WHO's First Global Report on AI in Health and Six Guiding Principles for Its Design and Use

According to a report published by the World Health Organization (WHO), "Digital technologies and artificial intelligence (AI), particularly machine learning, are transforming medicine, medical research and public health. Technologies based on AI are now used in health services in countries of the Organization for Economic Co-operation and Development (OECD), and its utility is being assessed in low- and middle-income countries (LMIC)."

The report, Ethics & Governance of Artificial Intelligence for Health, which is the result of two years of consultations held by a panel of international experts appointed by WHO, further says: Whether AI can advance the interests of patients and communities depends on a collective effort to design and implement ethically defensible laws and policies and ethically designed AI technologies. There are also potential serious negative consequences if ethical principles and human rights obligations are not prioritized by those who fund, design, regulate or use AI technologies for health. AI's opportunities and challenges are thus inextricably linked."

To limit the risks and maximize the opportunities intrinsic to the use of AI for health, the WHO provides the following six principles as the basis for AI regulation and governance:

Protecting human autonomy: In the context of health care, this means that humans should remain in control of health-care systems and medical decisions; privacy and confidentiality should be protected, and patients must give valid informed consent through appropriate legal frameworks for data protection.

Promoting human well-being and safety and the public interest. The designers of AI technologies should satisfy regulatory requirements for safety, accuracy and efficacy for well-defined use cases or indications. Measures of quality control in practice and quality improvement in the use of AI must be available.

Ensuring transparency, explainability and intelligibility. Transparency requires that sufficient information be published or documented before the design or deployment of an AI technology. Such information must be easily accessible and facilitate meaningful public consultation and debate on how the technology is designed and how it should or should not be used.

Fostering responsibility and accountability. Although AI technologies perform specific tasks, it is the responsibility of stakeholders to ensure that they are used under appropriate conditions and by appropriately trained people. Effective mechanisms should be available for questioning and for redress for individuals and groups that are adversely affected by decisions based on algorithms.

Ensuring inclusiveness and equity. Inclusiveness requires that AI for health be designed to encourage the widest possible equitable use and access, irrespective of age, sex, gender, income, race, ethnicity, sexual orientation, ability or other characteristics protected under human rights codes.

Promoting AI that is responsive and sustainable. Designers, developers and users should continuously and transparently assess AI applications during actual use to determine whether AI responds adequately and appropriately to expectations and requirements. AI systems should also be designed to minimize their environmental consequences and increase energy efficiency. Governments and companies should address anticipated disruptions in the workplace, including training for health-care workers to adapt to the use of AI systems, and potential job losses due to use of automated systems.

As the WHO notes: "AI for health has been affected by the COVID-19 pandemic. Although the pandemic is not a focus of this report, it has illustrated the opportunities and challenges associated with AI for health. Numerous new applications have emerged for responding to the pandemic, while other applications have been found to be ineffective. Several applications have raised ethical concerns in relation to surveillance, infringement on the rights of privacy and autonomy, health and social inequity and the conditions necessary for trust and legitimate uses of data-intensive applications."

"While the primary readership of this guidance document is ministries of health, it is also intended for other government agencies, ministries that will regulate AI, those who use AI technologies for health and entities that design and finance AI technologies for health."

The report importantly adds:

Implementation of this guidance will require collective action. Companies and governments should introduce AI technologies only to improve the human condition and not for objectives such as unwarranted surveillance or to increase the sale of unrelated commercial goods and services. Providers should demand appropriate technologies and use them to maximize both the promise of AI and clinicians' expertise. Patients, community organizations and civil society should be able to hold governments and companies to account, to participate in the design of technologies and rules, to develop new standards and approaches and to demand and seek transparency to meet their own needs as well as those of their communities and health systems.

Do you agree with the six principles as the basis for AI regulation and governance? What are you recommendations for how AI can be used for health?

Aaron Rose is a board member, corporate advisor, and co-founder of great companies. He also serves as the editor of GT Perspectives, an online forum focused on turning perspective into opportunity.

A Case Study on the Benefits and Challenges of Cancer Monitoring With Digital Apps

According to a case study written by The Economist Intelligence Unit (The EIU), "Advances in smartphone technology, healthcare provider information and communications technology infrastructure has enabled the development of new clinical pathways involving app-based remote patient monitoring. Patient monitoring apps allow patients with chronic diseases to report on their condition from outside of the hospital – where they spend most of their time – putting the patient, rather than the hospital, at the center of the care pathway."

What is more, "A high society-wide level of smartphone penetration has presented a large market for developers, with apps now used in clinical practice for chronic disease management in diabetes, chronic kidney disease, congestive heart failure and oncology. However, up until the covid-19 pandemic struck, the development of technological capabilities within healthcare had largely outpaced the capacity to implement many novel remote patient monitoring apps as part of real-world practice."

Titled Outside the hospital: cancer monitoring with apps, the study explains that the "covid-19 pandemic initiated a rapid reorganization of healthcare delivery systems, raising awareness of these digital tools that physicians can use to provide care outside hospitals. Chronic disease monitoring apps vary widely in their functionality but increasingly rely on patients to capture health data that can help inform clinical decision-making. This has enabled a high degree of patient-centricity, varying from enabling behavioral nudges from clinicians to providing real-time updates to care teams with on-demand care capabilities for patients."

