By: AARON OXLEY
The discovery of penicillin changed the world. In 1928, Alexander Fleming revolutionized the way we see microbial infections by discovering the first antibiotic, a feat that ultimately awarded him the Nobel Prize in Physiology or Medicine in 1945. Penicillin has saved more than 200 million lives since its introduction in 1942.
But almost as soon as antibiotics were developed, resistance began to develop too. Now more than 70 years on, over-prescription, unnecessary agricultural use, and complicated treatment regimens are allowing organisms to survive exposure to the drugs designed to kill them. These resistant organisms spread, with drug resistant infections claiming over 50,000 lives a year in Europe and the US alone.1 Globally, we are seeing rates of so-called “superbugs” such as methicillin resistant.
Staphylococcus aureus (MRSA) skyrocket, with increased mortality rates and costly price tags. It is not just antibiotic resistance that is an issue as viruses such as HIV or parasitic infections such as malaria are becoming drug resistant, too. This highlights a technical but important distinction: antibiotic resistance is just a part of the broader problem of antimicrobial resistance (AMR).
Nowhere is this more important than in the progress humanity has made on eliminating infectious diseases. Diseases once thought to no longer exist in the developed world, such as TB and malaria, have the potential for a devastating return.
2016 has seen unprecedented and desperately needed international attention to AMR. Earlier this year there was the ground-breaking publications of the Review on Antimicrobial Resistance,2 led by Lord O’Neill, a UK Treasury Minister and former Goldman Sachs Chief Economist. Established by former UK Prime Minister David Cameron, the AMR Review’s mandate was to analyse and propose solutions to the rise of antimicrobial resistance.
The report concludes there is an almost inconceivable human burden and economic cost facing the world. It warns of an estimated 10 million AMR deaths every year by 2050, resulting in a reduction of 2-3.5 percent of in global GDP.3 Not only could the global economy be reduced by up to $100 trillion USD over the next 35 years, but without action standard operations and medical procedures may be deemed too dangerous to conduct due to the threat of an untreatable infection.
The world’s deadliest infectious disease becomes drug resistant.
We do not need to look far into the future to understand the consequences of ignoring this issue, because it is already here in the form of tuberculosis (TB)—one of the world’s oldest diseases and also the deadliest. TB has claimed more lives throughout history and claims more lives each year than any other infectious disease,4 and it is well along the path of becoming resistant to antibiotics. TB was placed firmly at the centre of the O’Neill review;
“Tackling TB and DR-TB must be at the heart of any global action against Antimicrobial Resistance. The burden of TB is too great and the need for new treatment too urgent.”
Over the last few decades, TB has been quietly transforming into new strains of drug resistant TB (DR-TB).** DR-TB causes an astounding 500 deaths a day and cannot be cured with standard TB drugs.5 As the only airborne drug resistant infection, the AMR Review estimates that TB has the potential to cause a quarter of all AMR deaths by 2050, with an estimated 75 million people dying from the disease over the next 35 years.
The economic cost of DR-TB will be astounding, estimated at $16.7 trillion by 2050. This is equivalent to the annual economic output of the EU,7 with one person dying from the disease every 12 seconds.8 The bacterium that causes TB disease is a hardy organism that takes months of daily treatment before being eliminated from the body, even with the best drugs available. This picture gets even more dismal when looking at treating DR-TB. Treatment can take up to two years, 14,000 pills and include eight months of painful injections. The strong but sometimes ineffective drugs are toxic, so treatment has the risk of adverse effects such as deafness, blindness, and in extreme cases, psychosis. This, coupled with the length of treatment means people often have difficulty finishing the full course of antibiotics, leading to the development of further resistance.
We have arrived at this point because no new drugs have entered the standard TB treatment regimen in nearly 50 years. Getting TB treatment down to days or weeks instead of months, and removing the most toxic drugs from our regimens would dramatically arrest the creation of DR-TB.
This requires the development of new drugs which will be difficult due to a chronic lack of pharmaceutical investment into antimicrobials. There was less than 5 percent of venture capital investment in pharmaceutical R&D between 2003 and 2013 for antimicrobial development.
There are over 9 million new cases of TB each year with almost half a million of those being a form of DR-TB, these people predominantly live in lower- or lower-middle-income countries, and are often themselves the poorest people in those countries. Their ability to pay for expensive new treatments is limited, and has not provided the necessary motivation for private-sector investment in TB R&D to date.
