COUNTESS BETTINA. Dear Laureates, dear young researchers, Minister Bauer, guests and friends. It is a great pleasure to be able to welcome you here on Mainau for this panel discussion on Global Health. And I do this also on behalf of the Bernadotte family. This point is the one where we will continue yesterday’s lecture from Professor Deduve, where we can see why it is so important to do good research for society, because we all want to go into a good and sustainable future. And I think Professor Deduve made it very clear yesterday why we have to do so. So enjoy this panel, we have invited distinguished panellists today, and I want to express my joy to all of you that you are with us here today and introduce at the same time the moderator Geoffrey Carr, he was introduced earlier this meeting as a hippie! Maybe you remember. And I also want to take the opportunity to thank the Merck company for providing us with this very special technique today to show Professor Rosling’s presentation. And I hope, despite the good weather and the sunshine, you can see it very well. So welcome to the panellists, Geoffrey, they are yours. GEOFFREY CARR. Thank you very much, good morning. Good morning to the Laureates, good morning ladies and gentlemen and welcome to Mainau. I'm here as the chairman of the panel for third year now, and I seem to be doing something, right? I don’t know what's going on. I'm a science editor at the Economist as my day job and, as I said, I found a loophole in the rules, because I understand the rules are that the only way that you are allowed to come back is if you win a Nobel prize, but they keep inviting me. We are here to discuss Global Health, which is a big topic, it’s full of opportunity. And as we’ve heard over the past five days, it’s one where huge scientific strides are being made. I was particularly intrigued by two sets of talks about the beginning and end of proteins. We now understand, because we understand the ribosome almost perfectly, we understand how proteins are assembled, and we now understand through the ubiquitin system how they disassembled. And you know these two bookends of protein existence, proteins being the most important biochemicals apart from nucleic acids, understanding that shows how far we’ve gone and yet also how far we have to go. We’ve also learnt about personalised medicine, accurate diagnosis, accurate treatment and the possibilities of a new golden age of drug discovery that may come from this sort of information. I doubt we’ll ever live forever but this is the sort of work that will ensure we can live for a long time, we can live healthily, and when we die we die fast, with a smile on our faces. But it’s expensive, so this is only true for those parts of the world which can afford such things, an awful lot of people can’t. The greatest health needs are in the worlds’ poor countries, the solutions are often political and financial rather than scientific, so part of this discussion, I hope, will be about the science, and part of it will be about the economics and the politics. And we have Dr. Rosling here to talk about that sort of thing. So I will introduce the panellists. First of all Dr. Hans Rosling, he is professor of International Health at the Karolinska Institute, which supports the institution that decides who gets the medicine Nobel prizes, and he has revolutionised the field with his Gapminder chart, which he is going to show us in a moment. We have Harald Zur Hausen who won the physiology prize in 2008 for his work on the viral causes of cancer. We have Unni Karunakara, who is the international president of Medecins sans Frontieres, which is the militant wing of the Global Health movement, if I can put it that way. It sends medical help to places that other organisations fear to tread in. And it won as an institution the Peace prize in 1999. We have Georg Schütte, who is the State Secretary at the Ministry of Education Research here in Germany. He is another old lag at these meetings, we’ve been coming for several years. And finally we have James W. Vaupel, who is the director of the Max Planck Institute for demographic research in Rostock. And so, without further ado I shall hand over to Professor Rosling. We have to file down to those chairs there, because unfortunately we don’t have a screen in front of us, so I will put you in his capable hands and when he’s finished telling you what he has to tell you, we will come back and we can start the discussion. HANS ROSLING. Thank you so much. I’ve taken on the task to make an abstract of the world health situation in 15 minutes and I will cover what has happened during the last 200 years and what will probably happen in the next decades, about four decades ahead. So 250 years, the whole world, all diseases, here we go. This is a way of looking at the world, every bubble is a country. The size of the bubble is the population, and I show you 1960, the colour of the bubbles correspond to the continent where they are placed. And you can see that this is obviously China, this is India, big population. And here is United States, the brown ones here are West Europe, what do I show on the axis? The size of family, the number of children per woman, fertility rate, two, four, six, eight, big families - small families. And on this axis, our favourite, it’s life expectancy at birth, the length of life, thirty years, fifty years, seventy years or even more. So how long do you live, how big family do you have? And can you see that the world was divided in two different types of countries at that time. Even the back row can see it, we had what was called the developing world down here, with large families and short lives. And we had the western world here, which had small families and long life and very few in between. And look, Bangladesh was down there. Bangladesh, from which we have seen so many photos of misery from flooding and poverty and diarrhoea, and Germany was already up there living more than seventy years. This is when I went to school and my teacher told me, we are three billion people in the world and the world population is growing so fast, and we were amazed with it. Now I’ll show you what has happened. I will start the world, and you will see, if these countries get a longer life, if they get access to better hygiene, vaccines, antibiotics, and if they get access to family planning and can reduce their family sizes, has the world got any better or is it still as it used to be? Let’s take it down and here we go. China is getting healthier there, Latin America don’t care about the Pope, they start with family planning, China is already there with family planning, India is following, look at Bangladesh, Bangladesh is catching up very, very fast. They are going towards Germany, they are aiming at Germany and they are almost catching up, today Bangladesh is like Germany in 1960. This is absolutely amazing change, isn’t it? Just look at it and people are saying that the world is not getting better. The American has a very elegant word for that, it’s short, it fits in my abstract, it’s bullshit. The world has got a lot better, medical research has transformed itself into better life and freer choices, because what are we seeing here? What is this? Is this a public health measurement, no, it’s the bedroom, it’s what happens in the bedroom, the only decent way to look into the bedroom is to ask the demographers to give us the fertility rates. And you can see if it’s all patriarchal male biological sex here, without talking and you get as many kids as you get, still like that in Afghanistan largely. Or, if it is as the Americans say, very elegantly, pillow talk? The young couple discuss and say “We shall have two children, they shall have shoes, go to school, we should afford a guitar and our family should be able to go to the beach”. That’s modern life, that’s how it is in most of the world today, we are already there, there is in bedroom no difference between a western world and a developing world. And what is this? This is the bathroom and the kitchen, if you have water, soap and food on the kitchen table, you live to sixty years, then medicine can come up and give you even more backgates and the better life during life. Now, how does it look, how does the world look today? It looks like this: This is Bangladesh, father and mother and two children, fertility rate in Bangladesh: 2.3 today. Absolutely amazing, and they can afford a bicycle, he’s going to work hard to put his daughters through school. The greatest risk from him dying is traffic accident. For her it’s probably diabetes, this girl’s greatest risk of dying from one to five years today is drowning. Infectious diseases are there, but they are not killing to the same extent any longer. It’s an infectious disease burden, but they do survive. So here we are and we are trying to understand how this world works. This is 2011, where one billion in Europe, one billion in Africa, one billion in America and one, two, three, four in Asia. It’s a normal world again. It always used to be an Asian world, for 8.000 years we have had an Asian world with a majority here in Asia. And now it’s, after this 350, 400 years it’s turned again to a normal world, an Asian world. And what will happen in the next twenty years? Well, population will still continue to grow, but now mainly because of adding adults. We have reached what I call peak child, you’ve heard about peak oil, isn’t it? We have reached peak child. Since 1990 we get 135 million children per year in the world, it’s fluctuating a little but it’s not increasing. And 15 years later, 2005, we had peak children, the number of children below 15 is two billion, it’s not increasing any longer. What we are going to add is adult, world population growth is over, the only thing we have now is world adult population growth. So I can show you this in a tool that we are experimenting with here. We flipped the population pyramid over and put both sexes here. The number of children in 1960, when we had three billion, lots of children were born, you remember from my first graph how many children per woman there were. The children increased, they increased until here, look at the magic here. Can you see? It stops here. I flip over to get you 15-year groups instead. and there we are, you see they stopped growing there now, the young adults, your age group, is coming here and the rest is coming, and can you see the most successful group of the world population? It’s we, 60 plus, look here, we are the future of the world, we are the population growth group which are growing fastest. Get ready for that, we need a lot of drugs, we need a lot of treatment, we need to get vaccinated. It’s a glorious future for medical research, no problem there, we are going to consume much more, saving kids is, yes, a necessity, you can do it. Keeping us healthy, that’s the real task, you