The Cart and the Horse

December 1, 2006 at 10:23 am (Michael's Posts)

As I creep nearer to the day when I begin medical school, I have been giving some close thought to what exactly I want to be doing in the world as a healer. In other words, which ills do I feel the most drawn to? How can I be of the greatest benefit to suffering beings?
Well, it seems that the Western biomedical institution has some pathways to offer. There are technologies for caring for deadly diseases that are wonderfully effective in many cases. Some of these technologies leave something to be desired, but which system of health restoration does not?
When we of the Western biomedical leaning look at creating solutions for sickness, we often turn to these technologies as the building blocks. And why not? They are proven and powerful tools to battle sickness.
Recently, I heard of a program at a prestigious medical school whose aim is to convince pharmaceutical companies to test and produce vaccines against sicknesses that are common in “developing” countries but that do not affect “developed” ones. The idea is that these are often simple microbes that would be easy to design vaccines for, but Big Pharma balks at doing so because there is no market for them. In other words, people need them but cannot pay. So they are not produced. The idea of the campaign at this medical school is to convince companies that it is worth it to make these vaccines. A nice idea for sure. We care about the indigent and really want to help them in the ways we know how so we ask for vaccines for the diseases that they suffer from.
But do we really need them?
Have we forgotten the most simple lesson of public health? Have we disremembered that pristine water is really the best medicine? Have we become so blinded by technology that we forget that good food is good medicine? I think about going into the countryside in Africa armed with my vaccines and see hundreds of malnourished children lined up to recieve them. I can’t help but think that they might starve before they are stricken by illness. Or that if they were properly fed, that their immune systems would be sturdy enough to withstand the onslaught of disease. Or that if they had clean water to drink that they might not even catch the diarrhea that is shockingly high on the list of things that kills them. What’s really the problem here?
I think we are putting the cart before the horse here. It is paramount to have clean, sustainable sources of water. Once communities have this, then we can worry about which vaccines they can or cannot pay for. After they have clean water, they may not even need them because many of the target diseases are water-borne. So I am adding my voice to Sarah’s. Clean water should be the real concern of the health professionals of our generation interested in raising the basic level of health in poor countries.
It’s not sexy to call for food and water. There’s no technological trick. But there is a policy trick. And it’s up to us to be the ones to start raising our vocies in support of these basic improvements.

Sorry it’s been a while. Thanksgiving break and travelling for interviews have taken a huge chunk of my time and energy.



  1. acoria said,

    Vaccines are by far the most cost-effective way to prevent vector- and airborn infectious diseases such as malaria , tuberculosis, pneumococcal disease, AIDS, dengue, etc, which will kill and maim millions regardless of whether people have clean water. (Largely because of the AIDS epidemic.) I suspect that this medical school focuses on trying to get pharma to fund vaccine research into the “big three” (AIDS, TB, malaria), which cost the world billions of dollars and DALY’s yearly, which primarily affect the developing world, and for which no easy cures are available. Health depends on more than just water – it’s often about politics, corruption, and effective service delivery. We middle- and upper-class Americans don’t stay healthy and get fat because we have enough to drink – we also have a relatively transparent and responsible government (note the “relatively,” please, before you comment), excellent primary health care, we get vaccinated, and we can afford medicines.

    Also, keep in mind that no vaccine is simple; they take years and years of research and development, years during which basic infrastructure must be built up, governments must get their act together, and countries must prepare themselves for the advent of a vaccine. The point isn’t just that vaccines are expensive to produce; the point is that billions of dollars are spent every year on industrialized-world diseases, when millions and millions still die from infectious diseases that can be controlled in the industrialized world. Shouldn’t there be parity there?

    Clean water for all is certainly a priority for the world, but so is AIDS, and so are other widespread infectious diseases. Shall we tell people that the effort to develop a malaria vaccine, an effort that is on the cusp of fruition but is vastly underfunded, and could save a million lives a year, should be halted because we think it’s more important that they get a clean glass of water to drink? If children in Africa and Asia could be free of malaria, they could be free to go to school, where they will learn how to clean their water, and bring that knowledge home. Mothers could spend money, up to the 25% of their income that is spent on malaria treatment and prevention a year in some places, on improving the sanitation of their homes and the education of their children.

    My point is not that vaccines are a cure-all, but that efforts like this one at Med School X are an essential part of the cures to these dread diseases, diseases that have no simple solutions. Do people need clean water? A resounding yes. Do they need vaccines? Yes to that one too.

  2. Jessica Pickett said,

    I think that this post is conflating several different policy questions: 1) what is the greatest global health need; 2) what are the most cost-effective global health interventions; and 3) what are the comparative advantages of a specific stakeholder in implementing policy solutions?

