Our final thoughts...

As we reach the end of the course, we have developed an understanding of many different biotechnologies and their applications to modern medicine. It is often difficult, however, to recognize the fact that many such resources do not necessarily have counterparts in the developing world. One clear example is the lack of biopharmaceuticals and drugs that are the mainstay of healthcare in many Western nations. It is difficult to fathom the problems we would face if the drugs and vaccines we take for granted were suddenly out of reach, but for many people, this is the harsh reality. This disparity even extends to substitutive medicine through cervical cancer screenings, prosthetics, and treatment for end stage renal disease. Finally, a recent innovation in health, medical tourism, further augments the gap in availability of resources not only between nations, but also within nations.

Despite the vast need for drugs and vaccines, there are many barriers to introducing new pharmaceuticals into developing nations. The obstacles range from buying the drugs, to funding basic research, to ensuring that drugs developed in the West work with the genetic make-up of people in developing nations. The wide variety of problems involved with taking pharmaceuticals to the developing world makes it seem like no solution can address all of the associated complications, but great strides are being made to help people who need such resources most.

There exist many individuals and organizations prepared to exert their efforts to help reduce some of the global healthcare crises: whether it is Bill Gates and GAVI, universities and UAEM, or the United Kingdom, individuals are beginning to take on the overwhelming issues facing third world nations. Much of that effort includes funding the great costs that healthcare workers face when implementing important, yet specific, treatment and prevention programs; however, these organizations also help provide a broader infrastructure that will be crucial in the coming decades when the fruits of future discoveries need to be provided quickly and efficiently.

One specific example of a funding/infrastructure initiative is the United Kingdom’s promise to purchase 300 million doses of any future malaria vaccine. Additionally, a comment we received from blogger Jessica Pickett gave a little background on another concept of “pull mechanisms,” which have been introduced in order to provide research incentives for pharmaceutical companies. These companies would otherwise not focus on drugs for such underserved populations because they tend to be less profitable than drugs targeted for wealthier populations; universities and other private investors like Bill Gates, on the other hand, can stand up to those companies and provide incentives to aid deserving nations.

Even with the increased funding, the many contributors have choices to make in terms of what to fund. There are essentially two schools of thought on alleviating epidemic and disease in the developing world: prevention and treatment. The United States and other groups continue to struggle to find the perfect balance between both options so that the money they provide can go a further distance. Obviously, these individuals want to do all that is possible to treat and provide relief for those currently afflicted; but at the same time, the costs to treat many of these diseases will skyrocket if preventative measures are not employed. Increased funding also seems to create a problem that is not so obvious: a few nations, like Sierra Leone, won’t allow certain pharmaceuticals into their borders. In this case, allowing opiates related to palliative into the nation will create the increased risk of addiction epidemics and some government officials are not ready to take on the related problems.

Even with the help of such external forces, developing countries are still behind in acquiring the biotechnological developments that save and improve the lives of millions of residents in the developed world. This is mainly because developing countries simply do not have the money or the resources to invest in the devices, pharmaceuticals and manpower that come with new procedures. Some developing countries are, slowly but surely, getting some of the technology that by now seems old to us, such as dialysis for end stage renal disease. But in other places, where waiting is simply not an option for sick or injured residents, people have come up with ingenious ways to use locally available materials to create devices and procedures that are sometimes just as successful as their First World equivalents, especially related to prosthetics and cervical cancer screenings.

Of the developments this blog discusses, the new cervical cancer screening procedure is by far one of the most exciting. Not only is it cheap and effective, and thus perfect for developing countries with little money to spend on fancy machines and medicines, but also it is preventative, which saves the countries more money in the long run; and more importantly, it saves millions of women from life-threatening cervical cancer. This is one of the first steps in the right direction for biotechnology as it makes its way into the developing world, and other scientists and doctors should follow the steps of Dr. Blumenthal in coming up with new and inexpensive ways to treat diseases, or better yet, catch them before they take off.

Surprisingly, the emerging practice of medical tourism puts some of the developing world onto nearly equal footing as the developed . Primarily, there is much ambiguity in the term “medical tourism” because the phrase actually encompasses two very separate ideas. The older concept refers to the practice of Western trained doctors traveling to developing nations in order to serve overlooked populations; the other definition is quite the reverse, as Western patients travel to the developing world for significantly more affordable medical care. Each phenomenon presents its own set of problems and intricacies, but the developing world is greatly impacted by both.

The former trend, while seemingly altruistic, actually disrupts the normal flow of a developing community because the visiting doctors often know very little about the locality’s culture, history, practices, and even language. Antibiotic resistance, allergic reactions, and disjointed care are all hallmarks of medical care provided by traveling foreign doctors; the most common response by frustrated native medical professionals questioning the intentions behind such tourism is, “Who exactly is it that are you trying to help?”

Medical tourism in the other and more popular sense, however, is picking up momentum as doctors in the developing world run to embrace it; the hotel quality five-star accommodations of a lot of medical centers in countries like India and Thailand are widely touted, along with the professionalism of the largely Western-trained medical staffs and the tourism sightseeing perks thrown into the more affordable deal. This situation is ideal for many of the uninsured and chronically ill patients that the United State’s health care system has left behind, and even employers using private insurers hope to save many dollars by sending employees abroad for the routine and non-elective procedures that are substantially cheaper elsewhere.

