Posts Tagged ‘Public health’

Published in the New York Times on August 8, 2012 .  Read the full article here.  An excerpt is pasted below.

A two-year-old girl with a third degree burn at Kalomo District Hospital in the Southern Province of Zambia; she would have to travel more than 25 miles for her surgery. Photo credit: Sarika Bansal


Late one June afternoon, Angela Chibwe was heading home on a bus on this city’s main road when she noticed an elephant on the side of the road.  This would not have normally been cause for alarm, as elephants are a common sight here.  This one, however, behaved unusually: it charged at the bus and caused it to flip upside down.

Several hours later, Angela woke up in Livingstone General Hospital.  She was the only passenger who had been badly injured.  Both of her legs were broken, and a piece of metal had cut through her forehead and left eye.  The hospital’s surgeon had been able to restore sight in her eye, though it would unfortunately remain disfigured.  When I met her, three weeks after the accident, she seemed to be in pain but grateful to be alive.

Angela was perhaps luckier than she realized.  If the accident had occurred in a distant rural area instead of the city of Livingstone, which has more than 130,000 people and a relatively sophisticated medical system, she may not have woken up in a hospital.  She may not have gotten the surgery required to restore vision in her left eye.  She may have been permanently disabled, or worse.

Across Africa, countless people die or become disabled because they cannot obtain necessary surgeries.  It is conservatively estimated that 56 million people in sub-Saharan Africa — over twice the number living with H.I.V./AIDS — need a surgery today.  Some need cesarean sections or hernia repairs, while others require cataract surgery or treatment for physical trauma.

Continue reading here.


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Published in The Atlantic on Tuesday, April 3, 2012. Read the full article here. An excerpt is pasted below.

A man ponders a potato chip purchase in an East Harlem bodega. Photo credit: Sarika Bansal

“Healthy food in bodegas?” asked Ibrahim Hilou, owner of a convenience store in Central Harlem. “You’re wasting your time. Go 96th and down. Over here, they like it sweet. I made a coffee today with eight sugars.”

Like most bodegas in New York City, Hilou’s store is relatively small — the customer area measures about 400 square feet — and its shelves are stocked with non-perishable goods like potato chips and canned soup. The refrigerators are filled with artificially sweetened beverages, full fat milk, and beer. A counter sells hot sandwiches lathered with mayonnaise and cheese. The register is decorated with lottery tickets and candy bars.

Meanwhile, in a neglected corner, a self-standing metal shelf contains an assortment of fruits and vegetables. The bananas are overly ripe and the potatoes are of poor quality. Few people buy produce in Hilou’s shop; most of the onions end up in breakfast sandwiches, the store’s most profitable product.

New York City has over 10,000 bodegas like Hilou’s. In some New York neighborhoods, particularly lower income ones, bodegas are often the default option for groceries. In parts of Brooklyn, they comprise over 80 percent of food retail (PDF).

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Published in Forbes on November 22, 2011. Read the original article here

My last post discussed the reasons why neglected diseases have historically been neglected, the growing efforts to eradicate them, and why pharmaceutical companies should develop more drugs for them.

Unfortunately, the traditional economics of drug development are stacked against neglected diseases, which disproportionally affect the world’s poorest populations. Drug development is a costly and time-consuming process, and even if a pharmaceutical company did develop a viable drug for a neglected disease, they would have virtually no way of recouping their investment.

Luckily, there are many other ways the private sector can address neglected diseases (which are defined here as the seventeen neglected tropical diseases, malaria, and tuberculosis). I spent last week speaking with top officials from pharmaceutical companies, research groups, and intellectual property organizations to understand what the for-profit pharmaceutical industry can realistically do to push research forward on these diseases. All of the solutions presented below have, importantly, already been tested in the real world.

Without further ado, here are – in no particular order – the top five ways Big Pharma can address neglected diseases.

