World Health Day is April 7. Who remembers the theme of World Health Day 2010? Never mind. If you read any major media in the past week, you almost couldn’t escape knowing that World Health Day 2011 is about antimicrobial resistance (AMR), or drug resistance (here’s a link to an example from The Economist.) At least the World Health Organization’s (WHO) public relations machinery is ramped up. And they want us to be alarmed. Here’s a quote from WHO:
Antimicrobial resistance is not a new problem but one that is becoming more dangerous; urgent and consolidated efforts are needed to avoid regressing to the pre-antibiotic era.
The World Health Day publicity materials highlight all manner of disasters from drug resistance: people die, health care costs rise, trade and economic development are affected (I must admit that I hadn’t imagined that particular consequence), and more. But, understanding the perils of drug resistance is not a new phenomenon at WHO. Ten years ago, on the eve of September 11, WHO was preparing to roll out a global strategy to prevent and contain drug resistance which was already of great concern to public health officials. The next day, the world was too distracted to hear the important warnings and plans contained in that strategy, and attention to drug resistance languished for a decade. It has risen again. There are plenty of reasons to hope it remains squarely in the public eye.
WHO’s declaration of drug resistance as the theme of this year’s World Health Day is not coincidence. Last year, an enzyme that confers almost complete drug resistance on bacteria it comes in contact with, called NDM-1, popped up in India and quickly spread to 20 countries. It is almost always lethal. This new bug follows the discovery and spread of a whole range of “superbugs” that have made hospitalization, and even minor cuts and scrapes, a more threatening experience than ever before. Also last year, about the time that WHO regional and headquarters officials were deciding on the theme for World Health Day, CGD was preparing to publish an expert working group report on global drug resistance policy, The Race Against Drug Resistance. The report, the related policy brief, and the accompanying video have been widely circulated and were drawn upon by WHO in preparing materials for World Health Day 2011.
We’re happy that our working group report was useful to WHO, but we’d be a lot happier to see the momentum from 2010 turn into action in 2011. Here is a quick reminder of the 4 recommendations in the CGD report, and what has happened so far on each. The organizations responsible for carrying out each recommendation are clearly identified in our report. Here, I grade the progress on each recommendation and briefly explain my reasoning.
Recommendation 1: Build greater laboratory capacity and create a global network for drug resistance surveillance. Publish a report on global drug resistance every two years.
Grade: C Reason: More talk than action
Many drug resistance surveillance networks exist. The best global surveillance efforts for both HIV/AIDS and TB drug resistance have just published new reports, here and here, and a recent malaria drug resistance report is available here. WHO is making plans to gather its regional drug resistance surveillance gurus together for the first time, in an effort to help them organize and utilize a more global network. Improved laboratories in Africa (where they are needed most) are also gaining traction. The new African Society for Laboratory Medicine recently held an inaugural meeting in Addis Ababa, with PEPFAR as a major sponsor, and others are investing in better lab capacity as well. But is WHO really taking seriously the need to combine drug resistance data across regions and diseases so we have a full snapshot of the problem? Our new world map documenting drug resistance shows just how piecemeal the data are. The world desperately needs a more complete picture of this threat, which kills more people everyday than died in the World Trade Center tragedy.
Recommendation 2: Establish a secure supply chain from manufacturer to customer that ensures the safety and efficacy of the drug supply in developing countries.
Grade: D Reason: Lack of funding
The CGD report recommended that stakeholders at the global and developing country levels partner up to identify and fix weaknesses in the drug supply chain that allow good drugs to lose efficacy (for reasons such as humidity, extreme temperatures, expiration) and bad drugs to reach consumers (counterfeits and poor quality are rampant in poor country distribution systems and prescribers and dispensers are often not well trained to detect them). Who should do this? We suggest everyone along the supply chain—from manufacturers to dispensers to professional medical associations like pharmacists and doctors. But what has happened since our report came out? Very little. Despite enthusiastic and broad-based buy-in from many stakeholders to lead these partnerships at an August 2010 meeting sponsored by CGD in Upsalla, Sweden, organizations such as MSH, the Alliance for the Prudent Use of Antibiotics (APUA), and the International Pharmaceutical Federation (FIP) haven’t found funding to move forward. Times are tough in global health and expertise and good intentions are not enough to create long-term change. Multiple organizations are ready to bring their technical expertise and practical experience to the job of securing drug supply chains. Donors and funders need to do their part to help it get started.
Recommendation 3: Use regional networks to improve national drug regulatory authority capacity to safeguard drug supplies and enforce laws
Grade: F Reason: See above (1 and 2)
National drug regulatory authorities (NDRAs) are the front line for monitoring the quality and safety of drug supply systems, but are notoriously weak or corrupt in many developing countries. It’s a tough job and one that requires a rare combination of skills, including technical, law enforcement, diplomatic, and policymaking. The most well-known drug regulator in the developing world – Dora Akunyiki of Nigeria – finally got tired of the death threats she faced after seizing contraband drugs in her country and moved over to the quieter job of Information Minister. Something is needed to improve the regulatory culture and capacity among developing country drug regulators, especially in the African countries that are beset with a “wild west” atmosphere in their drug markets. The CGD report recommended that donors provide support to existing and new regional networks of NDRAs for training, information-sharing, and other activities that will enhance their capabilities and motivation to do the job. Donors have long lists of what they would like to see from NDRAs – including much faster and more harmonized drug registration (an example is the Gates Foundation effort through the Africa NEPAD in partnership with DFID and other donors) – but so far have been both more talk than action, and reluctant to put money into an enterprise that is so out of their control.
Recommendation 4: Establish a web-based R&D marketplace to spur innovation for disease-specific technologies
Grade: B Reason: It’s here! But can go further
The Institute for Drug Resistance (IDR) at the University of Massachusetts provides a web-based networking site for researchers to share ideas and build collaborations on drug resistance. The network is small and still pretty U.S.-centric, but the potential and desire exists to make this site the go-to place for sharing ideas about drug resistance innovation and perhaps, even spur relationships between drug resistance scientists and research and product development funders. And as an added bonus, the IDR has enthusiastically become the publisher of the Drug Resistance Newsletter, formerly published on a monthly basis by CGD. The newsletter reaches a community of over 2,500 people interested in news and research about drug resistance, and will no doubt grow under IDR’s banner.
Where do we stand then? Not far from where we stood last June when we published the CGD working group report. It’s only fair to say that a higher level of awareness (and yes, alarm) exists about the global problem of drug resistance. Was it NDM-1, the CGD report, World Health Day that did it? Or the many other efforts from research, advocacy, and public policy organizations to bring attention to drug resistance? Probably all of the above, but if those efforts don’t result in more action and money from global donors and health agencies, as well as developing countries and companies, we’ll see another decade and many more of the drugs we rely on today slip away. On a final positive note, the 1st Global Forum on Bacterial Infections is now being planned by the fabulous team at The Center for Disease Dynamics, Economics & Policy. It will focus on drug resistance and related policy issues in low- and middle-income countries. Let’s hope it follows an example set by the World Health Day to turn talk into action.
By the way, did you remember the theme of World Health Day 2010 yet? Urbanization and Health.