On the other hand, little is said about the behind-the-scenes chaos that the tourist destinations experience as a consequence of Western enthusiasts. Countries like India that already spend very little money in the public health sector now channel government funding towards attracting lucrative foreign patients; poor Indians then find it even more difficult to access and afford their critical health needs.

Finally, despite all of the media noise, medical tourism is not exactly popular in the United States – yet. Only about 150,000 Americans go abroad for medical attention, and for those wanting to increase the practice, there are many drawbacks. There is little legislation regulating medical care in other nations (which is one of the reasons that care is cheaper abroad in the first place), so questions regarding post-trip complications, relapses, and botched care have to find their place in the list of priorities before the practice will become very widespread. Even then, there may be strong resistance from the overlooked poor public of destination nations.

Biotechnology is thus responsible for the great strides that have been made in improving health in developed nations. With the efforts and energies of many international groups and with great determination from the developing world itself, the past decade has seen the realization of analogous end points in third world nations, albeit utilizing different approaches. As scientific advances are introduced into the developing world, and as the developing world even confers services to the international community, nations hopefully will be able to retain their cultural identities; only then can the nations be deemed truly healthy.

"Nearly every country in the world has a Coke or Pepsi bottling operation."

Procedure May Save Women In Third World From Cancer
By DONALD G. MCNEIL JR.
Published: March 25, 2003
The New York Times

     Sometimes biotechnology does not involve tons of expensive equipment or radical, involved procedures. Sometimes all it takes is ingenuity in putting readily available materials to work, as I wrote about in my post about O.H.I. (11/11/07). This article, published in the New York Times on March 25, 2003, highlights another case that showcases the ability to provide extremely inexpensive treatments for huge problems plaguing developing countries.

     Cervical cancer affects 470,000 new women every year in poor countries such as Africa, South America, and Asia. 225,000 of these women die from it every year. It used to be the leading cancer killing American women, but with the development of the Pap smear, it has been demoted to the seventh cancer killer. Unfortunately, once again, this life-saving technology available to people in developed countries is simply not available to residents of the Third World due to the cost and necessary technology.

     Thankfully, this disparity will not cost residents of developing countries much longer. Doctors from Johns Hopkins School of Medicine, led by Dr. Paul D. Blumenthal, worked with a prominent hospital in Thailand to conduct a 6,000-women study of a new procedure to detect and eliminate possible precancerous lesions on the cervix. The cervix is washed with 5% acetic acid - just common store-bought vinegar - which turns any potentially precancerous lesions (which may take 10 years or more to actually develop into cancer) white, and then looked at with a flashlight, or even the light from a bright window. Any white areas spotted are frozen with liquid carbon dioxide, which “kills cervical cancer virtually at birth.” In the study, 707 women were found to have visible white spots. Of “those who received cryogenic treatment on the spot and who returned for a one-year follow-up visit, 94 percent had no lesions a year later. None had a complication requiring hospitalization, 98 percent found the pain only mild or moderate, and more than 95 percent said they were satisfied with the procedure.”

     This procedure is remarkable and perfect for implementation in Third-World countries because it requires only one visit for both detection and treatment (which is ideal for poor residents living in rural areas), and requires only inexpensive materials. The technique was fine-tuned to suit the needs and the resources of developing countries specifically. As the article states “He [Dr. Blumenthal] even adapted it to use carbon dioxide as a freezing agent instead of the nitrous oxide used in the West. Carbon dioxide is much cheaper, gets almost as cold, and is readily available from any soda bottling plant, he said. Nearly every country in the world has a Coke or Pepsi bottling operation.” And most importantly, it is effective. Although the HPV vaccine has become available in the United States, it will take years before a cost-effective version reaches developing countries. This study proves that good biotechnology does not always produce the most advanced treatment, but the most applicable and available treatment for the target population, and that even the most simple procedures conducted with simple materials can save thousands of lives.

“The state of the art is not compatible with the state of our purse.”

The Management of End-Stage Renal Disease in India
By MUTHU KRISHNA MANI
Published: 1998
Artificial Organs Volume 22, Issue 3

     This article, written by a doctor working in an Indian hospital, discusses the economic impact of treating renal disease in a developing country.
There are currently 3 treatment options for patients suffering from end stage renal disease (ESRD) in India:
-- renal transplantation (which encompasses both live and cadaveric donor programs)
-- maintenance hemodialysis
-- continuous ambulatory peritoneal dialysis (CAPD)
     All of these treatments are routinely performed in the United States, and in other developed countries. However, the median American income in 1997 was $42,294, while the article states that the per capita income in India in 1995-96 was 9,321 Rupees per year, which is approximately $260. As the author chillingly concludes, “A renal transplant would therefore take more that 20 years’ earnings of the average Indian, and only a miniscule minority can afford to pay for it.” (The average cost of a renal transplant is 200,000 Rupees.) Dialysis, both hemodialysis and CAPD, is even more expensive, much more expensive, than this, and is usually only employed during the preparation period before a transplant is performed, rather than used for long-term treatment.
     Most of the population relies on health care that the government provides. But renal treatments are not provided for by the government, and must come out of pocket. The huge cost of renal transplantation may lead some to believe that not many are performed in India, but this is not the case. Many patients in need of a renal transplant take out loans, sell some of their possessions, or ask for help from their employers or charity organizations. Some patients also ask family members to pitch in or loan them money, but because the average annual income is so low, these loans hardly ever get repaid, and the family ends up poorer than before. Dialysis is even more out of reach, with CAPD being affordable exclusively to the very rich.
     In contrast, in the United States, renal treatment is paid for by the government, regardless of need. People have the option of either doing dialysis in the comfort of their own homes, or in a hospital setting. It is sickening to think that people in India and other developing countries are barely able to get the care they need to treat their end stage renal disease, while people in America are bringing their pets to the vet to have them undergo dialysis for $5000 a week. If only this money and these devices could be used to help the people of the developing world…
     Thus, the sad conclusion we must make is that while the biotechnology and the doctors are there, the resources, supplies, and funds are just not available to these developing countries to implement these simple and lifesaving procedures that are taken for granted in developed countries.

