Knowledge is Empowering
Turning dollars into better health,   by Dr Hans Rosling (with Harald zur Hausen, Unni Karunakara, Georg Schütte, James Vaupel).

Every year there is a Meeting of Nobel Laureates. In 2011, the year when there were seven billion humans, this forum in southern Germany was on global health, human population, medical research and where the dollars go. This is a precis of that forum from a presentation of the ABC's Science Show and Robyn Williams.

Geoffrey Carr, science and technology editor from The Economist, introduces the discussion -
(Human) life expectancy has increased as a result of increased prosperity, and medical research. The world's (human) population is now seven billion (and rising). Incomes are (also) rising . . and prosperity is spreading. We are living longer, . . we can live for a long time (because) we can live healthily,  but . . the greatest health needs are in the world's poor countries. Their solutions are often political and financial rather than scientific. 
Dr Hans Rosling is Professor of International Health at the Karolinska Institute, which is of course the institution that decides who gets the medicine Nobel prizes. And . . his Gapminder charts.

Hans Rosling: . . 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.
[Hans Rosling refers to Gapminder graphics.]
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 the United States. The brown ones here are Western Europe.
What do I show on the axis? The size of the 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, 30 years, 50 years, 70 years, or even more. So, how long do you live, how big a family do you have?
And can you see that the world was divided in two different types of countries at that time. 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 70 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.

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 us take it down here. And here we go.

China is getting healthier there, the Latin Americans 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 (now) like Germany at 1960. It's an absolutely amazing change, isn't it.

Yes, look at it. And the people are saying that the world is not getting better. 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 demographers to give us the fertility rate, and you can see if it is all patriarchal, male, biological, sex here without talking and you get as many kids as you get. Still like that in Afghanistan largely.

. . pillow talk. If a young couple discuss and say we shall have two children, they shall have shoes, go to school, we shall 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 (the)  bedroom no difference between the Western world and the 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 60 years. Then medicine can come up and give you even more decades and a better life during life. How does the world look today? This is Bangladesh. Father and mother and two children. The fertility rate in Bangladesh is 2.3 today. Absolutely amazing. And they can afford a bicycle, he is going to work hard to put his daughters through school. The greatest risk from him dying is traffic accident. For her it is 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 it.

So here we are, and we are trying to understand how this world works. 2011, we have 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, after this 350, 400 years, it has turned again to a normal world, an Asian world. And what will happen in the next 20 years? The population will still continue to grow, but now mainly because of adding adults.

We have reached what I call peak child. You have heard about peak oil, we have reached peak child. Since 1990 we get 135 million children per year in the world. It is fluctuating a little, but it is not increasing. And 15 years later, in 2005, we had peak children. The number of children below 15 is two billion, it is not increasing any longer. What we are going to add is adults. 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. Zero to four years, five to nine years, these are all the small age groups. Look at this one, 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. It stops here.

I flip over to give 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, you know, we are the population 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 problems there! We are going to consume much more. Saving kids is just a necessity and you can do it with [unclear]...keeping us healthy, that's a real task.

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 when children per woman, Vietnam was there, that was Vietnam, the United States was up there, and if you look at this, take away the other countries, 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 par, in the bathroom and kitchen they are one generation behind. Vietnam today has 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 really 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, (now) it is 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 changed this axis down here from fertility rate to income per person. Look here, I take income per person here...we will see how Vietnam is. Oh! They are only here, they are US$2,500. This is purchasing power dollar, what you can buy for them in your country. The United States is up here on $41,000. How far back do I have the United States to hit the situation of Vietnam today? I go back to the civil war. It's strange, Vietnam is on par in the bedroom, one generation behind in bathroom and kitchen, and they are five generations behind in the living room, the 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. They are now having an amazing economic growth.

And you can see how the world is, if I show the other countries, the simple graph where you have poor, rich, sick, healthy, and down here the 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 theses out of ten that come 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 will try to achieve impact.

Look here, we have to really have categories for the world. Perhaps this is the limit. Can you see there is some sort of a limit here? You can say this is the richer part of the world and this is the poorer. But there are really countries all the way. And even if we cut the limit here, we would find the Czech Republic on one side and the Slovakian 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 terms 'Western world' and 'developing world', the problem is the taxonomy into two groups. The population of Stockholm are not stupid and clever, there are a lot of people in between. This is the most important to realise, and how can we make this understood in a better way? We can take it all the way back here.

