The term “neglected tropical diseases” is on the way out.
Instead, global health experts are beginning to favor the less geographically-restricted “neglected poverty-related diseases,” which reflects not only the borderlessness of infectious illness, but highlights that, like poverty and climate change, these diseases care less and less about a nation’s gross domestic product.
“The word ‘tropical’ has become kind of an anachronism,” said Robert Terry, manager of knowledge management at the Special Programme for Research and Training in Tropical Diseases, housed at the World Health Organization.
“Historically and broadly, [tropical] is correct because that’s [the region] where [the diseases] reside, but I think the word tropical is perhaps falling away,” he told Devex.
Still, the word “neglected” isn’t going anywhere.
As the burden of such diseases shifts, and the threat of pandemics begins to hit home even in the world’s wealthiest countries, advocates are pushing for the health ministers of the G-20 — gathering in Berlin later this month for the first meeting of its kind — to do their bit in supporting global health R&D in tackling neglected diseases, antimicrobial resistance and pandemic preparedness.
Advocates point to the economic and political benefits of mobilizing a platform such as the G-20 toward better collaboration in global health, and emphasize the intersection of global health and security as one way to collectively drive new resources.
But how is the case being made, and what can the G-20 bring to the table?
A shifting burden
Of 1,393 new drugs brought to market between 1975 and 1999, only 16 were designed to combat neglected poverty-related diseases, according to a Médecins Sans Frontières report published in the Lancet. A drug is 13 times more likely to be brought to market for a central nervous system disorder or cancer than for one of the 18 diseases designated by the WHO as neglected tropical diseases. The pharmaceutical industry shies away from the types of R&D necessary to create drugs for these diseases, and the business models of pharma companies — which favor medications that must be taken frequently and over the long-term — are often at odds with the need to limit the use of antimicrobial drugs, in order to manage resistance.
These diseases are neglected for another reason: Historically they have mostly affected poor and developing countries, thriving on the lack of good water and sanitation infrastructure and of effective health systems. Funding for tackling them has historically fallen on the backburner, or flowed inconsistently. Inconsistency in global health R&D often means resistance, as under-funded innovation can’t keep up with the evolving diseases as they adapt to outdated drugs and interventions.
But the tide is changing. Climate change is shifting global temperatures, meaning the conditions that allow tropical diseases to emerge and thrive are also changing and, in some cases, expanding.
“As climate change starts to have an impact, what we’re seeing is that the spread of these diseases — if you look at, say, Zika … or malaria — as the environment changes their scope is also changing,” Terry said.
Likewise, national demographics are on the move. Globally, populations are shifting toward urban centers: In 1900, 14 percent of the world’s population lived in cities, but it is estimated that 70 percent will be urban-dwelling by 2050. For cities in middle and low-income countries in particular, but also for some high-income cities, this results in rapidly-growing urban slums, and a failure of inner-city infrastructure and basic services to keep pace, creating ideal conditions for the spread of disease and the risk of pandemics.
As the burden of neglected poverty-related disease shifts geographically, many in the global health space are calling for a corresponding shift in the priorities of the world’s most powerful countries. The Ebola crisis offered a sobering demonstration of poor pandemic response, reflected in a greater emphasis on global health R&D in the new Sustainable Development Goals. The SDGs signalled the United Nations’ hope to drive forward the improvement of health systems and improve access to vaccines and health interventions but, in the eyes of many, a more focused platform was needed to catalyse influence and resources.
Enter the G-20, a political coalition of most of the world’s major economies. In 2016, the G-20 officially put the SDGs — and specifically global health — on its agenda for the first time under the leadership of Germany, a stalwart donor for global health interventions.
As Germany’s term in the annual presidency nears its end, like-minded advocates and experts from the public and private sector gathered in the capital city of Berlin last week to call on the G-20 “to commit political and financial resources as well as expertise to science, technology and innovation in global health.”
Why the G-20?
As well as offering a more politically and economically-driven platform for better cross-sector collaboration on global health R&D, the G-20 countries now have a first-hand stake in some of the global trends in the burden of poverty-related disease witnessed in recent years.
Despite representing the world’s major economies, six G-20 member states — Brazil, China, India, Indonesia, Russia and South Africa — are also among the 20 countries with the highest tuberculosis burden. The effort to enlist the G-20 to the global health cause also came soon after the first drug-resistant cases of malaria were reported in the United Kingdom, hitting home the global implications of drug-resistance.
“The G-20 can help [answer] this need for better alignment and coordination across countries and the question of — who’s going to fund what? [This will] make sure we are funding across the value chain, from the start through to bringing a product to market,” Claire Wingfield, senior policy officer with the advocacy and public policy program at PATH, told Devex.
“How are we also aligning regulatory policies? If we’re not harmonizing our regulatory processes, how can we at least align standards, some of the activities we’re undertaking to streamline and clarify regulatory pathways? This is something else I think the G-20 could do across its block of member states,” she said.
Targeting the G-20 could also go a long way toward collating efforts being made by some G-20 governments — including Japan, Germany, the U.K. and the European Commission — to incentivize pharmaceutical companies and research institutions to focus on neglected poverty-related diseases, antimicrobial resistance and pandemic preparedness and response.
