 Our speaker today is Dr. Abdullah Dhar. Dr. Dhar and I have known each other for 10, 12, 15 years perhaps. I'd like to say we're old friends of Dhar. We are old friends of Dhar. Dr. Dhar comes to us from the McLaughlin-Rochman Center for Global Dhar at the University of Toronto, where he's a professor of public health sciences and of surgery and a senior scientist and director of ethics and commercialization at the McLaughlin-Rochman Center. His academic career has really been quite extensive. When I first met Dr. Dhar, he was the chair of surgery and doing renal transplants at Oman in one of the emerald states, and we met at a UN conference in Germany, as I recall, around Munich in 1997 or 1998 to work on some international questions. But Dr. Dhar is not only a surgeon and organ transplant surgeon, but has been involved in global health and bioethics. His major research focus is on global health inequities, which he will be talking to us about today, with a particular focus on building scientific capacity and increasing innovation in developing countries and in learning how to move things from the land up to the village in terms of health. He studied and later taught at Oxford, was the founding chair of surgery, as I said, at Oman and remains involved with the UN World Health Organization and UNESCO as an advisor and consultant. Currently, Dr. Dhar is the chair of the board of the UN University International Institute for Global Health. And the topic that we may touch on today is also the chair of a quite extraordinary global alliance for chronic diseases, an alliance made up of the leading research institutes of six countries around the world. And so Dr. Dhar chairs that. It's with great pleasure that I introduce a Deladar innovative approaches to reducing global health disparities. Well done. Thank you very much. It's a great pleasure and honor to be here and thank you very much for inviting me. And the timing is pretty interesting considering the elections yesterday, and particularly with the connection to Chicago. I'm going to be talking for about 35 or 40 minutes. And right up front I want to say that 70 to 80% of the work that I'll be describing here involves my dear friend and colleague Peter Singer, who is unfortunately not so well this week. He was due to come here next week to give a talk at the Fellows Conference, but won't be there. And we are hoping that we'll be able to reproduce some of my comments. So consider this as a presentation from both myself and my colleague Peter Singer. So I will describe our work mainly. Some of it is not yet in the literature or is not in an accessible form. And so it'll be quite new. And I hope that we'll have a lot of time afterwards to discuss that. So let me first of all start with the definition of global health. It's one of those things that's a little like the elephant and the blind men. It hasn't settled yet as to exactly what it is. My favorite definition is this one, from the Institute of Medicine report. Health problems, issues, and concerns that transcend national borders may be influenced by circumstances or experiences in other countries and are best addressed by cooperative actions and solutions. And that packs a lot of implications which I hope will emerge as we discuss issues today. So look at this picture. On the right, you have people living in North America, Western Europe and the rich countries of the world, expecting to live 80 years after at birth. On the left, you have sub-Saharan Africa mainly and other places in the world, but mainly sub-Saharan Africa where life expectancy is still 40 years and to some extent in a few countries actually dropping. And so that immediately raises two questions. First of all, how can this be acceptable? We're one species, we live in one planet. How can this be fair? How can it be sustainable? And the second question is what can you do about it? So that's partly why Peter and I got involved in global health. Look at the disparities in global health. And I want to enumerate many of these because the list can go on for hours. For every second of every day, four women will give birth and every minute one of those women would die. For every woman who dies, another 30 suffer lifelong consequences as a result of complications of their pregnancy or the delivery. And that's not to mention the kids who grow up in utero with malnourished mothers or who grow up in very constrained circumstances which then leave lasting legacy of being exposed to metabolic and cardiovascular diseases and mental health problems. So it's a huge problem predicated on poverty as one of the issues. I also want to highlight a human rights element to global health. Some of you may be familiar with Amartya Sen's article maybe 10, 12 years ago in the New York Review of Books about 100 million missing women. And those missing women, what you would have expected in a particular country to exist but don't exist because the human rights situation particularly vis-a-vis for the rights of women are such that those women die early or somehow disappear. Now poor health affects the poor predominantly including in the United States. Some of you may be familiar with this statistic that in Washington D.C. as you go down the subway from the richer parts of the city to the poor parts of the city for every two and a half kilometers along that path life expectancy drops by one and a half years. This is a problem between the developed and the developing world but even in the developed world there are disparities and some of the talks