Saturday, February 26, 2005

Remarks by the 2005 International Development Conference Panel on Delivery Innovations

Moderator

Judith Justice
Associate Professor, University of California, San Francisco

Panelists

Ophelia Dahl
President and Executive Director, Partners in Health

Jack Higgins
Digital Vision Fellow, Global Telemedicine Project

Vikram Kumar
Director, Dimagi, Inc.

Tony Carroll
Consultant, Merck and Co.

Judith Justice: My name is Judith Justice. I'm at the University of California in San Francisco. I'm an anthropologist by training. I do a lot of work in Asia and Africa, on health development, also looking at foreign aid to the health sector. And although much of my research is on international health policy, my interest is in how to make policies most effective to the needs of the people and how to get information from the delivery level into the decision-making and policy process. So I'm very much looking forward to learning from my panelists today. Ophelia, could you start, please?

Ophelia Dahl: I'm the executive director of Partners in Health, which is a community-based nonprofit with its main headquarters in Boston, Mass. We are a group that tries to address the inequalities in access to healthcare in certain communities around the world. We began really in earnest in about 1987 but to talk for just one minute about how we got involved, as a youngster I went to Haiti as a volunteer working with an ophthalmic organization with some handicapped children in Port au Prince. Having come from England, I was very affected,. Even though I considered myself pretty worldly, it was the first time I had really, really seen poverty at that level.

And while I was there for that year, I had the good fortune to meet a young anthropologist named Paul Farmer on his way to medical school. He said, "Why don't you help us move some of the resources from the United States down to a place like Haiti?" So together we worked and pulled in a number of other anthropologists, epidemiologists, friends, and people who'd been with us actually for a long time and built up the organization. And our heart is still in our work in Central Haiti but we've actually moved to other places. We've also got a project in Peru and in Siberia, and we work with a community in Guatemala and Chapas, Mexico. And also we have a project for treatment of HIV in inner-city Boston.

Vikram Kumar: My name is Vikram Kumar. If I have to give a one-minute pitch, like my elevator pitch, I sort of have to get stuck in the elevator for a half-hour. So in a couple of minutes, for me to describe to you what I do is a stretch. I think I'll tell you where we're from.

I'm the cofounder and CEO of a company called Dimagi. It came about when three of us—Vish Anantraman, Tarjei Mikkelsen, and myself—were all at the MIT Media Lab. We did a project together in India where we wrote software on a handheld and did what Apple took much more money over a very long period and wasn't able to do. As graduate students you just have to do it, so we did it.

And then at the end of that, one of the investors said, "These guys are pretty good. They can actually make things work." So with him we started this company two years ago. Today we're doing a project in Zambia and we did one in South Africa where we are the technical group working with nonprofits, writing software for them. We go in and say, "These are the issues. You want to deliver data to patients. How do you capture that information and do it in an efficient way on 16 kilobytes of data? How can you store a patient's entire medical record?" And that's what we're doing on smart cards in Zambia.

It's questions like that, which a lot of you guys can probably do in engineering or business classes. We figured that we could do it and we might as well actually try to make a company of it so that we could inspire some of the best people around to do it.

To me, the biggest victory is that earlier this year we hired a full-time guy who wants to make this his life. So that's where we are. Where we're moving forward is working more in these areas and at the interface between patients and devices that are out there. The question is: what motivates a patient to use a device? We're at the interface between the patient and the device, where you make them play a game or give them a smart card that they can put in their pocket and keep—looking at them as equal rather than as patients.

Jack Higgins: This morning we talked about the maldistribution of physicians in the world, the fact that in so many developing countries there's a brain drain of health workers who give up on their own country and head for better pastures.

We started the HouseCall Foundation as a means of trying to balance the supply and demand for medical services in the world. Our theory is that there are a lot of doctors in the world, probably enough doctors, to do what needs to be done if they were just in the right places. We'd rather live Palo Alto and London than Nairobi and Kabul. So it turns out that we tend not to be in the right place to do the most good.

But technology now allows us to take care of patients wherever they are. We don't have to be in the same location as the patient. We tested this out in Northern California, where I saw patients from my Chico office up in the boondocks, in the Trinity Mountains, and found I could take care of them just about as well up there as I could in my own office. We've been doing a project in San Jose with a number of Spanish-speaking, mostly Mexican-American patients who have no money and no insurance who come to our free clinic in San Jose and connecting them with a diabetes specialist in Redwood City who's been able to get them all under very good control. We've been able to see in these two applications, even with a language barrier, that this kind of thing really can work.

We're now setting up some projects internationally, starting with Southern India and the Dominican Republic, to have volunteer doctors from wealthier countries—mostly North America, Europe, and probably Australia and Japan—volunteer a couple of hours, maybe four hours per week or month. They'll be able to sit in front of their computers at home or at work and sip coffee while they save lives around the world. And that's the basic model for the HouseCall Foundation—we're making house calls and at long distance. Doctors who would like to volunteer but maybe can't make that trip to another country can do it from home and do it not as a one-time, two-week medical mission somewhere but as a day-in/day-out, perhaps lifetime, commitment to helping people elsewhere.

