Is Disease Eradication Possible In The Age Of Patents?

After reading about attempts to eradicate Polio in Uttar Pradesh, followed by several articles addressing the Trade-Related Aspects of Intellectual Property Rights (TRIPS), I was curious: Did the United States use a patented vaccine in its polio elimination campaign? The short answer is no.

This question was prompted by (what I guessed to be) an analogues situation in economic development. In the late 1990s and early 2000s, many economists promoted market liberalization as a pathway for economic development. Many rationalized this practice by pointing to the current economic policies of the United States, and its economic growth. Essentially, the prescription to developing countries was – make your economic policy reflect that of the United States, and economic growth will follow. However, this overlooked, or intentionally ignored, the fact that the United States utilized intense protectionist policies in its infancy, incubating domestic industries and enterprises before ever exposing them to intense international competition. There was no empirical evidence that market liberalization could promote economic development.

While disease reduction is a noble cause, I question if we are asking middle and low-income countries to execute an impossible task. To some extent, the current dialogue highlights the United States and says to developing countries, “if they could do it, so can you” – despite the fact that the rules of the game have changed drastically.

The March of Dimes “committed to give the formulation and production processes for the vaccine to several pharmaceutical companies for free,” ensuring that the polio vaccine could be produced cheaply, and in mass. Interestingly, patent law existed, but lawyers did not believe they could patent the Salk vaccine. Today, most vaccines are patented and expensive. ” In this context, one could argue that the recent decisions and threats by India and Brazil, respectively, are only attempts to recreate the same environment in which vaccination campaigns have been financially and operationally feasible in the past.

With patent law intensifying since the American polio eradication campaign, the United States Government has adapted. “The U.S. government is now the primary applicant for vaccine-related patents, followed by GlaxoSmithKline and a number of other corporations.” With the government as a competitor in drug development, it is possible that the public sector will develop new remedies funded by taxpayer dollars, enabling inexpensive distribution. However, this still leaves low and moderate-income countries out of the loop. Low-income countries have small tax and limited bandwidth to support such research – leaving them tied to patented drugs, and the support of NGOs.

To date, the only globally eradicated disease is smallpox. The original vaccine for smallpox did not have a patent. Without a significant shift in patent policy, utilizing vaccines to eradicate diseases appears to be an impossible task for low and middle-income governments to undertake on their own.

Both quotes from: http://www.slate.com/articles/technology/history_of_innovation/2014/04/the_real_reasons_jonas_salk_didn_t_patent_the_polio_vaccine.html

Polio Elimination in Uttar Pradesh – Individual impact in global health policy

The case of Polio Elimination in the Uttar Pradesh state in India serves to highlight the impact that specific individuals can have in any global health undertaking. Likewise with the smallpox elimination program administered in Africa as well as in India, individual will power serves as a great instigator and spur of driving action in global health policy – in this case of Polio eradication.

The theme of individualized leadership in global public health campaigns is signified through the work of two individuals throughout the course of the Polio Elimination program in Uttar Pradesh – Dr. Kaushik Banerjee and Dr. Jon Andrus.

The efforts of these two individuals quickly made in roads in the Polio fight in Uttar Pradesh. With collaboration with Global Polio Elimination Initiative (GPEI), a coordinated public health program compromising of Rotary International, WHO, the CDC, and UNICEF, Banerjee and Andrus were able to help establish a National Immunization Day (NID). The program helped foster greater immunization rates amongst children, and polio outbreaks in India became more localized. However, coverage gaps still existed amongst the northern portion of India, prompting Banerjee and Andrus to present a case for increased immunization rounds in India to six rounds in the North and four in the south, relying in surveillance data to augment their argument.

What became know as the 4+2 program, the impact was significant on India’s polio outlook – polio cases dropped from 1,126 in 1999 to 265 in 2000; however, a majority of these cases, over 200, were concentrated in the Utter Pradesh state, for a multitude of reasons – climate, public health conditions, etc. Ultimately, the success of the program was hinged on the arguments and persistence of Banerjee and Andrus.

When the pair left their respective posts within the Polio Elimination campaign in the summer of 2002, the Indian government decided to scale down it’s polio response within the northern region, using just two national and regional immunization days – which was against the recommendations of Banerjee and Andrus. In 2002, India Suffered a polio outbreak, and 1,600 Children came down with paralytic polio, including over 1,200 cases in the Uttar Pradesh region alone. This incidence found that past immunization campaigns were not robust enough in their strategies, leaving a “pool” of unvaccinated children contributing to the outbreak.

