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EMBO reports 4, 8, 737–740 (2003)
doi:10.1038/sj.embor.embor915
A global player for public health
An interview with Tikki Pang, Director of Research Policy and
Cooperation at the World Health Organization
The interview was conducted by Holger Breithaupt and Caroline Hadley.
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EMBO reports (ER): The SARS epidemic was brought under control
with the help of the WHO [World Health Organization]. The disease came out of
nowhere and spread rapidly. Could it happen again?
Tikki Pang (TP): I think this will most likely occur again in the
future. Exactly where and how and involving what kind of agent, I don't know.
But there is the potential for this to happen again, that's for sure. I
personally think that population pressures and the entire process of
globalization are contributing to the appearance of emerging pathogens.
Deforestation, climate change, increased travel, speed of travel, crowding,
proximity between animals and humans—they all contribute, too. So there
is definitely a higher probability of something like SARS happening again in
the future—from a microbiological perspective, that's a given.
ER: The WHO had a major role in tackling SARS, and pretty much
scored on all points. Do you think that we got away lucky this time?
TP: No, I don't think that we were just lucky. We built on past
experiences and, with the cooperation of the international scientific community
and national governments, we were actually quite well prepared. There have been
quite a few such situations in the recent past. I can cite the example of the
Nipah virus outbreak in Malaysia in 1998, which was exactly the same situation:
an unknown pathogen creating a severe disease with high mortality. There was
another scare with avian flu in Hong Kong, and we had set up a global
surveillance network that was immediately put into action. The striking thing
is that the [SARS] pathogen was identified in two weeks and it was fully
sequenced in a month, whereas with HIV/AIDS in the early 1980s it took two
years to identify the virus. The identification of the SARS agent could not
have been done without the support of the international scientific community
and the national governments. That is the way the WHO works. We do not have
laboratories with full-time staff doing cutting-edge research. We're basically
an intergovernmental agency and our 'power' is in convening countries and
scientists and institutions to work together, such as the CDC [Centers for
Disease Control] in the USA and the labs in Hong Kong, Canada and Holland, for
example, which all played a major role in the SARS epidemic. So, we were
prepared and we reacted in the way that we always knew we would. One of our
major early concerns was if SARS was causing so many deaths in Singapore,
Beijing, Shanghai and Toronto, what would happen if this virus got into Africa
or India, where the health care facilities are not as advanced? We would've had
a major disaster. This was one of the reasons for our strong reaction. We were
maybe a bit fortunate that the movement of people and air traffic between China
and Singapore and Africa is not as high as it is within Southeast Asia. But in
general, we were preparedfor SARS.
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| Marietta Schupp, EMBL Photolab |
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ER: In response to SARS, the United Nations granted the WHO
broader powers to deal with future epidemics. Do you think this could cause
political friction, given how some countries, such as Canada, reacted to the
WHO's travel warnings during the SARS crisis?
TP: It is important to have a certain amount of clout, but in
terms of enforcement, it has been and will be done in close consultation with
our 192 member states. Now, after the SARS epidemic, there is going to be a
review of the international health regulations within the WHO. And I can
imagine that this will be discussed extensively with the member states in the
next year, to update regulations and determine how they can be enforced. In
other words, it will not be a unilateral imposition on the member states, that
is not how we work. Whatever we do in terms of actions is always endorsed by
our member states. Yes, we do need some more clout, but that is something that
the countries would want to see. Canada was of course affected. But other
countries such as the USA were not affected as badly and would perhaps ascribe
that to the fact that we did impose restrictions. The idea is to discuss these
proposed 'extended powers' of the WHO openly and transparently with all the
member countries, and come to a set of regulations in such a way that they are
acceptable to everyone. Of course, you can't please everybody, and there will
be political ramifications in terms of reduced autonomy of countries. But if
you look at the ways some countries reacted, with some being less transparent
than others about sharing information, the general feeling globally would be
that it is a good thing to ensure that all countries share the information they
have on any infections and outbreaks of disease. Given the political and
economic implications, we do need to appeal to altruism, in that you don't just
think of your own personal situation, but of the people surrounding you, too.
Perhaps the issue is not one of having more 'power', but more of the WHO being
seen, and accepted by all, as the major international agency dealing with
global health issues.
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"Given the political and economic implications,
we do need to appeal to altruism, in that you don't just think of your own
personal situation, but of the people surrounding you, too."
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ER: The WHO has also issued regulations regarding a ban on
advertising, and stricter labelling of the health dangers of tobacco. Does that
mean that the WHO is increasingly becoming a political and economic power?