"Although 'pull' is relatively new to public health, it has a good track record"

Push and Pull
By JAMES SUROWIECKI
Published: December 20, 2004
The New Yorker

This article which appears in the New Yorker, introduces an interesting perspective about introducing vaccines and drugs to developing nations. Many developing nations simply lack the funds needed to buy drugs and vaccines for their people. The average amount of money spent on healthcare in some developing nations is only a few dollars where as in the US it is upwards of $5000 per capita. This huge discrepancy creates another similar problem. New drugs companies take massive risks when it comes to developing new drugs. Investments for such drugs can near a billion dollars and drug producers will target their drugs to the populations that will be most willing to pay high prices. Therefore, there has been a dearth in research and development for diseases afflicting developing nations. Companies realize that their investment, if directed towards solutions for developing nations, may not yield an acceptable return.

The author of this article introduces the concept of incentive and how the UK has promised to buy three hundred million doses of malaria vaccine once proven safe and effective. There are two ways that the governments of western nations entice companies to devote R&D to certain causes. The first method is called “push.” These push mechanisms are how much research has been directed. The government gives direct funding to labs and organizations that are committed to a certain cause. This is quite common and it is how the NIH does most of its funding now. The other approach to promoting research is through “pull” mechanisms. This is the strategy that the UK employed in its blanket claim. Pull mechanisms put the role of competition into the field of the drug companies. This approach seems highly efficient and more beneficial in the long run. It removes government funding of “failed attempts” as is common with push mechanisms.

It seems that world governments and private organizations such as the Bill and Melinda Gates Foundations current tend towards push mechanisms. And even though their contributions to the world of research and the movement to find cures are indispensible, their funding could be better spent by using them as “a carrot on the end of a stick.” By motivating companies to develop vaccines for malaria and other diseases that afflict the developing world, the governments and private organizations are in essence creating competition that will in the end aid the developing nations. This type of funding also removes the favoritism that arises with push mechanisms as politicians fund labs instead of labs directing research.

I think that it is heartening to see governments such as that of the UK taking a step in the right direction to bring funding to where it is most needed and in the manner that is most efficient.

Pain that can't be killed

Drugs Banned, Many of World’s Poor Suffer in Pain
 By DONALD G. McNEIL Jr.
Published: September 10, 2007
New York Times

This article, which appeared in the New York Times, chronicles the struggle that patients in Sierra Leone suffer from the lack of drugs. But the drugs that these patients don’t have access to are cheap and easy to produce. These drugs are morphine and other opiate derivatives. Patients in Sierra Leone and other African countries who are suffering through painful diseases do not have access many forms of palliative care. These patients usually don’t have access to the medical care that could have prevented their disease’s progression to such a stage. These early interventions tend to be expensive and most people cannot afford them, or even if they could, there is no medical facility nearby that could administer the treatment.

The lack of morphine leaves patients who are diagnosed with cancer, AIDS, and nerve damage with constant and intense pain. There is even a company in India that is producing oral morphine for only 1.7 cents a pill. So the simple question is: Why isn’t morphine being given to these patients? That is when politics meets healthcare.

It is a well known fact that opiates are highly addictive. However under proper medical supervision, these medications can be highly effective and not have intense adverse effects. This is why the government of Sierra Leone and some other African nations do not allow the importation or domestic growth of opiates. They believe that because there is a lack of widespread medical care and that because opiates could begin a huge addiction epidemic, no morphine should be administered.

Even though the outcome may seem a bit extreme, the logic of not bringing in opiates seems somewhat rational. Furthermore, the governments of these nations have relatively limited funds which tend to be directed to treatments for more immediate diseases such as diarrhea, pneumonia, tuberculosis and malaria. Yet there should be a better solution that letting millions suffer in pain. In the west, palliative care is almost a given birthright. People expect to not suffer disease in pain, and when they have to suffer it is only for short time. People in these nations never have had access to these medications, so the assumption that morphine will turn into an epidemic is just that, an assumption.

The words of the founder of a hospice in Sierra Leone resounded particularly strongly, “How can they say there is no demand when they don’t allow it?” he asked. “How can they be so sure that it will get out of control when they haven’t even tried it?”

