Perspectives on Global Health from Pharmacists Around the World

As healthcare continues to morph and adapt based on the requirements of kind, compassionate, evidence-based care, pharmacists are playing a vital role in ensuring patients needs are met in countless regions across the earth. In this four-part IH Blog series, these roles accompanied by profession-related challenges and pharmacist-led global health initiatives will be explored within a profession that is often underappreciated. The following perspectives, shared by practicing pharmacy professionals from the United Arab Emirates (UAE), India, Cambodia, and the United States of America (USA) aim at highlighting various aspects of healthcare that should be properly addressed by governmental bodies, NGOs, and all stakeholders by both sustainable political will and empowering solutions. This initial segment focuses on medication access in each of these areas and the thoughts that pharmacists from these respective nation states have been willing to share with IH Connect.

Throughout both developed and developing healthcare systems, access to medications is consistently a top priority for pharmacists and health care systems. As this health care profession attempts to provide services that meet the needs of their communities, access deficiencies habitually impede the ability to follow through with individualized and compassionate care. The lack of access to life altering chemical entities can affect anyone anywhere, from an affluent metropolitan city like Washington D.C. to a small rural Cambodian village in the province of Kampot. Despite the differences in these locations, each of these instances cause significant harm, breed mistrust in healthcare professionals, and create despair among those that seek healing. These frustrating situations are due to intensify because of the increased strain on medical resources who take a “do-what-has-always-been-done” approach. These following four pharmacists, all from various corners of this vast planet, will describe the barriers they consistently face regarding medication access and initiatives that are being undergone to ensure that a novel approach is commenced to address this looming medical tragedy.

Nazgul Bashir, B. Pharm

Registered Pharmacist – Super Care Pharmacy

Dubai, United Arab Emirates

Before discussing medication access in the United Arab Emirates, I would like to give a brief introduction about the United Arab Emirates (UAE). It is a middle eastern country with a population of 9.68 million. The country is comprised of seven emirates and healthcare in UAE is regulated both federally & at the Emirate level. 

Now, starting with the topic on hand about medication access in UAE, there are several factors that have an impact on it and I will touch on them individually and in detail. 

First and foremost, I think the most important factor is the number of medications available in UAE. The majority of medications available in UAE are imported drugs. UAE imports pharmaceutical products from 72 different countries. Of those, 10 countries constitute approximately 80% of the entire country’s supply. The domestic sector is rather small; however the UAE Ministry of Health (MOH) plans to increase the number of pharmaceutical manufacturing facilities to 30 by 2020 up from 16 in 2017. Availability of different medication combinations or different strengths are difficult to find due to the limited number of industries in UAE. One such example is oral prednisolone, which in UAE is available in strengths of 1mg, 5mg, 10mg & 20mg. In the USA, there are more strengths available including 1mg, 2.5mg, 5mg, 10mg, 20mg and 50mg. Tourists or expats coming from overseas that need a particular medicine or medicine combination or a particular strength may not find it available.

The second hindrance to medication access is the cost of medications. There are many reasons for the high cost medication. The aforementioned fact that about 80% of medications in UAE are being imported rather than locally manufactured is one reason. Another reason is an insignificant availability of generic medicines as the majority of medicines available are brand name. The final reason is the national health insurance model. Because all national citizens do not have to pay for their own medications, there is no incentive to keep the medicine prices low. As a result, individuals who are not insured under the public national insurance system, for example expats and tourists, face a huge barrier to obtaining medicines. 

With these barriers in mind, initiatives have started to take place in UAE to find a solution. The government reduced 24% of the prices for 8732 medicines over the course of 6 years. Another initiative which took place is increasing the number of generic medicines while also advising physicians and pharmacists to dispense the generic rather than the branded medicines. Through this initiative, generic medicines now account for 30% of the overall pharmaceutical market which has increased from 12% of the market two years ago. If the UAE can bump these numbers up to 70-80% of the overall market in UAE, the UAE will be seen in better position in terms of generic medicines. 

I am glad to be a part of a region where these issues are actively tackled, not just by the government but by private sectors as well. We are also seeing that pharmacists are playing a larger role, providing information on availability of cheaper alternatives on medicines. Pharmacists are the most accessible healthcare professional and it should be part of their responsibility to help make medicines as accessible as possible to their clients.

 Dr. Bryce Adams, Pharm D., RPh.

Oncology Medical Science Liaison

Washington D.C., United States of America

Although there are a host of issues surrounding access to medications, I will be focusing on oncology medications as oncology is my current specialty as a medical science liaison in the USA. 

