Tuesday 27 August 2019 ★ FINANCIAL TIMES 3

FT HealthCommunicable Diseases

Before2014,noEbolaoutbreakhad

everkilledmorethan300people.The

recentreturnofthediseaseinthe

DemocraticRepublicofCongohas

killedalmost2,000—justfiveyears

aftertheworst-everincidentofthe

diseaseledtothedeathsofmorethan

11,000—highlightingthegrowingrisk

ofepidemics.

The2014outbreakcouldhavebeen

defeatedfarearlierifavaccinein

developmentformorethanadecade

hadbeendeployedmorerapidly.More

than190,000dosesofthesamevaccine

havebeenadministeredinthecurrent

DRCepidemic.Thishascurbedits

spreadtoanextent,butconflict,attacks

ontreatmentcentres,andmistrusthave

hinderedeffortstobringtheoutbreak

undercontrol.

Recenttrialdatashowingthattwo

experimentaltherapiescouldreduce

thefrighteninglyhighmortalityrateof

Ebolaareextraordinarilypositive.But

thisbreakthroughcannot,byitself,end

anepidemic.

Weneedtopreventaswellastreat,

andforthatweneedeffectivevaccines

alongsideotherpublichealthmeasures

suchasinfectioncontrol,surveillance,

andcommunityengagement.

Thismattersmorethaneverbecause

wehavecreatedaworldthatpresents

pathogenswithheightened

opportunitiestospread.Therisksof

outbreaksandepidemicsareincreasing.

Astheworldbecomesmorepopulated

andinterconnected,theglobal

microbialecologyischanging.

Ebolahasafearsomereputation,

thoughitisaknownhazardand

relativelywellunderstood.Butconsider

thethreatfromapreviouslyunseen

pathogen—aso-called“DiseaseX”—

onethatspreadseasilyenoughtohitcha

rideonanaeroplanetotheothersideof

theworld.

Thisisnotsciencefiction.InMay

2015,a68-year-oldSouthKoreanman

returningfromtheMiddleEastwentto

hisdoctor’sofficewithanastycough.He

wastreatedinseveralhealthcare

facilities,infectingatleast26people,

beforehewasdiagnosedwithMiddle

EastRespiratorySyndrome(Mers),a

viraldiseaseidentifiedjustthreeyears

earlier.

Theoutbreakthatresultedwas

comparativelysmall,withonly186

casesoverall,buttheeconomicimpact

wasstartling.Beforeitwasbrought

undercontrolsometwomonthslater,

morethan2,700schoolswereclosed

andnearly17,000peoplewere

quarantined. Healthresearchers

estimatedthatthetotalcost,including

lossesinretailsalesandtourism,

approached$10bn.

Comparedwithotherdiseases,the

economiccostsofepidemicsarevastly

disproportionatetothenumberoflives

lostandareparticularlystarkwhen

theyoccurindevelopedeconomies.

WhilewestAfrica’s2014-15Ebola

epidemicmayhaveresultedinagreater

overallsocialandeconomicburden,

withaggregatelossesrecentlyestimated

at$53bn(oraround$1.8mpercase),the

impactofMersinSouthKoreawas

staggering,exceeding$50mpercase.

Suchnumbersshouldalarm

governmentsandcorporations.

Epidemicandpandemicdiseaseshould

beviewednotmerelyasapublichealth

risk,butasoneofasmallnumberof

transnationalthreatsthatdemandaco-

ordinatedandcollectiveglobal

response.

Thegoodnewsisthattheworldis

makingprogress.Internationalhealth

regulationswerestrengthenedin2005

andbecamebindinginstrumentsof

internationallawin2007.TheGlobal

HealthSecurityAgenda,launchedin

2014,isapartnershipofmorethan60

nations,internationalorganisations,

andnon-governmentalstakeholders

thataimstobuildthecapacitytomeet

specific targetsonbiologicalthreats.