"mere statements of principle and words on paper are not enough. It is time for universities to act on their promises"

Research Universities Must Act
By ETHAN GUILLEN
Published: October 3, 2007
The Boston Globe

As a student at an Ivy League University (Brown), I find this article especially interesting as it discusses the research university’s role in providing assistance to the developing world. Recently, led by its new president (Drew Faust), Harvard and other universities have joined together to state that they will provide whatever assistance they can to the developing world and will help ensure that any medicine that comes from university-sponsored research will go to aid individuals who need them. This is part of the larger effort of the Universities Allied for Essential Medicines (UAEM), a group dedicated to making university-produced cures available to the developing world.

I think it is admirable that the UAEM has criticized Abbot Industries for withdrawing helpful medications (essential for the survival of many Thai lives) in response to the Thai government allowing generic versions of drugs to be produced and sold to its citizens (generic drugs would have made treatment even more affordable for the Thai people). Additionally, the group is putting pressure on the University of Wisconsin-UW (the developer of Zemplar, a kidney medication withdrawn by Abbot from the Thai market) for failing to chastise Abbot when they withdrew the UW-developed drug.

It is important for researchers to ensure that their research ends up benefitting those individuals who need it most. Many of these individuals are found in developing nations. One thing that UAEM has done was the “Philadelphia Consensus Statement,” which not only implores that the products of university research become available to the developing world, but also says that generic pharmaceutical companies should be able to provide generic versions of life-saving drugs, even if only the developing world. This would help reduce the enormous costs of providing healthcare in some of the poorest nations. This would then allow for an improved quality of life in those countries as they would have access to life-saving drugs in higher quantities.

I think it is amazing that these universities are committed to helping these developing nations, even if it does cost them some points with wealthy pharmaceutical companies. Because of its persistent efforts, the UAEM is gaining power, and if they can put some muscle behind their statements and remain committed to helping the developing world, they will manage to make a great difference in the developing world. The key to improving healthcare in these countries often comes in providing cutting-edge medicines at a low cost. Universities are often doing much of the research that eventually results in a functional drug. If they can stipulate that some of the drug must be made available to individuals in developing nations, it will do a lot of good. It is important for the UAEM to remember that pharmaceutical companies require university-led research, and, with that knowledge, may be able to exert sufficient leverage to help those in needy countries.

It is heartening to recognize that many universities are helping lead the way in developing low-cost drugs that can be given to other nations’ sick. This sort of commitment to fellow man and his (or her) health is admirable and has been seen repeatedly in my entries. Whether it is the United States, Bill Gates, or a group of universities, it is wonderful to know that some people care, and are actively looking at mankind’s problems with a global perspective. I think that UAEM is especially important because of the high profile of many of the universities involved. They can help raise awareness of some of the world’s greatest problems and help showcase some of the problems associated with pharmaceutical companies in the developing world. Through groups like this, effective drugs and other remedies can be developed and distributed to developing nations and improve their standard of living to the level that all people living in the 21^st century are entitled to.

"America has done much - and still we face an ocean of need"

The AIDS Challenge
By MICHAEL GERSON
Published: October 8, 2007
The Boston Globe

This article outlines some of the problems associated with providing assistance to individuals with AIDS in Africa. One of the article’s main points serves to illustrate the difficultly in choosing between prevention and active treatment in order to end the AIDS crisis as found in certain developing regions.

Although the United States provides more money to combat the AIDS crisis through treatment than other nations combined, the author of the article questions whether certain goals are realistic and whether or not funding should be shifted to AIDS prevention efforts.

Currently, two million individuals are getting AIDS treatment in developing countries. Although this is an improvement over five to six years ago (where nearly no one was being treated), without proper prevention the number of individuals with AIDS (at a staggering 40 million) continues to increase by 4 million a year in these countries. This makes it seem highly unlikely that the United State’s and G-8’s goal of full coverage for individuals with AIDS will be realized by 2010.

Despite the daunting numbers these nations face, the effort is laudable and it is making and impact, often in unexpected ways. I found it interesting that the number of people diagnosed with AIDS has increased as a result of more widespread treatment. This surprising information is a result of the greater desire to be tested when the prospect of treatment is on the horizon. Individuals who would have not even considered being tested in the past (because they had no hope of treatment and did not want to know) are now getting tested. In this way, increased treatment is required for a certain aspect of prevention. The more the people from developing countries know about AIDS, the longer they will be able to live, and the greater the chance for them to prevent transmission.

In terms of prevention, one of the biggest things that can be done is to provide pregnant AIDS-positive women with the drugs required to help prevent transmission of AIDS to newborns. This kind of technology is important in providing the next generation with the chance to be born AIDS free. I sincerely hope that those children, at least, can be given a fair chance at a full life.

Some nations are trying many other methods (as seen in the article), and this does help lower transmission rates. Overall, prevention of transmission would be required to lower the amount of individuals requiring treatment. The United States has started to delve into prevention as they now provide more condoms to those who need them. Additionally, they recognize that the prospect for treatment will increase the number of people who get tested for AIDS.

The author of the article makes a great point towards the end of the article:

“Treatment and prevention, in the end, cannot be separated. And the goal of universal access to treatment seems morally unavoidable. However expensive this commitment might be, there is also a cost to letting 40 million people or more die - a cost the world should not be willing to pay.”

