July 3, 2011 | 1
What can be done about global health? It’s the question on everyone’s minds following Peter Agre’s moving talk on malaria ‘without borders’ earlier in the week and Christian De Duve handing the baton of all the world’s challenges to the young researchers in the last lecture: "Our generation has made a mess of it… the future is in your hands".
The need is clear: Better diagnostic tools, as discussed in the panel on the future of biomedicine, will be for people that can afford them. The Economist’s science and technology editor Geoffrey Carr starts the concluding panel of the Lindau meeting by setting out the stark reality: "The greatest health needs are in the developing countries".
Hans Rosling , professor of International Health at the Karolinska Institute in Sweden, and the founder of the Gapminder Foundation, kicks off the debate presenting an animated graph showing how life expectancy and fertility have changed over time for each country. He says that in the 60s, there was a clear ‘developing’ and ‘developed’ world division with people in the developing world having big families and short lives, and the opposite for rich countries. Rosling uses the case of Bangladesh to illustrate his point: In the 60s, it was typical of a developing country, but by 2006 the child fertility rate is 2.3 children and people are living longer because of better healthcare. "People say the world isn’t getting better… that’s bullshit," he exclaims.
Then Rosling turns to the most controversial topic in global heath: population.
Population a problem?
De Duve’s lecture the previous day set out population control as the solution to tame an out-of-hand population growth. De Duve saw it as an essential feature of the survival of the species, with birth control the preferred option to achieve this. As a result, population is one of the hot topics discussed by the excellent panel, which also includes Harald Zur Hausen from German Cancer Research Centre, Unni Karunakara Medicins Sans Frontiers, Georg Schütte, from the German Federal ministry of Education and research, and James Vaupel, from the Max Planck Institute for Demographic research
Rosling asks: What will happen in the next 20 years? Will population continue to grow until we reach "peak child"? He shows a graph that illustrates the largest growth demographic is projected for the over 60s. As older generations will outstrip children born because we will be living longer lives.
Vaupel says that he doesn’t think that a population expansion will be a problem, and that the world population will peak at 8 or 9 billion. He reckons the next problem will be population decline. "Old people are less of a burden [than expected with an ageing population], " he says, "Health in later life is growing in line with life expectancy." Even low income countries are rapidly catching up with life expectancy in rich countries. Vietnam has a longer life expectancy now than the US did in 1966.
"People will be able to work longer," Vaupel adds. This is incredibly controversial, politically, however. In the UK, there are issues around government proposals to extend working life before people are eligible for a state pension. And for young people, supporting the older generation’s pensions through taxes can seem unreasonable when they won’t benefit themselves. Carr says this sets out "an intergenerational conflict." – which makes me think ‘another one as well as protecting the environment, and world peace’. Anything else?
The key issue then, putting population growth firmly to one side, is money. Rosling shows his famous graph that explodes the myth of ‘developing’ and ‘developed’ countries. He shows that on the axis of life expectancy versus income per capita, it is not easy to discern two groups – especially as development the trajectories are different for different countries. For example, China ‘got healthy’ first, and then ‘got wealthy’, Rosling explains, whereas the opposite is true of the US. Therefore, Rosling says it’s more accurate to stratify countries according to ‘high income’, ‘middle income’, ‘low income’ and ‘collapsed’. "It’ a problem of taxonomy", he says.
Money, money, money
"Money is the best medicine, best vaccine, strongest determinant of health in the world," Rosling says. Vaupel agrees: "Economic growth is going to be the real engine for growing health." This can expand resources available, and biomedical research to expand the knowledge base, he explains.
But wealth also has to focused on overcoming the challenges of global health. For example, the HPV vaccine is $17 per shot at its lowest price. This is out of reach of African countries where cervical cancer is the second most prevalent cancer. So, what are the solutions to the money issue?
The most obvious answer is to make medicines and procedures cheaper to allow treatment to be delivered to those that need it most. Rosling tells us of the situation of a colleague in Vietnam – a middle income, emerging economy – who needed surgery, but simply could not afford it. He says: "There are limits to what can be done with research without the money to deliver it [the treatment]."
A positive example is cataract surgery, which became much more widely available worldwide when new innovation made it available for $80. Another example, put forward by Karunakara is that of anti-retroviral drugs, which are much more widely distributed than 10 years ago. The cost has fallen by 99 per cent to less than $100 per person per year, and five million people are treated by state-sponsored programmes now.
Another cost concern for ARVs, Rosling says, is that we have to stop resistance in its tracks by addressing behaviour change. "It has to be said: HIV resistance will develop and drugs will become expensive again."
Another important factor is the practical consideration of how the fruits of research can be distributed. "One of the basic aspects in the lack of basic infrastructure and lack of education of the politicians and also some physicians," says van Hausen. On the ground in middle-to-collapsed economy countries, this translates into: How easy is it for people to adhere to treatments?
Karunakara cites anti-retroviral drugs (ARVs) as an one instance of how adherence can be addressed. He says that what made it possible for people in poor countries to take ARVs was the innovation of a trice-daily tablet that was heat stable. The prior regimen included taking 24 tablets a day, some of which needed to be refrigerated.
