I hope I got your attention with my last post about the Pacific Health Summit and the acute global threat of Multi-Drug Resistant Tuberculosis (MDR-TB). All of the issues around innovation in public health that I are covered in this post need to be placed in the perspective of this challenge and the human costs associated with it. Public health challenges like MDR-TB also provide an opportunity to reflect on our current understanding of innovation and whether it has lived up to its promise outside the gleaming corridors of Google. There has been a healthy debate on this topic lately. A recent piece in BusinessWeek looks back at the most promising areas of scientific R&D of the last 10 years (like nanotechnology) and wonders why so few have lived up to their hype. There is no question that we have made enormous strides in the lab. Why not in the field?
This is just one of many assumptions that are limiting our ability to address the severe challenges facing our health-care system and respond to a crisis like MDR-TB. What are some of the other prevailing mindsets?
#1: Innovation Happens in the Lab
MDR-TB vividly demonstrates that solutions that work in the lab are not necessarily well-suited to the behavior and cultural conditions in the field. So why not build those conditions into the model from the beginning? As designers, we find those conditions to be inspiring. They help to shift your frame of reference and inspire new thinking. This is a hard lesson for the Health-care community to learn. And it was very evident at the Summit which panelists were directly engaged in the field, and which were not. In fact, the only panel that was stocked with real world experience (moderated by Paul Farmer, no surprise) was left for lunch on the last day, after the formal sessions had ended and when most people were leaving for the airport.
You see this mindset reflected everywhere. Even the mighty Gates Foundation is split down the middle between science and delivery. After interacting with folks from both sides of the organization out in Seattle you can probably guess which group I found to be more interested in open innovation. But…I bet you can guess which side of the house is more interesting to Bill.
#2: Innovation Only Flows in One Direction
#3: The Field is Messy
But the human part is messy. Drug companies can’t develop magic bullets in the lab to change human behavior and cultural conditions. Adherence is the most vexing problem facing drug companies today. They can develop the right drugs and get doctors to prescribe them but people still don’t take them the way they ‘should’. This is exactly why we have MDR-TB. It is not due to limited supplies of first line treatments. It is due to limited support resources and a very difficult protocol to manage. One that requires regular support and feedback in resource-constrained environments. Infected people leave hospitals in KZN with no idea what ‘TB’ is. And they stop treatment the minute they start to feel better even though they need to stay on their medications for three months to clear their system.
#4 Innovation must be Market-Driven
In many areas including public health, the prevailing assumption is that innovation requires some kind of public / private partnership. The assumption is that impact cannot be scaled and maintained without a market mechanism. This is based on the failure of many broad public health initiatives and the belief that the secret to scalability lies in market know-how. This is absolutely true when it comes to scaling up / industrializing the production of medications. But does it hold equally true to scaling up access, outreach and support? How innovative are the large multi-nationals in this area particularly in relation to the routine and chronic diseases of the poor?
Drug companies tend to view price breaks as major innovations. While these pricing breaks are crucial they don’t address one of the main obstacles to access: lack of information and support, particularly for treatments that are complex to manage (with multiple therapies) and have adverse side effects. One of the most disappointing aspects of this conference was the lack of strong representation from other industries that are better at information access, particularly mobile operators. Mobile networks are a unique point of leverage in impoverished communities. And the mobile operators are making huge profits selling minutes to the poor. In fact this is projected to be their largest growth opportunity as developed markets are becoming more and more saturated–hence the merger between MTN in Africa and Bharti Airtel in India.
It is not my intention to oversimplify the challenges facing the public health community. This community is filled with many talented people who have devoted their lives to the common good, often at some personal risk. But the challenges at hand, like MDR-TB, require a fundamental change in mindset. One that I don’t see happening yet based on my experience at the Pacific Health summit. But I do believe that there is reason to hope. As we are becoming more and more interconnected there are new species starting to wash up on the shore. That is the starting point for my next piece.
Read part 1: MDR-TB: A Health care Crisis of Our Own Design