I completely agree. Prevention will make the goal of universal AIDS treatment more obtainable and, over time, the problem can be controlled and drastically reduced from the current state of epidemic. Granted, it is difficult to simultaneously fund effective treatment and prevention efforts, but perhaps some effective combination can be found to produce the best outcome. Additionally, both could be more effectively provided if other developed nations opted to fund AIDS operations in developing nations. Still, the key lies in some combination that helps stem the transmission of AIDS while simultaneously treating those unfortunate enough to have contracted the disease already. Hopefully, scientists will someday find a vaccine that is both effective in treating developing world populations while it can remain affordable. Until that time, those nations that are better off should help to fund the $32-51 million required to provide universal treatment needed by millions of AIDS sufferers. AIDS is one of the greatest obstacles in helping the developing world transition into the developed world where they can experience a greater quality of life for a longer period of time. It is also one of the obstacles that we, as a species, most need to overcome in the coming decades.

"Immunization rates of children worldwide have reached a record high"

WHO: Vaccine effort saves 2.3m young lives; Immunization rates reach record high, review finds
By JOHN DONNELLY
Published: January 27, 2007
The Boston Globe

This article, highlights the involvement of everyone’s favorite Microsoft founder (and his wife) in improving vaccination coverage of children in some of the world’s poorest countries. Recognizing, in early 2000, that various US and UNICEF programs were beginning to fall apart and that childhood immunization rates were dropping in developing nations, Melinda and Bill Gates began to focus their time and money on remedying the growing childhood immunization problem found in developing nations. They founded the GAVI alliance and so far have personally committed $1.5 billion to the alliance ($750 million from 2000-present and $750 million more over the next ten years). GAVI has prevented 2.3 million deaths, covered 28 million additional children, and increased overall immunization rates to 77% for diphtheria, tetanus, and pertussis as of 2006. This was done with contributions of $983 million by GAVI along with $990 million from developed nations. These numbers are extremely impressive when considering the state of affairs in early 2000 and represent a complete reversal of these trends.

One of the problems associated with improving health outcomes in developing nations is the afflicted individuals’ or their government’s inability to afford the care they so desperately need. The disease can then spread and make the problem even more pronounced. This represents a good starting point in the improvement of public health in developing nations as those governments can help pass on some of the extensive costs to those in the developed world who can afford the treatments. Furthermore, as Bill Gates points out, it helps provide an infrastructure through which additional funding and vaccine distribution can occur.

Perhaps most interestingly, the GAVI alliance utilizes an incentive system to ensure the funding is going to the correct place and that those who need the care are truly benefiting from the millions contributed. They choose not to mandate how the money is spent, but only provide additional funding when the developing nations reach certain immunization coverage goals. The majority of nations (35 passed while only 5 failed) reach their respective immunization targets and receive additional funding (after verification by GAVI). This incentive scheme helps the two groups work together and helps overcome the “acceptance problem” whereby nations are sometime reluctant to utilize vaccines. Local governments are coordinated by the national governments and they work hard to reach their goals to secure additional funding. The acceptance of 70 “poor” nations will truly help improve childhood health worldwide.

Still, this foundation only provides money with which existing vaccines can be distributed, and is hardly enough for any one nation (who also lack the research facilities) to develop vaccines truly needed. Additionally, this alliance mainly deals with the three aforementioned conditions (tetanus, diphtheria, and pertussis). There are still many problems associated with HIV/AIDS, Polio, Malaria and Tuberculosis (to name a few) in the developing world, but these cures have either not be invented or are difficult to implement in developing countries. Raj’s entry (Nov. 12) highlights some additional problems found with providing vaccines to these nations.

This article shows how two individuals can begin changing the world by improving health outcomes for the truly poor. Their actions, along with their dedicated GAVI alliance, also inspired (or pushed) some developed nations into helping out. Through these kinds of initiatives, certain diseases may be eradicated and improve global health as was done with Smallpox in the previous century. The system is also overcoming some of the difficulties seen in previous attempts at improving vaccinations in developing nations and will hopefully innovate the way in which the international community deals with disease in developing nations. The extensive investments of a few private citizens will revolutionize healthcare in the areas that need it most while also setting up the infrastructure of a system by which developed nations can provide assistance to the neediest nations. Hopefully, a few more individuals/nations will be inspired by their actions so that humanity can turn the page on some of the most easily preventable diseases and focus on healthcare’s newest challenges.

Taking vaccines to the “Old World”

Introducing New Vaccines Into Developing Countries: Obstacles, Opportunities, Complexities

By JOHN CLEMENS and LUIS JODAR
Published: April 5, 2005
Nature Medicine

This review type article presents ideas about how vaccines are being brought into the developing world. I found these points particularly interesting because they pertain to the major obstacles to new vaccine introduction:

1. Although in the 1980s coverage of the BCG vaccine for infants had reached 80% in sub-Saharan Africa, that percentage has dropped to less than 50% in 2000. Negative gains like these are sure to play a factor in bringing in new vaccines, especially if old vaccines are still not being used as they should.
2. There has been an increasing gap in the type of vaccines used in developed nations versus developing nations. This has been caused by the innovation of improved vaccines that tend to be more expensive and thus producers favor their introduction into developed nations.
3. There is a difference in the type of vaccines demanded by the developing world and developed nations. Producers are inclined to manufacture vaccines that will yield the highest gain; therefore vaccines for diseases that generally affect developing nations are being overlooked/underfunded.
4. The increase in recent regulation for the development of new drugs has caused an exponential increase in the cost of research and development. There is much uncertainty about how developing nations will deal with increased costs.
5. People of different countries respond differently to vaccines. Randomized trials are largely neglected in developing nations and the efficacy of a new vaccine made for developed nations may be greatly overstated in developing nations.

