offers a unique setting for fostering intense, collaborative relations between clinicians and basic scientists, whether in universities, foundations, private practice, or government service. This unusual blurring of usually rigid boundaries stimulates projects, cross-pollinates ideas, and makes for unusual bed fellows. In a non-biblical sense, of course.
For example, after a late night conversation with Peter Schantz of the Centers for Disease Control and Prevention (CDC) at an annual meeting several years ago, I began a collaborative sabbatical project on neurocysticercosis in Ecuador. Secondary to relationships formed at ASTMH, I have had the pleasure of rounding at the Armed Forces Research Institute Medical Units in Bangkok, Manila, and Cairo. Various CDC laboratories have hosted Yale students on Wilbur Downs fellowships. A project on dracunculiasis was completed by one of my students under the guidance of Don Hopkins at the Carter Center. Innumerable clinical consultations and referrals have transpired between myself, my partner Frank Bia, and Jay Keystone, Marty Wolfe, Barbara Her-waldt, and other members of the clinical group. Diagnostic support to unravel particularly perplexing cases has been provided by Tom Nutman, Diane McMahon-Pratt, Rebecca Rico-Hesse, and other basic scientists. Thanks to the arbovirologist experts so accessible in our Society, such as Tom Monath, Charles Calisher, Bob Shope, and Jim LeDuc, it has been possible to dissect enigmatic tropical fevers. I will never forget C. J. Peters’ words to me the unfortunate night I diagnosed one of our ASTMH members with a lethal arenavirus (Sabia). With great anticipation I asked for patient evacuation to a CDC or Fort Detrick mobile hospital: C. J. replied: "Hell, Michele, we don’t do that anymore. We’ll just have to chew on this together." Membership in the ASTMH permits access to a company of scholars and collaborators and more distinctly, a Society of friends.
Clinical tropical diseases became my dominant career pathway in part for political reasons. They gave a chance to offer some skills unique to underserved populations, both in the United States and in developing countries. Presidential speeches are usually devoted to "The State of Our Union," at this meeting Society reflections. Tonight, instead, I would like to deviate from the norm and devote the rest of my remarks to what I view as the moral challenges for the future of this Society as it enters its 100th year: the challenge to become activist, and more of a public advocate for tackling the global health disparities that have widened dramatically during the era of globalization. Dick Guerrant presciently argued in his Presidential address that our post-cold war society appears to have lost its bearings; emerging diseases, growing health disparities, and exploding population growth without health threaten us all.1
The benefits of globalization are potentially enormous and include increased sharing of ideas, cultures, life-saving technologies, infrastructures, and resources to breach disparities and lessen the threat. Yet according to the United Nations Development Program, over the past 30 years the gap in per income capita between wealthy and poor countries has tripled (Table 1
). More than 1.2 billion of the world’s people live on less than one dollar a day.2 Life expectancy in the 48 least developed countries is just 51 years and infant mortality rate (IMR) averages 100/1,000.3 By comparison, in high income countries life expectancy is 78 and the IMR is 6/1,000. There are several areas where globalization itself has helped widen these gaps and directly affected the health and security of the world. The unprecedented interconnection and interdependency among human populations introduces newly shared risks of communicable diseases and accelerates global spread of antibiotic resistance and emerging environmental health hazards.
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The potential for transportation of infected individuals, pathogens, and antibiotic resistance is staggering; borders are crossed with impunity. Unfortunately, due to national interests or constituency priorities, often research, teaching, surveillance, public health infrastructure, and institutions are not as globally efficient at crossing these borders. This creates what I have loosely termed egregious globalization gaps (EGGs), of which I will try to address four major areas (Figure 1). The EGGs that affect eradication of tropical diseases are 1) a Research 10/90 Gap, 2) a Pharmaceutical Research and Development (R & D) Neglected Diseases Gap, 3) an Internet Gap, and 4) a Gender Gap. My challenge to the ASTMH membership is to take the U.S. lead in trying to breach these gaps.
