MDR-TB: A Healthcare Crisis of Our Own Design

Last month I attended the Pacific Health Summit in Seattle. It is a pretty exclusive venue (aspiring to be the "Davos of Health Care") attended by senior representatives from the world of health care and public policy (such as Dr. Anthony Fauci from the NIH, Dr. Margaret Chan from WHO, Chris Viehbacher CEO of sanofi-aventis and Tadataka Yamada who heads the Global Health program for the Gates Foundation). The conference chooses a specific challenge to focus on each year. This year's topic was Multi-Drug Resistant Tuberculosis (MDR-TB)—more about that in a minute.

The venue provided a remarkable opportunity to reflect on the gaps between the promise and "delivery" of innovation. The design and business community have conspired over the last few years to polish up the term "innovation" to a high gloss. It is like Apple chrome now, this shiny gleaming element that can be applied to any surface. But what happens when innovation meets with the messy reality of domains like public health? Domains with no reset button.

This is not an academic question. The term "innovation" comes up just as often in this sphere. In fact, there is a certain desperation in the way it is invoked, like a distant shore or mirage that you cant ever reach. Despite all of the rhetoric around innovation from major figures in public health, I walked away from this event terrified: first, because of the terrible human costs at stake in an area like TB and second because of the business as usual response within the public health community despite all of the lip service to innovation.

First, some background: The purpose of the first post is to give you some sense of what is at stake in an area like TB, and more importantly MDR-TB. You cannot fully appreciate the desperate need for innovation until you understand the severity of the risk associated with this epidemic. So let's start with some basic facts about garden variety TB:

  • It is estimated that 1/3 of the world's population is carrying latent TB. that's right folks— we are talking about 2 billion people! You could be sitting next to someone with TB on your next cross-continental flight.
  • The body can harbor TB with little adverse effect for some time. TB becomes an acute health risk when combined with other factors like malnutrition or immunodeficiency (i.e, HIV) which is why it is mostly prevalent in poor communities. In fact their is a striking correlation between TB levels and poverty levels around the world.
  • TB is pretty rare in the developed world and dropped off the radar of the major pharma and biotech companies as well as the NIH and CDC until pretty recently.
  • While the disease is eminently treatable and curable, the standard protocols were developed long ago: the diagnostics are 125 years old, the vaccine is 85 years old and the drug regimens are 40 years old. In fact, health officials in the 50's or 60's fully expected TB to be eradicated by now. Guess again!
  • This antiquated course of treatment for normal TB is pretty arduous, involving a combination of medications that must be taken for 6 months. No surprise since these meds were developed in the middle of the last century.
  • In the developing world, with the highest burden of TB and fewest health care resources, completing this regimen is a real trick. Which is why we are now at risk of a global MDR-TB epidemic.

Now some basic facts about MDR-TB:

  • MDR TB has developed over the last decade in the developing world because of the challenges of successfully managing the treatment protocol for TB as well as the spread of HIV. Co-infection rates between HIV and TB are pushing 80% in some hospitals in Africa.
  • The treatment for MDR is much more complex, arduous and expensive than standard TB, requiring a complicated mix of second line medications that must be taken daily for up to two years with severe side effects.
  • You can imagine that if developing markets are having a hard time managing treatment protocols for standard TB then MDR management is hopeless, with treatments that cost 1000x than the standard drugs. This has lead to, you guessed it, Extensively Drug Resistant TB (XDR-TB) which is about as scary as it gets.

So why should you care:

  • TB is extremely communicable—unlike HIV—through the air. Standard cloth masks are not sufficent to filter the molecules.
  • MFR-TB infection rates are exploding in Southern Africa, like KZN (where frog is working on a mobile health partnership, Project Masiluleke) and rapidly spreading in China, India and Eastern Europe.
  • Mortality rates for MDR-TB are ~60% and for XDR-TB are 80+%...and that is with treatment!

I trust that I have your attention now. MDR-TB makes the swine flu look like the common cold, which is kind of ironic given that, according to Margaret Chan MDR fell off the agenda at a recent WHO summit when the swine flu hit.

One more thing (just to make sure you didn't miss it): We created MDR by not providing enough resources for frontline TB services. That's right, MDR is a product of the public health system. And the surest way to get it in poor communities like Edendale is to visit the hospital. These "facilities" are often referred to as "TB factories."

This is an acute public health challenge. And one that the health community has been fully aware of for some time. To be fair, the community is mobilizing with some new diagnostic tools and possible vaccines in the pipeline that will take years to get though clinical trials and to market. There is a lot of talk about increasing budgets for research etc...In other words, they are doing what they always do. Responding in a typical manner—leading with the research lab.

Public health is not an easy area for experimentation. And innovation always brings risk and failure with it. Even accounting for those challenges, there were some obvious patterns on display within the public heath community that make it extremely unlikely that we will see much effective innovation soon. Please come back tomorrow and read my next post to find out why.

Next Post: The Galapagos Effect in Health Care

Read more of Robert Fabricant's Design4Impact blog.

Robert Fabricant is VP of Creative for frog design based in New York, where he leads multidisciplinary design teams for clients such as BBC, Comcast, GE, MTV, Nextel, and Nissan. He has developed user experiences for numerous digital platforms, including handheld devices, in-car information systems, medical devices, retail environments, networked applications, and desktop software.

Robert is a leader of frog's health-care expert group, a cross-disciplinary global team that works collectively to share best practices and build frog's health-care capabilities. An expert in design for social innovation, Robert recently led Project Masiluleke, an initiative that harnesses the power of mobile technology to combat the world's worst HIV and AIDS epidemic in KwaZulu Natal, South Africa.

Robert is an adjunct professor at NYU's Tisch School of the Arts where he teaches a foundation course in Interaction Design. In 2009, he joined the faculty of the School of Visual Arts in New York and is a faculty member of the Pop!Tech Social Innovation Fellowship Program. A regular speaker at conferences and events, Robert recently gave a keynote speech at the 2009 IxDA Interaction Conference. He is a frequent contributor to a wide variety of publications, including I.D. Magazine, The Wall Street Journal, and Wired.

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1 Comments

  • JA Ginsburg

    Excellent post! But let's trace things a little further upstream (which could be what you're planning already given that tease for the upcoming Galapagos post...). Although the experts you cite are, to a one, brilliant in their fields, the list itself underscores an Achille's heel in public health. I am guessing there probably weren't very many experts in animal health. YET the tentacles of MDR are deeply woven into modern agriculture, where antibiotics are used as "growth promoters" (1984 meets Animal Farm...) In the interests of keeping this comment fairly short, here are a couple of links. Check out the first segment on hog farmer Russ Kremer's bout with MRSA: http://www.freshthemovie.com/a... (while MRSA is different from MDR-TB - it underscores how & where we are creating a gusher of superbugs). "Underlying Condition," a post I wrote, mostly focuses on swine flu, but includes a section on a strain of ebola recently identified in Philippine pigs. It's pretty stunning: http://tinyurl.com/maopc8

    None of the emerging disease threats over the last 30 years have been man-made, but almost all to some extent have been man-mediated. "A Healthcare Crisis of Our Own Design" - so sadly true...

    - j.a. ginsburg, editor, TrackerNews.net

    (another contributing factor: the rampant market in fake drugs. It is beyond all belief - and if you think they have a hard time tracking & controlling the trade in human medicine, all bets are off for animal drugs...)