This is 1800...I promised you...the United Kingdom, richest in the world, then the Netherlands, then the United States, and here Germany. And most of the countries were down here. And this is what happened. We saw the West with industrial

revolution, a market economy, better institutions, 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 just compare the United States and China. It's so clear if I run these two. From 1800 you can see how the United States go this way and China go that way. This is where Mao Zedong died and Deng Xiaoping took over. Deng Xiaoping said, yes, health is good but we also want money. So they went this way. And you can see how fast they go every year and how the United States now went one step backwards. Like the Lehman Bros turned the United States backwards to go and meet China to wait for them.

And this has implications. What are the implications that this has on 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. So yes, that is the fact, that the world is changing in numbers.
In money we have collapsed countries down here. The poorest ones here, Afghanistan, Congo, Somalia, Sierra Leone, Central African Republic, all with civil war problems or severe, severe political problems.
Up there are high income countries, here are middle income countries, and there low income countries. This is a much, much more fact-based and (a) scientific taxonomy of the world. Although it is arbitrary, exactly as blood pressures are when we divide in normal and hypertension. But here we can grasp a little more.

This is a collapsed country, it's Congo on the border to Angola. The disease they have is konzo, it's a sudden-onset toxico-nutritional disorder, I spent 20 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 destituted. I have permission from the community leaders and the families to show these photos.
One of the problems in our research was that the families didn't have clothes and couldn't participate in the 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 in into this.

However, this is a low income situation. This is a much younger version of me standing here when I worked as a 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 had one shot of tetanus vaccine, not the two she needed, so she got the 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 1% of the resources in Sweden. And how to do the right thing there, to find out which health investment is it that can help the 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. It's a nurse from Vietnam...I also have 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, streptococci infection, she got an endocarditis and was almost dying in cardiac insufficiency. She was saved from the acute infection but then Vietnam cannot afford valvular surgery. There is no way, Vietnam on their level. Remember, they had the civil war income of the United States, and they have the diseases of when McCain came back from prison. It's a very dramatic situation. It has never existed in the history, that countries have had so low income with this modern or semi-modern disease burden.
So I got the 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 surgeons, 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 is not money. It is this thing which is the challenge that limits access to the good things of research.

And 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 also, 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 cost $200 until Indian polymer researchers went on to it and found out how to make it for 80c. They reduced the cost to less than half a dollar, and now people across India in all the income groups can get cataract surgery.

So the interesting thing is  This is a high income country. This is a cochlear implant, 40,000 on one side. Is it a human right when you are deaf to get a cochlear implants on both sides? In Sweden you get it today, all children. Should we get cochlear implants for the whole world? We have to reduce the cost from 40,000 down to below 400, or even 40. And this may happen because digital technology can be amazingly cheap, and the surgeons to insert the cochlear implant, 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 makes 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, it 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 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 13%. 13% of the cost of health services comes out of pocket. Sweden it's a little the same and there are some countries here which are even lower. In France it's only 6%. The poorer the country gets, the higher proportion of health services are 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 complicated, poverty causes disease.  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, partly political, but don't leave that for the political, go in with your biomedical research also, go in with the clinical research, make it possible. Reduce the number 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? Here I show you, on this axis income per person again, $300, $3,000, $30,000. Remember this, there are two zeros difference on the incomes. These countries have 1% of the resources. When I worked in Mozambique as a government employed doctor, I had less then 1% of the resources in Sweden. My job was done by more than 100 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 1% of the patients? I had to strike a balance between those two.

And see here, Ethiopia, they have a very low income and a very low health budget. This is the government health budget in dollars, $10, $100 and $1,000. Also here there are two zeros difference. This is government health spending, and in Ethiopia the government spents $13 out of $600 in GDP. It's a smaller proportion. Why do smaller countries spend the smaller proportion? Because they first need to have education and roads and 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 quite an interesting challenge to know this. If you put in this economical analysis it will generate new ideas and you will 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. And we cannot put Czech Republic, Argentina in a developing country group together with the Congo, it doesn't make sense.

These monies out here are purchasing power money. What's the difference between purchasing power and market exchange rate? You hadn't expected that at the symposium or here. It's very important to understand the difference of that. Here is the difference, because here I show government health spending in market exchange rate, and here in purchasing power. This is what's called international dollar purchasing power, that's according to how much you can buy in the country. And look, in Ethiopia they can buy $4 in forex corresponded to $13 in the country. That means countries can pay for the health staff to vaccinate 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 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. And 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 gets so difficult when we want to discuss cost of health service, because we can't grasp that health service is composed by the 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 you can also see in the clinical round at Karolinska Hospital, you have 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 with a queue, he is talking for three or four minutes with the patients 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 finds out, ha! 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.
Hans Rosling, 2011

Robyn Williams: You're listening to The Science Show on ABC Radio National coming from Lindau in Germany with as many Nobel laureates as you can fit into a large hall, all wondering about health, science and seven billion people.

