Some Updates on Global Healthcare

Stephen DeAngelis

May 17, 2010

In past discussions about Enterra Solutions’ Development-in-a-Box™ concept, I’ve pointed out that there are several factors that help speed development along. One of those factors is a healthy workforce. As employers and employees in the U.S. know, health insurance costs are significant and rising. Trying to operate with an unhealthy workforce, however, can be even more costly. That’s why many companies shy away from countries whose population suffers from diseases such as tuberculosis, malaria, and HIV. Over the past few years there have been both advances and setbacks on the healthcare front. Just when the international community thinks it’s getting a handle on a particular disease, drug resistant strains of that disease begin appearing. Tuberculosis is one such example [“Drug-resistant tuberculosis poses global risk, World Health Organization says,” by David Brown, Washington Post, 20 March 2010]. Brown reports:

“The percentage of tuberculosis cases around the world resistant to two standard drugs remains low — about 4 percent — but is three to six times as high in the vast area that once encompassed the Soviet Union, according to a report released … by the World Health Organization. The report is based on information from 114 countries. Because testing for TB drug resistance is not uniformly carried out and is not even done in some countries, experts cannot say whether the problem is getting worse or better. ‘What we can say is this is a serious threat to global health, with rich and poor countries, all countries, at risk,’ said Mario C. Raviglione, director of the WHO Stop TB Department. In the Russian Arctic city of Murmansk, 28 percent of new TB cases in 2008 were ‘multidrug-resistant’ (MDR) — the highest fraction recorded in a region, the report said. In the Central Asian nations of Kazakhstan and Tajikistan, the rates of MDR-TB were 25 and 17 percent, respectively. In Moldova and Belarus, in Eastern Europe, the rates were 25 and 17 percent. In the Baltic nations of Estonia and Latvia, they were 15 and 12 percent. … Despite the seriousness of the problem in Eastern Europe and Central Asia, nearly half of all MDR-TB cases occur in China and India. That’s because those countries have so many TB cases overall.”

Drug resistant diseases not only take a toll on individuals and families, they can have a significant negative impact on a country’s economy. Individuals with drug resistant diseases can’t work and their families often require state support. The loss of a worker means that companies have to train new workers. And treating drug-resistant diseases is costly.

“MDR-TB costs 10 times as much to treat, with a cure rate of just 60 percent. Ultimately one-quarter of MDR-TB victims die. … About 5 percent of MDR-TB cases worldwide (and more than 10 percent in the former Soviet regions) are ‘extensively drug resistant,’ which means they are resistant to two alternative drugs, as well. Most of those patients die. WHO estimates that to adequately treat MDR-TB in the 27 most-affected countries by 2015 will require about $3 billion a year; just $400,000 is being spent this year.”

Tuberculosis is not the only drug-resistant disease raising concerns. Malaria is another one [“Malaria strain rendering powerful drugs useless,” by Margie Mason and Martha Mendoza, Associated Press, 28 December 2009]. Mason and Mendoza report that the problem is particularly acute along the Thai/Cambodian border:

“The Thai-Cambodian border is home to a form of malaria that keeps rendering one powerful drug after another useless. This time, scientists have confirmed the first signs of resistance to the only affordable treatment left in the global medicine cabinet for malaria: Artemisinin. If this drug stops working, there’s no good replacement to combat a disease that kills 1 million annually. As a result, … international medical leaders declared resistant malaria here a health emergency. … Malaria is just one of the leading killer infectious diseases battling back in a new and more deadly form, the AP found in a six-month look at the soaring rates of drug resistance worldwide. After decades of the overuse and misuse of antibiotics, diseases like malaria, tuberculosis and staph have started to mutate. The result: The drugs are slowly dying. Already, The Associated Press found, resistance to malaria has spread faster and wider than previously documented. Dr. White said virtually every case of malaria he sees in western Cambodia is now resistant to drugs.”

One of the ways that drug resistant strains of diseases get started is that people take too little of a prescribed drug (hoping to save money) or, even worse, treat their disease using fake medicines. Mason and Mendoza explain:

“People generate drug resistant malaria when they take too little medicine, substandard medicine or – as is all too often the case around O’treng – counterfeit medicine with a pinch of the real stuff. Once established, the drug-resistant malaria is spread by mosquitoes. So one person’s counterfeit medicine can eventually spawn widespread resistant disease. Yet in most parts of the world, people routinely buy antimalarials over the counter at local pharmacies and treat themselves. A recent study out of neighboring Laos found 88 percent of stores selling artemisinin-based drugs, the same ones scientists are desperately trying to preserve, were actually peddling fakes. Worse, nearly 15 percent of the counterfeits were laced with small hints of artemisinin, which could prompt resistance. The researchers found indications that some were made in China, feeding smugglers’ routes that snake through Myanmar and into Laos, Thailand, Cambodia and Vietnam. The counterfeits, along with outdated drugs, are jumping continents. In Africa, where malaria is endemic in 45 countries, the fake drug industry is thriving. A 2003 World Health Organization survey found between 20 percent and 90 percent of antimalarials randomly purchased in seven African countries failed quality testing, depending on the type of drug.”

