There have been two recent interesting stories about helping Iraqi medical professionals. Before I begin, please see the request for donated medical textbooks at the end of this post. The first story is about an ICT non-profit in San Francisco that is helping equip (with computers) and wire up 19 teaching hospitals in Iraq. The organization, Wired International, was founded in 1997 with a mission to provide “medical and healthcare information, education and communications resources to communities in developing and post-conflict regions”. They seem to have achieved both scale and scope, since that time they have 76 information centers in 11 countries that serve 1 million year. Now they are getting involved in Iraq:

News Release, Jan 27, 2007 -
“Thanks to communication Professor Gary Selnow and his dedicated band of volunteers, Iraq’s medical schools are no longer without critical telecommunications and access to global databases. After equipping medical information centers at 19 Iraqi teaching hospitals, Selnow and WiRED, the nonprofit he founded to do this work, finalized arrangements to equip an additional 20 centers throughout the war-torn country. For the first time since Saddam Hussein cut off communications between Iraqi doctors and the rest of the world, faculty and students have the technology to consult with colleagues in other countries and tap such critical information sources as those at the World Health Organization.” (State Department press release can be found here)

The second story has to do with an almost accidental wide scale mission to supply Iraqi clinicians with up to date medical textbooks and journals. The doctor who started this never expected so much support. It is a neat story that is worth reading. DONATIONS are still needed, please pass the word (info on donations is at the end):

The Power of an Idea: Help for Iraqi Medical Professionals, Excerpts from Medscape:
Nearly 3 years ago I learned from my son, then in Iraq with the Army’s 4th Infantry Division, that the medical college in Tikrit had virtually no teaching or research library. I also learned that, for historical reasons, Iraqi medicine has been taught in English since Iraq was a British protectorate following World War I. My initial reaction was to seek a few donated copies of textbooks from distributors and publishers for them…

After publishing this first Medscape article, donations from Medscape readers began to be sent…Thus began a totally volunteer project that has no formal name, no budget, and no staff, but that has met with astounding success… The influence of the Internet is such that the AMA’s American Medical News, the Associated Press, the newsletter of the American Medical Library Association, and others have subsequently publicized the program, bringing in new interest and offers to donate.

The true heroes of this story are the American military personnel who have volunteered to receive and distribute donated publications…What has also become apparent is that there is at least equivalent heroism among the Iraqi medical professionals who struggle with limited resources to provide the best possible care to their patients. Donations now far exceed 200,000 textbooks and nearly a half million professional journals.

***Donations Still Needed: Please Help***
The need for medical publications remains largely unmet. Our contacts in the region describe the situation clearly: “This area has very competent physicians and healthcare providers who simply lack the necessary supplies and resources to perform at their true potential. They do a fantastic job with extremely limited resources and anything that can be done to help them is a true blessing. Clinics and hospital are very short on modern books and recent journals.”

Iraqi medical training and practice is modern although severely strapped for resources. Their needs are for contemporary publications, both texts and journals. The Iraqi Ministry of Health has requested that donated text editions have publication dates no earlier than 2000 or, for journals, nothing published prior to 2002. Primary care materials are very useful in community clinics. Specialty materials are extremely scarce in the hospitals and teaching institutions and will also be well received. Pharmacy, physical therapy/rehabilitation materials, dental, and veterinary publications are useful with no language barrier to understanding.

Please contact David B. Gifford, MD at dgifford at hot.rr.com for up-to-date information about how and where to send donated medical publications and medically related materials.

Other sources: Michael Yon

Novartis has asked for clarification on a set of patents related to Gleevac, a leukemia drug. Today’s New York Times describes the battle between Novartis and Indian generic drug manufacturers in an article entitled, Battle Pits Patent Rights Against Low-Cost Generic Drugs.

Most of you are probably very familiar with the ongoing debate pitting further pharmaceutical innovation against access to essential medicines. This article does not resolve this issue, but it does provide further evidence that international agreements on IP rights have emboldened ‘big pharma’. At issue here is breakthrough vs. incremental innovations of pharmaceuticals. According to the article,

It would also effectively tighten patent legislation passed by India in 2005 to limit the manufacture of generic drugs. The law was intended to bring India in line with the World Trade Organization’s agreement on intellectual property rights.

