system that could be engaged for this purpose.Some advocates have suggested creating a

new global institute for health research, alongthe lines of international projects such as theparticle accelerator at CERN, the EuropeanLaboratory for Particle Physics near Geneva.The International Vaccine Institute in Koreacomes close to this concept, although it is stilllimited in scope and resources. The WHO’stropical disease research programme and theMultilateral Initiative on Malaria, with a rotat-ing secretariat located at various institutions,are other ‘prototypes’ for global health R&Dfunding. Others, seeking to generate resourcesand avoid creating yet another UN-stylebureaucracy, have proposed a global fund forhealth research with an independent, highlystreamlined secretariat, analogous to theGlobal Fund to Fight AIDS, Tuberculosis and Malaria5 .

Confounded by politics, the debate haslargely ignored the organizational exigenciesof what Ernst-Ludwig Winnacker — president of the DFG, Germany’s mainresearch-funding agency — has called the“small science” of global health research6.‘Big’ science requires initial down paymentsand large investments in infrastructure, but investment in ‘small’ science can be scattered among many funders engaged inan independent but coordinated pursuit ofscientific inquiry. The happy deduction, asGeorge Radda, head of the UK MedicalResearch Council, has noted7, is that there is no theoretical justification for preferring

a highly orchestrated, centrally controlledeffort to a decentralized one.

ProposalsTo initiate serious discussion, the CMH proposed the creation of a US$1.5-billionfund to promote global health research, witha research model based on that seen in theorganization of national health-researchagencies and councils in North America,Europe and elsewhere. The rationale behindthis proposal was that research agencies suchas the US National Institutes of Health(NIH) and the UK Medical Research Council have long, proven track records in promoting the ‘best’ science in healthR&D, through an investigator-initiated,peer-reviewed, merit-based research support system. Implicit in the CMH reportwas the concept that the global effort shouldtap into this enormous wealth of experienceand focus on increasing the amount ofresearch oriented towards improving thehealth of the poor in developing countries.

Although it is unlikely that the CMH’svision for a new global health-research fundwill take root and flourish in the current economic and political climate, we can stillexplore the idea of harnessing the power of the international biomedical research community to respond to the most urgent oftoday’s global health challenges. Althoughmuch of the existing public global R&D capacity is located in Australia, Japan, Europeand North America, a number of middle-

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Gerald T. Keusch and Carol A. Medlin

Research and development (R&D) into healthis increasingly recognized as critically impor-tant in the fight against the major causes ofmorbidity and mortality among poor peoplein developing countries. Although this mayseem self-evident, it is a striking statement, as health (and health R&D) has only been recognized as a global development goal since 1993, when World Development Report:Investing in Health1 was published. After thisreport, a World Health Organization (WHO) committee2 suggested priorities and made recommendations for the mobilization ofnational, international and private-sectorR&D support to ensure scientific and techno-logical progress in these areas.

Most recently, the WHO Commission on Macroeconomics and Health (CMH)3,chaired by Jeffrey Sachs, made concrete proposals to push this agenda still further.Significantly, the commission defined healthR&D as a “global public good”4, thus empha-sizing the collective benefit that could bederived by all countries from such invest-ments in knowledge for better health. It mandated “research and development into diseases (often, though not exclusively, tropical diseases) that are concentrated in poor countries”, and noted that enlightened self-interest is as compelling ashumanitarianism as justification for action.

Putting theory into practiceThe status of R&D investments on the inter-national health agenda has been elevated bythe designation of health research as a globalpublic good. Now, we urgently need to makeit happen. Unfortunately, therein lies theproblem, as the theoretical underpinnings of such global public goods with respect to productive capacity, delivery systems and finance are relatively weak. From an economics perspective, for example, weknow that it makes little difference whetherthe investors in R&D are many or few, publicor private, or based principally in the northor the south. Fundamentally, the only thingthat matters is that the investment is made.

From an ethical, institutional and prac-tical perspective, careful consideration is essential in the organization of any globalR&D strategy — what should the priorities be? How should decisions be made? Whoshould participate? Who should take the lead?If it is to be a truly global effort, it must emerge and take shape by global discussion and debate— yet not every nation has a robust research

Tapping the power of small institutions Now is the time to create a virtual, global network for health research.

Thinking big: a virtual network of health-research institutions could readily tackle global issues.

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income countries — such as Brazil, Mexico,Argentina, South Africa, Malaysia, China,India and Thailand — are already investing inscience, have developed similar mechanismsto promote excellence in research, and already contribute significantly to the globalknowledge base. How could the skills, talentsand resources of these scientific communitiesbe put to better use in the service of improvinghealth globally?

National agencies for biomedical andhealth research have at least three kinds ofresources at their disposal that — if effectivelyharnessed — could make a difference in thenear term. The first is the scientific capacityrepresented by their ‘in-house’ expertise andextensive networks linked to universities andindependent research institutions.

Second, they determine their own scientificpriorities and allocation of research resources,a portion of which is already used to fund ini-tiatives in global health research. The amountsinvested are substantial. Overall, governmentsin developed countries invested US$34.2 billion in health R&D in 1998, with five countries (the United States, Japan, Germany,France and Britain) accounting for approxi-mately 90% of the total8.

