The Imaginations of Unreasonable Men (16 page)

Hotez’s grey cinderblock office at George Washington University reinforces his isolation. The phone doesn’t ring all that often. When we toured the lab we met only two other technicians, working alone in two small rooms down the hall.

For many years Hotez scraped by with almost no support. “Neglected diseases, neglected scientists,” he said with a grin. He delved into the reasons that hookworm is neglected. “First of all, it doesn’t kill. It is chronic, and debilitating and disfiguring, but many of the neglected diseases don’t kill and so they don’t rank high in rankings of factors that cause mortality.”

Eventually the Gates Foundation came through with two multimillion-dollar grants. “I don’t think they are all that interested in hookworm,” Hotez confided, “but they
are interested in the model we’ve developed of technology transfer to what we call Innovative Developing Countries (IDCs), like Brazil, China, India, and others.”

In an interview for the Department of State’s electronic journal (
America.gov
), Hotez explained:

As if to underscore how far he’s come, he chuckled: “I even have a hookworm movie.” He wasn’t kidding: He turned to his computer to call up a video taken during a routine colonoscopy that included footage of a hookworm at work. We watched a five-minute excerpt of it together.

Hotez seems to have been destined for this work. As a thirteen-year-old in 1971 he had on his bedside table a volume
of
Manson’s Tropical Diseases
, which, through twenty-one editions since 1898, has been considered the bible of tropical medicine for both clinicians and researchers.

Upon his enrollment at Rockefeller University he was told that Rockefeller’s students were “supposed to do remarkable things.” He took the words to heart. When he read a famous 1962 paper by parasitologist Norman Stoll describing hookworm as “the great infection of mankind,” his course was set.

In a lecture in 2006 at the University of Georgia, Hotez described the long process of making a vaccine, beginning first with dog hookworm. It required one to collect the necessary ingredient of worm spit, which, because you can’t get enough of it from the worms themselves, means turning to genetic engineering. “It took twenty-five years of work to develop a viable strategy for this disease—and that was the easy part!” Hotez recalled. Hotez emphasized that there was essentially no way to create a company to manufacture the vaccine without losing money, describing the project as “the biomedical equivalent of the Broadway play, the Producers—an intentional flop—a guaranteed money-losing enterprise.” But he also cited Gandhi’s aphorism that “no movement ever stops for lack of funds,” a telling point that revealed something of what makes Hotez tick.
¹⁶

Despite the idealism that became evident at moments like this, Hotez is nothing if not practical. One vaccine, using a recombinant version of an enzyme, proved effective, but it was costly and difficult to manufacture in bulk, so
Hotez devoted his energy to developing a different vaccine. If his ultimate objective is to save lives, he does not have the luxury of just developing an effective vaccine for hookworm, as difficult as that is, but must develop a different vaccine, one that is effective but can be delivered for less than $1 a dose.

“If you can’t make it cheaply, you might as well not make it at all,” Hotez told
The Scientist
. “We have to build into our design process the ability to deliver this vaccine at less than $1 a dose.”
¹⁷
This provocative assertion has obvious implications for global health science and medicine. It also suggests a different way of approaching social science. It means at least two things.

First, if you contract a disease in a developed country and your prayers are answered by a cure being discovered, you will get that cure and you will live. But if you contract a potentially fatal disease in a developing country, the discovery of a cure does not necessarily answer your prayers, because there may be no economic way to get that cure to you, even if, by not getting it, you will die.

Second, because the life and death stakes are so explicit and unambiguous when it comes to neglected tropical diseases, vaccine developers must build the economics of manufacture and distribution into their work from the beginning. Consider what is being asked of them. No one expects university economists to know how to isolate protein molecules in lab flasks to determine which ones trigger immune reactions and might be candidates for a vaccine. But
doctors who are able to do just that in their labs must also master the rigors of international economics if they want to see their efforts to prevent disease come to fruition.

Businesses face this issue head-on every day. So must the nonprofit sector.

I’ve never heard the term “gross margin” raised in a nonprofit context, although clearly that is what Hotez is getting at when he says of his vaccine efforts: “If you can’t make it cheaply, you might as well not make it at all.” This is not a new principle, or a very complicated one, but neither is it widely appreciated or subscribed to in the social sector.

If one accepts that there is a moral obligation to share our strengths and intellectual gifts to develop solutions to human need, then the moral obligation may be even greater to ensure that such solutions, including vaccines and other preventive measures, are not accessible only to the privileged few.

