There is a nice list of global health wins this year from Karl Hofmann, President and CEO of PSI, the world’s largest social marketing firm. You can see his list on the Huffington Post. Highlights include exciting progress on a malaria vaccine, “Treatment as Prevention” for HIV, and progress on the rate of vaccination against pneumonia.
December 30, 2011
June 2, 2011
Stopping polio for good using technology
“Polio eradication – it’s the ultimate in equity and it’s the ultimate in social justice” – Bruce Aylward
I just watched Bruce Aylward’s TED talk, and it was an amazing display of how new technologies are enabling humanity to meet the most difficult of challenges, the eradication of all three types of the polio virus from the face of the earth. There has been an active debate of late about whether polio eradication is the right thing to do, or even possible to do. This was due in part to a resurgence of polio cases and outbreaks across the world in recent years. However, Dr. Aylward says in his talk that not eradicating polio stands as “a stark reminder that we are failing, as a society, to reach children with the most basic of services”. In this, and the quote at the title of this post, he makes a convincing Rawlsian argument that polio eradication is both just and fair, and that due to the way that such eradication is being attempted, it also serves as a marker of how all childrens’ access to essential medicines is progressing. A huge army of volunteers hikes to the most remote places on the planet, through heat, extreme cold, and war zones, to administer two drops of oral vaccine to every single child. This is the only way to eradicate the virus, and to accomplish this would mean that we can access every child on the planet. Indeed, these same volunteers often bundle many health care services into every visit, including other vaccines, malaria bed nets, and vitamin drops. But how to ensure that every single child is vaccinated? This is where technology is playing a huge role. Satellite imaging provides new views of where the children and the infections are (remote villages, slums, and other areas not on other maps), and GIS sensors given to the volunteers track where they go. Overlaying these two technologies allows teams to see that every street has been walked down, every village visited, and hopefully every child vaccinated. In his talk, he also presented a graph depicting polio cases over time, and showed with digital geographic accuracy that for the first time in history this year, no new polio paralyses have been detected in the two most problematic Indian states, Bihar and Uttar Pradesh. All in all, a tour de force for the eradicationists, and a death knell for the “let’s control it” argument.
One point not covered in the TED talk but worth noting is the effect of herd immunity in eradication of polio. Given that only 95% of vaccinated individuals develop immunity to polio (i.e., 5% vaccination failure rate), there will always be at least 5% of the population that is susceptible to polio. However, it has been estimated that herd immunity will protect these susceptible individuals if between 80 and 86% of all people are immune. So, it is important not only to get the vaccination rate as high as possible, but to keep it there forever.
I think this effort is amazing. Every child on the planet getting the same vaccine, now and forever. Although two other diseases have been eradicated from the planet, smallpox and rinderpest, neither of these involved the scale of the polio effort due to the endemic countries affected and the number of susceptible individuals in these countries. Surely this is the first time in history a global disease eradication of this magnitude has been attempted, and if successful, it will open a new chapter in humanity’s ability care for itself.
April 16, 2011
YAIA: Yet Another Index Acronym
I visited a link today from the Center for Global Development’s Amanda Glassman about a panel struck to discuss vaccine funding for the GAVI Alliance. Amanda’s presentation focused on which of the G-20 countries were paying their “fair share” toward funding GAVI given that herd immunity from vaccines is a global good. Her first attempt to quantify which countries were paying into GAVI appropriately was to compare the percentage of GAVI’s funding by country to that country’s contribution to global GDP. Using this analysis indicated that the UK was paying way more than their fair share, whereas the US was paying way less. Given the Jenny McCarthy debacle recently in the US regarding vaccinations as well as the protracted economic downturn, this may not be surprising. In her post, Amanda suggested that perhaps a more sophisticated analysis would be to create a GAVI funding index in analogy to CGD’s Commitment to Development Index. This led me to learn more about this index.
At first glance, this index suffers from the same downfall as other indices – that is, it’s an index, which necessitates decisions about scaling, standard deviation, weighting, etc. The full scoop on CGD’s answer to these questions is found here. Once the waves of index ennui washed over me and dissipated, I began to look at some of the salient features of this particular index. Interestingly, the index quantifies not just spending, but contributions to global development in other areas as well. I focused on technology contribution, since that is my main interest. Wanna guess who came out on top in terms of technology contributions to global development last year? Portugal! South Korea was 3rd, Japan was 4th, and the US was 13th. One of the reasons is because of changes made to the index since last year:
“The intellectual property rights (IPR) section of the technology component gained two new indicators: one on whether countries allow patent applications to be challenged before they are officially approved, which discourages companies for claiming ownership of ideas already in the public domain; and one on whether patent exceptions are provided for research purposes, increasing access to such innovations in developing countries.”[1]
This bumped Portugal way up above where it was last year. But even still, looking at the 2009 numbers yielded the top five technology contributors as: Spain, South Korea, Japan, France, and Canada, which contained some surprises for me. Funding for technology development counts in the index, as does virtually every component of intellectual property rights and protection law for that country. The US ranks low because of its rather draconian patent law. It will be interesting to track this index over time to see if some of the interesting IP developments in the US and Canada affect their rankings over time. In the meantime, I feel the need to make an index to rank all of the global health indices out there. Perhaps there’s a support group for that.
