Deplorable lack of healthcare equity in the developing world
DRUG BUST by Alan Cassels
Inequity. It’s a damnable word, a cruel word. A word that characterizes the most distasteful, egregious thing that we humans tolerate – namely, the very inequitable way human health is distributed across our planet. One part of the world drowns in medicines and potions for the most trivial of ‘diseases’ and conditions while the other part of the world dies for the lack of the most basic of life-sustaining things: clean water, adequate food, basic medicines. Inequity in the world is at the heart of the great divide between those who will live long and productive lives and those who won’t. Inequity is irascible, callous and shameful. It is entirely human-created and its existence diminishes our humanity.
Not only does modern society seem to accept inequity, but our policies also tend to breed it. Even as we delude ourselves with lofty pronouncements and say we are working hard to reduce inequity, in reality, we mostly just tolerate it.
Last year, the world witnessed humanity’s capacity to rise to a challenge in the face of a perceived global health emergency, an outpouring that included enormous amounts of most everything that counts: human ingenuity, advanced science and medicine, media attention and public and private money – all to combat a potential global influenza pandemic. Without mentioning that much of this might have been a waste, we can say with certainty that the pandemic taught us one key lesson: there are no limitations on resources if we feel our health is being threatened. When we’re talking about our health –those of us in the rich part of the world – the sky, literally, is the limit.
The reality of life for those on the other side of the inequity divide – the world’s poorest countries – is the daily grappling with real epidemics, which leaves nothing extraneous to put towards a health risk that is merely a “potential” emergency. There, several million people die every year from diseases due to poor community hygiene and lack of clean water, in situations where dysentery, cholera and other entirely preventable water-borne diseases wreak an incredible burden of ill health throughout the developing world.
Can we really understand dire poverty in the same way as the inhabitants of poor countries who witness their children dying of diarrhoea for the lack of 25 cents worth of oral rehydration therapy? It is almost as if ‘we’ and ‘they’ lived on separate planets.
Far be it for me to proffer solutions for the most dire problems of planetary inequity, but let me suggest at least two interim suggestions for how Canada and Canadians could work to reduce that inequity: the first serious and the other more glib.
For immediate needs, we need to be creating more toilets.
Before you go thinking that’s the glib answer, consider this: the lack of access to toilets is one of the world’s most dire health emergencies. Many diseases of poverty wouldn’t survive or thrive if proper human sanitation denied them the opportunity to do so. Effective sanitation has long been recognized by physicians and other health experts around the world as the world’s most pressing health issue. Don’t believe me?
Almost three years ago, more than 11,000 readers of the prestigious British Medical Journal (whose readership consists mostly of physicians) were asked to vote for what they thought were the most important medical advancements in the last 150 years. What won the contest? Antibiotics? Anaesthesia? Vaccines? Nope, nope, nope. Access to clean water and sewage disposal – “the sanitary revolution” – was judged the world’s most important medical achievement.
In her book, The Big Necessity: The Unmentionable World of Human Waste and Why It Matters, author Rose George notes that access to a toilet is not a laughing matter. It is a matter of life and death. Nearly half the world’s population, or about 2.6 billion people, lack access to a toilet and Rose George notes that nearly 80 percent of the world’s illnesses are caused by fecal matter. Diarrhoea, the key consequence of poor sanitation, is a lethal condition that kills 2.2 million people a year in the developing world – more than AIDS, tuberculosis or malaria.
I thought that such an urgent issue would mean that Canada’s development agency CIDA, which dispenses nearly $3 billion a year in foreign aid, would be a major contributor to the world’s sanitation revolution. I was dead wrong. Canadian taxpayer-funded aid, directed towards solutions that flush, gets almost nothing. In fact, the Global Sanitation Fund, claimed as one of the best global sanitation initiatives in existence, has never seen Canada contribute a single penny. That stinks. And, perhaps most of all, it shows Canadian unwillingness to contribute to what is probably seen in development circles as a very ‘unsexy’ cause. C’mon – saving lives with low-tech, high impact solutions is very, very sexy.