Geoffrey Carr: Professor Rosling, that was awesome, that was truly awesome. My first question to ask the panel, which you have 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 to the way that the West or 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. How do you change the incentives for the medical companies to make things cheaper for poor countries? Unni?

Unni Karunakara: As an organisation we work in some of the really destitute poorest parts of the world. What you have are diseases, and especially now after the presentation it is also clear that even though there are poor parts of the country, people are living longer. There is infectious disease morbidity but they don't die from infectious diseases as much as they used to die in the past. If you take a developmental approach where we want to grow income and then achieve better health, the problem with that is what about the people who are dying today? 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 five million people on treatment. The cost of HIV treatment in 2000 was $10,500 per person per year, and today it's 99% cheaper, it's less than $100 at the moment, it's about $80 per person per year.

What this has allowed is even for Global Fund or Clinton Foundation or, the big state funded programs, they are able to put large numbers of people on 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 rationale for companies to actually do R&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&D for these sorts of diseases.
One model that is being talked about now is the patent pool, where companies get a price for developing a drug, for example, they put it in a patent pool, they get some money for it, but then the ones in the pool, it is licensed to companies in the 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 of the future where the current model of intellectual property and patents for drugs is perhaps not a way for the future.

Geoffrey Carr: What about the idea of a vaccine purchase fund? We've heard quite a lot of that recently. Is that a good model?
Unni Karunakara: It is definitely making vaccines available for advance 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 have developed; the lowest price that has been negotiated for that vaccine is about $17. That is completely out of reach for countries, especially where the biggest burden on 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 is much more research that needs to be done on delivery mechanisms and implementation research, and the more we work in countries the more that becomes very clear, that there is a lot of attention that needs to be put in that area of research.

Geoffrey Carr: Dr zur Hausen, it's your vaccine, how would you get it out to people at a price that they can afford?
Harald zur Hausen: That's really 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 are some chances to reduce it in the future, in part due to the competition which is probably going to arise in view of the fact that some companies are now starting in some of the developing countries to produce a vaccine by themselves.
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, but it is more strategy which we have to develop. We had to think strategically how to do it and where to do it and to which extent to do it.

James Vaupel: I think, as we heard earlier, the main way to make medicine cheaper in developing countries is to develop more, and that 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 people's incomes.

Hans Rosling: But the problem is that what you call developing countries is different groups, and they are so successful. So as soon as they have done that, there are more costly diseases to manage. And what I think is most important is that there is 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 an 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 cost 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, and 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 more medical research, you can have a shorter treatment period.

You tell about the ARV treatment, but we know that resistance will develop and the 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 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 15-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 28%. This 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 a person has been infected. Please give that to epidemiology, come out with a test and tell us how long they've been infected and we can solve the transmission issue and we can measure the effect of impact.

We need to get the economy, health service, basic medical research to come together for this and find out new solutions. I think that the Gates Foundation have done a great job in finding this out, not having big political discussions. And that old 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 to the patient, but how do you actually get the patient to take it? The last-mile problem, I think it's absolutely important. So we've got the price of HIV drugs down, but how do you expect people living in very remote parts of the world to take a bowlful of 24 tablets a day, and some of them need to be refrigerated because they are not heat stable. The challenge is how do you make it easy for patients to take it? How do you increase or improve adherence? The innovation was to make a fixed-dose combination, putting three drugs in one pill, heat stable, you take it, 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 antimalarial drugs, but how do you actually get it to 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 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 diagnostic test, test and treat right then and there.
So these sorts of solutions are absolutely essential if you want to get people to take treatment. So it's not just about making drugs cheaper, which is 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.

Young researcher: Hello, good afternoon, my name is Sharif, I'm from Egypt. There were rumours flying around about the swine flu and the bird flu, that the swine flu is that lethal and the vaccines they have are the only treatment for this flu. Of course I cannot deny or confirm this rumour, but by this year it was proven that neither swine flu was that lethal, nor the vaccines that efficient. So maybe the pharmaceutical company may not allow you...or Dr Hans, for instance or Dr Harald for instance, to make his medication or vaccines that cheap because of their interest, the money. So would they be that nice? I'm not sure.