    Question 1 & 2 were the focus of the Disease Control Priorities Project, and according to their findings, unsafe water, sanitation and hygiene account for approximately 3.5% of the burden of disease in developing countries. That is a lot, to be sure – but still less than the share caused by communicable diseases for which vaccines are or will soon be available. DCPP found that both improving water supply and immunization are very cost-effective interventions, with the cost per DALY – and the inherent trade-offs – varying by region.

    However, I think the real issue is question 3: Given that a U.S. based institution wants to leverage their influence to improve global health, what should they focus on? Here I fall squarely on Alex’s side. Access to water is at its very heart a systemic issue that depends on the country context and needs to be incorporated into broader infrastructure. Its solutions are much more complex; in fact, the health policy community has yet to reach consensus on how to even measure “improved water supply” (see Measuring Commitment to Health for detail). And the U.S. medical establishment lacks any transferable expertise from the domestic sphere. In contrast, medical schools and teaching hospitals have vast experience with the pharmaceutical industry, from intellectual property licensing to clinical trials to reimbursement incentives. So in my book, it’s clear that their comparative advantage falls in the latter category.

  3. msoule said,

    First of all, you must understand that my post is not railing against vaccines. Personally, I am a fan of vaccines. People should have them. However, there are problems better solved by other courses of action than a vaccine.

    I am talking about vaccines that are not like one for malaria or tuberculosis or HIV. These organisms are all incredibly difficult for the immune system to “see” which is why they are so infectious. These vaccines have taken decades of work hours and millions of dollars already and I am not convinced that we are much closer to an effective vaccine agent for any of them. I will be happily surprised if a safe, effective, practical vaccine is invented for any of them, but until then, I retain my skepticism.

    I am talking about vaccines for little things like rotavirus (a diarrhea-inducing pathogen) which we here in the states simply treat with electrolytes and rest but which can kill children if there is no such thing as clean water to mix the electrolyte solution in. We don’t even think about a vaccine here because it’s relatively benign. To us. In Africa, it kills hundreds of thousands, if not millions, of children a year. In the US, it kills a handful a year because we can treat it. With water and sugar and salt.

    There are millions of TB carriers in the world who are asymptomatic because their immune systems have a dynamic equilibrium with the bacilli. When these individuals suffer great stresses (like other illness, malnutrition, etc), the immune system loses its grip in the tug-of-war and the bacillus breaks out. However, with proper nutrition and good public health, these carriers potentially remain asymptomatic. Asymptomatic people are also non-infectious. The reason HIV and TB are so closely linked is because HIV destroys the immune system that is keeping the TB in check. Hence, potentially asymptomatic people get ravaged by this truly awful microbe. The solution to TB? Raise living standards.

    A malaria vaccine may be a solution to this scourge in Africa and Asia. Even though in wealthier parts of the world it was controlled by public health measures, I recently heard a talk given that escribed qualitative differences between malaria in the Southern US and Europe and malaria in Africa and South Asia and am becoming convinced that maybe these same measures can’t work there.

    However, I am still skeptical. Any patient healthy enough to withstand the course of intense antibiotics that is used in the “developed” world to root out this bug once it’s in you can be cured. Arguably, we have the weapons we need, just not the resources to deliver them to people. So why invest so much time and energy in a vaccine to a microorganism that is really not an ideal vaccine candidate? (for those of you not familiar with the life cycle of malaria, the short of it is that the bug spends *very* little time outside of the cells it invades and so it’s really hard for the immune system to “see” because the immune system only works outside the cells of the body. When the bug is outside the cells of the body, the arms of the immune system that usually target parasites do not have time to build a sufficient response to it. Vaccines are only a way of prepping the immune system to face a foe. No matter how well-prepared it is, if the system can’t see its foe, it can’t fight). But what if. . .?

    This is exactly my point. The approach from the vaccine-invention side seems more like an intensely fascinating scientific puzzle than true health work. The pathogens that you picked to talk about are the rockstars of the disease world. They’re the holy grails of vaccinology. Whoever comes up with the topples these monsters gets major, major scientific kudos. So we lust after them with great fervor, proclaiming our commitment to the Poor People.

    But mosquito nets (decidedly NOT sexy) are able to trim the spread of malaria, too. Granted, not completely. But they do have some effect. Simple, available technology. How widespread are they where they are needed most? I’ll let you guess.

    And brief rejoinders on the other two: The spread of AIDS can be controlled through education and CONDOMS (a cheap, mundane method if I ever heard of one) and antiretrovirals (an incredible contribution by biotechnology to the fight against AIDS). TB is linked to poverty all over the world and always has been. Eliminate poverty and you eliminate deaths due to TB.