January 5, 2011
Higher prices for drug development
As a follow-up to my previous post on the high costs of developing new drugs and vaccines for diseases impacting global health, a new Tufts Center for the Study of Drug Development (CSDD) outlook report states that the average cost of developing a new drug has risen to $1.3B. An excerpt from the press release announcing the report states:
Actions that will help improve R&D productivity, according to Tufts CSDD, include greater reliance on translational science to help identify the right disease targets for new molecules; greater use of partnering with external service providers to share risks, reduce cycle times, lower costs, and improve resource management; and greater use of sophisticated portfolio management techniques.”
The full report is available for purchase at http://csdd.tufts.edu/reports.
December 31, 2010
2011 Global Health Resolutions
Today is the last day to make New Year’s Resolutions (on the western calendar, anyway), and so I thought I’d make a list of what I think the humans on Planet Earth should try to accomplish in global health this year. I welcome your inputs on this as well. Just add them in the comments section below.
1. “Eliminate” polio.
This one has been on everyone’s list for many years now, but we are closer than ever. This is, of course, subject to the realization that most diseases for which there are vaccines are rarely completely eliminated, but let’s get as close as we can.
2. Cut meningitis infection in Africa by 75%.
I think with the new vaccine approved by the WHO recently and now available in Niger, Burkina Faso, and Mali, we are closer than ever to removing this scourge from the lives of children the world over.
3. Continue advances in diagnosing and treating TB using DOTS.
DOTS is a remarkable success story in many countries, but not in all. We need to find ways to make TB treatment more uniform and successful across the world. Recently-approved rapid diagnostics for TB will help.
4. Drive advances in helminth diagnosis and research.
Helminths are a bane on the human population and have been for centuries, if not always. There is relatively little work in this area, yet the effects of helminth infection, particularly in children, are huge. More work clearly needs to be done. I personally resolve to look at the feasibility of molecular diagnostics for helminth infection using some of the work we are doing in malaria diagnosis in our lab.
5. Continue work in malaria diagnosis and treatment.
Here, there is also progress we can build on. A new vaccine is almost available, although it has critically low effectiveness. There are also new diagnostics being developed that may eliminate the cold-chain required to store and transport current tests.
6. Continue work in treating and preventing HIV/AIDS.
As the major killer world-wide, we need as much effort here to continue as possible. The knock-on effects of treating HIV/AIDS are definitely worth the effort.
December 27, 2010
Twice as fast
A major challenge facing global health is the disparity between the time it takes to develop a new therapeutic and the time until that therapeutic becomes obsolete due to drug resistance. Drug resistance is emerging against virtually every current therapeutic drug against global health diseases. Malaria is a classic example, where the use of symptomatic diagnosis, incomplete courses of treatment, and counterfeit drugs led to resistance against quinine, although that drug is still sold in some malaria-endemic regions. Malaria has also become resistant to chloroquine, sulfadoxine-pyrimethamine, mefloquine, and it is only a matter of time before resistance to the artemisinin family emerges (see Table). Many other diseases are also resistant, however, particularly the bacterial infections due to the fast lifecycles of bacteria and the ease with which they transfer genes horizontally. Ironically, the more antibiotic is available, the faster the emergence of resistance due to the effects mentioned above.
Resistance to malaria drugs. Source: P.B. Bloland, "Drug resistance in malaria", WHO, 2001.
A chart of the number of new antibiotics on the market per decade shows a steep decline in the past 20 years, to almost none today. This phenomenon is likely to be due to a number of causes, including market share, difficulty of discovering new antibiotic modes of action that evade resistance, and the lucrative potential of drugs for other first-world diseases including cancer. This notwithstanding, the trend is towards fewer new antibiotics and faster emergence of resistance.
Number of new antibiotics entering market by decade, 1940-2000. Data from: http://en.wikipedia.org/wiki/Timeline_of_antibiotics
The story is even more urgent when we consider vaccines. Vaccines are held as the silver bullet of global health because they are the only treatment method that provides long-term protection, significant knock-on effects within populations due to immunized individuals (known as herd immunity), and wide availability at low cost once the vaccine is developed. However, the timeline for development of new vaccines is long and arduous. Even here there is resistance, including the H1N1 strain of influenza, whooping cough, and meningitis C.
Exact numbers on how long it takes to develop a vaccine are hard to find, as this depends on the disease target, but a general estimate is between 9 and 14 years. The cost also varies, but can reach well into the hundreds of millions of dollars ($300-800 million). In contrast, H1N1 resistance to Tamiflu emerged in just under 5 years. As you can see, the timelines don’t match up – we are fighting a losing battle.
The solution is twofold. First, application of emerging technologies and methods to disease target discovery and potential vaccine candidates will speed the time it takes to develop a candidate vaccine that can enter clinical trials. After this point is where the policy and the economics enter. Although the research is expensive, the clinical trials are extremely expensive. There needs to be a better way for drug companies to make the money they need to develop these vaccines, which will undoubtedly save millions of lives. The answer is upon us, I think. Within the last 10 years, several large pharmaceutical companies have spun off nonprofit vaccine development organizations focused on vaccines for neglected diseases. The nonprofit model fits these challenges well because there is virtually no way to make money on these vaccines and drugs. Once they are developed, they will be distributed at very low cost to the world’s critically poor, making sales an nonviable method to recoup costs. These nonprofits can apply for grants, raise donations, and use other methods to fund the critical research that needs to be done in order to ensure that the vaccines are developed, and that they are safe and effective.
Here’s the happiest news of all – you can help make this happen! Power to the people! You can donate or help raise funds for groups like the Sabin Vaccine Institute, the Novartis Vaccines Institute for Global Health, and PATH that are doing this critically important work. I have included links to many of them on the “Get Involved” page. I encourage you to donate so that others may live.
