Am. 4. trop. Med. Hye... S9¢4), 1998, pp. 24-28
Copyneht © £998 by Phe American Society of Tropical Medicine aod Hy gicne

NATIONAL INSTITUTES OF HEALTH IN THE TROPICS’

HAROLD E. VARMUS
National histitutes of Health, Bethesda, Marvland

INFRODUCTION BY DR. GUERRAN

itis certainly an extraordinary privilege and a great honor
for me to introduce our very distinguished Charles Franklin
Craig Lecturer this year. Named for one of our Society’s
founders and the editor of our Journal for 20 formative years
from 1927 to 1947, the Charles Franklin Craig lecture is a
traditional highlight of our program. Thanks to our archivist,
Don Burke, we actually have here Colonel Craig’s original
sword, now offered symbolically for the cutting of red tape
and for leadership in the attack on tropical diseases. lead:
ership that is clearly being forged by our distinguished Craig
lecturer this year, Dr. Harold Varmus.

Dr. Varmus grew up in Long Island, New York the son of
a family physician and social worker. His bachelors and mas-
ters degrees from Amherst and Harvard are in English lit-
erature. After medical school and medical residency at Co-
lumbia University and Columbia Presbyterian Hospital and
two years at NIH. he then joined Dr. Michael Bishop at the
University of California at San Francisco to study tumor
viruses. It was there as Professor of Microbiology, Biochem-
istry, and Biophysics and as the American Cancer Society
Professor of Molecular Virology that he and Bishop showed
that cancer genes (oncogenes) can arise from normal cellular
genes, work for which they shared the 1989 Nobel Prize in
Physiology or Medicine. Dr. Varmus is beginning his fifth
year as Director of the National Enstitutes of Health.

Author of some 300 scientific papers, a member of [OM,
the National Academy of Sciences, and the American Acad-
emy of Arts and Sciences. his most recent of four books is
for a general audience entitled Genes and the Biology of
Cancer.

But perhaps most poignant to this audience in this Stellar
career, Dr. Varmus worked us a medical student for three
months ina mission hospital in north India. work that clearly
influenced his profound commencement address at his alma
mater, Columbia College of Physicians and Surgeons earlier
this vear. Ladies and gentlemen T present to you Dr. Harold
Varmus, who will speak on NIH in the tropics.

Dr. Varmus:

Well, Dick thank you very much for the sword, As TF do
a lot of cutting of red tape. this will be quite useful. 1am
very pleased to have a chance to speak in memory of Colo
nel Craig, whose 1909 book on malarial fevers had a vers
Strong influence on the field f will talk about a bit. Phere is
indeed some irony in my giving this lecture today. Because
al one tine, perhaps 30 or so years ago, | might have viewed
the prospect of giving this lecture as a high point in a career
in tropical disease. | went to medical school with an interest
in psychiatry but quite quickly deviated from that focus and,
* Presented as the Charles Franklin Craig Lecture at the 40th Annual

Meeting of the American Society of Tropical Medicine and Hygiene,
Orlando. Florida, December 10, 1997,

under the influence of a number of factors, became interested
in tropical disease. First | was influenced by tales of adven-
ture and exciting medical science in the classroom of Harold
Brown—so called stooly Brown— perhaps known to many
of you. FE then became an International Follow at Columbia
University as a medical student und indeed wrote a paper
about social and economic consequences of reducing child-
hood death rates in poor countries.

Then in my fourth year in medical school, as Dick men-
tioned, TF received a fellowship from a drug company to work
ina mission hospital in north India. Phis was a valuable and
fascinating experience. It was also sobering and, perhaps un-
fortunately, once again course altering. I recently found, as
a result of my wife’s insistence that we unpack the boxes
we brought from California four years ago, a 20-page report
that f had written in 1966 describing my several months in
that north India mission hospital. In the report. } encountered
my harsh criticism of the medical, social, and fiscal practices
in the hospital in which T worked: the unfortunate billing
practices; the reluctance to supply transfusions until pauients
had put up their money: the abysmal conditions in which
patients lived: the failure of the hospital retrigerator that
housed blood, which was not detected until several patients
had died of septicemia. Phese case reports were mixed with
another case report of a medical student fellow— namely.
myself—who was suffering from amebiasis and scabies. |
also found fixed to that report a letter from the Director of
the Internauonal Medical Education of the
American Association of Medical Colleges. saying he found
my report “particularly informative’ but adding that he pre-
sumed that F had no plan to publish the report. Its publica-

Division of

tion, he said, would not be constructive. So this experience,
with many facets of suppression and degradation of some of
the patients F watched. and the simultaneous ture of academ-
ic medicine and later research in molecular biology and vi-
rology moved me into a very different career track — one that
would not normally lead to an opportunity to give this Craig
lecture.