know. So this is more or less where we are. Now, why is it that the world still, we think it’s so different? Look here, if I go back to 1960, I mark here, this was children per woman, Vietnam was there, that was Vietnam, the United States was up to there. And if you look at this, you take away the other countries, here, and I run this, you can see how Vietnam has been successful increasing life, and they almost caught up with the United States. In the bedroom they are on a par, in the bathroom and kitchen they are one generation behind. Vietnam today have the same life expectancy or even better than the United States had when senator McCain came home from prison in Hanoi. We are not ready to realise that fully, I have had leading people in the United States, saying we didn’t have the slightest idea about that. So what's the difference? The difference is not in the bedroom, not in the bathroom, not in the kitchen. It’s in the living room, the garage and the garden. It’s where you pay with money, that’s where we have the difference. So I’ll change this axis down here from fertility rate to income per person. Look here, I take income per person there, we’ll see how Vietnam is. Oh, they are only here, 2.500 dollars, this is purchasing power dollar, what you can buy for them in your country. And the United States is up here on 41.000 dollars, how far back do I have to take United States to hit the situation of Vietnam today? I go back to the civil war. It’s strange, Vietnam is on a par in the bedroom, one generation behind in bathroom and kitchen, and they are five generations behind in the living room, garage and the garden. That’s why they work so hard in Vietnam. They don’t just want to be healthy, they want to be wealthy also. And they are now having an amazing economic growth. And you can see how the world is if I show the other countries, I take away them, this is the graph I gave you on the shares. The simple graph where you have poor, rich, sick, healthy. And down here, Congo, this is Afghanistan. And up here we have countries all the way. So where is the line between the western world and the developing world? Still, nine thesis out of ten that comes out of my university writing about the world, talk about developing countries, so I have a problem, I have gained fame but no impact. So I will now go into a phase where I try to achieve impact. Look here, we have to really have categories for the world. It’s here, perhaps this is the limit, can you see, there's some sort of a limit here, where you could say this is the richer part of the world and this is the poor. But there are really countries all the way. And if you would cut the limit here, we would find the Czech Republic on one side and the Slovak republic on the other side. To me that is the final proof that there is no such thing as two categories of countries. The problem is not the term ‘western world’ and ‘developing world’, the problem is the taxonomy into two groups. The population of Stockholm are not stupid and clever, there’s a lot of people in between. This is the most important to realise, and how can we make this understood in a better way? Well, we can take it all the way back here, this is 1800, I promise you. United Kingdom, richest in the world, then the Netherlands, then United States and here Germany. And most other countries were down here and this is what happened. We saw the west with industrial revolution, market economy, better institution, more technology, more research, getting rich first and then getting healthy. And then the rest of the world, the majority gained their independence and they got the kids into schools, they got health, and they came up there, got first healthy and then they got richer. Let me compare United States and China, it’s so clear if I run these two. That is from 1800, you can see how United States go this way and China goes that way. This is where Mao Zedong died and Deng Xiaoping took over. Deng Xiaoping said “yeah, health is good, but we also want money”. So it went this way and you can see how fast they go every year and how United States now went one step backwards, like Lehman brothers turned United States backwards to go and meet China, to wait for them. And this has implications, what are the implications this has for health, why do I talk so much on money when I'm a professor of Public Health? Because I love money. I love money, because I know how to use it. And money is the best medicine, it’s the best vaccine, it’s the strongest determinant of health in the world, but like all medicines and vaccines you must know how to use them. You use them wrongly, they can kill more than they can save. So what is it we need to grasp? We need to grasp that by 2050 we will have two billion people more in the world, we can split North and South America, we can split East and West Europe, and we can see that the Old West in numbers will just be one ninth of the world population. That is the fact that the world is changing in numbers. Now, in money we have collapsed countries down here, the poorest ones here, Afghanistan, Congo, Somalia, Sierra Leone, Central Africa republic, all with civil war problems or severe, severe political problems. Up there are high income countries, here middle income countries and there low income countries. This is a much, much more fact-based and scientific taxonomy of the world. Although it’s arbitrary, exactly as blood pressures are when we divide in normal and hypertension, but here we can grasp a little more. Let me show you, this is a collapsed country, it’s Congo on the border to Angola. The disease they have is Konzo, it’s a sudden onset toxic and nutritional disorder. I spent twenty years of my life, and that was my research career, identifying this, finding out that it was not infectious, it was caused by malnutrition and badly processed cassava roots. These people are really poor, they are what we call destitute. I have the permissions from the community leaders and the families to show these photos. And one of the problems in our research was that the families didn’t have clothes and couldn't participate in interviews, so this photo which we published, they are borrowed clothes. This is the sort of destitution, this is poverty at its worst. And we still have people in the world, we have a sizeable part of half a billion people living almost at this level or going out or into this. However, this is a low income situation, this is a much younger version of me, standing here, when I worked as district medical officer in northern Mozambique. And I'm treating a woman suffering from tetanus. You see risus sardonicus, her smile there. And we could save her, because she had one shot of tetanus vaccine, not the two she needed. So she got a milder form of it, and this was the great health staff I worked together with in this district hospital. I was the only medical doctor for 360.000 people. That’s one percent of the resources in Sweden. And how to do the right thing there, to find out which health investment is it that can help a country, both economically and in education? You can’t just provide everything people need, you have to find the most important and the most effective. Here is a middle income country, a nurse from Vietnam, I also have her permission to show this photo, that participated in the joint Karolinska Institute-Hanoi Medical University project about antibiotic use for respiratory infection. And she caught an infection herself, streptococcal infection, she got an endocarditis and was almost dying in cardiac insufficiency, she was saved from the acute infection, but then Vietnam cannot afford vascular surgery. There’s no way, Vietnam, on their level. Remember, they had the civil war income of United States and they had the diseases of when McCain came back from prison, it’s a very dramatic situation. Has never existed in the history that countries have had so low income with this modern or semi-modern disease burden. So I got a mail in my inbox, everyone involved in the project had to take money out of their own pocket to pay for her surgery. And she got the surgery, where? In Vietnam by Vietnamese surgeon, Vietnamese nurses, Vietnamese anaesthesiologists with technology produced in India. It was the money that was lacking, not the human skill, this is the new thing. Asia can deliver, but there’s not money, it is this thing which is the challenge that limits access to the good things of research. My conclusion is going to be - I give it already - we need a final step in medical research that also makes it cheap. And that’s not about economy, sometimes it’s just biomedical research to find out the clever way of producing that vaccine or that drug that can make it cheaply available in volume. The intraocular lens for cataract surgery costed 200 dollars until Indian polymer researchers went onto it and found out how to make it for 80 cent. They reduced the cost to less than half a dollar. And now people across India and low income groups can get cataract surgery. So the interesting thing is, in a poor country you need more research, not less research. And sometimes even more clever ideas and challenges to do this. And with Professor Zur Hausen here I had the discussion that he is just longing for the real prize. The real prize for him would be if the vaccine against papilloma virus could be accessible for everyone in the world. Then the work would be really meaningful, because just having it accessible for the rich and not for ones who need it more. The research is not finished until people can use the results. This is a high income country, this is a cochlear implant. Is it a human right, when you are deaf, to get cochlear implant on both sides. In Sweden you get it today, all children. Shall we get cochlear implants for the whole world? We have to reduce the cost from 40.000 euros down to below 400 euros, or even 40 euros. And this may happen, this may happen, because digital technology can be amazingly cheap and the surgeons to insert the cochlear implants, they will be rapidly trained across the world. That will not be the limitation. So we need a clever model, and I'm not blaming the pharma industry, I think that time is over. What we need is a business model and a regulation model that make it possible for all these different types of research we have to be transformed into products and services. And that the pharma companies cannot do, that has to be regulation that makes that possible. Now, how would I end this? I have to end with money again, since I said that I love money. And I would like to show you a health budget. Look here, we are going to look at health budgets, first this one. This is how much do people pay out of their own pocket when they get sick. Well, in Germany, when people get sick there are some fees and so on, I think it’s thirteen percent. Thirteen percent of the cost of health