To begin, I would like to highlight encouraging statistics that show the accessibility of oncology medications in the USA. A recent 2019 study found that 96% of new cancer medications were available within the United States, the next highest nation was at 71%. Furthermore, the average delay in the availability of cancer medications within the United States was 3 months, with the next closest nation being at 9 months.

In terms of novel and innovative treatment options, oncology drugs have been increasingly approved by the Food and Drug Administration (FDA) throughout the last few years. The FDA has enacted policy changes to attempt to increase the efficiency of drug reviews. The results have been significant – in 2017 alone, 46 new oncology drugs were approved. Moreover, from 1991 to 2016 there was a 27% decrease in cancer related deaths in large part to the expanded and more targeted-based therapy. The chance that a patient will live for 5 or more years has increased by 41% since 1975.

Outside of regular treatment options of those living with cancer, patients have the ability to participate in a clinical trial. Currently, there are 24,351 clinical trials listed as active (defined as not yet recruiting, recruiting, enrolling by invitation, or active) – 11,813 of those trials are active in the United States. However, even with the surplus of ongoing clinical trials, it still seems there is a lack of patient enrollment. It is estimated that roughly 70% of patients are interested in clinical trials, and yet <5% of patients actually enroll in clinical trials. Some of these barriers to enrollment include: lack of availability at a specific clinic, lack of a specific trial available, patient ineligibility, physician is unaware of trials/not offering them to patients, and a patient deciding not to enroll in a clinical trial (perhaps due to a fear of receiving the placebo).

An aforementioned barrier to cancer treatment that needs to be emphasized is the locations of specialized cancer clinics. Studies have shown that patients who are diagnosed with advanced staged cancer are likely required to drive an hour or more to the nearest cancer clinic for the appropriate care they need. Additionally, travel distance may affect treatment decisions. A patient may select a slightly less efficacious therapy if that means they have to travel less often. 

Two initiatives have recently been instituted to further increase the accessibility of medications. First, in an effort to go towards value-based contracting, some companies are beginning to only charge patients if their medications are effective. While this is a rarity, it will be interesting to follow the impacts of this on other more costly treatments and to determine the impact on patients. Secondly, in 2018, the right to try act was passed. This essentially gives terminally ill patients who are unable to enroll in a clinical trial and have no other remaining FDA approved options, access to other treatments. While this is a relatively new policy and there are some restrictions, hopefully it will give patients hope and additional treatment options. 

Dr. Moeung Sotheara, Ph.D. 

Clinical Research Assistant & Part Time Lecturer – University of Health Sciences

Phnom Penh, Cambodia 

In rural Cambodia, access to medication is especially limited when compared to urban areas. Access is limited by two main factors in these communities. Firstly, many people living in rural areas have low incomes which means it is difficult for poor rural individuals to buy medicines for serious illnesses. Secondly, community drug outlets and public health facilities are generally concentrated in the provincial capitals/cities, making it difficult for people from rural, remote areas to get access to those places. 

Usually, medicines imported from other Asian countries such as India, China, Vietnam, Thailand, or Malaysia are cheaper and therefore, more accessible. These cheaper medications, however, tend to be held toward a lower quality standard which can lead to disease state progression, antibiotic resistance, and other situations that can inflict harm onto patients. However, western brand medicines, which are usually held to a higher standard of quality, are less accessible because their prices are higher. Locally, they are generally considered “medicines for the rich.”

The lack of access due to  these aforementioned barriers makes diseases difficult or impossible to treat in cases where medication is necessary to cure it. Patients may see their disease aggravated and could die of it.

In order to address these medication access complications, a specialized team should be created that assists patients or their relatives to get medication which is far from their home and provide a specific loan with very low or no interest rate for villagers who cannot afford to buy medicines. This approach has been initiated in Cambodia through the increased access of health equity funds (HEF). These funds, allocated to individuals unable to afford the out-of-pocket expenses for public services, are pooled from a variety of sources like the national health budget and various donors. These patients are then given a specialized card to receive these funds when public services are used. The HEF focuses on addressing low medication access through the initial financing as aforementioned, community support, quality assurance, and finally policy dialogue. The results of this project have been promising – there was a 28% increase of patients utilizing public services with HEF than before without the HEF. In addition, the patients were not perceived to be more stigmatized within their communities.  

Veda Peddisetti, B. Pharm.

Clinical Pharmacist – Satya Sree Clinic & Diagnostics 

Hyderabad, India 

India is the largest country in South Asia and the second most populous country (1.35 billion) in the world. In addition, India is said to be in the third stage of demographic transition with birth rates declining and death rates decreasing. In the past few decades, India has experienced monumental population growth. This has led to many problems in healthcare management throughout the country, in particular, medication access. The direct cause seems to be the over-demand of medications. However, various indirect causes include poverty, varying per-capita incomes, unemployment, and out of pocket expenditures (India doesn’t have an established federal healthcare insurance system like Medicare in the USA, National Health Service in the United Kingdom, etc.).