So it is with some trepidation that 1 deliver this lecture,
with its implied claim to knowledge about tropical diseases,
to an audience that is much more devoted to the discases.
schooled in the sciences, und traveled in the tropics. Nev-
ertheless, it has come to pass that in my not-so-new job as
Director of NIH, bE have become very familiar with mans
aspects of one important tropical disease, namely. mularia.
‘Phis happened because of a somewhat innocent proposal that
Toimade at the end of a workshop organized by the Fogarty
International Center in July 1995. This workshop was sel up
with my approval to explore ways to enhance science and
health in Africa. This was being done in part because of
concern by many of us in feadership roles at NIH that most
of Africa was being left increasingly far behind, behind even
Latin America and poorer parts of Asia, with respect to tech-
hicul development, scientitic infrastructure. and health.
NIH IN THE TROPICS 25

In the one day of that conference we listened to descrip-
tions of many health problems and scientific opportunities
in Africa on a very wide range of topics: the genetics of
many diseases, iron metabolism diseases. hypertension,
many aspects of diabetes in Africa, and a wide range of
infectious illnesses. We learned about multiple ways in
which various nations and research and development agen-
cles were independently attempting. usually one to one (one
agency or one country to one site in Africa), to nurture sei-
ence in many different countries in Africa. This discussion
made many of us feel that it might be useful to test the merits
of a more coordinated attack. We proposed to do that by
focusing on a single important disease and trying to mount
a joint multinational effort to combat that chosen illness with
the full participation of our African colleagues.

ft seemed to me and to others at that meeting that malaria
might be a particularly appropriate focus. Indeed, it is a very
big problem, with roughly 300-500 million people infected
on the surface of the earth: roughly 1-2 million deaths, 90%
of those in Africa, each year. And yet only 85 or so million
dollars being spent world wide on malaria research. It was
also an attractive target because there were many points of
attack on this problem: prevention through insect control and
bed nets. many forms of treatment available, approaches at
the biological level to parasite and mosquito and even lo the
human host, and evidence of an immune response that had
not yet been harnessed to produce a vaccine. Many aspects
of health services, such as control and education, were in-
timately linked to the biology of the disorder and its trans-
mission. There was also considerable research experience in
many countries in Africa, with many funding agencies doing
various things to try to foster research on malaria. There
was. happily a significant cohort of African scientists. Many
of them were now working in their home countries. usually
after being trained in the northern countries. And there was
clearly a need to do the science in Africa because the study
of the epidemiology and pathogenesis, clinical trials of either
preventive or therapeutic maneuvers, and the study of health
services and case management clearly had to be carried out
where the diseuse was actually occurring. Phis need also
allowed us to stress a companion need to maintain both prac-
tical approaches and more theoretical scientific approaches
moving ina hand-to-hand fashion. ‘Uhat is. for example. to
study the efficacy of bed nets together with the nature of the
insecticide in which they are impregnated: to study water
control side-by-side with the epidemiology of the disease.
The distribution of mosquito vectors, insect reduction. pro-
vision of common treatment, education programs —all! these
things need to go hand-in-hand with a scientific appreciation
of the disease. Furthermore, there remained an appreciable
scientific Interest in northern countries in the problems that
malaria poses, while there ts also a clear appreciation of the
potential that recent scientific advances present in addressing
malaria as a research problem. In addition, there is an al
Jeged loss of support from pharmaceutical companies for
malaria research. Nevertheless. a focus on malaria raised the
prospect of substantial local political support for any initia.
uve we might undertake.

So malaria was clearly a good choice. But one had to ask,
with many kinds of activities already under way and many
other possible targets for such initiatives, why would this be

a propitious time to undertake an expanded effort specifi-
cally on malaria? There are at least three reasons that seemed
powerful to me. First is the evidence of the strong resurgence
of malaria. a resurgence that can be attributed to a number
of factors—in some cases, simply the failure of will to main-
tain control programs; but also. perhaps more profoundly,
the gradual ticrease in resistance of insects to insecticides
and of parasites to drugs. Chloroquine-resistant organisms
have arisen independently in at least two places, Southeast
Asia and northern South America, and spread throughout
much of the tropical world. (Sue and Wellems and their col-
leagues recently published a paper on a gene candidate for
chloroquine resistance in Plasimodiwn falciparum.)