Hans Rosling: It's a good example. The difficult thing with whether you should order a swine flu is that you have to decide as a politician before you know if the disease is bad or not, because you have to give the period for the production of the vaccine. It's a little like climate change; we have to decide before we know if it is really bad. The pharmaceutical industries, they behave as we treat them. If we buy like stupid customers they will behave badly, 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 and 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 what to drag to the market, you know? So your suspicions shouldn't be directed to the pharmaceutical industry. It's to keep the government independent, to keep the government guided by research and the research is communicated to it. Then we order the stuff and we get it.

Unni Karunakara: So, to take that example, fewer than 20,000 people died of the H1N1 virus, while 60,000 people died of, for example, kala-azar, a disease, each year, they die each year and we know that they will die. There are people working on new therapy but it will take a new therapy before they will come. So I think some of our priorities are misplaced, but part of it is also as Dr Rosling said, that we don't know, we have a doomsday sort of scenario of these new viruses, so I think that the pharmaceutical companies, they reflect the society we live in and they played to the fears, and it's a market opportunity for them as well.

Young researcher: Thanks, Melanie from Germany. 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 few young people actually working, earning money which we can put in the health system again to pay for the illnesses of the elderly? So how do you manage that problem?

James Vaupel: First of all, I don't think there are too many people in the world. And secondly, the world's population is growing, but it will reach a peak at perhaps 9 billion or 10 billion in the middle of this century and will start to decline. The next demographic problem we're going to have 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 healthy span of life has risen in the same proportion. So there is 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.

The rise in life expectancy has just been astonishing. We saw some statistics about this. In the year 1800 there was no population in the world that had 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 in the countries doing the best has been about 2.5 years per decade, that'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 has been a remarkable increase in life expectancy and healthy life expectancy, and age is no 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 grandparents' generation. So there will be an older population but it will 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 system, or do we have the wrong systems? And since demographic change changes societies, we have to adapt the systems, the social security systems, the educational systems. 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 costs, for the retirement costs, so we have to adapt the system.

Geoffrey Carr: 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, but circumstances, as you've observed, have changed, and it is not at all unreasonable to expect people to work into their late 60s. I don't think it's unreasonable to expect them to work until they are 70, but they don't want to do that, and I think there is a serious political problem there.

Of course, as the population ages so does the voting population, and it seems to me that it's likely that you're 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.

Young researcher: 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. We are also faced with war and terrorism, so our countries and the governments are faced with the problems of assigning a major chunk of our budget through those problems, and that's why our health and education gets neglected. I think that we are resourceful in terms of human resources, so if we are somehow empowered by the help of other countries, probably we will be able to help ourselves better.

Geoffrey Carr: I think that's an extremely good point. Given Dr Rosling's observation that eight-ninths of the world's population will be outside the old West by 2050, that's where all the talent is going to be, obviously. 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? Do you mean high income countries?
Question: Yes sir.

Hans Rosling: Is South Korea included, because the United Nations still labels South Korea as developing. You have high human resources in the middle income countries, the big pharmas know it, they outsource research and development. We know that big technology firms are now moving their research and development where the resource is.

This doesn't solve the problem for the low income countries, and not at all for the collapsed countries.
And I heard about that statement that there are too many people on the Earth, that's an ugly statement. Intellectually it also draws the attention from what has to be done. The population issue is solved, full stop. We will become nine billion, there's nothing you can do about it. It is so bad, this orientation on population when we need to solve the energy system, health system, we need to deal with this world.

There was 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 US$400 million to China for drugs, and they have $2.6 trillion in their foreign exchange reserve. That's stupid. They should give aid to low income countries and then have fair trade with middle income countries.

Let's face the world. There is no trade tariffs on products from Asia which are better than the European.

Geoffrey Carr: That would be a good start I agree, yes.

Unni Karunakara: I come from India which is not unlike Pakistan in the challenges it faces. The health budget in India is 1% of the total budget, compared to what they spend on defence, which is about 15%. Speaking to some Ministry of Health officials, the government is willing to raise the percentage, they want to go to, let's say, to 5%. But the problem is even if you raise the budget tomorrow to 5%, 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 are being done by nurses are now being done by community health workers. This task shifting, it is 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 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 get to the point where you have a developed health system.