service comes out of the pocket. Sweden, it’s a little the same, and there are some countries here which it’s even lower, in France its only six percent. The poorer the country gets, the higher proportion of health service is paid out of the pocket. This means that when I started to lecture about Global Health, I said Global Health is easy, poverty causes disease. Today I say Global Health is complex, diseases cause poverty. The most common reason that people fall back into deep poverty is that someone got sick, and they sold everything they had, the bicycle, the sewing machine, everything to save that loved family member. That is an enormous challenge to bring it down, it’s partly administrative, particularly political, but don’t leave that political, go in with your biomedical research also, go in with a clinical research, make it possible. Reduce the numbers of doses needed, reduce the treatment period needed, and you can make it available for all. So we are facing a situation where the poor people are paying themselves. Now, why are the governments not paying? Look here. Here I show you, on this axis, income per person again. There’s two zeros difference on the incomes. Two zeros difference, you lose one zero you lose to zeros. These countries have one percent of the resources. When I worked in Mozambique as a government-employed doctor, I had less than one percent of the resources in Sweden. My job was done by more than one hundred doctors in Sweden, and I asked myself every morning: What should I do? Should I work faster and do the same service but faster for every patient, or should I maintain the quality and just take one percent of the patients. I had to strike a difference, a balance between those two. And see here, Ethiopia, how much, they have a very low income and a very low health budget. This is the government health budget in dollars. The text is cut out there, but this is government health spending, and in Ethiopia the government spends thirteen dollar out of 600 in GDP. It’s a smaller proportion, why do poorer countries spend a smaller proportion? Because they first need to have education and roads, they need to defend themselves, they need to have the others. The richer we get, the higher proportion of the GDP we spend on health, and the lesser part of health is paid by the individual. It’s a quite interesting challenge to notice. If you put in this economical analysis, if you generate new ideas, then you would see that things that you think is not worth doing in research, may be worth doing in clinical and biomedical research, just because it can help cut costs. Vietnam is then up here, China here, it’s a continuous line. It’s a continuous line. And we cannot put Czech republic, Argentina in developing countries together with Congo, it doesn’t make sense. Now, these moneys out here are purchasing power money. What's the difference between purchasing power and market exchange rate? You hadn’t expected that at this symposium here, it’s very important to understand the difference of that. Here is the difference. Because here I show government health spending, here in market exchange rate, and here in purchasing power. This is what's called the international dollar purchasing power, that’s according to how much you can buy in the country. And look, in Ethiopia they can buy, four dollars in forex correspond to thirteen dollar in the country. That means that countries can pay for the health staff to vaccine against papilloma virus, but they cannot pay for a costly vaccine. Countries can train surgeons to put in cochlear implants, but they cannot pay the high price for the cochlear implant. This is also you see the logic of aid, providing the input here by the rich countries in a good system where staff can use it makes a lot of sense. Here in Vietnam the relation gets a little less and then up here the difference between the government, if you are in Spain, the exchange rate and the purchasing power is almost the same. This is why it’s so difficult when we want to discuss cost of health service. Because we can’t grasp that health service is composed by cost of buildings and staff in the country and cost of imports of technology. And in poor countries, the cost of import of technology is huge. In the poorest countries, the cost of the drugs is 50% of the health budget. Whereas in Sweden it’s less than 10%. But as you can see, also in the clinical rounds in the hospital you had qualified doctors discussing for a very long time whether to add half a tablet or not. So the salary cost around the bed is much higher than the cost of that half tablet they will add. Whereas in a poor country you see someone in a queue, just talking for three, four minutes with a patient and then giving the drugs. Understand all of these different contexts and you will find your research much more interesting and you may be one of those who find out: Ah, I can provide this vaccine in a much cheaper production form. I can find out the way of treating this disease much shorter with one dose a day and then you can help improve the health of the world. Thank you very much. GEOFFREY CARR. Professor Rosling, that was awesome, truly awesome. I think we could all go to lunch, now we’ve learnt so much. However, we have an hour or so. My first question to ask the panel, which you’ve gone a long way to answering, is how do we make the treatments cheaper? How do we make the devices cheaper? You made the point very well that modern developing countries have developed in an opposite way from the way that the west, that the old countries did. They are acquiring the education and they are acquiring the modern country diseases without acquiring the modern country incomes, yet so we have to reduce costs, we have to make things better. You’ve talked about that for a while, so maybe we should ask somebody else. Who would like to address that question? How do you change the incentives for the medical companies to make things cheaper for poor countries? Unni, you’ll be the man for that, I think. If anybody wants to ask a question or make a comment there are microphones everywhere. Please line up, once I’ve taken two or three ideas from the panel I will start demanding input from you lot. UNNI KARUNAKARA. Right, I’ll take a stab at it. As an organisation we work in some of the really destitute, poorest parts of the world. And what you have are diseases, and especially now, after the presentation, it’s also clear where we are working in, even though there are poor parts of the country, people are living longer, there are infectious diseases, epidemiology. I mean they suffer, there is a morbidity, infectious disease morbidity, but they don’t die from infections diseases as much as they used to die in the past. If you want, if you take a developmental approach where we want to grow income and then kind of achieve better health, but the problem with that is what about the people dying today. So how long do you want to wait for a better future for people. I’ll just take the case of HIV for example. In 2000 there was not a single person on state-funded treatment in Africa for HIV, not a single person. Now there are about five million people on treatment. The cost of HIV treatment in 2000 was 10.500 dollars per person per year. And today it’s 99% cheaper and it’s less than 100 dollars at the moment, it’s about 80 dollars per person per year. What this has allowed is, even for global fund or Clinton Foundation, or even for PEPFAR, the big state funded programs, that they are able to put large numbers of people onto treatment because the cost has come down. So I think that is one thing to keep in mind. The other is that there are certain diseases that affect poor parts of the world and do not affect people living in rich countries. There is no market motive or market rationale for companies to actually do R and D for diseases such as Kala Azar or diseases such as Sleeping Sickness, diseases such as Chagas disease, so you have to find a different way of doing R and D for these sorts of diseases. One model that is being talked about now is the patent pool, where companies get a prize for developing drugs for example, they put it in a patent pool, they get some money for it, but then, once in the pool, it’s licensed to companies in affected countries or even other generic companies who want to take it on and produce it. So there are different models that are being proposed and I think this might be a way for the future where the current model of intellectual property and patterns for drugs is perhaps not a way for the future. GEORG SCHÜTTE. Let me just follow up on Unni’s remarks on neglected diseases, another approach from a research perspective that we try to follow is to enter product development partnerships, so to combine forces with others in a non-profit environment and pool resources on an international level to address research on those neglected diseases. And do it in a way that you do it on the ground, in the countries, together with the countries. And by doing this, we try to provide not only an incentive but also a mechanism towards developing inside, into the diseases, and then produce medicine, to produce products that address these diseases. So that is one approach, and another European approach would be what we call European-Developing Countries Clinical Trials Partnerships. That’s also a partnership approach in order to address research along the line of clinical research. So the bottom line is do research together, create know-how and create intellectual property in the countries, together with the countries, and then also develop a capacity. GEOFFREY CARR. And that presumably is doing the research in those countries, paid for by the richer countries, the ones at the top right hand corner of your continuum. What about the idea of Vaccine Purchase Fund, we’ve heard quite a lot of that recently, is that a good model? UNNI KARUNAKARA. Well, it is definitely making vaccines available for advanced market purchasing, guaranteeing a low price for vaccines. So again, you have to keep in mind these are for diseases such as pneumonia, diseases such as hopefully malaria in the future, but for example HPV vaccine, which you helped develop, the lowest price that has been negotiated for that vaccine is about 17 dollars, 16,99 or 16,95. That is completely out of reach for countries, especially where the biggest burden of cancer lies, so again there has to be, I think, much more work done. I think there’s a lot of focus on discovery and development, but not enough focus on delivery. I think there’s much more research that needs to be done on delivery mechanisms and on implementation research. The more we work in countries, the more that becomes very clear that there’s a lot of attention that needs to be put in that area of research, which is not the case at the moment. GEOFFREY CARR. Dr. zur Hausen, it’s