Point of View

Needed: new ways to deliver our medical miracles to the world

December 5, 2013 

The U.S. government’s decision to reduce funding for direct support for AIDS treatment in South Africa has stirred up a hornet’s nest of controversy. After more than a decade of offering life-saving HIV-AIDS treatment to millions of people in Africa, the President’s Emergency Program for AIDS Relief (PEPFAR) will begin shifting more responsibility for providing this care to local nations.

Given that PEPFAR serves millions of suffering people, the stakes couldn’t be higher.

“These are real patients whose lives are literally hanging in the balance now,” Charles Holmes, former chief medical officer of the Office of the U.S. Global AIDS Coordinator, warned last month in the New England Journal of Medicine.

While promising new breakthroughs attract the biggest headlines, this decision illuminates one of the most fundamental and challenging questions in medicine: how to deliver proven therapies to those who need it. A vaccine is only as good as the money available to produce it, as the roads to deliver it and the clinics to administer it. PEPFAR has made a difference by providing a bridge between medicine and patients.

Many experts are concerned about the proposed changes because they know how fragile that existing infrastructure is. The heartbreaking truth is that we are failing on a massive scale in delivering the best treatments to people in Africa.

My colleagues at UNC-Chapel Hill are all-too familiar with this tragic dynamic. Two years ago, a world-wide team of medical researchers led by Dr. Myron Cohen made a monumental discovery. Using available anti-retroviral drugs, they reduced the transmission of AIDS by a staggering 96 percent, potentially saving millions of lives almost immediately.

At a Washington event titled “The Beginning of the End of AIDS” and attended by three presidents, the U.S. government’s top HIV/AIDS scientist, Dr. Anthony Fauci, called the study “astounding.” The prestigious journal Science honored the work as the “Breakthrough of the Year.” The News & Observer named Cohen Tar Heel of the Year for 2012.

And yet today only a small fraction of AIDS sufferers around the world are receiving the cocktail of drugs that would save their lives and safeguard those around them. UNC’s main testing site in the African nation of Malawi is enjoying extraordinary success. About 45 percent of Malawians in need of the cocktail of drugs widely available in the U.S. have started therapy. While impressive, this means that even in Malawi a majority of sufferers are not receiving this therapy.

The reason is no surprise: The medicines are expensive and because they are a treatment, not a cure, they must be taken every day.

These problems are not confined to AIDS in Africa but also affect patients in wealthy nations, including the United States. A RAND Corporation study led by Dr. Elizabeth McGlynn found that, on average, only about half of proven effective therapies are provided in the U.S. “Knowing what to do is not enough,” Dr. McGlynn told me recently. “Implementing is so much harder.”

As Americans debate Obamacare, we must remember that providing health insurance is only one piece of the puzzle. The other is developing systems to deliver established therapies to patients who need them.

This growing effort is gathering force as health care organizations implement common sense programs such as providing automatic refills for medicines and devices for checking blood sugar or cholesterol at home. McGlynn calls such efforts “making the right thing to do easy.”

PEPFAR is asking the right question: how best to deliver necessary treatments, whether in Africa or America. Too often, we take for granted the marvels of modern medicine, which has all but vanquished ancient scourges such as polio and smallpox and turned many of us into high-tech creatures with space-age knees and hips. Yet, at the same time, millions of people around the world are not getting the most basic health care services.

As researchers crack the code of countless mysteries, we must also work on developing the infrastructure to deliver these wonders. Unlike other sciences, medicine isn’t just about discoveries – it’s about translating innovative ideas into improved health. Our breakthroughs can be measured only through the number of people they help.

Marschall S. Runge, M.D., Ph.D., is executive dean of the School of Medicine at the University of North Carolina at Chapel Hill.

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