Nigeria is one African country that knows all too well the challenges created by fake medicine [“Awash in Fake Drugs, Nigerians Fight Back,” by Will Connors, Wall Street Journal, 12 March 2010]. The story in Nigeria, however, is not all negative.

“Biofem Pharmaceuticals Ltd., a Nigerian medicine distributor, wanted to arrest a slide in sales after a counterfeit ring targeted its best-selling drug. Sproxil Inc., a start-up founded by a Ghana-born Ph.D. student at Dartmouth, promised to do what Nigerian authorities could not: help companies and consumers detect fake pharmaceuticals. Sproxil’s founder, 28-year old Ashifi Gogo, overcame initial skepticism and a lack of funding to persuade investors to back a technology that offers a quick counterfeit-drug test. The technology could pave the way for wary foreign drug makers to enter the huge African market. The market includes Nigeria, Africa’s biggest country by population but one rife with scams and scamsters. … Sproxil received several small start-up grants and more recently won a $100,000 grant from USAID and Western Union. It is also supported by a small group of shareholders in Nigeria. The company hasn’t sold its technology to any outside investors. The company has developed technology that allows customers to use their mobile phones to check on newly purchased drugs. Using scratch-off labels and ID numbers, customers can send a code via text message to a database in the U.S. to check whether the medicine they purchased is authentic. Nigeria is Africa’s biggest mobile-phone market, with more than 70 million users.”

At least one big drug company is also trying to help get real medicine into the hands of those that need it [“Ally for the Poor in an Unlikely Corner,” by Donald G. McNeil, Jr., New York Times, 8 February 2010]. McNeil reports:

“Andrew Witty is … the chief executive of GlaxoSmithKline, the world’s second-largest drug company. Besides being the youngest person in such a post — he was appointed in 2008 at age 43 — he is also making a name for himself by doing more for the world’s poor than any other leader of a colossus of Big Pharma. ‘I want GSK to be a very successful company, but not by leaving the population of Africa behind,’ Mr. Witty said in an interview. ‘In any village hospital, you can see the beds filled with women and babies severely febrile with malaria, staring into space, and you wonder: Who’s taking care of the other children? It’s so obvious, the damage that’s being done.’ That tone is still rare in an industry once pilloried for keeping its prices up while millions died. Until a decade ago, all major drug companies treated Africa, Latin America and most of Asia as not worth the trouble of marketing to. … Now Glaxo is ranked No. 1 on the Access to Medicine Index created in 2008 by an organization based in the Netherlands that rates pharmaceutical companies on their stances toward the poor much as Transparency International ranks countries on corruption.”

McNeil goes on to detail some of the activities that GSK has undertaken to help get affordable medicine into the hands impoverished populations. For the most part, Witty and GSK have been praised for their efforts, but some critics insist that even more can be done.

Not all news about the fight against malaria is bad [“Optimism grows as target is in sight,” by Andrew Jack, Financial Times, 23 April 2010]. Jack explains:

“With just eight months to meet his goal of distributing hundreds of millions of mosquito nets around the world to people at high risk of contracting malaria, Ray Chambers is feeling confident. The UN special envoy on malaria believes efforts are on track for completion of deliveries during 2010, supporting broader plans to reduce greatly, within five years, the huge burden of illness and death from this leading killer disease. ‘This is the most optimistic World Malaria Day to date,’ he says. ‘Today, we know we can achieve the goal of universal coverage of nets by the end of this year and near zero deaths from the disease by 2015.’ His optimism is shared by other top officials who have observed a recent resurgence in efforts to tackle the disease, which the latest estimates suggest infects 250m people and kills more than 850,000 a year. Imaginative advocacy has helped raise awareness, in turn stoking an upsurge in funding from $60m a year at the start of the millennium to nearer $2bn annually today. Some far more effective tools for prevention and treatment have become available and the pipeline of technologies is growing to include more potent and easier-to-take medicines, and even possible vaccines.”

Jack reports that “Ethiopia, Ghana, Rwanda, Zambia and Zanzibar have cut death and disease by up to 70 per cent in recent years. … But others – including some with the greatest burden such as Nigeria and the Democratic Republic of Congo – have performed much less well.” He concludes:

“The final challenge is sustainability. History has proven the extraordinary versatility of the parasite in defying elimination. Resistance to the latest drugs – already identified in south-east Asia – risks undermining the best drugs available. If mosquitoes adapt to bite outside humans’ sleeping hours, nets will be rendered less effective. Any effort to reduce, and maintain at low levels, the burden of malaria will require large sums over many years. Yet even current needs are significantly under-funded. The financial crisis and ‘donor fatigue’ risk diverting support further. Steven Phillips, medical director for global issues at ExxonMobil, says: ‘Once you get even a 10-30 per cent decrease in malaria, how do you persuade people to spend more when the problem appears to be going away?’ Recent progress is impressive, but World Malaria Day will be marked long into the 21st century.”

