The Epstein-Barr virus is present in about 95 per cent of adults in
the world, and is believed to be a key causal factor in certain types of
cancer, especially a nose and throat cancer which each year kills 40 000
to 50 000 people in Asia. In the West, the virus causes glandular fever
(infectious mononucleosis), a flu-like illness which, though usually mild,
can sometimes be incapacitating.

Hans Wolf of Regensburg University in Germany reported the Chinese trial
of an anti-EBV vaccine at a recent international meeting in Annecy, France.
Out of nine children given the vaccine, six were protected against natural
EBV infection over a 16-month period. However all 10 children who were not
vaccinated were infected.

Wolf admits that the number of children involved in the trial was small.
Nevertheless, he says, ‘the fact that all 10 controls were infected, and
two-thirds of the vaccinated children were protected with only a single
dose of the vaccine, suggests that some protection ‘is possible.’

The German-Chinese group tested their vaccine on humans before testing
whether it could protect animals from infection, a choice that raised a
few eyebrows at the Annecy meeting. Wolf defended this by say-ing that animal
tests do not reliably predict how an anti-EBV vaccine will perform in people.
When questioned about the ethics of the trial, Wolf said: ‘I am not using
the Chinese as guinea pigs. This is a Chinese vaccine and it was approved
for human trials by a Chinese ethical committee.’

The vaccine used in this trial was made in China from a prototype designed
by Wolf’s group in Germany. It consists of a vaccinia virus genetically
engineered to produce an EBV protein called gp 220-340. The vaccinia virus
multiplies in the body, continuously releasing the immunising protein. The
British vaccine uses the same protein but without a virus ‘carrier’. Presumably,
it will need to be coupled to an immune-stimulating ‘adjuvant’ substance
to produce strong immunity.

Wolf notes that ‘one advantage of working in China is that the Chinese
live with the constant threat of EBV-induced cancer and desperately need
a vaccine against it.’ But not everyone is convinced that the vaccine is
effective against cancer. Guy de The, a viral epidemiologist at the Institut
Pasteur in Paris, is sceptical about an anti-EBV vaccine protecting against
cancer because the virus is only one factor contributing to the disease.
Salted fish in the diet, for example, is also known to play a role. De The
also says that the vaccine’s anticancer potential will take decades to
measure.

In the short term, the most attractive target for an anti-EBV vaccine
is not cancer but glandular fever. Rich Mahoney of the Program for Appropriate
Technology in Health, based in Seattle, believes that ‘the demand will
be tremendous. We’re talking about vaccinating every 12-year-old kid in
the developed world and well over 10 million doses of vaccine annually’.
The program is seeking firms interested in developing a commercial vaccine
from the German-Chinese prototype, or the one designed by Britain’s Cancer
Research Campaign.

Wolf would not use the vaccinia virus to ‘express’ the immunising protein
for a vaccine to be used in the West. He believes the risk of side effects
might outweigh the benefits of protecting against a relatively mild illness
such as glandular fever.

The danger is malaria, which the Cambodian health ministry estimates
is killing between 15 and 25 people a day. This is ten times the number
of victims of land mines reported to the Cambodian Red Cross. In parts of
the country, the effect of the disease is ‘devastating’, says the WHO.

The threat from malaria is especially serious because a form of the
disease that resists all the usual antimalarial drugs has appeared in the
northwest of the country, near the border with Thailand. When the border
is opened under the UN’s peace plan, returning refugees could become infected
with these drug-resistant malaria parasites. As they move through the country,
the parasites could ‘sweep right across Cambodia to the Vietnamese border,’
says William Rooney, who works with Thailand’s Malaria Division in Bangkok.

In the short term, those in greatest danger are the troops of the Malaysian
UN contingent, who have been assigned to protect refugees crossing the border.

But Malaria also threatens the 360 000 Cambodian refugees who will start
to return home from camps in Thailand at the end of this month. More than
half of the refugees are under 15 and have no immunological ‘experience’
of the disease. More than 70 per cent of the refugees have said they want
to settle in the northwest provinces, where according to Cambodia’s Regional
Antimalaria Team, one in four khums (communes) is malaria-ridden.

The team has also found malaria parasites taken from patients in the
area to be totally resistant to the common antimalarial drugs chloroquine
and Fansidar and highly resistant to the newer drug mefloquine. Some patients
failed to respond even to quinine and tetracycline, generally considered
extremely effective.

‘Malaria is clearly the number one problem in the country,’ says Jean-Paul
Menu, WHO representative in Phnom Penh. ‘And we just don’t have the means
to deal with it.’ His immediate concern is to help the Cambodians to set
up the rudiments of a health service that could provide proper treatment
for the 6000 people who come down with malaria each week. About 90 per cent
of the cases are infected with the potentially fatal falciparum variety
of the disease. ‘But drugs, microscopes, trained staff and transport are
sorely lacking, and many people die for lack of proper treatment,’ he says.

Menu’s chief concern has been to make sure that the UN troops know what
to expect. With Kevin Palmer, of the WHO, and Lec Sandy, head of the Cambodian
Health Ministry’s Malaria Centre, Menu is forming a ‘Committee of Experts’
to advise on prevention and treatment.