For example, the Japanese government is a long-time investor in global health R&D efforts, and was a founding investor in the Global Fund to Fight Aids, Tuberculosis and Malaria. But more recently, with its Global Health Innovation and Technology Fund, the government hopes to facilitate the entrance of Japanese pharmaceutical companies into the developing country market.
“The market in Japan and also in the developed countries like the United States and in Europe is going to shrink as the populations in these regions will be declining very fast,” Dr. Kei Katsuno, director of investment strategy and development at GHIT, told Devex.
“So not only from the philanthropy or [corporate social responsibility] perspective, the private sector companies need to look at the market outside of the developed countries and also look at emerging countries,” he said.
The U.K. Department for International Development has also ramped up its research funding with the new Research Review, which sets out how the government will spend 390 million British pounds per year ($505 million) on researching “challenges of the 21st century,” including infectious disease. It also launched the 1 billion pounds Ross Fund in 2015 to develop, test and deliver a range of new products to help combat infectious diseases in developing countries.
Meanwhile, the European Commission invested 683 million euros ($748 million) in 2014, in the second phase of its European and Developing Countries Clinical Trials Partnership to accelerate the development of new drugs for neglected poverty-related diseases. The EDCTP also seeks to encourage the capacity-building of health systems and ownership of vaccines and interventions in partner countries in sub-Saharan Africa.
“EDCTP is well-placed to take that leadership role, and bring other countries, industry, foundations around the table and jointly invest in expensive clinical trials,” said Bernhard Schnittger, deputy head of the EU’s office in Berlin.
“EDCTP is the model of leadership in partnership. It has the government’s model, we think, of the 21st century, where European and African countries have equal say in priority setting,” he told participants at last week’s summit.
By bringing these initiatives together under a health innovation-driven agenda, global health experts who pushed for inclusion on the G-20 agenda also hope to set an example for nations looking to set up similar initiatives. Uniting these efforts, Wingfield said, would facilitate better information sharing and more streamlined governance between new and emerging initiatives.
A political moment for global health innovation
As many political advocates within the G-20 nations work to make the case among colleagues and constituents that aid investments also strengthen national security, the push for putting global health R&D on the G-20 agenda provides them with one of the clearest cases for increased funding: A defense against global pandemics. The security angle is often more effective than a purely aid-driven stance in arguing for more domestic resource mobilization in low and middle-income countries.
“There are some contexts where that linkage with more traditional national security issues is quite clear, as with Ebola for example. These diseases clearly disrupt economies, disrupt societies, particularly in regions where they have fragile infrastructure to begin with, so it’s not a hard case to make,” said Richard Hatchett, the new CEO of CEPI, an international alliance working to develop vaccines for neglected poverty-driven diseases. Hatchett is also the former deputy director of the Biomedical Advanced Research & Development Authority, and worked for more than 15 years on public health emergency preparedness before taking up his role at CEPI.
“Famously, the CIA declared HIV a security issue 10 or so years ago, for essentially the same reasons … In some places, [HIV] had become so prevalent that it was destabilizing, and that was not the kind of argument about security that traditional security specialists were used to hearing,” he said.
Hatchett said the argument was “kind of radical at the time,” and that it likely influenced the public understanding of the importance of health infrastructure and delivery as components of national health security.
“It’s becoming more widely accepted, and it’s an important way of framing the problem that many members of the global health community probably aren’t necessarily comfortable with or adroit at deploying yet,” he said.
“It does serve a [public relations] purpose, obviously. Once you can persuasively make the argument that something is a national security issue, it can help you achieve a stability of funding and resources that might be more challenging in other environments, where you’re having to compete with other entities that are making equally valid claims on a limited pool of resources. When national security comes along, it almost becomes non-discretionary,” he said.
By putting global health R&D on the shortlist for not only development and foreign affairs ministers, but also the health ministers of the G-20, the advocacy effort for funding innovation in the global health space becomes more united and begins to resemble the kind of cross-cutting defence Hatchett said is necessary to protect against future pandemics.
Jeremy Lefroy, a member of the U.K. parliament, agreed, adding that advocates at the political level across the G-20 must learn to identify where local and global politics converge.
For example, you might make the case for immigration in the U.K. by pointing out that a lot of the social care workers the country relies on were born outside of the country. The same line of reasoning can be applied to global health innovation, he told Devex.
“You broaden that in terms of health to saying yes, health is extremely important, but let’s not forget that in the U.K., we’re not just talking about the [non-communicable diseases], we’re also talking about quite substantial amounts of TB … Malaria is a very small problem in the U.K., but it’s a substantial cost for the 5 million traveling to [malaria-endemic] countries every year.”
Lefroy acknowledged he should do more to encourage colleagues in parliament to make the case for the U.K.’s role in global health innovation.
But by sharing strategies for effective advocacy across parliaments and even wider platforms such as the G-20, the prospects for putting innovation in global health front and center begin to look brighter, he said.
By Molly Anders