Tony Carroll: It's good to learn that the house call is not yet dead or extinct in American medical practice! So congratulations on that.

I'm a lawyer and an economist and I'm up here with medical professionals and IT people. You wonder why I'm here but I really began my path as a Peace Corp volunteer in Botswana some 25-27 years ago. In that capacity, I worked at the district government level trying to design and implement development initiatives in Botswana which, when I was there, was the fourth poorest country in the world.

Over the course of my career as a lawyer and economist, I've been specializing in the development and elaboration of public/private partnerships, building relationships that often reach across traditional lines in governance and private sector and trying to bring the best of those organizations together to try to identify and combat common problems and challenges.

My work in HIV/AIDS began actually as assistant general counsel with the Peace Corp itself years after my volunteer service—in the mid-'80s when we began to confront the beginning of the pandemic of HIV/AIDS, particularly in Africa. Not only did that challenge the institution and the agency pertaining to the usual legal issues of volunteer selection and HIV positive incidence in our currently-serving volunteers but also in programmatic areas—because back then HIV/AIDS suffered and still suffers from the problems of stigma and lack of understanding. And we had to be very careful how we crafted our programs to address these issues.

In the subsequent 15 years, I've worked for a variety of institutions and in the last five or six years for Merck and its foundation, the Merck Foundation. We've established a partnership—a public/private partnership—with the Gates Foundation and the government of Botswana called the African Comprehensive HIV/AIDS Partnership Program. I think it's among the first if not the first effort to elaborate and establish a national treatment model in Africa for HIV/AIDS. The path has been slow but we're starting to show some very promising results, some of which I'll address in the body of my presentation.

Judith Justice: The panel has been given a list of three basic questions that were developed and put together by the organizers, and we were asked to address these. We were concerned that if we took each one of these—which would be the best way to do it, one by one—and went through the panel's responses we wouldn't have sufficient time to have any discussion at the end. So the panelists have very kindly agreed to try to address the three key points within five minutes each. Not only is the effective delivery of services challenging—our panel is challenged.

I'm just going to read these to you so you'll know how wise the organizers are, because these are excellent questions. And then I fortunately just have to moderate—I don't have to answer!

Okay. One: what are the main delivery challenges in providing large-scale access of life-saving or health-improving therapies to patients in emerging economies? Two: how does your organization address these challenges and with what scale and success? How applicable is this model to other needy geographies? What are the barriers, other than funding, to wider-scale rollout? (I said they gave us three questions. They have five questions in each one of them!) And three: what innovations would be most valuable in enabling more effective and efficient delivery of therapies? What would need to happen to make this a reality?

So this is our challenge, to address this as best we can. Ophelia, are you brave enough to start?

Ophelia Dahl: I'll give it a go. I can speak from PH's experience, obviously my own experience, in trying to address these challenges. Haiti—Central Haiti particularly—is a very challenging place to work so delivering any kind of innovation and any kind of treatment is difficult.

We did not go into this with any kind of plan except to listen to the patients, listen to what ailed them, and try to address that because we had no experience at the time with our own set model of what it is we think the patient should have and want and should need at this point.

In the early '80s when we did a community-based health surveillance census, the patients asked us for access to clean water and a hospital. We were able to provide that slowly, over a number of years. The water was actually not very difficult to provide. We were able to tap springs and give them access to water from a large reservoir that was the result of a hydroelectric dam project.

But what we found with these patients who were very sick was that the patients had a difficult time getting to the clinic—getting to this one place. This is rural Haiti, and a lot of what we've been addressing is happening today in rural places in Africa and elsewhere in the world. So what we decided to do is provide a community health worker model to address these patients' needs.

The challenge was dealing with a very, very sick patient population that had no access to any kind of sustainable funding whatsoever and to be able to bring them healthcare in the middle of Central Haiti. When they asked for this hospital there were also no doctors or nurses or anything else. So a small group of us started training community health workers, several levels of community health workers, in addressing women's health issues and a number of other issues. What we found when we started seeing patients with infectious diseases was that they were unable to be compliant because they couldn't actually get to our clinic.

As soon as we started using the community health worker model and sending the community health workers from the community to the patients, this problem was actually alleviated completely. We haven't had a single death from uncomplicated TB since 1998 in our area of several hundred-thousand people because of this delivery mechanism, I think.

