Pharmaceuticals for Developing Countries: Conference Proceedings (1979)

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KEYNOTE ADDRESS PHARMACEUTICALS FOR DEVELOPING COUNTRIES United States Senator Edward M. Kennedy It is a special privilege for me to be here today to keynote the Conference on Pharmaceuticals for Developing Nations. I owe a special debt of gratitude to Dr. David Hamburg, President of the Institute of Medicine, for responding so magnificently to my request that such a Conference be convened. He and his colleagues, Dr. Leighton Cluff, Mr. David Tilson, and Dr. Harold Simon, have not assembled the top experts from around the world for just a one-shot enterprise, but have made this three-day Conference the first step in a continuing and sustained effort in this area by the Institute of Medicine. Since Dr. Hamburg became its president, the Institute of Medicine has played an increasingly prominent role in developing national and international health policy alternatives for the United States. His compassion, his concern, his commitment to people and their problems, have made Dave Hamburg an exceptional figure on the Washington scene. The Institute of Medicine reflects his energy and skill. Over the next three days leaders of government, industry, and academia will share their knowledge, their ideas, their problems in an effort to form a partnership to begin to address the overwhelming health problems in developing nations. Much of the talk will be tech- nical, much of it will focus on specific problem solving. This is important and hopefully, concrete solutions will begin to emerge from the process. But before we get into the detail, before we examine the technical problems, let us remember, in human terms why we are here. As Archibald MacLeish put it: "When the fact is disassociated from the feel of the fact in the minds of an entire people and in the common mind of a civilization — that people — that civilization — is in danger."

We are here because one-quarter of the people on this earth — one billion men, women, and children — have no access to any health care whatsoever. We are here because 15.6 million children under five years of age will die on this planet this year; 15.1 million of these children will be from developing nations. We are here, in this International Year of the Child, because 2.6 million children will die this year from immunizable diseases because they won't have access to already-developed vaccines. There will be 72 million cases of measles in the world this year. And at a time when measles is nearing extinction in the United States, 1.2 million chil- dren around the world will fall victim to it this year. Six hundred thousand people, most of them children, will die from tetanus this year; 200,000 will die from polio, and 300,000 from whooping cough. Measles, tetanus, whooping cough, polio — we have vaccines for all of them. We are here because 70 percent of the human family worldwide does not have access to clean water, and millions die each year from dysen- tery and gastroenteritis. We are here because hundreds of millions of people in developing nations contract parasitic diseases each year, for which inadequate therapy exists or is not available when and where it is needed. We are here because we know that what is a statistic to some is a face to others. Behind these statistics are the faces of millions of people suffering from symptoms we can alleviate, dying from diseases we can treat, developing diseases we can prevent entirely. But most important, we are here because we know that progress can be made and that between us we have the skills, the energy, the compas- sion, and the commitment to lend a hand, to make a contribution. My brother Robert Kennedy liked to quote these lines written by Albert Camus: "Perhaps we cannot prevent this world from being a world in which children are tortured. But we can reduce the number of tortured children, and if you don't help us, who else in the world can help us do this?" That is why we are here today. Our focus for the next three days will be on the development and delivery of drugs necessary for the developing nations. Although devel- oping nations spend 50 percent of their health budget on drugs, over 70 percent of their people have virtually no access to them at any time. 4

And that makes a very real difference to the quality of their lives. The current president of the World Health Organization, Dr. F. Johnson Romuald, put it very well in his presidential address last May: "You only fully understand the vital importance of drugs for health care when you see the long queues of the sick in front of a little dispensary out in the bush which has nothing on its shelves, not a single tablet or an anti- malarial or ... antibiotic. Yet this is the situation in entire regions of the world." The problem of delivering existing pharmaceuticals to villages and hamlets in developing nations is indistinguishable from the overall problem of delivering primary care. We have all learned, at a tragical- ly high price, that the industrialized model of high technology, urban- based medical care exacerbates existing problems in developing nations. We have learned that it is not a question of bricks and mortar. It is a question of building a primary care infrastructure in each country. And that infrastructure must be built by the individual country, adjusted to its particular needs. It cannot be imposed from outside. This means training local people to solve local problems. It means building a new structure of health care in the only way it can be built — from the ground up by the people who live there. In this effort no single nation has all the skills or answers. We must develop a partnership among nations, each contributing what it can to the common effort. We are talking about the development of rather basic systems, by industrialized standards; but systems that can make an enormous differ- ence to peoples' lives. But if it is to be a simple, basic system, then it will not be equipped to handle the distribution of the 25,000 drug products cur- rently marketed in the United States. Such a distribution system is not only out of the question from a health systems standpoint — it is also economically impossible for the developing nations. That is why I endorse and applaud the effort of the World Health Organization to develop the concept of an essential drug list for devel- oping nations. Nothing could make more sense. The World Health Organi- zation concept is a simple one. Its premise is that the first priority must be to meet basic health needs. That requires a primary care infra- structure. A myriad of competing drug products is inconsistent with that — therefore, a relatively small essential drug supply is what is needed. The list need not be, and should not be, the same from country to country. It would have to be based on individual needs. But to the extent common needs can be identified, group purchasing would reduce