Commissioned by Siemens Healthineers, a multinational digital healthcare company based in Germany, The EIU's study explores "the use of remote monitoring, particularly in oncology. We review recent health system developments, challenges to implementation of these digital tools and the emerging opportunities for their sustainable use throughout health systems."

The study presents the following benefits in using monitoring apps:

• Patient monitoring apps can provide real-time data on cancer patients, thereby enabling much faster feedback loops between individuals and their healthcare teams.
• Clinicians can develop personalized cancer care plans that respond to patient behaviors and support better management of adverse events related to treatment.
• Cancer apps could support a reduction in healthcare costs arising from preventable hospital admissions.
• They can help to improve a patient's quality of life by allowing them to become participants in co-creating their care and opening the door for shared decision-making.

Conversely, challenges of using monitoring apps include:

• Reimbursement pathways for mobile health tools have traditionally been a barrier to implementation, but leveraging beyond the pandemic could accelerate adoption into clinical pathways.
• Healthcare providers need to invest in ICT infrastructure that can rapidly translate data from apps into actionable and meaningful insights for clinicians – without becoming an additional administrative burden.
• Providers will need to invest in different skills for digital workflows, or new roles will be required within healthcare settings, to support the digital patient journey.
• Confidence in these tools could be achieved with the use of digital formularies.
• Healthcare providers and developers will need to continue to work together to prioritize the standardization of apps so that they are interoperable across health systems. As regulations differ across geographies, this will require taking into account factors including different IT architecture, connectivity requirements, and data sharing and communication standards.

"Mobile apps can provide a more valuable, real-time dataset by enabling a much faster feedback loop between patients and their care teams," the study importantly notes. "Increased reactivity allows for deeply personalized cancer care plans that respond to patient behaviors, in addition to better management of adverse events related to treatment, a reduction in healthcare costs arising from preventable hospital admissions and ultimately improved patient quality of life. These apps provide an avenue for patients to become participants in co-creating their care pathway and open the door for shared decision-making, which may have other behavioral benefits in terms of adherence."

Having engaged with companies developing digital solutions for the healthcare industry for over ten years, I have witnessed significant advances in innovative technologies and services that provide a direct benefit for the patient. While I acknowledge the existence of the aforementioned challenges, I remain optimistic that the healthcare industry worldwide will continue to evolve to incorporate patient-centric tools including remote monitoring apps. In doing so, patients will enjoy a sense of empowerment when the receive their health information in real-time. This information will also enable the patient's healthcare team to formulate a collaborative plan with the patient to combat diseases such as cancer.

What benefits and challenges do you see in the use of patient monitoring apps?

Aaron Rose is a board member, corporate advisor, and co-founder of great companies. He also serves as the editor of GT Perspectives, an online forum focused on turning perspective into opportunity.

Report Looks at the Promise and Current Limitations of Precision Medicine

"Precision medicine has the potential to transform healthcare," a report by The Economist Intelligence Unit (The EIU) explains. "By moving away from trial and error towards more targeted, accurate diagnoses and treatments, people should be able to live longer and healthier lives and social outcomes should improve, all with less wasted time, money and energy. This is what medicine has always aspired to, but has not yet been able to deliver."

Commissioned by the Qatar Foundation, a nonprofit organization made up of more than 50 entities working in education, research, and community development, Doing well? Fulfilling the promise of precision medicine, "looks at the promise and current limitations of precision medicine, the barriers to its implementation in public health systems, and the areas where policymakers – indeed, all stakeholders – must focus their efforts in order to realize its potential."

The key findings listed below are based on an extensive literature review and a comprehensive interview program conducted by The EIU between March and September 2020.

• Defining the term precision medicine is challenging. It is best understood as the potential outcome of four interwoven, data-related enablers: (1) the increasing volume of data available to health systems; (2) vast growth in the kinds of data from which health systems can draw insight; (3) the increasing availability of data storage systems that permit easier access to relevant information; and (4) the quantum leaps in analytic technology that make it possible to draw greater insights from this information.
• Hopes are high. Precision medicine is expected to benefit all healthcare stakeholders: patients will have quicker access to the treatments they need, and will be able to avoid the risks of taking incorrect medication; health systems will reduce waste and improve outcomes; payers will receive better value for money; and the overall health of populations will improve.
• Current advances are limited but remain highly promising. There are already a number of important examples of precision medicine in action. Thanks to a better understanding of tumor genetics, more effective treatments are now possible for several cancers, notably those of the lung and breast. In the field of rare disease, genomic sequencing is cutting diagnosis times for a large number of patients. Pharmacogenomics—the study of how a person’s genetics interact with particular drugs—is a growing field, and genetic sequencing is being used to recognize pathogen mutations.
• Proof of value remains a pressing issue. Given the possible breadth of applications for precision medicine, it is challenging to determine whether the field as a whole is cost-effective. Some interventions may be; others may not.
• There is controversy around the concept of precision public health. This highlights fundamental issues that must be resolved if precision medicine is to become more widely integrated into health systems.
• Those seeking to incorporate precision medicine into healthcare systems will need to address a diverse and complicated range of issues. Innovation in healthcare systems is notoriously difficult. Integrating precision medicine into standard care will require the creation of new care pathways and new kinds of interventions, all of which will require different infrastructure. In most health systems, this process is only in the initial stages.
• To be successful, precision medicine must be delivered in a patient-centered way. Patient-centricity involves working with patients as co-creators of healthcare and health research, which involves a conversation of equals. Clinicians will need to help patients understand the implications of precision tests, the relevant data and the treatment choices. Both sides can then determine together what the patient values most in terms of the outcome(s) of any intervention. Adopting a patient-centricity can also helpto address some of the pressing ethical issues surrounding precision medicine.