your vaccine. How would you get it out to people at a price they can afford? HARALD ZUR HAUSEN. That’s one of the major problems at the moment, that the price is much too high. And many of the countries cannot afford this vaccine right now. I mean there is some chance to reduce it in the future, in part due to the competition, which is probably going to rise in view of the fact that some companies are now starting in some of the developing countries to produce a vaccine by themselves, and this goes back to what Dr. Schütte said before. It’s of course important that in those areas themselves the production of the respective products is being done. And so I hope that it will be done, but at the moment I think we see more, how should I say it, more sporadic application in some countries for certain period of time only, and that is not very helpful in my view. I mean, if you talk about Global Health, of course, it’s not really something which is coming out of the brilliant mind of a single researcher, as we discussed it during the meeting in Lindau right now, but it’s more strategy which we have to develop. We have to think strategically how to do it and where do it and to which extent to do it. I believe that we can only do it initially for certain types of pilot countries, we cannot do it globally at once. GEOFFREY CARR. Dr. Vaupel, any thoughts? JAMES W. VAUPEL. I think, as we heard earlier, that the main way to make medicine cheaper in developing countries is to develop more and economic growth is going to be the real engine for improving health. So that we shouldn't just view the situation as a static situation but as a dynamic situation. And the more rapid economic development can proceed, the cheaper medicine will be as a percentage of peoples incomes. GEOFFREY CARR. Right, so money is the best medicine. HANS ROSLING. But the problem is what you call developing countries is different groups. And they are so successful that, as soon as they have done that, there are more costly diseases to manage. And what I think is most important is that there’s not one drug policy, one medical research policy, it breaks itself down into multiple solutions. Small molecules can be extremely cheap to synthesise, but it was enormous cost in the research to find out how the molecule should be done and how it should be dosed. That can be licensed to countries, middle income countries can produce that. But they must not allow re-exportation then to the rich countries that need to recover the costs, because we need to give profit to the capital, otherwise we get no capital. I'm not against market economy, I just want it to be cleverly regulated and given clever opportunities. Complex molecules or complex technologies, there you need new research, you need to license, not have a patent period for 20 years, when no one does research on that molecule like this just wait for the money coming in. Put people doing research during the patent period and bringing it down and run trials on that. And others are, the whole more medical research can, you have a shorter treatment period, you tell them about the ARV treatment, but we know that this system will develop and price/cost will come up for that. And we know that for everyone we put on treatment on ARV, two new are infected. So it’s completely unsustainable, the present situation. And we need, we cannot even wait for a vaccine, we have to stop transmission by behavioural change. We have to stop transmission by behavioural change in the most affected countries, someone has to dare to say that. Whereas in Africa the variation in HIV is enormous, within Kenya it’s about more than fifteen-fold difference in HIV between the provinces, between the different income groups in Tanzania it’s different. The least affected African countries are like the United States. The most affected, which are the best literate countries, they have twenty-eight percent, there’s enormous diversity. And we still haven’t found out the reason, because no one has given us a test that can tell us for how long time a person had been infected. Please give that to epidemiology, come up with a test and tell us how long they have been infected and we can solve the transmission issue and we can measure the effect of impact. We need to get economy, health service, basic medical research to come together for this and find out new solutions. I think that the Gates Foundation has done a great job in finding out this, not having big political discussions, and that all fighting of the big pharma, that should be over by now. It’s not this, it’s clever solutions for each product that makes sense. UNNI KARUNAKARA. Just to go beyond the whole issue of cost, I think cost is absolutely important to get the drugs to the governments, to buy it, to get it to the patient. But how do you get a patient to take it? The last mile problem, I think it’s absolutely important, for example we got the price of HIV drugs down, but how do you expect people living in very remote parts of the world to take a bowl full of 24 tablets a day? And some of them need to be refrigerated because they are not heat stable. Now, the challenge is how do you make it easy for patients to take it, how do you increase or improve adherence. And the innovation was to make a fixed dose combination putting three drugs in one pill, heat stable, you take one tablet three times a day. That is what made it possible for people to take the treatment and to stay on treatment. Malaria, so you get cheap drugs from Switzerland, Novartis makes one of the big anti-malaria drug, but how do actually you get it to the people and get them to take it? Again, what made it possible was, before people had to come to the clinic to get microscopy done, so you have to actually see the parasite, but now a simple rapid test, diagnostic test, which was developed in India, but made heat stable, you didn’t need to refrigerate it anymore, you could go on your bicycle with your rapid diagnosis test, test and treat right then and there. So these are the solutions that are absolutely essential if you want to get people to take treatment. It’s not just about making drugs cheaper, which is absolutely, absolutely important, but there are other barriers to keep in mind as well. So that’s why I say that we really need to start looking at delivery research or implementation research, which is a very essential part of addressing the health care problem. GEOFFREY CARR. I'm sorry about the bells, I hope they are not too disturbing. Can I put a poll, if you want to ask a question, would you go to one of the microphones, thanks. Please do, but we need you to be at the mic, so we can hear what you are saying. Can I do a straw poll, who here thinks that the current patent laws are about right, that they encourage innovation by rewarding the inventors but don’t create too much of a monopoly? Put your hands up if you think they are about right. Not many. Who thinks that they are not right at the moment, serious majority. Of that majority, who thinks they are simply granting protection for too long? And who thinks that they should be just got rid of completely and there should be no patent laws? No one, okay, so what we need to do is reduce the length of time that patents last for, is that your opinion? Yes? Sir? QUESTION. I’ve got a speculative question. I hardly understand why people in Western countries feel responsible for the rest of the world who are living in poor conditions. In the end we know that the resources of world are limited and we know that the Western countries do not wish to share it with the others equally, which might solve the problem in one extent and, again, the limits of resources. So it seems to me that its discrepant to set out this question, so how we can improve health issues in other countries, because it seems to me so obvious at the same time discrepant. GEOFFREY CARR. Thank you, I suspect that the single word answer to your question is ‘guilt’, you know for what happened with imperialism. I don’t know but what's your view about that, why do Western countries feel an obligation? JAMES W. VAUPEL. What I picked up from the question was this notion of limited resources and I think that’s the wrong way to think about it. There are some resources that are limited but economic growth, as we talked about before, can expand the pie, so that the resources are no longer so limited. And so I think that of course we have to try to make the best use of the resources that we have, but we should try to expand via economic growth but also through biomedical research to expand the knowledge base that we have so that we are better able to cope with the diseases in developing countries. So I don’t see, I don’t think this limited resource notion is the best way to think about it. DR. HARALD ZUR HAUSEN. Let me just add, in my opinion it’s not only money, it’s not only the availability of cheap pills for some kind of disease. I think one of the basic aspects is really the lack frequently of appropriate infrastructure within many of these countries. It’s a lack of an education of the politicians on the one hand, and also in some degrees of the physicians in some of those parts of the world. And I think we need to act at several levels and it’s not clearly an easy task. And it’s, as I see it at least, it can’t be done at once for all over the world, it has to be done initially as a model, as a type of model in specific types of countries. QUESTION. Good afternoon. I am from Pakistan and I have a question for Hans Rosling. Your presentation was very good, it kind of was very inspirational as well, but you mentioned in your presentation about the demographic status of Bangladesh in the 1960s. But Bangladesh actually gained independence in 1971, so according to you, were you actually referring to the Pakistani community at that time? And, after the independence of Bangladesh, does your demography, which part of the population were you referring to after 1971? HANS ROSLING. The Bangladeshi part all the time, we put that part out. Remember, political shifts doesn’t have that fast impact if the question is whether the grandmother can read or not. So you don’t get so fast impact on that. But let me answer this question about the Western world, what's the Western world? Because look here, this is the income distribution of urban China, this is the income distribution of the United States of America, 1970. And here we go, wow, they were separated until 1985, today it’s covered like this, today 40% of the people in the United States have a counter part in urban China that earn the same amount of money. Swedes learnt this when Geely bought Volvo. So what's the Western world today? And the big pharma knows this, because the best chemists they find in China and India today. It is still a converging world, and we don’t have that separation. I want a good world for my