The resurgence of malaria is well documented. even in
my own lite. When - look back at my 1966 report from
India, what T read is, “although malaria has been largely
eradicated by the efforts of WHO, other infectious problems
remain in abundance, particularly tetanus, cholera, ameba.
and round worms.” Some years later, in 1988. TI returned to
India for teaching purposes. and [ did not have long to wait
to see how the fortunes of malaria had changed in 22 years.
Soon after getting off the plane, 1 picked up a newspaper
that had on its front page stories of a wide spread epidemic
in Bujurat, with many thousands of individuals dead of P.
faleipartun. Any of us can see clearly from our travel that
this resurgence is very strong.

The second reason | believe expanded efforts are especial-
ly appropriate at this time is that the very strong scientific
infrastructure and the availability of new techniques are go-
ing to have a profound effect on our approach to malaria.
Phere are genome projects under way on P. falciparum itself
and Anopheles gambiae, the major African vector There are
advances in cell and developmental biology that are pro-
foundly altering our understanding of the parasite and its
vector, We do not have to think very hard. especially in this
group, to envision how such information could be applied
to the design of new vaccines by choosing more appropriate
Immunologic tools with better antigens, by understanding
the immune system and its response to the malarial parasite,
by defining better targets for new drugs such as proteases
and others. [t has become apparent from recent experiments
that by understanding the life cycle or the parasite more
profoundly that gene targeting approaches may have the po-
tential to detect and alter genes that might not have been
suspected as being essential for the development of the par-
asite in the mosquito. New understanding of adhesion of the
parasite to red blood cells and the role of this process in the
pathogenesis of malaria is also promising. For example, by
identifying the cell surface proteins encoded by the parasite
that are involved on the surface of red blood cells. we raise
the possibility of designing drugs that might interfere with
those interactions and thereby open new possibilities for pre-
venting and treating cerebral malaria in children or improv-
ing the fate of pregnant women with malaria.

Phe third reason for believing that this is a good time to
expand our efforts. especially efforts carried out in Africa,
is the rapid advance in Our means to communicate in Africa.
It is now possible, in principle if not in practice, to be an
up-to-date scientist any where. even in Africa. E-mail. pub-
med, the Internet. and computer links to databases and to
colleagues are advances that profoundly change the prospect
26 VARMUS

for doing science in parts of the world thal were previously
incommunicado.

So these workshops and discussions have led to what is
now called the malaria initiative or the Multilateral Initiative
on Malaria (MIM). I want to review with you some aspects
of this initiative to give you some sense of how this kind of
thing develops. Remember our workshop was held in July
1995. Over the next several months additional meetings were
held to try to plan a major gathering of the malaria research
community and its funders,

Over the course of 1997. three major meetings were held:
in Dakar, in the Hague. and in London. These three meetings
seen in order describe a kind of Hegelian rhythm with a
thesis, antithesis, and syntheses. The first meeting in Dakar
was a distinct upper. Many in the malaria community now
lalk about “the spirit of Dakar” because the meeting was
simply extraordinary in my own experience and in the ex-
perience of most who were there. First, among the 150 par-
ticipants were very many African scientists, most of whom
were working in their home countries. Roughly one-third of
the scientists at the meeting were Africans working in At-
rica. Many of these scientists were meeting their colleagues
for the first time because. as many of you Know better than
1, traveling from Fast to West Africa can be rather difficult.
The African scientists shared a role completely equal to that
of the sponsors and scientists from Europe and Amertea. and
that too was unusual.

Second, the mecting was unusual because of its format,
which was entirely communal. We divided up into nine or
sO special topic groups, and the purpose of these groupings
wus not to allow the three or four most prestigious scientists
to present their hottest results but. instead, to allow the entire
group to think together about the goals of their common
interests-— whether il was case management. entomology,
immune response, or pathogenesis—and to ask what had
been achieved, what should be achieved over the next 5S or
1O years. and what were the obstacles to achieving those
goals. Some very interesting themes emerged that, in fact,
cut across all the groups: the variability of malaria from site
to site, the difficulty people were having comparing results
al different sites because of the use of different methodolo-
gies and different reagents, the need for a reagent inventors
so that people could use standard strains and standard mos-
quitoes, and a very common need for improved communi-
cations among African scientists and between African sci-
enusts and those in Europe and America.