1) Create cross-sectoral research partnerships for neglected diseases
Though pharmaceutical companies have generally shied away from independently developing drugs for neglected diseases, several are open to creating drugs with partners. Just this past Thursday, Novartis and collaborators, including Scripps Research Institute and Swiss Tropical and Public Health Institute, discovered a new dual-acting class of anti-malarial compounds. “It was a multi-disciplinary, multi-continental effort,” said Paul Herrling, head of corporate research at Novartis. “Each partner brought unique knowledge and skills needed to obtain the common goal.”

Other pharmaceutical companies have also created partnerships for neglected diseases. Sanofi has, for instance, partnered with non-profit drug developer DNDi to develop medicines for up to nine NTDs. GSK has similar partnerships with foundations including Medicines for Malaria and the Global Alliance for TB Drug Development. In most cases, the partnerships are funded through a combination of sources, including the private sector, government, and other donors.

Partnerships for neglected diseases appear to be on the rise across the pharmaceutical industry. The International Federation of Pharmaceutical Manufacturers and Association (IFPMA) found that partnerships for neglected diseases have increased five-fold from 2005, and that today, 80 percent of neglected disease research efforts are done through collaborations. Mario Ottiglio, Associate Director of Public Affairs and Global Health Policy at IFPMA, said, “[Partnerships are] basically a very pragmatic solution to address market failure in neglected diseases. Pharmaceutical companies bring adequate resources, while academia and government bring the epidemiological context.”

This does not mean, of course, that every research partnership is guaranteed to succeed. Scientifically speaking, neglected diseases are quite complicated and few efforts will yield positive results. Robert Sebbag, Vice President of Access to Medicines at Sanofi, also discussed how strong relationships are crucial to the success of a partnership. “Each partner has to respect and trust each other,” he said. “They must also have a common objective.” Without those fundamentals, he said, everyone will assume the worst in each other and the fruits of collaboration will be lost.

2) Join patent pools for neglected diseases.
Patent pools are created when two or more companies agree to cross-license certain products or technologies. Recognizing the need for shared progress in neglected diseases, the World Intellectual Property Organization (WIPO) and BIO Ventures for Global Health recently created a patent pool, WIPO Re:search, for neglected diseases. In addition to maintaining a searchable database of relevant intellectual property, it will also facilitate new research partnerships.

“Most pharmaceutical companies have some form of CSR programs. They also have intellectual property. This is basically an effort to put those two things together,” said Francis Gurry, Director General of WIPO.

Since it was only created this year, the potential of a patent pool is yet to be seen. However, Gurry has high hopes. “In the best case scenario,” he said, “[WIPO Re:search] will help create partnerships between public and private entities… which over a five or ten year period will create good candidates for products.”

Many pharmaceutical companies have responded positively to the effort, and seem generally willing to share intellectual property related to these unprofitable disease areas. Sebbag from Sanofi believes it is a “very good step forward” in neglected disease research, and a GSK spokesperson said the program was “a natural evolution” of existing efforts in the field.

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Published in Forbes on November 9, 2011. Read the original article here.

What do schistosomiasis, cysticercosis, and lymphatic filariasis have in common?

Besides verging on the unpronounceable, they are all classified as neglected tropical diseases (NTDs). NTDs are a set of diseases – seventeen, by the World Health Organization’s count – that collectively affect over a billion people, but have historically received little attention. The most common NTDs, including those listed above, are caused by parasitic worms or protozoa. Others, such as leprosy and trachoma, are the result of bacterial or viral infections.

Though caused by a range of pathogens, NTDs share some important characteristics. First, many are diseases of rural poverty. Most neglected diseases affect the poor in the developing world, particularly in Africa and Asia, but some have also been found in “pockets of poverty” in the United States. For instance, hundreds of thousands of Americans, most of whom are Hispanic immigrants, suffer from Chagas disease. Second, most NTDs cause bodily impairment and disability (i.e., they have high morbidity) but are not very lethal (i.e., they have low mortality). Some result in blindness, others in unseemly swelling, and still others in impaired cognitive development. Most patients do not die, but the morbidity often hinders wage-earning capacity, thereby creating a vicious cycle of poverty.