In addition to the aforementioned causes, the literacy level in villages and rural areas are quite low. Many of the farmers and laborers from rural India are uneducated. As a result, many don’t know how medication can help them get better and how important it is to take medication every day to keep chronic conditions like hypertension and diabetes in control. In urban areas, all income classes are more educated and are given awareness more frequently about healthcare when compared to individuals in rural areas. So, they tend to use medication and other healthcare facilities more frequently. Accessibility is not a huge issue in cities but this creates competition among providers and results in high costs which turns into a problem for low and average income communities of the urban population.

Usually, regular medications like anti-diabetics, anti-hypertensives, common antibiotics, analgesics, vitamins are available throughout the country except in some deeply located tribal areas. Medications which are used for some cancer chemotherapies, auto-immune diseases, and some orphan drugs are not widely available. People have to go to highly rated hospitals in developed metropolitan cities to get these medications, and I believe this scenario is the same anywhere in the world. This kind of accessibility shouldn’t affect any patient or healthcare provider unless there is any medical emergency. And thanks to the continuous efforts of the Government of India, India is improving the accessibility of medication. Recently, various health benefit schemes were implemented like free supply of in-patient medications in civil hospitals and sale of reasonably priced generic medications in rural and urban communities.

It is a well-established fact that India is a potential supplier of medications to many countries in the world. India is a manufacturing and research hub for many reputed pharmaceutical companies. However, this often leads to pharmaceutical companies who are exporting their products in large quantities rather than supplying them domestically. These medications range from certain medications for chronic diseases like diabetes drugs to life saving medical devices like the Epi-Pen. These pharmaceutical companies more interested in profit are preventing the Indian population from getting the best medications.

With the lack of proper medications, healthcare professionals cannot take the proper steps in patient care that they could actually do if they had adequate access to medications. So, it is vital to educate people of India, especially the rural population, while simultaneously framing and implementing some regulations and limits on the export of medications by pharmaceutical companies in order to improve healthcare in India.

Repurposing Medications: Reimagining Treatment Options

Last month around the Chinese New Year holiday, a prominent Chinese scientist from Guangzhou Medical University made an announcement that stirred controversy both domestically and internationally while also highlighting a route to combat ailments that global academia and pharmaceutical industries have been attracted to for years. The scientist revealed that his team had been injecting patients with a malaria-causing parasite in order to cure a range of cancers – with two patients seeming to have no cancer cells remaining at the site of tumor and five additional patients having no disease progression out of ten total patients receiving this malarial therapy for at least a year. Although this type of treatment has been attempted in the past in an attempt to combat HIV in the 1990s, the Centers for Disease Control (CDC) and other health governing bodies determined that there was insufficient pre-clinical data to justify human trials during this time period. The controversy revolving around this announcement encompasses the aforementioned determination by CDC, the release of trial results before being published in a peer-reviewed journal, and, most importantly, the possibility of creating a malaria public health emergency for a country due to eradicate the communicable disease by 2020. Although the scientist who underwent this study clearly abdicated internationally conferred health principles, this avenue of repurposing – repositioning, re-profiling, re-tasking, etc – medications and therapy is becoming more appealing to those invested in novel treatment options for both established and emerging diseases.

Throughout the development lifecycle of new chemical entity (NCE), the process for regulatory approval could span over ten to fifteen years with an associated cost of over 2 billion dollars. This has led to an average of only 20 to 30 NCEs being approved by the Food & Drug Administration (FDA) each year. However, through repurposing medications, the development span can be cut to five to eight years at approximately 60% of the total NCE cost – in addition to higher approval rates from regulatory agencies. This repurposing process, as shown by the statistics, is enormously appealing for pharmaceutical companies/investors, but also provides targeted therapy for patient’s disease states at a theoretically lower price than an NCE. Even for rare genetic diseases, repurposing has become common due to only 400 medications being on the market to treat over 7000 genetic conditions. Repurposing is accomplished through the theory of translational research which takes a look at basic scientific discoveries and determining how a medication can be made to match this discovery – for example, examining the molecular pathway of diabetes and then matching it with a chemical entity that has an effect within the pathway like glucagon-like peptide 1 (GLP-1). The known chemical entities are commonly stored in giant databases within academia and the industry. Through big-data analytics, advanced modeling, and high throughput screening techniques, these chemical entities can then be extracted from the databases and determined if it has a possible role in a certain molecular pathway.

