Research Article: The Four Horsemen of the Apocalypse: Tropical Medicine in the Fight against Plague, Death, Famine, and War††Presidential address given at the 60th Annual Meeting of the American Society of Tropical Medicine and Hygiene, December 7, 2011, Philadelphia, Pennsylvania.

Date Published: July 01, 2012

Publisher: The American Society of Tropical Medicine and Hygiene

Author(s): Peter J. Hotez.


Partial Text

I want to thank Dr. Lance Gordon for his very generous introduction. I was especially thrilled that Lance was able to make introductory remarks this evening because he bridges two of the most important institutions in my professional life. Lance previously served on the Board of the Sabin Vaccine Institute, an extraordinary global health institution that I have been associated with for the last 12 years, and he recently began a new position with the Bill & Melinda Gates Foundation. Not only has the Gates Foundation generously supported our work on the human hookworm vaccine for the past decade, but in addition Gates, together with Sabin, has introduced me to some of my most important scientific mentors, including Drs. Philip K. Russell, Ciro de Quadros, Regina Rabinovich, and Jan Agosti. It is also through the Sabin Vaccine Institute that I met some other extraordinary individuals including H. R. Shepherd, the founding Sabin Board Chair who died this year at the age of 89; Ambassador Michael Marine, (Sabin CEO); Brian Davis (Sabin COO); Mrs. Heloisa Sabin; and the current Sabin Board Chair, Mort Hyman, who is a unique combination of mentor and friend.

To highlight the devastation wrought by the tropical diseases I invoke an apocalyptic vision found in the last book of the New Testament. The Four Horsemen of the Apocalypse ride on black, white, red, and pale horses, with each symbolizing a distinct aspect of the Last Judgment. One of the better known representations of the Four Horsemen is from a late 15th century woodcut by the gifted and psychological artist, Albrecht Dürer (Figure 1Figure 1.Woodcut of the Four Horsemen of the Apocalypse, ca. 1497–1498, Albrecht Dürer (German, 1471–1528).). There are differing accounts and interpretations of the meaning of each mounted horse, but for this evening we will focus on their representations as pestilence, death, famine, and war.

Over the past two decades enormous strides have been made in NTD control and even elimination through mass drug administration (MDA).4,14,18,25,32 The concepts and implementation of MDA have been pioneered by several important members of ASTMH, including many persons here with us this evening! During the 1980s and 1990s, China became one of the first large countries to eliminate lymphatic filariasis as a public health problem through MDA with the drug diethylcarbamazine citrate.4,25,32 The success of this enterprise in China in turn built on the pioneering work conducted by Frank Hawking (father of the cosmologist Stephen J. Hawking) and others during the 1950s and 1960s.25,32 Through widespread MDA requiring more than a billion treatments annually with low-cost diethylcarbamazine or ivermectin (Mectizan®) and albendazole donated by Merck & Co. and GlaxoSmithKline, respectively, lymphatic filariasis has now been eliminated as a public health problem in more than 20 LMICs.4 Similarly donated ivermectin has resulted in the elimination of onchocerciasis from Mali and Senegal, and will soon lead to onchocerciasis elimination in Latin America; donated azithromycin (Zithromax®), together with simple surgeries, facial cleansing, and environmental control, have led to trachoma elimination in more than a dozen countries.4 Thus, MDA has become a powerful global tool in eliminating these three devastating NTDs.

Manufacturing vaccines in partnership with developing country vaccine manufacturers may also have a profound geopolitical dimension. To understand this concept, we must look to the legacy of Dr. Albert Sabin, who during the late 1950s developed the oral polio vaccine jointly with Soviet virologists. This period coincided with an apex in the Cold War in the years immediately after the launch of Sputnik and the first successful test of a hydrogen bomb by the Soviet Union. Despite heightened political tensions, the polio collaboration provided proof-of-concept for how two nations can set aside ideologies for purposes of vaccine development, something that I have termed “vaccine diplomacy.”43,44 Based on our successful collaborations with members of the DCVMN, I have started to ask if there might be modern day examples of vaccine diplomacy, particularly with nations that 1) often differ ideologically with the United States, 2) have capacity for vaccine development and production, and 3) simultaneously have high rates of NTDs. Among the more poignant examples would be NTD-endemic Islamic nations of strategic security interests to the United States, such as Indonesia, Iran, and Pakistan.43,44 A number of countries where vaccine diplomacy might one day be practiced is shown in Table 5 . Such collaborations will be fraught with political challenges but potentially they also offer huge rewards.