Black Fever and Resilience

Stephen DeAngelis

August 01, 2006

Yesterday’s New York Times contained an interesting article about a charity that was formed to promote drugs that are effective but not considered profitable enough to pursue by mainstream pharmaceutical companies [“A Small Charity Takes Lead in Fighting a Disease,” by Stephanie Strom]. For its first drug, the charity called the Institute for OneWorld Health selected paromomycin which was all but abandoned in the 1960s. The drug is effective against black fever which is estimated to kill half a million people a year worldwide – almost all of them poor. Today a course of treatment with the drug costs around $500, OneWorld Health hopes to bring that cost down closer to $10. The article begins by telling the story of Munia Devi who is undergoing treatment with the drug.

Black fever is the second-largest parasitic killer in the world after malaria. It is spread by sand flies, and Banthu, the squalid village about an hour’s drive from here that Mrs. Devi calls home, is an ideal breeding ground for them. The flies multiply in the cow dung that Mrs. Devi uses as fuel for cooking. They relish the sap in the banana groves and bamboo stands, and they thrive in the thatch used to make the tiny houses. Flies that have bitten infected humans transmit the disease when they bite another person. Smaller than mosquitoes, they can pass through most netting. Roughly 90 percent of black fever cases worldwide are found here in Bihar State in India and in Bangladesh, Nepal, Sudan and northeastern Brazil.

One would think that eliminating disease and death are such noble goals that getting the support of governments and international organizations would have been easy. Such was not the case.

The Internal Revenue Service at first denied the charity nonprofit status, concerned that it looked too much like a for-profit enterprise. The World Health Organization, which controlled the drug, was reluctant to hand over the data needed for further development. And OneWorld Health had to set up clinical trials matching United States and European standards in one of the poorest parts of the world.

The reason the story caught my attention is that it addresses many of the principles I promote when discussing Development-in-a-Box. First and foremost of those principles is the use of standards. OneWorld Health “conducted the medical trials needed to prove that the drug is safe and effective. Now it is on the verge of getting final approval from the Indian government.” Second, a holistic approach to development must be undertaken. OneWorld Health, for example, is beginning in India which already has much of the supporting infrastructure necessary to make the program effective. It is using a government research institute as its clinic. In countries without such infrastructure, it must be developed simultaneously if sustainable progress is to be made. Third, OneWorld Health has joined an informal community of practice, cooperating with other charities and non-governmental organizations to address global health problems.

The idea of a nonprofit drug company struck many as folly when Dr. Victoria Hale, a former Genentech executive and Food and Drug Administration official, founded OneWorld Health in 2001. So Dr. Hale and her husband started the project using their own money, though they have since won support from the Gates foundation, among others.

One final principle worth remembering is that good intentions don’t make up for a lack of expertise. OneWorld Health was founded by individuals who knew the drug industry, not by people who simply had a desire to address health problems. That, in fact, is the basic concept of Development-in-a-Box. Most failed or developing states have neither the infrastructure nor the expertise to kick start a development program. Development-in-a-Box helps set up the infrastructure using accepted standards and automated processes and is accompanied by an education and training program that transfers the necessary knowledge to make the programs sustainable.

The article is worth reading for another reason. It recounts the difficulties that OneWorld Health had with the World Health Organization who gained the rights to paromomycin when commercial pharmaceutical companies abandoned it. One would have thought that WHO bureaucrats would have been thrilled to learn someone was interested in resurrecting the drug. Not so. WHO was reluctant to cooperate because it had entered into an agreement with Zentaris, a large pharmaceutical company, and the Indian government to develop another drug to fight black fever. That drug, miltefosine, began life as an anti-cancer treatment. Commerce was getting in the way of progress. That is one of the few downsides of public-private partnerships — the intentions were good but the consequences weren’t. Eventually, those involved saw the light and OneWorld Health got what it needed.

Good news like this is generally difficult to find among the chaos covered in today’s news. Another good news story caught my eye because it mentions Tom Barnett’s blog and the ideas he is well known for promoting. The article was found in yesterday’s New York Sun [“Good News,” by Michael Barone]. Barone asks readers to take a strategic pause and consider the news behind the news.

The world seems aswirl. Where do we stand today? Let’s use the analysis of bestselling author Thomas Barnett, who divides the world into a functioning “Core” (North America, Europe, East Asia, rising China and India) and a nonfunctional “Gap” (the Middle East, most of Africa, part of the Andean chain in South America). Mr. Barnett argues that our task is to expand the economically interconnected core and establish what he calls connectivity to shrink the gap. How are we doing? Actually, not badly.

Barone then takes a tour d’horizon of world’s hot spots from Israel to Iraq and hot issues from trade talks to immigration. His conclusion is that the vector of progress may have slowed but not stopped. Barone recognizes that challenges certainly exist, but even so he insists that we should continue to face the future with hope. He writes:

Most Americans continue to moan and groan about our situation, and to yearn for the holiday from history we seemed to be enjoying in the 1990s. As Mr. Barnett argues, “Time is on our side, as are all the major dynamics that count — energy, investments, demographics, sheer firepower, enduring ingenuity, strength of our societies, our enduring resilience.” With fits and starts, the core is expanding, connectivity is increasing, and the gap is closing.