Commencement Talk, Columbia College of Physicians and Surgeons

Fellow alumni; those soon to be fellow alumni; and friends, faculty, and families of those soon to be fellow alumni:

I'd like to begin with two memories--one distant, one recent.

In the first, it is the spring of 1966. I am a fourth year medical student from P and S, interested in a career in tropical disease and working at a mission hospital in northern India. In the clinic, a young woman pulls back the edge of her headdress. A large gold earring rests on a mass of swollen lymph nodes along the left side of her neck. This is scrofula, the form of tuberculosis once claimed to be cured by the touch of British monarchs. The woman had likely ingested unpasteurized milk, contaminated by the bovine tubercle bacillus. This is unusual among the several cases of tuberculosis I see each day, so I take a picture. It is later seen by many classes of medical students in my microbiology classes at the University of California, San Francisco, where I taught and did research on retroviruses and cancer for twenty-three years. I never learned what happened to the woman and never worked on tuberculosis.

In the second memory, it is January of this year, nearly thirty-one years later. I am the Director of the NIH, interested in strengthening research programs in Africa and visiting the main hospital in downtown Bamako, the capital of Mali. Another young woman pulls back a curtain. On a bare bed lies a comatose child whose blood smear I have just seen, rich with Plasmodium falciparum, the causative agent of most cases of malaria in this part of West Africa. It is the dry season and the child lives within the city limits. So (my African friend, Ogo Doumbo, tells me) the chances of an infective mosquito bite should have been low. Still, the next morning the child is dead, one of an estimated two million who die each year of malaria in Africa. I spend the day with Ogo and his university colleagues, visiting in Bancomano, a town near the River Niger and its mosquito breeding grounds, where their research station has dramatically reduced deaths from cerebral malaria. An aerial picture of Bancomano and its lush river now hangs on my office wall in Bethesda, where one of my projects is a multi-national initiative against the disease.

Why do I juxtapose these memories? What do they tell us that we did not already know about the persistence of diseases we rarely see in the more affluent parts of the world? What do my different responses mean?

For me, these images of raw disease are like two bookends flanking volumes that record years of dramatic changes in the world. Consider some of these changes. The world I entered when my class graduated in 1966 was divided by political and economic philosophies. The United States had faced off against Russia, China, and other Communist nations in a Cold War that extended back to the time of my earliest memories. We were also in a hot war in Vietnam, a war that divided our own public and affected our daily lives and careers. In my own case, the NIH provided sanctuary and taught me to love a kind of research it would have been impossible to pursue in the tropical settings of my earlier ambitions.

Now, three decades later, the deepest divisions in the world are instead matters of wealth and well-being--the divisions between the highly developed, industrial countries in Western Europe, North America and parts of Asia, and the still developing, the deteriorating, and the intransigently poor nations spread throughout the rest of the world. In today's world, political instability and warfare are more often linked to ignorance, hunger, and disease, than to ideological differences.

Listen to what a young reporter, Jeffery Goldberg, wrote in a powerful article about Africa recently published in The New York Times Magazine:

"Chaos...is the best incubator of disease. And disease is also an excellent incubator of chaos. It is an endless cycle of misery: war and corruption mean no health care and no family planning; no health care and no family planning mean too many sick people; too many sick people create desperation and poverty. Which lead back to corruption and war."

For these reasons, ours is a world in which knowledge and science have become more important than arms and political realignments. A world in which foreign policy and defense should be closely tied to education and health. A world in which recent accomplishments in biology and medicine--new vaccines to combat viruses, like hepatitis B, or new drugs to kill parasites, like the guinea worm--should be powerful instruments to secure peaceful societies.

Yesterday, Christopher Murray, from the Harvard School of Public Health, talked at the NIH about his new text, The Global Burden of Disease. At one point, he displayed a bar graph of childhood mortality rates in different parts of the world. The bar for Sub-Saharan Africa towered over the others, a product of infantile diarrhea, malaria, measles, and malnutrition. He called this "our unfinished agenda."

The phrase struck a nerve. My trip to Africa this past winter was inspired by a similar sense of incompletion, by a sentiment that we have not done enough in the poorest parts of the developing world. Some months earlier, science funding agencies from America and several European countries had resolved to hold a meeting in Africa to think about a single disease and how we might work more constructively to combat it together. We chose malaria for several reasons: its magnitude (nearly half a billion people are infected); its concentration in Africa (90% of the deaths from malaria occur there); and its resistance to many once-promising forms of control and treatment.

We were also concerned about the perception that too few young investigators were tackling the problem and about the relatively slim financial support for research on malaria--now only about $85 million per year worldwide. With declining budgets elsewhere, the NIH is the narrow leader, spending about $20 million of our nearly $13 billion budget on malaria. These trends seemed out of touch with the global impact of the disease and with new scientific opportunities to confront the parasite, its insect vector, or its disease-causing mechanisms. The Plasmodial genome is being fully dissected and can be altered by gene replacement. Biotechnology makes possible new kinds of vaccines and drugs. Fascinating biological properties of the several forms of the parasite present new therapeutic targets. And new genetic methods are available for manipulating the insect vectors.

The meeting we convened in January at a seaside resort near Dakar proved to be extraordinary. Fully a third of the participants were African scientists, many of whom had never met each other because communication and travel are so limited. The range of topics was diverse: Vaccines. Drugs. Insects. Health services. Bed nets. Case management. Pathogenesis. Epidemiology. The objective was not the usual flaunting of new research results, but a cooperative effort to debate and define that is needed to solve the problem of malaria. E-mail and Internet in Africa. International training programs. Standardized laboratory methods. Research networks to map epidemiological patterns. Repositories for research reagents and insect stocks.

The collegial ebullience of this unusual meeting has come to be know as the "the spirit of Dakar." Funding agencies immediately banded together to ask for proposals for collaborative research. Over one hundred proposals involving scientists in many African, European, and American labs have been received. They will be discussed at a follow-up meeting in The Hague in a few weeks.

Those of us involved in this exciting initiative see ramifications that extend well beyond these new one hundred proposals. More balanced partnerships with scientists who work at the sites where tropical diseases occur. A revitalized interest here and in Europe in the medical problems of developing countries. And similar multi-disciplinary and multi-national approaches to other devastating diseases, wherever they occur.

Our efforts against malaria are not merely altruistic. Cases of malaria are treated in this country each year, and not only on ER. Millions of Americans take anti-malarial drugs when traveling or working abroad. I have already discussed the important implications for political and economic stability. I also believe there is much to learn from this fascinating disease that will be useful against diseases rampant in the developed world. The profoundly different agents that cause three of the world's most lethal infectious diseases--malaria, AIDS, and tuberculosis--have common properties: they establish chronic infections, they fail to elicit effective host immune responses, and they have foiled attempts to make successful vaccines. Surely what we learn from a success with any one of them is likely to help us with the others. For these reasons and others, it is time to move malaria and other so-called tropical diseases out of the exotic alcoves in which medical schools have traditionally housed them, and to put them in the mainstream of genetics, cell biology, immunology, and medicine where they belong.

I recognize that malaria will not be a daily concern for most of you who are graduating today. But there are many other "unfinished agendas" here at home. Indeed they abound. In our inner cities. In rural America. And in the laboratories where we still struggle to understand cancer or Alzheimer's disease, schizophrenia or AIDS--the many "unfinished agendas" I oversee each day at the NIH and try to infuse with the "spirit of Dakar." Now go find your "unfinished agendas" and bring to them your own version of that spirit.

Congratulations to you and good luck.