The report's concluding paragraph insightfully notes: "We are still in the early stages of learning how to implement precision medicine and understanding what this will look like in practice. All relevant stakeholders need to ensure that they develop the appropriate and necessary foundations for precision medicine in order for this radically new way of doing things to deliver on its promises."

To complement its report, The EIU produced the video below (also viewable through this link) entitled "Can precision medicine fulfill its promise?"

What are your recommendations for how precision medicine can transform healthcare?

Aaron Rose is a board member, corporate advisor, and co-founder of great companies. He also serves as the editor of GT Perspectives, an online forum focused on turning perspective into opportunity.

Global Health Business Case Competition Focuses on Ending Malaria

In the middle of a three week trip to Uganda in 2004, a driver I hired to escort me from my hotel to various meetings said his young son had just died from malaria, an infectious disease transmitted by the bites of infected mosquitoes. While malaria has been eradicated in the developed countries, the U.S. Centers for Disease Control and Prevention says an estimated 445,000 people died of the infectious disease—most were young children in sub-Saharan Africa.

Having spent a large amount of my career working to strengthen the private sector in developing countries, I have come to appreciate the collaborative role entrepreneurship plays in combating infectious diseases such as malaria. Therefore, it was with great pleasure to participate as a volunteer judge at the fourth annual Global Health Business Case Competition on Jan. 26, 2019. The event was hosted by the Global Business Center (GBC) at the University of Washington Foster School of Business, in partnership with the Jackson School's Center for Global Studies and the UW Department of Global Health. As explained in a blog post, "This competition provides a unique opportunity for students to experience hands-on, cross-disciplinary teamwork while tackling a global health challenge."

Thirty-two teams (26 undergraduate and six graduate) were given The Mosquito Network: Collaborative Entrepreneurship in the Fight to Eliminate Malaria Deaths, a 2016 case written by Gaylen Williams Moore, and published by the Harvard Kennedy School. The case was supplemented with a 2018 article, "Countries must steer new response to turn the malaria tide," which highlighted how malaria reduction efforts had recently stalled in the last two years, especially in high burden countries.

The GBC blog post further explains:

The students were asked to take on the role of an Africa-based team of consultants hired by the RBM Partnership to End Malaria. The teams were tasked with recommending how to spend an extra $6 billion on malaria reduction in the context of a new "high burden to high impact" malaria program, an approach that supports countries most affected by malaria. Specifically, students addressed how much would be allocated to the ten high burden countries in Africa and explored why malaria control efforts have not been effective in curbing malaria in these countries. Next, they had to identify the right mix of malaria interventions and best practices for a country where previous efforts proved ineffective.

Students had just 48 hours to do their research and create the slide deck to accompany their presentation. On Saturday morning, January 26th, interdisciplinary UW teams presented their solutions and judges scored teams on their analysis, style, rational, and ability to handle the question and answer session.

I was grouped with three other volunteer judges who heard presentations from four teams of talented undergraduate students. Focusing initially in the Democratic Republic of Congo with future expansion to Nigeria, Niger, and Mozambique, a team presented "The Domino Country" whose mission calls for using individualized action as an adaptable model to stimulate awareness and the economy to create a domino effect throughout Africa's high burden countries. Its benchmarks were trifurcated by educate (provide knowledge of diseases and prevention, and train community leaders and civilians in diagnostics), enact (create incentives towards malaria fighting organizations and initiate national malaria programs), and evaluate (high rates of net usage of bed nets and malaria awareness and economic stability towards malaria initiatives).

The vision of team "IMPACT Consulting" is to transform health intelligence and save lives in the fight against malaria through improved data analytics and partnering with local officials. They identified Cameroon as their initial test country with a phase two expansion to Burkina Faso, Ghana, Mali, and Uganda.

"Uniting to Combat Malaria in an Era of Industrialization and Globalization" aimed to achieve four goals: (1) Develop a strategy that will appeal both to politicians and large donors while at also promoting community-based solutions in order to endure a long-term solution, (2) delegate funds to high risk countries and international organizations so that the marginal product per dollar spent is equal among productive capital to maximize total utility, (3) demonstrate a comprehensive analysis of past policies both good and bad to ensure progress for the future, and (4) establish an exhaustive Global Guidance Policy which will ensure there is cohesion in communication between global and local settings and to keep the various efforts on track for success. This team chose Nigeria as its country of focus.

Also focusing on combating malaria in Nigeria, team "Tumaini" made a presentation outlining two goals: developing an effective malaria vaccine or treatment by funding an established research program and immediately reduce malaria impact and mortality by fighting malaria through specialized clinics.

Undergraduate Track 1st Place

While neither of the teams we heard presentations from made the top three among the 26 undergraduate teams, we were quite impressed with the way each team employed essential critical thinking tools to understand the problem they were charged with solving and their creativity to formulate a possible solution.

With a rising middle class among its 1.24 billion inhabitants, government officials representing African nations often approach me about expanding my investment and business holdings on the continent. While I am keen to do so, having a workforce in good health or not otherwise impacted by sick young family members by a preventable disease such as malaria is essential to achieving long-term success. Programs like the Global Health Business Case Competition are an important piece to the process of creating sustainable solutions.