Ultimately, there is no way we will beat TB without a new vaccine. The current TB vaccine (the BCG) is almost 100 years old and not effective against the most common forms of the disease.10 A more effective vaccine could bypass drugresistance and be as game-changing as a new drug regimen. We must pursue both approaches simultaneously.
We know what the solutions are.
The AMR Review offers ten recommendations for addressing AMR around the world, including the development of a new fund to support basic academic research into new drugs and a pooled fund to provide a commercial incentive for private sector organizations to invest in new antimicrobials. This pooled fund includes the introduction of a market entry prize for a new TB regimen and individual antibiotics.
Encouragingly, the AMR Review emphasizes how important it is to ensure global access to any future and existing products. No solution to drug development is complete without getting the drug to the people who need it, including in low- and middle-income countries. New TB tools are no exception. A number of non-profit initiatives are already devoted to the search for more effective TB treatments, such as the TB Alliance for new drugs, and Aeras who is in the process of developing a TB vaccine. The recommendations made by the AMR Review will ”supercharge” these existing efforts by providing an incentive for new funders to invest in the development of TB medicines.
Looking upstream, providing funds for organizations that provide high-quality treatment that helps prevent the emergence of drug resistance is a powerful complimentary investment. Organizations like The Global Fund to Fight AIDS, TB and Malaria, or the Stop TB Partnership’s Global Drug Facility all contribute to this vital work.
An opportunity we cannot miss If increasing drug-resistance continues on its current trajectory, we may return to an era where treating simple infections becomes practically impossible. This is, in some ways, already true for TB and the scale of the human and economic impact that TB creates, means we urgently need new tools right now.
There is already an international action plan to tackle AMR led by the WHO as well as a collaboration between the United Kingdom, the European Union, the United States and others. AMR is on the agenda of this year’s G20 in China with countries agreeing to coordinated international action. However, just as the microbes that increasingly threaten us all are global in nature, we need more than the G20’s leadership. We need a global response from all states and their governments.
On 21 September, 2016, a crucial high level meeting on AMR at the UN General Assembly will take place. This meeting provides a unique opportunity to make a step change in global levels of awareness of AMR among politicians, professionals and the public.
More than words and promises, G20 leaders and the global community must act quickly to implement the AMR Review’s recommendations. This means fully funding new mechanisms for incentivising the development of drugs, diagnostics, and vaccines needed to defeat AMR. Failure to fully fund these mechanisms is to invite a catastrophe that will strike indiscriminately in an incredibly costly yet entirely predictable way. We can, and must, prevent this.
Innovative Financing: Opportunities and Challenges for the Future of Global Health.
The goals of reducing poverty, improving maternal and child health outcomes and decreasing the incidence of infectious diseases are laudable goals. The costs of these efforts are monumental. To date most developed countries have failed to meet the 0.7 % of gross national income committed to development at the 2002 International Conference on Financing for Development. Most developing countries have also failed to meet the budgetary goal of allocating 15 % of Gross National Product to social and healthy development as agreed to in 2001. In addition, to limited resources there is significant competition within countries for development resources.
It is within this funding gap that truly innovative mechanisms of funding global health are developing. By no means are these efforts meant to replace traditional development assistance, but they are meant to complement existing programs. The goal is to not only increase funding but also to leverage existing funding to be more productive in order to have a sustainable positive effect on global health.
A number of mechanisms for innovative financing have been developed over the last several years. These include voluntary micro-contributions by individuals on services including travel and mobile phone use, taxes on services such as airline tickets, branded trademark sales that direct a proportion of sales into financing programs, buy-down debt programs and the issuing of bonds in capital markets. Many additional mechanisms are being explored including levies on foreign exchange transactions, voluntary 1 % waiver of VAT and auctioning of permits to emit greenhouse gases. These efforts have raised over two billion dollars.
Innovative financing efforts have also proved to increase value for money of current funding levels by accelerating the implementation of programs in country with greater efficiency. The Pledge Guarantee of Health (PGH) has made it possible for governments to obtain funds based on pending commitments to allow the execution of critical health programs in both a timely and more efficient fashion. This type of financing effort has assisted programs including malaria net distribution ahead of peak infection periods and contraceptive implants to avoid stock-outs.
