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How China can reshape the mechanics of global healthcare innovation by taking on Tuberculosis

An interview with Professor Madhukar Pai

{{{Kushal Prakash & Gian Marco Brizzolara}}}

Prof. Madhukar Pai, MD, PhD, FCAHS is a Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal. He is the Director of McGill Global Health Programs, and Director of the McGill International TB (Tuberculosis) Centre. He serves on the STAG-TB committee of WHO, Geneva; Scientific Advisory Committee of FIND, Geneva; and Access Advisory Committee of TB Alliance, New York. He also serves as the Chair of the Public-Private Mix (PPM) Working Group of the Stop TB Partnership. He is on the editorial boards of Lancet Infectious Diseases, PLoS Medicine, and BMJ Global Health, among others. He has over 300 publications and has been a recipient of several awards including the Union Scientific Prize, Chanchlani Global Health Research Award.

Professor Pai came to Schwarzman College recently for a lecture on global health technologies and bridging the gap between innovation and access. Post the visit, he shared his thoughts on tech innovation in China and how innovation in the health sector, especially by low and middle income countries, is crucial.

China is becoming a significant player in developing a wide range of medicines and medical equipment at an affordable rate. How do you see this development, and how are other countries reacting to it?

Yes, China is significant player in the area of medical technologies including drugs, vaccines, diagnostics, and technologies such as AI. As a global health professional, I welcome this, and see it is as a positive development.

The traditional model in global health is for innovations to be developed in the rich world, and a slow diffusion of these innovations in low and middle-income countries (LMICs) – a process that can take a decade or more, as we have seen with anti-retrovirals for HIV, vaccines for HPV, etc. It takes tremendous effort to reduce the price of Western innovations and make them accessible to those who need them the most. While this slow process unfolds, millions can die without adequate prevention or treatment. We must find a way to change this traditional model.

A researcher using modern diagnostic devices in China to test Tuberculosis - Courtesy of Madhukar Pai

Picture: A researcher using modern diagnostic devices in China to test Tuberculosis - Courtesy of Madhukar Pai

That is why it is important for LMICs to innovate and address their pressing health needs with appropriate solutions that are scalable. For example, if BRICS countries have a high burden of tuberculosis, then why can they not innovate and find solutions that can be scaled up?

As I have argued earlier, the world cannot depend on a few wealthy countries with very low TB incidence to support all the research that is required to tackle TB. High-burden, middle-income countries with high TB rates must step up and take leadership. China is one such high-burden country, with about 1 million new cases of TB every year, more than any country except India.

Pharmaceutical companies tend to not produce cures or innovate further on the existing cures that have low payoff potential. How can innovation and tech be used to fix this market failure?

The pharmaceutical industry in high income countries are incentivized to maximize return on investment for shareholders. But this market-driven model will never serve the poorest people who suffer the most from diseases of poverty (e.g. tuberculosis, malaria, diarrhea, pneumonia, neglected tropical diseases).

 

Pharmaceuticals in LMICs are known for their generic drugs, vaccines and diagnostics, and they are seen as the ‘pharmacy for the world’. Undoubtedly, generics are critical for global health and countries like China and India deserve credit for their work in this space.

 

But the key issue is whether companies in LMICs can go beyond making generics and innovate. Countries like China and India are showing that this is indeed possible. China, for example, has developed several indigenous technologies for TB and other diseases (companies include CapitalBio, Ustar, Zeesan Biotech, ZFSW). China is now a powerhouse for gene sequencing with incredible capacity for innovation in this area.

 

India, for example, has developed a point-of-care molecular assay platform (Molbio Diagnostics), and an indigenous rotavirus vaccine (Rotavac by Bharat Biotech).

 

So, I am hoping the traditional market failures in global health can be addressed, at least in part, by innovations coming out of LMICs. At the very least, competition from companies in LMICs should help drive down the price of products from high income countries. Also, it should be easier for indigenously developed products to get scaled-up in their countries of origin. Both China and India are giving priority for domestically made technologies (“made in China/India” emphasis).

What are some of the major hurdles you see in medicine and pharma R&D in China and around the world? What can drive innovation in the space?

From my rather limited experience of dealing with Chinese companies in the TB space, I see the following hurdles:

  • Chinese companies seem to be primarily concerned about getting CFDA approval and selling their products within China. This is an important first step, but there is a big potential market outside of China, and very few Chinese products have entered that global health market. For example, none of the Chinese TB diagnostics or vaccines are widely used outside of China, and none have WHO endorsement or prequalification.
  • To enter the global health market, technologies would need to undergo independent, international evaluation studies, for policy review and WHO endorsement. Such policy review has not happened (to my knowledge) with Chinese TB technologies.
  • Also, there seems to be concern about the quality of products made in China, and this is also the case for products made in India. Such concerns often stem from the fact that very little data on Chinese technologies are published in peer-reviewed, international journals, and few studies exist beyond the data used for CFDA approval.
  • Without endorsement from international agencies like WHO, global procurement and scale-up via Global Fund, Unitaid, Unicef, UNAIDS, etc. is not feasible.

To address these hurdles, Chinese companies would need to:

Based on the past trends, how do you see the likelihood of ending the TB epidemic by 2030? How responsive have tech innovation and new R&D been in fighting the epidemic? What needs to change?

The 2014-2016 Ebola outbreak in West Africa caused an estimated 11,000 deaths and yet it resulted in a huge amount of innovation around Ebola — including a brand new vaccine and new, rapid diagnostic tests. These innovations were rapidly deployed during the recent Ebola outbreak in the Democratic Republic of the Congo (DRC).

During the same two-year period, TB killed more than three million people. And yet we are still using a TB vaccine that dates back to the 1920s. The front-line diagnostic tool for TB dates back to German bacteriologist Robert Koch who identified the TB bacteria under a microscope in 1882.

Patients with drug-resistant TB have to endure a prolonged (up to two years) and toxic treatment with multiple drugs (more than 14,000 pills) — including painful daily injections that can make people deaf.

The fact that we are still using century-old tools to tackle the biggest killer infection betrays a complete lack of ambition. So, as I have pointed our earlier, before we can eliminate TB, we must end our lack of ambition. Only then can we end TB by 2030.

If we put our minds to it and make investments, we can definitely ‘science the shit out of TB’! Thankfully, several innovations have emerged in the recent years. In a recent blog post, I wrote about my ‘dream TB clinic’ of the future (graphic below), and showed examples of innovations that already exist, but need to come together and serve the millions who desperately need them.

If we modernize TB care and make investments that match the scale of the problem, I am optimistic we will end the TB epidemic within a generation. I am hoping China will make a huge contribution to ending the global TB problem, both as a donor country, and as a nation full of innovators.

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