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A new initiative to attack key 'roadblocks' to the treatment of diseases, though welcome, must not lose sight of the broader picture.

In December 1971, US President Richard Nixon signed a generous research funding law in which he declared a 'War on Cancer'. His move was based on the premise that if scientific prowess and technological ingenuity could place man on the moon, then surely they were capable of defeating one of the biggest health scourges facing mankind. More than thirty years — and almost $50 billion of research — later, the war has not been won. Despite numerous breakthroughs in prevention and therapy, cancer rates continue to climb throughout the world, and more than 12 million Americans alone die from it each year.

One hopes that the same fate will not face a new project being launched this week to identify a list of 10 to 15 "critical scientific and/or technical challenges" that could, if resolved, lead to significant improvements in health in the developing world (see Researchers asked for 'top medical roadblocks', 6 May 2003). The project, ambitiously titled 'Grand Challenges in Global Health', is being backed with $200 million from the Bill and Melinda Gates Foundation. It was unveiled by the foundation's sponsor, Microsoft billionaire Bill Gates, at the World Economic Forum in Davos, Switzerland, earlier this year as the latter's latest contribution to improving global health (see Bill Gates gives $200 million to health research, 27 January 2003).

The strategy adopted by the project's organisers is to support research on key scientific stumbling blocks that currently stand in the way of developing effective therapies for some of the world's major diseases. One example they quote might be "a viable method to alter mosquito behaviour" as a way of reducing malaria; an open invitation has been issued for similar suggestions. Their promise is that applying the world's best scientific minds in such a highly targeted way will "remove the roadblock[s] that stand between where we are now and where we would like to be in science, medicine and public health."

Redressing the balance

The Gates Foundation is not alone in calling for measures to redress the current imbalance in expenditures on global health research. It is an embarrassing fact that — as is frequently repeated by development groups and others — only 10 per cent of the world's spending on medical research goes on diseases that primarily effect 90 per cent of the world's population. The reasons for this range from a lack of political will to the low levels of profitability on novel drugs for developing country diseases that would otherwise act as an incentive to pharmaceutical companies.

Various measures have recently been proposed to correct this imbalance. Last year, for example, the Commission on Macroeconomics and Health, headed by US economist Jeffrey Sachs, suggested creating a Global Health Research Fund, to which governments around the world would be invited to contribute (an initial target of $1.5 billion was suggested). Since then, the head of the international branch of the US National Institutes of Health has called for "virtual global network" of health researchers, bringing together the world's leading medical research councils "in a voluntary, independent but coordinated collaborative effort" (see Creating a virtual health research network, 10 April 2003).

Whatever their undoubted merits, such approaches have several dangers. One is that, like any form of institutional collaboration, the organisational tasks involved will still require a substantial bureaucracy that could inhibit scientific flexibility. A second is that the requirement for government backing could lead to inhibiting political pressures (as the World Health Organisation has experienced in its efforts to combat tobacco). The Grand Challenges to Global Health sensibly seeks to steer clear of both of these dangers by focusing on individual research groups and their potential scientific achievement, and by avoiding any ambitions to co-ordinate the work of such groups into broad programmes.

Placing disease in context

But there are also risks in this approach. One is that it encourages the misleading impression that curing disease is essentially a question of scientific breakthroughs alone. But as even researchers are will aware, there is a long and slippery path between the research laboratory and the chemist's shops — or even basic research and the design of effective therapies (witness current disappointment over the failure of genomics to deliver instant remedies for major diseases). At the same time, some of the factors that contribute significantly to the spread of disease — such as poverty and malnutrition — are not susceptible to quick scientific analysis or solution.

Secondly, appealing to the world's best scientific minds and relying primarily on the scientific merits of research proposals may be the fastest way of getting high-quality research done. But it risks marginalising yet further the efforts of researchers in developing countries who lack the facilities or resources required to engage in research. Part of the real challenge of promoting health in the developing world is building the capacity to carry out research on such topics. That must not be ignored.

There is a third danger, namely of taking pressure off governments to act in this field. The sums involved are still a relatively small proportion of current overall spending on developing country diseases — or of the increases in such spending required to make a significantly greater impact. It would be a shame if private philanthropy were to remove the obligation on governments to correct this situation. Or if short-term technical fixes were to be seen as a replacement for a long-term political commitment to the overall improvement of health systems.

Avoiding the risks

Those heading the Grand Challenges initiative are no strangers to such issues. Emphasis is being placed, for example, on the need to ensure that all projects proposed for funding are linked to potential — and feasible — applications of their results. The research fields selected for potential support include not only basic sciences, but also epidemiology and behavioural sciences. And the involvement of a number of developing country scientists in the scientific committee that will make the final selection of topics to be funded will hopefully ensure that capacity building remains a priority, at least in principle.

Hopefully this awareness will be sufficient to avoid the hubris that characterised — and ultimately undermined — Nixon's war on cancer. Certainly their ambitions, while sounding suitably imaginative, are also more realistic. And the timing is propitious; a growing number of the world's leading biomedical researchers have been expressing their personal disenchantment with skewed priorities of global health research. Many are looking for an alternative framework from that offered by national agencies in which to apply their skills to major diseases. Provided that the caveats listed above are acknowledged, Grand Challenges in Global Health will help many of them do precisely that.

Suggestions for appropriate scientific and/or technical challenges must be submitted by 15 June 2003. For further details, visit, or e-mail [email protected]

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