Morethan100countrieshave

voluntarilyagreedtoexternal

evaluations,whichassesstheircapacity

toprevent,detectandrespondtopublic

healthemergencies. In2017,myown

organisation,theCoalitionforEpidemic

PreparednessInnovations,was

establishedbyafar-sightedgroupof

sovereignandphilanthropicinvestors.

Vaccinesareourmostpowerfultool

againstinfectiousdiseases,theone

weaponthatcanstopthemdeadintheir

tracks.Cepi’sraison d’êtreistoaccelerate

thedevelopmentofvaccinesagainst

emerginginfectiousdiseasesandto

enableequitableaccesstothemduring

outbreaks.

Asaglobalpartnershipbetween

public,private,philanthropicandcivil

societyorganisations,Cepifillsagapin

thesystem,becausemarketforcesalone

areunlikelytoincentivisethe

developmentofvaccinesweneed.

Cepi’sapproachistodevelopvaccines

forknownthreatsincasetheyare

needed—andtotakesuchproductsinto

large-scaleclinicaltrialsintheeventof

anoutbreak.

Wearealsodevelopingajust-in-time

strategytodealwithunknowndiseases

byinvestinginplatformsthatwillallow

thecreationofnewvaccinesinthespace

ofweeksandmonthsratherthanyears.

Developingsuchtechnologywillnot

becheap,butitwillbemoneywell

spent.Thecostofdevelopingone

vaccinecandidateforeachofthe11

epidemicdiseasesprioritisedbythe

WHOwouldbearound$3bn—lessthan

40centsperpersonglobally.

Thedreadfulhumanandeconomic

costofepidemicsrenderssuchaglobal

insurancepolicyabargain.

Richard Hatchett is chief executive of Cepi,

the Coalition for Epidemic Preparedness

Innovations

‘Staggering’ economic cost of epidemics should cause alarm

OPINION

Richard

Hatchett

Ebola screening station in Goma, on

the border of Rwanda and DRC

John Wessels/FT

Diseases should be viewed

as one of a small number of

transnational threats that

demand a co-ordinated

and collective global

response

S

cience journalists generally

receive two contrasting views

of the growing threat from

antimicrobial resistance. On

the one hand are dire warn-

ings of a coming antibiotic disaster as

germs become resistant to existing

drugs while market failure blocks the

developmentofnewones.

On the other, a stream of cheery press

releases from universities and biotech

companies around the world describe

advances in research. Science writers

probably get more emails with positive

news about AMR than any other medi-

calissueapartfromcancer.

Thesecontrastingimpressionsarenot

contradictory. The spread of superbugs

resistant to most or all existing drugs

seems relentless — but at the same time

there is a ferment of research activity,

supported by governments, charities

andafewbravefinancialinstitutions.

The leading funder is Carb-X, a global

non-profitbasedatBostonUniversity.It

is investing more than $500m, provided

by public and philanthropic sources

between 2016 and 2021, to take projects

intothefirststageofclinicaltesting.The

Carb-X portfolio already includes

29 projects in five countries, with the

simpleaimof“acceleratingthedevelop-

ment of life-saving products in the fight

against superbugs”, as executive direc-

torKevinOuttersonputsit.

The trouble is that the pharmaceuti-

cals industry has little financial incen-

tive to pick up promising projects in

early clinical trials and take them

through the later stages required for

regulatoryapproval,whichmaycosttoo

muchforasmallerbiotechcompany.

This market failure has several

causes, including the very low price of

existing generic antibiotics, the fact that

the drugs are taken only for a short time

— and the possible need to keep effec-

tive new antibiotics in reserve to treat

the most serious infections and prevent

resistanceemergingthroughoveruse.