TP: The way we see it, and always will, is primarily from the
health perspective. The political and economic implications are secondary to
health. It just so happens that some of these actions involve major consumer
items and multibillion-dollar industries. There are well-documented attempts by
the tobacco industry to actually sabotage what we are doing and try to
discredit the WHO. Another example is the recent report on sugar levels in the
diet. The Food and Agriculture Organization and the WHO produced a report that
recommended that refined sugar should not be more than 10% of your diet. That
was immediately challenged by the sugar lobby in a leading developed country,
which cited another report that said it should be 25%. I don't think you need a
PhD to work out that 25% sugar in your diet is absurd, but once again there was
political pressure to withdraw the report. But full credit to our Director
General [Gro Harlem Brundtland], she held the line. Basically, we are a global
advocate of actions for better health, based on strong scientific evidence. And
if we need to ruffle a few feathers, that's part of the process. But first and
foremost, our mission is to improve the health of people all over the world,
especially poor people. So if it means taking on the food industry in the case
of sugar, or the tobacco industry in the case of the Framework Convention [on
Tobacco Control], this is nothing we will shy away from.
ER: As an advocate for the health of poor people, the WHO is very
active in addressing 'neglected diseases'. Do you see an increasing role for
researchers in the developing world in this area?
TP: Absolutely. I see a lot of emphasis on neglected diseases,
especially malaria, tuberculosis [TB] and HIV/AIDS, especially in the context
of the Millennium Development Goals. The Global Fund to Fight AIDS, TB and
Malaria is also pouring lots of money into developing countries, and for the
first time they will have a research component into some of these activities.
We put a lot of emphasis on research in the three neglected diseases that I
mentioned, but tropical diseases in general are still an issue: leishmaniasis,
Chagas disease and dengue fever are all priorities with the WHO. From a
personal perspective, typhoid is another problem in developing countries.
ER: It's still a very expensive process to develop a drug and
test it. The developing world can't manage that on its own.
TP: You're right, and that's why people have looked at other
models of developing drugs that the major pharmaceutical companies are not
interested in because of limited profitability. Good examples are the
public–private partnerships in malaria and TB that the WHO has had a
major hand in putting together. The MMV [Medicines for Malaria Venture] and the
Global Alliance for TB drug development have both taken the approach of
public–private partnership, rather than trying to convince big pharma to
get involved. The idea is to develop an alternative model by bringing private
sources of funding, like venture capital, together with the public sector
that's doing the research, and trying to accelerate the development process.
Another good example is IAVI, the International Alliance for AIDS Vaccine, that
has succeeded in bringing a candidate AIDS vaccine from basic research to
clinical trials in less than two years, and for much lower costs than
traditional drug development. So there are models that are being currently
tested for overcoming the reluctance of the big pharmaceutical companies to
take on these issues.
The other aspect is improving the capacity of developing countries to
actually do some of these things themselves. In the long term, that may even be
the better way to go, particularly with advances in genomics, especially
pathogen genomics. In maybe two or three years, 95% of all the known human
pathogens will be completely sequenced. Now, with much of the genomic pathogen
data available in the public domain, you could develop capacity in
bioinformatics and data mining in developing countries. And some countries
already have a viable pharmaceutical industry—for example, India, China,
Indonesia, Brazil, Cuba and Vietnam have these capacities. If they can form a
consortium and use the power of genomics, indigenous bioinformatics capacity
and indigenous pharmaceutical industry, they could make a tremendous difference
in making some of these drugs available. These are countries that have a vested
interest in developing these products. Personally, I think that is the way we
should be focusing our attention, in addition to the public–private
partnerships.
ER: Given that the knowledge and expertise is still based in the
First World, is there the danger that these partnerships are imposing First
World solutions on Third World problems?
TP: Yes, I agree that there is a risk of this happening. But, as
I said, if the developing countries themselves can apply their perspective on
the problem, use their own experience with those diseases, and couple that with
the capacity to utilize the genomic data, they will be able to evaluate
solutions based on their own experience, rather than, as you said, having
solutions being imposed upon them by people who have no idea of the realities
of the disease. In the initial stages, you do need linkages with First World
centres of excellence to ensure that advanced technologies such as
bioinformatics, data mining and microarrays help you identify which pathogen
genes are being expressed in a patient. That would clearly need some capacity
building and transfer of technology, but once that initial hurdle is taken, my
vision is that, in the future, researchers in developing countries will be able
to contribute in their own right to a better understanding of these diseases.
They will not be second-rate players who are just receiving and utilizing
technologies developed in the West. By virtue of their own insights and
knowledge of the disease conditions in the real world, they will be able to
contribute on an equal footing.
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"Basically, we are a global advocate of actions
for better health, based on strong scientific evidence. And if we need to
ruffle a few feathers, that's part of the process."
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ER: I could see this working in South America and Southeast Asia,
but do you think this approach could work in sub-Saharan Africa?
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| Marietta Schupp, EMBL Photolab |
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TP: In this area, Africa's capacity unfortunately is still behind
Asia and Latin America. What is true though is that all the attention on
diseases that affect mainly sub-Saharan Africa is going to have an impact on
national governments, in terms of building capacity in their own countries. I
see some fairly encouraging developments in African countries getting together
to overcome this lack of capacity. For example, 20 or 30 African countries
formed an African health research forum in Arusha [Tanzania] last year that
aims to address some of these problems and improve health research capacity. At
the higher political level, the development of NEPAD, New Partnerships for
African Development, is another potentially powerful regional network-ing
activity to give more political support. It's really a matter of building
capacity at all levels, not just in research, but also in health systems, in
the delivery of health care. It's a major challenge.