Third, the national research institutionsfor health and biomedicine have well-devel-oped systems for funding and promoting the best science, relatively unfettered andunimpeded by politics, fostering rapid scientific discovery and advancement. In theUnited States, for example, these highly competitive funding mechanisms are governed by an independent and objectivetwo-level peer-review system conducted byand for scientists. Expert peer review is partof the culture of science and is well integratedinto NIH programmes that emphasize investigator-initiated proposals. Other programmes, including targeted planningawards and research programmes initiatedby the agency, contracts for the research andmethod development that are considerednecessary to stimulate scientific progress,and cooperative agreements with the privatesector for product development are also subject to rigorous peer review.

After many discussions with directors andheads of the international programmes of themain biomedical agencies in North Americaand Europe, we believe that the time is nowright to consider the creation of a globalhealth-research network. Although manytypes of models are possible, the most feasibleat the moment is a ‘virtual’ model. This con-sists of several of the world’s leading medicalresearch councils in a voluntary, independentbut coordinated collaborative effort. Criteriafor participation — beyond the commitmentof their directors and senior staff — couldinclude an assured national source of funding,scientific autonomy in priority setting andallocation of research resources, an indepen-dent peer-review system, a long and consistent

history of scientific accomplishment andengagement in science for global health. Generation of new resources would be nice but not necessary initially, as these researchagencies could prioritize global healthresearch when allocating resources that theyalready receive from their national govern-ments, on the basis of scientific opportunity,disease-burden considerations, and potentialimpact. No single agency could — or should— be expected to shoulder this responsibilityalone, yet together their investment could besignificant. The major problem would be tokeep the network coordinated, functional andfocused on science rather than becoming a politically correct, all-inclusive, but dysfunc-tional, tool for development.

Not everyone will be satisfied with the narrow scope implied by this concept proposal. Some will correctly argue that an initiative by the biomedical researchagencies in the scientifically developed high- and middle-income countries will notdirectly address a parallel problem of majorconcern to low-income developing coun-tries — that of building the capacity of theirown researchers and institutions. As the UNSecretary-General Kofi Annan puts it: “Theidea of two worlds of science is anathema tothe scientific spirit.”9 Others may also argue,possibly correctly, that the involvement of the leading biomedical research agenciescould inevitably encourage too much focuson basic science, and not enough in the areasof operations and health-services research.However, the network itself could addressboth issues, perhaps in conjunction withWHO and, eventually, a global research fundto support the development of science in themost resource-constrained nations.

Seizing the opportunityTo focus on such limitations is to ignore theurgency of the global health crisis, which hasreached such enormous proportions that wecannot afford to wait for the perfect solution.Neither can we wait for the creation of a newfund for research while the existing GlobalFund to Fight AIDS, Tuberculosis and Malaria(which is not oriented towards research) continues to search for adequate financial support,the most appropriate disbursementmechanisms and to demonstrate that it willactually make a difference in the absence ofnew tools (the products of new research) incontrolling these devastating diseases.

Nor can we afford to permit large pockets ofpotential capacity to remain untapped. A vigorous response to the crisis is urgentlyneeded now, and the international commu-nity must flexibly embrace the diverse range ofskills, expertise and contributions of any andall potential investors.

When a coordinating council of the leading research agencies, north and south,is up and running, it will be a constantreminder to the heads of these agencies toremain committed and engaged in the globalhealth-research effort, and will enable themto collectively identify the knowledge gapsthat their agencies can address, alone ortogether. As they become better organized incoordinating, collaborating and comple-menting one another, it will become increas-ingly possible for development agencies andphilanthropists to link their work — of capacitybuilding in developing countries — to thebasic and translational research growing outof the investments by the cooperating researchagencies. Competition, an essential element to ensure excellence in science, can be focusedon coming up with new knowledge in theshortest time frame, and not on which country or agency announces the discovery.

The alternative is to ignore the potentiallylarge contributions of the national health-research councils and their effective mobilization. These nationally organizedagencies have a specific mandate to focus ondomestic health priorities, and so cannoteasily play by the rules of other more globallyoriented stakeholders — such as the multi-lateral agencies, foundations, or even thebilateral development agencies of their owncountries. They are, after all, science agencies, and not donors. Yet while reflecting their own institutional cultures,they can make an important, highly significant contribution that would other-wise remain untapped. Given the enormityof the global health crisis we are facing, howlong can we really afford to leave these institutions on the sidelines or only partiallyengaged? Not much, we submit — the timeto move from concept to reality is now. ■

Gerald T. Keusch is director of the FogartyInternational Center, National Institutes ofHealth, Bethesda Maryland 20892, USA. Carol A. Medlin is a Senior Researcher at the Institute for Global Health, University of California, SanFrancisco, California 94105, USA.1. World Development Report: Investing in Health (World Bank,

1993).

2. Investing in Health Research and Development: Report of the Ad

Hoc Committee on Health Research Relating to Future

Intervention Options (World Health Organization, 1996).

3. Macroeconomics and Health: Investing in Health for Economic

Development: Report of the Commission on Macroeconomics and

Health (World Health Organization, 2001).

4. Feachem, R. & Medlin, C. Nature 417, 695 (2002).

5. Nossal, G. J. Immunol. Cell Biol. 81, 20–22 (2003).

6. Winnacker, E.-L. Science 295, 446 (2002).

7. Radda, G. Science 295, 445–446 (2002).

8. The 10/90 Report on Health Research, 2001–2002 (Global Forum

for Health Research, 2002).

9. Annan, K. Science 299, 1485 (2003).

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The internationalcommunity must

embrace the skills andexpertise of any and allpotential investors.

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