The main talking point here revolves around the significance and displays of influence Banerjee and Andrus held towards the Polio elimination campaign in Uttar Pradesh and India overall. Once their opinions, perspectives, and arguments were no longer voiced, the Indian government immediately took retroactive steps in the Polio elimination campaign. Likewise to an extent to the smallpox global eradication program, although many international and national organizations and institutions were behind this public health campaign, the realization of the elimination of Polio in Uttar Predesh is fundamentally tied to the efforts and insights of a few particular individuals. I feel it’s quite interesting to find such a relation – that problems so inherently tied to the well-being of millions individuals can rest on the capabilities of just a few individuals in global health policy.

Polio, a disease of cultural and religious differences?: a look into polio in Nigeria

dancing african children

Northern Nigeria is plagued with many issues, one of them being Polio. Nigeria, along with Afghanistan and Pakistan are the only countries left in which Polio is still endemic. Considering that Polio has been eradicated in most of the world, this fact is quite disheartening and begs the question: Why hasn’t Polio been eradicated in these countries? Unfortunately, the answer to that question is more complicated than simply providing vaccines to the respective populations.

Interestingly, these marginalized populations are Muslim. An interesting fact that was also observed in Uttar Pradesh, India. That is not to say that Islam is a major factor affecting polio eradication. It simply is a commonality shared by different populations affected by the same disease and begs the question: Are these people being marginalized by their government as a result of other cultural and religious tensions? This is the question that I attempt to shed some light on.

Nigeria is arguably divided 50/50 by Christianity and Islam with the south being predominantly Christian and the north being predominantly Muslim. Data shows that northern Nigeria is disproportionately affected by poverty and health issues when compared to southern Nigeria (for instance, higher rates of malaria, cholera, poverty, malnutrition, hunger, etc). To combat these issues, national efforts have focused largely on vertical approaches to these public health issues, which was the approach taken to eradicate polio via the Global Polio Eradication Initiative (GPEI). However, there has been a current shift in global health trends to health systems strengthening as a new public health approach. Also, the failure to eradicate polio in countries such as Nigeria further heightens the need for this approach and the need to comprehend the underlying issues exacerbating the spread of polio.

As mentioned, northern Nigeria is plagued by many issues, most of which is intertwined with the recent insurgence of Boko Haram. It is difficult to use a strictly vertical approach to scale up polio efforts when a huge influence on the community, Boko Haram, continually thwarts these efforts. Due to the presence of Boko Haram, there has been an increase in distrust of the government and deteriorating security, compounded with low levels of education creating a melting pot that is ripe for continued spread of the disease.

Despite these set backs, the number of cases in Nigeria has dropped indicating that is it possible to eradicate the disease once and for all. Also, Nigeria’s successful elimination of Ebola shows that the government is capable is responding swiftly and effectively to public health issues. However in order to replicate this success in polio, Nigeria would need to scale up polio immunization efforts by increasing community engagement and use of community health workers and integrating polio vaccination to other immunization efforts and possibly maternal and child health treatment cascade as a whole. 

Polio in India: Using the End as a New Beginning

India has successfully eradicated polio. India’s last polio case was reported in January 13, 2011. In 2009, India still reported half of the world’s thousand plus new cases but by March 27, 2014 was certified polio free by the World Health Organization[1]. The turnaround was incredible, unexpected, expensive, and required massive effort from multiple organizations including the Indian government, WHO, and Rotary International.

The road to elimination was tough with many challenges.

  • For one, India needed to vaccinate 172 million children twice each year.[2]  $2.3 billion in government funding was used. Although each vaccine cost only about 12 cents, they needed to be kept cold, and refrigerating them was a major problem. To combat this, refrigerators powered by kerosene were used to target remote areas without electricity.
  • Mobile units were also used to provide comprehensive coverage. These units set up quickly and then moved on after immunizing the children in the immediate area. Booths were set up in train stations and workers immunized children passing by and on the trains. A small percent of children were immunized by door to door efforts.
  • In addition, illiteracy and misinformation can create difficulties in communicating the importance of eradication. When the eradication program began in the 1980’s, religious tensions arose when Muslims believed the vaccination was a conspiracy to sterilize the men. Religious leaders, celebrities, and other social faces were included to increase understanding about immunizations.
  • Another challenge encountered was that the effectiveness of the polio vaccine was crippled if children had diarrhea. Therefore along with the vaccine, a more holistic approach was needed. Community volunteers emphasized the need for hygiene, sanitation, and diarrhea management.
  • In order to quantify which children had been immunized that day, a black mark was made on the child’s finger. This proved a simple and cost-effective way to estimate immunization rates, prevent wastage of supplies, and identify non-vaccinated children.

India is now in the phase of polio endgame. Children must keep getting vaccines due to the prevalence of the disease in countries that India shares borders with. Cross border infiltration could lead to polio resurgence without upkeep of vaccinations and surveillance. All states in India must also be prepared for any potential challenges and plans to implement a rapid responses to new outbreaks. Strong program management and community engagement is still needed.

