Cooperation with industry / by John F. Dunne

Cooperation with industry by John F. Dunne Or John F. Dunne heads WHO's Pharmaceuticals programme Just 100 years have elapsed since the roots of the modern re-search-based pharmaceutical industry were first established along the Rhine Valley in Central Europe. Inspired chemists then sensed that newly-developed tech- niques for producing virtually un- limited numbers of aromatic com- pounds from coal-tar derivatives held important implications for medicine as well as for the manu- facturing industries. Even they , however, could never have fore- seen where their visionary commit- ment would lead. It is providential that outstanding early achieve- ments in drug development, such as the demonstration of pain-killing activity in aspirin and phenacetin , assured the long-term survival of a commercially-sustained research activity. Some 40 years were to elapse before the discovery of the sulfon- amides heralded the subsequent ex- plosion of innovative pharmaceuti- cal chemistry that has transformed the basis of therapeutic practice within the professional life-span of a single generation of clinicians. Fifty years further on the pace of innovation shows no sign of slack- ening. Indeed, the rapid develop- ment of DNA recombinant tech- nology has provided the basis for a second pharmaceutical revolution , by creating a biological mechanism for synthesising a virtually unlimit- ed range of complex naturally- occurring enzymes and vaccines with unprecedented ease . This prodigious innovative capac- ity should assure the industry of an exemplary commercial image. Paradoxically, however, companies have too often found themselves to be targets for vociferous allegations regarding promotional excesses and abuses of trust , not least in some developing countries. The relation- ship between the pharmaceutical W ORLD HEALTH, July 1988 industry and WHO should be one of productive partnership in health care delivery, but all too often the dialogue has been diverted to issues of ethical precept such as advertis- ing norms and the rational use of drugs . The industry's responsibility to health care may never be totally reconciled with its commercial obli- gations. Nonetheless, both health objectives and the image of the in- dustry will suffer unless individual companies find a basis for effective rapprochement with the govern- ments which constitute their major trading partners, and unless they act spontaneously to exorcise activ- ities that are perceived to exploit rather than to support the commu- nities they are entrusted to serve. Tons of pharmaceutical products await- ing shipment from the UNECEF ware- house in Copenhagen, Denmark. Photo W HO/E . Mandelmann Governments also hold manifold reponsibilities that are not readily reconciled one with another. They need to contain health-care expen- diture in the public sector within re- alistic limits, but in the industria- lised world they must also remain sensitive to the need to conserve a socially-responsive programme of research within the pharmaceutical sector. This is necessary not only to advance standards of health but even , in some instances , to retain the status quo. The advent of AIDS has delivered a dramatic demonstration that man exists tenuously in an unstable envi- ronment; that infectious disease remains a potential hazard every- where-and not only in those under- privileged countries where it has never ceased to inflict an inadmis- sible burden on society. In fact, viral diseases remain singularly resistant to treatment , and the conquest of the bacterial diseases remains de- pendent upon an unrelenting battle against drug-induced resistance. Over the years, this phenomenon has successively compromised the value of the sulfonamides, many of the broad-spectrum antibiotics in- cluding the aminoglycosides, and successive generations of penicillins and cephalosporins. It has created a challenge that has recently resulted in the development of quinolone derivatives , antimicrobial agents with a fundamentally different bac- tericidal mechanism. These are of particular significance since they may ultimately provide a more se- cure means of stemming the rising tide of hospital-acquired infections that are at present unresponsive to most conventional antibiotics. This same phenomenon of resis- tance is responsible for frustrating earlier hopes of eradicating malaria and for the sharply rising attack rates in many of the countries where the disease is highly endem- ic. Not only is the most virulent of the malaria parasites commonly be- coming resistant to previously effective drugs , but the mosquito vectors have become resistant to available insecticides. Innovative pharmaceutical research alone holds the potential for stemming the ravages of the disease. The re- cent discovery of not one but three promising antimalarial substances has at least provided a basis for temporarily alleviating the situation while research goes on towards the 27 Cooperation with industry longer-term goal of developing an effective vaccine. This is not an isolated instance of successful and continuing research into the therapy of transmissible tropical disease . wHo itself has col- laborated directly with pharmaceu- tical companies over the past de- cade in the initial screening and development of many other com- pounds with antiparasitic activity. In less than a decade , drugs have emerged