What solutions would propose if you had the opportunity to participate in this year's Global Health Business Case Competition?

Aaron Rose is a board member, corporate advisor, and co-founder of great companies. He also serves as the editor of Solutions for a Sustainable World.

Mobile App Designed to Document Sick Chickens in Rural Thailand

Having dined in restaurants from Afghanistan to Uruguay, Brazil to Vietnam, and many points in between, the most common item found on the menu is Gallus gallus domesticus. In its Jan. 17, 2019 issue, The Economist published an article on how chicken became the world's most popular meat. "The chicken industry is a dirty business, but it is also a profitable one. In the OECD, a club of mostly rich countries, pork and beef consumption has remained unchanged since 1990. Chicken consumption has grown by 70% (see chart)."

The article further notes that "[h]umans gobble so many chickens that the birds now count for 23bn of the 30bn land animals living on farms." Importantly, "Chicken is cheap... . A pound of poultry in America now costs $1.92, a fall of $1.71 since 1960 (after adjusting for inflation). Meanwhile the price of beef has fallen by $1.17 a pound to $5.80."

A hen and her chicks I saw in
Jinja, Uganda

Moreover, "It is not just fussy Western eaters who increasingly favor chicken. Rising incomes mean that demand for the meat is growing even faster in poorer countries. As a result, chickens are now the world's most widely traded meat. In economic terms they are, in effect, the opposite of cars. They are produced whole. But their value is maximized once they are broken up.

"Though westerners prefer lean, white meat; many in Asia and Africa prefer dark meat, which includes legs and thighs. These preferences are reflected in local prices: in America breasts are 88% more expensive than legs; in Indonesia they are 12% cheaper. Differences in the price of chicken feet are even starker. The thought of eating talons is abhorrent to many Westerners, but they often feature in Cantonese recipes. China now imports 300,000 tonnes of 'phoenix claws' every year."

Poor food security in industrial and developing countries alike, however, have been well documented over the past several years. Fred de Sam Lazaro, director of the Under-Told Stories Project at the University of St. Thomas in Minnesota, and a special correspondent for the PBS NewsHour, produced a report explaining that "viruses like Avian flu, Ebola and Marburg often fester in animals before moving into human populations. Animals in regions that are geographically remote present particular challenges for disease containment. But in Thailand, local residents are using technology, including digital scanning, to track animals and stop outbreaks before they start."

As Mr. de Sam Lazaro notes: "There are more chickens than people in remote Thai villages like Huay Ton Chok, and people do worry when their chickens stop crossing the road. That's because, five years ago, this village suffered an outbreak of flu-like disease that killed hundreds of birds. So when farmer Udom Putipatharakal thought one of his chickens wasn't doing well and another looked really ill, he reported it."

"For four years," according to Mr. de Sam Lazaro, "Pariwat Roomak has been dispatched from the local health department, responding to calls about sick animals in the area."

Mr. de Sam Lazaro further explains:

Pariwat enters all of this information into an app on his smartphone and transmits it directly to the local government health office, the veterinary department and to a major university to be analyzed. It's part of a participatory One Health disease detection program, more simply called PODD. And it has become a model for programs like this all over the world. It's villages like this one that scientists fear could be the cradle of the next superbug, one that can jump from animal to human, and then mutate so it can leap from human to human. So the objective of this exercise is to track every diseased animal, particularly chickens, so as to contain an outbreak before it becomes a pandemic.

According to Jarwan Chaicom, who heads the local health department for this region in Thailand, "Before we adopted the system, the villagers didn't have a way to connect with each other or with us. The local government is quite far away from them. Language is another barrier, because we have seven ethnic groups and seven languages in this area."

A smartphone app developed for the program translates those languages, so all the responders can track where the diseases are occurring. Patipat Susumpow leads the firm that designed the app. It had to be simple. "The penetration rate of smartphone is not really high in those communities," says Mr. Susumpow. "So most of our volunteers either never used a phone before or used like a very simple phone."

In the case of documenting the ill chicken in Huay Ton Chok, Mr. de Sam Lazaro reports the next stop for the diseased bird was a two-hour bus ride to Chiang Mai University where "scientists determine the type of disease, the likely cause, and, accordingly, recommend action to prevent its spread, whether it's administering antibiotics to animals or disinfectant spraying."

By utilizing mobile technology, Mr. Susumpow adds: "We hope the app can be the placeholder for democratizing the power of response and disease management back to the community."

Click here to watch the video or read the transcript of the PBS NewsHour segment.

What mobile applications are you seeing that are helping to document occurrences of infectious diseases?

Aaron Rose is an advisor to talented entrepreneurs and co-founder of great companies. He also serves as the editor of Solutions for a Sustainable World.

Exploring the Recent Progress and Challenges of Tackling Tuberculosis

In the previous post in this blog, I discussed a report published in 2014 by The Economist Intelligence Unit (EIU) that investigates the health challenge posed by tuberculosis (TB) and ways to improve the effectiveness of the global response to it. On Oct. 26, 2016, The EIU announced the publication of an updated report, which evaluates "the progress made in the global response to TB since The EIU’s 2014 study." The 2016 report, Tackling tuberculosis: Recent progress and challenges, first considers "the socioeconomic and political context of tackling TB and then look at policy and progress in the areas of prevention, diagnosis and treatment. Moreover, four country case studies shed light on recent progress and challenges in tackling TB in Ethiopia, Kenya, Nigeria and South Africa."