However, India still has a long road ahead. These strategies that worked to eliminate polio are now being used to encourage routine immunizations. Avoidable illnesses like pneumonia and diarrhea claim the lives of 500,000 children each year.[3] Sanitation in India is also a huge problem with 60% of Indians not having access to sanitation facilities. The sanitation crisis increases the likelihood of diseases spreading and could lead to polio rebound.

[1] Basu, Moni. “India Beats the Odds, Beats Polio.” CNN. Cable News Network, 27 Mar. 2014. Web. 21 Nov. 2014.

[2] Weiss, Jonathan. “Polio Eradication Set For 2018, Why So Many Setbacks?” Medical Daily. N.p., 25 May 2013. Web. 23 Nov. 2014.

[3] Pneumonia and diarrhoea: tackling the deadliest diseases for the world’s poorest children. UNICEF, 2012.

Polio Elimination in Uttar Pradesh: Dream or Reality?

 

Although eradicated in developed regions of the world, such as the entire Western Hemisphere and Europe, poliomyelitis (or polio) never truly stopped effecting India. The international public health effort to eliminate all cases of polio and vaccinate infected persons began in 1988 via a collective effort on behalf of the World Health Organization (WHO), The United Nations Children’s Fund (UNICEF), the Rotary Foundation and The United States Centers for Disease Control (CDC). Each organization contributed differing yet complimentary resources and expertise in ultimately facilitating The Global Polio Eradication Initiative. Since 2012, an impressive 99.9% reduction of polio cases has been achieved. Yet, in spite of this substantial reduction rate some countries such as India continue to be at risk.

The Indian state of Uttar Pradesh in particular has succumbed greatly to polio. For instance, in 2002 alone, 1,242 of 1,600 cases of polio in India occurred in the Northern providence of Uttar Pradesh. Historically speaking, Uttar Pradesh has remained economically crippled, with large portions of its population living in poverty. The region’s status of healthcare services parallels such poverty – having the second highest prevalence of malnutrition in children less than three years of age in comparison to any other Indian state or territory. Given Uttar Pradesh’s population density as India’s most populous state and its prevalence of diarrhea-related illnesses, vaccine and immunization coverage have proven less effective.

By 1985, India as a whole exhibited high prevalence rates for polio and was in dire need of eradication efforts. In response, governmental campaign efforts to combat polio, predominately amongst children, and make vaccination readily available were coordinated and since implemented. These public health initiatives and vaccination programs yield some successes – but not without some adjacent concerns and limitations.

India’s polio immunization campaign began locally. WHO’s Southeast Asian regional office in New Delhi aimed to implement public health strategies that had proven successful in the Americas in India. However, the assumption that any supposed “best practice” method would function as one-size-fits-all program by which to implement is foolish thinking. Regional differences must be taken into consideration in order to execute more appropriate programs in the future. Also, the monitoring of house-to-house activities in terms of calculating immunization coverage may have been an ultimate waste of time and human resources. The mere 2-3% increased coverage may arguably fail to justify such efforts in the future. Additional limitations concerned the cold chain coordination and storage of an already limited vaccine supply.

Despite these hurdles, Utter Pradesh’s polio immunization campaign increased vaccination coverage and data surveillance. Recent developments pertaining to current polio rates in Uttar Pradesh and India in general are promising and reiterate the importance of how collaborative public health efforts can yield a considerable collective impact. In this way, polio elimination has made strides in India and in time the dream of a polio free India may eventually become a global health reality.

Lessons we learn from the India’s of the world

By Shahela Sajanlal

The most recent election that took place in India earlier this year was termed to be one of the most complex management exercises. It cost the country over $ 600 million, was carried out in 9 phases, over 45 days, in over 500 constituencies, where 800 million people were eligible to vote, with over 900,000 polling stations using over 1 million electronic. A mammoth production the country was able to pull off successfully. In spite of the lack of infrastructure, resources and awareness, I believe there has to be something the world can learn.

In comparison to an election, running a focused polio eradication program with a much smaller population seems much easier, but take a look at these numbers from a program implemented in the 1980’s in India – An estimated cost of $ 30 million, 125 million children under the age of 5, 300 million doses of OPV (needed to be kept in a cool place), now does not seem simple either, but it worked even though it was a long time ago. The graph below shows the remarkable progress of polio eradication in the country since 1980.