The article goes on to explain the complexities that entail introducing new vaccines along with new opportunities to introduce vaccines that were previously non-existent (push mechanisms, private/nonprivate funding, and copy-cat vaccine production).

What was most interesting to me as I read this article was the 5^th obstacle that the authors mentioned. It seems that the problem that faces most developing nations in receiving new vaccines is the cost. The focus of much health media today revolves around new discoveries in developed nations and how the new drug will cost hundreds of dollars per dose and how that is controversial because poorer nations cannot afford them. Yet, the authors of the article highlight the fact that this expensive medicine may not even work well in other populations. Furthermore, the authors mention how conducting secondary trials in developing nations after the drug has been released in developed nations can delay the release of crucial medications by years only to find out that the drug’s efficacy is compromised. The additional cost of such trials can also be insurmountable, creating a whole other set of complications.
So while a considerable amount of energy goes into the cost aspect of introducing new vaccines (that is not to say that cost is not important), a new focus should be introduced that ensures new vaccines are effective in different populations. 

"Consider whether you are treating the patient for your own good or for theirs"

Medical Tourism Can Do Harm
By RACHEL A BISHOP and JAMES A LITCH
Published: April 8, 2000
British Medical Journal

This article is actually an editorial, and it is only marginally related to our topic. It is interesting, however, because it explores another definition of medical tourism!

So far, we have been defining medical tourism as Western patients going abroad to seek health care in the cheaper, often more accessible, developing world (this is also a faulty definition because patients from the developing world also go abroad to other developing nations to seek such care; for example, Indian services are also used by Pakistanis and Middle Easterners); medical tourism also encompasses the trend of Western doctors going to developing nations to practice to gain the international experience through altruism.

This editorial, written by two Nepali doctors who have witnessed first-hand the arrival of Western doctors into their communities, discusses the harm that can come of this seemingly helpful practice. Because the travel to established hospital and clinics in a nation is often arduous and expensive, many Western doctors set up clinics right on the outskirts of villages to make care more accessible; instead of being helpful, however, this is detrimental because the Western doctors often know little about the local patterns of disease transmission, the culture, or the language. In addition, these clinics tend to be temporary or have a high rate of turn-over in staff; thus, it is unrealistic to assume that the staff at a clinic can accurately diagnose and treat a condition after just a single consultation.

Also, there is no integration of the temporary clinic with the permanent health care system in a developing country: Western doctors often prescribe antibiotics, setting off huge courses of resistance in very vulnerable communities. Established doctors also don't know how to pick up treatment of patients who once visited Western doctors at a clinic, but now turn to the established route because the clinic is gone.

The two authors of this article argue that the single mandate of medicine is "First do no harm";
Western doctors seeking experience in altruism, then, need to reconsider who they are actually helping, themselves, or the patient.

"...an increasing number of patients headed for...operations climb out of the car at the airport, rather than at the hospital"

Medical Tourism Takes Off, But Not Without Debate
By LISA A HIGGINS
Published: April 2007
Managed Care Magazine

This article fits into the puzzle by analyzing the perks of medical tourism from a completely different angle: the US health care market. By tapping into the forces in the US that drive medical tourism in the first place, this article highlights underlying problems in this country, and also shows that medical tourism may not be as popular as the media thinks it is.

The major points in this article were:

• The only company in the US to have tried medical tourism as an option for its employees is located in North Carolina, but the company rescinded the offer after a labor union was against the idea
• Medical tourism may really take off in the US if HMOs implement a cash reward for going abroad: they may choose to split the difference between cost in the US and cost overseas with a patient who will travel; this scenario is ideal for patients with high deductibles.
• Many more companies may join the medical tourism trend only if they see that there are no huge consequences that have yet to manifest; the second wave may actually never happen, many experts caution
• Seeking medical care abroad has traditionally been the chosen path of the uninsured seeking necessary and expensive care
• Care abroad may actually be better than care in the US: facilities in India rival the Mayo Clinic in outcomes, they offer higher staff to patient ratio, etc
• A large benefit that the US may derive is in the form of competition: perhaps US institutions will offer better procedures to keep patients here
• The long-term consequences of medical tourism that have yet to be explored involved post-op complications and malpractice litigation abroad

This was a very dense and informative article, but the point that I thought was most relevant was about the effect of competition in the US. If American facilities try and improve high-end surgeries to keep patients in the US, the focus is going in the wrong direction! People that are uninsured go abroad the most: focusing on improving the health care system so that they are not driven abroad is the primary concern here; by improving high-end surgeries that are very lucrative but only cater to a few, the US system is still only tapping the market of people who are able to pay. They are not the primary audience when trying to alter the system today: we care about the uninsured, the neglected, and those who cannot pay.

