I get particularly excited when I see Global Health issues being debated in mainstream magazines and newspapers, and since the outbreak of Ebola has captured global attention, there has been no shortage of such discussions. Perhaps that is why I am blogging again. Why, the mainstream media asks, can we not curb the spread of this deadly epidemic that is ravaging a few countries in West Africa?
Sadly, however, I think there has been too much of reacting to Ebola as though Ebola was just any other global health problem: Ebola is about Poverty, Ebola is about Globalization, or Ebola is about Culture. But Ebola is Ebola, and it is unique in some important ways.
In next week’s New Yorker’s James Surowiecki laments about the lack of treatments for Ebola. His article is littered from quotes that could come from just about nearly any global health piece on the challenges in developing new pharmaceuticals for neglected tropical diseases:
“The lack of an Ebola treatment is disturbing. But, given the way drug development is funded, it’s also predictable.”
“When pharmaceutical companies are deciding where to direct their R. & D. money, they naturally assess the potential market for a drug candidate. That means that they have an incentive to target diseases that affect wealthier people (above all, people in the developed world), who can afford to pay a lot. They have an incentive to make drugs that many people will take. And they have an incentive to make drugs that people will take regularly for a long time—drugs like statins.”
“But it also leads to enormous underinvestment in certain kinds of diseases and certain categories of drugs. Diseases that mostly affect poor people in poor countries aren’t a research priority, because it’s unlikely that those markets will ever provide a decent return. So diseases like malaria and tuberculosis, which together kill two million people a year, have received less attention from pharmaceutical companies than high cholesterol.”
It is true: poor people in poor countries are not profitable so there is not enough investment in drugs that disproportionately affect people in poor countries. Showing that he is up on the current literature on what works in global health, to remedy this problem Surowiecki recommends governments put forward the resources to incentivize more investment in R&D for Ebola, ideally through some mechanism like an Advanced Market Commitment program (read more about those here):
“The key is to reward companies for creating substantial public-health benefits. And the simplest way to do this would be to offer prizes for new drugs.”
While I would agree with most of this if we were talking about most diseases that disproportionately affected people in the developing world, like tuberculosis or malaria, I don’t agree for Ebola. Why? Simply put, I think we are overestimating the “substantial” public health benefits and that they are not likely large enough to justify the relatively large fixed costs associated with developing any new medicine (which are at least a few billion a drug). In particular, he ignores the fact that there is a relatively effective treatment for Ebola already on market: well functioning health systems.
Up until the current epidemic there had only ever been about 2300 cases of Ebola and 1500 deaths in a handful of countries over nearly 40 years. Add the additional 1200 deaths from this epidemic, and conservatively estimate the cost of a new treatment at $2 billion (in 2005, this article suggests at least this much would be required for an AMC to work), we are looking at more than $750,000 per life saved, ignoring discounting and net present values (these estimates are highly uncertain, but would probably need to be be off by at least an order of magnitude to change the conclusion). Very high for developing world standards, and these are drug costs alone.
Ebola is spreading throughout West Africa not because there is no known treatment, but rather because of the lack of investment in the health facilities, health workers, and health information systems that are required to detect, contain, and deal with Ebola. It is not even clear how many deaths in this current epidemic could have been averted even if a miracle drug had been available during this epidemic: without well functioning health systems this epidemic may have spread nearly as quickly and drugs may have arrived too late to have saved that many lives. In the case of Ebola, treatment is not prevention.
I don’t want to argue that there should be no investment in research for treatment for Ebola, and I am personally happy that there has been some and that there are a few potential drugs in existence (despite the lack of investment in an AMC). It is also great that Ebola is focusing more attention on global health and on health systems in general. But IF anyone was actually willing to donate a few billion in prize money to prevent the next epidemic of Ebola, my vote would be to pour it into health systems. It has been reported that in some of the treatment centers there is not even enough money to buy gloves for health workers to protect themselves from the disease: and those are only a few pennies a pop. Alternatively, invest that money in R&D for drugs for which the public health benefits are more clear – like malaria or tuberculosis. Both are likely to have more clear public health benefits in the long run.Share on Facebook