that you will be covering including here in Chicago will highlight those issues. Now infectious diseases have received a large part of the attention in the past decade or so. HIV, tuberculosis, malaria, neglected tropical diseases and that has actually attracted some significant funding from many sources, the biggest source being the Gates Foundation to address some of the real big challenges facing us with regards to infectious diseases. Part of this is humanitarian impulses and part of it as I will show you in a minute is national security considerations. So viruses do not carry passports and that has been one of the factors that I say but then neither does climate change or environmental degradation. So people think about infectious diseases but do not give as much attention to the health implications of climate change and environmental degradation and those too don't respect borders. Now our consumption patterns in North America and in the rich countries of the world are such that directly or indirectly we harm people in the developing world. Take our meat consumption, the fact that we have to use good land to produce feed crops to feed the cattle with all the environmental implications of that to the rest of the world and all those greenhouse gases released but also we export things like tobacco aggressively. The markets here are saturated, people are smoking less so what do we do? We export that to the developing world and that's a huge problem as we will see in a minute and then a focus of my work over the past four years on chronic non-communicable diseases that is an area that has been totally neglected and indeed mental health which I'll come to at the very end is even more neglected than that and that is actually not so just in the developing world but throughout the world. So this is the national security angle. This is a comment from Sandy Berger, you guys might remember him from the Clinton days he was a national security advisor and he says that a problem that kills huge numbers crosses borders, threatens to destabilize whole regions is the very definition of a social security threat to dismiss disease as a soft issue is to be blind to the hard reality. So that's been some of the calculation. Let me paint another layer to this. What stresses the planet will stress global health. So if we put a stress on food supplies the poor will suffer. If we don't take care of energy sources the poor suffer and of course climate, if we don't take care of the climate it is primarily the poor who will suffer, not the rich. In some parts of the world like Canada we might actually be better off if the climate got a bit warmer. It is usually the poor that will suffer. Water, totally underestimated as a potential threat to the health of people in the developing world and this is something that we need to pay more attention and areas like Darfur where there are people suffering there are health implications and so on one of the reasons that that war has perpetuated itself is water shortage in that part of the world and underlying it literally under the ground are some aquifers that people are thinking about exploiting in the future. And then another element which is not often thought about in global health is this willful negligence of the consequences of military action. So you go into Iraq you have your policy objectives but you forget that you have displaced 4 million people and those 4 million people from the moment they are displaced become not only victims but then become a problem in terms of health but we never think of that as a health issue and it is happening in Afghanistan too displaced people, migrations, etc. are a huge health problem. So let me tell you now a little about our center which Peter Singer and I have built over the past decade and it is evolved from various different prior institutionary arrangements to what we have now which is the McLaughlin Rotman Center for Global Health which is at the University of Toronto and the University Health Network. The niche that we have evolved is this interesting intersection, convergence between global health as defined here looking at the bigger picture life sciences, we came to this via genomics initially and then biotechnology and now we just call it life sciences wider definition. And innovation, I feel in its own right innovation studies, commercialization, product development, entrepreneurship. So that's the area where our work has ended now. It's that interesting intersection. Our work is currently organized under 4 pillars. One is grant challenges which is what I'm going to be talking about next. A whole area of ethics, most of that work now we do with the Gates Foundation and it's funded by the Gates Foundation. We have a large body of work looking at commercialization and I will talk about that. And then we actually have a laboratory component. So we have a big research lab led by Kevin Cain ahead of the Sandra Rotman Labs and he does interesting work on tropical diseases, malaria and so on. So it is actually a center that encompasses lab to village in a real sense and that part after you leave the lab is really the most complex to do. We work closely with the Bill and Melinda Gates Foundation. We have several grants from them and I'll talk about some of them now. And we host in the McLaughlin Rotman Center this interesting new initiative called Grant Challenges Canada which I'll describe. So let's just look at if you took a new technology or even new policy for health and kept it at the center and then asked yourself