Health Care and Development

Stephen DeAngelis

July 30, 2009

Health care reform continues to make headlines in the United States. As president and CEO of a business, I am obviously following the debate because the outcome will affect both my company and my employees. Health care is a concern around the world. It is improving in some countries and remains woefully bad in others. In fact, health care in some developing countries has improved so much that those countries are now attracting “medical tourists.” Mexico has become a destination of choice for many Americans, while others travel to places like India, Singapore, or Thailand. Often the reason that people seek medical care outside their own country is cost [“Overseas, Under the Knife,” by Arnold Milstein, Mark D. Smith, and Jerome P. Kassirer, New York Times, 9 June 2009]. Milstein, Smith and Kassirer are all doctors. They write:

“One consequence of the high cost of medical care in the United States has been the rise of medical tourism. Every year, thousands of Americans undergo surgery in other countries because the allure of good care at half the price is too good to pass up. Average total fees at well-regarded hospitals like Apollo and Wockhardt in India are 60 percent to 90 percent lower than those of the average American hospital, according to a 2007 study by the consulting group Mercer Health and Benefits (where Dr. Milstein is affiliated). Even compared with low-cost American hospitals, the offshore fees are 20 percent to 50 percent lower.”

They note that although many of the medical procedures being sought by medical tourists are cosmetic, “an increasing number have high-risk operations like heart surgery and joint replacement.” They claim that many of the people seeking high-risk procedures do so because they “have either no health insurance or meager coverage. Though not poor enough to qualify for Medicaid, they cannot afford a good health plan.” The doctors warn that the cost benefits of seeking medical care in developing countries should be weighed against the potential risks.

“People having surgery done halfway around the world are far from their regular doctors as well as friends and family. Consider, also, what happens if an American abroad falls victim to negligent care. Arranging transfer to another hospital may be difficult — and malpractice suits typically face longer odds and smaller payments than in the United States.”

The authors aren’t condemning overseas health care. In fact, they openly admit that “there is reason to think that the quality of care at some foreign hospitals may be comparable to quality in the United States.” Sadly much of that excellent health care isn’t available to the local population because they can’t afford it. Some hospitals address this challenge by charging different fees for locals and foreigners. People living in the most impoverished countries can’t even dream of having access to good medical care. Even worse, they are often victims of medical fraud that can be life threatening. One of the most serious problems is fake drugs. To meet this challenge, Dr. Facundo M. Fernández, a professor at the Georgia Institute of Technology, recommends using mass spectrometers to ferret out fake drugs [“Using Scientific Tools in an International War on Fake Drugs,” by Thomas Fuller, New York Times, 20 July 2009].

“[Mass spectrometers] can instantly identify the chemical makeup of food, drugs and just about anything placed in front of their stainless-steel aperture. … Dr. Fernández’s main focus is counterfeit pharmaceutical drugs, especially in poorer countries, where government regulation is weak. He is part of an informal group of researchers and government officials spanning Africa, Asia and the United States who have teamed up with Interpol, the international police agency, to use cutting-edge technology in tracking fake drugs that claim to treat malaria. Counterfeit malaria drugs are of particular concern because of the scale and severity of the disease — it kills more than 2,000 children a day in Africa alone — and fears that fake or substandard malaria drugs are aggravating a growing problem of drug resistance.”

To learn more about the malaria problem and what’s being done to address it, read my blogs entitled for example, News About Malaria Continues to Improve, Mapping Africa, The Rise of “Creative Capitalism”: Tackling Malaria, and New Malaria Initiative Launched. Returning to Dr. Fernández’s fight against fake drugs, Fuller reports that the big breakthrough for using mass spectrometers came just a few years ago.

“A scientific breakthrough in 2005 added an ‘ion gun’ to the machines and allowed Dr. Fernández to check hundreds of pills a day. A technician simply holds the sample — a pill, dog food or a dollar bill, for example — up to the machine, which emits a jet of helium gas and captures a minute amount of the material, instantly identifying its component parts. Contrary to the common belief that counterfeit drugs are just sugar pills, Dr. Fernández said, most fakes have some level of active ingredient. Many contain the cheap and readily available pain reliever paracetamol, which might temporarily soothe some symptoms but will not fight the underlying disease. Sometimes researchers find harmful or very unexpected chemicals. Once, when analyzing what was suspected to be a counterfeit antimalarial pill, his team discovered traces of sildenafil, the main ingredient in the anti-impotency drug Viagra. … The counterfeit drug business has become increasingly attractive for criminal syndicates; the profit potential is vast, yet the punishment for those caught is typically much less severe than for illegal drugs like cocaine, law enforcement officials say. This is especially true in Asia, where many countries impose the death penalty for trafficking heroin, Ecstasy or even marijuana but where combating counterfeit drugs is not a priority. Three years ago, the World Health Organization estimated that as many as one in four pharmaceutical drugs sold in the developing world were counterfeit. It is impossible to know the exact level, but there is general agreement that the level of fake drugs is ‘unacceptably high,’ in the words of the organization.”

