In a world where advances in technology and ease of travel are continually eroding national boundaries, global health problems can rise up swiftly, threatening the lives and prosperity of vast populations.
Throughout the developing world, infectious disease and chronic illnesses confront more than one billion living in poverty. Rich countries face their own difficulties in finding ways to pay for sophisticated medical care. To make new strides in global health, governments and businesses must find a way to foster innovative, breakthrough solutions not only to cure or treat illnesses, but also to improve the delivery of health care itself.
Nobel Prize winners and experts in global health care will be exploring these issues during a Festival of Thinkers panel titled, Future Well-Being: Towards a Healthier World. “All of us are participants [in and profit from] globalization and enjoy global travel. We all must become more actively involved in global health issues by donating, advising and sharing responsibility,” says Richard Ernst, the 1991 Nobel Laureate in chemistry. Ernst is among the Nobel winners scheduled to participate in the panel.
The magnitude of the problem is enormous and marked with glaring disparities. Sub-Saharan Africa alone accounts for 24% of the global disease burden even though only 11% of the world’s population lives there. More striking, according to World Bank figures, Sub-Saharan Africa receives only 1% of global health expenditures. The World Health Organization estimates that basic health care would cost $35 to $40 per person in Sub-Saharan Africa, yet half of all health care in the region is paid for out-of-pocket by desperately poor patients. To begin to meet the growing health care demands in just this one region, an estimated $25 billion to $30 billion in new investment for hospitals, clinics and warehouses is necessary.
J. Robin Warren, who shared the 2005 Nobel Prize for Medicine and will participate in the panel, cautions that global health problems are not limited by geography. He points out that infectious diseases — including those that are now resistant to standard antibiotics — can spread across all nations in today’s era of global travel and migration. If affluent countries, like the United States, fail to manage global health problems better, in another 50 years the world could have more levels of infection than 100 years ago, he suggests. “I think the American government should be prepared to buy drugs and give them to poor countries because the poor countries cannot afford to pay for [them]. The American government — for the good of America — could get diseases treated more efficiently. If the rich countries help the poorer countries, they are helping themselves.”
Better Use of Resources
Neal Nathanson, associate dean for global health at the University of Pennsylvania’s medical school, says the challenges to global health fall into three main categories. First are broad-based problems — such as pollution, overpopulation and strained resources — that affect the entire planet. When people lack basics, including food and water, they are likely to suffer health problems, he points out.
The second problem is economics. With 1.4 billion people living on $1.25 a day, according to The World Bank, poverty is a major factor in global health. “If that many people are living below the poverty level, the health budget is going to be miniscule and everything else that affects health will be less than optimal,” says Nathanson.
The final impediment to improving global health is what Nathanson calls “social development.” Non-economic concerns, such as literacy and women’s rights, can help create a foundation for community-based health care systems even with limited financial resources. “You’re not going to lift the poorest billion out of poverty overnight, but you can do a lot with social development. My sense is that social development is an area where one can intervene and do something that is practical rather than just hypothetical.”
Nathanson says that while multilateral institutions, such as the World Health Organization and the United Nations, along with charities and foundations are attempting to alleviate global health problems, they often experience difficulty effectively allocating the resources they already have. In some countries, well-meaning organizations are working without licenses and coordination. “It’s sort of chaotic,” he says. “It’s not just raising money, but making better use of the resources that are being poured in.”
In many instances, the will and resources are in place to treat illnesses in the developing world, but countries lack basic infrastructure. Without roads, power, clean water and basic health care providers — including nurses — medicines and life-saving treatments simply can’t reach the patients who need them, Nathanson notes.
Marjorie Muecke, assistant dean for global health affairs at the University of Pennsylvania’s School of Nursing, says global health initiatives in the developing world are always looking for new ways to make the best use of limited technology and health care providers. In some cases, she says, countries are developing community health networks made up of volunteers, most of them women. Indeed, many of the volunteers are the wives of influential leaders in the community with the standing to make health care a priority. In India, nurse practitioners are being used in rural areas to help triage populations and identify patients who may need to travel for more advanced treatment in a doctor’s office or hospital.
One challenge in global health care delivery actually has been created by well-meaning aid organizations, Muecke notes. In many poor rural areas, non-governmental organizations have come in and identified bright, promising local people, then hired them to run specific programs. While that is good for the individual endeavor, Muecke points out that over time this practice leads to a brain drain in local public health systems and government health ministries. “In the long run, it’s a problem because the government’s ability to carry out its responsibility in promoting health is undermined.”
At the same time, however, health care personnel working in developing countries are finding innovative ways to use technology and increase the efficiency of available personnel, Muecke notes. For example, in some areas field workers are using cell phone cameras to photograph patients with certain diseases and then sending the photos to better-trained doctors for advice on additional care. “Poor people may not have a television or a computer, but they do have cell phones. We need to use technology in new ways so that we can spread the expertise of those who are expensively trained to far-flung populations.”
Meanwhile, according to Festival of Thinkers panelist Myrna Weissman, professor of epidemiology and psychiatry at Columbia University, illness can have a strong impact on economic development in countries where there is little or no ability to provide health care. Depression is a major factor holding down progress in the developing world, she notes. While it might be somewhat more difficult to sift out the costs of depression and mental illness compared to other health problems such as infectious disease or malnutrition, the effect can be just as debilitating.
