The Global Health Center at the Institute for Public Health is hosting its fourth annual Global Health and Infectious Disease Conference with a focus on “Shrinking the Cure and Prevention Divide that Separates Populations from Life-Saving Drugs and Vaccines.” The Institute approached a select group of conference presenters to get their thoughts on the cure/prevention divide, and perhaps a preview of their talks.
These individuals participated in our interview:
Ingrid Bassett, MD, MPH
Associate Professor of Medicine, Harvard University
Sarah Brown, PhD
Assistant Professor, Department of Pediatrics and Pathology and Immunology, Washington University School of Medicine
Rear Admiral R. Timothy Ziemer
U.S. Global Malaria Coordinator, President’s Malaria Initiative, USAID
Q: How does your own work relate to the idea of “shrinking the cure and prevention divide” when it comes to global health and infectious disease?
Ingrid Bassett (IB): I am an implementation science researcher in the field of HIV and Tb. I am interested in the substantial gap between what the evidence tells us in terms of what works and what we are actually achieving in HIV treatment and prevention programs in resource-limited settings. This is an incredible time in the field of HIV—antiretroviral therapy has become more effective, less toxic and cheaper. People who are diagnosed with HIV early in the course of their disease and stick with their treatment can live near-normal lifespans compared to people their age without HIV. And in fact, people on antiretroviral therapy who have suppressed their virus to undetectable levels are very unlikely to transmit to their partners. This has created a “treatment as prevention” concept which has further energized the rationale for expanding treatment as widely as possible.
However, in sub-Saharan Africa, where about 70% of people living with HIV reside, only ~45% of people with HIV know their status. And only about 40% of people who are eligible for antiretroviral therapy are actually receiving it. My work has focused on innovative ways to improve access to HIV testing and improve linkage to HIV care following testing. I have been involved with routine HIV testing programs (that is, offering testing to anyone who presents to healthcare, regardless of chief complaint) and more recently with mobile HIV testing, where HIV screening stations are set up in community venues like taxi stands and markets.
Sarah Brown (SB): My work involves developing and strengthening clinical laboratories in resource-poor environments. Access to quality clinical laboratories is essential to shrinking the cure and prevention divide. You can’t treat something if you can’t test for it, and you can’t prevent disease if you don’t know it’s there – quality diagnostic tools are essential. For example, in the United States it is estimated that 70% of clinical decisions are based on a laboratory result. Labs in the US are accredited by government agencies and directed by pathologists or clinical laboratory scientists. In contrast, Liberia has only one pathologist for its entire population. There is little to no governmental or other laboratory standards or oversight.
Beyond lab testing for diagnosis, most of the world has no access to preventive lab testing. Screening for diabetes and high lipids is unheard of in most resource poor countries. Patients are diagnosed when they present with one of the co-morbidities of these conditions. Maternal-fetal transfer of disease is yet another area that can be positively impacted by lab testing. Congenital syphilis can be completely prevented if diagnosed (with a lab test!) and treated in time.
R. Timothy Ziemer (TZ): No child should have to die from a mosquito bite, yet malaria still kills a child every two minutes. Just a decade ago, the picture was very bleak. Malaria – largely preventable, treatable and curable – was an insidious disease of poverty and a cause of poverty, killing more than 1 million people each year on the continent, with the vast majority of deaths among young children in Africa.
President Bush created the President’s Malaria Initiative (PMI) in 2005, committing $1.2 billion for the first 5 years. Its initial overarching goal was ambitious: to cut in half the death toll of a disease that ravaged Africans, hitting children and pregnant women the hardest. And US government support over the past decade has been instrumental in assisting the most affected countries to actually reach that ambitious goal. This bold initiative was buoyed by new tools to prevent and treat the disease including new diagnostic tools and antimalarial medicines as well as insecticide-treated nets to hang over sleeping spaces. The bottom line – for the first time, the tools, the political will, and the funding were in place at sufficient levels to really have an effect.
As a result of PMI’s support, millions of people have benefited from protective measures against malaria and millions more have been diagnosed and treated for malaria. Even in the poorest of settings where malaria flourishes, in places like rural Africa, we are arming women, children, and families with tools to protect themselves from malaria and we are providing them with fast-acting medicines to cure malaria if they do become infected.
Q: What do you think are the biggest challenges that separate populations from life-saving drugs and vaccines?
IB: I think translating what we know into action in different contexts is one of our greatest challenges. For a country like South Africa, with an overwhelmed public health sector and over 6 million people infected with HIV, finding innovative ways to make testing and treatment more available, and to keep people on treatment for a long time, is critical. This has led to some creative solutions—like taking HIV treatment for stable patients out of the healthcare system altogether and allowing people to pick up medications and receive support at community venues like libraries.
SB: From my experience in the field I think three of the biggest challenges are 1) accurate diagnosis, 2) lack of infrastructure, and 3) cost. My answer to the first questions also relates to the challenge of accurate diagnosis. Lack of infrastructure remains a large problem in most countries. For example, in Haiti the distribution of vaccines is complicated by the fact that the vaccines need to be stored at cool temperatures and most local health facilities and certainly most warehouses lack continuous energy required for cooling. There’s also a lack of a distribution system, be it doctors, nurses, or community health workers, outside of major cities and this severely limits accessibility to those living in rural areas. Lastly the costs of testing, drugs, and vaccines are still beyond what many people can pay making it difficult to develop a sustainable approach to testing for diseases and providing the right drug for treatment.