how would we actually implement that and get it to the people that need it in the village in the derogatory sense village but where it's needed. So you need to look at the science behind it. You need ethical, social and cultural considerations. You need to find financing and then there are politics and then with each of those you can subdivide the issues and you can just keep going outwards with this kind of diagram finding more and more issues that need to be tackled before you'll get success. This is based on a study that we carried out at the center which we published about three years ago in Nature describing these very complex issues. If you develop a fantastic vaccine today and you think that the job is done, you're completely wrong. That's just the beginning. So let me just now begin to talk about this idea of grant challenges. A grant challenge as it has evolved. You may be familiar with the grant challenges in mathematics about 100 years ago that led to departments of mathematics all over the world focusing on those grant challenges but as it has evolved particularly with our work with the Gates Foundation and more recently a grant challenge is a specific critical barrier. So for example if you don't have a vaccine against malaria the answer is the question is what is the critical barrier? Why haven't we done that? We've been researching this for 50 years. So it is about focusing on the barriers, the critical barriers that if removed would help solve an important health problem in the developing world with the high likelihood of impact globally through widespread implementation and implementation is now becoming a science in its own right. More money is going to go into implementation research in the future in the next few years and perhaps in any other area of global health research. So I'm going to describe four initiatives that have the name grant challenge connected to them. One is the Gates Foundation grant challenges in global health initiative which was launched seven years ago. Then the grant challenges in chronic non-communicable diseases. Grant challenges Canada which I've just talked about and I'll say more in a few minutes and then lastly some of the work that I'm involved in at the moment with NIH and the Wellcome Trust and others in identifying what are the grant challenges in global mental health. And I think for me that's and I'm sure for many people that's the next big, big challenge to address. So this approach of grant challenges which is quite different from funding research in the traditional way. You're all familiar with the NIH where you put in your ideas it goes through peer review etc. Here it's a rather different approach. It's more hands-on. It's based on those critical barriers that we need to do and we will fund the best ideas without bureaucracy and if someone comes with a great idea presenting a two-page proposal we'll fund it and we'll see if they can take it to the next stage. That kind of approach. And it's brought in very significant resources. Bill Gates put in, Bill and Melinda Gates Foundation put in $450 million to address 14 grant challenges and funded just 44 research projects. Just 44, $450 million or more to try and solve those really critical barriers. It's brought in new talent so that particular initiative by the Gates Foundation brought in three Nobel Prize winners who are working on other things refocus them on global health research and a lot of talent, some of it from the developing world. It has energized communities to rise and meet the challenges particularly in providing funds for research and I'll talk about the Global Alliance for Chronic Diseases in a minute. It's fostered public engagement so people have become excited like after talking to you, those of you who haven't heard about this will probably go and read about it on the Internet so people get engaged because of the idea of this grant challenge. As I said, it's an antidote to conservative approaches to funding research and to a certain extent it addresses the defects that we have in global governance of global health. You would imagine that the World Health Organization would be a governing body for this. Well, they do serve a purpose but they don't have funds to do research so it's not the global governance mechanism that you would expect. There are huge gaps in global governance and this grant challenges approach with its focus on priorities is one way to address those gaps. Let's start with the grant challenges in global health. We worked with the Gates Foundation and the NIH in 2003. We did the research in Toronto to identify those 14 grant challenges laid out in the form of seven aims. So just let's look at some of the aims to improve childhood vaccines meaning let's try and make a vaccine that doesn't require refrigeration to stop it from degrading. Develop needle-free delivery vaccines and so on. Create new vaccines that currently don't exist. Control insects that transmit agents of disease. So how can we stop the mosquito from carrying malaria both through genetic approaches and chemical approaches and so on. So these were 14 huge challenges and as I said nearly half a billion dollars went into funding 44 research consortia and that's become pretty successful. Not only in terms of the research that is produced some of which is really fascinating particularly with vector control, biology and also producing better food crops for the developing world particularly for micronutrients. And then there have been a lot of subsidiary outcomes people emulating the