A third issue that was palpable to me was a very strong
link between the theoretical and the practical, between the
basic and the applied. Considerations of the epidemiology
of the disease were closely linked to efforts to understand
the genetic bases of drug resistance and to the development
of drugs that would be effective in those regions where there
has been high penetration of drug-resistant strains.

Another aspect of the mecting that was unusual in my
e\perience as a fairly veleran meeting goer was the very
strong political support from African leaders. For example,
al the opening of the meeting, we received President Diote
of Senegal and many other leaders who turned up to offici-
ate. Lam nota lover of ceremonies, as many of those who
know me wil appreciate. Nevertheless, the strong political
buy-in that comes from having the President of the host

country come and display not just an interest in the formal-
ities of the meeting but an actual understanding of the impact
of malaria on his own country sent a profound message and
a very strong sense of the importance of the meeting to those
who were there. At the end of the meeting, if was decided
to form this Multilateral Initiative on Malaria, or MIM. and
to call for some letters of interest from scientists who wanted
to work together to develop collaborative urrangements, par-
ticularly so-called research networks in which methods and
materials would be shared and better forms of communica-
ion would be developed.

The nest gathering of the clan, at the Hague in July, was
billed as an effort to evaluate those letters of intent for form-
ing those collaborations. Instead it became the antithesis in
our Hegelian formulation. the point in the growth of MIM
at which reality was cncountered. At this second meeting, it
Wus appreciated more profoundly than before that funds
were quite limited. It becume apparent as the funders began
to discuss the mechanism or mechanisms by which proposals
would be supported that there were competing bureaucra-
cies, with no clear consensus on methodology that could be
used for funding these proposals. Many saw a need to create
broader interfaces with government and industry and to cre-
ate a much more extensive role for advocacy for malaria
research, as opposed to doing a few small things that had
primarily symbolic value.

After that meeting. in which there seemed to be some
realignment of interests in the proceedings and some slowing
down of progress toward the common goal, there was a third
meeting, in London just last month, hosted by the Wellcome
‘Trust. Vhis meeting seemed characterized by a much more
harmonious assignment of tasks. The task became more di-
verse than perhaps had been originally intended. but it seems
clear now that the Wellcome ‘Prust is going to act as a sec-
retariat for this activity. Phe Malaria Foundation will be act-
ing as the chief advocate for malaria research. The WHO,
TDR, headed by ‘Tore Godal, has established a small pot of
common funds—~ provided by the NIH. World Bank, TDR
itself, WHO Africa, and we hope a few additional organi-
zauions—and they will be funding some of the proposals
when they are submitted in a more refined form. Those pro-
posals are intended to emphasize collaborative research net-
works and resource building. It is sulla small amount of
money, but we think it can do a great deal to improve the
infrastructure in which malarial scientists work, especially
in Africa.

In addition, the National Library of Medicine-—a com-
ponent of the NIH—has been making real progress, one
country ata time. in developing a stronger informational
infrastructure and a better communications network. NIH
computer scientists have gone to Mali and helped at the
NIH-supported center there. and they are now going to Ke-
nya. Panzania, and one still-unselected Francophone country
to try to build more secure Internet communication and hard-
ware and software in those countries. This means not just
supplying the materials and moving on but actually helping
to train individuals to handle problems on the ground as they
occur after our scientists leave. Phe National Institute of Al-
lergy and Infectious Diseases (NIATD) at the NIH has also
been hard at work trying to build databases, a repository,
and common research protocols. They have recently held a
NIH OIN THE FROPICS 27

workshop on this topic, which is one of the tasks we agreed
to at the meeting at the Hague.

Now FT want to go beyond malaria for a few minutes and
think about the significance of these developments in the
comext of efforts that might be undertaken for other dis-
cases, because you might legitimately ask whether the NIH
is interested only in malaria or has interests in other diseases
that affect the developing world. You have heard from your
President that a fairly small fraction of the total NIH budget
is distributed in such areas. | want to give you a little more
feel for what really goes on. We have about two hundred
million dollars in our budget that is identifiably international,
Phat is. it is devoted to the training of foreign nationals that
come here, to training programs that we support abroad, and
to our own citizens who go to other countries for training.
It also includes awards for research projects and awards for
collaborative research that involves foreign components. Phe
NIH also spends a great deal of money on diseases that arc
uniquely tropical or seen abroad but are studied only in this
country, These would not be counted inherently as interna-
tional expenses, but they involve many of the grants awarded
to many of the people in this room for studies carried out in
the United States that clearly involve diseuses that are unique
or nearly unique to other parts of the world. In general, our
work on such diseases, particularly tropical illnesses of the
sort studied by members of your Society. has been increas-
ing. kor many of the major disease areas that you are con-
cerned with here, such as filariasis and malaria research and
research on vectors and tropical viruses, NIH spending has
been imcreasing quite dramatically. And in) general the
amount of money we are spending in tropical diseases has
been rising, particularly in the one institute. NIATD. that
does support most of the NIH work in these areas.