The actual challenges that we're finding today also are not so much the challenges that you would expect in terms of getting ARVs or all of that kind of thing. We actually have access to those. It's dealing with the other symptoms that are commensurate with these kinds of populations, which are issues of poverty. Our community health workers are very well-trained. For some of them, during the rainy season, we can't get them shoes. Roads, access to patients' houses, education, housing—all of these kinds of things that we've tried to build into a primary healthcare model. I think also we've made sure that we're not treating one disease at a time, which is what tends to happen at the moment. As you've heard from this morning's panels, there's a lot of money for the treatment of AIDS—treatment for prevention of AIDS. We have tried to make sure that we're not just treating this one disease—because that's not just what our patients have. Our patients have a number of different diseases and so you can't open up a clinic that's AIDS treatment only and then when patients come in with broken arms or dysentery or anything else…you have to make sure that it's part of the primary healthcare model, which is, I think, one of the ways that we've been able to address the challenge most effectively.

One more minute? Thirty seconds to wrap up healthcare in Central Haiti! A lot of people this morning touched on creativity and imagination and I really, really, really do think that this is the key. If you're given money to address HIV, find a way to incorporate it into a larger model. So when the Global Fund says, "We'll give you money to just treat HIV" and you say, "What about TB?" and they say, "No, we said HIV"—then you say, "But TB is the leading opportunistic infection killing people with HIV." And they say, "Okay—maybe we'll do it." You can find all kinds of imaginative ways to pull this into your system of healthcare. But you can't treat one disease only and I think you can find creative ways around that.

Vikram Kumar: I'm lucky because Ophelia sort of answered most of the questions. I tried yesterday—I was talking to my friend and trying to sell my pitch to her. This is a very difficult question. The question is: if there is technology, why are people still dying? And here's my pitch, and you can tell me whether or not you think it's true.

As physicians we're trained to see people as patients. So we see people and we think that they're sick—they're patients. Now, the question is: what do they see themselves as? They are fathers, sons, brothers, etc. They see themselves as people. They're people who have a role in society, which often trumps the fact that they have an illness.

To go to them and expect them to spend their lives managing their disease is a bit ridiculous. Once we realized, okay, these people see themselves and their role as different from being our patient, then we have to do some social innovation and think: what can we deliver to them that's going to actually motivate them to avail themselves of these services?

This morning I learned that, for example, in Mozambique there's a clinic where they have antiretrovirals. They have everything, but only 80 percent of the patients who could avail themselves of these services do so. So the question is: why don't people go to the clinic? They can get the drugs and they can get better. Then comes in all the social questions and there's stigma, there's access…..

So let's assume that you agree with me—because otherwise the rest of what I say is useless. Let's assume for a second that I'm making some sense. So people see themselves as people, not patients, and we have then to provide them with a reason to use this medication or address their problems. Therefore, we identify a problem.

One of the projects that we've done in South Africa working with the Africa Center for Health and Population Studies is realizing—they actually made this clear to us—that people were concerned about confidentiality of test results. They don't get tested for HIV/AIDS because they're concerned that their test results are made public. A person would go down to the village with a scroll, a ledger, with everybody's test results. It was very tough to encrypt the paper. You can encrypt data very easily, so we wrote handouts on very simple two-key encryption software. The patient has a key, the healthcare worker has a key, both of them are added together, and then you see the result. So all of a sudden you've encrypted.

But to get to the third question of what innovations would be valuable—that's still pretty silly, to think that somebody is going to get tested if you talk to them. The problem still is that people don't come to get that second test result. So then the question is: where is innovation? Where does innovation have a role? That's where low-cost diagnostics has a role. And David, who's somewhere in this audience—David spends his day doing low-cost diagnostics. So there are people out there who will give you a rapid test. You can have a low-cost CD4 count and you don't have to come back then. Right away you get the test results, so again you've addressed it further and you've gotten closer to the solution.

Then what Ophelia said about poverty is what I feel is the ultimate problem. People want a livelihood. If I give them a drug or if I give them a dollar—again, we're assuming my model of the world is correct—they'll take the dollar. If they take the dollar, then what can I do to couple the two? So we're looking at ways where you can use micro-finance as a tool, which works in places. People adopt it. I don't have to convince them to get a loan but I have to convince them to take their drugs. We're trying to think of ways we can couple the two. We use smart cards in Zambia to convey medical information. Why can't we take cash out of a system and give a smart card and somehow require compliance to be a condition of your loan?

So ideas like that, which you guys in business school or otherwise, could come up with far better than I could, are what I believe ways where we could actually start looking at people not as patients, but as a regular person and how can we motivate for them to adopt this technology so they can actually be adherent or compliant?

Jack Higgins: As I said, and as they were saying this morning, there's a shortage of healthcare personnel in developing countries in general and there are a number of ways of dealing with that. One is to build capacity in-country, and that's obviously the ideal. The unfortunate problem has been that, for example, in Malawi there are more nurses trained from Malawi who are now in London than in Malawi, I believe Dr. Zewdie was saying. And that tends to be the case in many places. India, for example—there are 35,000 Indian expatriate physicians here in the U.S., and that's a lot. Some of them would like to go back and do medical missions, but most find that they have kids and families and a practice and they really can't go back and do much there.