methodology, people using the priorities and so on and also including our grant challenges Canada which in a way was very inspired by the grant challenges in global health program. Secondly, let me talk about chronic non-communicable diseases so just let me paint the scene here for you. So about, I'm sorry, I don't know what I did there. So about 60 million people die every year and people imagine that a lot of people in the developing world die from infectious diseases. Well, it's not so. Of the 60 or so million people who die about half die from cardiovascular disease 30% die from cardiovascular disease cancer kills about 15% chronic respiratory diseases 7% and diabetes although it looks like 2% actually diabetes causes cardiovascular disease, causes stroke and so on so it's grossly underestimated what diabetes does. And then if you look at communicable diseases maternal and perinatal conditions and nutritional deficiencies which are big killers all that amounts to only 30% So chronic diseases which are cardiovascular diseases mainly heart disease and stroke certain cancers, not all of them doesn't include infectious cancers chronic respiratory conditions which kill more than 2 million people just from indoor pollution alone and diabetes that has been an area that has been totally neglected in the developing world understandably partly because they have to deal with tuberculosis, malaria, HIV other neglected diseases and what's the budget? The budget in many sub-Saharan African countries for health is 20-25 dollars per person per year which is remarkably low so how do you deal with this kind of problems? There is factors I actually pretty well understood not exactly how they interact and what you can do about them but it's tobacco so smoking will kill 1 billion people this century if we don't do anything about it 1 billion people unhealthy diets so both over nutrition and under nutrition physical inactivity and harmful use of alcohol So we did a study to identify what are the grant challenges in chronic non-communicable diseases and published in Nature exactly 3 years ago and we identified 20 grant challenges and suggested 39 research approaches to deal with those 20 grant challenges and we put those 20 grant challenges in the form of 6 goals so it's easier for me to just give you the 6 goals and then you can imagine the challenges arising raise public awareness enhance economic legal and environmental policies modify risk factors engage business and community mitigate health impacts of poverty and urbanization and re-oriented health systems including medical and health education now it might sound wow that's easy that's easy as physicians and scientists we would focus on goal C risk factors we know a little about that genetics etc but the others are actually more difficult much much more difficult so at the end of that paper we said chronic non-communicable diseases must urgently receive more resources research and attention as mapped out in these grant challenges in action is costing millions of premature deaths throughout the world so you can't just end with that what do you do having identified this crucial need so we went ahead and got together NIH, the Canadians, Australians, Chinese and we created this global alliance for chronic diseases so you can read about it in a piece of science at the time we launched it so that's Betsy Nable, a visionary who was at the time the director of NHLBI at NIH National Heart Lung and Blood Institute she's now president and CEO of Brigham and Women's in Boston the head of the Canadian body which is equivalent to the NIH the head of the British body Chinese, Australian who got India now coming aboard in South Africa so what is this global alliance about so it's a funding agency it's an alliance of funders together these six agencies account for about 80% of all research funding available for biomedicine and health it's the first of its kind it focuses on chronic diseases in low-income countries and low-income populations of high-income countries it supports collaborative, coordinated research at global scale on low-cost interventions and capacity building and it identifies common approaches to provide the evidence that policymakers need in order to put in programs so that's what that's about and we can discuss a little more about what are the priorities to be funding first and so on when we come to the discussion now let me transition to Grand Challenges Canada which in some ways is even more exciting because it is a policy development of a government which is very creative as you will see so Grand Challenges Canada is an organization it's a funding body it's not for profit organization Peter Singer is the CEO and the chief scientist at the consortium with two government-related bodies in Canada the International Development Research Centre which has amended to do research for development for the developing world and the Canadian Institute of Health Research which is our NIH equivalent it's governed by a very tough and strong Board of Directors it's advised by an international scientific advisory board which I happen to chair the McLaughlin-Rotman Centre as we heard its mission is to identify Grand Challenges so from an idea you test it you say well this is important you then go and talk to content experts and you go through scientific advisory board identify a Grand Challenge so phone me and I after this talk we'll be discussing one of these in the area of cancer to see whether it's something worth funding and then you get the board to say