The opportunities presented by innovative financing are endless. No longer are we constrained by health models based upon large donor to developing country donations. Technology allows us to link individuals with means- to individuals with needs. We have the opportunity to make the health and well-being of our global neighbors our personal responsibility, and to participate in assisting them directly as evidenced by internet based efforts to provide maternal care funding through individual donations.
While financing options are limitless we are still faced by many challenges. Some groups continue to be at significant risk, particularly women and girls. MDG5, the reduction of maternal deaths and achievement of universal access to reproductive health, remains unmet and underfunded. We highlight these issues in a special section of this issue because in order to meet MDG5 we must explore additional innovative financing mechanisms. Increased awareness of violence against children and forced child marriage is necessary to promote future economic development in many countries. The advancement of women itself is a study in innovative financing. Increasing employment of women improves GDP. Improved economic status of women leads to direct, local reinvestment resulting in improved education and health services and reduction in poverty.
As we enter into a new year we need to be invigorated by the efforts of all of the authors featured in this edition of GHD news and look within ourselves for innovative solutions to the challenges that face us all.
— Joanne Manrique
The challenges present in global health are well recognized. Diabetes, cardiovascular disease and cancer have taken their places in the pantheon of scourges alongside the age-old challenges of infectious diseases, maternal and child health, sanitation and clean water. Donor and recipient governments, multinational agencies, NGOs and health workers all combine their efforts to combat global health issues. Can we affect the rate of these efforts in a positive fashion?
In the field of chemistry the addition of a catalyst to a chemical reaction increases the rate of reaction. Catalysts allow reactions to occur using less energy than the corresponding uncatalyzed reaction. Catalysts are not consumed in the reaction and thus they may participate in the acceleration of multiple reactions. The discovery and use of catalysts in manufacturing has revolutionized many technologies creating a rapidly growing industry. The principles of catalysis can be applied to the human condition and thus the identification of “catalysts for global health” is critical in affecting changes in the rate of implementing global health solutions. This issue of Global Health and Diplomacy highlights individuals and advances that are helping to accelerate our global efforts to improve the health of all.
Advances in technology are important catalysts for reducing mortality and morbidity. Efforts such as the Child Survival Call to Action have accelerated the distribution of vaccines and medications to prevent childhood mortality from pneumonia and diarrhea potentially saving hundreds of thousands of lives over the next several years. Initiatives to bring oral rehydration solutions with low osmolarity zinc supplementation to rural areas offers the opportunity to increase the use of a highly effective, yet potentially low cost, treatment of diarrhea.
Catalysts for changes in global health are also individuals. Many global leaders work tirelessly to accelerate the improvement in standards of health care within their home countries. His Excellency Macky Sall, President of Senegal, reviews the remarkable reductions in neonatal and under five mortality achieved through strategic planning and effective partnership. Dr. Ernest Bai Koroma, President of Sierra Leone, outlines his commitment to the expansion of the Free Health Care Initiative that creates a roadmap for creating a sustainable healthcare network to provide for the people of Sierra Leone. Its progress in increasing access and utilization of healthcare services including obstetrical care and the identification and treatment of malnutrition is remarkable.
The activity of catalysts can be affected by other substances including those that inhibit their activity. One of the great challenges to the achievement of universal health coverage in all countries is the potentially enormous costs. Recognition of these inhibitors can lead to development of policies that both limit their impact and create solutions. An example is the use of taxes on items such as cigarettes that can both generate income for the health care system while creating a negative reinforcement for unhealthy behaviors.
Promoters are substances that increase the activity of a catalyst. In fact all of the contributors to this edition of GHD are promoters of global health. Their innovative ideas, commitment and perseverance should serve as an inspiration.
The Millennium Development Goals, established in 2000, set forth a framework to encourage development by improving social and economic conditions in the world’s poorest countries. The MDGs have led to significant progress in the improvement of health in populations across the globe. Progress towards the achievement of the MDGs, however, has been uneven with some countries unlikely to accomplish some or all of the MDGs by 2015. While reductions in incident cases of malaria and AIDS related deaths in many areas have decreased significantly we continue to face unacceptable levels of maternal and child mortality.
As 2015 approaches we look to new leaders to shape the agenda that will define the post MDG era. To be successful this plan will need to incorporate an honest appraisal of the successes and shortcomings of the MDG results and build upon this foundation. Health is a critical part of sustainable development, thus, making this discussion of the utmost importance. Achieving our goals beyond 2015 will require leaders with vision, determination and commitment.
