A Better Rx for Global Health?

Conferees seek broader approach, more public-private collaboration

The global health crisis that has focused much of the world’s attention on AIDS and other infectious diseases cannot be solved by sticking to traditional medical and public-health approaches, several speakers at an international conference here declared.

What’s needed, they said, are innovative collaborations in which philanthropic institutions work with various other public and private organizations on a host of issues relating to international health.

“We need to bring in new partners to this mix who can talk of the importance of poverty and hunger,” said Nils Daulaire, president of the Global Health Council, in Washington, a membership coalition working to improve health worldwide. “This cannot be run just by a bunch of health technologists, doctors, and public-health practitioners. It needs to be a much broader approach.”

Other speakers echoed his remarks.

“We need more than just experts. We need to broaden these alliances,” said Paul Farmer, the founding director of Partners in Health, a Boston charity that provides health care to poor people in Haiti, Honduras, Mexico, Peru, Russia, and the United States. “Inequality is the basic problem of the 21st century,” he added. “So equity needs to be a primary concern of the philanthropic community.”

Indeed, the need to promote greater equity in health-care delivery was a continuing theme at the conference this month sponsored by the Academy for International Health Philanthropy, which drew some 120 medical and public-health experts, foundation officers, government officials, and corporate executives to the Royal College of Physicians to consider ways of pooling their human and financial resources to increase their impact on world health.

People in many parts of the developing world lag far behind those in industrialized countries in numerous health indicators, including infant and maternal mortality and deaths from infectious diseases and the gap is growing.

The 131 million children born last year have widely varying life expectancies, for example: 48 years for the bottom 20 percent but 74 years for the top 20 percent. And while life expectancies in the industrial world are still rising, Dr. Daulaire noted, those in some poorer countries continue to decline — most significantly in sub-Saharan Africa, where AIDS deaths have trimmed life expectancies in some countries by more than 10 years.

Communicable diseases like malaria and tuberculosis, as well as AIDS, account for more than half of the deaths among the poorest 20 percent of the world’s population but just 8 percent of deaths among the richest 20 percent. Yet the bulk of the estimated $2-trillion spent each year on health care worldwide is directed at caring for the affluent, not the poor.” We’re looking at an extraordinarily polarized world,” said Dr. Daulaire.

Role for Donors

The challenge for philanthropy, conference participants suggested, is to find ways to close that gap, whether by financing research on vaccines, drugs, and diagnostic tests; making existing products more widely available; upgrading the capabilities of public-health systems in developing countries; or promoting public education and clinical work.

Philanthropists also must play a role in combating chronic diseases of the developed world, some speakers suggested — in part because some of those problems are diffusing more widely as well.

Jeffrey P. Koplan, who directs the Centers for Disease Control and Prevention, in Atlanta, noted that health problems of the affluent — particularly obesity and chronic diseases related to fatty diets, smoking, drinking, and sedentary habits — have been growing in industrialized countries. As wealthy populations adopt similar patterns of consumption and behavior, he predicted, demand for sophisticated medical technologies to diagnose and treat those diseases of affluence will rise sharply, thereby diverting resources from immunization programs and other primary health care focused on the poor.

This means that public-health measures to prevent chronic diseases — by increasing taxes on cigarettes, for example — can be helpful, not least because they can free up resources for treating diseases of the poor, Dr. Koplan said.

Whether in affluent nations or poor ones, however, “philanthropists are perfectly positioned to exert those strategic, small influences” that can have major effects in complex, chaotic systems, Dr. Daulaire observed. In particular, he said, they can offer the kind of broad, long-term vision that government agencies and nonprofit groups are seldom able to provide, caught up as they are in short-term election cycles and preoccupied with doing the work at hand. Grant makers also have much greater freedom to experiment than do other institutions, and to try novel ideas that may fail, he said. And they are well positioned to bring together people from different camps to work on common problems.

Foundations have a long history of involvement in health causes, of course, whether promoting public-health measures, combating disease, or establishing research institutes, for example. But recently there has been a surge of interest in global health issues among several prominent new foundations, including the Bill & Melinda Gates Foundation and the United Nations Foundation.

“The growth of global health philanthropy in the last five years is nothing short of astonishing,” said Timothy G. Evans, director of health equity at the Rockefeller Foundation. From 1998 to 1999, for example, giving by U.S. foundations for international health and population programs grew by more than 50 percent, from $158-million to $240-million, according to the Foundation Center.

Because health is inextricably linked to issues of poverty, population growth, political instability, international travel, and even national security, no single foundation has the resources to make much of an impact. Grant makers must therefore find pieces of the mosaic that they can reasonably hope to accomplish, and that complement the efforts of others.