Economic laws and market forces may be morally neutral, but our willingness and discipline to embrace and marry them to social science represents a choice. It is a choice that we have yet to make and take full advantage.

Most vaccine developers devote their entire lives to creating and testing a vaccine without ever seeing their work finished. Hotez is no different. Now at the pinnacle of his profession, he has been working on hookworm since medical school. As complex as the scientific challenges are, the economic challenges may be even greater. “The hepatitis B
vaccine started at $150 a dose,” Hotez told me. “It took thirty years before it penetrated the population.”

But what interests me most about Hotez is not only the science of what he is doing, and the economics of it, but also the determined and sophisticated effort to build political will where it does not exist, and to do so by projecting a voice where there has been silence.

There are 540 million children, some halfway around the world and many here in our own hemisphere, whose intestines are literally crawling with blood-sucking worms. There are tens of thousands of doctors around the United States and the globe, but there is only one who devotes all of his waking hours to doing something about hookworm.

In an article in the prestigious
New England Journal of Medicine
, Hotez and some of his colleagues attempted to combat a critical notion that contributes to the plight of neglected diseases. Scientists know that more people are dying from HIV/AIDS, malaria, and diarrheal diseases than are dying from hookworm and some of the other tropical diseases, and they conclude that the more fatal illnesses must be given greater priority. As a result, considerably more talent and money go into those endeavors. But by adopting a different metric, one of “disability adjusted life years,” or “DALYs,” Hotez’s team said, the neglected tropical diseases can be shown to constitute large burdens on the health and economic development of low-income countries. Indeed, in terms of DALYs, the neglected diseases rank closely with the better known malaria and tuberculosis. The obvious conclusion:
Some of that talent, and money, needs to be going toward combating them.
¹⁸

History has traumatized and scarred the malaria community. Several times over the past fifty years it was believed that the world was on the verge of eradicating malaria. The result of premature celebrations was a decrease in focus, funding, and research, and soon a dramatic increase in the prevalence of the disease. Too often the malaria parasite has been underestimated. Discussion of eradication has been seen as somewhere between naïve and recklessly dangerous. Melinda Gates changed all that.

On October 17, 2007, the Bill and Melinda Gates Foundation hosted a three-day forum in Seattle on malaria, bringing in prominent experts from around the globe. Melinda gave the opening address. Her speech was candid and courageous, passionate and provocative. Historians may look back on it as a pivotal moment. After recounting some of the history of the disease and the way it has plagued people around the world, she said:

Anticipating the concern of those in the audience with far more expertise than her, she added:

Gates gave three specific reasons why we should embrace the goal of eradication. The first one was that it was the ethical thing to do. “Every life has equal worth,” she stated. The second was economic: “If we plan only to control malaria, we will never eradicate it. That means we will keep bearing forever the human costs of malaria, even as we keep paying forever the financial costs of trying to treat and control it.” The third was epidemiological: “Without eradication, we will continuously adapt our strategies to the parasite and the parasite will continuously adapt to us—in a back-and-forth battle that will never end.”
²¹

Both Melinda and Bill Gates made the case that with enough time we could develop the partnerships, political will, and scientific breakthroughs necessary to eradicate malaria. It would take relentless research, coordination, and especially long-term commitment. And eradication would require intensifying efforts as fewer and fewer people were infected, which may sound counterintuitive but is true. Political will and funding diminish when the mortality is reduced.

The pros and cons that Melinda Gates articulated were almost identical to those we’d discussed at Share Our Strength when we had been debating whether to set a goal of ending childhood hunger in America—not reducing it, but ending it. Many of the experts in our community cautioned
us about the complexities of measuring our progress and the risk of failure. But as Gates understood in making her remarks, the experts are often expert in what has been, but not in what could be.

“The world is failing billions of people,” Bill Gates told the World Health Assembly in Geneva in 2005:

In October 2008 I flew to Seattle to check in with the global health experts at the Gates Foundation on the progress of their malaria vaccine initiative. Joe Cerrell, director of global health and advocacy for the foundation, echoed his boss in explaining that, first, markets don’t work for 2 billion of the world’s poorest, and, second, “sheer visibility”
is a challenge, in that “the problems are 7,000 miles away and don’t factor in to the psyches of those who could make a difference.” Perhaps most important, the Gates staff had come to learn, as Steve Hoffman and Peter Hotez had, that “the best science is not always the best solution,” in the words of Tom Brewer, senior program officer for infectious disease at the foundation. Sometimes the best science is the science one can afford to scale.