A Global Village
Issue 5 » Researching Development

Are UK Universities Tackling Local or Global Health Issues?

Honor Bixby, Imperial College London

The institutional principles of universities – to create and disseminate knowledge for public benefit – are often forgotten in this age where universities strive to top league tables and attract lucrative grants. Universities are in a unique position to be a promising catalyst for change, but often campus decision-makers can be insulated from the realities of global health and funding priorities can consequently become skewed in favour of local challenges.

With the two N’s – Neglected Tropical Diseases (NTDs) and Non-communicable Diseases (NCDs) – gaining prominence on the international agenda, how can universities re-orient their priorities to serve our global, rather than solely local, community?

Neglected Tropical Diseases (NTDs) are diseases of poverty, flourishing most in communities where substandard living conditions that optimise transmission of these parasitic and bacterial infections are commonplace. As Western nations have developed, and standards of hygiene and sanitation have improved, these diseases been forgotten. In terms of donor support, the big three – HIV/Aids, tuberculosis and malaria – overshadow them today. This seems counterintuitive, however, as their cumulative burden (measured in disability-adjusted life years, DALYs) exceeds that of either TB or malaria and is comparable to that of HIV/Aids. The immense burden of NTDs has become increasingly visible in recent years in no small part due to the valiant efforts of several UK-based academic institutions to alleviate the suffering, However, the overwhelming majority of research at UK universities still goes into largely domestic diseases or the headline-grabbing big three diseases of the developing world.

The overwhelming majority
of research at UK universities
still goes into largely
domestic diseases
or the
headline-grabbing big
three diseases of the
developing world 

Furthermore, non-communicable diseases (NCDs) including cardiovascular diseases (CVDs), cancer, diabetes and respiratory disease, which constitute the primary burden of developed countries, are emerging as an immense concern for the developing world. Indeed, NCDs cause 63% of global deaths, with 80% occurring in the developing world1. In resource-poor settings, particularly in relation to NCDs, prevention is better than cure. Access to treatments is cost-prohibitive and lack of infrastructure and resources rarely allow for advanced procedures to be carried out. It is therefore imperative that universities consider cost and health equity in the development of new treatments and products.

NTDs – Neglected no More?
The approximately 1.4 billion sufferers of NTDs are from the world’s poorest populations: Africa, Asia and Latin America account for 90% of the disease burden. Their weak political voice and the profitless market they provide for pharmaceuticals mean their suffering has been neglected, earning these diseases their title.

NTDs not only result from poverty but also significantly contribute to it. Many infections are chronic so that, although they may not cause high levels of mortality, they are associated with high morbidity, restricting sufferers’ ability to work and resulting in decreased economic productivity on a regional scale. In addition to this is the drainage of severely limited healthcare resources and the limitations they can place on childhood development both through direct suffering resulting in physical/mental disability and reduced school attendance and the responsibilities they face when family members are affected taking priority over their education. Countries are trapped in a cycle of stunted development.

In recent years the full extent of this burden has been realised. Over half of the United Nation’s Millennium Development Goals (MDGs) that aim to end poverty cannot be achieved without action to address NTDs. They have achieved a priority position on the international agenda and the outcome of the first meeting of the Global Partners on NTDs, organized by the World Health Organization (WHO) in 2007, was the Global Plan to Combat Neglected Tropical Diseases 2008-20152.
One consolation is that NTDs can often be simply and cheaply treated/prevented with existing medicines, making the problem more readily solvable although investment for research and development (R&D) of products aimed at an impoverished market is rare. This poor return-investment ratio removes any incentive in the eyes of profit-driven pharmaceutical companies. Conversely, the restricted distribution of NTDs also acts in their favour as it means there is no alternative wealthier market that these companies can make money from and therefore no risk of lost revenue if companies donate the required medicines.

It is imperative that
universities consider
cost and health equity
in the development
of new
 treatments and
products

The first WHO report on NTDs released by Dr. Margaret Chan, WHO Director-General, stated that aiming at the complete control and even elimination of NTDs is fully justified. Pharmaceutical companies’ drug donation programs have made a significant contribution by lessening the financial barriers faced by control initiatives. Merck, by the end of 2010, had donated over 55 million tablets to prevent more than 10.2 million school children from developing schistosomiasis. GlaxoSmithKline (GSK) has made an recent five year commitment to expand its donation of albendazole, used to treat infections with soil-transmitted helminthes that cause lymphatic filariasis, ascariasis and other NTDs, by 400 million tablets each year in addition to the 600 million already provided3.

However, this ambitious goal relies on a collaborative effort. Universities here in the UK have played an important role in successful control initiatives to date. Notably the Schistosomiasis Control Initiative (SCI) of Imperial College and the Centre for Neglected Tropical Diseases (CNTD) based at the Liverpool School of Tropical Medicine (LSTM) are both collaborators of the Global Network for Neglected Tropical Diseases.

Pharmaceutical investments
rely on financial incentives
resulting in money going
towards the prevention
and cure of diseases
of affluence
 

The SCI’s main focus is setting up or expanding NTD control programmes in countries most affected including Burkina Faso, Burundi, Mali, Niger, Rwanda, Tanzania and Uganda. It relies heavily on private donations. Due to the success of the programme, it has been granted £25 million by the UK Department for International Development (DfID), enabling provision of 75 million treatments. The SCI goes beyond life-saving drug administration, working with the WHO and African governments towards sustainable control of all NTDs through providing proper training to domestic health workers in recipient countries.