The 2005 law allows patents to be granted on new versions of older, off-patent medicines if the new version can be shown to represent a significant improvement on the original, but not in the case of “incremental innovations.”

According to Novartis the new version allows for better absorbtion into the body over previous and off patent versions of the leukemia drug. John Gilardi states “If there is no patent protection, we will not see billions of dollars being invested in the research of medicines,”. But, monetary investment aside, at what point does expanding the protections on intellectual property decrease incentives to innovate. Without in depth familiarity of the case, it seems the Indian court ruled that the new version did not represent a significant incremental innovation. The issue of patent violation was never seriously on the table.

Novartis already gave free supplies of Gleevac to 6,800 patients in India suffering from the rare form of leukemia that it was developed to combat. He [John Gilardi] said that number represented more than 90 percent of all the cases in the country.

Donations as a model does not represent a sustainable solution to the “access to essential medicine” problem. Yet, it has been and continues be trumped as a possible model for mitigating the problem. See Making Sight Affordable (Part I): Aurolab Pioneers Production of Low-Cost Technology for Cataract Surgery for a discussion of this issue for intraocular lenses.

The titles of these two articles – Thailand to break AIDS, heart drugs patents from ETNA (Thailand) and Thailand backs patent drug copies from the BBC – suggest different actions on behalf of the Thai government, but they both report on the same: Thailand has approved production of patented HIV and cardiovascular pharmaceuticals.  The drugs in question are Kaletra, an antiretroviral protease inhibitor produced by Abbott Laboratories, and Plavix, an anti-clotting agent from Sanofi-Aventis and Bristol-Myers Squibb.

From the ETNA article:

BANGKOK, Jan 30 (TNA) – The Thai Public Health Ministry confirmed Monday that it has issued compulsory licenses for the production of two drugs, one for the treatment of HIV/AIDS and another for a cardiovascular drug, paving the way for immediate production and imports of lower-cost generic versions.

… 

[Thai Public Health Minister Dr Mongkol na Songkhla] said the decision to break the patents was not taken lightly but the move was necessary to ensure that the affected Thai patients have access to cheaper generic versions of the life-saving drugs.

He added that generic production of Plavix, for instance, would reduce the cost from about 70 baht (US$2.06) a pill to less than six baht (18 cents).

This is the second time Thailand’s military-backed government has broken an international drug patent in the interest of the health needs of the country’s poor.

In November it introduced Thailand’s first compulsory licencing for Merck’s Efavirenz anti-retroviral AIDS treatment.

There were 47 “Technology Pioneers” (Full Report, PDF) named for the Davos World Economic Forum meeting last week. Selections was based on innovative organizations that were developing life-changing technologies. There are several known names on the list and one that we heard about last year is Aresa, a start-up company that is trying to commercial a biosenor technology for landmine detection. There are an estimated 100 million unexploded landmines globally. The remarkable thing about this is they are using a genetically modified version of a naturally occurring weed. More details below:

Saving Lives And Limbs With a Weed, Time December 2006
“Aresa, a Copenhagen-based biotech start-up, has genetically modified a common weed called thale-cress so that its leaves turn red when the plant comes in contact with nitrogen dioxide–a compound that naturally leaches into the soil from unexploded land mines made from plastic and held together by leaky rubber seals.”

Previous BBC story (which points out potential limitations of this technology).