TZ: Malaria and poverty are intimately connected. Since malaria is both a root cause and a consequence of poverty, its burden is greatest in the poorest countries in the tropical regions of the world. Malaria affects the health and economic growth of nations and individuals alike. Particularly in the high-burden malaria countries in Africa, where pregnant women and young children bear the greatest burden of the disease, malaria control is central to improving child survival and maternal health, eradicating extreme poverty, expanding access to education, and ending preventable death. Less malaria means fewer days missed at school and work, more productive communities, and stronger economies.
The tools to prevent and treat malaria exist and they are cost-effective. But hundreds of thousands of children die from malaria in Africa each year and, despite the huge improvements, access to nets, spraying and drugs is still way below where it needs to be. Millions of people at risk of contracting malaria still do not receive the services they need. In much of sub-Saharan Africa Malaria, malaria remains both the leading cause of missed work and school absenteeism.
Lack of physical access to health services, shortages of life-saving commodities (including malaria treatments, diagnostics, and insecticide-treated bed nets), poor training of health care workers, poorly educated communities, and cultural norms and practices are some of the major barriers that prevent affected communities from reducing the burden of malaria. We are making great progress in lifting the barriers of access to these life-saving preventive and curative tools, but much more needs to be done to reach the hardest to reach populations, particularly ethnic minorities, migrant workers, marginalized populations, and the poorest of the poor.
Q: How can we better address these issues? Do you have any examples (from your own work or others’) of when this has been successfully handled?
SB: This is a very hard question. Sometimes I think that working in global health is a very strange mix of motivating and overwhelming. The best example I have is from a project in Eritrea, where in the process of establishing a clinical lab, it was noted that the average hemoglobinA1C of hospital patients was 11.6. A team of dieticians worked with local health care workers to come up with healthy eating charts based on items available at the local markets, and physicians were educated on how to use screening lab test. A year later, the average A1C was 6.0. I’ve also seen success in improving lab quality in multiple countries by educating local physicians, installing Lab Information Systems, and enrolling labs in external quality control programs.
Something that would help is increased funding for translation and/or program building in resource poor areas. We have fantastic basic scientists uncovering mechanisms but it’s difficult to find funds to take what was discovered in one area and implement the same thing in another. There’s no novelty in that – yet there’s a tremendous need to replicate things that work. Maybe sometimes things should be done because it’s the right thing to do and not necessarily because there’s a huge academic achievement associated with it.
TZ: I’ve already mentioned some of the work PMI is doing to address these key barriers, including support for bringing health services closer to communities and filling gaps in key malaria control commodities. I’ve also talked about how we target our efforts to the most vulnerable, including children and pregnant women. Achieving scale with these core interventions also requires that we focus our efforts on the areas and populations that are most heavily affected to increase the efficiency by which we use our limited resources. Doing that requires that we build health information systems that enable us to identify those high burden areas in countries that because of climatic, ecological, economic, and behavioral factors often have highly variable malaria burden from form town to town, village to village. Therefore, increased focus must be placed on strengthening disease surveillance and monitoring systems, to ensure that all malaria cases are identified and appropriate action is taken.
Although our efforts have paid off in increasing coverage of key interventions, we still have more work to do to assure that those hardest to reach are able to benefit from these efforts. Creative approaches will be needed to reach out to some of the hard-to-reach groups such as migrant workers and ethnic minorities. We are already piloting approaches, such as in Cambodia where we are working with plantation owners to provide ITNs and diagnostic and treatment services to migrant workers. In some countries, where a large percentage of persons with fever and malaria seek care in the private sector, we are piloting approaches to improve the quality of the services provided. As we are increasingly successful in reaching stable populations, we will need to be increasingly creative in how we identify and reach out to those who have been missed.
Q: What are your recommendations for other researchers facing these issues?
IB: Learning to do rigorous implementation science is important. It’s a relatively “young” science, and I think finding mentors who can ensure that your research is locally relevant, appropriate, and carried out with attention to scientific thoroughness is absolutely critical.
SB: For me, I think it’s important to raise awareness of the global need for pathology and laboratory medicine. I recommend that other researchers try to incorporate capacity-building into their projects as much as possible. Are there local students, scientists, or medical personnel that can be involved in the project? Also, if your project needs lab testing of any kind, is there a local lab you can work with do get the testing done or is it possible to bring the capacity into a local lab?
TZ: There is an immediate need for new malaria treatments and new vector control tools to address these challenges. We also need more effective means to manage and/prevent resistance among our existing tools. Further evidence is needed to determine the effectiveness of strategies like focal spraying and insecticide rotation in managing insecticide resistance. Rotation strategies are also being tested to manage drug resistance in the Greater Mekong Subregion.
Harnessing innovation and expanding research will be key to sustain our efforts and for future success. PMI relies on our research and development partners to develop the new tools that countries need to reduce and even eliminate malaria burden. It is no secret that we must expand basic, clinical and implementation research. Basic research is essential for a better understanding of both the parasite and vectors, and for the development of more effective diagnostics and antimalarial medicines, improved and innovative vector control methods, and other tools such as vaccines. Implementation research will be fundamental to optimize impact and cost–effectiveness, and to facilitate rapid uptake of new tools.