the economic burden. An example of this is the recently developed South Pacific List of Essential Drugs. Remember, we are talking about unimaginably poor countries which are already spending an unbelievably high percentage of their health dollar on drugs. The essential drug list would help, and would be con- sistent with the efforts to develop "bottom-up" delivery systems. So, in my view, the delivery of drugs is linked to the development of primary care infrastructures. And the development of those infra- structures must be based on the particular needs of each country. And the role for developed nations is to help — in a collaborative way. One of the ways they can help is to urge and provide incentives for the private sector to get involved in the effort. As industry enters developing nations and builds plants, then the health of the workers becomes of vital importance to the corporation. There are many exam- ples of significant corporate contributions to the health of people in developing nations: — In Ghana, Kaiser Aluminum has helped develop a primary health care program for the area surrounding its operations. — In the Dominican Republic, Alcoa has, in cooperation with the government, developed an integrated primary care program. — In Indonesia, the Weyerhauser Company established a small hospital and has worked with the local community to control malaria, conduct immunization campaigns, and deliver other preventive services. — The Xerox Corporation and the Children's Television Workshop have developed mass media preventive health messages for presentation throughout Latin America. There is a long list of private industry cooperation with local community efforts to help develop primary care systems. It is some- thing to be built upon. In the common effort by all nations, the pri- vate sector can and should play a role. Although the delivery of pharmaceuticals is beyond the immediate control of the scientific community and the pharmaceutical industry, the development of new drug products is not. It is here that this Conference may well make its most significant contribution. I hope you will identify areas of great scientific promise; review areas where more basic research is needed; identify obstacles to carry- ing out such research. I, for one, would like to know — how to encourage the pharmaceutical industry to focus more attention on the development of drugs for diseases of developing nations;

— how to build a strong scientific capability in the United States in this area; — how to build a scientific capability in developing nations themselves; — how clinical trials can be carried out if the disease exists only in countries which lack the capability to do clinical trials; — how the current export provisions of the Food, Drug, and Cos- metics Act affect drug industry research priorities and what differ- ences, if any, the newly proposed Drug Reform Act would make; — if there is a special role for the university community in the effort to research and develop new drugs and vaccines, to carry out clinical trials, and to train personnel. Within the next few weeks, I will introduce a major international health bill. Its goal will be to improve the ability of the United States to help solve some of these problems. It will attempt to strengthen the research capability, to improve and expand our training programs, to improve our service and technical assistance capabilities. Your work at this Conference will have an important impact on that legislation. To a large extent, it is dependent upon the answers you develop to the questions I have raised. As Chairman of the Senate Health and Scientific Research Subcom- mittee, which has the jurisdiction over most aspects of international health policy, I pledge hearings on this legislation in the spring and prompt action by the Senate this fall. There are some in this city who must wonder why so many talented people are being convened to focus their energies on the problems of faraway places. It is, after all, incongruous with the "me first" atti- tude, the spirit of retrenchment, so prevalent in America today. That you are together here, from all over the world, willing and anxious to help in this effort is a reflection of what is best in us. It is a recognition that in this effort, perhaps more than in any other of which we may be capable, we are all one people, harnessing our talents for the benefit of others in this struggling world we share. We cannot retreat from that responsibility without retreating from mankind itself. The prayer for children has these lines: "Somewhere — the place it matters not — somewhere, I saw a child, hungry and thin of face, Eyes in whose pools life's joys no longer stirred, Lips that were dead to laughter's eager kiss, Yet, parted fiercely to a crust of bread."

That is why in this endeavor there is neither Jew nor Gentile, neither male nor female, neither authoritarian nor democratic nation, neither liberal nor conservative. There is only illness to be cared for, hunger to be fed, death to be driven off. That is why you have come. I am grateful to you for it.