grandkids, that’s why I don’t want instable countries and terrible diseases, it’s an egoistic motive basically. GEOFFREY CARR. So are we focusing in on the wrong diseases here? I mean, I put my cards on the table: One of the things that has mostly interested me, I thought it most worthwhile to write about in my day job as a journalist, is infectious diseases in the poor world, writing about malaria, writing about HIV, trying to keep these things in the public eye, so that politicians will continue to finance them. Is that a mistake, should we be saying these problems should probably go away with money and we should be looking at a future where what we are dealing with is not those diseases but with cancer and with metabolic syndrome? Are we looking at the wrong place for things? Well, I’ll leave that question. Sir? QUESTION. Hello, good afternoon, my name is Sharif I'm from Egypt, thanks Dr. Rosling for the presentation, although I think you explain it in a very straight forward way. I mean you mentioned that the whole process depends on three parties only, which are the individuals, scientists and the governments. But I think there is another party, a very important party that got a lot of influence on the process, which is the pharmaceutical companies. For instance there were rumours flying here and there during the very few years, about the swine flu and the bird flu, that there was this pharmaceutical companies that were behind the rumours that the swine flu is that lethal and the vaccinations or the vaccines they have are the only treatment for this flu. By years, of course I cannot deny or confirm this rumour, but by this year, by years passing, it was proven that neither swine flu is that lethal nor the vaccines are that efficient. So maybe the pharmaceutical companies may not allow you to, or to Harald for instance, to make his medication or vaccines that cheap because that’s their interest, their money. So would they be that nice? I'm not sure. GEOFFREY CARR. Would you like to answer that question, no. Sorry, Dr. Rosling then. HANS ROSLING. It’s a good example. The difficult thing with whether you should order a swine flu, is that you have to decide it as a politician before you know if the disease is bad or not. Because you have to give a period for the production of the vaccine. Isn’t it like climate change, we have to decide before we know if it’s really bad. And that’s why. The pharmaceutical industries, they behave as we treat them. If we buy like stupid customers, they will behave bad. If we behave like clever customers, they will learn how to behave. I regard the pharmaceutical companies like the horse in the old farm. We honour the horse because the horse brought food on the table, the family spoke well about it. But the family never asked the horse for advice. They never let the horse decide what to plant or drag to the market, you know. And that’s how, we can’t expect the pharmaceutical... So I mean, your suspicions shouldn’t be directed at the pharmaceutical industry. It’s to keep the government independent, to keep the government guided by research and the researcher communicated to it, then we order the stuff and we get it. UNNI KARUNAKARA. To take that example, fewer than 20.000 people died of the H1N1 virus, while 60.000 people died of for example Kala Azar disease each year, they die each year and we know that they will die each year, because there’s absolutely no research being done. Now there is with the PDPs, and funded by certain European governments there are PDPs working on new therapies. It will take a few years but they come. But I think some of our priorities are misplaced, but part of it is also what Dr. Rosling said. We don’t know, we have a doomsday scenario with these new threats and the new virus, so I think, you know, the pharmaceutical companies, they reflect the society we live in and they play to the fears and they are also, it’s a market opportunity for them as well. QUESTION. Good afternoon, I hope you can hear me now. I have a comment and suggestion. In the first slide you mentioned situation and comparison between Vietnam and the US, showing how the Vietnam is back with the property and having a low number of children in the family. And I think you completely missed one point which was the Vietnam war in which the US killed off pretty much, like two million Vietnamese and shattered the country into pieces by Napalm and bombs. So I mean we should also talk about causes which kind of are important for the development of the world, and not try to be too much descriptive. And maybe a suggestion for the Nobelists, if you could use all your power you have and try to convince these in the developed world to kind of cut down on the military spending, then we suddenly would have like hundreds of billions available for treating the poor kids and sick people in the developing world. So thank you. GEOFFREY CARR. It’s a nice thought. This lady? QUESTION. Yesterday we heard that there are too many people on this planet, and for obvious reasons we can’t remove the old ones, so we have to control the fertility rate. But don’t we face then the problem that we have too many old people and too little young people actually working, earning money which we can put in a health system again to apply for the illnesses of the elderly. So how do you manage that problem? GEOFFREY CARR. You are a demographer, you answer it. JAMES W. VAUPEL. First of all, I don’t think there are too many people in the world. And secondly, the world’s population is growing, it will reach a peak at perhaps nine or ten billion in the middle of this century and then start to decline, so that the next demographic problem we are going to worry about is population decline, which will have major consequences for economies and societies. But in terms of older people being a burden, the good news is that, as the length of life has gone up, as life expectancy has risen, the length of healthy life, the healthy span of life has risen in the same proportion. So there’s still a period of ill health at the end of life for many people, but that period of ill health at the end of life has been pushed to higher and higher ages. And the rise in life expectancy has just been astonishing, we saw some statistic about this. In the year 1800 there was no population in the world that had a life expectancy of more than 40, and today there are many countries with a life expectancy above 80. So life expectancy has doubled in a couple of hundred years. The rate of increase in life expectancy is in the countries doing the best, has been about two and a half years per decade, it’s three months per year, six hours per day. For a couple of hundred years, life expectancy has been going up. And healthy life expectancy has been going up at about the same pace and, as we saw, countries who are not among the world’s leaders are beginning to catch up, most of these countries. So there’s been a remarkable increase in the life expectancy and healthy life expectancy, so that age is not longer what it used to be, to be 65 years old today in a country is like being 55 years old or 45 years old in your parents’ or your grandparents’ generation. So there’ll be an older population, but there’ll be a healthier population and people will be able to work many more years of their life. GEORG SCHÜTTE. So the question cannot be ‘Do we have the right number or the wrong number?’, but ‘Do we have the right systems or do we have the wrong systems?’. And since the demographic change changes societies, we have to adapt the system, the social security system, the educational system. If you look at Germany, in the eastern part of Germany we have closed more than 2.000 schools, why so, because there are no more children anymore. We also have to adapt our social security system in order to pay for the health cost, for the retirement cost, so we have to adapt the system. GEOFFREY CARR. If I could stick my oar in here, in Britain at this very moment we are having this problem, because the pension terms for civil servants are being changed, the whole country’s national default retirement age is being put up and people don’t like it. They have been told to expect that they can retire at a certain age. Circumstances, as you’ve observed, have changed and, you know, it is not at all unreasonable to expect people to work into their late sixties. I don’t think it’s unreasonable to expect them to work until they are seventy, but they don’t want to do that. And I think there is a serious political problem there, and of course, as the population ages, so does the voting population and it seems to me it’s likely that you are setting up an intergenerational conflict whereby you people out there and people of our age on the panel are going to have different interests because we, not me personally, I'd like to work until I die, but people of my age, who are looking to retire in two or three decades time are going to want you lot to pay for us. And you won’t want to do it. I don’t know if anybody from the younger end of the audience wants to comment on that point, I'd be very interested to hear. QUESTION. Good afternoon, I actually had my own question, can I ask that? As I understand that human resource is also an important part of the health system and the developing countries are pretty resourceful when it comes to human resource. So if the developed countries would somehow help empower the human resource in the developing countries by helping and assisting them technically and skillfully, if they can empower them, then probably we in our country can cater for and take care of the diseases ourselves without external aid. Furthermore, in our part of the country - I'm from Pakistan - we have natural catastrophes that come quite often, like earthquakes and floods, so, as compared to acute and chronic diseases, sometimes a major chunk of our budget goes in emergency preparedness and taking care of these problems, as well as I would agree with my Vietnamese friend, that we are also faced with war and terrorism, so our countries and the governments are faced with the problems of assigning major chunk of our budget to those problems, and that’s why our health and education gets neglected. So I think we are resourceful in terms of human resource, so if we were somehow empowered by the help of other countries, probably we will be able to help ourselves better. GEOFFREY CARR. I think it’s an extremely good point, given Dr. Rosling’s observation that 8/9 of the worlds’ population will be outside of the old west by 2050, that’s where all the talent is going to be, obviously. And so what can we, the West do to encourage the flourishing of that talent, anybody want to take that one on? HANS ROSLING. I don’t understand what West is until someone defines it, be very careful with terms which are not defined, that’s what we learn in science, isn’t