This Sunday’s LA Times has a story about a so-called A vaccine development ‘renaissance’. This resurgence in vaccine development is being led by improved scientific knowledge, increased government research funding and interest among global drug companies, innovative financing schemes and purchase guarantees and finally better delivery mechanisms. Vaccines have done much to improve global health in the modern era, but it is clear the dynamics of vaccines have changed significantly. As described by Rachel Glennerster, Michael Kremer, Heidi Williams in their article Creating a Market for Vaccines (MIT Press journal -Innovations Case Discussion, PDF):

Vaccines are perhaps the paradigmatic example of a cheap, easy-to-use technology that can have tremendous health impacts even in very poor countries with weak health care infrastructures. Vaccines (relative to drug treatments) require little training or expensive equipment to implement, do not require diagnosis for use, can be taken in a few doses instead of in a longerterm regimen, and rarely have major side effects. They can be prescribed and delivered by health care workers with very limited training, and resistance rarely develops against vaccines.

However, it is clear to many that the market for vaccines has a large role to play in the dearth of progress developing vaccines for the prickly and prevasive diseases, such as HIV, malaria and tuberculosis. Glennerster, Kremer and Williams further state,

Poor countries have benefited enormously from such vaccines, but these benefits have for the most part been a fortunate byproduct. Little public- or private-sector R&D is targeted toward developing new health technologies for diseases concentrated in poor countries.

Of the 1,233 drugs licensed worldwide between 1975 and 1997, only 13 were for tropical diseases; of these 13, five came from veterinary research, two were modifications of existing medicines, and two were produced for the U.S. military—only four were developed by commercial pharmaceutical firms specifically for tropical diseases of humans.

According the to LA Times article:

Prevnar, a vaccine introduced in 2000 to treat pneumococcal pneumonia — the cause of up to a quarter of all community-acquired pneumonia cases each year — runs about $250 for a four-shot series. It became the first vaccine to clock $1 billion in annual sales, giving it so-called blockbuster status.

This potential for blockbuster sales has facilitated the return of drug giants to the market, but does this change the story for diseases centered in the Global South. The answer is unequivocally NO! but not to be disheatened, this rennaissance has ushered in mechanisms to create markets for vaccines targeting diseases found mostly in the Global South. Perhaps most famous of these initiatives is the International AIDS Vaccine Initiative. Read the recent case study on the IAVI by Seth Berkley – Ending an Epidemic: The International AIDS Vaccine Initiative Pioneers a Public-Private Partnership.

The Global Alliance for Vaccines and Immunisation (GAVI alliance) has also played a seminal role in distributing and administering vaccinations in those regions of the world with barely functioning health care systems.

At the World Economic Forum in Davos, Switzerland, last week, GAVI announced it would commit an additional $500 million over three years to strengthen healthcare systems in poor countries, a key problem in implementing vaccine programs in many locales. The organization says it has prevented 2.3 million deaths from disease since its inception, including 600,000 last year.

Finally, another major piece of the puzzle is reducing uncertainty regarding effective demand for vaccines. The most often discussed mechanism for ensuring effective demand of vaccines has been advance purchase commitments. see the article cited above for detail on this mechanism. Another issue addressed in the following recent post – Vaccine Demand Forecasting: Creating Markets and Incentives – is the issue of demand forecasting. Though the benefits of vaccines are clear, we must refrain from reductionist thought about the nature of human behavior. Much work needs to be done educating and advocating for the immunization of children and adults. Under the current circumstances it can be quite challenging to forecast demand for vaccines. As the recent issue in Northern Nigeria illustrated, sometimes cultural, religious and other factors often trump sound health practices. The history of development in the Global South has created much acrimony and distrust. As professionals, academics, and practitioners of technology, health and development must always realize the complexity of technological interventions – the case of vaccines is especially illustrative of this fact.

It appears that some movie celebrities in India are woefully behind the times. Another attempt is being made in Bollywood to bring HIV/AIDS education to the public, however getting the top actors involved has been difficult. This is unfortunate given the tremendous impact of Bollywood, the influence of which cannot be emphasized enough with an estimated 15 million viewers daily. There have been two full length films on HIV/AIDS in Bollywood, but those were unsuccessful commercial ventures. Considering the stigma surrounding the full length features it will be interesting to see what happens with this new effort:

Bollywood Plots AIDS Message Despite Stars’ Apathy. Scientific American Jan 2007.
Four top Bollywood directors are to make short films dealing with HIV/AIDS that will be shown before blockbuster releases, hoping to use their stars’ pulling power to spread awareness of the deadly virus in India…The low-budget, 12-minute movies will be shown at theatres ahead of full-length commercial Bollywood films that star well-known actors, said Mira Nair, the India-born director of “Mississippi Masala” and the sensuous hit “Kama Sutra”.

