Health Affairs

As life spans increase and birth-rates decrease, the world’s population is aging. From 2000 to 2025, the over-60 demographic segment will double from 600 million to almost 1.2 billion. By 2050, it will nearly double again, surpassing two billion and accounting for an incredible 22% of the total global population. A society this “old” has never before existed, and it is a social, ethical, and economic imperative to keep older adults healthy and engaged. It is timely for the global public health community to re-align its thinking, policies and activities to this new demographic reality.

Organizations at national and global levels have begun to pursue initiatives to promote healthy aging, and these efforts are going to intensify in the coming years. Thus far, the progress has been admirable, with the World Health Organization, the United Nations, the Organisation for Economic Co-operation and Development, and others taking leadership roles. Yet, despite many promising developments, the potential of “life-course immunization,” which stresses the administration of vaccines throughout all stages of life – including for adults – to prevent disease and promote health, has been largely overlooked, especially among adults.

This is a missed opportunity. There is a growing body of research and data to show that immunizations against some of the more specific age-related health challenges – such as pneumococcal disease, herpes zoster, and others – are economically feasible investments that can create large public health benefits.

In the Narrative Matters essay in the April Health Affairs issue, Laura Blinkhorn and Mascha Davis write about how working with an obese woman in a Gabon hospital led them to seek solutions to obesity and its related health problems in the developing world. “Public health campaigns, government regulation, and improved education are necessary to bring about real change,” write Blinkhorn, a fourth-year medical student at the Pritzker School of Medicine, University of Chicago, and Davis, a registered dietician and public health professional who lives in Addis Ababa, Ethiopia, and works for Catholic Relief Services.

Poorly manufactured and fraudulent medicines kill thousands of people around the world each year. For infectious diseases like malaria and HIV, shoddy medicines also accelerate drug resistance and dramatically alter the course of epidemics. With few new drugs under development, recent progress against these major killers in the poorest countries is precarious.

Bad drugs have become a big problem for one major infectious disease in particular: tuberculosis. If we don’t solve this issue, we may see the gains we’ve made against TB slip away.

According to the World Health Organization, global TB cases continued on a slow downward trend in 2011. While this is good news, the disease still claimed 1.4 million lives that year—more than any other infectious disease except HIV/AIDS. Meanwhile, multidrug-resistant TB cases rose to 630,000 worldwide. Resistant TB is deadly and costs significantly more to treat. For example, curing a single case of it in the United States can cost more than $200,000. Treatment takes two years, and the side effects can be severe, including nausea, vomiting, joint pain, and even hearing loss.

The April issue of Health Affairs, released today, examines how all high-income countries are struggling to achieve the “Triple Aim” — better health and better health care at lower cost. The articles in this issue find that the United States and other high-income countries have much to learn, with the “trade” in strategies and tactics likely to flow both ways.

Join us on Thursday, April 11, for a briefing on the April issue. Support for the new Health Affairs volume was provided by The Commonwealth Fund, Britain’s Nuffield Trust, and the Institute of Global Health Innovation at Imperial College London.

Drug Payment And Pricing — How Do US Practices Compare With Other Countries?

A featured study by Panos Kanavos of the London School of Economics and Political Science and coauthors compared prescription drug prices among selected countries that are members of the Organization for Economic Cooperation and Development in 2005, 2007, and 2010. Depending on how prices were adjusted for the volume of drugs consumed in the various countries, drug prices in the United States were between 5 percent and nearly 200 percent higher than in the other nations studied. A key contributing factor is that the United States takes up new and more expensive prescription drugs faster than other countries. The authors recommend that the United States require pharmaceutical manufacturers to provide more evidence about the value of new drugs in relation to cost before use of such drugs is reimbursed.

As the debate over federal budget allocations and cuts continues, the National Institutes of Health (NIH), a leading funder for both domestic and global health research, could experience a whopping $1 billion budget cut. To date, modest investments in global health have helped create platforms for discovery science, such as large multiethnic studies of genetics and epigenetics; transformative programs, such as the President’s Emergency Plan for AIDS Relief; and life-altering interventions, such as oral rehydration salts, now widely used in the management of dehydration caused by diarrhea. Not only would large cuts to the NIH slow our progress in improving health worldwide, but they would also be out of step with the burgeoning interest in global health at universities across the United States.

Today, Health Affairs released a Web First article by Tsung-Mei Cheng describing early results from a pilot project underway in several of China’s rural provinces that combines new case-based payments for providers and evidence-based clinical pathways for management of patients. Before and after studies and analyses show a reduction in overall length of hospital stays, drug spending and usage, and patients’ out-of-pocket spending. Patient-provider communication and relations reportedly improved, and hospitals did not experience any revenue losses.