it? QUESTION. I said developed countries, like you said in your presentation. HANS ROSLING. What is that, you mean high income countries? Is South Korea included? Because United Nations still label South Korea as developing. You have high human resources in middle income countries, the big pharma know it, they outsource research and development, we know that big technology firms are now moving their research and development where the resources. This doesn’t solve the problem for the low income countries. And not at all for the collapsed countries. It is that different stratification which we need. And I heard about that statement that we had too many people on the earth, that is an ugly statement, intellectually. And it also draws the attention from what has to be done, population issue is solved, fullstop. We will become nine billion, there’s nothing you can do about it if you don’t like a new holocaust. It is nothing you can do about it. It is so bad, this orientation of population, when we need to solve energy systems, health system, we need to deal with this world, there’s no way we can become an old world again, where the West was dominating, this will be solved. But what works in successful emerging economies, middle income countries, doesn’t yet work in low income countries. It’s stupid to give aid to China, the global funds give 400 million US dollars to China for drugs, and they have 2.6 trillion in their foreign exchange reserve, that’s stupid. They should give the aid to low income countries and then have fair trade with middle income countries. Let’s face the world. No trade tariffs on products from Asia which are better than the European. GEOFFREY CARR. That would be a good start, I agree. Sir? UNNI KARUNAKARA. Perhaps I’ll add something about. I come from India which is not unlike Pakistan in the challenges it faces. The health budget in India is one percent of the total budget, one percent. And compared to what they spend on defence which is about fifteen percent. Now, speaking to some ministry of health officials, you know, the government is willing to raise the percentage, they want to go to five percent. But the problem is, even if you raise the budget tomorrow to five percent, the absorptive capacity, the capacity of the system to take on that additional funding is not there at the moment. We just don’t have enough nurses, we just don’t have enough people to deliver services. In much of Africa, the problem is being solved with task shifting, so jobs that were formerly being done by doctors are now being done by nurses, jobs that were being done by nurses are being done by community health workers, so there’s task shifting. It’s not a solution, it’s not a long term solution, but in the short to medium term, this addresses some of the issues, especially getting services out. Once you innovate treatment in a way that people with low levels of education can actually deliver it, then you are addressing, and that’s also one of the reasons why countries are able to kind of increase their health indicators with very little money. So this is something to keep in mind, that you have to go through some hoops before you can get to the point where you have a developed health system. QUESTION. So my name is Kostas, I come from Greece and I'm a post-doctor researcher at the German Cancer Research Center. So in the first place a small comment about your presentation, it was really fun and interesting, but Greece is considered on the group of one of the richest countries and at the same time we are almost bankrupt. That’s an interesting issue, but that’s not my focus, not my question. So we are researchers, we are doing research in order to develop drugs. So you have the drugs on one side and you have the patient on the other side. And allow me to give you a short story about a case that profit gets into the middle and disrupts everything. So a hypothetical thing, speaking about world health, cancer is a major issue, right? So imagine you have a substance, it is developed by some researchers, so they studied, they have very nice invitro results, they have really nice mouse models and they see great responses. And then they have some funding and they perform some small-scale clinical trials and they have excellent results. Imagine that this substance has almost no side effects, because this has been used for thirty years for another disorder. So now imagine that the problem is that this substance is so simple that no pharmaceutical company is interested in investing in that, because it cannot be patented. So now imagine this story is true. GEOFFREY CARR. We are doing a lot of imagining here, can we have a question? QUESTION. Yes, please, people, how many of you are aware of the substance DCA, dichloride citric acid, please could you raise your hands, I guess just a couple of people. So this is a true story and this is a really nice drug and really promising, the problem is that no pharmaceutical company invests on large-scale clinical trials at the moment, just because it cannot be patented, so there won’t be any profit for this company. My question is, in this case, I mean it’s really disappointing and sad seeing that something so promising doesn’t reach to the patients just because of the profit. GEOFFREY CARR. I think this is quite a specific question. Do you have any, you are our oncologist here. HARALD ZUR HAUSEN. I would have a comment. If there is a drug which is really, as you say, so cheap that it does not bring any profit for a company, I would guess that those drugs still would find some distributors locally in those countries where they need them or they would be widely distributed. Take aspirin, for instance, which is very cheap right now, which is sold worldwide for many purposes really, even as a cancer preventive drug as well. Still, I mean, in spite a very low price it’s well distributed. But here of course it’s taken up by pharmaceutical companies, and I'm sure that in other instances, some pharmaceutical companies would take it up even if it’s very cheap. GEOFFREY CARR. Sorry, I have to cut it off there. I wanted you to go off on a slightly different direction. Picking up on the point you were making about innovation. We haven’t got anybody from a drug company here, unfortunately. One of the things that I’ve noticed is that ten years or so ago, when I was still wet behind the ears as a journalist, I wrote a very long piece about all the innovation that was going to be coming in the drug world over the next decade or two, based on the Human Genom Project, based on massive parallel screening, all sorts of technologies looked as though we were going to go into a golden age of new drugs. And then we got to a point where the pipelines are shrinking in the pharmaceutical industry. And we’ve heard all these great stories this week about how this platform or that platform or the other platform, and the things I was referring to in my introduction are ways that one can go off and produce new drugs, but the drug companies aren’t actually coming out with them. Anybody like to comment on that? No? Guess who wants to comment on it. HANS ROSLING. Go for Indian and Chinese venture capital, for god’s sake. Someone commented the Vietnam war, remember that Vietnam war, Vietnam won the war. And we had great capital coming from China and India wanting to invest in Karolinska Institute Holding Company. There are people out there who think in other business models, so you can find this out, but the problem is we don’t have a good global coherent system where we can make these different models flourish. And we cannot have one system across the drugs, and you gave a very good example of what I try to say, all drugs are not the same. One could be an old one and you find a new diagnoses. You need a more clever system and in this we give the multiple different companies, because in the end Soviet Union didn’t deliver so many new great pharmaceutical discoveries. We need the companies in the end to deliver it, but we need to regulate it. GEOFFREY CARR. But why is everything I read about the drug companies at the moment, that the pipelines are drying up, they are not innovating, what's going on? No one knows, doesn’t matter. QUESTION. I just wanted to defend the point that the overpopulation might not be an ugly idea, because we cannot forget that this earth doesn’t belong to humans only. And we have broken an equilibrium and there are other species and there is nature that is suffering because we are too many. So there could be place for more billions of us, but that wouldn’t be fair for the earth. So I think that stopping to multiply would help not only humans but the whole earth which we have attacked so much. GEOFFREY CARR. I think surely the point of these graphs is that we have stopped multiplying. HANS ROSLING. I disagree, because we are stopping with two children per woman, but it takes the braking distance. We are there, this will happen and we won’t solve the problem by contemplating if we are going to be eight billion or nine billion, and decreasing takes too long time to solve it, there are more pressing environmental problems than can be solved by slow decrease of population. We have to face directly the energy system and the ecology, it is the wrong direction, it’s a metaphysical direction. HARALD ZUR HAUSEN. Of course we should not exaggerate some kind of actionism in this case, I heard recently at the meeting in Lindau that we should probably destroy all mosquitoes globally for preventing malaria, which of course, basically at first view it sounds good, but it would be a disaster worldwide if we do it. I mean, how many birds, how many reptiles, how many amphibians, how many fish are becoming extinct by getting rid of the all the mosquitoes. So we need to consider the environment as well, I think that lady was quite right when she was talking about it. GEOFFREY CARR. I would personally push the button get rid of all mosquitoes because, I hate them, but ... Sir? QUESTION. I come from the same school as Hans Rosling and I'd like to comment on the drug companies and their dry pipelines. I think, I see two reasons, first one that they built up huge in-house research organisations in hierarchic system that is not really stimulating the creativity rather than continue collaborating with academia and basic research where there is more creativity. The other reason, they all went for block busters that they can sell in large scale in wealthy countries. And if you try to develop a block buster drug, it’s fine as long as you don’t have a side effect, but even a small side effect can kill a drug like we saw with the COX-2 inhibitors. What we need to see, I think, to get a better distribution and more drugs developed, is not to shorten the patent time, because then the drug companies have to increase the prices even further to recover their costs. What we need