TCS Daily


Future Flu Fight

By Anders Sandberg - December 16, 2005 12:00 AM

When new influenza strains develop in Southeast Asia it is thanks in part to the combination of high population density and too many people living too close to animals. When chickens are kept in the home to provide eggs or meat or as pets they also provide a link between the pool of human and bird diseases. The same goes for other domestic animals. As long as people live in close proximity to animals, the number of hosts in which viruses can evolve is much larger and they have more chances to find ways around human immune defenses.

From a disease-control standpoint, then, every country should use industrial farming. Free-range chickens that are allowed outdoors come into contact with other birds and catch diseases from them. Once in the population these diseases spread more easily through feathers and excrement. Bans on preventive medication in organic farming make this problem worse for endemic diseases like salmonella and parasites. If all animals were kept indoors, isolated from each other and most people, the evolutionary opportunities for disease would be reduced.

This is of course not feasible today. But it points out that poverty does play a role in the flu epidemic. Poverty and a traditional agricultural society helps the flu develop and once it is loose it hits poor people disproportionately hard. When a pandemic arrives most fatalities will be among the poor. Getting people out of this situation by enabling economic growth in the area will reduce the risk of the flu to everyone.

Another way of dealing with the flu is to enable faster development and use of vaccines. Current government regulations have led to a situation where there are few vaccine manufacturers (from 25 in 1970 to only 5 today) and little production. The small revenues, costly development and dedicated production facilities for vaccines make pharmaceutical companies less motivated to develop them. Testing requirements drive up development costs and once in the market prices are kept artificially low.

As a society we have become rather complacent about epidemic diseases: thanks to vaccinations we seldom encounter them, and hence the problem seems smaller than it is. That some parents refuse to give their children vaccinations against measles, mumps and rubella out of unfounded fears of them causing autism is a good example: even if they did increase the risk of autism that risk would be worth it compared to the deadly effects of the prevented diseases.

But when a pandemic panic occurs, this complacency shifts into high demand -- while the feeling of entitlement to low cost vaccines remains.

As the Tamiflu affair shows, it might even be bad for business to have a successful treatment. There is a general perception that it is immoral to profit from a necessary treatment and this has paved the way to destructive precedents of forced licensing. It makes manufacturing drugs against emerging diseases even more commercially risky: if they are unsuccessful you lose money; if they are successful you make less money since governments declare you must license them to competitors or sell them at a certain price. It makes companies concentrate on illnesses that are less likely to be a subject of a political panic and less useful in third world countries.

In the end new technology could help solve some of these problems. One important development that indirectly helps is pharmacogenomics, the use of genomic methods to find the right medicine for the right patient in the right dose. With a gene test it is possible to determine what variant of a drug and at what dosage would function best in a particular patient. While useful in itself this is also promising a shift in the business model of pharmaceutical companies away from single blockbuster drugs to more specialized drugs (and vaccines) for individual therapies. It is also driving (and being driven by) the move to a more individualized medicine, where patients become health consumers. Active health consumers are not only demanding treatment but also show willingness to participate in medical trials if that gives them a chance to try out new drugs.

The big roadblock is drug approval systems. The demand for large phase III studies of drug effectiveness, side effects and data gathering drives up the cost and lead times. This is why most companies aim for the blockbusters rather than a wide range of drugs (not to mention vaccines). It is becoming increasingly clear that this regime is not working and that the industry is in crisis. Pharmacogenomics makes this even clearer, as many potentially useful drugs are shelved as too expensive to get approved.

The confluence of this crisis and the rise of health consumers have a chance to change how drug approval is done. If access to phase III trials could be widened much would be gained. Thanks to information technology and e-medicine it has become easier to keep track of patients and their health, especially if they agree to extra monitoring in exchange for participation.

Reforming the approval process will take time and political will. Patient organizations are already putting increasing pressure on regulators but other groups need to get involved to find the right balance between safety and speedy development. Some medical risks are worth taking both individually and collectively, especially compared to the definite risks of emerging diseases.

Anders Sandberg (anders.sandberg@eudoxa.se) is research director at the Eudoxa think tank in Stockholm, Sweden.

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