On the chapter titled "The Political and Socioeconomic Context," the report explains that "the prospects for improving TB prevention, diagnosis and treatment efforts are intrinsically linked to socioeconomic and political factors. For a start, a country's level of development has a strong influence on its response to the disease."

According to Michael Kimerling, director of the technical services division at the Netherlands-based KNCV Tuberculosis Foundation, which works to strengthen health systems in the fight against TB, "As you build up primary health infrastructures, the stronger these become, the better TB can be managed. It's such a classic disease of public health. Development is important for overcoming TB."

A stronger political will to tackle TB is necessary as "the disease continues to receive relatively less attention than other higher-profile diseases, the experts interviewed for this report say." Mario Raviglione, director of the Global TB Program at the WHO, is quoted as saying, "Fundamentally, what needs to be recognized is a lack of political commitment. As we mentioned in [the UK medical journal] The Lancet a few years ago, TB is not a main priority among any of the main UN agencies; it does not have a special UN program, is not in UNICEF's portfolio and is not a special presidential initiative in the US. It does not have strong support from the pharmaceutical industry."

On the topic of policy and progress on prevention, diagnosis and treatment, the report notes the World Health Organization's goal of reducing TB by 90 percent by 2030 "will require new tools that are currently lacking . . . including better prophylaxis, the development of vaccines and new treatment regimens, especially for MDR TB."

With respect to improving diagnostics and prevention, the report asserts that "reliably identifying vulnerable populations that are most likely to go on to develop TB would allow for a more rapid management of the disease and avoid exposing those at lower risk to treatment regimes that involve significant side effects, Dr Raviglione says. He adds that current tests only show whether a person has been exposed, but not whether they are likely to develop full-blown TB. Around one-third of the world's population has latent TB—where they have been infected with mycobacterium tuberculosis but have not developed the active disease —according to the WHO."

The report's conclusion notes: "Two years on from our original report there is evidence of some progress on the global response to TB, including, for example, efforts to shorten treatment regimens. At the same time, however, public-health experts observe that TB retains a relatively low disease profile in terms of R&D, both compared with diseases such as HIV/AIDS and in proportion to the impact of the disease. Major political and socioeconomic challenges remain, notably the lack of universal access to health coverage in many endemic countries, insufficient political will and deficient national TB control plans."

And I agree with the report's final paragraph: "Ultimately, progress will depend on the political will to underpin greater investment in research and the willingness of more countries to commit to both national policy frameworks and cross border partnerships."

Lastly, given the interest of colleagues and I have regarding the development of mobile software solutions to prevent infectious diseases such as TB, I would be reminiscent not to mention how the EIU's 2014 report or 2016 update addresses this topic. Below is an excerpt from the 2014 report:

The Kenyan Ministry of Health, along with Safaricom, one of the country's major mobile-phone companies, and a number of other partners have developed a data management system called TIBU, which means 'cure' in Swahili. Since November 2012, this has allowed the direct entry of details on new TB infections, using tablet computers at the point of diagnosis, into a national database that currently holds details on around 90,000 patients. The information can then be used in a wide variety of ways. At the national level, it enables the monitoring of trends, as well as indicating if any districts are performing poorly and need support. Local clinicians can use it to determine in real time if drug stocks are able to meet local need and to order new medication where required. It allows the treatment of individual patients to be followed even if they migrate to a different part of the country, and sends SMS messages to anyone who does not attend a clinic, reminding them to take prescribed their pills. Finally, TIBU is linked with Kenya’s mobile payments system, M-Pesa, to allow faster dispersal of support payments to those with MDR TB who continue to adhere to treatment.

Do you agree with the findings of the report? What is your recommendation on achieving WHO's goal of reducing the incidence of TB by 90 percent by 2030? What role should mobile technology play in achieving this goal?

Aaron Rose is an advisor to talented entrepreneurs and co-founder of great companies. He also serves as the editor of Solutions for a Sustainable World.

A Time for Greater Action Against Tuberculosis

On Oct. 26, 2016, The Economist Intelligence Unit (EIU) announced the publication of a report that notes: Although tuberculosis (TB) "was responsible for around 1.5m deaths in 2014, down from nearly 1.8m in 1990, it is now the leading infectious disease killer worldwide, surpassing HIV/AIDS," according to the World Health Organization. The EIU report is intended to serve as an update to a 2014 report, Ancient enemy, modern imperative: A time for greater action against tuberculosis. This post, however, will focus on the 2014 report, which investigates the health challenge posed by TB and ways to improve the effectiveness of the global response to it. I will address the findings from the 2016 report in a subsequent post on this blog.

Supported by Janssen, the EIU's 2014 report "draws on interviews with 17 public health officials, funders, academic and medical experts, researchers, and activists as well as on extensive desk research to consider the state of the TB challenge, barriers to further progress, and how efforts need to evolve." The report's key findings include the following:

1. Despite important successes, progress against TB is still slow and significant weaknesses remain;
2. Drug-resistant TB has become a public health crisis that is receiving too little attention and shows up failings in current efforts;
3. To date, TB efforts at various levels have often suffered from a lack of compelling ambition and interest;
4. A high level of stigma still affects those with the disease and hampers efforts against it;
5. Efforts against TB remain overly provider-centered and set apart from health systems; and
6. Improved success against TB will require changes on a number of levels.