So in looking at that problem we started coming up with the idea that maybe distance doesn't have to be that big a barrier if you have technology that will help to fill that gap. For example, in our first project in India we'll have mostly Indian expatriate physicians here in the Bay Area and on the U.S. East Coast who will be providing the services for the patients in India. And as much as possible, that makes sense to us—if the docs in-country can't care for their patients then perhaps docs who are from that country can in many cases provide that care, with the rest of us being available as sort of a backup network for the situations where they simply aren't enough expatriates to do the job.

I should point out that Paul Farmer is one of my heroes. I was just telling Ophelia I haven't met him yet but for a number of years I've been following his work in Central Haiti and now expanding to other countries. And I think that's absolutely wonderful, that he and many others have been able to devote their lives to either traveling somewhere on regular medical missions or living in developing countries and devoting their lives to helping out there.

What we're trying to do now is to create a mechanism whereby those who can't afford to do that or just won't do that can still contribute in a major way. Perhaps we can build a large-enough network of volunteer physicians to be able to provide care in a lot of places. Now, we understand that as that starts to scale we start to hit limits in terms of how many volunteer hours we can find, and appropriate places. There will be a time when we'll probably need to have a means of providing some payment for some physicians to help fill in the gaps. But our hope is that as we scale up this volunteer model we can also be building capacity in-country by providing distance learning opportunities for physicians and other health workers who are in-country so that they can take up more and more of the load. And perhaps at some point we'll work ourselves out of a job, which would be the ideal situation—they don't need us anymore because there's enough there in-country.

Now, another challenge in using technology then—using information/communication technologies in developing countries—is being able to adapt it properly to the needs and desires and customs and belief systems of the people who are there. I want to introduce Dr. [Renée Chin]—Renée, wave and smile at people. Renée is my partner in this project. We're essentially sharing a fellowship here at Stanford this year. Because we both have to work outside of this fellowship we're doing, we talked Stanford into letting us each do half a fellowship so we could both continue pursuing our other jobs to make a living since we didn't have a corporate sponsor, as do most of the other fellows.

Renée is an ethnographer, with PhD-level training in that branch of anthropology that, in her case, looks mainly at how technology affects people and how they adapt to technology and how they feel about technology and how they look at it. And if you talk to her afterwards, she'll explain it much better than I can.

But the idea is rather than going in blindly with a cookie-cutter sort of model and saying, "Okay—here's a great technology, guys. We're going to drop this in the middle of the Kibera slum outside of Nairobi and make it work"—unless you know a little more about the people there, it ain't gonna happen. You have to know what's there. You have to know what the belief system is, what kind of healthcare system exists, what alternative health systems might exist, how people relate to health and to themselves and to their society and families, etc. Without that knowledge, you really can't do a very good job of bringing a technology in. So Renée's role in all of this is to develop a field guide that allows us to adapt the technology to virtually any culture and any society in the world—we hope. By the time we have started in a few locations we hope to be able essentially to adapt that model to any other culture and any other community in the world where care is needed. So the idea then is a global telemedicine system that can use an Internet infrastructure basically and a volunteer organization, and volunteer doctors worldwide who then can provide care at least until we can help build capacity in those countries to take care of themselves more.

Judith Justice: You did very well! Can I just ask one question of clarification? The technology is to be used by patient to adopt, rather than healthcare providers to adopt?

Jack Higgins: I should point out that this is a different model from most. You've all heard about telemedicine. In almost every case, it's a university medical center connecting with very high-end access to the Internet or to a T1 line in a developing country—and that's a very expensive model.

We've tried to come up with one that's less expensive using Web-based videoconferencing and not necessarily a doctor. In fact, we're going to places where there are no doctors. So it's a patient and maybe a health facilitator—a village health worker in Ophelia's model—who's at that end with a doctor somewhere else in the world, preferably in-country but somewhere in the world to take care of the patient.

Tony Carroll: In first addressing the issue of obstacles to treatment in Botswana, I think one of the things that ACHAP tried to do was look in a more holistic perspective on just the issue of what resource constraints existed but look at some of the fundamental social underlying factors that prevented people from undergoing testing, learning of their status, and then undergoing treatment themselves.

In Botswana—and I'll speak on a phenomenon that certainly exists beyond the borders of Botswana—stigma and denial are huge factors in preventing people from learning of their status. Sociocultural determinants pertaining to gender and pertaining to sexual practices and empowerment are huge factors. Looking at Botswana's historic patterns of mobility, Botswana had been migrant laborers for hundreds of years, outside the country and even within Botswana. The relationships that exist between the village and the city dweller and outposts where they tend their cattle and raise their produce are important to understand—how the sexual patterns travel with them as they move among and between these various locations.

We understand and tried to develop programs in Botswana with ACHAP to address—through teacher training, through developing networks of people with HIV/AIDS—in trying to give them the resources to project that they can be healthy models in life. These were ways in which we could try to de-stigmatize the issue of HIV/AIDS. And that of course is an ongoing problem and it certainly is something that manifested itself as we began to roll out some of the treatment models.