well this is great put in this much money and develop an RFP so it's a really exciting kind of work and we will support implementation and commercialization of the solutions that emerge so we are building a capacity to actually support commercialization which is not an easy thing to do so we've got 225 million dollars for five years to just do five programs one of them is going to be in chronic non-communicable diseases one is going to be in in a point of care diagnostics and another one in maternal neonatal child health and we are working on others but just five and the government in its budget 2008 talked about supporting the best minds in the world as they search for breakthroughs in global health and other areas so that other areas they haven't yet funded there might be funding of equivalent amounts for let's say energy or agriculture but those have yet to unfold now here's the clincher and the most important part of all this this money comes out of the foreign aid budget of Canada about five percent of the foreign aid budget and this is the first time that any country in the world has taken the risk of taking money out of foreign aid budget and putting it into this kind of grand challenges approach to solve problems for the benefit of the developing world and that's controversial we can discuss that whether that's the right way to spend foreign aid money or not but if other countries did take this up then this could be a way to get a lot of money into global health and other areas environment, energy, agriculture etc to solve real problems rather than simply hand out money which sometimes doesn't work and grand challenges Canada has this particular niche so the Gates Foundation focused primarily on fundamental basic science there are people that do social sciences research on health systems and cultural issues and so on how to get technologies and policies to improve health and then there are business schools that think about business innovation the sweet spot we think is where those three meet and that's where our focus is between technological scientific innovation business innovation and social innovation that spot in the middle is where we want to do some creative work and finally amongst the grand challenges is this new initiative going on for about 10 months now I'm working with this with the National Institutes of Mental Health at NIH our center in Toronto the Welcome Trust and all under the aegis of the Global Alliance so the initial impetus for this came from the Global Alliance for Chronic Diseases and although the definition of chronic diseases that we used and the WHO and the World Bank uses for what constitutes chronic disease does not include mental health and indeed the risk factors and the approaches are a little different from the others this needs a treatment of its own and we will finish this research before the end of the year and publish it early next year and my hope is that this will lead to the same kind of energy in terms of funding as did the chronic diseases one and then we will have more focus on this totally neglected area global mental health so those are the four grand challenges that I was going to talk about let me now transition to some other work that we have been doing and I want to introduce that by talking about the hepatitis B vaccine which was discovered in 1967 here in the United States the virus was discovered by Baruch Blomberg the vaccine was created very rapidly two years later it became available initially from the blood of patients later on genetically modified form in the early 80s and was adopted quite widely in the developed world, the rich world but if you look at what happened to the poor countries even now a large part of the developing world does not have hepatitis B vaccine and I'll show you how cheap it's become and yet it's not available so what do you do about this problem? and when we asked ourselves that question the first thing we did is we went out and studied Cuba, Brazil, China, India, South Africa and what the countries were doing in terms of internalizing modern scientific knowledge and producing health products then we went to the level of looking at companies and then we went to the level of looking at technologies regenerative medicine for example so this piece of work was at the companies level and an example is a company in India a pretty remarkable country called Shanta Biotechnics which is in Hyderabad and to cut us a long story short one of its products was a hepatitis B vaccine that they made, they improved on the process and at the time the vaccine was available for actually more than $15 at that time if you wanted a shot in New York it would cost $175 they were able to bring that down to 50 cents and in fact now UNICEF purchases this for 39 cents or less a shot so now this one company supplies 40% or until recently did of the hepatitis B vaccine for UNICEF then distributors throughout the world so we say to ourselves if India can do that and there are companies in China doing this and there are companies in Brazil those emerging markets what about Africa which is the area of the most need and the area of the most opportunity in terms of being able to do something about it let me just introduce this work by quoting Paul Kagami of Rwanda who says that we in Africa and I was born in Africa I have a sensitivity for that country I was born in Tanzania we in Africa must either begin to build up our scientific and technological capacity or remain an impoverished appendage to the global economy so what that