Young researcher: My name is Kostas, I come from Greece, and I am a postdoctoral researcher at the German Cancer Research Centre. A small comment about your presentation, it is really fun and interesting that Greece is considered in the group of the richest countries and at the same time we are almost bankrupt. That's an interesting issue. But that's not my question.

We are researchers, we are doing research in order to develop drugs, so you have the drugs on one side, you have the patients on the other side. Allow me to give you a short story about a case where profit gets into the middle and disrupts everything. A hypothetical situation, considering cancer is a major issue. So imagine that you have a substance, it is developed by some researchers. So they studied, they have really nice in vitro 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 was being used for 30 years for another disorder. Now imagine that the problem is that this substance is so simple that no pharmaceutical company is interested in investing in that because it can't be patented. So this is a true story. This is a really nice drug and really promising. The problem is that no pharmaceutical company invests in large-scale clinical trials at the moment just because it cannot be patented, so there won't be any profit for this company. It is really disappointing and sad, seeing that something so promising doesn't reach the patients just because of profit.

Harald zur Hausen: If there is a drug which is really as you say, so cheap, it does not bring any profit, those drugs still would find some distributors, locally and 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 preventative drug as well; despite its very low price, it is well distributed. But here of course it is taken up by a pharmaceutical company and I am sure that in other instances some pharmaceutical companies will take it up, even if it's very cheap.

Geoffrey Carr: 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 gene 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 now we've got to a point where the pipelines are shrinking in the pharmaceutical industry. We've heard all these great stories this week about how this platform or that platform or the other platform and there are ways that one can then go off and produce new drugs, but the drug companies aren't actually coming out with them. Is there anybody who would like to comment on that?

Hans Rosling: Go to Indian and Chinese venture capital, for God's sake! Someone commented about the Vietnam War...remember that Vietnam won the war. And Asia is coming, we have great capital coming from China and India wanting to invest in the 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 that 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 tried to say; all drugs are not the same. We need a more clever system, and in this we give multiple different companies, we need the companies in the end to deliver it.Geoffrey Carr: Everything that I ever read about drug companies at the moment, the pipelines are drying up, they are not innovating.

Young researcher: I just wanted to defend the point that overpopulation may not be an ugly idea because we cannot forget this Earth doesn't belong to humans only, and we have broken an equilibrium, and there are other species, there is nature that is suffering because we are too many. So there could be a place for more billions of us, but that wouldn't be fair for the Earth, and so I think that stopping to multiply would help not only humans but also the whole Earth which has been attacked so much.

Hans Rosling: I disagree, because we are stopping with two children per woman, but it takes . . 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 it takes too long to solve. There are more pressing environmental problems than can be solved by a slow decrease of population. We have to face directly the energy system and the ecology. It's a wrong direction, its metaphysical direction.

Harald zur Hausen: Of course we should not exaggerate some kind of action in this case. I heard recently in at the meeting in Lindau that we should probably destroy all mosquitoes globally for preventing malaria, which of course basically on the first view sounds good, but it would be a disaster worldwide if you did it. How many birds, how many reptiles, how many amphibians, how many fishes and mammals are becoming extinct with getting rid of all mosquitoes? So you need to consider the environment as well. I think that lady was quite right when she was first talking about it.

Young researcher: 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 middle and low income countries espouse in the future? Would it be like insurance companies or would it be the taxpayer?

Hans Rosling: That is a very good question and it doesn't have an answer. We see different attempts. In China we see that the government keeps down their spending 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 cancers 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 is 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 that 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 US$300 billion into agricultural subsidies and just a fraction into green technology research. This is appalling. To me it's appalling to find that the politburo in 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 agree with you, the Chinese government is horrible in many ways. Perhaps one of the reasons why it 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.

Robyn Williams: That Science Show from Lindau and a gathering of Nobel laureates and young scientists was chaired by Geoffrey Carr.

Thanks to the Lindau Nobel Laureates Meeting for permission to broadcast that discussion which took place on the island of Mainau on Lake Constance in Germany and which ended the 2011 Meeting of Nobel Laureates.

Geoffrey Carr
 Science and technology editor
The Economist 
Hans Rosling 
Karolinska Institute 
Harald zur Hausen  
German Cancer Research Center
Unni Karunakara 
President, Medecins Sans Frontieres 
Georg Schütte
 State Secretary
 German Federal Ministry of Education and Research 
James W. Vaupel 
Founding Director
 Max Planck Institute for Demographic Research 
Rostock Germany 

Presenter: Robyn Williams
Producer: David Fisher
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