These and other characteristics have unfortunately led to neglected tropical diseases being, well, a bit neglected. Since most policymakers live in urban centers, geographically separated from the rural areas with high NTD prevalence, there has traditionally been limited awareness of NTDs. Similarly, because NTDs cause more disability than death, they have historically flown under the radar of many public health efforts. Perhaps most importantly, the populations NTDs disproportionately affect have little money to spend on medicine, resulting in what Peter Hotez, President of the Sabin Vaccine Institute, calls “the business plan from hell.”

How can we change this status quo? What needs to happen for the pharmaceutical industry, academic researchers, and other key players begin investing more seriously in diseases that debilitate over a billion people?

To some extent, the status quo has already begun to change. It has not yet changed nearly enough, and there is ample room for the pharmaceutical industry to invest more in NTDs, but it is important to acknowledge how far the fight against neglected diseases has come.

The term “neglected tropical diseases” was only coined in 2005; before that, each unpronounceable disease fought its own uphill battle with limited success. WHO Director-General Margaret Chan explained in 2007 the benefits of having a catch-all term: “When these diseases are viewed together, we gain critical mass. We get a better grip on the scale of the economic and social consequences as well as the health burdens. Arguments for giving these diseases higher priority become more powerful, more persuasive.”

Since the term was coined, there has been considerable activity in the neglected disease space from governments, donors, pharmaceutical companies, and nonprofits alike. The US government, the UK government, and the Bill & Melinda Gates Foundation have collectively pledged or spent over $200 million on NTD prevention and treatment by 2013. Pharmaceutical companies have donated billions of doses of drugs to various NTD control programs. Some, such as GSK and Merck, have also entered “patent pools” to allow cross-licensing of NTD innovations. The Global Network for Neglected Tropical Diseases has engaged in NTD advocacy and on-the-ground coordination efforts. They also run a frequently updated blog, End the Neglect, that discusses NTD news and reminds readers that “just 50 cents” will provide a year’s worth of treatment against several NTDs.

There has also been a marked increase in NTD product development. The nonprofit pharmaceutical company OneWorld Health, which is partly funded through the Gates Foundation, conducts R&D for drugs against kala-azar (visceral leishmaniasis) and hookworm. It also ties up with for-profit pharmaceutical companies, such as Sanofi-Aventis and Anacor, to develop and manufacture some of their medicines. “Pharmaceutical companies have become more interested in NTDs than they were five to ten years ago,” said Richard Chin, CEO of OneWorld Health. “They would have sent us to their PR department before, but now they send us to their research department.”

Chin noted how their for-profit partners have invested significant time and money into the partnerships: they put their scientists on NTD projects at their expense and allowed OneWorld Health to manufacture drugs in their facilities. Many other product development partnerships (PDPs) for NTDs, such as PATH and the Sabin Vaccine Institute, seem to function along similar lines.

These developments are impressive, especially given the short time frame, but there is still a long way to go. This is perhaps most evident in the product development space. Hotez believes the pharmaceutical industry is “generally doing very well” in donating drugs, manufacturing space, and time to NTDs, but says most have invested relatively little in developing NTD drugs and vaccines themselves. Direct pharmaceutical investment has greatly helped the fight against the “big three diseases” (that is, HIV/AIDS, tuberculosis, and malaria): most recently, GSK invested in a malaria vaccine that is in final rounds of a large-scale clinical trial. Similarly, pharmaceutical companies can invest in drugs and vaccines that spur improvements in NTD morbidity rates.

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Published in Forbes on October 13, 2011. Read the article here or below.

Last Tuesday, researchers announced that an experimental malaria vaccine called RTS,S may help reduce the risk of malaria by half. The results – which are preliminary, as the researchers have only analyzed 40% of the study’s 15,000 participants so far – are based on a study being conducted across seven countries in sub-Saharan Africa, which accounts for 90% of worldwide malaria deaths.

RTS,S is being developed jointly by GlaxoSmithKline and the PATH Malaria Vaccine Initiative, a program funded by the Bill and Melinda Gates Foundation. When the study’s preliminary results were announced last week, Bill Gates lauded the research team and said, “A vaccine is the simplest, most cost-effective way to save lives.”

