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Wednesday, November 3, 2010

Are We Running Before We're Walking?

Researchers recently announced that they have discovered a medication that is highly efficacious in the treatment of the Ebola virus.  This is good news if you are one of the hundreds of people who are likely to get this virus in the next decade.  However, if you’re one of the 4,500 children in the developing world who will die of diarrheal disease in the next 24 hours, you may not view this as much of a triumph.

Ebola is sexy.  It passes the “bleeding out of your eyes test” so crucial for media coverage (that is, any disease that causes ocular hemorrhage tends to attract a good deal of mainstream coverage).  However, in terms of global health scourges, it doesn’t crack the top 10.

They probably won't get Ebola.
I don’t mean to be glib.  Anyone who has read the Hot Zone understands the graveness of an Ebola infection.  And Ebola’s penchant for devastation makes it a possible candidate for use in bioterrorism.  However, the drivers of death rarely make for compelling narratives, nor do they receive the funding they deserve.  The list of leading causes of death throughout the world includes many diseases that shouldn’t be fatal or shouldn’t occur in the first place.  Pneumonia (#3 worldwide, #1 in low income countries) is usually treated without hospital admission in America.  Ditto for diarrhea (#5 worldwide, #3 in low income countries).  Measles (#16)?  We average 56 cases a year in the U.S.

These diseases have at least one thing in common: there are vaccines that reduce (but do not eliminate) their incidence.  These vaccines are cheap, effective, and widely available in the developed world.  But vaccination requires more than vaccines;  an effective inoculation campaign relies on primary care infrastructure- both physical and human.  Want to give vaccines?  You probably need a clinic where patients can go.  That clinic needs doctors and nurses to administer the shots.  And electricity to keep the vaccines cold and unspoiled.  A medical records system would be helpful to keep track of who is due for their vaccines.  And, should someone get sick in spite of all of this, the clinic can serve as an early point of intervention where antibiotics or oral rehydration solution could be dispensed.

Ensuring that the health needs of the industrializing world are met requires a concerted effort to build capacity, not a scattershot approach targeted at the rarest and most shocking diseases.  Vaccines, health care workers, clinic construction, antenatal care, water and sanitation.  This is an argument I will return to time and again (and one made quite convincingly by Laurie Garrett) and you may even begin to agree with me.  But will you agree when I argue in my next post that overfunded HIV interventions are jeopardizing the very infrastructure I'm calling for?


  1. Hi Adam, hope you're keeping well!

    This is a great blog and looking forward to following it.

    I have been doing lots of work in the past couple years on incentivising R&D for neglected diseases, which also echoes your sentiments on not just paying attention to the "sexy" diseases, but focusing on where we can make the greatest impact. While the Big 3 (HIV, malaria, TB) get a lot of attention, many of the truly neglected diseases fall through the cracks. Its heartening to see that recently major funders of neglected disease R&D are certainly starting to look to areas where they can get the biggest bang for their buck, such as investing in the development and roll-out of expanded valency pneumo vaccines (13-valent by Wyeth in advanced stages now). PneumoADIP is also doing great work in this area (

    The question of whether funding for the Big 3 is too much is a tricky one, but I do think that there is a lot of low-hanging fruit that people are ignoring (like better point-of-care diagnostics), while simultaneously keeping an eye on scientifically risky, but important, investments like the HIV vaccine.

    For me, and I think others in public health, its hard to always maintain a view of the whole process, from product development to implementation, so I'm looking forward to reading your thoughts from the primary care perspective.

  2. Dear Adam, I eagerly look forward to your "HIV money ruins everything" argument. I hope we will have quite a debate in the comments section.

  3. I think I will agree with you. Especially when the HIV funds come funneled through US centered avenues. The number of Americans in target countries following PEPFAR skyrocketed. Now what happens when we need to turn the reigns over?


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