You might say that, after sanitation and clean water, what the poorest of the poor need is access to proper food and medicine. The unique forms of medicine, which would actually address the neglected diseases that afflict the poor most, are almost nowhere to be seen on the pharmaceutical research and development agenda. Again, inequity raises its ugly head and the poorest are left to suffer.
Modern medical science has been missing-in-action for quite a while when it comes to creating new treatments for diseases afflicting the very poor. According to the medical humanitarian group Médecins Sans Frontières (MSF), of all new medicines developed between 1975 and 1999, only one percent was developed for tropical neglected diseases and tuberculosis.
So how do we ramp up the investment in the neglected diseases that most affect the poor?
The major impediment to directing resources towards diseases of the poor is the fact that the drug industry is largely uninterested. There’s no money in treating poor people. Some groups, such as the Institute for OneWorldHealth (www.oneworldhealth.org/) and MSF’s “Drugs for Neglected Diseases Initiative” (www.dndi.org) have recognized this reality and are on the front lines of using both public and private money to develop novel therapies for some of the most common tropical diseases.
While pharma companies understandably want a return on investments in research, the lack of any promising commercial returns for diseases of poverty seriously slows the flow of capital needed to develop and deliver those treatments. When you look at the historical development of tropical disease treatments, many were developed by the simple fact that we (we who inhabit the rich ‘developed’ world) felt threatened. The drugs currently available to prevent and treat malaria emerged out of the American and French experiences in Vietnam, where our scientists were given the resources they needed to create treatments which would keep their soldiers out of harm’s way.
The lesson here seems simple: being in foreign places may not be so good for our soldiers’ health, but it could be good for the development of treatments for infectious diseases that exist primarily in poor countries. When our armed forces are sent abroad, our governments suddenly become seriously interested in investing in researching new treatments. Am I suggesting we start more wars in poor countries? Not at all. The easier solution is to import more diseases from the developing world. As I said earlier, there are no resource limitations if we feel our health is being threatened. The only way to get governments in the developing world (where a middle country like Canada can drop a billion and a half dollars on a single flu season) to invest in treatments for neglected diseases is for us to start getting them.
I am proposing it is high time we started ‘catching’ the same diseases of the poor. Malaria in Southern Alabama? Now here comes some serious antimalarial research. Hmm, maybe that would be a positive side effect to climate change? Tuberculosis outbreak in Toronto? Watch out for the new development of novel antibiotics. Chagas disease in cottage country? Instant research money for that disease.
Last month, I wrote about the drug company Pfizer and its seeming disregard for the law. I left out the part where Pfizer has an active humanitarian side to it. It is an active partner in a number of projects to advance international efforts to create treatments for tropical diseases. Just last November, Pfizer and the “Drugs for Neglected Diseases Initiative” (DNDI) signed an agreement to create treatments for human African trypanosomiasis (HAT) (also known as sleeping sickness), visceral leishmaniasis (VL) and Chagas disease. These parasitic diseases afflict many in the developing world and Pfizer will offer the researchers access to a huge library of novel chemical entities so they can start screening for compounds that could form the basis of new treatments.
In terms of one of the world’s biggest killers, malaria, the World Malaria Report (2008) reported there were as many as 247 million cases of malaria across the globe. In light of this epidemic, the drug company GlaxoSmithKline is opening up access to an extensive dataset on 13,500 compounds, which could be potential malaria fighters. These data are on chemical entities that have been tested against the Plasmodium parasite that causes malaria and researchers will use it to help isolate those compounds most likely to work.
These are all very important developments and even as we may one day see research and development for neglected diseases becoming the highest of priorities – and the gross inequity in the health of the world’s population starts to shrink – we shouldn’t just sit here and wait for things to happen.
Let’s get cracking on exporting toilets and importing diseases. While improving access to clean water and sanitation can improve the fundamental building blocks of any healthy nation, let’s see a little more tuberculosis and malaria in North America and stimulate our research enterprises where, at the end of the day, the inequity of healthcare will shrink even further.
Just a thought.
Alan Cassels is a drug policy researcher at the University of Victoria.