from these activities that are safe and effective enough to be employed in mass chemotherapy of schistosomiasis , intestinal ascariasis and, most recently, onchocerciasis (river blindness). Other compounds with promising activity against filar- ia! worms and trypanosomes main- tain the momentum of these pro- grammes. No less urgent , and of prime importance in the face of predictions that populations of some of the least developed coun- tries are set to increase fourfold by the middle of the next century , are analogous collaborative attempts to develop contraceptive methods that are culturally as well as technically acceptable to the communities in greatest need . The ultimate challenge for both partners in this research is to assure that the end products ultimately be- come widely available where they are most needed. More is at issue , however, than an assurance of ade- quate deliveries of the products. Workable systems of drug registra- tion and procurement need to be instituted within the target coun- tries to provide an effective frame- work for their subsequent distribu- tion and control ; supply channels have to be upgraded to assure the quality of the products up to the time of their delivery ; objective prescribing information needs to be issued to ensure they are employed effectively; and new cadres of health workers may need to be trained in how to use them. Several companies have already made valuable contributions to these objectives but the task re- mains daunting and cannot , in many instances , be separated from the need to strengthen the whole infrastructure of health delivery. The hope is that the existence of more effective drugs will attract the multilateral and bilateral support on which success is ultimately dependent. • 28 Talloires : a quiet revolution by Robert Walgate Or Robert Walgate is the Editor of the London-based Panos Features Service A" quiet revolution" in world health care was announced a few weeks ago at a meeting of health leaders in a lakeside priory under the snowclad foothills of the French Alps . The revolution, which will combine high technology with basic primary health care, was in- spired by the successes of the Expanded Programme on Immuni- zation (EPI) which was started in the 1970s in a bid to immunize all children against six killer diseases of childhood - tetanus, measles, whooping cough, diphtheria, tuber- culosis and polio . A special " Task Force for Child Survival " links W HO with the UN Chil- dren's Fund (U NICEF), the UN Develop- ment Programme (uNoP), the World Bank and the Rockefeller Founda- tion. In four years of work it has raised money, engaged govern- ments at the highest levels, and pro- vided and delivered cheap and effec- tive vaccines to 50 per cent of the world's children using existing health structures. lt is therefore halfway to- wards the eventual target of reach- ing 80 per cent of the world's chil- dren by 1990. Vaccines are now saving a million children's lives each year, and are protecting another quarter of a mil- lion children from crippling polio. That's a result that gave a boost to the 60 delegates attending the meeting in Talloires, beside Lake An- necy in France - delegates who in- cluded health ministers from each continent, international agency lead- ers and donors. Mr James Grant, Executive Direc- tor of UNICEF said that in 1984-when untold numbers of children were dying from vaccine-preventable diseases-the prospects for achiev- ing universal immunization seemed very uncertain . By late 1985, when the target was reviewed at a meet- ing in Cartagena, Colombia, "it was like Spring : there were a lot of green shoots coming up, so it looked as if the idea might work . " Reviewing the progress towards Universal Childhood Immunization (UCI), Mr Grant said: "We've seen the figures. Immunization rose from just 10 per cent in 1980 and less that 20 per cent 1n 1984 to 50 per cent in the autumn of 1987 -with an expectation of reaching a worldwide average of over 80 per cent by 1990. " As a result of this global success, Talloires saw a number of barriers broken, new agreements forged. On the one hand, the technologists learned from the UCI work that health was not just a matter of injec- tions, but was a social process of education, inspiration and "empow- erment" of the primary health care movement. They learned that, how- ever magical a treatment, it is use- less unless a willing, effective health system can deliver it year in year out to, say, an African woman giving birth in her hut or a boy in a Calcutta slum. On the other hand, those who had been highly suspicious of "Western" technologies and their champions had learned that life-sav- ing vaccines, at least, had now been delivered to half the world 's children . Dr Halfdan Mahler, Director-Gen- eral of the World Health Organiz- ation, has always believed that UCI (a UNI CE F term) should not be just a target to satisfy " institutional vani- ty" but a campaign to provide lasting benefit. UCI should lead, Dr Mahler always insisted, to two further goals: continuing immunization for successive generations of children, and lasting improvements in local health systems. But he summed up the mood of the Talloires meeting exactly when he said that development consisted of "knowledge-and motivation," that the immunization campaign was delivering both, and that the result was not the weakening that had WORLD HEALTH, July 1988