“The idea is to piggyback on blockbusters to spread AIDS awareness” Nair Said. Nair, who is making one of the 12-minute films which will be titled “Migration”, said she had been unable to get A-list Bollywood actors to feature in the films on AIDS…”Lots of stars don’t want to be associated with the virus”.

Other sources: Reuters

A fun and clever public health message with a strategically placed door nob to prompt hand washing among men. The stickers that decry poor practice link to viral videos at http://www.washyourhands.tv/

Life sized stickers of Indian child beggars were used to bring awareness of their needs to wealthy shoppers. It’s not quite clear if this was only a concept or an actual campaign.

An enjoyable blog that highlights other smart and compelling non-profit advertising and social campaigns is Houtlust

• Breakthrough in Vaccine Manufacturing via Tobacco & Other Plants-
  “A breakthrough in research will help make certain vaccines much cheaper and ideal for people in poor countries…Henry Daniell (his website had video as well) has found a way to genetically engineer plants to make large amounts of certain vaccines…Scientists first inject plants, like tobacco, lettuce or carrots, with vaccine genes. These are then planted in a greenhouse before being crushed and put into capsules to be taken by patients…ust one acre of tobacco plants, for example, could produce enough anthrax vaccine to inoculate everyone in the United States…Professor Daniell says he decided to work on cheap vaccines after witnessing the impact of disease in his native India.” LINK. As a side note, for more innnovate work on vaccines, check out the work by the CGDEV (Center for Global Development.

• Bush on Malaria and AIDS Relief (PEPFAR) -
  From last nights State of the Union 2007 – “I ask you to provide $1.2 billion over five years so we can combat malaria in 15 African countries…We must continue to fight HIV/AIDS, especially on the continent of Africa”. LINK.

• Davos (World Economic Forum) Conversation -
  There are many people blogging about Davos, NextBillion has some more references. One more for you to check out is DavosConversation.org (LINK).

• Gates Foundation and Ethics of Philanthropy -
  The decision by the Gates Foundation continues to be debated. Check out this carnival of opinions sounding off from the blogosphere in one spot. LINK to TactilePhilanthropy.

• Infrastructure in India -
  Vinod Khosla’s Marshall Plan for rural India, “One out of 10 people on this planet is a rural Indian…” LINK to Salon article.

Public-private partnerships have been all the rage, here are two recent articles on that front. The first is an opinion piece calling for more private sector involvement and the second is a demonstration of using private businesses to distribute insecticide resistant mosquito nets.

Increased innovation needed in the fight against epidemics , Jan 11, 2007

In a Jan. 1 editorial, the P-I rightly pointed to the need for partnerships to address global health challenges and meet goals to reduce disease and death. However, the editorial overlooked the integral role of the private sector in developing new solutions to fight epidemics… “The only way to win the war against malaria is to find new and even more effective ways to prevent infection and treat those who are sick. That includes the development of new drugs and diagnostics, as well as a malaria vaccine that has the potential to offer widespread protection against the disease… While the research that will fuel new tools is often found in academia and in the government sector, we need the involvement of industry — namely pharmaceutical and biotechnology companies — to turn research into life-saving products.”

Public-Private Cooperation Helps Fight Malaria, Jan 18, 2007

Dr. David McGuire is the director of USAID’s NetMark Project, which promotes the use of bed nets and helps African businesses distribute them.  He says NetMark is partnered with nearly 40 companies in eight countries (Ghana, Nigeria, Mali, Senegal, Zambia, Uganda, Ethiopia and Zimbabwe), which in turn sell more than 15 brands of ITNs…Health experts say there are many advantages to such private-public partnerships; donors are able to stretch their dollars by taking advantage of the private sector’s efficient distribution network, stimulate the local business community in high unemployment areas, and create competition among venders to keep prices low…The involvement of the private sector has also led to the creation of Africa-based factories, including several in Tanzania, that can manufacture the nets, rather than relying on imports.