This method of establishing novel treatment options ought to be utilized more frequently and effectively, though there are medications over the years that have undergone this type of approval. The following are examples of already approved medications and others undergoing clinical trials:

Approved Repurposed Medications:

  1. Thalidomide, which was originally developed as a racemic mixture of enantiomers for the treatment of morning sickness but found to be teratogenic due to the effect of the (S)-isomer, was later successfully developed by Celgene as a single (R)-isomer product for the treatment of leprosy and multiple myeloma.
  2. Viagra (Pfizer’s sildenafil) was a drug that initially failed as an angina treatment in clinical studies; however, during these trials, its effect on erectile dysfunction was noted and then later approved for this indication.
  3. Celebrex, commonly used in osteoarthritis, works by inhibiting COX-2 receptors. Recently it has been shown that for patients that previously had colon cancer, taking this agent can reduce the risk of additional polyp formation without negative gastrointestinal effects associated with existing treatments.
  4. All-trans retinoic acid (ATRA), which is an acne medication, when combined with traditional chemotherapy, results in complete remission of acute promyelocytic leukemia in 90% of treated patients.
  5. Tamoxifen, a hormone therapy medication, treats metastatic breast cancers, or those that have spread to other parts of the body, in both women and men, and it was originally approved in 1977. Thirty years later, researchers discovered that it also helps people with bipolar disorder by blocking the enzyme PKC, which goes into overdrive during the manic phase of the disorder.
  6. Raloxifene was initially developed to treat osteoporosis, but has since been shown to reduce the risk of invasive breast cancer in postmenopausal women in 2007.
  7. Zidovudine (AZT) was initially developed to treat various types of cancer, but was determined to be ineffective. However, it was repurposed into the first approved HIV/AIDs medications in 1987 and has had a tremendous impact on the progression of the autoimmune disorder.

Repurposed Medications Undergoing Clinical Trials:

  1. The lipid soluble simvastatin is currently undergoing a trial in the UK to assess the efficacy of reducing the progression of Parkinson’s disease. The statin drug class is thought to prevent this ailment through its pleiotropic effects including reducing inflammation, reducing oxidative stress, reducing the formation of sticky bundles of alpha-synuclein, and increasing the production of neurotrophic factors. The results are expected to be released in 2020.
  2. Purdue University received a grant from the National Institutes of Health (NIH) to discover the effectiveness of Ebselen, a chemical entity, against methicillin-resistant Staphylococcus aureus (MRSA), and auranofin, which is FDA-approved for the treatment of unresponsive rheumatoid arthritis, against Clostridium difficile.
  3. Metformin, a first line agent for many diabetics, has been shown to reduce the risk of breast cancer in diabetes patients and is being investigated as a treatment for cancer in many different clinical trials

Although this is certainly not an exhaustible list of the impacts repurposing has had on healthcare, the majority of this repurposing stems from serendipitous observations rather than targeted interventions. Through these unanticipated occurrences, a range of disease states can now be more effectively treated ranging from communicable diseases like HIV/AIDS to mental health ailments including bipolar disorder and Parkinson’s disease to non-communicable diseases. As the rising cost of healthcare continues to devastate humanity and lead to health inequalities, heads of governments, pharmaceutical industries, academia, and nonprofits need to commit themselves into investing their time and resources into this repurposing method. The targeted repurposing interventions are more vital and should be devoted to in order to expand options for health disorders rather than the unexpected observed effects. The financial and health outcomes will lead to novel treatment options accessible to a majority of the world which will allow health care professionals to properly accompany their patients through their disease state.

The Future of HIV: Novel Treatment Options & A Possible Cure

As the medical community and those it serves welcomed in a new year, it brought with it the hope of scientific advancements that will alter the course of certain disease states. These advancements include the use of stem cells to treat to treat macular degeneration, novel microscopic techniques to capture images of the brain, the continued observed effectiveness of the experimental Ebola vaccine, and countless other interventions aimed at creating a healthier global society. Included in these optimisms for 2019 is the possibility for novel treatment options and a possible cure for one of the world’s leading causes of death, HIV. The stories of Timothy Brown – the only individual ever to be cured of HIV, the Mississippi baby and Clark Hawley – both having an extended period of time with undetectable HIV viral load with an interruption of Antiretroviral Therapy (ART), and the Boston patients/Mayo Clinic patient – all three having undetectable HIV viral loads for an extended period of time after a stem cell transplant, have brought much sanguinity to health care professionals and patients alike. However, these exciting results have been unable to be replicated in the majority of the population suffering from HIV and remain unique in their respective occurrences. Although ART has been vital to the HIV community in terms of longevity and quality life, there are still certain populations that are seeking other mechanisms to treat this infectious disease – and, of course, always coveting the idea of a cure. The following is a brief glimpse at the vast pipeline that awaits 2019 and the anticipations of the global healthcare community.  