As I often stress in my discussions of Development-in-a-Box™, one of the preconditions of sustainable development is having a healthy workforce. When a workforce’s health is being undermined by the pervasive availability of fake drugs, other developmental efforts are negatively impacted. According to Fuller, mass spectrometers aren’t the only tools being used to uncover fake drugs.

“Counterfeiters have become more sophisticated in recent years, churning out pills and packaging that look like the real thing. But as the work of Dr. Fernández and others indicates, the sleuthing, too, is becoming more high-tech, relying on innovative forensic tools. Dallas C. Mildenhall, another scientist in the anti-counterfeit network, helps track fake drugs by analyzing the microscopic pollen grains embedded in the pills or packaging. Forensic investigators have used pollen grains for decades to help solve murders and other crimes, but Dr. Mildenhall pioneered using the tiny grains, which are ubiquitous in clothing, nostrils, hair, food and nearly everything exposed to air, to help combat counterfeiters. Because many plants are specific to certain parts of the world, pollen helps determine where the drugs were manufactured. … Dr. Mildenhall’s work has helped establish that many counterfeits come from the border area between China and Vietnam as well as the general vicinity of the Golden Triangle, the area famous for heroin production where the borders of Laos, Myanmar and Thailand meet. … Dr. Mildenhall is now involved in a project led by Paul N. Newton, the head of the Oxford University Center for Tropical Medicine in Laos, to determine whether counterfeit antimalarial drugs found in Africa were imported from Asia or manufactured locally.”

All these places (i.e., Laos, Myanmar, and Thailand) are located within geographical areas that comprise what my colleague Tom Barnett calls the Seam. Seam states lie between desperately poor and disconnected countries in the Gap and the developed economies of the Core. Seam states are invariably poorly governed and are, therefore, corruptible. They are disconnected enough from most of the global economy to allow criminals to act without fear, but are connected just enough for criminals to get their products to market. Sustainable development requires good governance; but good governance eliminates wealth created by corruption. As a result, fight corruption and corruption fights back. Aline Plançon, head of Interpol’s counterfeit drug department, claims “the main obstacle to cracking down on fakes [is] a lack of political will and cooperation between countries.” Fuller reports that the problem is spreading beyond counterfeit drugs to other “fake medical supplies like blood bags, syringes, bandages and contact lenses.” Dr. Fernández would like to see a mass spectrometer in every pharmacy in the developing world, but at $150,000 a unit that dream remains out of reach. Inventing an effective mass spectrometer that could be manufactured for under $1,000 would be a great goal for an innovation prize contest (see my post entitled A New Approach to Innovation).

Technology can also be used to improve health care in ways other than tracking down fake medical supplies. It can also be used to track diseases and predict their spread [“Predicting Flu With the Aid of (George) Washington,” by Donald G. McNeil, Jr., New York Times, 3 May 2009].

“In the past decade, the Internet has allowed health agencies to spot emerging viruses much sooner: local public health reports posted on the Web along with items from newspapers and radio stations are harvested by keyword-scanning programs. Now, in tandem with that, supercomputers are being enlisted to predict their spread.”

I’m a big supporter of predictive models. The challenge, of course, is getting good information that can be used by computer models. Dirk Brockmann, an engineering professor who leads the epidemic-modeling team at the Northwestern Institute on Complex Systems, has created a global model that “can put out a simulation in two days.” McNeil reports, “His model covers the globe, and it is based on air and land travel records for nearly the whole world. ‘In Africa, predictions are less accurate, but we have truck traffic,’ he said.” Helping get developing nations more connected helps improve the business environment and will increasingly play an important role in improving health care as well. The developing world is already providing some methods that can be used in the developed world to keep down health costs. We need to continue to drive down costs so that better health practices become available to world’s poorest populations.