“Global problems require global solutions,” said George Poste, chief executive of Health Technology Networks, a health-care consulting group in Scottsdale, Ariz. “Complex multifunctional problems will not be solved by simple unitary approaches.”

Many speakers described how their organizations are teaming up with other institutions to tackle a major problem, such as developing an AIDS vaccine or developing new treatments for drug-resistant tuberculosis.

The Wellcome Trust, in London, has formed numerous partnerships with individual researchers and their institutions, government agencies, and private industry, and with other nonprofit groups and grant makers. Such collaborations can often result in unexpected benefits.

For example, Wellcome joined with the Juvenile Diabetes Research Foundation to sponsor research on the genetics of that disease — and in the process was prompted to reconsider some of its views. The diabetes foundation has nonscientists on its board of directors, said Richard Lane, who directs the trust’s international program, whereas Wellcome has always been deeply suspicious of having nonscientists involved in making decisions about scientific research.

“But having seen the process and the involvement of lay members,” he added, “we’ve had to reevaluate our prejudices about the value of lay people,” who can provide a passion and a perspective that scientists may lack. The trust is now thinking about how it might incorporate such people into its own decision-making processes.

Foundations can also seek to ensure that basic research does not become entirely proprietary. Wellcome, for instance, has spent around $500-million on the massive international collaboration to map the human genome, an achievement expected to have significant commercial and medical applications. The trust’s participation in the project, which some partners had argued could be done more cheaply by commercial laboratories, helped ensure that the sequencing information remained in the public domain, freely available to scientists everywhere. The alternative — private ownership of the entire detailed blueprint for human DNA — could have severely constrained research in many areas, particularly by scientists from poor countries.

“This is such fundamentally important information that it was more of a human-rights issue than simply one of commercial advantage,” Dr. Lane said.

Who Deserves Help?

Also a question of human rights, Dr. Farmer suggested, is the treatment of destitute people already afflicted with disease. He takes issue with analysts who contend that efforts should focus on preventing future infections rather than treating existing ones, which they view as far less cost-effective.

By working with pharmaceutical companies, Dr. Farmer noted, along with the Open Society Institute, the World Health Organization, and several other organizations, Partners in Health was able to obtain tuberculosis drugs at reduced prices, cutting the cost of treatment considerably. The medicine is being used to combat multidrug-resistant tuberculosis in Russia’s prison population, where the incidence is alarmingly high.

Dr. Evans of the Rockefeller Foundation observed that “as a global society, we’re very successful in producing health and getting to high levels of standards in health, but we’re not very good at distribution.”

While trying to facilitate the wider use of existing therapies, Rockefeller is also seeking to stimulate new products in areas that the market has neglected, Dr. Evans said. The fund has also been supporting research to develop male contraceptives, as well as collaborative efforts to develop an AIDS vaccine and new drugs to combat tuberculosis.

Particularly in the field of health research, for-profit companies can sometimes be very suitable partners, several speakers observed. The Rockefeller Foundation, for example, has created what it calls a Program Venture Experiment to invest in young companies pursuing technologies that dovetail with the foundation’s program interests. So far, it has invested in a small biotechnology company working on microbicides to help protect women from sexually transmitted diseases, as well as in another company that is working on a novel approach to an AIDS vaccine.

‘Try Something Different’

Other foundations also seek to bring together researchers who would otherwise not tend to cross paths, in hopes of stimulating some innovative thinking.

The Steven and Michele Kirsch Foundation, in San Jose, Calif., uses that approach where conventional research efforts appear to have stalled. One example is work on glaucoma that the fund has supported jointly with the Glaucoma Research Foundation, which brought in neuroscientists to collaborate on studying eye diseases. The majority of people on the committee that selected the researchers came from outside the glaucoma field.

“If you want different results, you have to try something different” rather than simply repeating something that didn’t work, said Steve Kirsch, a Silicon Valley entrepreneur who founded the philanthropy. His fund is contemplating or supporting similarly crosscutting research in areas as varied as aging, gene therapy, and psoriasis.

But pervading the conference sessions, if only as a backdrop, was an awareness of the global AIDS pandemic, which has infected 25 million people in sub-Saharan Africa. An additional $10-billion a year is needed to combat AIDS and other infectious diseases in developing countries, says United Nations Secretary General Kofi Annan, who recently proposed the creation of a global fund for that purpose.

Despite what Dr. Evans called “an unaffordable free fall in life expectancy” in many African countries, he said the world has been far too slow to respond to the crisis there. “If there was anything like this level of epidemic in Britain, Canada, or the United States, we would have $100-billion a year,” Dr. Evans observed. “This is proof that we do not value lives equally as a global society.”