Columnist George Will has observed that when the Titanic steamed into that iceberg, the disaster was not democratic: 56% of women sailing in third class died, while only four of 143 women in first class perished. You don't need to ask which class was traveling near or below the waterline.
When it comes to healthcare research, development and delivery--or, to be more precise, the lack thereof--those closest to the "waterline" are less-developed countries.
Health-related R&D has been designated officially as a "global public good" by the World Health Organization's (WHO) Commission on Macroeconomics and Health, reflecting the need for more and better medical research in less-developed countries. Unfortunately, such actions are largely symbolic; the real question is how do we translate lofty goals into real-world benefits. One model for the pursuit of projects particularly relevant to less-developed countries is a new global institute along the lines of "big science" undertakings such as CERN, the European Organization for Nuclear Research, which sits on a huge campus in Geneva.
Gerald Keusch, director of the Fogarty International Center at the National Institutes of Health, and Carol Medlin, University of California, San Francisco, have proposed an alternative model: They want to create a virtual "global health-research network" that would consist of "several of the world's leading medical research councils in a voluntary, independent, but coordinated collaborative effort."
This project is like a mollusk that hasn't yet found its rock. Although the United Nations would seem a perfect attachment site for such a specimen--huge, ponderous, undynamic--a major problem, as Keusch and Medlin acknowledge, would be "to keep the network coordinated, functional, and focused on science, rather than becoming a politically correct, all-inclusive, but dysfunctional tool for development."
While they enumerate some difficulties that such an undertaking would present, the authors leave unresolved two pivotal issues. The first is the logical outcome of their observation that "competition, an essential element to ensure excellence, can be focused on coming up with new knowledge in the shortest time frame, and not on which country or agency announces the discovery"; namely, the most funding would go to laboratories in the United States, Japan, Germany, France, and Britain. Not that there is anything wrong with this result, given that competition for research funding is, or should be, a meritocracy.
The second is that, as the Soviet Union and many former Eastern bloc countries learned to their dismay, centralized planning of R&D seldom works. As the late Nobel laureate and chemist Max Perutz observed: In science, "discoveries cannot be planned; they pop up, like Puck, in unexpected places."
Arguably, therefore, in lieu of creating some sort of centralized, international mechanism intended to avoid the further segregation of what has been called "two worlds of science" (that is, the richer and poorer countries), the larger public and private funding sources in the major industrialized countries could agree simply to redirect more of their resources to the problems of less-developed countries. The Rockefeller Foundation has done this by supporting the development of recombinant DNA-modified, vitamin A-rich 'Golden Rice' varieties that can address nutritional deficiencies.
Funders of such projects could coordinate their work through E-mail, and although the concept may be foreign to the United Nations, the $1.5 billion (US) proposed by the WHO's Commission on Macroeconomics and Health "to initiate serious discussion" actually could be spent on conducting health research, instead of just talking about it.
Of course, without centralized coordination, there may be some redundancy, but as long as laboratories compete for funding through an "investigator-initiated, peer-reviewed, merit-based research support system," which Keusch and Medlin acknowledge promotes the "best science," healthy competition will ensue. Most major research problems, after all, are pursued by many laboratories.
If health research is to be treated as a "public good," it must be approached in a serious and intellectually honest way. It must be administered dispassionately and efficiently, and in a manner that does not shrink from this reality: Curing the public-health ills of less-developed countries might be delivered most efficiently by the work that trickles down from the wealthier countries' high-powered research machines.
Henry Miller, a physician and molecular biologist, is a fellow at the Hoover Institution. He was director of the Food and Drug Administration's Office of Biotechnology from 1989 to 1993.