Screen Shot 2014-11-22 at 7.01.21 PM

In spite of poor health infrastructure, over populated cities, a big population living below the poverty line, it seemed like something was going well. The model adopted for the program was simple and focused. Today this model is being referred to and replicated in similar situations where programs need to be run at scale. The goal and strategy for the program was straightforward:

– Immunize every child below the age of 1 with at least 3 doses of OPV (orally administered polio vaccine )
– Run National Immunization Days and House to House Campaigns that would serve as a vehicle to pursue the consistent effort
– Surveillance of AFP (Acute Flaccid Paralysis) to identify reservoirs of where the disease persisted

I could talk about the plans, the logistics, the resources used and the challenges faced, but I would like to offer something simpler. The model proved that simplicity, thoughtfulness and persistence can achieve large scale and sustainable impact. Some of the most important elements of the program that can be associated with its success were:

Meeting people where they were: The campaign used local religious leaders and community milk sellers to influence people. The state of Uttar Pradesh, where the program was implemented successfully, is one of the poorest states in the country, with a high rate of labour movement. Campaign workers would target families at the train and bus stations, when they were moving to find work or at religious places where people spent a lot of their time. Even though the campaign had specified days where people would come to the booths, they had simplified their distribution model to a large extent and were going where people were.

Coordinated effort through a strong workforce: The Government of India along with WHO set up NPSP – National Polio Surveillance Project also joined by Dr Banerjee who was involved in the fight against polio initially. Given their strategy the program’s biggest asset was their workforce. They provided government employees time to work with NPSP, the CDC also provided employees and shared costs to run the program. Funding initially came from Rotary International, a non profit organization with members from middle class and upper middle class families. The WHO and UNICEF provided program support, technical expertise, strategic planning and logistical expertise for implementation of the program. It was not only about the big names being involved, but was also about people on the ground who ran the program.

Simple Solutions: A black mark on the child’s finger to indicate that she had been immunized helped in more accurate data collection. At that point the campaign may not have had a more efficient way of marking a child or a house that they had immunized, but this was simple and effective way to tell. Today, if we were to come up with a method to track data from a program, we wouldn’t look beyond technology, which isn’t always the best option.

Having offered this angle to one of the most successfully run global health programs, I do not intend to undermine in any way the amount of expertise – both technical, program related and medical that would have gone into this effort. It was a well structured and organized effort, detailed logistical plans in the hands of field workers that helped the program. It is creditable what the program was able to achieve. In each national polio campaign, 2.3 million lakh vaccinators, led by 155,000 supervisors, visit 209 million households to immunize 170 million children up to the age of 5 years.

According to BBC’s article, Rukshar Khatoon is India’s last polio patient.Screen Shot 2014-11-22 at 8.04.40 PM

We realize soon enough that everything going forward does not have to be about BIG data, connecting the world, scalable technologies – though each of these have a big impact on health and on the world, some things are still about using simple and straightforward methodologies.

Waivers and Exemptions of User Fees for Health Services: The Debate Shall Continue

By Gelila Getaneh

Governments have the responsibility to provide health care to their citizens and finance their health systems. Yet, we know that some have had the ability to invest more than others. Low and middle-income economies experiencing a large population boom have been forced to come up with innovative fundraising mechanisms to fund their health systems – and most countries implemented informal and formal user fees. The World Bank argues that this can be a powerful tool for financing, as it allows allocating resources according to the need of the health care system. Moreover, countries have the obligation to offer a waiver or an exemption to people that can’t afford to pay the fees; so it argued this would also eliminate the access issue.

However, current evidence from countries like, Tanzania suggests that waivers or exemptions have not increased equity in access and in financing of health services. For example, people who had these “privileges” were not visiting health centers more than other people in their community. In addition, waivers and exemptions did not address the issue of demand; so there were poor people with exemptions, but did not have the opportunity to receive health services. Most of these countries don’t have the means to differentiate between the poor from the non-poor; so implementing these policies has been difficult. Also, opponents point out that the quality of the health care service in these countries needs to improve before implementing these types of tools.

On the other hand, supporters of waivers and exemptions advocate for the strengthening of these type protection mechanisms. They argue that private hospitals or clinics do not have the incentive to waive fees for the poor people; so it is important for the government to make this decision. After comparing the waiver systems between Tanzania, Thailand and Cambodia, researchers said these programs could work, as long as, they are implemented correctly. For the most part, the protection mechanisms in, Thailand and Cambodia are working properly; so it might be easy for other countries to adopt the same model.

Countries have tried different approaches to make access health care fairer. Since, the World Bank introduced the idea of user fees, many developing countries have tried to implement the program, but it is very clear that some countries are definitely doing a better job than others. So, while the debate on waiver and exemption of user fees continues, researchers and countries must come together and see how they can strengthen this model in countries that have been “unsuccessful”? Of course, at the end governments are the only ones that should decide their health financing policy.