April 23, 2014
CDDEP talked to Dr. Adel Mahmoud about the recommendations of the Lancet Commission on Investing in Health’s Global Health 2035 report. Dr. Mahmoud is a Global Health 2035 commissioner, a professor at Princeton University’s Woodrow Wilson School of International Affairs and Department of Molecular Biology, and a CDDEP board member.
CDDEP: Though one might expect low-income countries to have the highest burden of infectious disease, Global Health 2035 points out that two-thirds of TB and AIDS deaths actually occur in middle-income countries. Why is this?
DR. MAHMOUD: This occurs for multiple reasons, the first being that there is no concerted effort to control or prevent the spread of disease in these countries. Second, the tools aren t available or accessible. With TB, for example, we have a few reasonably effective drugs, but they must be taken for six months to treat the disease and the bacteria that cause TB are becoming increasingly resistant. Third, the interaction between TB and HIV is making both infections very difficult to control.
CDDEP: What exactly is the interaction between TB and HIV?
DR. MAHMOUD: HIV suppresses the immune response in infected individuals, which makes them more susceptible to TB infection. The interaction between the two infections has become a major challenge in the areas where the two infections coexist.
CDDEP: What strategies exist for middle-income countries specifically to achieve the “global convergence” outlined in the report?
DR. MAHMOUD: In some ways the problems for the poor in middle-income countries are problems are even bigger than those in the low-income countries something the report acknowledges. Many middle-income countries have very large populations; the poor in these countries are at a major disadvantage.
Meanwhile, major global efforts such as the Global Fund or GAVI focus more on low-income countries. This is a reasonable approach the low-income countries need to be prioritized. But if you start looking at the poor in the middle-income countries and you see that their number exceeds the population of the low-income countries, then you have a very serious problem how are you going to reach those people? What system will raise the profile of these issues? That s another dilemma that we re facing. The global attention is always on the poorest of the poor, but you eventually must realize that the poor in middle-income countries also present a significant problem.
CDDEP: Certain programs through the WHO, or other organizations or governments, focus on sending travelling health professionals to remote areas or training local volunteers to manage clinics where people in these areas can access medication for malaria or other diseases without travelling hours to reach the nearest doctor. How do you feel about such initiatives?
DR. MAHMOUD: These are commendable efforts, but we will need to do a lot more than that. What is needed are both global efforts and national efforts. These countries must identify the problems and demonstrate and learn to focus on and prioritize these problems. As is written in the report, the amount of wealth that is now available in MICs is much higher than it was when the World Bank released the World Development Report in 1993. You are not dealing simply with an issue of poverty, but rather an issue of spending resources in a balanced way and recognizing the need to prioritize health as an investment in the future. As we say in the report, all governments need to consider these points
CDDEP: How does the report suggest low- and middle-income countries deal with the dual burden of disease and the rise of non-communicable diseases (NCDs)?
DR. MAHMOUD: The report addresses these issues on several levels. One is prevention or an attempt at prevention. Global Health 2035 identifies a few things that can be done easily. For example, if you increase the price of cigarettes, people smoke less. The government can achieve these results in very little time by simply passing legislation. In the report, we propose increasing taxes on three products: tobacco, alcohol, and sugar. Reducing the consumption of these three things in the developing world would have a major impact on NCDs.
CDDEP: How does antimicrobial resistance factor into the recommendations of the report?
DR. MAHMOUD: We believe there are two issues that could present a major problem in the future even in the next decade or two vis- -vis infectious diseases. There will either be a pandemic or an expansion of antimicrobial resistance. There has to be a concerted global effort to deal with either of these issues.
With regard to antimicrobial resistance, this should include the restriction of use of antimicrobials in animal feed, for example. At least on paper today, the Europeans have a clear-cut position and have already banned the non-therapeutic use of antimicrobials in many countries. The US Food and Drug Administration has also made recommendations to this effect. We need to make a concerted effort to block the indiscriminate use of antimicrobials, to ensure the proper use of these drugs in treatment, and to promote clear-cut research programs that aim to discover new antimicrobials.
Most, if not all, antibiotics that we actually use today are molecules found in nature. We took them over, experimented, increased their effectiveness, and are using them in very large doses. This has given way to a major question: in nature, where antibiotics are naturally used to create a balance between species, we don’t see resistance developing, but in clinical settings we do. Why is this? We ve done something in the clinical setting that amounts to indiscriminate use. What s needed is the discovery of absolutely new classes of antibiotics. This is unfortunately not a research program that will deliver immediately, but it needs to start today because we have no alternative.