Several authorities have analysed the

problem, notably Jim O’Neill whose

review of AMR for the UK government

suggested solutions such as a “pay or

Biotechs

fight fears of

‘antibiotic

apocalypse’

SuperbugsInvestors are tackling the market failure that has hitherto given pharma companies little incentive to develop new drugs, writesClive Cookson

As one of Africa’s poorest countries,

Ethiopia has limited resources. Yet in

2015, it reached its target of halving

ratesoftuberculosisfrom1990levels.

Thiswasachievedwithoutbringingin

specialists or developing sophisticated

medical systems, but by focusing on

something simpler and cheaper: pri-

mary care delivery via a network of

communityhealthworkers.

Ethiopia’s programme — which was

launched in 2004 and trains village

healthworkersforayearbeforesending

them back to their communities —

shows the power of primary care in

helping prevent the spread of highly

infectious disease. Yet governments

continuetounderinvestinthispowerful

public health tool. “In the US,

something like 4-5 per cent of health-

care is spent on primary care and pre-

vention,” says Rushika Fernandopulle,

chief executive of Iora Health, the com-

pany he co-founded to promote team-

based approaches to primary care.

“That means 95 per cent goes on what I

call ‘failure care’ — it goes to fix the

problem.”

For developing countries, where com-

municable disease is still widespread

andhealthcareresourcesarethinonthe

ground, the “fix the problem” approach

is not an option. “Their capacity to pro-

ducedoctorsandnursesislimited,”says

JeanKagubare,deputydirectorofglobal

primaryhealthcaresystemsattheBill&

MelindaGatesFoundation.

By focusing on prevention, he says,

community programmes such as Ethio-

pia’s provide a more effective and

affordable defence. He cites a similar

programme in Rwanda that over 15

years has amassed an army of about

50,000 community health workers,

mainlyvolunteers.

Workers go from house to house

checking whether immunisations are

up to date, treating disease and provid-

ing health authorities with early warn-

ings of outbreaks via cell phone.

“Because they live in the community,

they are the eyes and ears of the formal

healthservices,”saysMrKagubare.

Being part of the community, the

workers are able to gain the confidence

of the people they advise and treat —

something that is also important in

developed countries, particularly at a

time of growing scepticism over the

valueofimmunisation.

“There is a trust to that primary care

giver, and that has implications for vac-

cine uptake,” says Jeremy Farrar, direc-

toroftheWellcomeTrust.

He also argues that, while the trend in

medicine is towards specialisation, pri-

mary care should remain a vital part of

health services, since general practi-

tioners can assess how to treat someone

who,forexample,hasTBbutisalsoHIV

positiveandmaybetakingotherdrugs.

“Youhavetoseethewholeperson,”he

says. “Polypharmacy [taking multiple

pills daily] goes with multimorbidity

[having two or more chronic condi-

tions], and that’s as relevant with infec-

tiousdiseaseasitiswithanythingelse.”

In countries with universal health-

care, primary care practices can moni-

tor immunisation rates and outbreaks,

and report those to national authorities.

By contrast, the fragmentation of care

services in the US works against

nationalsurveillance.

“It’s not as well organised in the US as

in countries that have a more central-

ised healthcare system,” says Paul

Auwaerter, clinical director of the infec-

tious disease division at Johns Hopkins

UniversitySchoolofMedicine.

However, even in countries with uni-

versal healthcare, primary care tends to

be seen as the poor cousin. “General

practice has fallen down the political

peckingorder,”saysMrFarrar.

With this has come a decline in the

training of general practitioners as

more medics embark on specialist

qualifications.By2032,forexample,the

US could face a shortage of between

21,000 and 55,000 primary care physi-

cians, according to the Association of

AmericanMedicalColleges.

Part of the problem is that it is hard to

put a price tag on prevention: a process

that stops something happening. More-

over, benefits such as reduced disease

andlowermortalityratesonlymaterial-

ise over time, while politicians with an

eye on election cycles need to demon-

strateimmediateresults.

Yet neglecting primary care is risky.

If outbreaks are not caught in time, the

consequences can be devastating.