ER: The advances in computer and information technology have led
to a growing technology gap between the developing and the developed countries.
Are you confident that this will not happen with the genomics industry?
TP: No, I think that the information technology revolution will
actually help developing countries to become more equal players in taking
advantage of genomics data. Having said that, I'm well aware of the fact that
95% of internet connectivity is in the developed world. And, for example, 95%
of internet connectivity in Africa is in South Africa. So there are clearly
parts of the world that do not have access to the World Wide Web. We're working
with other organizations to develop alternative methods of access, using
satellites and handheld radios to provide access to information that is not
web-based. But as far as maximizing the potential of genomics, I think the
information technology has been beneficial.
ER: Do you see intellectual property protection as a potential
hurdle in neglected disease research, given that an increasing number of genes
are being patented by biotech companies in the First World.
TP: The whole issue of innovation and intellectual property
rights is a major topic, and it was actually one of the agenda items in the
World Health Assembly just a few weeks ago. We've come up quite clearly on the
patenting of genes, but there are also other areas that could affect drug
development. Once again, this is where we really need to tread very carefully
because of the potential implications for a whole range of players, and we need
to work with other United Nations organizations that have more technical
experience in these areas. That includes WIPO, the World Intellectual Property
Organization, the WTO [World Trade Organization] and maybe even UNESCO [the
United Nations Educational, Scientific and Cultural Organization] in terms of
scientific research in general.
The position we took in the last World Health Assembly was that it
really requires a lot more dialogue as to what the implications are of genes
being patented. Of course, the pharmaceutical industry needs to be involved in
this dialogue. There are some alternative models to patents, for example. Other
possibilities are the pharmaceutical industry relaxing patents for certain
diseases. The issue of tiered pricing is another idea that we discussed, and
it's actually been applied in the area of vaccines.
ER: With genomics playing an increasingly important role in
research in developing countries, should you also tackle the ethical problems,
such as informed consent or patient participation in research, as early as
possible?
TP: Absolutely. Developing countries need to be aware of these
ethical issues, otherwise they won't be aware of the implications and risks.
And this is why we recommend in our report [Genomics and World Health] that
governments of developing countries first build their own capacity in the
ethics of genomics and of biotechnology in general, such as ethical review
committees. Second, it means education of society in general and most
importantly of the medical professionals. These concepts are new for many
practising physicians in both developed and developing countries, and they need
to understand not only the ethical issues but also the scientific advances and
their implications. We're investing quite a bit on capacity building in ethical
review in developing countries. We actually created a separate unit last year
called Ethics in Health that is involved in those areas.
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"Ultimately, you can produce the best research
in the world, but if somebody in the Ministry of Health does not decide that it
will be implemented, you'll never see the benefits."
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ER: You said that physicians in developing countries should be
educated about scientific advances. What about the scientists in basic
research—should they also be more aware of the applications of their
work?
TP: Yes, and it is actually working both ways. You clearly need
scientific research at the highest levels. But educating scientists to give
some thought about how their research is going to be used, that would be even
better. In terms of output that research institutions produce, which is
measured mainly by publications in high-impact journals, that is quite
different from what we measure, which are health indicators such as reduction
in infant or maternal mortality or the incidence of specific diseases. It's a
matter of how do you make one influence the other in such a way that it's
complementary.
ER: So you're saying that research institutions and health care
organizations should cooperate more closely in the future?
TP: Yes. The people who deliver health care understand where the
gaps are and then inform the researchers. Of course, most of the time we're
talking about basic biological research, but there are other areas of research
that people tend to forget. Often, it's not a problem that you don't have a
good drug, but you don't have the knowledge about how to deliver it in the most
optimal way. We're talking here about operational research, about people's
behaviour, about cost-effectiveness of various delivery modes. Many people have
this misconception that research is all about biomedical or clinical research,
and yet if you want to ensure that it is used, there are other areas which to
me are just as important, but sometimes short-changed. Economists,
sociologists, psychologists, health services and health delivery researchers,
they don't get published in Science or Nature or Cell, and
in fact sometimes they don't get published at all. Ultimately, you can produce
the best research in the world, but if somebody in the Ministry of Health does
not decide that it will be implemented, you'll never see the benefits. And then
the question is, how do these policy makers actually make their decisions? They
are not scientists, they don't read Science, they don't read
Nature. In the end, synergy always means that the two together have a
bigger impact than the two separately. And I think there is a potentially
powerful synergy between research institutes and an organization such as the
WHO that applies the knowledge for improving the health of people, especially
in the developing world.
ER: Dr Pang, thank you for the interview.
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