Ingrid Laux, the UN’s medical director in New York, says she has advised
all the peacekeeping units to provide their troops with insect repellents
and bed nets impregnated with insecticides. They should all take doxycycline
tablets every day, she says. So far, the malarial parasites do not seem
to have developed resistance to this antibiotic. But the drug has some unpleasant
side effects, particularly vomiting and sensitivity to light. It is not
clear whether prolonged use of an antibiotic against malaria might lead
to long-term gastrointestinal problems.

Kunal Bagchi, medical coordinator for the UN Border Relief Operation,
who is overseeing the repatriation of the refugees from the Thai border
town of Aranyaprathet, says he is awaiting instructions from the WHO. ‘We
are providing all the refugees with bed nets and a lot of information about
how to protect themselves against the mosquitos,’ he says. As for treatment
of refugees who fall sick with malaria, ‘I don’t know what the situation
is on the other side of the border.’

An epidemic of cancer will sweep across the developing world in the
next 30 years, a group of eminent epidemiologists is warning. At the WHO
in Geneva they accused industrialised countries of doing too little to help
poor countries prepare for the epidemic.

According to Timo Kaulinen, professor of epidemiology and biostatistics
at the Karolinska Institute in Stockholm, the number of people dying from
cancer in developing countries is expected to jump in the next 30 years
from 2.7 million a year to 6.5 million. This is an increase of 140 per cent.
In the poorest countries of the Third World, the number of new cancer cases
each year is likely to double, rising from 5 to 10 million.

Over the same period, the number of people dying from cancer in developed
countries will increase by 20 per cent, from 2.2 to 2.6 million a year.
New diagnoses of cancer will probably rise by 25 per cent, from 4 to 5 million.
‘This means that for each cancer case diagnosed in the developed world,
there will be two cases in developing countries,’ says Kaulinen.

The reasons for the predicted cancer epidemic are simple. First, cancer
is a disease of the elderly, and the elderly population of the developing
world is expected to increase by 240 per cent over the next three decades.
But the main reason for the epidemic is that people in poor countries are
adopting the lifestyles of developed countries – particularly cigarette
smoking. According to the WHO, tobacco consumption is increasing by more
than 2 per cent a year in the developing world. The result, WHO says, will
be an extra 1.5 million cases of lung cancer, of which 90 per cent will
be incurable.

Already well over half of the 9 million new cases of cancer discovered
each year are in developing countries, says Howard Barnum, an economist
at the World Bank. Around 80 per cent of cancers of the oesophagus, cervix
and liver, 70 per cent of cancers of the mouth and pharynx, and just over
half of all Hodgkin’s lymphomas and leukaemias are diagnosed in developing
countries. Despite this, there is little medical help for cancer sufferers
there.

Jan Stjernsward, the chief of the WHO Cancer Unit, says that 90 per
cent of cancers in developing countries – over 4 million each year – are
incurable by the time diagnosis is made. In developed countries the figure
is below 60 per cent. ‘At least 80 per cent of cancers are treatable,’ he
says, ‘but in the Third World over 80 per cent of cancers are not detected
until they’re in an advanced incurable stage. In these poor countries only
one in ten patients has access to a well-equipped health centre. Africa
has 75 cancer specialists for a population of over 500 million.’

Without much chance of curing a patient’s cancer, pain control is a
priority, but, says Stjernsward, there are 55 countries where ‘not a single
morphine tablet can be found’, largely because of outdated laws on the use
of opium-based drugs. Many of these countries, China for example, are major
opium producers.

‘It’s just scandalous that only 5 per cent of the world’s resources
for cancer control go to the countries that are producing 60 per cent of
the world’s new cancers,’ he says. John Maurice, Geneva On the rise: cancer
cases will more than double in the Third World-

With Mahler as director-general, WHO became less of a technical advisory
body and more of a conscience-prodder, pushing its 166 member countries
to accept health as a basic human right and anything detrimental to health
as anathema. The vigour with which he shattered a glass ashtray in a ceremony
marking the start of a ban on smoking on WHO premises was likened by some
to righteous wrath.

So, it was with a sense of letdown that many of WHO’s 4500 staff, particularly
the 1500 or so working at the Geneva headquarters, learnt of Mahler’s decision
not to run for another term as director-general. And an even greater surprise
when his successor was announced: Hiroshi Nakajima, 61 years old, Japanese,
director for the past decade of WHO’s Western Pacific Regional Office in
Manila in the Philippines, and reputed to be very much a bureaucrat’s bureaucrat.

From Danish missionary fire (and occasional brimstone) to Japanese pragmatism
(and inscrutability) is quite a long jump. Since Nakajima’s arrival last
summer, WHO has been awash with rumour and uncertainty. Early staff changes
– to be expected with any new management – have caused particular uncertainty.
A rumoured hit list of those in the new boss’s firing sights has dominated
corridor talk. Not only people, but whole programmes and divisions, are
spoken of in tones normally reserved for the terminally ill.