Aside from those NTDs that are easily treatable, there are those that do not have suitable therapeutics, such as Chagas’ disease, Human African trypanosomiasis (African Sleeping Sickness) and Leishmaniasis. Chagas’ disease kills more people in the Americas than any other parasitic disease. Two treatments are currently available, but cure rates are only 60-70% and less than 50% if the chronic phase of the disease has been reached. These drugs are by no means ideal, resulting in severe side effects and are either not well tolerated or are ineffective once the chronic phase has commenced. Therapeutics and diagnostics that are effective and suitable for use in the field are clearly in severe need for these diseases.

In 2007, North America, Europe and Japan carried out 76% of the world’s R&D. This demonstrates the dependence of developing nations on industrialised countries for such activities. The UK remains second to only the US in its research quality and productivity. Such leadership comes with a responsibility to focus more research attention on the neglected diseases that affect only the world’s poorest.

NCDs – An Emerging Threat
It is non-communicable diseases (NCDs) that afflict Western populations, and attract the focus of the major research universities. This tendency can be attributed largely to funding allocation. Most academic research is funded by public money, through government research councils including the MRC (Medical Research Council), industry investment (such as pharmaceutical companies) and donations from charitable organizations (including the British Heart Foundation and Wellcome Trust). The latter, in 2009, comprised around 22% of research income to UK HEIs but donations frequently fail to cover the full cost of research (e.g. salaries) and sourcing is often globally competitive. Pharmaceutical investments rely on financial incentives resulting in money going towards the prevention and cure of diseases of affluence. The Department for Business, Innovation and Skills’s Economic Impact Reporting Framework set the objective of public funded science and technology research as to ‘generate many beneficial outputs and impacts which underpin the UK’s long-term economic growth, economic well being and quality of life’ – economic/societal gain for the UK is at its heart. It is, therefore, unsurprising that funding directs research towards NCDs4.

However, these diseases are also an immense concern for the developing world. NCDs cause 63% of global deaths, with 80% occurring in the developing world. Around 21 million years of future productive life are lost each year to CVD. Margaret Chan of the WHO has said that if rates continue to increase as they are currently, not even the wealthiest nations will cope with the economic strain of these diseases. Despite this early alarm, they received no mention in the MDGs. From this perspective academic research carried out in the UK can be seen to be addressing a major global health issue that has thus far been missed off the global agenda, but how may this research translate for developing world issues?

NCDs cause 63% of
global deaths, with
80% occurring in
the developing world

With the example of CVD, much of the UK research is inclined towards gaining a deeper understanding of the disease pathophysiology. This applies to much of the research at the British Heart Foundation Centre of Research Excellence at Oxford University5 and is fundamental to fighting CVD. Often knowledge gained, such as identifying the main disease determinants, can be applied globally and provides the groundwork for new treatments to be built on. However, more targeted research such as the Artificial Heart Muscle Project at Leeds University that looks into pioneering treatment for CVD has a more restricted target demographic. Only in countries with adequate healthcare systems in place including both facilities and expertise can the successes of this project be advantageous. Resource-limited countries don’t fall into this category.

In resource-poor settings it is particularly true that prevention is better than cure. Access to treatments is cost-prohibitive and early intervention is key. Imperial College has been involved in successful clinical trials of a polypill for CVD prevention. A polypill simplifies treatment and therefore enhances adherence – the benefits have been seen with antiretroviral combinations against HIV6. Although this is promising, access to NCD therapies, as with NTDs for which effective treatment exists, is frequently limited due to lack of affordability. Universities should take responsibility to ensure that the products of their research reaches developing countries to encourage health equity. Through the process of technology transfer universities pass the intellectual property rights of their research to commercial companies. In licensing promising new drug candidates to pharmaceutical companies, access by low- and middle-income countries at the lowest possible price should be stipulated in the agreement to ensure global accessibility.

With current funding priorities and measures of success there remains little incentive for universities to address the needs of a global population. As awareness of NTDs and NCDs in developing countries increasingly breaks onto the international agenda, new models of partnership between academia, government and industry need to bring progress in prevention and treatment for diseases of those for who most need it, but can least afford it.

Honor Bixby is studying for a Masters in Public Health (MPH) at Imperial College London. She also coordinates the neglected diseases workshops for UAEM (Universities Allied for Essential Medicines).

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[1] UnitedHealth, National Heart, Lung, and Blood Institute Centers of Excellence (2011) Global Response to Non-Communicable Disease. BMJ. 342(3823).
[2] WHO (2010) Working to Overcome the Global Impact of Neglected Tropical Diseases: First WHO Report on Neglected Tropical Diseases.
[3] GlaxoSmithKline (2010) Support for WHO Strategy to Improve Children’s Health with New 5-year Commitment to Expand Donations of Albendazole Medicine. [online] Available at: <http://www.gsk.com/media/pressreleases/2010/2010_pressrelease_10110.htm> [Accessed 30 July 2011]
[4] The Russell Group Universities (2009) Submission of Evidence for the House of Lords Science and Technology Select Committee Inquiry: Setting Science and Technology Research Funding Priorities. [online] Available at: <http://www.parliament.uk/documents/lords-committees/science-technology/strfrgu.pdf> [Accessed 14 August 2011]
[5] University of Oxford (2009). Oxford Cardiovascular Science: Research Themes. [online] Available at: <http://www.cardioscience.ox.ac.uk/bhf-centre-of-research-excellence/research-theme-descriptions> [Accessed 15 August 2011]
[6] Hoen E. et al. (2011). Driving a Decade of Change: HIV/AIDS, Patents and Access to Medicines for All. Journal of the International AIDS Society. 14(15).