The Indian Supreme Court announced a decision this week that allows drug makers to continue developing cheaper generic versions of the leukemia drug Gleevec in that country. The case centered around whether certain patents held by the brand-name drug’s manufacturer were true inventions. The decision was shaped in part by the complexities of Indian patent law, which is considered far more stringent than U.S. patent policies.


The issue of secondary patenting or “patent evergreening,” to extend the life of a brand-name drug and whether secondary patents represent true innovation was the subject of an October 2012 Health Affairs article by Tahir Amin and Aaron Kesselheim.

You are invited to join us on Wednesday, April 11, when Health Affairs will hold a briefing to discuss its April 2013 issue, “Triple Aim Goes Global.”

The April issue examines how all high-income countries are struggling to pursue better health, better care, and lower cost – and to bring all of these goals into alignment. The issue received funding support from The Commonwealth Fund, the Nuffield Trust, and Imperial College London.

The briefing will take place at the Barbara Jordan Conference Center at the Kaiser Family Foundation, 1330 G Street, NW, in Washington, DC, on Thursday, April 11, 2013, 8:00 a.m. – 12:30 p.m.

In 2004, Health Affairs’ Fitzhugh Mullan interviewed C. Everett Koop, who passed away on Monday. The full interview is freely available to all readers, as is a 1998 Health Affairs article coauthored by Dr. Koop evaluating health education programs designed to reduce health risks and costs. Health Affairs Blog will carry more about Dr. Koop’s life and work in the coming days.

Koop is probably best-known for his pioneering work as Surgeon General under President Ronald Reagan, but his interview with Mullan begins with a discussion of children’s health, reflecting Koop’s role in helping to found the discipline of pediatric surgery. Koop sounds a warning about the nation’s treatment of its children. “We always talk about children being our future,” he notes,

but I’m afraid we don’t always deliver … the older I get, the more I understand the relationship of poverty in a child and poor outcomes in everything else. I’m not beating a socialist kind of drum here. I think as we look to the future, unless we take into account what a severe role poverty plays in the lives of many children, we will never be able to achieve good child health in the United States.

Since children can’t vote or lobby as seniors do, “In the long run, child health is about advocacy,” says Koop, who also highlights the challenge of pediatric obesity.

Antibiotic resistance is a major concern confronting our health care system, and there is tremendous pressure on the Food and Drug Administration (FDA) to “do something” about it. Unfortunately, the FDA is responding by approving drugs that are likely to do more harm than good.

FDA advisory committees are supposed to provide independent advice from experts across the country, but recent meetings have left observers wondering whether too many FDA advisory committee members are providing neither scientific nor independent advice, and whether the committee process itself is fundamentally flawed. These concerns dovetail with essential questions about FDA objectivity and scientific judgment in its review of antibiotics.

For example, a few weeks ago, the FDA approved a new drug for multidrug-resistant tuberculosis (TB) — bedaquiline, to be sold under the name Sirturo — shortly after data reviewed by FDA scientists indicated a higher death rate for the new drug compared to the usual standard of care. The FDA’s Anti-Infective Drugs Advisory Committee had publicly reviewed the TB antibiotic on November 28, 2012.

The week of December 17 was a grim one for the polio eradication effort in Pakistan. Seven Pakistani women health workers and two Pakistani men, all working to ensure the success of the polio campaign, were killed, presumably by members of the Pakistani Taliban. This is a tragedy, for the families of those killed, for the children who will go unvaccinated after the government’s suspension of the vaccine campaign, and for the effort to eradicate polio worldwide. Pakistan is one of only three countries remaining with endemic wild polio virus (the others are Afghanistan and Nigeria). It also had turned a corner in its efforts, with only 56 confirmed cases of polio caused by the wild virus this year, down from the 175 confirmed cases at this time last year.

One observer said, “In the same way that the northern-Nigeria boycott was a game changer, I think this is.” She was referring to the 2003-2004 boycott of polio immunization in parts of Northern Nigeria that led to the spread of polio to previously polio-free countries. Clearly, the suspension of the polio vaccination campaign in Pakistan following the killings is a setback. The real question is: Where does the global eradication program go from here?

