The challenges of implementing healthcare innovations in the developing worldAt the World Economic Forum in Davos in January a coalition of governments, philanthropists and business pledged to put money and effort into making vaccines to stop the spread of diseases that could threaten humankind while trying to prevent another outbreak as devastating as the Ebola epidemic.
The Norwegian, Japanese and German governments, the Wellcome Trust and the Gates Foundation announced they were putting in $460m (£373m) – half of what is needed for the first five years. Three diseases will be targeted initially: Lassa, Mers and Nipah. All are caused by viruses from animals that infect humans and could trigger global epidemics.
Whilst this is good news, previous initiatives to tackle infections in developing countries have not been total success and those tasked with implementing the latest programme may need to heed the lessons derived from earlier activities. Five years ago, some of the world’s largest pharmaceutical companies, in partnership with the WHO and various government entities, committed to an unusual medicines programme. In the London Declaration, they pledged to work together rather than compete in an innovative programme, and to donate rather than charge for supplying large volumes of drugs.
Their products were to be used not to treat widespread western illnesses, but instead to work towards the elimination of “neglected tropical disease” (NTD) infections in poor countries by 2020.
The impact since has been significant. Yet there are now concerns that progress may stall given a shift in global priorities and funding under new political and health leaders, and the challenges of tackling the diseases themselves.
Sharp falls have been reported for elephantiasis (caused by the filarial worm), onchocerciasis (caused by infection with the parasitic worm Onchocerca volvulus) and trachoma (caused by bacterium Chlamydia trachomatis) — all helped by mass drug administration programmes under the London Declaration.
Yet there are mixed results for some of the other diseases identified in the original WHO road map. That partly reflects the different nature of the diseases, not all of which are so easy to tackle through the “chemo-prevention” strategy of prophylactic drug use to prevent and control infection. For most of the conditions, there is a need for accompanying initiatives to develop new drugs and associated diagnostics, and to reduce the risk from the worms, insects and other “vectors” that carry the diseases.
Most of those who suffer from NTDs live in the most remote and poorly developed regions of the world. Tackling the diseases effectively will also require far wider economic and social development, including improved hygiene, sanitation, diagnostic tools and education.
Such broader efforts will require greater political and financial commitment from the countries with a heavy disease burden. That is especially true given a global economic slowdown and nationalistic tendencies in some donor countries affecting the UK’s Department for International Development and US aid programmes under President Donald Trump.
Whilst these initiatives have tended to focus on infectious diseases caused by microbes or parasites, there is a new threat arising from the prevalence of non-communicable diseases (NCDs) in developing countries, one which is comparable to the greatest global health challenges we have had to confront in recent history.
Professor Peter Piot (Director of the London School of Hygiene & Tropical Medicine) has noted recently that, contrary to what most of us might think, deaths from cardiovascular diseases like hypertension occur disproportionately in low- and middle-income countries. Almost half of Africa’s population suffers from hypertension, yet many of those affected don’t know they have it.
The picture is very similar when it comes to diabetes. Whilst the number of people with diabetes worldwide has quadrupled since the 1980s, much of this increase has happened in low- and middle-income countries.
Health systems in these regions are ill-equipped to address this emergency. They are stretched under the pressure of fighting infectious diseases, which still make up a majority of deaths in much of the developing world. It will take decades before sufficient health coverage is achieved that can adequately address the scale of the NCD epidemic. New approaches are required.
Innovation in healthcare delivery can help the resources we have go further for patients with chronic conditions. One example of how this can work in practice is the Community-based Hypertension Improvement Project run by the Novartis Foundation and FHI360 in Ghana, with support of the London School. Licensed chemical sellers, which sell over-the-counter medicines, lie outside of the formal health system, but often serve as the first point of access to health advice for members of their local community. The goal for this project is to involve these private business owners as well as nurses and other local agents, and to provide them with basic training in blood pressure screening and management.
Crucially, patients taking part in the project are empowered to manage their condition with information, access to blood pressure monitoring within the community and automated mobile phone reminders about treatment and lifestyle changes that will benefit their condition. This looks to have better outcomes for patients, who would otherwise have to rely on crowded hospitals often located many hours’ travel away, and in a more efficient use of formal health facilities.
It is becoming increasingly recognised that similar innovations in healthcare delivery can make a big difference in the outcome of the global fight against the NCD epidemic.
In another initiative announced at the World Economic Forum in Davos, more than 20 of the world’s leading drug companies have pledged to work together to treat cancer and other NCDs in poor and developing countries. Cancer and NCDs are responsible for more than 80% of deaths in the poorest parts of the world, killing far more people than the diseases such as malaria, Zika or Ebola that tend to capture greater global attention.
The companies, which include Pfizer, Eli Lilly, Johnson & Johnson, Roche, Novartis, Sanofi and GlaxoSmithKline, will work with the World Bank and the Union for International Cancer Control, a non-governmental organisation.
While the companies have set aside $50m to establish a secretariat and begin work on the ground, the focus of the effort will be to “build on” their existing commercial presence in developing economies to remove barriers to care for cancer. But the initiative is likely to be met with some scepticism given past accusations on affordability. However, the initiative is also intended to address institutional issues such as the lack of infrastructure and experienced physicians. For example, the consortium will look at funding the creation of labs and other infrastructure needed to detect and treat cancer.
Another approach to addressing healthcare infrastructure issues in developing countries is to create simple, cheap, robust and power-free laboratory instruments, so-called frugal innovation. A brilliant example comes from the work of Professor Manu Prakash of Stanford University.
Prof Prakash and Dr Saad Bhamla, his colleague, have designed a cheap, hand-powered centrifuge that can be used in clinics in the developing world. Centrifuges tend to be expensive, bulky pieces of kit that require power. In fact, Prof Prakash embarked on this project after visiting a rural clinic in Uganda and discovering a $700 centrifuge being used as a doorstop. The lack of electricity rendered it useless. He returned to his laboratory with the ambition of developing a light, hand-powered centrifuge costing cents.
The breakthrough idea came from studying the whirligig, a plaything that has entertained children since 3,300BC. It comprises a disc with a length of string threaded through its centre. Repeatedly pulling the string taut causes the disc to spin at dizzying speeds. Blood, they discovered, would separate on a hand-spun whirligig made with a paper disc.
They managed to push the speed of a hand-powered paper prototype up to 125,000 rpm, which matches expensive, off-the-shelf centrifuges and is capable of separating malaria parasites from red blood cells. The “paperfuge”, costing 20 cents to make, is being tested in the field in Madagascar, in collaboration with Pivot and Institut Pasteur, non-profit organisations dedicated to improving healthcare for the rural poor.
The paperfuge is not the only potentially transformative technology to emerge from the lab of Prof Prakash. He has also developed the “foldscope”, a folding paper microscope with a glass bead for a lens that costs less than $1.
There are now 50,000 foldscopes in 135 countries. They are being put to a variety of uses, from mapping pollen in cities to detecting cervical cancer. He has cornered the market in “frugal science”, developing cheap, rudimentary scientific tools and distributing them to those, mainly in the developing world, who cannot normally afford them.
The scale of the healthcare challenges faced by developing countries may appear overwhelming but it is encouraging that a variety of innovative approaches, from multinational initiatives through to creative problem solving in the lab, are showing much promise for addressing these obstacles.