Seth Berkley, CEO of the GAVI Alliance, echoed this sentiment in a recent Huffington Post op-ed. Titled, “Vaccines: The biggest bang for the buck in global health,” Berkley wrote that vaccines offer enormous return on investment because they “cut healthcare and treatment costs, reduce the number of hospital visits, and ensure healthier children, families and communities.” Given their ability to “yield real results,” he encouraged the US to allocate more of its foreign aid to vaccines.

To an extent, Gates and Berkley are right: prevention is generally cheaper than treatment, and among prevention methods, vaccines can be quite cost-effective. Lois Privor-Dumm, the Director of Alliances and Information at Johns Hopkins’ International Vaccine Access Center, also believes that more generally, preventing disease is the right thing to do. “It gives people a better quality of life,” she said, “and it allows [the country’s hospitals] to treat people who really need it.”

If vaccines are so cost-effective and so important for society, why do 20 million children still not get the immunizations they need?

In his op-ed, Berkley pointed primarily to a lack of funding for vaccines. More money, he said, would result in a “transformation in child health and survival.” This is not, however, the whole story. Additional funding would certainly help close the immunization gap, but it would not eliminate it. Even if vaccines were free, there would still be significant obstacles preventing them from being universally accessible.

First, the cost of a vaccine may not reflect its true price to a consumer. Shipping vaccines can be expensive, and many countries pose import duties and taxes on medical supplies. Some vaccines need to be refrigerated, which makes transportation even more expensive, especially in developing countries with limited electricity and cold chain infrastructure.

There are also many indirect costs associated with getting people vaccinated. Patients have to pay, both in money and time, to go to clinics whose hours of operation may not be convenient for them. This is particularly problematic for vaccines that require multiple rounds, including RTS,S. Patients can take the time to go to a clinic once, but it may be difficult to prioritize going on a regular basis.

Compounded to these are non-monetary bottlenecks to getting people vaccinated. Medical professionals are pitifully few and far between in rural areas, and each one can only see a certain number of patients a day. Some communities may have to build demand for vaccinations through time-consuming public awareness campaigns. And regardless of vaccine availability or intention, there will always be some parents who either procrastinate or simply forget to take their children to the doctor.

Surmounting these obstacles may seem daunting, especially since many are indicative of broader failures in countries’ health systems. Luckily, many can be overcome with sustained action and a bit of creativity – and in the case of vaccines, several groups are looking to do just this.

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Published in Forbes on October 13, 2011.  Read the article here or below.

This Saturday afternoon, 100,000 Peruvian schoolchildren will collectively attempt to break a world record previously held by Bangladesh. In 25 regions of the country, in large cities and small towns alike, they will line up in their school courtyards and wait for a signal. As soon as someone yells, “En sus marcas, listos, fuera!” all 100,000 children will begin to wash their hands.

This event is one of thousands that will occur as part of Global Handwashing Day (GHD). Celebrated annually on October 15, GHD intends to educate the world about the importance of handwashing and encourage people to make it a habit. Last year, 200 million people and 700,000 schools are estimated to have participated in handwashing events around the world, in countries as diverse as Kenya, Japan, and Tajikistan.

Perhaps surprisingly, handwashing plays a vital – and often overlooked – role in disease prevention. Studies have found handwashing to cut risk of diseases like diarrhea and pneumonia by half, which otherwise kill a combined two million children a year. Soap is easy to find and affordable for most households. The real challenge is convincing people to use it on a daily basis.

Global Handwashing Day is an important effort in promoting that simple behavior change. It began in 2008 under the auspices of a public-private partnership for handwashing (PPPHW). Myriam Sidibe, Unilever-Lifebuoy’s Global Social Mission Director and co-founder of GHD, said the team essentially wanted to create a day with lots of press and a big global profile. “Having a dedicated day,” she explained, “really helps you talk about an issue and increase its visibility.”

The fascinating thing about Global Handwashing Day is the degree to which the private sector is involved. Sidibe was part of the team that created Global Handwashing Day, and other consumer goods companies, including Proctor & Gamble and Colgate-Palmolive, came on board soon afterward. “We worked hand in hand [with NGOs and multilateral organizations] for months,” said Sidibe. “We had conference calls every week. We designed the logo, picked the day, everything.”