    Even when you have vaccines, delivery is so, so difficult. We’ve had a polio vaccine for how many years? And we still can’t pin it down in parts of the world that are impoverished. What if the malaria vaccine requires refrigeration? What if it has a limited shelf life (as many vaccines do)? How will it get delivered to the people who need it who don’t have refrigerators and who can’t always get somewhere when they need to?

    Don’t get me wrong. I don’t think that all the science is in vain. I am not for ceasing research on these vaccines. I am trying to see what the true priority is here. I think we may have the weapons to fight these diseases already, but we haven’t tried using them; we just keep searching for the silver bullet. They who discover it will be laurelled and throned in the annals of microbiology. What’s really the motivator? I’m not saying everyone’s motives are impure. I’m just questioning them.

  4. msoule said,


    I posted the above comment before I rescued yours from some weird “spam blocker” that this blog format has that had somehow mistakenly marked your comment as “spam.” It’s obviously not. Sorry about the confusion!

    My point is not just about water. It’s also about access to food and other infrastructure improvements. The disease burden in today’s wealthy parts of the world fell when sanitation was introduced, not vaccines against measles and smallpox and rubella. Those made only a reatively small dent in the burden of disease. At the same time sanitation was being introduced, other changes were occurring in these societies related to the concentration of wealth in those parts of the world. That’s my reaction before reading the link you included. Maybe I’ll change my tune.

    My point also is that US medical schools need to have a greater focus on these more “mundane” solutions because they may be getting passed up for “sexier” medical- scientific ones.

  5. Jessica Pickett said,

    Michael, I agree with your underlying message: technology alone isn’t the solution. This is one of the primary critiques of the Bill & Melinda Gates Foundation (see Anne-Emmanuelle Birn’s Lancet commentary), which the Foundation is still grappling with, partly through their new water, sanitation and hygiene grant program. And you’re right that systems play a huge role even within the narrower scope of new products and technology. I just don’t see these competing priorities as always a strict “either/or” dichotomy. We need better access to clean water and new and underused drugs and vaccines. But that doesn’t mean that all stakeholders should focus equally on those – or any other – interventions; rather, they should hone their expertise where it is most valuable. U.S. medical schools have a lot to contribute on the medicine and technology front, and so should focus their limited resources there. Similarly, institutions with comparative advantages in systems and infrastructure, like the World Bank, should tackle the problems – like water and sanitation – that they are better equipped to solve, under the leadership of the countries themselves.

    And, as a side note, don’t underestimate the value of a rotavirus vaccine.

  6. acoria said,

    Michael – Yes, we have solutions that work. Bed nets are a good example. But bed nets need to be retreated, replaced every few years, and used correctly in order to be effective. A vaccine can be difficult to deliver, but you only have to deliver it once (ideally.) It’s a much, much more effective long-term, sustainable preventive solution, and is therefore MUCH more cost effective in the long run. The ideal bed net WOULD BE a type of vaccine; it would last forever, be completely non-toxic to humans, and kill most if not insects, preventing the vast majority of infections. But, it would still need to be used correctly, which means training for HCWs, who must then train community members, and then trust them not to use the nets for fishing, a problem in many places. Millions of dollars are being spent trying to develop these types of nets.

    Also on malaria – it becomes drug resistant very, very quickly. We may have the tools we need to cure it now, but we won’t for long. A vaccine would be the only long-term solution.

    Second, I just wanted to address what you say about rotavirus. Rotavirus is one of the most dangerous diseases in the world, and yes, it can be treated with a simple mixture, but that’s a treatment, not a preventive measure. The kids have to get sick first, before it will work, and moms have to take time (even in the US) to care for them. ORT can take a long time to work, depending on the severity of the infection, during which time the child will require constant attention. From a socioeconomic perspective, essential in public health, ORT is simple, but not ideal. It requires more than just clean water – it requires a good health infrastructure, mothers with extra time, strong children, and education.

    A rotavirus vaccine, on the other hand, is much more cost-effective, easier for parents to implement if they have access to any kind of health care provider, and already available. (Also, note that kids in the US don’t not get vaccinated for rotavirus because they don’t need or want it – there are complicated political and regulatory factors at work there.)

    Condoms are the same story – better never to get the disease in the first place, because no matter how much you spend on education and health care, you’ll always have people who don’t get tested, and people who have unprotected sex even though they know their status. Vaccines don’t depend on human nature to work. But, for the record, millions are also being spent to develop microbicides, and research is being carried out in the use of diaphragms, circumcision and control of other STDs as HIV prevention measures. But, we can’t stop looking for a vaccine – it would be immoral.

    Finally, on polio – it’s not totally eradicated, but where would we be without the vaccine?

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