Combination Approaches

  1. The AIDS Clinical Trial Group (ACTG) is currently exploring the option of combining vorinostat, a HDAC inhibitor along with tamoxifen, which is an FDA approved medication the treatment of breast cancer for postmenopausal women. Utilizing this approach is thought to prevent the reactivation of HIV in CD4+ cells that are latent in addition to increasing the latency-reversal effect of vorinostat through tamoxifen.
  2. Researchers from the USA, France, Germany, Italy, Spain, Switzerland, and the UK are collaborating for a trial testing the combination of two HIV vaccine candidates alongside a monoclonal antibody called vedolizumab. This method of treatment is thought to target a certain protein in the body, α4β7 integrin, that plays a role in transmission of HIV into CD4+ cells. In a macaque model, this combination has shown the control of SIV (HIV but in simians) after discontinuing ART.
  3. At the University of Minnesota, researchers are testing infusions of natural killer (NK) cells with the administration of cytokine interleukin-2 (IL-2). The researchers are hoping to add to the evidence of NK cells being able to exhaust HIV reservoirs and to control virus replication.
  4. In a version of the “kick & kill” method of curing HIV, researchers in Oxford and Barcelona are using a medication to active the latent HIV reservoir while boosting the immune response 1000 times stronger than the usual to rid the body of the virus. Preliminary results showed that 5/15 patients had undetectable viral loads for seven months without ART.

Immunotherapy Approaches

  1. Immunocore, a company founded in Oxford with heavy investment by Bill Gates, has designed T cell receptors that seek out and bind with the HIV virus. These receptors then instruct immune T cells to eliminate any HIV-infected cells, even when the levels happen to be extremely low. Since levels can be rather low in the reservoir of HIV virus that exists in an infected individual, this is a promising lead to completely remove this retrovirus from the body. This immunotherapy has shown to be effective in human tissue samples, but no results being tested in humans have been released.
  2. In France, a company known as InnaVirVax has established a vaccine, VAC-3S, that allows the body to stimulate a production of antibodies against the HIV protein 3S. This, in turn, causes T cells to attack the virus. This is considered a novel approach because it encourages the immune system to recover while equipping it with the tools to continue fighting off the virus. VAC-3S has completed Phase 2a trials, and is partnered with a DNA-based vaccine from FIT Biotech, a Finnish company, that both parties believe can lead to a functional cure.  
  3. In a recently initiated trial, IMPAACT 2008, held in the USA, Botswana, Brazil, and Zimbabwe, a broadly neutralizing antibody termed VRC01 is being investigated for its effectiveness in infants with HIV who are also started on ART within 12 weeks of birth. Although the study aims at establishing the safety profile for VRC01, it is also observing the difference in the HIV reservoir compared with only ART.

Novel Antiretroviral Agents

  1. The manufacturer, ABIVAX, believes it has developed a compound that may help the immune system recognize cells infected with HIV by allowing an increased presentation of HIV antigens on the cell’s service. This would lead to an augmented immune response to abolish these infected cells. This compound has been labelled ABX464 and targets the HIV protein Rev, which is responsible for the transcription of HIV RNA. Reductions of measured HIV DNA have been reported from 25% to 50% in eight of the fifteen patients participating in the study; however, no delay in viral load rebound was found when compared with placebo.
  2. Gilead has created a novel mechanism of targeting the HIV virus through the capsid inhibitors class. Capsids are involved in protecting HIV RNA and related proteins, and capsids also breaks down to release the viral contents into CD4 cells which enable reverse transcription to take place. The novel agent by Gilead, GS-CA1, blocks both the assembly and disassembly of capsids that create non-infectious and defective viruses.

Gene Therapy

  1. Chimeric antigen receptor (CAR) T therapy has been re-initiated in the first cure related clinical trial of this approach in people living with HIV who are on ART. CAR T cell therapy involves the modification of an individual’s T cells that can target antigens of interest. The specific cells modified by the initiative in China, called VC-CAR-T cells, have been modified to target HIV gp120. These modified cells were able to induce the destruction of HIV-infected cells, including latently infected cells exposed to latency-reversing agents, in the laboratory setting.  
  2. With the knowledge of knowing that about 1% of the world’s population is immune to HIV due to a genetic mutation on the gene that encodes for CCR5, US-based Sangamo has begun to edit DNA to introduce the aforementioned mutation. The CCR5 protein is attached to the surface of CD4 cells that allows HIV to enter and infect the cell; with the mutation, it would be impossible for HIV to enter cells. This company extracts patient’s CD4 cells in order to use zinc finger nucleases to edit patient’s DNA to make them resistant to HIV.
  3. Although a highly controversial topic amid the recent publication of the use of CRISPER in twin daughters in China, scientists believe that this tool can lead to a cure for HIV as it is believed to be a much easier, faster, and effective approach than other gene-editing methods. However, the majority of the global health community is in agreement that years of laboratory research and ethical standards need to be established before human trials are properly started.