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The Commission on Macroeconomics and Health has found it helpful to distinguish between three types of diseases to identify R & D activities. As one can see, our Society is mostly involved with the study of the very neglected diseases.8 The Commission drew attention to the high burden and low investment in research of these diseases. According to their economic analysis, at least $3 billion per year should be allocated to the R & D of health priorities of the poor.8 Half of this three billion is proposed to go to a newly created international version of the National Institutes of Health (NIH) called the "Global Health Research Fund" with a key goal to build long-term research capacity in developing countries themselves. For comparison, the entire budget of tropical disease research at the World Health Organization (WHO) directed at the eight major tropical diseases is only $30 million.7 For further comparison, it is estimated that worldwide, countries spend more than $800 billion on weapons and military resources. The economists on this panel estimated that the cost to a donor country would be 0.1% of the donor gross national product (GNP) or approximately $34 per person.8 Currently, the United States musters approximately $5 per person in donor aid.9
Our Society can and has supported Fogarty and NIH budgets for research in neglected diseases by lobbying Congress with our legislative initiatives via Capitol Associates. Hopefully, most of you received the e-mails I sent with copies of advocacy letters for increased NIH-Fogarty budget, reorganization of study section guidelines, and reorganization of bioterrorism research. At The Fogarty Center, ASTMH members Gerry Keush and Joe Bremen have spearheaded initiatives such as "GRIP" (Global Health Research Initiative Program for Foreign Investigators) to combat brain drain and fund young scientists from developing countries to return to their indigenous countries with financial and institutional support. I urge our members to host such overseas scientists and create collaborative field sites to enhance research capacity around the world.
The ASTMH has developed specific awards (with support by Pfizer, Burroughs-Wellcome, and The Gorgas Institute) that offer seed money to young investigators to study and collaborate in overseas settings. We need to find more serious and sustainable funding streams for these initiatives. The Ben Kean Fund initiated by Stephen Hoffman sends young clinicians to overseas settings. We need to nurture this fund to spark interest in neglected disease research and foster cultural understanding and overseas partnerships. Reviewing our first 15 years experience of the Yale International Health Program, a colleague of mine, Dr. Anu Gupta, found that the 192 resident physicians who spent even a small amount of time overseas were more likely to work with the underserved in the United States, patients infected with human immunodeficiency virus, or in a public health arena than their stay-at-home colleagues.10 For sure, selection bias plays a role. However, many of us in this room were inspired to go into tropical disease study by a hands-on experience in the developing world. Certainly, my early clinical exposure at the Hôpital Albert Schweitzer in Haiti and at the Kilimanjaro Christian Medical Center in Tanzania helped direct my career choice. In the end, though, these are minuscule assaults on a huge and intractable burden of disparity.
$406 billion) while Africa, Asia, Latin American, and the Middle East will account for 20% of the market, despite representing 80% of the world’s population.12 It is no surprise then that of the 1,393 new drugs approved worldwide between 1975 and 1999 only 1% (16 drugs) were specifically developed for a tropical disease or tuberculosis.13 A recent survey of the world’s pharmaceutical companies, to assess the level of R & D in neglected diseases compiled by one of our past Presidents, Dyann Wirth, reveals that the pipeline of new drugs for tropical diseases is virtually empty.14 At last year’s annual meeting a plenary session was devoted to eflornithine, an effective drug for African sleeping sickness that was discontinued as a parenteral preparation, only later to be marketed in the United States as a depilatory for women’s facial hair. Even when effective drugs are available, patent protection, access to drugs, and the WTO agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPs) can hinder availability to those with the most need15 (a well-named agreement = TRIPs). Although many multinational pharmaceutical companies have initiated drug donations to overcome access problems and to combat specific diseases, economic analysis of the donation model reveals that the cost of such programs to the donor country (after tax gains and tax incentives to the pharmaceutical company) exceeds by four-fold other suggested models, such as purchasing and distributing low-quality generics or differential prices of a branded drug for a needy country.16 It is obvious one cannot expect a market-driven pharmaceutical industry to invest in non-profitable research or R & D. Donated drugs cannot be the primary solution to the vast inequities in global drug access.