to do is strengthen the power of the buyer to treat them as you do in a market and demand more of them, and for the global society to strengthen the buying power of the low income countries, so that they can demand the drugs that they need, and here we need I think to help as a global society. GEOFFREY CARR. What do you think of the effect of all this partition that’s going on with personalized medicine, the idea that you get more and more specific, more and more precisely targeted drugs, but presumably therefore with smaller and smaller markets. You know, the block buster paradigm is based on the fact that an awful lot of drugs are being wasted, it’s a fraud in a way. It’s, because diagnostics were not there, it was an inevitable fraud. But is it simply that the cost of developing drugs is now too expensive compared with the size of the market, is it slimmed down? QUESTION. I think that’s part of it, and therefore we need probably to look at the regulations and how that is handled. So it’s a complex problem, I don’t have one solution for it, but these are some of the points that one needs to consider. QUESTION. Hello, I'm working at Lund University, my question has to do with the responsibility of information, previously it has been addressed that we need to improve not only research and development but also for example delivery. And also to improve the strategies to get to know how is going to be performed public health in the future. But at the same time we also learn during this Lindau meeting that we have to do a bit of science, having fun, but also with responsibility. Now, my question is trying to connect these two things. In order to make it more responsible we need to know the specific needs, and my question is: Who delivers this specific and concrete need for specific research? Who is responsible for informing us, the researchers, of a specific need? Are there public health specialists, are there governments, are there universities, who shortens this gap? GEORG SCHÜTTE. Well, I can talk a little bit about the German example and how we set a research agenda. Part of it is of course curiosity driven, we have research funding agencies who provide funding based on excellence of proposals. And this is one thing. On a political level, as a ministry we try to address the most pressing illnesses and pool resources to address them, like cancer, like lung diseases, like cardiovascular diseases. And we currently build national research centres to address those diseases. We try to provide funding, if we talk about how are drugs being developed, we provide funding also for what we call non-commercial clinical trials. So in addition to the pharmaceutical industry, it’s both the research agency, the German research council and the ministry, we provide for non-commercial clinical trials and we do it based on proposals from the scientific community and at the same time we also will address specific illnesses and call for proposals to address those illnesses. So it’s a bottom up and a top down approach and we do have a forum of both researchers and representatives of the German health system who provide the German health forum as an advisory body to the government to define a research agenda and this is a broad agenda addressing scientific questions, both in the very narrow field of health research but at the same time, we also do research on the economy of the health system. Just on a different level to also address some of the questions which are being asked here now. QUESTION. This sounds great but it’s a German example, Germany is already well structured. I would like to hear the comments on the same question from Unni Karunakara or Prof. Rosling on what do they believe or think could be the strategy or who has to inform for example in developing countries. UNNI KARUNAKARA. I think civil society has a big role to play in this, I think even if you go to, let’s say Congo, and I’ll give you an example about Congo. Today Belgium is the only country that funds treatment programs for Sleeping Sickness. It’s the only country that actually funds treatment programs. And they are actually deciding to, they are thinking about ending that funding. And so, someone I know went to the ministry and asked them ‘Why are you doing this? Because you are the only country, you have a niche.’ You know, the Belgians have a special relationship with Congo, they were told that the government has told them that they don’t want the money for Sleeping Sickness. They don’t consider it a priority because even within the Congolese society, people who suffer these diseases are the most marginalised, most hidden, hidden by conflict, hidden by disease, hidden by poverty. So they have other, as a big country developing, slowly, but surely, they have other needs as well, so the little money they get from outside, they want to use it for other priorities. So even within the countries, going to the ministry for health is no guarantee that you will get the right picture. So you have to dig deeper, you have to kind of get civil society involved in raising profile on some of these issues, people who shout the loudest will be heard the most. HIV is a good case in point, the reason why it is one of the superdiseases with superfunding is also because of the activist community it has. But for the other diseases you don’t have the kind of community to that level at least that can fight for their own kind of illness or their own problem. GEOFFREY CARR. HIV was a very unusual disease in that it was first noticed in rich countries and had an awful lot of very, very interested and wealthy people from the beginning. HANS ROSLING. In collapsed countries with sleeping disease you have to have philanthropy money or WHO money in some way, that is a special issue with the research. Low income countries have to be clever in choosing, purchasing and delivering the drugs. Middle income countries, they have research capacity, they pool money now for their own tuberculosis research, because tuberculosis continues to drag along in that world. They pooled their research to lower the cost for diabetes and cancer, to find that low cost solutions and they go into venture capital agreement, even provide capital for it. I was so surprised at Karolinska Institute, when we got a visit from India, and we said ‘Should we ask our development aid organisation for money?’, So India is funding for research in Karolinska Institute, it’s a nice world we are coming into. The Indians can decide, but think not ‘developing world’, think ‘middle income’, ‘low income’ and ‘collapsed’. GEOFFREY CARR. Gentleman at the back there. QUESTION. Thank you, earlier in this discussion we heard shortly about the concept of equitable licensing, so the concept that we get profit for our medical inventions from the industrial countries or the high income countries and provide the same medication for lower price in poor countries. So that sounds very clever to me, why don’t we apply this concept to all our pharmaceutical inventions? GEOFFREY CARR. Anyone want to take that one on? I would have thought, the main reason is the risk of leakage, you’ve got to be very clear about, I mean, going back to the example of HIV, which is really what triggered this off I think, the drug companies were very nervous at the beginning, that, because the drugs are very cheap to make, they were very nervous at the beginning that if they started selling them cheaply in poorer countries, that people in rich countries would demand the same price. They actually, you know, essentially ended up doing a deal with the American government to say And it worked reasonably well, there wasn’t a huge amount of leakage but there was still some. QUESTION. I think we know from the success story of d4t that the profit of the pharmaceutical companies doesn’t decrease from this concept. GEOFFREY CARR. Now we do, but at the beginning they were quite nervous about it. QUESTION. I think there are really good concepts to prohibit reimport and make sure that these companies get the profit that they need. HANS ROSLING. You are damn right, no comment. GEOFFREY CARR. That is the first today. Sir, yes? QUESTION. This sounds a bit long comment but it’s a comment to your question, Geoff Carr. We are here, I think all of us agree that we are here not to listen to the old and boring people. We are here to be inspired by the wise and all-knowing people in our generation. So I would be willing to pay my taxes not to just raise my children, but also to keep my grandparents alive, so that they can teach us what knowledge they have learnt in their lifetime and so that we can pass it on to our generations lower and also protect our own space. But paying taxes is one issue, how much of corruption would affect us? and I'm pretty sure that Dr. Rosling or Dr. Karunakara would know a lot more about this, having come from or seen developing countries or the middle income countries. GEOFFREY CARR. Thank you, Madam? QUESTION. Hi, I take as a premise that our population will at some point in the near future become stable, so I don’t want to deal with that issue. But we have noticed that the countries that are on the rise, especially the very large ones like China, have followed a very different development trajectory than those countries which were richer earlier. And I think that increase in per-capita buying power and income has also come with a severe environmental cost and a much higher impact on the resources and need for energy, and our energy crisis is not solved and is not going to be solved in the immediate future. We also heard from Dr. Deduve yesterday, regarding the possibility of collapse of society, and some kind of doomsday scenario, in which there were mass conflicts and perhaps migrations. At this panel so far we’ve mostly talked about increasing life expectancy and the possibility of continued increase in the growth of the economy of these low income countries which have so many health problems. Do you as a panel believe that it’s possible that we might be facing some of these more severe sort of possibilities in the future, and if so, what do you think we can do about it and what are we doing about it? GEOFFREY CARR. Sounds like a question of demography to me. JAMES W. VAUPEL. Let me try to respond to this question, which is a very good question. Of course there are possibilities in the future that life will be worse in the future than it is now. There’s lots of reasons that might occur, it could be some sort of economic collapse as you mentioned, it could be lots of wars that take place. It could be consequences of global warming and climate change, there could be some new epidemics that we can’t control, so there’s a lot of negative things that could make the world worse in the future. The evidence though is that over the past couple hundred years there’ve been many bad things that have happened. There’ve