With the HIV virus adapting and mutating to evade treatments almost as rapidly as the world is producing novel approaches to treating this infectious disease, the drive for continued research and testing should be relentless. These aforementioned examples of novel treatments and possible cures display the creative and diverse thought processes the medical community has put forth to tackle one of the most stigmatized diseases on this earth. However, the ethics behind these trials need to be sound and forthcoming for all of humanity. The trials that occur need to ensure an assortment of demographics including individuals from both developed and developing nations – a subtle form of medical colonialism has no place in the global health community. In addition, trials that enroll patients who willingly accept the benefits and risks associated with the experimental therapy have the moral obligation to supply lifetime treatment if it happens to be effective. The researchers and medical professionals who monitor these participants need to take extreme caution in ART interruptions/discontinuations and certify that the patients realize what complications could transpire due to them. Finally, and most importantly, the interventions that show promise of novel ways to approach HIV or even a cure have to be accessible, affordable, and available to all humans who suffer from HIV. The health inequalities that plague this fragile planet have already been clearly highlighted in this ailment throughout history; the global health community is in debt to humanity for a cure for all when discovered.  

With the global health community’s commitment, the future of the HIV virus continues to transition from infectious disease to chronic disease. While the step that will advance the chronic disease to a cure is still thought to be unknown, the excitement behind the aforementioned gene editing therapy is substantial. The ability to safely, effectively and ethically modify human cells to prevent the entry of the virus into the immune system is certainly the most promising option recently and possibly from this disease’s initial appearance; although, health care professionals haven’t quite figured out how to combine these aspects yet. A cure or even functional cure may be years away, but the global health community needs to continue to accompany those inflicted by this chronic infectious disease to meet the hopes and expectations of alleviating the burdens of HIV.

The Developing World & Non-Communicable Diseases: A Pandemic of Drug Shortages & Inequitable Access

Throughout the developing world, health demographics are rapidly shifting from communicable diseases to non-communicable diseases (NCDs) due to urbanization, lifestyle changes, and introduction of processed food. Although still retaining a significant portion of their communicable disease burden like tuberculosis and malaria, the prevalence of hypertension, diabetes, and cancer in developing countries has increased dramatically and is expected to cause every 7 out of 10 deaths by 2020. With the rise of these health ailments, the global health community has highlighted the importance and severity of these diseases through UN High-level meetings, incorporating relevant indicators in the Sustainable Development Goals (SDG’s), and forming interagency coalitions within countries to address the barriers of NCD prevention and treatment. However, NCD medication supplies have remained an underappreciated barrier that humans affected by global health inequalities confront each day. The complications of drug supplies range from common medications being out of stock to not having a vital class of medications available at the health facility. The medication shortages that plague developing nation states often have a more pronounced effect on underserved populations – essentially causing an impossible barrier to treating their chronic condition and preventing morbidity/mortality.

Last month on November 20thThe Lancet Diabetes & Endocrinology revealed predictions in the year 2030 regarding the world’s insulin supply that stunned health care professionals around the globe. From data gathered recently, the number of individuals diagnosed with Type 2 diabetes is estimated at 405 million people. Although some patients can be treated with oral or injectable diabetic medications like metformin or GLP1 inhibitors, there are approximately 63 million people on earth today that require the use of insulin to manage their diabetes. However, only 30 million individuals use insulin due to availability, affordability, and inequitable access to this essential class of medications. Although these numbers provide a clear indication of the necessity for change in regards to access to insulin globally, the scientists at Stanford that conducted the aforementioned study in The Lancet predicted that the number of individuals diagnosed with Type 2 diabetes will increase to 510 million in 2030 – 79 million of those will need insulin to proper manage their health disorder with only 38 million having equitable access to insulin. These statistics exhibit that, in 13 years, less than half of the people on this planet will be able to access insulin, a medication developed 97 years ago. Though over half of the world’s diagnosed Type 2 diabetics will reside in China, India, or the United States, the study continued and stated that the insulin supply shortage will distress those inhabiting Africa and Asia most significantly. The reasons formulated to explain this health disparity include the fact that three pharmaceutical industries control almost 100% of insulin being manufactured in the world, the complexity of insulin which is a hormone produced by living cells, and generic companies’ lack of interest in producing a biosimilar at an equitable price.   