As staff are moved about, divisions divided and new programmes created,
Nakajima does little to dispel uncertainty. A difficulty in communicating
in any European language, combined with a natural oriental reserve and an
understandable tendency to surround himself with a close circle of intimates
– many of them Asian-born like himself – familiar with his ways, makes for
an incipient ‘big brother’ atmosphere. An exaggeration, but only just.

At a meeting of the executive board in January, Nakajima went some way
to clarifying his intentions. He said he favoured ‘management by information’
and a ‘streamlining of our programme management, delivery and evaluation’.
He called for more ‘unity in all our programmes’, and ‘steps to strengthen
the operation and delivery of programmes, especially at country level’.

During a recent interview in his spacious offices on the 7th floor of
the WHO building, Nakajima was more explicit. ‘Management must become more
problem-oriented. Problem solving must be more imaginative, innovative.
Better use must be made of staff skills. Staff members must be more involved
in the decision-making process.’ A Japanese approach? ‘An Asian approach,
if you like,’ he explained, ‘with decisions made after a consensus is reached
at all management levels.’

Nakajima believes that grafting ‘the Asian approach’ onto an organisation
accustomed to a more individual Western approach will call for more decentralisation,
more efficient communication between all areas and greater cohesion within
the WHO family. ‘WHO should speak with one voice,’ as he and his close colleagues
are fond of saying.

At the Geneva headquarters staff involvement and decentralisation mean
a greater say for the deputy director-general, the five assistant director-generals
and the directors of the 25 or so divisions or programmes. And, if theory
becomes practice, for all staff members.

On the other hand, the directors of some programmes who have enjoyed
a degree of autonomy up to now will probably have to play in closer harmony
with the regular WHO orchestra under its new conductor. This is particularly
true of the five ‘special’ programmes – on AIDS, diarrhoeal diseases, onchocerciasis
(river blindness) in west Africa, human reproduction and tropical diseases.

Funded largely from sources outside WHO’s regular budget, these programmes
have enjoyed a certain independence from the main management hierarchy.
The 1988-89 biennium marks the first time that such outside funding is likely
to exceed contributions by member states ($804 million and $609 million
respectively). Nakajima has to work out how to keep the special programmes
within the WHO management fold without jeopardising its ability to attract
such funds.

Beyond WHO headquarters, greater cohesion and decentralisation will
mean a closer working relationship between Geneva headquarters and the directors
of the six regions – Africa, the Americas, the eastern Mediterranean, Europe,
Southeast Asia and the western Pacific. Some regional directors are known
to have felt out on a limb, far from the mainstream of WHO activities. Also,
the many representatives in different countries, who have sometimes tended
to be used as pillar boxes for visiting headquarters staff, are to be given
a bigger say in how things are done. The aim is to involve those who are
closest to the communities more in decision-making.

This sounds fine. But is it not just an example of worthy wishful thinking,
like primary health care, which is often criticised as an empty slogan?
To Nakajima’s thinking, there is too much of a gap between slogan and reality.
‘When I was regional director in the western Pacific,’ he notes, ‘there
was even an enormous gap between words said in the regional office in Manila
and the reality that many of the people in the Philippine islands close
by were experiencing. So you can imagine the size of the gap between Geneva
and the rest of the world if communication breaks down, if unity is lost.
What is needed now are words of reality, frankness, followed by quick action.’

‘The problem,’ he adds, ‘is that once you start working with the people
in their communities, educating them about health and healthy lifestyles,
they begin to clamour for health technology and expertise. And they believe
WHO should transfer the technology and know-how and implement disease-prevention
programmes. But WHO cannot meet expectations that go beyond its mandate
or financial resources. Already about two-thirds of WHO’s resources are
used to provide technical cooperation for country programmes. All we can
do is help countries to identify health problems and to find their own solutions
to these problems. WHO is not a bilateral donor agency that says: ‘Here’s
the money and the equipment and here is the policy you have to carry out.’

One of Nakajima’s greatest difficulties, he says, is to convince governments
of the link between health and development. In a report to the executive
board, he pointed out that in many areas of sub-Saharan Africa, West Asia
and Latin America the incidence of disease has increased over the past three
or four years as a result of economic deterioration and growing debt. And
this at a time when chronic health problems, such as malaria, are on the
increase in many countries and new problems, such as AIDS and environmental
pollution, are emerging. He fears that for many countries this situation
could make the year 2000 an unrealistic target date for ‘health for all’.

A time of transition for the WHO. A time of transition for the world.
And also for Nakajima. ‘You know, I look on my assignment as director-general
of the WHO as kind of transitional. We’re moving from the 20th to the 21st
century. So it’s perhaps fitting that a man of 60 is chosen to fill the
gap. But I’m looking to the next generation. And the next generation’s going
to have to deal with at least two transitions: from military to economic
power and from political to social power. And with at least three explosions:
a technology explosion, an information explosion and, if our health programmes
work as they should, an explosion of the elderly.’

If Nakajima can prepare the WHO to respond quickly and adequately to
the coming explosions, he will have fulfilled his self-appointed mandate.

John Maurice is a freelance science writer specialising in international
health.