Money always seems to be the long pole in the tent when it comes to fighting diseases. Sometimes even money doesn’t seem to help. Just ask Bill Gates, a man with deep and generous pockets [“Gates Rethinks His War on Polio,” by Robert A. Guth, Wall Street Journal, 23 April 2010]. Guth reports:

“Bill Gates walked into the World Health Organization’s headquarters in Geneva—for a meeting in an underground chamber where global pandemics are managed—and was greeted by bad news. Polio was spreading across Africa, even after he gave $700 million to try to wipe out the disease. That outbreak raged last summer, and … a new outbreak hit Tajikistan, which hadn’t seen polio for 19 years. The spread threatens one of the most ambitious health campaigns in the world, the effort to destroy the crippling disease once and for all. … The organizations behind the polio fight, including WHO, Unicef, Rotary International and U.S. Centers for Disease Control and Prevention, plan to announce a major revamp of their strategy to address shortcomings exposed by the outbreaks. … Mr. Gates asked: ‘So, what do we do next?’ That question goes to the heart of one of the most controversial debates in global health: Is humanity better served by waging wars on individual diseases, like polio? Or is it better to pursue a broader set of health goals simultaneously—improving hygiene, expanding immunizations, providing clean drinking water—that don’t eliminate any one disease, but might improve the overall health of people in developing countries? The new plan integrates both approaches. It’s an acknowledgment, bred by last summer’s outbreak, that disease-specific wars can succeed only if they also strengthen the overall health system in poor countries.”

I like the new strategy because it targets an entire population rather than focusing only on those who are sick. Researchers will continue to specialize on specific diseases, but the overall health of entire populations is what makes a workforce more attractive for companies looking to invest. I’d like to focus on one last “good news” story. Three years ago in a post entitled Carter’s War on Worms, I discussed an article by Nicholas Kristof about former President Jimmy Carter’s effort to eliminate river blindness in parts of Africa. Kristof recently published an update on the war against some of the worms that cause horrific health conditions in Africa [“Winning the Worm War,” New York Times, 28 April 2010]. Kristof writes:

“Since ancient times, one of the world’s most terrifying ailments has been caused by what the Bible calls ‘the fiery serpent,’ now known as Guinea worm. Guinea worms grow up to a yard long inside the body and finally poke out through the skin. They cause excruciating pain and must be pulled out slowly, an inch or two a day. In endemic areas like this district in Lakes State of southern Sudan, people can have a dozen Guinea worms dangling from their bodies. Yet this is a good news column. This district is, in fact, one of the last places on earth with Guinea worms. If all goes well, Guinea worms will be eradicated worldwide in the next couple of years — only the second disease ever to be eliminated, after smallpox. For the last 24 years, former President Jimmy Carter has led the global struggle against the disease. When he started, there were 3.5 million cases annually in 20 countries. Last year, there were fewer than 3,200 cases in four countries: Ethiopia, Ghana, Mali and Sudan. The great majority of the remaining cases are here in southern Sudan. Mr. Carter, 85, told me a few years ago that he was determined to outlive Guinea worm. I called him by satellite phone from here and asked if he still thought he would win the race. He laughed and said he was increasingly optimistic that he would outlast the worm. ‘If I can survive two more years, I’ll meet my goal, he said. … The campaign against Guinea worm is succeeding because — unlike many foreign aid projects — it puts villagers themselves in charge. Now that they understand that it is contaminated water rather than witchcraft that causes the disease, village elders have barred anyone with a dangling worm from entering a water source. Violators are fined, typically one goat. Elders also encourage families to use a well drilled by Unicef, or if it is too far away to use filters handed out by the Carter Center. But it’s an uphill struggle. The well broke down while I was visiting, and I came across a family drinking filthy, unfiltered water collected from a mudhole. … In recent decades, the world has learned that fighting poverty is harder than it looks. But the Guinea worm campaign underscores that a determined effort, with local people playing a central role, can overcome a scourge that has plagued humanity for thousands of years.”

The world needs to hear about success stories. Overcoming health challenges is a prolonged and costly fight. Donors can easily be overtaken by fatigue without some encouragement that their efforts are making a difference. Anyone who has given care to an ailing loved one understands that the fight against disease and suffering is really fought one individual at a time. Although the numbers of people suffering from various diseases around the world are staggering, in the long run it is not the cumulative number but the individual sufferer who matters. But as I noted above, the best way to reduce future individual suffering is to begin by targeting healthcare for entire populations. It’s good to know that so many people continue to fight the good fight.