Cardiovascular diseases (CVDs) pose an implausible health burden on the global society with 30% of all deaths worldwide being attributed to these ailments. Of this mortality caused by CVDs, it is estimated that 80% occurs in the developing world with projections suggesting a steady increase in this percentage. However, with equitable access to cardiovascular medications, approximately 75% of recurrent CVDs can be prevented causing a decrease in both mortality and morbidity for humanity. To determine the access to common cardiovascular medications like atenolol, captopril, hydrochlorothiazide, losartan, and nifedipine, the BMC Cardiovascular Disorders journal published findings in 2010 of a survey within 36 countries. The findings revealed that the drug shortages transcended more complex medications like insulin and affected the access of medications that are considered ubiquitous in the developed world. The analyzed data revealed that of the abovementioned medications in the 36 countries, only 26.3% was available in the public sector and 57.3% in the private sector. The study also stated that in several nations, the wages earned within one working day was insufficient to meet the cost of one day of purchasing treatment. When considering situations where monotherapy is inappropriate, this finding would disclose that treatment would be particularly unaffordable.

When considering access to NCD medications generally, wealth has been a substantial determinant of inequitable access to treatment of hypertension, asthma, cancer, and others classified as NCDs. In many low-income to middle-income countries (LMICs), a wealth gradient has even been observed. In order to gather information to disprove or support this theory, the BMJ Global Health Journal published a study conducted in Kenya in August 2018. The study administered surveys to patients prescribed hypertension, diabetes, and asthma medications and collected data on those medications available at their home, including location and cost of the service. When analyzing the data, the results clearly indicated a wealth gradient for each of the three diseases included in the study in terms of access. As household income increases, so does the likelihood that a family has an opportunity to obtain proper medication. In addition, the results showed that poorer patients had to travel further to obtain treatment than those with a higher income. Finally, and most meaningfully, poorer patients paid more for their medications than their fellow humans inhabiting other parts of the country.  

These global health inequalities are unjustifiable in a global society where the quantity and quality of medications on the market is incredible. The drug shortages and inequitable access differ between the developed world and developing world, but also by socioeconomic stratifications within countries themselves. In order to provide compassionate care to every human suffering from any of these ailments, governments need to begin initiatives to make insulin, losartan, albuterol, and every vital NCD medication available to every citizen in their country. Heads of states, pharmaceutical industries, ministries of health, and health care professionals need to accompany their citizens and patients with a health mindset moving away from health as a commodity to health as a right. Most urgently, universal health care coverage needs to be at the forefront of every national health agenda to properly address this pandemic of drug shortages and inequitable access.

Antibiotic Resistance: Hidden Rates in Rural Areas of the Developing World

When the age of antibiotics commenced in the 1950s, diseases and infections that typically would lead to humans being stigmatized by society, a permanent stay at a sanatorium, and then ultimately death were suddenly able to be treated quickly and efficiently. Penicillin and Streptomycin, not only improved a patient’s quality of life and longevity, but reshaped the very nature of treating infectious diseases. Health care professionals now possessed a cure to end the spread of the ailment and to eliminate the actual microorganism that created the suffering. However, these agents brought with them negative consequences that the global health community is still combating today – antibiotic resistance being one of the most significant issues. Antibiotic resistance is the predator’s (bacteria, virus, other microorganism) ability to resist an antibiotic that once was able to eliminate it. Although antibiotic resistance can occur naturally due to the cleverness of bacteria, fungi, and protozoa, the misuse of antibiotics in humans has tremendously accelerated the rate and severity of resistance. This inappropriate use of medicine and skills has led to difficult to treat infections like Extended-spectrum beta-lactamase (ESBL) producing strains of Enterobacteriaceae and even untreatable infections with no known drug on the market able to help an infected patient. The concept of antibiotic resistance often differs within the medical community when comparing the developed world, particularly urban areas, and the developing world, particularly rural areas. The amount of research, minds, and technology mobilized to address this unruly behavior by microorganisms varies drastically between the two sets.