On the topic of improving success against TB will required changes on a number of levels, the report says that "further progress against TB is essential, but will mean new strategies that address current weaknesses while not throwing away gains to date." These new strategies include: 

• Finding and treating people where they live. To find the nearly-3m new cases of TB every year, health systems in countries with a high incidence of TB need to look across the entire population, and even those with a lower prevalence have to find better ways of going into, and working with, sometimes marginalized populations;
• Taking TB control out of existing silos. TB needs to treat the whole person, including addressing common co-morbidities such as HIV/AIDS, and co-ordinating public and private health provision;
• Harnessing cost-effective technology. Although progress in the field of TB remains frustratingly slow, new tools available today—both medical and non-medical—have the potential to transform treatment;
• Raising the profile of TB. Perhaps most important, activists and other stakeholders must find better ways to elevate national and global ambitions to deploy the tools at hand with sufficient intensity to make more rapid progress against this disease.

The 2014 report concludes by stating "TB strategies need to move in practice beyond medical silos to work in and with communities on finding cases and improving treatment outcomes. This involves a range of changes, including those listed below:

• Seeking and treating the ill in new ways, where they live. Clinic-based efforts alone will not reach the nearly 3m undiagnosed TB cases. In high-burden countries, the search will need actively to look for TB across the population as a whole. Even in lower burden ones it will involve finding effective ways to target and treat the disease in sometimes challenging marginal populations;
• Integrating care to take account of the whole human being. Those with TB frequently have co-morbidities and lack the social or economic resources to be able to complete their treatment—especially of MDR TB—over the long term. Effective TB care means finding ways to overcome these barriers;
• Taking advantage of the resources of health systems as a whole. National TB programs are an effective way to focus attention on the disease, but they should not become a TB care silo. The whole health system needs to be involved in finding TB, and medical facilities— including HIV clinics and private care providers— are proven ways to help address the disease; and
• Harnessing new technology (both medical and non-medical). Medical advances in TB are still frustratingly slow, so those that come along need to be applied in the most useful way. The WHO has encouraged the use of GeneXpert and such a test will be essential in rapidly diagnosing and defeating MDR TB. Health systems need not rely solely on medical technology, however. Mobile information technology and integrated databases show great promise in being able to understand the challenge that TB poses at both national and local levels, as well as in tracking patients and helping to avoid issues with drug stocks.

A video produced in conjunction with the 2014 report, which may be viewed below or through this link, correctly explains that "combating tuberculosis globally required finding and treating people where they live, involving the health system as a whole, and harnessing cost-effective technology."

Aaron Rose is an advisor to talented entrepreneurs and co-founder of great companies. He also serves as the editor of Solutions for a Sustainable World.

Symposium on Global Health in China

"Contribute to strengthening global health through supporting the collaboration of China in the global health arena" is one of four strategic priorities of the World Health Organization's (WHO) collaboration with China as outlined in the China—WHO Country Cooperation Strategy. I have witnessed a number of initiatives over the past few years focused on China's increasing role as a major contributor in the global health arena. Given my personal and professional interests on global health, I appreciated having the opportunity to attend the "Symposium on Global Health in China: Harnessing the Power of Universities" at the University of Washington in Seattle. This post addresses a few points made during the symposium that took place from April 5-6, 2016.

It their welcoming letter, Judy Wasserheit and Stephen Gloyd, co-chairs of the symposium, wrote: "The symposium goals is to create a forum to help define future directions for academic global health in China, and to discuss how best to facilitate university collaborations with institutions from both high and low income countries." Drs. Wasserheit and Gloyd continue to explain that "the symposium will provide our Chinese university colleagues with an opportunity to meet a wide, interdisciplinary array of faculty, students, and other stakeholders to strategically plan for future collaborations."

I was surprised to learn about China's long history of sending medical aid teams to over 60 countries and regions, with most teams being sent to Africa. In his keynote speech, "Emergence of Global Health in China: Prospects and Implications," Lincoln Chen, President of the China Medical Board, noted the first China Medical Team (CMT) was sent to Algeria in 1963.

Regarding its domestic market, Dr. Chen said, "China has increasingly equitable care that can provide a model for the developing world." However, while China is making progress in modernizing its domestic healthcare system, the speed of such progress is slow. "China is still evolving from a Soviet-style medical system to a Western-style system."

He also remarked that China "is intellectually engaged in global health issues" and as a global economic power, the world's most populous country "wants to contribute more, which shows it is taking up its responsibilities as a global power."

During the plenary panel titled "Global Health in the Chinese Context," panelists discussed how global health is defined, what global health means in the context of activities supported by China, and how Chinese universities contribute to this global effort. In remarks made by Yinou Li, Director of the Bill & Melinda Gates Foundation's China office, Dr. Li noted that China has made progress in certain areas such as reducing tobacco use through restrictions on tobacco advertising and banning indoor smoking. Moreover, she provided some insights on collaborative efforts by the Chinese government, health organizations, and universities to create advocacy campaigns in support of tobacco control measures and social marketing campaigns that aim to educate people and change attitudes about tobacco use (namely, making smoking socially unacceptable and unappealing). Success in this area could serve as a model for other emerging or developing countries.