Dr. Zewdie talked a little bit about some of the resource constraints in developing a national treatment model pertaining to availability of human resources, lack of testing capacity in laboratories, and so forth. So she talked a little bit about those, and those are present in Botswana.

What differentiates Botswana from many of the other countries in Africa where the pandemic is rife is the fact that Botswana—if you remember Dr. Zewdie's statistics this morning—was probably among the most successful developing countries in the world on any measure. Whether it be life expectancy, degree of literacy, penetration of fundamental health services in the country, Botswana was really very much out front.

And one of the reasons Botswana was chosen as an opportunity to develop a national treatment model is because we had so many positive factors to deal with. By the way, I was on the board of I CARE for many years and Haiti is a much different situation than Botswana from the standpoint of resource constraint.

So ACHAP, again, took a holistic approach of looking at sociological messages and prevention models as well as dealing with technical support for the government and even donor agencies in supporting the establishment of treatment and testing and laboratories and so forth. And I won't go through that list. It's all contained in the material in this book that's available to you outside.

But let me just say I think it's important to talk a little bit about specifics in our experience in Botswana. ACHAP started three years ago. Merck and the Gates Foundations both pledged $50 million each to create this project, and Merck decided to donate on a national scale its two prominent antiretrovirals, CRIXIVAN and STOCRIN, to the first-line world-class ARVs to all of Botswana to support this program.

Nonetheless, because of those issues pertaining to stigma we had a very, very slow time and there were certain administrative decisions that were made that looked, in hindsight, to be wrong ones. We had a hard time ramping up and scaling up our project. After 24 months we only had 1,500 people enrolled in our program. However, in the course of the last 12 months we've really started to establish progress.

We've established 31 out of 32 treatment centers across the country. It enables people to not have to travel three or four hours to get tested. Now we're bringing the testing capacities to them. We now have about 40,000 people enrolled and tested and then if they qualify or are required to undergo therapy we have about 25,000 people under ARV therapy right now in Botswana. That represents about 25 percent of the Botswana population that would otherwise not qualify for ARV therapy. There's no place in Africa that comes close to that right now.

We've also effected changes at the national level. Botswana now requires testing of all people who come into the health system. And they have to opt out of learning of their results. This is a surprise to many people but most in Botswana have elected to receive those results. That is creating a knowledge base and behavioral change that didn't happen. And to the great credit of the Botswana government and the support of ACHAP they've taken that step, and it's proven—like Paul Farmer's original works—once in a while you really have to think outside the box and the Botswana did that.

So we're now starting to see great results. Of these 25,000 people on treatment our toxicity levels are between 6-7 percent. The adherence is over 90 percent. We have lower viral loads in people in Botswana now, so the infection of the disease is lower than it was. We have lower opportunistic infections because the people are healthier and are on treatment. We also have lower healthcare system costs because Botswana was being driven by the chronic problems of HIV/AIDS and there were no other medical issues being dealt with, so we're now freeing the medical system to deal with all sets of other unrelated medical conditions. And that's making Botswana a healthier nation as a result.

Lesson learned—I think the lesson learned in Botswana in the almost four years now that we've had this program is that if you don't have leadership at the top in supporting this it's not going to work. President Museveni in Uganda, President Diouf in Senegal, and President Mogae in Botswana have all been at the forefront. I can't talk about other parts of the world, but they certainly have been leaders that have shown that that really can make the difference. Other countries—and I don't need to name them but they're well-known—have not had leadership and their programs have stalled and not taken off.

We need to develop a relationship with all the strategic players to make sure—remember the issue that Dr. Zewdie mentioned this morning about competing resources and various criteria, the 3-1s. Well, we did that in Botswana at a national level before the 3-1s was announced at the international level. We've established, again, networks across the country where people don't have to travel distances—where they can get tested and their result data can be stored. And we've also recognized, slowly, that without developing the human resource capacity as we go along—along with what Jack said, leaving resource capacity on the ground in Botswana—we're not going to be able to develop a sustainable model of how the Botswana deal with this problem until we find a cure, which may be many, many, many years away.

Judith Justice: The panel has been exemplary in their timeframe! And I think they have given us excellent examples of both approaches and technologies that we can really address.

First, I want to ask the panel if you have anything you want to respond to with each other before we ask the audience. I thought we could take fifteen minutes for discussion, questions and answers, and then we have been given one other question that I want to reserve time for which we will address at the end. Is there anything that you wanted to respond to with each other or shall we open it for discussion?

And I must say—you were very successful, and probably one of the few people who can talk about Haiti in a positive way and can come across and give an encourage impression. Thank you! Poor Haiti has a hard time.

Q: This question is primarily centered on Botswana, but I would love an answer from any of you.