In the urban developed world where physicians are equipped with the most innovative antibiotics known to man like daptomycin or the “Crispr” agents, antibiotic resistance is frequently a topic of discussion along with funding, human resources, and technology available to address it. Also, common ideology is that antibiotic resistance arises from the direct misuse of antibiotics rather than of natural causes. Contrasting the rural developing world, the aforementioned necessities to deter antibiotic resistance are often lacking due to health inequalities that unfortunately are ubiquitous throughout this fragile planet. More interesting though, health care professionals have formed an impression that antibiotic resistance more commonly stems from the dissemination of resistant organisms. With this mindset ingrained in world health leaders, the agenda has been to focus on prevention through this venue in the rural developing world – often lacking a call of funding to determine actual causes of antibiotic resistance and their associated rates in the rural developing world. While the dissemination of strains of Escherichia coli through feces and Multi-drug resistance Tuberculosis through poor air quality certainly needs to be addressed, the Centers for Disease Control and Prevention (CDC) released a report in 1999 encouraging health care professions to consider a range of socioeconomic and behavioral factors including misuse of antibiotics by physicians, unskilled practitioners, the public, counterfeit medications, inadequate surveillance, and political factors. To follow up with this theoretical account, the World Health Organization (WHO) conducted a survey across twelve (12) low to middle income countries across the world in 2015 to interview the population about their beliefs towards antibiotics and resistance. Some of the results are presented below:

  • In lower income countries, it was reported that antibiotic use is higher (42%) than in higher income countries (29%).
  • Across the countries, the range of patients obtaining their antibiotics with a physician’s prescription ranges from 56% to 93%.
  • The percentage of individuals believing they can use the same antibiotic as a family member did to treat a similar illness is 25% while 43% believe it is acceptable to buy the same antibiotic from a local pharmacy.
  • When patient’s start to feel better, 32% of the those interviewed believe they can stop the antibiotics and not follow through with full course.
  • When treating colds and viruses, 62% of respondents believe antibiotics could be used to treat these ailments.
  • Finally, 44% of those interviewed believe antibiotic resistance is only a problem for those regularly taking antibiotics.

These specific social results from patients in the developing world directly conflict with the thought of the major distributor of antibiotic resistance being through dissemination of the disease. The beliefs presented through these percentages seem to lead to a whole host of factors being involved similar to the developed world. In addition to these social results, PLOS Biology released data in 2018 that Escherichia coli was resistant to commonly prescribed antibiotics like ampicillin (92%), ceftazidime (90%), cefoxitin (88%), streptomycin (40%) and tetracycline (36%) in the rural areas of Sikkim, India in pre-school and school-going children. The Journal of the Pediatric Infectious Diseases Society reported similar rates among children in 2015 with Klebsiella pneumoniae having a median resistance to ampicillin with a rate of 94% in Asia and 100% in Africa, and cephalosporins having a rate of 84% in Asia and 50% in Africa. Also, The World Health Organization informed the global community that in Malawi in 2018, nearly 100% of Neisseria gonorrheae genital isolates were non-susceptible to ceftriaxone and roughly 15% were non-susceptible to azithromycin. When analyzing both the social and technical results from above, a renewed emphasis and novel perspective needs to be created in order to properly address antibiotic resistance in the rural developing world.

At the beginning of this year (January 2018), the World Health Organization released its initial reports utilizing an innovative reporting system for antibiotic resistance christened Global Antimicrobial Surveillance System (GLASS). This system was developed in order to preserve human and animal health throughout the globe in relation to antibiotics and their resistance. Although GLASS was officially launched in 2015, it is still in its early implementation period with only 22 countries reporting on actual resistance within their nation states and 40 countries reporting on their national surveillance program. However, GLASS aims at a variety of measures that will ensure antibiotic resistance is more appropriately addressed in the rural developing world by providing a standardized approach to collection, analysis, and dissemination of information to participating countries. GLASS will strengthen nation states antibiotic resistance surveillance systems and modify the data being studied from solely laboratory data to epidemiological, clinical, and population-level data. The preliminary results that were released by WHO revealed that across the 22 reporting countries, there were 500,000 individuals suffering from an infectious disease with antibiotic resistance. Although this data varies with completeness and accuracy across countries, the outcomes highlight the global emergency antibiotic resistance posses from the urban developed world to the rural developing world and everywhere in between – these mutated organisms will fail to respect national borders.

The global health bodies throughout the world have initiated programs and offered advice to nations that will serve the battle against antibiotic resistance well. However, the concealed rates of resistance in the rural developing world will need to be undertaken medically and socially in order to properly end this global emergency. Pipeline innovative antibiotics like relebactam, a novel beta-lactamase inhibitor and an educational emphasis on behavior habits will aid these parts of the world – but the health community will fall short unless the world changes its perception of antibiotic resistance in the countryside of Cambodia, the rice terraces of Vietnam, the jungles of Belize, and areas with similar socioeconomic status.