On the topic of eradicating infectious diseases such as tuberculosis, the Gates Foundation says, "According to the World Health Organization (WHO), nearly 1 million people develop tuberculosis (TB) in China each year—more than in any other country except India. In addition to a high burden of the disease, China has about one-fifth of the world's cases of multidrug-resistant TB (MDR-TB), which is especially difficult and costly to treat." Dr. Li noted that a majority of funding by the Gates Foundation in China is allocated to supporting the efforts of the Chinese government. For example, the Gates Foundation's website explains its support of a grant to the National Health and Family Planning Commission, which focused on "developing and demonstrating innovative TB-control models that can help China further reduce the number of patients who develop TB, and particularly MDR-TB."

The Gates Foundation is also helping China control its HIV epidemic by "reaching high-risk groups with prevention programs and accurate information, testing, and efficient and effective treatment programs." This has been done, according to the Seattle, Wash.-based organization's web page on combating HIV in China, through financially supporting "the Chinese government and community organizations on a program to expand HIV prevention (through testing and interventions) among those most at risk of infection and to provide care and treatment to those infected. In some program cities, more than half of all newly detected cases were identified through our collaboration with community organizations." Again, if done efficiently and effectively, China's efforts of reducing tobacco use, eliminating TB, and controlling HIV could serve as a model in other emerging or developing countries.

In the plenary panel, "Chinese University Partnerships with Low and Middle Income Countries," panelists talked about China's efforts in improving its bilateral health cooperation and greater participation in global health work and governance. Feng Cheng, Professor and Chief Physician, Research Center for Public Health and School of Medicine at Tsinghua University said expanding partnership opportunities will facilitate the development of health technologies and quality products to contribute to global health. Such partnerships will help transfer appropriate health technologies between Chinese universities and low and middle income countries with the aim to improve global health outcomes.

I want to express my appreciation to the symposium's co-chairs, planning committee members, and organizers. While I am not a member of the academic community, I found great value in attending this symposium to learn more the benefits through the collaboration among Chinese and American universities. I plan to learn from these lessons and apply them to the efforts my colleagues and I at ROI3, Inc. are developing to promote health and wellness in emerging and developing countries through localized mobile software solutions designed for smartphones and tablets.

Aaron Rose serves as President and CEO of ROI3, Inc., a Seattle, Wash.-based company that empowers people in emerging economies through innovative, technology-based solutions. He is also the editor of Solutions for a Sustainable World.

PATH does not Consider China a Recipient, but a Partner

The focus of the previous post on this blog is on the role China plays in the strategy of ROI3, Inc. In doing some research for the post, I found some notes that I took while attending an event at The Bureau of Asian Research (NBR) on March 15, 2013 entitled "China's Evolving Health Industry Investments" featuring Jiankang (Jack) Zhang, PATH’s China Country Program Leader. While the event occurred eight months ago, there are a few points that remain relevant and worth sharing in this post. [Photo of Jack Zhang: PATH/Mike Wang]

Program for Appropriate Technology in Health (PATH)

"PATH's mission is to improve the health of people around the world by advancing technologies, strengthening systems, and encouraging healthy behaviors," according to its website. The Seattle, Wash.-based international nonprofit organization, which was founded in 1977, says that it "transforms global health through innovation. We take an entrepreneurial approach to developing and delivering high-impact, low-cost solutions, from lifesaving vaccines and devices to collaborative programs with communities. Through our work in more than 70 countries, PATH and our partners empower people to achieve their full potential."

In 2011, according to its Consolidated Financial Statements, PATH's total revenue was $283,838,000. Their funding derives from foundations; the United States government; other governments, other nonprofit organizations, and multilateral agencies such as the World Health Organization (WHO); individuals; and interest from investments 75.5 million people worldwide benefited from PATH's work in 2011 including 4.8 million mothers, newborns, and infants; 8.3 million children and adolescents; and 5.4 million people living with HIV/AIDS or tuberculosis.

Specific to China, PATH, since 1979, "has worked with Chinese government agencies, nongovernmental organizations, research institutes, and manufacturers to improve health. Our team in China has focused particularly on addressing reproductive health and infectious diseases." Coordinated from the organization's office in Beijing since 2003, PATH's strategy for success includes:

• Developing and expanding public-private partnership models for health product development that take into account health needs, the best interests of donors, PATH's core competencies, the interests of Chinese public agencies, and synergies with Chinese public and private companies;
• Identifying opportunities vertically and horizontally to build on this model to meet the multiple health needs of vulnerable populations in and outside of China; and
• Promoting global access and supply of affordable, accessible, and sustainable health products in China, and through China to other low-resource settings.

PATH in China explains how "PATH views collaboration as the key to providing innovative, sustainable, affordable, and culturally appropriate health solutions for low-resource settings. We conduct rigorous monitoring and evaluation to ensure the efficiency and effectiveness of our work. PATH's strategy in China includes:

• Developing and expanding public-private product development partnerships that align with donor interests, PATH’s core competencies, the interests of China’s public health agencies, and the needs and perspectives of Chinese companies;
• Identifying opportunities to build on these partnerships to meet multiple health needs of vulnerable populations inside and outside of China; and
• Promoting sustainable access to supplies of affordable health products in China and through China to other low-resource settings.