It seems like capacity and building capacity in human resources has to do both with the number of people you have on the ground and also the utilization of their time. And I'm wondering if you can comment on what kind of impact underutilization or misutilization of human resources has on delivery.

Tony Carroll: Let me at least talk a little bit about what's being done in Botswana, but what's also being done in KwaZulu-Natal, a province in South Africa at the center of the HIV/AIDS pandemic in South Africa. And I do work for the Mandela School of Medicine, which is a part of the University of KwaZulu-Natal, the largest university in South Africa. And they have a very well-known medical school.

And one of the issues that we dealt with—and perhaps borrowing on Paul Farmer's experience in Haiti—was that rather than having highly-qualified people doing routine administration of HIV/AIDS treatment and testing what we decided to do was try to scale down and identify people who would give them the requisite skills for the routine administration of routine procedures related to HIV/AIDS.

So in effect what we tried to do was broaden the aperture of treatment personnel in the country by giving people who may not necessarily have highly technical skills the requisite training and resources so that they could in fact administer tests, monitor treatment, and so forth and so on, to deal with at least routine opportunistic infections.

Rather than concentrating all the resources and all the demands on a few highly-skilled people and therefore rendering them ineffective, what they've done in KwaZulu-Natal to a certain extent and Botswana in ACHAP is try to give more people routine fundamental training so that they can deal with the ordinary elements or problems that arise.

Q: The question I want to ask is—all of you have taken a proactive measure in each of your ventures, instead of asking the question of how not to do something you asked how best to do something. And in my experience, I've been working in the United Nations system and I worked at the director-general's office at WHO, and I wish on a day-to-day basis I was interacting with people like you who are asking these progressive questions.

But instead, at the global level and in my perception, the people I've been interacting with have been asking the question or have been stating why not to do something. I think that was actually exemplified by a question raised earlier today by a member of the audience who asked: what are we doing about resistance? What are we doing about these other issues? Never mind that our own countries have been giving monotherapy for HIV when it first came out, full well knowing that resistance was coming. Never mind that our adherence rates are lower for various diseases including tuberculosis, yet we set up a double standard for other countries.

My question to you is: how can we change the global perception to adapt the mantra that you've taken on how to best do something, as opposed to why we shouldn't do something?

Vikram Kumar: I can address that. I think things are changing. I think there's a conventional funding paradigm where it's for charity, then nonprofit, and slowly companies like ours—for-profit companies—coming into the space. My bias is that potentially we'll be seeing more proactive ventures where, end of the day, if you have to produce something you're going to sit there and not sort of wonder what you can't do but you're going to have to actually produce something.

So that's my incredible bias. But I feel that through for-profit ventures there's actually a way that you can get things done. And the question is: what better than doing something important and interesting and having an impact? So it behooves people in the audience to say—before you start your next company think and say, "Okay—well, why can't I do something somewhat along those lines?" because it's obvious that in this time you can attract the top people—technical business minds who want this. And they're not looking for the returns you would imagine from sort of conventional companies.

Given all that, I think at the global level when there are more people, when you can point to a bunch of companies that have done it, there will be hopefully out of this audience another couple dozen. And people will say, "Well, we can all do this. It's important and interesting."

Ophelia Dahl: I'll jump in. I would say probably just examples, examples, examples—you know, however small it is, if you can make sure that you continue doing it. And also if you can—and this will please the academics in the audience too—make sure you document it. It's very hard to refute evidence that this many patients got better at this cost without it costing a trillion dollars.

I think if you keep the patients in mind as you're doing this work—and I think probably all of us and a number of you in the room consider ourselves enormously privileged to be able to work with patients, even though I'm in an office in Boston and I'm not part of a larger policy-level structure—I know it's very important to carry on influencing these larger policy-driven organizations. And I think that one of the things that Partners in Health is negotiating right now is how we can be more effective in influencing a global perspective of how to treat patients without it sounding grandiose. We don't think that we have the recipe. We don't think it's formulaic, even. But there are bits and pieces that we can take from our own experience and translate them to other places in the developing world.

It's very difficult when you see so much money going towards a disease and you know that it's all done for the right reason and then you meet the woman in Kenya who's on ARVs—she herself is a caregiver for 12 orphans and she's lying on the ground of her hut, not doing well despite being on ARVs for six months. And when we asked her a number of questions, fearing resistance or something, she just explained that she hadn't eaten anything for five or six days or a week.

I still think it goes back to imagination. I really do. I think that all of the answers are finding imaginative and innovative ways to make this work.

Jack Higgins: But I think also that the nonprofits are being encouraged more and more now to try new things and at the same time to be held accountable for how they spend their dollars, more so perhaps than nonprofits have been in the past. And as Ophelia said, you've got to document everything. That can be a burden, as they were saying this morning, when you have to document for 27 different funders for your organization.

But at the same time, the need to document what you're doing and to show the social value for the investment makes an awful lot of sense. And I think that trend in philanthropy will have a big influence on helping us to do a better job.