Looking into the post 2015 era requires global health leaders to prepare for health challenges not considered by the original MDGs. Specifically, the emergence of major non-communicable diseases (NCDs) including cancer, diabetes and cardiovascular disease that threaten population health and resources. Leadership will need to integrate the fight against traditional enemies like malaria and TB with surveillance programs to hasten early detection and treatment of the major NCDs. Without this commitment we risk trading one epidemic for another.
The MDGs emphasized the need for individualized policy solutions to meet a country’s specific challenges. Visionaries in the post 2015 era will look beyond the confines of health priorities alone to include health in a broader discussion of development. Already we see what these integrated approaches may look like in Nigeria where careful analysis of the country’s needs and priorities has helped to develop an ambitious plan to save one million lives by scaling up primary health services for women and children, while utilizing the revenue from domestic resources to create a sustainable funding model.
Leaders for the post 2015 era face great challenges. Changing economics will require that more be done with less, making the need for clear goals, improved management and greater accountability for performance and results critical for success. Leaders will need to avoid becoming mired in politics to move forward an aggressive agenda that places an emphasis on human rights and equalities. Leaders must be inclusive and co-operative to ensure that all organizations maximize their efforts to improve global health.
The post 2015 era faces many challenges that have not been completely addressed by the current MDGs. In this issue of Global Health and Diplomacy we hear from the voices of leadership for the current MDGs and the post 2015 era. Their commitment and intellect will help to guide the successes of the post 2015 era.
Janus, the two headed Roman god, had the ability to look both forward and backward in time simultaneously. This image is symbolic as we embark on a new year. We traditionally take time to reflect on the events of the previous year and look forward to the challenges of the next. We must evaluate our successes and our shortcomings to ensure continued progress. Sometimes this process can be difficult. It is only through honest and open review of our past that we can achieve success in the future.
As we approach 2015 there is an increasing need to evaluate our progress in the global achievement of the Millennium Development goals. The common beliefs enshrined in the MGDs have not changed since their inception. The world in which we live in has changed significantly. Changes in the global economies have created new pressures to use our resources more effectively.
Accountability and transparency are fundamental to accelerating progress in global health. It allows for recognition of global health programs where we have fallen behind in our goals. It allows us to accept that some strategies may not produce the desired results and make modifications necessary to continue with our achievement of the MDGs. In 2010 shortfalls in our commitments to maternal and child health were recognized by the Muskoka Initiative for Maternal, Newborn and Child Health and the UN Global Strategy for Women’s and Children’s Health. In 2011, the global health community took steps to ensure that initiatives launched in 2010 led to results by creating the Commission on Information and Accountability for Women’s and Children’s Health, led by Prime Minister Stephen Harper and President Jakaye Kikwete. This Commission has assembled an accountability framework that provides an outcome based system to monitor and review actions leading to adjustment of future strategies to accelerate progress for women’s and children’s health.
The principles of accountability and transparency are not only important in maternal and child health but also in continuing the fight against infectious diseases including malaria, HIV/AIDS and TB. Review of efforts to sustain universal coverage of malaria control interventions led to the recognition of financial shortfalls. Outcome based efforts led by President Ellen Johnson Sirleaf and global health partners led to identification of new strategies to improve procurement strategies to support the fight for eradicating malaria. Honest and accountable review of our global health efforts can also lead to innovative thinking to address challenges as evidenced by the African Leaders Malaria Alliance’s (ALMA) plans to develop innovative new funding streams to support malaria control.
Ultimately accountability requires metrics by which we can measure successes and failures. The Global Burden of Disease, Injuries and Risk Factors data provides a new standard for quantifying global health problems. It also helps to identify the areas of greatest need in a given region.
This issue of GHD News also provides a special focus on efforts to address tuberculosis, particularly in Afghanistan. While these articles highlight the challenges of drug resistance and the success of earlier diagnosis techniques it also brings focus to the personal challenges faced by much of the world’s population. The personal costs of tuberculosis are not only measured in mortality and morbidity data but also in the ability to pursue our dreams and those of our children.
Global health challenges do not discriminate. They affect all of us. In this issue of GHD News some of the authors share their own personal experiences with potentially life threatening complications which face all mothers around the world. It is only though accountable review of our global efforts on health that we can refine our plans to create healthier futures for all.