I'm also questioning the logic of sending patients with high deductibles abroad. Patients that have higher deductibles also tend to be patients with chronic illnesses and pre-existing conditions. These are some of the most vulnerable patients, and sending them abroad is tricky because they are already in bad medical states. Also, dealing with issues of complications brings me to the next important point in this article: procedures in countries like India and Thailand are substantially cheaper because there is no environment of litigation in these countries, and there is no malpractice system in place.

If American patients with chronic illness or expensive and life threatening conditions receive care abroad, what happens when they return home and have complications? This emergency care will be paid for either out of pocket (which is so expensive that going abroad in the first place to save money gets canceled out) or through the government, which increases overall costs to the entire system that sending patients abroad is once again, negated.

This article, interestingly enough, does not address the issue of elective surgeries abroad. Many patients go abroad for routine dental care, cosmetic care, abortions, etc. While this is not a new trend, it is an important trend: wouldn't the patients with these non-emergency needs who are willing to go abroad already have more disposable income for health care? They aren't part of the US-health-care-system-in-trouble analysis that is the biggest controversy surrounding medical tourism in the first place. This article, then, is the perfect complement to "The Private Health Sector in India" because we are once again faced with sugar-coating the larger problems by pursuing medical tourism.

"The medical system is failing its own people"

The Private Health Sector in India
 By AMIT SENGUPTA
Published: November 19, 2005
British Medical Journal

It is interesting that this article is also from the British Medical Journal. In fact, many of the sources that I found are from the BMJ, which makes me think that perhaps medical tourism is a more marked force in the UK than it is in the US.

This article is very compelling because it analyzes all the problems with the public-private sector relationships in India to show that medical tourism can in fact wreak havoc on the Indian public. The main points of the article were:

• India is among the bottom 5 countries in the world on public health care spending and among the top 20 countries in the world in private health care spending
• The public sector of health care doesn't even have basic technologies or capabilities, the doctors are so strained that they see more than 100 patients in a typical round at an outpatient clinic, and bribery is rampant. In fact, 30% of Indians seeking public health care say that they had to bribe their doctor, who told them to visit him in his private practice in off-hours.
• There is a huge brain drain in India in two capacities: first, talent in medicine is going abroad at an alarming rate; then, of the individuals who stay on to practice in India, a large percentage practice exclusively in the private setting, which is unaccessible to the poor majority.
• Another major problem in India is a new trend marked by Non-Resident Indians (NRIs): NRIs are educated and often live abroad, but return to India to cash in on the lucrative private sector by catering to India's wealthiest patients, who seek the best care by the best Western trained doctors. NRIs also invest a lot of money in some private sector practices, attracting talented doctors from the public sector with better working conditions and higher salaries. Finally, NRIs also have political clout, so they are able to maneuver easily through the bureacracy to meet their often money-driven goals.
  
• This article had the same quote as the previous article (Wooing Patients) by the same guy about not fishing for patients abroad, only telling them about the available opportunities for medical tourists in India.
• 500,000 Indians die every year from tuberculosis, while another 600,000 die from diarrheal disease.

This is most certainly alarming, and paints a picture that few people searching for better medical care abroad see. Of course, few patients trying to save time and money by going abroad will care about the detriments to India's poor; but someone along the chain has to care. Unfortunately, the Indian government seems to be heading away from the direction of caring, individual doctors are following suit, and the poor have no leveraging power.

While the numbers of patients going abroad for medical care are substantial, I wonder if they are large enough (or if the increase will be large enough) that the hordes of public sector doctors abandoning their work for that of the private will have work available for them. Also, as hospitals in India compete to offer the lowest cost surgeries in order to attract more foreign patients, will the situation ever result in only minor marginal benefit for the hospital providing surgeries? Does it have to get to such a far-flung economic low to reverse the tide of doctors back to the public sector?

While the NYT article offered an overall backdrop and the previous BMJ article focused on India's possibilites, this article really illustrates all of the problems specific to India. This fits into what we already know by elaborating on and reinforcing the many possibilities that India has been experimenting with, and it adds new knowledge by showing that only very few Indians are benefited by what is a loudly touted phenomenon.

"Doctors here speak excellent English"

Hospitals in India Woo Foreign Patients
By GANAPATI MUDUR
Published: June 5, 2004
British Medical Journal

This article, part of the British Medical Journal, is a more microscopic view of medical tourism than the artice from the NYT because this one focuses mainly on India. This zoomed in view is a particular interest of mine because my family is from India - and surprisingly enough, when I searched for tourist facilities in India, a prominent hospital in my hometown in India, not far from my relatives' home, popped up.

This article's major points were:

• The three major destination cities in India are Chennai, New Delhi, and Mumbai
• The Indian government hopes that the medical tourism industry will be a $2 billion industry by the year 2012
• The government promotes the industry abroad by telling foreigners of the great opportunities availalbe for health care in India, but when accused of channeling money and attention away from the medical needs of the Indian poor, the government replied that it wasn't "fishing for patients"; it was just promoting opportunites that could be sizable boosts to the economy
• There is an enormous disparity between costs of procedures in the US and their corresponding costs in India: India offers procedures for about 20% of the US' price
• The British NHS doesn't yet support the travel of patients to India because India falls beyond the 3-hour tranfer limit
• Most Western patients who travel to India pay out of pocket
• Many Western patients still don't trust the care they may receive in developing countries, even though the medical outcome is the same or better than that in the US
• The Indian government promises to standardize care in Indian facilities and to make medical tourism a priority

I think the most important issue in this article is that most people travelling abroad pay out of pocket; this fact, combined with the NYT article's assertion that most people travelling abroad are uninsured puts in perspective how desperate the American uninsured really are: they will travel around half the world and pay about $20,000 out of pocket for surgeries! While this makes sense because this is a mere fraction of the cost in the US and because there surgeries are often life-saving, it speaks strongly of the dilemma of the US health care system. Sending patients abroad is certainly not the issue; it is only the superficial gloss of a solution to a much larger problem of lack of access and affordability. It takes a money-driven business in a third world country to offer services to the uninsured that their own communities can't.