Weissman has done field work in Africa exploring treatments for depression among people caught up in civil wars or the HIV crisis. She says effective mental health programs take into account cultural sensitivities, but Africans respond to group therapy and other approaches used to combat depression in developed countries. “What’s amazing is how similar people are. There are cultural differences in style, but not so many cultural differences in emotions.” Weissman is currently preparing for a project in the Congo that will test the idea of providing small grants for mental health along with other forms of economic development aid.
As emerging economies such as India and China continue to build a functioning middle class, demand for health care is expected to rise rapidly. Wharton professor of health care management Mark Pauly says that with so many people in developing nations already paying a sizeable portion of their small income for health care, it might be possible to develop private insurance markets to reduce the risk of financial ruin if a family member becomes seriously ill.
Some countries, including China, have limited forms of government-run insurance, but Pauly says it is possible that a private market could evolve in poor countries where families now save up huge cushions to protect against illness or an accident that would require expensive treatment. Many economists argue that if China were able to better develop a social safety net that would protect its citizens against the risk of illness or outliving retirement savings, the country could begin to support a more vibrant consumer market. Growing consumer spending, in turn, could energize the Chinese economy and make it less dependent on export markets. At the same time, it would also provide new outlets for Western products and trigger overall economic growth.
According to Pauly, research indicates that only about 10,000 subscribers are necessary to build a viable insurance pool, particularly with health insurance because the science in place to predict the number of people who will become sick in a given year is well developed. “The whole point of insurance is that the premium is modest compared to what” a person would pay if he or she, or a family member, became seriously ill, Pauly adds.
Despite the magnitude of the problems involved in improving health globally, some promising solutions are emerging, according to Stephen Sammut, a senior fellow and lecturer in Wharton’s health care management department. Multinational pharmaceutical firms and emerging biotech companies, he says, have been on the leading edge of private sector response to global health problems in the developing world, while a number of new models are surfacing that may help provide solutions to the problems confronting the global health system.
Many of the ideas for addressing problems in global health care, he points out, rely on public-private partnerships. The effort to cure tuberculosis, malaria and other infectious diseases that kill millions across the developing world require both a push and a pull mechanism to engage the private sector in sustainable solutions.
Governments or foundations can provide some money to “push” discovery and development of drugs or vaccines to treat diseases in the developing world that pharmaceutical firms or academics would otherwise tend to ignore. However, companies need to know they will be rewarded if a cure or effective treatment is identified. “The amounts of money for the push are nowhere near what they would have to be to fully finance the development of the drug or vaccine,” says Sammut. “There has to be some incentive beyond that.”
The “pull,” he adds, can be generated through a number of public-private partnerships that seek new ways to create viable markets for innovative health care products and services. One example is Product Development Partnerships (PDPs) — not-for-profit, virtual research and development organizations designed to accelerate the introduction of new products through a portfolio of partnerships engaging industry and academia. The Bill and Melinda Gates Foundation is involved in partnerships focused on HIV/AIDS, malaria, respiratory infections and the discovery of new diagnostic tools.
Another idea revolves around Advanced Market Commitments (AMCs), which create a guaranteed market for private sector companies that come up with a new drug or treatment for an unmet need. Donors, such as UNICEF or governments, contract to pay for a vaccine or treatment up front. “The general concept is to address the so-called market failure with funds to push development,” says Sammut. “The pharma company still takes on discovery and development, but knows that in the end there’s going to be a market.”
Priority Review Vouchers (PRVs) are one more emerging solution, this one coming out of amendments in 2007 to legislation governing the U.S. Food & Drug Administration (FDA), which grants approval for new drugs and treatments. The FDA can now offer a company speedy approval of one drug in return for the company’s pledge to underwrite development of a less-profitable product that might be used primarily in the developing world. Under this system, a company could earn a voucher by investing in treatments for a neglected disease, then use that voucher to jump ahead in the approval process with a drug that would be highly successful in the developed world. Sammut estimates the voucher can trim four to 12 months off FDA approval time and generate value ranging from $50 million to $600 million. The FDA issued its first PRV to Novartis Pharmaceuticals for an antimalarial drug.
Intellectual Property Pools (IPPs) are an additional way to engage the private sector in developing products for poor countries. The pools are an agreement between at least two companies to cross-license patents in order to find new treatments more quickly. In 2005, a patent pool was formed by companies active in Radio Frequency Identification (RFID). The hardest part of managing a patent pool is sifting through the portfolio of technologies available, Sammut says. Another obstacle, he points out, is the potential for antitrust problems. In March, GlaxoSmithKline (GSK) announced it would create a patent pool that would provide other companies access to GSK intellectual property to treat 16 neglected diseases identified by the FDA.
Finally, licensing of patented products for production by low-cost generic manufacturers is another way in which companies can help solve global health problems, while also remaining profitable. Governments in some countries have initiated compulsory licensing of products for dire problems, such as HIV/AIDS, that override international trade rules protecting intellectual property. Sammut points to the idea of voluntary licensing, which would permit a company that takes on development risk to partner with a generic firm and retain some piece of the business. Even if the generic is sold at a lower price than the branded pharma company would charge in mature markets, voluntary licensing might generate more sales than would occur if the product were not sold in the developing countries at all. The U.S. biotech company Gilead Sciences has licensing agreements with 10 Indian manufacturers and one in South Africa for distribution of HIV/AIDS treatments in 95 low-income countries. Gilead receives royalty payments of 5% on the finished products.
Sammut says these new partnership models do not necessarily build on one another in an evolutionary fashion, but represent alternatives that can be tailored to suit specific conditions in countries or within companies. Different aspects of the overall global health care challenge, he notes, stand to benefit from “the creativity of every one of these ideas.”