Tony Carroll: I think ACHAP was created because of those frustrations. And the Botswana, to their great credit, ceded a lot of their authority on this issue to this ACHAP model, recognizing that even their own bureaucracies were getting in the way and we needed to find a way in which to act much more aggressively.

And I do think it might be a little bit of an apples-and-oranges example, but 24 years ago Merck developed a drug called Mectizan. Mectizan was basically the cure for river blindness, which was a very widespread illness in Africa. Merck donated Mectizan, without any benefit to its own company, to the Carter Foundation and other NGOs to administer all over the world. Last year, we administered the 250-millionth dose of Mectizan in Africa. And it basically eradicated that illness. I mean, there are still pockets of it—you can't get everything. And of course you only have to take one pill a year—river blindness is a lot easier to treat than HIV/AIDS with the mutability issue and so forth.

But it does show that if you really try to push a new model and you bring the power of research and the power of philanthropy and the capability on the ground of many NGOs then you can at least start addressing some of these problems.

Ophelia Dahl: I want to just jump back in because I agree with my co-panelists about all of that but I also think, to go back to accountability—it is very important but I can't emphasize enough that Partners in Health was able to succeed in the early days because we were lucky enough to have a funder who didn't ask us to be accountable for a while. That was lucky. And when you're dealing now, as we are, with Global Fund and PETFAR and various things, we have several different reporting mechanisms that we have to use. And we're dealing with illiterate and innumerate populations, so it puts huge burdens on our clinicians who have to drive from their rural villages to meet and make sure that all of this funding….so it's necessary, but I think we also need to include in this model training bookkeepers and all of that sort of thing as we train community health workers, to make sure it's done too.

Judith Justice: I'll just add one thing that also related to the discussion this morning about NGOs and funding from the international and UN donors to NGOs, following on what Ophelia said.

When an organization or a group has money that's not tied—that are donations, as you said, that comes from individuals or someone who doesn't have this—it does provide a certain flexibility. I'm not advocating non-accountability, but that you have the flexibility. You can start over again. As you said, in Botswana you learned that things didn't work the first time. If you have a grant from USA Idea and you have three years—that's it. But if you have money where, okay, it didn't work and you can start over and work with the community or the patients where they are then you have that flexibility.

But that's hard money to come by now, money that doesn't come with all the strings. More questions from the audience? I'm sorry. I'm cheating you. I can't see!

Q: I'm going to make some assumptions here. Having gone to school here recently, I know there are probably a number of people that are very excited about actually doing some of the things that you all have done in terms of being social entrepreneurs or going to developing countries and starting organizations like you've started.

Given the fact that health care is an industry that requires a lot of capital, is regulated, and requires a lot of investment from an educational perspective, I wonder whether or not you all can give us some examples or some advice on areas where you think somebody young—who hasn't been out in industry or hasn't already dedicated many years to developing expertise in an area—what areas do you think are sort of ideal or the best for fast growth or fast movement? For example, Vikram is working on something that's more high-tech versus drug development. I work in drug development—I know that it's a painfully slow industry compared to the sorts of things that people do here in the Valley.

So I wonder whether or not amongst your experiences and your peers you can give people here advice on areas where, if you wanted to start something, you could get that done—particularly given that you may not have inroads to the health organizations, the government, the regulatory bodies, etc. in many of the places that we go as outsiders.

Judith Justice: I was just going to say maybe we should….in terms of our timing, should we address that? That is our fourth question—to really have the panelists discuss ways in which people with your diverse backgrounds as graduates and undergraduates could most effectively get involved in global health.

Should we take the one question over here and then come back and really have that discussion? Would that be fair?

Q: My question is—I realize that nowadays there are a lot of NGOs and organizations that care about the grassroots level I'm thinking about: what is the mechanism that we can best evaluate? Because I realize that a lot of people just go directly to the field and do the work because we feel that most effectively provides care. But how do we evaluate and find the way that is not only the good way—because there are a lot of good ways to serve people, but there may be a better way or the best way to provide.

For example, in Botswana—what if you realized that's a really, really good method to serve the people? How do you evaluate that and publicize it and provide those lessons to other people in other countries? And that links to another issue I'm hearing about the whole day, which is collaboration between the grassroots level, the corporations, and the government. I keep thinking about—like this morning the keynote speaker said it could be very powerful….whenever a developing country hears that there is funding coming most of the time they say yes, except occasionally for Indonesia. But most of the time they say yes. So I was just thinking: what if all this—the World Bank represents international organizations, USAID, and the grassroots level—if they come together and maybe pressure the government to form a committee that aggregates all the work to go to the country so that they can evaluate and find out what is the best job that can be done? Is it a possible measure? So it's about evaluation and collaboration.