Ewill make another point as a kind of advertisement about
NIH’s involvement in international health. We are currently
secking through our cons entional recruitment process an As-
sociate Director tor International Health who would be
working within the Office of the Director—my office —-
meeting with my own staff and serving Concomitandy as the
Director of the Fogarty International Center. Uhis recruit-
ment implements a recommendation that comes from a re-
cent report by Barry Bloom and Josh Lederberg. who re-
viewed the international research activities at the NIH for
me about two years ago. So if you have friends. candidates,
worthy folk you think would be suitable for this position.
please recommend them to us so the search committee 1s
aware of candidates that we might not otherwise know
about.

1 would also like to make a point about the interest of the
NIH in international health that has to do with the kinds of
arguments we believe we should be making as a federal
agency for funding and political support in these areas. Your
President has reviewed many of these and | definitely agree
with him. In fact, EF was quite touched by the poem, “Un-
thinkable Entrapment.” because I have recently reread an
article about malaria that appeared in the New York Times
last January. in which the reporter describes a woman with
five or six children and one bed net trying to decide each
night whether to put the two-week-old child who probably
won't survive or an older child in the bed net. The kinds of
ralionales that my own thinking leads me to espouse in gov-

ernment councils or in places like this are very similar to
the list you heard about from your President. First, the hu-
manitarian approach, that is, this is the right thing to do,
Second, the economical approach, that is. there is a real vir-
tue to developing stronger countries that buy the commercial
products that create better health and better markets. And
third, there is an Amcrican foreign policy interest in political
stability that seems to me quite powerful.

My favorite article on this topic was one by Jeffrey Gold-
berg, published in the New York Times Magazine on March
2. 1997.1 recommend to those of you who have not seen it
that you get hold of this article. whose point is summarized
in the following quotations: that “biological stability flows
from political stability” that “‘chaos ... is the best incubator
of disease.” and that “disease is also an excclient incubator
of chaos. tis an endless cycle of misery.” The notion of
coupling the political stability of a country to its health and
well-being is a particularly profound msight—- perhaps an ob-
vious insight to many of you who have been to those coun-
tries, but to the average person in our country who ts un-
aware of the way in which these two components are closely
linked in countries of Africa and other parts of the devel-
oping world. ‘Fhis is an important idea. This was brought
home most powerfully to me by a trip [ took to Mali after
the Dakar meeting. | could see the effect of the strong col-
laboration between the NIH and the Malaria Rescarch and
‘Training Center at the University of Bamako--the effect on
the University, on the town, and on the entire government.
Phe President of Malt, Dr. Kanary, himself an archeologist,
is inlmately acquainted with the personnel and the activities
of the Center. He ts proud of the Center. [is a strong point
in his effort to democratize Mali. Those research efforts,
which are often conducted in the villages. can have profound
effects on health. In the town of Makainono, at which the
Malaria Center has an active program. not only have the
townspeople who are actively tnvolved in the research pro-

ject learned about malaria and how it is transmitted, but they

have also improved their local health and health resources
for many other diseases. A good well has been built, and the
incidence of infantile diarrhea has diminished markedly.
This kind of effect can obviously be transmitted to many
other places.

1 would like to conclude with a few general obsers ations
of things that | have learned from my intermittent but active
involvement in the problem of malaria in the last couple of
years. First, health issues in the tropics are becoming more
like health issues elsewhere. Despite the need to focus on
diseases like malaria, we have all learned from the book that
your President cited many times, The Global Burden of Dis-
euse, by Murray and Lopez. that for the aging of the pop-
ulation and the partial control of infectious diseases, we are
beginning to estimate that by 2020 the difference between
the dev¢gloping world and the industrialized world will be-
come Jess. We need to take that into consideration as we
continue our efforts in the classically tropical diseases.