In its November 2012 report, the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI) suggests that, in addition to planning for the final push (the so-called endgame), the GPEI also must engage in contingency planning. They suggest two scenarios that require such thinking:

From fake Avastin to contaminated generic Lipitor, every month Americans are becoming more aware about the dangers of lethal products they might be unlucky enough to take. With attentive regulators and competent companies, most incidents of dangerous drugs in US pass without significant harm, but when tainted steroid injections were recently distributed to thousands of patients, 36 died and over 500 suffered painful conditions.

The tragedy for those Americans harmed is multiplied at least a thousand fold in the carnage reeked in developing countries. Perhaps 100,000 people die every year from dangerous medicines and by most estimates the situation is deteriorating. To put it simply we are losing the global fight against bad medicines.

Efforts are being made by law enforcement officials. Eighty-two million doses of counterfeit drugs in Africa were seized by numerous national authorities, comprising about $40 million worth of antimalarials, antibiotics, cough medicines, contraceptive pills, and fertility treatments.

With global spending on medicines likely to reach one trillion dollars by 2014, and growing concern about the cost-effectiveness of all parts of healthcare spending, an examination of the ways in which medicines are used is both timely and relevant to understand their impact on patient outcomes and the costs of delivering healthcare.

A recent report by the IMS Institute for Healthcare Informatics tackles the issue of understanding the linkage between responsible medicine use and health system costs. By examining six levers for improving medicine use, and developing an economic model to estimate global avoidable costs, the Institute was able to illuminate the magnitude of the opportunity for improvement – avoiding costs for health systems while maintaining or improving health outcomes.

As we mark World AIDS Day and the Obama Administration releases its new “PEPFAR Blueprint,” Health Affairs Blog wanted to remind readers that the July 2012 issue of Health Affairs provides a comprehensive look at PEPFAR, the President’s Emergency Plan for AIDS Relief. The issue contains a wide array of articles by leading voices such as Ambassador Eric Goosby, the US Global AIDS Coordinator in the Department of State, Michael Merson, the founding director of the Duke Global Health Institute, and many others. Health Affairs also published a Health Policy Brief on PEPFAR to accompany the issue.


In addition, readers may view the release event for the July issue on the Health Affairs website. The briefing featured many of the authors from the issue as well as others such as Jim McDermott, the co-chair of the Congressional HIV/AIDS Caucus.

To mark World Diabetes Day, I wanted to call readers’ attention to the thematic issue on diabetes published by Health Affairs in January 2012. Much of the issue dealt with the diabetes crisis in the United States, but several articles dealt with the global diabetes epidemic. For example, K.M. Venkat Narayan of Emory University and colleagues argued for four “policy paradigm shifts” in the global battle against diabetes:

conceptually integrating primary and secondary prevention along a clinical continuum; recognizing the central importance of early detection of prediabetes and undiagnosed diabetes in implementing cost-effective prevention and control; integrating community and clinical expertise, and resources, within organized and affordable service delivery systems; and sharing and adopting evidence-based policies at the global level.

The issue also included a look at a diabetes pay-for-performance program in Taiwan. Interested readers can visit the Health Affairs website to view our briefing on the January issue.

While society should be careful about its uses of genetic testing and its efforts to modify the genome, some people overreact when dealing with DNA. Consider two recent examples reported in the media. A genetic cancer test. In a fascinating series on genetics in medicine, Gina Kolata reported in the New York Times on a genetic test... Read the rest of this entry »

Editor’s note: The current issue of Health Affairs is a thematic volume focusing on the President’s Emergency Plan For AIDS Relief (PEPFAR). Last week’s 19th International AIDS Conference in Washington, D.C. convened 25,000 scholars, activists, practitioners, policy makers, and members of the general public; people living with HIV and people living without the virus; students,... Read the rest of this entry »

This year’s International AIDS Society (IAS) conference, taking place in the US for the first time after a 20-year boycott, has a special meaning to me.  As an infectious diseases doctor, I provide primary care to HIV-positive patients.  I first became drawn to HIV/AIDS in 1989 when I was 10 years old.  At that time... Read the rest of this entry »

On the eve of AIDS 2012, the international HIV/AIDS conference, soon to get under way in Washington, DC, a new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines the President’s Emergency Plan for AIDS Relief, or PEPFAR. This major program of assistance to foreign countries affected by HIV/AIDS was created... Read the rest of this entry »

Articles published yesterday in the July 2012 issue of July 2012 issue of Health Affairs focus on the President’s Emergency Plan for AIDS Relief (PEPFAR), the US program to address global HIV and AIDS, and the largest investment to date of any country to fight a single disease.  The thematic issue examines the origins of... Read the rest of this entry »