Health is on the G20 agenda for the first time and the German Government as host of the G20 has to be congratulated for putting this important issue on the table. This historic moment starts this weekend with the G20 Health Ministers Meeting in Berlin. Brot für die Welt alongside many other civil society and faith based organizations in Germany and abroad are keen to see ambitious global health commitments in the final G20 Declaration in early July.
In the area of health as in so many other areas we have seen that what affects people in one part of the world sooner or later affects us all. This is the case not only for fast spreading epidemics but also for antibiotic resistance, and for the more silent epidemics that still cost more than a million lives a year, the epidemics of TB and HIV. We live in one world and we need solutions which make it possible for everyone to enjoy a healthy life, no matter where people live. The Constitution of the World Health Organization of 1948 already sets out this interconnectedness: The achievement of any State in the promotion and protection of health is of value to all. Unequal development in different countries in the promotion of health and control of diseases, especially communicable disease, is a common danger.
What are the main global health issues?
We see that antimicrobial resistances, that is resistance against medicines that are used to treat infections caused by bacteria, parasites, fungi and viruses, are on the increase. Many medicines are not working anymore and this has disastrous results. People need to be switched to other medicines but these medicines often do not exist. In the field of TB, the first effective anti-tuberculosis agent was developed in the 1940s. Other TB medicines followed in the 1950s and these medicines remained in place for decades to come. Why? Because there was nothing else available to treat TB. TB patients still need to take a pill cocktail over 6 months and the medicines have side-effects, so it is not surprising that people default on taking the tablets.
But it is this non-adherence due to the number and side-effects of the tablets that causes multi-drug resistant (MDR) or even extreme drug resistant (XDR)-TB and then the chances of survival diminish to about 50 percent for people taking medicines for MDR-TB and 25 percent for people on medicines to treat XDR-TB. When people get treated for MDR or XDR TB, the pill cocktail is even greater and needs to be taken for 2 years. Recently a couple of new TB medicines have been developed. The testing of these medicines is done by MSF – an organization that has never been involved in clinical trials before but stepped in so that the new TB medicines can finally fulfill the criteria for registration and become available for people. And we still need more TB medicines with fewer side-effects. One lesson we have learnt from HIV is that in reducing the number of tablets, in combining substances into one tablet, one can improve adherence – this still needs to be realized for TB. And the G20 is affected as much as the rest of the world. For TB alone, the G20 carry 50 percent of the disease burden, for HIV more than a third of the disease burden.
But it is not just about TB. We have an increasing problem with antibiotics not being effective anymore due to human overuse and misuse. And we have the problem of overuse of antibiotics in animal farming and soils and rivers being polluted with resistant strains of antibiotics. This clearly calls for changes on many levels: for stricter regulations and more control, for better informed patients, for changes in the way animals are kept and reared, for better control of the waste-waters of firms which produce antibiotics. But it also calls for new antibiotics to be developed. Why is this not happening - is the low price of antibiotics an issue? Most of the much-needed medicines have simply not been financially lucrative for the pharmaceutical industry to produce. It is only now that we thankfully see pharma companies also getting involved in developing some vaccines and medicines for neglected tropical diseases as well as for TB. And yet, it is often still not clear how they will become registered or what price they will be sold at. We also need more medicines for anti-fungal resistance, for antimalarial and anti-viral resistance. And we realize that infections that need life-long treatment like HIV will require newer medicines as resistance increases. These medicines need to become available for people at affordable costs. If this is not the case, people will be treated for a number of years and then die because the medicines to continue therapy are either not there or too expensive for countries to purchase and make available.
New Incentives for Research and Development Needed
Now is the time that countries need to re-think the incentives for producing needed medicines. It is clear that we need more research and development of new substances for various infectious diseases. The model used for many decades to reward pharma companies for their investment by granting patents and thus monopoly rights is not the solution for medicines which are potentially very cheap, like antibiotics, or for medicines which are primarily for few people in low-income countries like many medicines for neglected tropical diseases or for a disease like TB. But even for HIV and HCV, where medicines exist, monopoly rights are often a hindrance to making newer medicines available at affordable prices for people globally. With hepatitis C (HCV) we have seen that countries in Europe are also struggling to pay astronomical prices for a medicine which was actually very cheap to manufacture. And in the case of HIV we notice that the 3rd line medicines, which people need when resistance has occurred to 1st and 2nd line medicines, are not available in many countries due to their high prices.
Business as usual is therefore not an option. The G20, as we have seen, are affected themselves and have an obligation to show solidarity with the rest of the world. Will the G20 Health Ministers and the Heads of State be visionaries and invest in putting an end to all infectious diseases? This would mean putting more money towards one’s own health budget as well as making more money available internationally to end the deadly diseases of TB, malaria and AIDS as well as all neglected tropical diseases and HCV. This would also require putting public money into R&D, perhaps by setting up a global fund for R&D. And it would also mean finding new ways of offering incentives to the pharmaceutical industry, so that the industry invests in research and clinical trials for needed medicines and gets rewarded without the state having to pay several times for the medicines it needs.
World Health Organisation Needs to be Strengthened
And the G20 should ensure that there is a strong and independent World Health Organization that gets the majority of its funding from member states with no strings attached so that it can do the work it is meant to do: to ensure the highest attainable level of health for all people, to combat communicable and non-communicable diseases and to ensure the safety of medicines and vaccines, of food, water and air. For this a 10% rise in the contributions of its member states would be an important step to take.
The G20 at a historic moment
The G20 can trigger a lasting change in world health and usher in an end to the deadliest diseases by 2030, if they commit to make SDG 3.3 and SDG 3.8 (two sub-goals of the sustainable development goals which the UN passed in 2015) come true:
3.3: By 2030 end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases.
3.8: achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.