Another interesting and very disturbing point was the Indian government's commitment to make medical tourism a priority on the scale as other export trades; if the Indian government spends money on standardizing care and advertising the medical tourism industry, it is indirectly supporting the health care of foreign visitors. At the same time, the Indian government is ignoring the medical needs of a large proportion of its poor population. This makes as little intuitive sense as the above scenario where an American is driven to India to seek health care. While medical tourism is an interesting and complex force, it has a lot of facets below the surface that proponents choose to ignore.

"public backlash against medical visitors"

Heads Up! Medical Tourism: Sometimes, Sightseeing is a Look at Your X-Rays
By JOSHUA KURLANTZICK
Published: May 27, 2007
New York Times 
 
This article, part of the NY Times, was a great starting place to learn about the background associated with medical tourism. The major points in the article were:

• The staff of the popular international medical facilities are mostly Western trained
• There are many amenities offered at these medical destinations, like yoga, restaurants, and sight-seeing
• 150,000 Americans go abroad each year for their health care needs
• Procedures abroad cost 60-80% less than they do in the US
• Some insurance companies are beginning to cover internationally offered services because this saves money for the company and the patient
• Hospitals that offer medical care to "tourists" now compete with each other in terms of who offers the best amenities at the lowest price
• There is some public backlash to medical tourists in poor countries like India and Thailand because the public clinics are understaffed while private facilities have the best staff

I think the most relevant point in this article is that these facilities offer not only excellent medical care, but also a safari or a visit to the Taj Mahal, 5-star accomodations, and an overall luxurious experience. I wonder if the competition to offer the best peripheral perks will eventually overshadow the emphasis on good health care? Also, as the hospitals try to out-do each other in terms of patient experience, will the costs increase to the point where the money saved is only a marginal concern?

Another important topic that this article addresses is the public out-cry in poor nations that are popular medical tourism destinations. The article only touches on the issue briefly, but just how intense is the backlash? Because the wealthier population can afford the private care, the dissatisfaction lies only with the poor, and they already have little bargaining power in these countries. Medical tourism, then, while fueling the economy, drives the health care industry even farther away from the needs of the poor; they are only very indirectly benefited by the increased money that an economic boost provides. The poor may not even experience the benefits for many more years (or generations!) to come...

“an unusual experiment in medical technology”

Aranyaprathet Journal; For Innocents Scathed by War, a Sort of Self-Help
By BARBARA CROSSETTE, SPECIAL TO THE NEW YORK TIMES
Published: June 13, 1988, The New York Times

     This article, published in the New York Times on June 13, 1988, focuses on a program developed in 1979, Operation Handicap International, that helps people in developing countries, such as Thailand, Laos, Cambodia, Vietnam and India, fashion their own medical devices, such as crutches, wheelchairs and prosthetic and orthopedic devices, out of locally available materials, mainly wood, leather and rubber tires.

     In the back of my mind, I always thought that there was a prosthetics company somewhere that was nice enough to donate prosthetics to developing countries, or some kind of a “Lions Club” initiative that allowed people to donate the prosthetics they outgrew to those in need in the Third World. But O.H.I. is even better in that it provides people with jobs, and allows them to create their own limb with care and purpose. Susan Walker, an American who directs O.H.I. in Southeast Asia, said, “And also we believe [the amputees] are best able to understand the difficulties and the needs of the handicapped. We also try to get patients themselves to work on making devices. They have a vested interest in making them look good and fit well.”

     The most interesting lines of the article were in the last paragraph, a quote by Ms. Walker:

“Many people feel that appropriate technology prostheses are primitive, that they are not as good as high-tech or sophisticated-technology devices,” Ms. Walker said. “Something I certainly learned since coming to work with O.H.I.,” she continued, “is that appropriate technology prostheses are based on the same scientific principles, and are just as good as expensive plastic. It's only the material and the look that are different.”

     This quote really struck me because in class we spent a reasonable amount of time discussing how prostheses are getting makeovers to look more and more lifelike on the outside, with translucent plastic coverings that even have nails and knuckles (!). Or how some people opt to get prostheses that have absolutely no function but are just “prettier” than functional prostheses. And while these innovations are very interesting from scientific and technological perspectives, not everyone in need of a limb has the luxury of an aesthetically pleasing prosthetic, functional or not. In developing countries, so many people just need to have a limb they can use so that they can get back to work and get on with their lives, and Operation Handicap International makes this possible in a realistic way in countries that are, sadly, not yet able to take full advantage of the technological developments available to residents of the First World.