Continued from previous page....
The obstacles that prevent progress being made against neglected infectious diseases are varied and differ in nature. Market and public-health failures are clear contributors, but there is also the dilemma between continuing to carry out disease control with the tools available at present, and investing in health research for the benefit of future generations (
Curtis, 2000;
Hoffman, 2000;
James et al., 2001)—a variation of the classical tension between use and understanding. The different cultures and visions of policy makers and decision makers, disease control experts and health researchers (
Morel, 2000) are a hindrance, in particular the belief that 'the job can be ...military-orientated governments are prone to finance war and armed conflicts at the expense of the health systems and services of their populationsdone' using existing tools, for 'all one needs is good management'. Although this reasoning can be valid on those rare occasions when a powerful, cost-effective intervention exists, history has shown that having research as an integral component of public health campaigns is the key to success (
Henderson, 1998a;
Molyneux & Morel, 1998). Another obstacle is the belief that investments in basic research alone will automatically lead to the development of new tools and their seamless adoption and use by the health systems of poor countries. This vision correctly emphasizes the existence of knowledge gaps, but disregards how difficult it is to translate health research into policy and practice and how complex the relationships are between basic science and technological innovation (
Kealey, 1996;
Stokes, 1997). Finally, the low priority given to public health and health research by most disease-endemic countries themselves exacerbates the situation.
A long-term, multi-pronged approach is needed if we are to move beyond these short-sighted dilemmas and the resulting virtual boundaries that undermine synergy, team-building and collaboration between all health stakeholders. Only in this way can we start to work seriously towards achieving the Millennium Development Goals (
United Nations, 2002) of combating child mortality, HIV/AIDS and neglected diseases. In the context of this article, I would like to single out one challenge, one threat and one responsibility among all those facing humankind, which, if addressed, will significantly help towards achieving these goals.
The challenge I consider fundamental is how to rescue the role, the need and the importance of strategic research—research that is both basic and applied and thus falls into Pasteur's Quadrant (
Stokes, 1997). The information that modern science and technology can generate, particularly in genomics and associated fields, has to be transformed into breakthroughs for public health (
Morel et al., 2002). This 'genomics knowledge' will be the basis for the development of the new health interventions that are so desperately needed for the control of infectious disease. However, if this challenge is left exclusively in the hands of market forces, or addressed by
laissez-faire scientific and technological policies, genomics will increase the divide between the rich and the poor, instead of bridging it (
Singer & Daar, 2001;
Advisory Committee on Health Research, 2002;
Daar et al., 2002).
The threats of infectious diseases are so numerous that it is impossible to single out a specific one. Instead of attempting to select 'the' killer disease, I nominate as the most dangerous threat the deeply rooted perception that the war against infectious diseases has been won. This perception not only ignores the extraordinary capacity of our biological enemies to evolve continuously and to spread death and terror, but also does not take into consideration the possibility of the voluntary spread of infections by bioterrorism and biological warfare (
Henderson, 1998b,
1999,
2000;
Feldmann et al., 2002). Although an 'Ebola with wings' is still a hypothesis rather than a reality, one should not forget that influenza pandemics are permanently on the horizon and that bioterrorism has already killed innocent people. The postponement of the destruction of the last stocks of smallpox virus, and the resulting necessity of spending millions of dollars on mass vaccination campaigns against a disease that was officially certified as having been eradicated on 9 December 1979 (
Fenner et al., 1988), is a sad outcome (
Cassels, 2002) and illustrates how real, powerful and far-reaching is the threat of infectious diseases.
Who should bear the responsibility of tackling neglected diseases? In the international health arena it is common to divide nations into 'donor' and 'recipient' countries and to refer to them collectively as 'the North' and 'the South'—the result is a strange atlas in which, for example, Australia is in the North and India is in the South. This heritage from the colonial era stimulates alienation and favours the
status quo, as its subliminal message implies that a major responsibility for the solution of the problems of the 'the South' relies on help or charity from 'the North'. As a matter of fact, it is true that the health systems of some of the more highly developed countries rely continuously on foreign aid to keep alive their basic infrastructure and the delivery of essential services. Indeed, the real picture is much more complex than a simple North–South divide.
Figure 2 reflects the priorities in public spending in education, health and military expenditures for the 108 countries for which this information was available (
United Nations Development Programme, 2002). As the proportion of military expenditure increases from 0% of GDP (for example, in Iceland and Costa Rica) to 10% or more (Eritrea with 22.9%, Angola with 21.2%, and others not included due to lack of health and education data), the share of the health component (the darker area in the figure) shrinks drastically when compared with education. In other words, military-orientated governments are prone to finance war and armed conflicts at the expense of the health systems and services of their populations.
Continued on next page....