You might be wondering what celebrities and babies have to do with chronic diseases in devleoping countries. An article in the New England Journal of Medicine (NEJM) last week implied that sympathy for HIV+ poor babies has an impact on funding for chronic diseases in developing countries (see excerpt 1 below) and that this should be pointed out. This linkage is weak at best, more likely not linked at all, and in either case posits a false dichotomony of supporting a single response to either chronic or infectious diseases.

We may be starting to turn the corner with respect to attention paid to chronic diseases in the “Global South” and let me state up front that I think this is overdue. Health Affairs last week published an excellent piece ["Reducing the Burden of Cardiovascular Disease (CVD) in the Developing World"] and the current issue of the New England Journal of Medicine (NEJM) has two articles on chronic diseases ["Expanding Priorities - Confronting Chronic Disease in Countries with Low Income" and "Obesity and Diabetes in the Developing World"]. I would like to bring your attention to the first NEJM piece ["Expanding Priorities"] by Dr. Anderson, professor at Johns Hopkins.

Jan 18, 2007 NEJM Excerpt 1 (from Expanding Priorities -Confronting Chronic Diseases) – “Sympathy is also a powerful driver of public opinion and funding. When a celebrity holds a baby with AIDS, the heartrending photographs generate attention, compassion, and donations. A photograph of a 40-year-old man with hypertension would be far less compelling, even if we knew he was a father, husband, and primary breadwinner.” [emphasis added].

While my current research focuses largely on chronic diseases and I do understand the frustration of the authors (infectious diseases such as HIV/AIDS get all the attention) there is something critical missing from their overall point. Anderson discusses reasons why more attention is paid to infectious diseases and in my opinion makes a mistake in trying to make comparisons to chronic diseases. In the article he seems to imply that because many more people die from chronic diseases and because the associated treatment is more cost-effective and lower cost compared to HIV/AIDS, we should shift funding and attention to things like hypertension in developing countries. To Anderson’s credit, this message may have not been his intention, after all the article is entitled “Expanding Priorities”, not “Changing Priorities”. I also have to give him credit for his willingness to enter such a potentially contentious debate (if framed as such) . However, the tone, approach, comparisons made, and failure to mention critical aspects about the implications of infectious diseases leaves the article lacking.

It is one thing to call for increased attention to the burden of chronic diseases in the global health arena; however it is entirely another thing to insinuate that there are misaligned priorities (which would be a fine if backed up by a well thought out argument). The critical piece Anderson fails to mention is the tremendous impact on the basic social, cultural, and economic fabric that HIV/AIDS is having in some regions of the world. If people are dying before they get chronic diseases, what would be more prudent – a focus on chronic diseases or a focus on acute infectious diseases (even if chronic disease treatment is lower cost)?

The article on CVD in Health Affairs lays out a much more cogent argument with a different tone that appeals to the cause the authors are trying to make, it is definitely worth reading. I am surprised this article was even published in NEJM. Perhaps I am being too harsh and mis-read the article, if someone has another perspective, I would love to hear it.

Excerpt 2 – NEJM (Expanding Priorities -Confronting Chronic Diseases) “…cardiovascular disease alone accounts for nearly 30% of all deaths worldwide and 10% of all years of healthy life lost to disease…Three infectious diseases — tuberculosis, human immunodeficiency virus (HIV) infection or the acquired immunodeficiency syndrome (AIDS), and malaria — have attracted the greatest attention from international donors, but together they are responsible for only 10% of the deaths in the world (12% in low-income countries) and 11% of the disability-adjusted life-years (13% in low-income countries). Despite the fact that a substantial burden of disease in the world’s poorer countries is caused by noncommunicable chronic diseases, most international aid agencies have focused primarily on preventing and treating infectious diseases.”

Number of Deaths in Low and Lower Middle Income Regions – NEJM Jan 18th, 2007