Global health expert Laurie Garrett has witnessed the technology used to fight disease all over the world. These are her best ideas for the changes needed to change the world.
Topic: The Battle for Global Health.
Laurie Garrett: I think the state of global health is that all the money that has poured in over the last 8 years, which had been a substantial increase over anything previous to that, has paid off.
I'm Laurie Garrett, Senior Fellow for Global Health at the Council on Foreign Relations.
Question: How much progress have we made on global health in the last five years?
Laurie Garrett: A decade ago, it would have been almost inconceivable that Mexico could have tracked down all the various traces of H1N1 in rural parts of that country, and today it was done almost as if it were a matter of routine. That is extraordinary. We still have a long ways to go, but at least the money and the commitment has panned out to help us at this time.
Question: Is the world prepared for a global flu pandemic?
Laurie Garrett: We don't have a global supply of vaccine. We don't have a global supply of Tamiflu adequate to meet the challenge or a distribution system, and then this global solidarity could quickly fall apart, and we would see rich countries getting the tools necessary to treat, and poor countries not, and real rage and anger and retribution actions akin to what Indonesia has been doing for the last three years, refusing to share samples of bird flu, some viruses, on the grounds that only the wealthy world would profit off of them, and the vaccines would never be available to the poor.
Question: What technologies are needed for improved action?
Laurie Garrett: Well for many years, I've argued that the biggest, most important missing piece were rapid diagnostics. Even here in the United States, if you're sick and doctors aren't quite sure what's wrong with you, and they order basic microbiology tests to see if you have staphylococcus or tuberculosis or what have you, for the most part they are ordering tests performed that haven't improved much at all in decades. The technology is pretty much the same darn crap we've been using to determine whether you have strep or staph, since the '60s.
The irony is that if you go to the academic level, or in the biotech industry, you see tool kits being used now, based on DNA, that are extraordinary that do things like diagnose previously unknown organisms, that we don't even know what it might be. Find it, identify it, put it in a class of viruses and tell you that answer in a matter of hours. And yet these tools are not getting put to use in any routine clinical settings, not in the United States, not in poor countries. This is just an absurd problem.
The reason they haven't been in use, in places like the United States, has to do with insurance reimbursement, with how hospitals structure their whole pathology departments. Just stupid stuff that government or good corporate intervention could fix.
In poor countries, it's still about the cost and the specifications of the test. When you hear, for example, that RCDC has developed a so-called rapid screening test for H1N1, well yes and no. It's rapid in that it takes six hours instead of three days, but it has been performed by skilled personnel inside of a laboratory with relatively sterile hygienic conditions and safety precautions for the scientist that perform it. And it would require a scientist.
What we need down the road is something that is sort of equivalent of a home pregnancy test. If we can pee on a strip and tell you whether or not you're pregnant, we ought to be able to develop something, or the target should be something, where you can spit on a piece of paper, or something very rapid, that can be performed by a rank amateur, by a paramedic, a community health worker, that doesn't require a physician, a trained scientist, a trained lab technician and certainly doesn't require a five million dollar laboratory in order to do those tests.
This gets very profound when you take something that's life or death, like drug resistant tuberculosis. Right now, we have strains of TB in circulation, especially in hard hit HIV belts of Africa, that are basically, utterly incurable, where they have mutated to such a degree that the antibiotics we usually throw at tuberculosis don't work. And yet, because the nature of our screening devices and our diagnostic tool kit, and the cost, we are usually diagnosing this after the person's dead.
We need much more rapid ways of assessing whether or not a child is infected by a drug resistant form of malaria. We shouldn't be finding that out on a populating basis. Meaning, you look at 5,000 kids who've been treated for malaria, a thousand of them died, so I guess the drug doesn't work. That's not satisfactory.
We need a lot more technology dedicated to the pursuit of genuinely rapid diagnostics that are not affected by heat, that can be used in tropical, humid environments, that can be performed accurately by minimally-trained individuals and that don't cost a lot. That's a tough tool kit.
Question: What technologies currently exist?
Laurie Garrett: I actually am aware of several prototypes of rapid screening devices based on DNA that cost about $50 a run, take about three hours to complete. You don't have to stand there for three hours. You start the process, you walk away, you come back three hours later. They're capable of diagnosing. Let's say you had a fever of 102 and some really dire symptoms, you couldn't stand anymore, you were so weak and so on, and we want to know what is infecting you. We're sure it's an infection, but what is it?
Currently, at most American hospitals, the doctor would make a set of guesses and instruct the hospital lab to run this test, this test, this test. Each one of which billed at some exorbitant amount of money.
But there are now screening devices available where a single blood drop; literally we don't need to put a syringe in you to pull out. That's another thing, we want to get rid of syringes because they spread disease. Where you just take pin pricks from your finger, put that blood down little wells, and on those wells are plaited reverse DNA that will pick up conserved segments of genetic material that have to be present in each class of viruses.
I don't have to know, I don't have to guess that you might have Ebola. And I don't even have to guess about some unknown previously unseen organism, but Ebola's part of the filovirus category, and this thing will have little bits of DNA on it that detect whether you have a filovirus and it will come back and say, "All right, it's this class of virus. It does not match a previously known form."
And, in three hours the doctor knows whether we need to quarantine you, whether we have any drug that will work for you, whether we're going to have to give you supportive care, lots of fluid, what the problem is.
Similarly, there are rapid diagnosis that can scream for antibiotic resistance and anti-viral resistance, on a large scale. So you're basically saying, in theory, in the United States right now every hospital, every clinic, could screen your mystery illness with one single test and come back with an answer that would inform the doctor's choice of treatment. And then a second test that would tell you whether the treatment you chose is going to work or whether the organism is a mutant that can resist that drug. None of this is being implemented.
Question: What healthcare systems do it right?
Laurie Garrett: I always like to bring up Costa Rica because here's a poor country dependent on tourism as its primary economic engine, with no key natural resources other than the beauty of the place, but no oil, no big commodities. They have basically the same health indicators as the United States of America. They spend about 1% of what we do. They have far lower per capita earnings and spending for health. And yet they live as long, they have healthier children, skinnier children and the same infant mortality rates, and better rates of vaccination than we do of their children.
And it's because they made that social contract and decisions. And by the way, they don't end up having chosen universal health care as a single payer model. What they end up having chosen is that the role and duty of the government is to the health of its children. Every child from pregnancy all the way through to age 20 has all their health needs taken care of by the state, which includes nutrition, exercise, vaccination, you name it.
After age 20, the state is defined as responsible for primary care but if you need triple-bypass heart surgery you're on your own. It's a cruel formula that a poor country has to make but you can buy health insurance to cover those catastrophic needs like open-heart surgery, and it works.
Recorded on: May 19, 2009.