says is not only do we want to find solutions to our health and development programs sorry concerns but we also want to benefit economically from this if we can so we begin on a program of identifying both stagnant technologies in Africa in Sub-Saharan Africa and there's a paper coming out in science in the next month or two which documents these stagnant technologies developed by African academics and researchers but going nowhere I'll give you some examples now so what did we think was a way to stop that constipation of knowledge and get it out to where it's needed we started working with that's to tell me I have five more minutes so we started working with Tanzania with Uganda where I initially went to medical school before becoming a refugee and then Ghana and more recently with Rwanda and it was all at the invitation of these countries that had somehow found out about our work and said come and help us think through we do a lot of research and you'd be surprised at how much research there's been even starting from colonial times there have been research institutes so there have been around 60, 70 years and the best that they can do is research very little of that research actually gets translated into policy improved lives improved economies or makes much difference other than to the CV of the researchers and the governments are saying how long can we continue to fund research so come and help us identify ways of unclogging that so that we can get some benefit so one of the things that we began to think about was we were based in this incredible center in Toronto called the Mars Center Mars supposedly stands for medical and related sciences and this is Toronto General Hospital, the facade which we kept and built a huge complex behind this is where insulin was first used for diabetes and the idea of the Mars Center is to bring business, science and capital together so in that building in the complex behind it we have laboratories we have venture capital companies we have legal experts working on intellectual property issues we have incubators for new companies and so on in one building they meet for lunch they meet in the cafeteria, they interact they walk to each other's offices and somehow magic happens as opposed to the old approach which scientists still for I'll do my science I'll publish in nature or in science or somewhere important and maybe somebody will pick it up and maybe somebody will fund it and I really don't give a damn I've got my CV and I've got my promotion and so on but this does a different kind of thinking and we thought that it's been rather successful in Toronto and it may be a solution for those countries so we have identified a mechanism which is localized to the circumstances called life sciences convergent centres, initiatives which are partly physical, smaller scale virtual and a lot of other kinds of activities with the idea that this would promote commercialization and African innovation by bringing together science, business and capital develop innovative products and services to address local health and agriculture needs create one-stop shopping for investors establish an innovation-based business environment and move Africa towards a knowledge-based economy now forgive me for saying Africa as if it's one country it's varied countries that are far ahead of others they're really quite varied but they do also have a certain amount of commonality and then reduce reliance on aid and promote self-sufficiency so that's what we're working with those four governments at the moment to do now I've talked about Peter Singer I've talked about myself but this kind of work needs a team and we have quite a large team we have component we're talking of 60-70 people we have people in our team working in South Africa, in India in Ghana and so on so this is quite a large team and these are some of our funding sources thank you very much you know in our discussions around ethics we often talk about challenges that patients face locally here and people why should we invest and spend our our dollars globally your ethics background likely to address two issues one we have a moral imperative to do so and secondly how did Canada get to the point where they actually decided to donate $20 million to the initiative that has global you know such a global scope I think those are two very important questions why should we care partly because we are one species and we will either survive and thrive or destroy ourselves as a species not as Americans and Tanzanians and Rwandans if we have a disease it's like the bees currently dying from unknown causes the whole species will die so if you think species wide there is an imperative as you said and it's a moral imperative to try and save each other and make our lives better there are also those national security issues there are also there is also the understanding that we have contributed to those problems either through colonialism through global warming through selling tobacco and that somehow we go to take responsibility for what we have done and so on so I think that a child born in Chicago is as valuable as a child born in Kigali and if we think like that and actually understand our responsibilities that answers your question partly Canada has always been slightly different in the sense that we neither Europeans nor Americans much of our policies are somewhere in between it's a country that actually respects diversity very seriously Toronto is the most multi-ethnic city in the world something like 135 140 ethnicities in one city