By Roy M. Poses, MD, Clinical Associate Professor of Medicine at Brown University, and President of FIRM, the Foundation for Integrity and Responsibility in Medicine, a not-for-profit organization (NGO) designed to raise awareness of external threats to the core values in health care as the first step toward addressing them. Originally published at Health Care Renewal.
The Ebola virus epidemic in West Africa continues to grow, and now appears to be the worst known epidemic of that disease to date. In the US and Western Europe, press reports are now raising concerns that the disease could spread there. For example, CNN, in an article entitled “Ebola Fears Hits Close to Home,” was a section headed “Could Ebola spread to the US?” An ABC article was entitled, “How the US Government Could Evacuate Americans with Ebola.”
Reasons for fear of spread are the increased mobility of people made possible by air travel, and the lack of specificity of early symptoms of Ebola, so infectious people may not realize the dangers their travel might pose. A US citizen with Ebola was on his way back to the US via several connections, and made it as far as Lagos, Nigeria before becoming too ill to travel further (per CNN). Making the fears worse are the high fatality rate of Ebola, the current epidemic included. According to Vox, the current outbreak is the Zaire subtype of the virus, with an expected mortality rate of 68%. Finally, there is no known effective treatment or vaccine for the Ebola virus.
Economics, not Science the Reason for Lack of Medical Options for Ebola
The reason there are no vaccines or treatments available for Ebola does not appear to be the scientific difficulty involved in developing them. Vox also published a discussion for the economic genesis of the problem:
Researchers have devoted lots of time to building a vaccine that could stop the disease altogether — and according to Daniel Bausch, a Tulane professor who researches Ebola and other infectious diseases, they’re making really significant progress.
Bausch says that the obstacle to developing an Ebola vaccine isn’t the science; researchers have actually made really great strides in figuring out how to fight back against Ebola and the Marburg virus, a similar disease.
‘We now have a couple of different vaccine platforms that have shown to be protective with non-human primates,’ says Bausch, who has received awards for his work containing disease outbreaks in Uganda. He is currently stationed in Lima, Peru, as the director of the emerging infections department of Naval Medical Research Unit 6.
The problem, instead, is the economics of drug development. Pharmaceutical companies have little incentive to pour research and development dollars into curing a disease that surfaces sporadically in low-income, African countries. They aren’t likely to see a large pay-off at the end — and could stand to lose money.
Prof Bausch elaborated,
These outbreaks affect the poorest communities on the planet. Although they do create incredible upheaval, they are relatively rare events. So if you look at the interest of pharmaceutical companies, there is not huge enthusiasm to take an Ebola drug through phase one, two, and three of a trial and make an Ebola vaccine that maybe a few tens of thousands or hundreds of thousands of people will use.
Of course, that assumes that this outbreak, like previous ones, will remain relatively confined, at least to Africa.
The 10/90 Gap
So the implication is that had things been otherwise, those in developed countries now worried that Ebola could spread their way could have been reassured by the availability of a vaccine, or other treatment.
The irony, if that is the right word, is that we do not have an effective treatment or vaccine for a viral disease that is relatively easily spread, and could likely rapidly kill nearly 70% of those infected. Yet in the last months, we have been arguing about how the use of an extremely expensive treatment for another viral disease that is difficult to spread, and may kill a few percent of its victims over up to 20 or 30 years after infection.
I am referring, of course, to Sovaldi, the recently announced $1000 pill for hepatitis C. Hepatitis C does affect a lot of people, including relatively affluent people in developed countries. As we noted previously, though, the majority of people infected with hepatitis C will never have serious medical repercussion from it. Small proportions of patients will eventually develop severe liver disease, including cirrhosis, liver failure, and liver cancer, and may die from the disease. (See the report by the Center for Evidence Based Policy). Yet the treatment is being promoted for all patients with hepatitis C, most of whom could not benefit from treatment. Furthermore, the evidence that treatment will actually prevent bad clinical outcomes, cirrhosis, liver failure, liver cancer, and premature death, is weak (look here). Yet considerable money was devoted to developing multiple hepatitis C treatments, with the expectation that huge amounts of money could be made from selling them.
This is an example of the 10/90 gap.
A long time ago, in 1998, I was invited to Forum 2 of an organization called the Global Forum for Health Research The GFHR was an organization dedicated to overcoming the “10/90 gap”:
Less than 10% of the worldwide expenditure on health research and development is devoted to the major health problems of 90% of the population
Yet the 10/90 gap is probably getting worse. In the US, our health care has now been heavily influenced by advocates of neoliberalism, or economism. Health care is now largely run by generic managers trained in business schools, with no specific training or expertise in health care, and doubtful loyalty to its values. Current business school dogma emphasizes the primacy of economic efficiency over all other goals (look here), to maximize “shareholder value,” which usually practically means maximizing short term revenue, to the immediate advantage of shareholders sometimes, but nearly always to the great and immediate financial advantage of paid managers and executives. The emphasis on short term revenue uber alles helps explain how we have multiple expensive hepatitis C drugs, and no Ebola drugs or vaccines.
The real irony is now that some very well paid managers may be worrying about the possibility of contracting Ebola whose transmission was facilitated by our increasingly global economy, globalized in part due to the advocacy of those advocating neoliberalism and economism.
Unfortunately, the fortunes of the Global Forum for Health Research seem to have faded. It went into sudden decline in 2010, and was subsumed into COHRED, the Council on Health Research for Development. The last Global Forum meeting was in 2012, although there seem to be plans for another next year. Meanwhile, multiple international organizations. including Medicins Sans Frontieres, established a Drugs for Neglected Diseases initiative, although its progress seems to be slow (see Pedrique B, Strub-Wourgaft N, Some C et al. The drug and vaccine landscape for neglected diseases (2000-11): a systematic assessment. Lancet Glob Health 2013; 1: e371. Link here.).
In my humble opinion, as long as much of the health care system is run so as to put short-term revenue ahead of all else, a manifestation of financialization encouraged by the generic managers who run so much of health, partly in their own self-interest, and by business schools promoting the shareholder value theory, we will not make much progress on the 10/90 gap. Ironically, the realization that even rich generic managers may no longer be protected from some of the deadliest diseases that used to only afflict the poorest people in the world may have an effect on this problem.
As I have said before, true health care reform would put in place leadership that understands the health care context, upholds health care professionals’ values, and puts patients’ and the public’s health ahead of extraneous, particularly short-term financial concerns. We need health care governance that holds health care leaders accountable, and ensures their transparency, integrity and honesty.
But this sort of reform would challenge the interests of managers who are getting very rich off the current system. So I am afraid the US may end up going far down this final common pathway before enough people manifest enough strength to make real changes.