Earlier this year, I had the pleasure of representing this Society at an international conference in New York sponsored by Medecin Sans Frontiers on the Crisis of Neglected Diseases, Developing Treatments and Ensuring Access. I was able to offer our membership’s support for their new needs-driven drug development network, the Drugs for Neglected Diseases Initiative (DNDi) that seeks to correct the R & D gap for neglected diseases. I e-mailed you the proposal accepted this year by Council offering our assistance to the Medecin Sans Frontiers initiative. Many members have already gotten involved; for members who want to get more active in the initiative, the website is www.neglecteddiseases.org. We have many active Society members who are leaders within the pharmaceutical industry. I invite any member to offer suggestions to our newly formed corporate industry liaison group spearheaded by Tom Monath, Adel Mahmoud, Brad Connor, and Phil Coyne. Clearly, radical and innovative incentives need to be built into the R & D of treatment for tropical diseases. Existing capabilities of indigenous countries need to be expanded and creative partnerships in drug research and trials need to be fostered, while maintaining high cross-cultural ethical standards. Who better than our Society membership can advocate for these changes?
). In Africa, with a population of 700 million, fewer than three and a half million have access to the Internet and most of those are in South Africa.19 Over time this division between developed countries and developing countries is increasing. Internet usage is even larger than the spread of gross domestic product between the world’s rich and poor countries and larger than disparities in other technologies such as television and telephones.18 Access to the Internet is often gauged by the number of registered online computers. In April 2001, there were more than 77 million computers registered online in the United States and almost six million in Japan, but a number of countries had less than 10 (Bangladesh, Angola, Chad, and Iraq) or even zero (Burundi, Benin, and Syria) computers registered under their country code.18
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We will soon be going on-line electronically with our journal now that a new contract was finally negotiated. I propose that we as a Society either donate free access of our journal to targeted countries with a low GNP or consider offering free full text access of certain relevant articles selected by our editorial staff or by our cyber space committee led by David Freedman. Precedents have been set by the British Medical Journal, which offers free access to all scientists on-line and the Lancet, which offers access to selected full text. (see the Web site freejournals.com). Even if there is a large gap to electronic access in developing countries, at the very least the ASTMH can offer its journal free to institutions and libraries in developing countries.
Members of the ASTMH are now encouraged to incorporate sex and gender into research design by funding agencies, yet more awareness of gender differences in disease acquisition and treatment is needed. Women scientists need to be recruited into tropical medicine (35% of our membership is female) and more women need to be nurtured to ensure professional success. Women’s voices need to be heard in negotiations for funds at the International Monetary Fund, the World Bank, the NIH, on the Internet, and most importantly, in the field to highlight gender issues to disease patterns. Given how progressive the ASTMH has been in the last eight years in its election of four women presidents, why not be a Society in the forefront of advocacy for women’s issues in the tropics?
In conclusion, I would like to return to where I began, with the title Diseases Without Borders and the contribution that our special expertise in tropical medicine can make. In the medical condition of the world’s poorest people, we can see the incubators of political and social pathology as well as medical ones, and as events of the past year have pointed out, the borders of the advanced industrial countries are permeable to all three. Tropical medicine specialists are a kind of distant early-warning system of public health. We see problems in their early stages. We have seen the acquired immunodeficiency syndrome catastrophe building in Africa for 20 years. Yet only now does it occur to some of our most powerful politicians that a threat to a continent is not only a human tragedy for the continent of Africa, but a threat to the world. Priorities must be chosen carefully, we cannot be issuing orange or red alerts all the time, but we should make sure that our voices are heard. Globalization means a threat to any of the world’s peoples is a threat to all the world’s peoples. Advocating for resources to bridge the egregious globalization gaps I have referred to is no longer a moral imperative, but an imperative for the health of all. It is also an imperative for the ASTMH as it enters its next century.
Author’s address: Michele Barry, Office of International Health, Yale University School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, CT 06520-8025, Telephone: 203-688-2476, Fax: 203-785-6978, E-mail: michele.barry{at}yale.edu.
Editor’s note: The full text of Dr. Barry’s Presidential Address with slides can be found on the ASTMH website at http://www.astmh.org/q&a/pp/index.htm.
* Presented as the Presidential Address at the 51st Annual Meeting of the American Society of Tropical Medicine and Hygiene, Denver, CO, November 12, 2002. 
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