The 1918 Spanish flu pandemic, for

example, infected an estimated one-

third of the global population and led to

upwardsof50mdeaths.

Today, the likelihood of this kind of

crisis being repeated is increasing, with

accelerating rates of migration and

urbanisation and the emergence of dis-

eases like Ebola and Zika, about which

lessisknown.

Insuchaworld,arguesDrFernandop-

ulle, primary care should be receiving a

larger share of funding and resources.

“We all worry about these potential glo-

bal pandemics,” he says. “Shame on us if

wetakeoureyesoffthatball.”

Powerful preventive care continues to

suffer from global under-investment

Public health

Community programmes

help stem spread of diseases,

writesSarah Murray

Community nurse gives advice to women in a Ugandan village— Corbis/Getty

play”levyonsalesofotherdrugstofund

a reward pot worth up to $1.2bn for

effective new antibiotics created. This

levy might need to be supplemented

withpublicmoney,hesuggested.

This year the UK government

announced that the National Health

Service would test a “subscription-style

model” that pays pharma companies

upfront for access to antibiotics, based

on their usefulness to the NHS. That

would guarantee an income from a suc-

cessfully developed drug even if it was

heldinreserve.

Although details of this pilot scheme,

its timing and funding remain unclear,

people involved in antibiotic develop-

ment welcomed the announcement as a

first step that could be a model for the

rest of the world. “We in the UK should

be proud of having made the first move

but fixing the market failure requires

global action,” says Mike Ferguson, pro-

fessor of medicine at the University of

Dundee, who was instrumental in set-

ting up its Wellcome Centre for Anti-In-

fectivesResearch.

Investors in antibiotic-focused bio-

techs have lost money recently — one of

them, Achaogen, recently filed for

bankruptcy — but the few financial

institutions still prepared to back AMR

companiesaredeterminedlyoptimistic.

One is Novo Holdings of Denmark,

which launched its Repair Impact Fund

last year with the aim of investing

$165m in 20 AMR start-ups, early-stage

companies and corporate spinouts in

Europe and North America. It has

alreadyput$30mintosixcompanies.

Aleks Engel, the fund’s director, gives

several reasons for the bright outlook.

“The proposals reaching us now are

much more innovative than the prod-

ucts that have disappointed recently,”

hesays.

“When they reach the market,the

unmet need will be even greater than

today. At the same time I am encour-

aged by movement on the public policy

sidetocorrectthemarketfailure.”

He adds: “We are very focused on

making money with this fund, because

ifwedon’t,itwillexacerbatethepercep-

‘Proposals

reaching us

now are

much more

innovative

than the

products

that have

disappointed

recently’

MRSA bacteria in

a chainlike

configuration

being ingested

by a white blood

cell

tion that you can’t make money from

AMR.” Novo has given the fund more

time to achieve its benchmark return

than other investments “because the

marketissohard”,hesays.

Glyn Edwards, chief executive of

Summit Therapeutics, a UK antibiotics

company,takesasimilarview.“Thelast

four or five antibiotic launches from

biotech companies have had poor sales

but I believe they were very poor prod-

uctpackages,”hesays.

For him, the future lies in antibiotics

that kill a specific pathogen without

harming other bacteria, such as Sum-

mit’s lead product ridinilazole which is

in Phase 3 trials for treatingC. difficile

infection. “I doubt that anyone will find

a new broad-spectrum antibiotic,” he

says. “Narrow spectrum, combined

with new diagnostic technology, is the

placetobebecauseitleavesthepatient’s

microbiomeintact.”

The doom and gloom has been over-

doneamidalltheinnovationunderway,

Mr Edwards concludes. “We are not

goingtohaveanantibioticapocalypse.”

AUGUST 27 2019 Section:Reports Time: 23/8/2019 - 17: 52 User: darren.dodd Page Name: CMD3, Part,Page,Edition: CMD, 3 , 1

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