been world wars, major depressions, there’ve been major epidemics but nonetheless over the past couple of hundred years, life expectancy has gone up, as I said gone up by about three months per year in the countries doing best. And then countries not doing as well have been catching up, so life expectancy is even going up faster than three months per year. And the various terrible things that happened over the course of the 19th and 20th century did not result in any kind of permanent decline in life expectancy or any permanent worsening of health. If you look at Germany, just to give an example, the 20th century was, especially the first part of the 20th century was not the best time for Germany, there was World War I, the economic depression, there was fascism, there was World War II, but none the less German life expectancy rose from under 50 in the year 1900 to 80 today in Germany. And as life expectancy has gone up, there’s been an increase in healthy life expectancy, as emphasized before, and part of that increase has been due to biomedical research, a large part of it, and the fruits of biomedical research. And then you start off by saying that the world was going to, there was going to be a stagnation or a stationary of population, that’s not true. What’s going to happen is the population is going to rise, maybe to a maximum of nine or ten billion, and then the population is probably going to start to decline. And that it will be a dynamic process with a lot of changes, and as life expectancy rises, as population rises and declines, life expectancy will be going up, so there’ll be an increase in population, and then a decline in population. So when you are older, you will have to cope with the consequences of declining population. Also there’s this remarkable increase in life expectancy and healthy life expectancy. A majority, if the trends that we’ve seen over the past couple of hundred years, continue, then a majority of children in richer countries today will celebrate their 100th birthdays. So many people in this room will live into their nineties, maybe past one hundred. So it’s going to be a very, very different world, in which there are long healthy lives that can be used to improve human welfare. Where you can devote many, many years to research and to making life better and also being a happier person. So I'm optimistic about this, even though there are, I have to admit that there are some possibilities of terrible things happening. GEORG SCHÜTTE. Just two brief comments, one shouldn't take a mechanistic view and only take into account the natural environment. I'm somewhat optimistic that there is also a process of social learning and social evolution and we should also take that into account. And life wasn’t that good at the beginning of the 20th century, and it may be much better to a much larger population today than it was one-hundred 100 years ago, so we are able to learn, and there is a development here. And the other comment that I would make is just to repeat a change of perspective that a psychologist pointed out to me. We speak about aging societies and she told me to simply change the perspective and no longer talk about an aging society but to talk about a society that lives longer. And that change of perspective induces a change of political approach, because for example in terms of health research and health delivery, it’s not how do we treat people who are old and sick, but what can we do in order to make life more pleasant at age 60 and 70, and that’s a change of perspective that translates into a change of policy. GEOFFREY CARR. The other point I would make is, your point about energy is a very good one. Actually an earlier one of these meetings which I was at, addressed that point precisely. And we do have a technological problem there, but it probably is one which will have a technology fix. We can tranduce solar radiation into electricity, we can probably do almost everything else, because if you’ve got abundant cheap energy, you can move atoms around in any way that you want, so an awful lot of the future environmental problem is an energy problem. If you’ve got cheap solar energy or maybe cheap geothermal energy, you can abandon fossil fuels and a lot of the threats that we are faced with at the moment go away. Sorry, yes? UNNI KARUNAKARA. Could I make a point about corruption. The problem with Global Health today, and especially the situation in the poor countries, the low income countries, is not really that of corruption. Sure there’s corruption, there’s corruption in Africa, there’s corruption in India, there’s also corruption in the US, how insurance companies deal with, it’s a bit more institutionalised, but there is still a lot of corruption. There’s just not enough money in the health system, that’s the problem. There needs to be much more infusion. I mean, if you look at it, for a dollar spend they are getting much better bang for the buck than, say the US is getting at the moment. So the problem is that we need to infuse the system with more money, and I think then things will start picking up. There’s just far too little money in the system for corruption to have an effect, I believe, that’s my belief I don’t think corruption is the problem. GEOFFREY CARR. I had a long list of questions here of which we’ve covered about one and half, but there was one on this list which I would like to ask in that context, which is: Will we ever have enough money? Will there come a point, can we envisage a point when all of this wonderful research has been done, and we have conquered cancer, we’ve conquered metabolic syndrome, we’ve conquered the neurological diseases of old age, which get exposed because they’ve never been subject to national selection? Will there come a point where the fraction of GDP that’s spent on health starts shrinking? Because everything that Dr. Rosling showed us is it goes up. It starts off at about one percent, when you are dirt poor, in the United States we were told on Tuesday it’s seventeen percent, it’s almost a fifth of GDP the Americans spend on their health. Will it continue to rise indefinitely, or will there come a point where effectively all demand has been satisfied and the economy continues to grow so the fraction shrinks? I think that’s one for you. JAMES W. VAUPEL. Yeah, let me respond to that, as people get richer and richer, they are going to want to have better health and invest more in health. So in the United States today there’s more than one television per room, there’s more than one radio per ear, and there’s more than one car per driver. So what are you going to do with additional money? Instead of investing additional money in materialistic goods, the additional money will be spent on non-materialistic goods. And one of the very most important non-materialistic good is health. So as people get richer, they’ll want to invest more and more money in health, and they’ll be willing to spend more and more money on biomedical research that helps improve their health. GEOFFREY CARR. So you think it will continue, not merely that it will continue to rise indefinitely, but it will continue to rise, it will plateau as a factor of GDP or will it fall? JAMES W. VAUPEL. Yeah, it will increase as a fraction of GDP, because if you have enough money to satisfy your material needs, you’ll want to spend the extra money on non-material needs. GEOFFREY CARR. So being a doctor is a tremendously good career. JAMES W. VAUPEL. Yeah, this is a good career, absolutely. UNNI KARUNAKARA. But I think the distinction needs to be made between spending on health and spending on essential health services. I think that distinction sometimes gets lost in some of this discussions. I think, if you look at it again from an overseas development assistance from a health point of view, I think the question is, what you raised, yes, but how do we actually spend that money. I think, you know, we haven’t really figured that out yet. Most of the time when I'm in countries, when I hear development experts talk, they have a very kind of one solution that they try to apply in most countries. And we need to kind of look at what are the basic essentials, and we were talking about this earlier, we need to define basic packages in each of the countries that need to be subsidized or provided for free, and then the others, once people get to a point where they can be economically productive etc, they can actually pay for some of their health care. So we have to make that distinction a bit more and we haven’t done that very well in the past. GEOFFREY CARR. Sir? QUESTION. So I was really intrigued by the statistic that Dr. Rosling showed, about the fraction of costs that has to come from the wallet per capita. I was wondering what financing models would or should middle and low income countries espouse in the future. Would it be like insurance companies, or would it be the tax payer who would take up this. The fraction changes over time? DR. ROSLING. That is a very good question and it hasn’t an answer, we see different attempts. In China we see that the government keep down their spendings, because they want the people to pay to get the savings into the economy, because they know in the end it’s only economic growth that can help them treat cancer and the other things. I can see actually one reason why health spending would fall, and that is if we don’t do the right actions for the environment. If we keep thinking about population, when that’s not the issue, if we keep discussing nuclear energy as a separate issue from the energy system. Then we might run into a climate crisis that crashes our economies, and then health spending has to go down. I'm extremely concerned about the environment, it’s just that I want us to do the right thing. And the right thing is to focus on how we produce energy, it’s our behaviour, it’s the services we need for that behaviour, it’s the technology we provide to manage those services. And we have to be much, much more serious, the OECD countries can’t throw 300 billion US dollars into agriculture subsidies and just a fraction into green technology research. This is appalling. To me it’s appalling to find that the politburo of the communist party in China is more serious than the democracies in West Europe and North America when it comes to climate. There are other things they are not serious about. GEOFFREY CARR. I think that’s a good note to end on, I would merely observe that... perhaps one of the reasons why approaches that is that almost everybody who is at the top of the Chinese government is an engineer, and they think in that way. You have been a wonderful audience, thank you very much. I’d like to thank everybody, Dr. Rosling, Dr. zur Hausen, Dr. Karunakara, Dr. Schütte and Dr. Vaupel. It has been a privilege chairing this, I’ve really enjoyed it and please go off and enjoy your lunch.