Second. we need to remember that there are those diseases
that ure nearly unique to the tropics. with only some modest
penetration into the more developed countries, and then there
is a whole class of diseases —tuberculosis, HIV. and certain
other viruses among them—that are very common in both
cultures. It is important to remember as we think about the
28 VARMUS

impact of NIH-supported research on the third world that
many of the things we do and we consider uniquely NIH
efforts. like our work on HIV, has a major impact in the
developing world as well,

It has become apparent to me that there is an increasing
potential for basic science, perhaps of the type now possible
only in the most developed countries. to enable more rational
approaches to those things most desperately needed in the
developing countries— namely, simple therapies and more
effective vaccines. This may be true of a much wider range
of diseases than simply malaria. It is a phenomenon that |
believe is also affecting our thinking about cancer and heurt
discuse and many oiher diseases that we encounter in all
parts of the world.

[ have been struck with the power of interdisciplinary
messages. if you will. the effect of learning about one thing
on our attempts to understand something else. Mhat has cer-
tainly been profoundly true in my own field, cancer, in which
our efforts to understand how cancer genes work has had a
tremendous impact on our thinking about many other dis-
eases in which it is important to understand how a signal is
transmitted from the surface of a cell to the interior of a cell.
Our thinking about cardiovascular and metabolic disease has
been profoundly affected by the availability of certain genes
we know to be involved in the causation of cancer. Similarly.
our efforts to understand the immune response in malaria ts
going to have important implications for (so other major
diseases caused by very different hinds of infectious agents,
namely, HIV and the tubercle bacillus, which also establish
chronic infections to which there is an immune response
which is incomplete and for which there are no vaccines
currently available.

Another point that occurs to me as | think about the im-
pact of new basic science und new methodologies on our
attempts to solve disease problems ts that although many of
these new tools are generated only in the developed coun
utes, they can be transferred into research projects tn coun-
tries like those of Africa without the great difficulty. one
might have supposed. kor example. the use of simplified
genctic analysis tools like array chips and other kinds of
devices, PCR. may have a great effect on our understanding
of the epidemiology of malaria, case management, and fol-
lowing drug resistance. These tools may indeed be the so-
lutions to the long-standing problems of how to do genetic
analyses of organisms and vectors under conditions where
claborate and complex manipulations have proven difficult,
Another observation that has become quite clear lo me is
that there is now an increasingly robust cohort of well-
trained scienuists native to many of the countries that for

political and economic reasons often do not foster the re-
search environment necessary to do some of the science so
urgently needed. It is important for us to be developing the
interactive tools to maintain strong collaborations with these
scientists, but in a way that maintains these scientists as
equals in the partnership and that gives them credibility in
their home country so that their political framework is as
supportive of them as we would like our fellow scientists to
be. Finally, if we are going to expand our activities, we need
to stress the importance of thinking about many disciplines
al once. ROL just the setence but also the economics, the
politics, and the health services components of what our re-
search conveys.

I know that over the fast 20 or 30 years, since J was a
medical student, tropical medicine research has moved quite
far into the mainstream at medical schools and academic
health centers. This has happened in a way that has been
effective in trying to draw the attentions of geneticists, cell
biologists, and computer scientists to the problems that your
members are most concerned about. This is a very important
factor in the changing environment at such institutions and
I very strongly believe that departments of cell biology and
genetics should have people that are working on these prob-
lems. Nevertheless, it is the core of the tropical disease sci-
entific community, the core represented by this Society. that
will continue to be central to the developments that I and
others would Hike to see occur in our efforts to combat dis-
eases of the tropical world. I] am very pleased that we have
had such enthusiastic support for the malaria initiative from
your members and look forward to many other productive
projects in the future. Phank you very much,

Author's address: Harold EK. Varmus, National Institutes of Health,
Building 1, Room 126, 1 Center Drive, MSC 0148, Bethesda, MD
20892-0148.

Dr. Guerrant:

Dr. Varmus, | know that | speak for all of us in thanking
you tremendously for the support, your vision, and all that
you are doing for our field. your field, our field together of
‘Vropical Medicine. In appreciation, the Society presents you
this plaque stating that “The American Society of Tropical
Medicine presents to Dr. Harold E. Varmus this certificate
of recognition and appreciation for vour efforts as Director
of the ULS. National Institutes of Health to increase recog-
nigion of the severity of malaria as a global health problem.
to stimulate collaborative research and training, and to de-
velop and improve tools for malaria control.” We are very
grateful lo you for this pioneering effort.