PATH's specific initiatives in China include work in vaccine research, development, and introduction; Woman's Condom product development and promotion; and new diagnostic tools for tuberculosis (TB). A sampling of PATH's projects includes the advancing rotavirus vaccine development; assessing Chinese vaccine manufacturers, the Japanese Encephalitis project; polio vaccine development and scale-up project (PVD); Protection Options for Women (POW); the tuberculosis new diagnostic demonstration project; the Woman's Condom project; and the Safe Water Project.

"China's Evolving Health Industry Investments"

As PATH's country program leader in China, Jiankang (Jack) Zhang is responsible for program development, project management, office management, and liaising with local and international collaborators, including local health authorities, public and private institutions, and other nongovernmental organizations in China.

During his presentation, Mr. Zhang said that the Chinese government is encouraging more private investments in the pharmaceutical and biotechnology sectors. He noted, however, intellectual property protection remains a significant concern by private enterprises, particularly companies based outside of China.

In Mr. Zhang's interview with NBR's Claire Topal and Karuna Luthra on May 25, 2011 entitled "A Pivotal Moment for China and Vaccine Manufacturing," it is noted, "The World Health Organization (WHO) announced on March 1, 2011, that the national regulatory authority of China—the State Food and Drug Administration (SFDA), along with affiliated institutions—now meets WHO indicators for a functional vaccine regulatory system. This means that Chinese-made vaccines are now eligible to apply for WHO pre-qualification."

WHO prequalification ensures that vaccines used in national immunization services in different countries are safe and effective for target populations at the recommended schedules, and that they meet particular operational specifications.

During the 2011 interview, Mr. Zhang said, "WHO's clearance opens the door for [Chinese vaccine manufacturers] to apply for WHO vaccine pre-qualification—a regulatory status that opens the door for United Nations agencies and governments to begin ordering the vaccine— with the aim of becoming eligible for vaccine procurement by the United Nations Children’s Fund (UNICEF)."

Responding to a question, during the 2011 interview, on the implications of the announcement for China's role as an international partner in global health, Mr. Zhang explained, "The Chinese health authority considers the WHO clearance a significant step in China's efforts to contribute to global health, notably to African countries where China has already donated to infrastructure, health systems, and anti-malaria treatment and control programs. The addition of vaccines to this portfolio is truly exciting for the Chinese government."

However, according to Mr. Zhang, "Obtaining a WHO pre-qualification certificate is complex and can be difficult to maintain. Ultimately, in my opinion, the biggest challenge for China won't be in building infrastructure, but instead in sustaining the commitment of public agencies and encouraging manufacturing executives to strictly comply with WHO requirements and the new Good Manufacturing Practice code."

The new Good Manufacturing Practice (GMP) code, adopted by the SFDA and effective March 1, 2011, aligns with WHO GMP standards, containing stricter requirements for the production of pharmaceuticals (including vaccines). The SFDA has asked that all newly-built pharmaceutical manufacturing enterprises should comply with the new GMP code. Existing factories, which produce sterile drugs, including blood products, vaccines, and injections, are mandated to reach the new code before the end of 2013. The deadline for other plants is Dec 31, 2015. Companies that cannot meet the new requirements before these deadlines will be forbidden from continuing to produce drugs. See SDA website, www.sda.gov.cn/WS01/CL0844/59017.html.

While Chinese companies may apply for WHO pre-qualification to manufacture vaccines for the African market, Mr. Zhang remarked during his presentation on March 15th that most vaccines used in Africa are manufactured in India. Despite the lack of Chinese-manufactured vaccines in Africa, he emphasized that the 4th International Roundable on China-Africa Healthcare Cooperation, which is scheduled for May 2013 in Gaborone, Botswana, will attract senior government officials and company executives from China and throughout Africa alike. (The World Bank published an article on December 10, 2009 about the initial China-Africa Healthcare Roundtable that was held in Beijing from December 4-5, 2009. This article by UNAIDS dated May 7, 2013 provides a summary of the aforementioned conference held in Botswana.) (Photo: UNAIDS)

Upon the conclusion of Mr. Zhang's presentation, I asked for an update on how China's vaccine manufacturers were complying with WHO requirements including the GMP. He replied that while Chinese-made vaccines are now eligible to apply for WHO pre-qualification, not a single manufacturer has yet be approved for pre-qualification.

While polio was eradicated in China, Mr. Zhang noted tuberculosis remains a problem. PATH produced a document, Collaborating to Control Tuberculosis, about its work to combat TB in China that says, "China has the most MDR-TB (management of multi-drug resistant TB) cases in the world and the second largest number of overall TB cases. The World Health Organization classifies China as a high-burden country. There are an estimated 120,000 new cases of MDR-TB each year in China, accounting for 24 percent of the global total."

Furthermore, according to the TB document, "With funding from the Bill & Melinda Gates Foundation, PATH is responding to the challenge. In collaboration with the Foundation for Innovative New Diagnostics and the Hong Kong Supranational Reference Laboratory, PATH assists the Chinese National TB Reference Laboratory with determining the operational feasibility, cost-effectiveness, and impact of new TB diagnostics in order to help the Chinese Ministry of Health decide whether to introduce and scale up these technologies."

Regarding his organization's operations in China, Mr. Zhang remarked that "PATH does not consider China a recipient, but a partner."

Aaron Rose is a board member, corporate advisor, and co-founder of great companies. He also serves as the editor of GT Perspectives, an online forum focused on turning perspective into opportunity.