Global health has been on my mind again recently. An article I wrote for Nature Reviews Drug Discovery (subscription required) examines efforts to find new drugs for tuberculosis.
Scanning electron micrograph of TB bacterium/ image: CDC/Dr. Ray Butler, credit: Janice Haney Carr
TB is a wily organism that finds a way to wall itself off in the body. Under the best circumstances, knocking out “the best” TB, the drug susceptible variety, requires 6 to 9 months of antibiotics. That’s a long time to stay on drugs, particularly in a developing country where the health clinic could be miles away. But if people start treatment without completing it, drug resistant disease can develop. With multi-drug resistant (MDR) or extensively drug resistant (XDR) disease, that prognosis is far more uncertain. The treatments being given in these cases don’t have much scientific validation to show that they work. In some cases of XDR TB, doctors are cutting out portions of diseased lung tissue from patients because there’s not much else that they can do.
My article mostly talks about the drug discovery challenges: how do you find a new drug for an old disease particularly when half a century ago we thought this problem was solved. But there’s another piece of this story that didn’t make it into the article: how do you then do the clinical studies to test these drugs among the people who need these drugs most?
In countries where health care systems are already taxed and where doctors and nurses may not be trained to carry out clinical trial protocols, there’s an additional wrinkle. TB treatments– somewhat uniquely– are written into health care policy in countries around the world. Almost all other diseases have recommended treatments, but the final decision belongs with the medical professionals who see the patients. What does that mean for TB clinical trials? Many more layers of red tape to set up a clinical trial. Not only do researchers have to work out trial protocols with the hospitals, they also have to get approvals from local and national authorities to modify the existing TB treatment protocols. I was amazed at the amount of coordination that’s involved.
Learn more about the search for new TB treatments at the Global Alliance for TB Drug Development.
The policy side of my reporting head has also turned to health issues over the last year or so, particularly global health. From a Western perspective, it’s easy to take for granted the scope of care and treatments that are available. But the developing world is light-years away from even hoping to have access to so many of the (not even cutting edge) medical innovations that we often take for granted.
My growing interest in global health policy and a talk by Franco Cavalli at a symposium on translational cancer research at Hunter College in January, led me to take on the issue of global cancer control planning in my article that was just published in the Journal of the National Cancer Institute (subscription required). Here are some of the stats that impressed me as I was working on the article:
- More than half of the expected 27 million cancer cases in 2030 are likely to occur in low and middle income countries.
- At least 80% of the world’s population lives in areas not covered by cancer control registries, that keep track of basic data about cancer, who gets it, what types and the outcomes. It’s incredibly difficult to figure out any sort of policy solution when policymakers don’t have a real handle on the problem.
- Most countries in Subsaharan Africa have no radiotherapy machines available to treat cancer.
Providing better cancer care in these countries is first and foremost about developing a plan, and then figuring out how to bring in the resources to support their needs. Without a clear plan, any resources provided don’t get used in the most effective way.
I learned a lot about Tanzania’s cancer control planning. Although an extremely poor country with a number of problems to solve, it’s humbling to realize that even with their challenges– not enough facilities to meet demand and a shortage of trained medical professionals– the situation there is probably better than in most neighboring countries. As another example, India seems to have more overall resources, but planning is regionalized and care is more available in urban areas than in rural ones.
It’s these moments that make me stop and realize how fortunate I am– I was born to educated, middle-class parents in a country with a functioning (albeit sometimes dysfunctional) health care system. The tricky challenge in the developing world is finding the solutions that fit the needs of individual countries– physically and culturally– and bringing in the right combination of government, NGOs and others to put those solutions into practice.
A related note: over the last few weeks, Denise Grady of the New York Times has published articles about women’s reproductive health in Tanzania (here and here) with detailed first-hand reporting.