and of course New York is closed and there are other places and it's already had this IDRC the only one the first one of its kind that actually has been funded for 35 years now 30 or 35 years by the Canadian government to do research and fund research in the developing world but research to find solutions to developmental problems and then we had a minister of the finance department that got captured by partly the grant challenges of the Gates Foundation partly from reading some of the work that we had published and said we'll take a risk on this and partly it's this conservative government saying that direct charity doesn't always work let's try something else and see if that will work so it's a combination of things and they took a risk and they have been questioned about this approach but they're continuing with it at the moment, it's pretty new it was only launched this May some of us in the room are very jealous of your extraordinary successes and look to see the model that you developed to achieve both funding from the Canadian government but also this ability to create a global alliance of the six major scientific funders from six great countries the MRC in England, the NIH here the Canadians, the Chinese I mean that's incredible it looks to me like and correct me on this one is it's really a question what you work from is that you put together a fabulous group of people I saw that first paper with Varmas as the lead author and Zarouni and Little and then your people near the end you publish in very high quality journals so much is published in science and nature journals with international distributions you then use the group and the publication to go for high level financial support for the projects that you've identified as important and maybe with reliance on Gates a sort of a backdrop you get enormous credibility in your applications and you're able to get 225 million from the Canadian government for five years I don't know how much this grand alliance for chronic disease may give over the years but it's tremendous achievement have you thought through this model or have I described sort of what you're doing it is sort of what we're doing we've been lucky I think identifying that niche life sciences, global health and innovation early on was important there aren't other groups working even now in a focused way we were lucky to get substantive grants right early on the 225 million is not for us we are going to disperse it so people will be applying for grants from Grand Challenges Canada and our hope Mark is that other countries and other centres will particularly other countries and Grand Challenges Canada approach and put in 3, 4, 5% of foreign aid money into finding long term solutions as opposed to charity and end outs which are needed I mean if there are people dying of malaria you need to save them now so that's needed I'm not saying that's not needed but put a tiny percent into doing some research that will be long lasting it will actually provide a huge amount of resources so you remember the 1990 there was a report that identified this 1090 gap that 10% of research money goes into solving the problems of 90% of people so only 10% for the rest of the world 90% is for the rich 10% of the population somebody took a look recently in the last 2 years to see is it gone up to 20% now 2080 the current figure is 1.5% and 98.5% so it's got worse we need more resources to address these very complex issues and if other countries adopt this we might begin to solve this problem somebody over there wants to ask a question Thank you for your talk your comments on the collect of unintended consequences with the war western wars on global terrorism and tyranny made me think of a related question are there potential unintended consequences as we declare war on global chronic illness and global disparities are there unintended consequences that we may be guilty of neglecting as well and is that a place where your hypertension is give me an example of what you were thinking of what's in mind at first glance trying to do away with a tyrannical dictatorship seems like a good obvious unintended consequences that have happened to a culture with this place I'm doing away with early death and thinking or hypertension seem like a good but are there impacts on society that our western culture are blind to I mean we see in our current one of the consequences of living longer is we have a silver tsunami and a change of our whole economic structure and the way that we now institutionalize the sixth, the dying the old and firm there's a great impact culturally to the biomedical model I think it is something that one has to be alert to all the time and also it's not something that individuals or centers or even countries can can address ab initio will we have more problems down the road if more people survive maybe but not if you think about more people surviving as ingenious people creating jobs building economies consumers even then it's a different perspective and you see this with countries that have a lot of immigrants the United States Canada there's always people say they're taking our jobs away but in fact these economies wouldn't grow without immigrants so there's always the flip to that are they potential black swans yeah but it's in the nature of black swans that we don't know about them now but you know your question is really valid we've got to just be aware and think about these issues I hope you all join me in welcoming Dr. Dara for visiting it's been a pleasure thank you very much