Another barrier can actually be the diagnosis itself. In the ace of Malaria, it is now possible to use a simple and rapid diagnostic test instead of microscopy. "You can take it on your bicycle and test right then and there," says Karunakara.
From the point of view of politics, Schüte says that wealthy countries can support research to target the neglected diseases that affect poorer countries by creating international partnerships. "It’s a mechanism towards developing and producing treatments in the countries that need it," he says.
European countries also form clinical trials partnerships to do research together with middle-to-collapsed economy countries. These foster know-how, the capacity for production and keep the intellectual rights where they need to be.
Zur Hausen thinks that the most realistic scenario for bringing the cost of treatments down is a strategy whereby ‘pilot’ countries lead the way in using a new treatment, such as the HPV vaccine, and then it is rolled out globally. In a way, a similar thing happened with HIV/AIDS, because rich countries were seeking to help the people in their own countries before solving the adherence and pricing issues for low-income countries. (Tiered pricing works for ARVs and this shows ‘leakage’ is not such as problem as the Pharma industry feared).
Different solutions for different problems
Rosling says that we have more economic convergence now than ever before. In 2006, 40 per cent of people in US have a counterpart in China, he says. But he stresses that what are widely called ‘developing’ countries should be re-classified and their issues treated appropriately. For instance, Rosling thinks that small molecule therapies can be licensed to middle-income countries because they are affordable to produce, but that the technology should be cleverly regulated because the initial R&D was very costly. He says it is stupid to give aid to China, which should be given to low income countries – fair trade is the way forward with middle income countries.
But for ‘collapsed’ countries, the solution is more research, and to be more clever about addressing the challenges that face, according to Rosling. "The research is not finished until people can use the results," he says. To make ochlear implants available for the whole world, for instance, entails a drop in price from 40,000 Euros to under 400 Euros. This is possible, he says, as new digital technologies are very cheap.
Deciding on solutions is a "thing for epidemiologists" says Rosling. Even within countries different solutions will impact on people with different levels of income, such as HIV transmission rates in Tanzania.
This is complex, because it disease causes poverty, not just the other way around. People will sell anything to treat a loved one, Rosling says. Furthermore, it is important to understand that the import of services and treatments are very expensive to people in poor countries. They may have a wealth in research, but they may spend 50 per cent of their health budget on drugs, whereas in Sweden the spending on medicines is 10 per cent of the health budget. This is partly because of market exchange rates.
Karunakara says that sometimes the problem for low or middle income countries is that, even with an influx of money, there is no capacity in the health system to improve healthcare. For example, in India, only one per cent of the government budget is spent o healthcare, compared to 15 per cent on defence. "They want to raise the budget but there is not enough nurses or people to deliver services," Karunakara says.
Interestingly, Karunkara tells us that in Africa, jobs are being done by doctors that were nurses, and by nurses that were community workers. "Once you innovate treatment that people with low levels of education can do, then you can address the capacity problem," he says.
"We need a business model and regulation model that enable the ideas to be turned into products and services – something Pharma can not do," Rosling insists.
Carr asks for a show of hands on whether the length of drug patents should come down. The majority of young researchers agree that 20-year patent laws are not right.
Karunakara says that: "Pharma plays to our fears and reflects our fears." He explains that fewer than 20,000 died from swine flu in 2010, but 60,000 people a year die of kala-azhar. Another neglected disease is sleeping sickness, which affects people in the Democratic Republic of Congo. Karunakara says that because the people that suffer from this are ‘hidden’ and marginalised by poverty, the Congolese government would rather prioritise other diseases for their aid funding. "Civil society has a big role to play in this… look at the role of the activist community in HIV," he says.
Zur Hausen responds to a question from a young researcher asking if pharma companies will invest in clinical trials for drugs that work but they can’t patent – perhaps because they have already been used to treat another condition. Sur Hausen says he is confident that pharma companies will deliver as long as something works, even if the drug is very cheap, such as in the case of aspirin. "In spite of low prices, in spite of low prices, in some instances some pharma companies will invest in it."
To end the discussion, Carr asks: "Will we ever have enough money? Will there be a point where health investment will start going down? Will demand be satisfied?"
Vaupel says that as as people gain wealth, they will invest it in their health, so demand will actually increase for healthcare, as a factor of GDP. Karunakara objects that for global health it is important to differentiate between ‘essential’ healthcare and other kinds of healthcare – although what the basic essential are is difficult to define.
Rosling gets the last word in the debate to say that only economic growth can help treat cancers, which are a big challenge for global health. He forsees that: "The only reason that health spending will fall is an energy crisis or if a crash of economies will force spending down."
About the author: Christine Ottery is a freelance science writer who writes on for the Guardian, TheEcologist.co.uk, SciDev.net and Wired magazine. She recently graduated from a MA Science Journalism at City University London, U.K. She blogs at Open Minds and Parachutes and tweets at @christineottery.
The views expressed are those of the author and are not necessarily those of Scientific American.