The private sector seems to add tremendous value to this particular advocacy effort. Katie Carroll, Secretariat Coordinator of the PPPHW, said, “In the case of handwashing, the private sector brings scale, market access, and amazing marketing know-how. Donors also can’t match private sector ability to work on behavior change. Having that is really helpful to the rest of the organizations.”

The consumer goods companies’ engagement with social advocacy is a clear example of what Michael Porter and Mark Kramer deem “creating shared value.” In a recent article in the Harvard Business Review, the authors discuss how businesses and governments have for decades created false dichotomies between economic efficiency and social progress. They contend that to remain competitive, sophisticated business leaders must reconnect economic success and societal benefits. Specifically, they must consider the latter to be “not on the margin of what companies do but at the center.”

How widely applicable is this concept? Is it feasible for businesses to promote social progress as strongly as, say, Unilever has promoted handwashing?

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Published in Forbes on September 22, 2011.  Read the post here or below.

Everyone reading this article has suffered from diarrhea at some point, but did you know that it kills nearly 4,000 children a day? The World Health Organization estimates that diarrhea – simple, annoying diarrhea – is the second leading cause of death in children under five, after pneumonia. It may even be responsible for taking more children’s lives than AIDS, malaria, and tuberculosis combined. Not surprisingly, nearly all diarrhea-related deaths occur in the developing world, and are especially prevalent in areas with endemic poverty and poor nutrition.

The perplexing thing about diarrheal disease is that unlike many other global health epidemics, cheap diarrhea treatments exist. Since the 1970s, the WHO has been recommending oral rehydration therapy (ORT) and continued feeding as the “gold standard” for treatment. It is very effective in helping children regain vital nutrients they lose during diarrhea, and crucially, it costs pennies. The medical journal The Lancet even once said ORT may “potentially [be] the most important medical advance of the twentieth century.” Other treatments for diarrhea, including zinc therapy and rotavirus vaccination, are also inexpensive and quite effective.

Given this, we must ask ourselves: why are 1.3 million children still dying of diarrhea every year?

I believe there are two primary reasons. First, diarrhea treatments have yet to reach everyone who needs them. In the case of ORT, only 39 percent of children with diarrhea actually receive it. Between stock-out problems in shops that sell the mixture, confusion of how and when to make the solution, andhealth workers’ mixed levels of adherence to treatment guidelines, there are several formidable barriers in getting this WHO recommended treatment to sick children.

Second, universal access to diarrhea treatment does not guarantee an end to the epidemic. Improving ORT availability is not a silver bullet; rather, stopping diarrheal deaths requires an integrated approach that addresses both treatment and prevention of disease. In this case, we must prevent children from contracting diarrhea by improving drinking water quality, hygiene standards, and childhood nutrition levels. Realistically, the epidemic will persist until and unless these broader social ills are addressed.

This does not mean, however, that markets should wait for issues like malnutrition to be “solved” before helping make treatments more readily available. While improving access to treatment will not result in an ultimate end to diarrhea, it is a vital piece of the puzzle. It is also probably the most tangible way the private sector can get involved.

Within the private sector, logistics and consumer goods companies can probably make the biggest difference to the epidemic, by helping streamline distribution of treatments to communities that need it. A recent study by Johns Hopkins University found that in sub-Saharan Africa, out-of-stock rates for ORS were as high as 38 percent – in contrast to consumer goods like mobile phone cards, which boast out-of-stock rates of 6 percent in the same geographies. Consumer goods and logistics companies could significantly help ORS manufacturers with improving their datasets, sharing knowledge of best practices, and even potentially sharing distribution infrastructure. The Johns Hopkins team believes such partnerships could be constructed not as donations or CSR activities but in ways that would benefit both parties.

Improving distribution logistics may seem like an odd and un-sexy way to stop a global health epidemic. When faced with a disease as un-sexy as diarrhea, however, it may be just what the doctor ordered.

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