Tony Carroll: Let me just start with the Botswana connection and then we can move on from there. We're really now starting to ramp up an evaluation exercise on ACHAP—because in a way I think we did start with a scatter approach saying, "We need a comprehensive model. Let's try everything, and then eventually reduce our effort to a real sort of core competence." So really now we're finding that what they need from us—at least, as a company participant in this model—is more technical training for their staff and more laboratory support and maybe leave some of the other elements to other institutions that can do that more effectively.

So we're trying to build in—and it isn't often done because sometimes the time horizons are too short—a sort of self-evaluation mechanism in this process so that we can better educate and better concentrate our resources to where they're most effective.

And to your point regarding how to get involved in this process, I promised my friends over here that I wouldn't leave the table today without at least talking about the Peace Corp. I mean, I can't tell you—we're a two-generation family of Peace Corp volunteers. My niece just graduated from the Tulane School of Medicine in tropical medicine and public health. She's going to go down—after having completed a three-year assignment in Honduras or Nicaragua she's going to go to a short-term critical-care assignment in Livingston, Zambia, on HIV/AIDS. The Peace Corp will give you the most amount of responsibility, the greatest amount of exposure, and really invaluable field experience that you will carry with you throughout your life in whatever you do. You may never go back to Africa or you may never necessarily go to a developing world. But it will give you a level of experience in communicating with people different than yourself that you'll never get anywhere else. And I can't tell you enough how much that meant to me in my life, and in a way I'm still repaying the debt that I incurred by making $59 a month in Botswana because it was the best money that I've ever earned in my life.

Ophelia Dahl: I can jump in for another seven seconds on that. I would say in terms of how to leverage it, I think that forming committees can be a little bit dangerous because you can get loads and loads of experts who then are flown out and spend a lot of time meeting in large hotels and places to talk. But I think you do need to form collaborations—public and private partnerships. Teaming up is not always easy with ministries of health and government. But I think that will sustain it—that will sustain things in the end.

We at Partners in Health were actually able to do that with the Ministry of Health in Haiti once we got Global Fund money. We were able to revamp certain area hospitals so they weren't all coming to us. As soon as we started paying and supplementing the doctors—paying the community health workers—with their salaries, the doctors weren't leaving Haiti anymore. They needed to earn a living and they needed to know they had the tools to be able to treat the patients. It doesn't mean that some people don't want to come to the United States.

So I think leveraging partnerships is very important—forming committees but knowing who your partners are.

Judith Justice: All right. Let's address the issue that you raised. From the experience of the panelists, what kind of advice would you give on how you could get more involved if you wanted to and what kinds of steps you could take to move towards a career in global health, if that's what you want to do?

Vikram Kumar: I'll start by saying that we all have skills of varying natures. For me to do drug discovery would take many, many years. For me to read a complete book would take even longer. But I can sort of get some things done.

The first question is: why should you care? You care and you've asked the question. And to other people, you're here and you care. But to people who don't, I just have to share what I think is something pretty neat.

If you look at the life expectancy currently in Zambia and compare it to our life expectancy in the U.S., we in the U.S. have two lives for every one life of a person in Zambia. So it sort of behooves us to spend at least one of our two lives working on important and interesting problems.

So that said, there's no limitation behind where you can use your skills. I have a friend who is from Bangladesh who has a finance background. He's spent the past three to four years working with one of the largest microfinance institutions over there to figure out how they can do securitization of loans and create funding opportunities in that. He doesn't have a medical background. He doesn't know how to code. He doesn't know how to bill stuff. But he's realized that it's an important area and it's an interesting place to do work.

So I think the first step is to say, "Okay. I have skills." We all have skills in an area. What's interesting? And then it doesn't take long to find out the three or four big players in the space. And the greatest thing about working in this area is you'll meet the best people in the world who are passionate about what they do. They've filtered through, so they're good at what they do—because it's very tough to survive unless you're really good at what you do—and they have time. So if you find them, email them, and then pretty quickly you'll realize where you can actually have an impact.

Q: But what are some of the areas that you personally excited about? Some concrete examples?

Vikram Kumar: Sure. If I look at health services, what we're doing obviously we think is interesting. There's data that's sort of dead. How can you make data interesting and how can you give feedback to patients who are taking a drug to show them the result of taking the drug to increase compliance? You can show a CD4 count—if you can show it changing maybe they'll start taking those antiretrovirals more frequently.

Then the question is, okay, how do you price it? That's the second question. So direct-observed therapy works, it doesn't work, if you have multi-drug resistance to TB. So I would do basic, basic science on drug resistance. CML—you give Gleevac, you get drug resistance. It's the exact same problem we have with HIV and TB. Go do basic science and understand why we have drug resistance.

From then onwards, look at a lab on a chip—where can you bring nanotechnology to have a dry lab in a rural area in Ghana where you don't need water or reagents? Can you have a reagentless chemistry lab where you can start picking up signals which are important for somebody's physiology or disease? Again, it's basic science.

So that's my bias and that's what I can think of.

Ophelia Dahl: If I were young and energetic that's exactly what I would do, would be to try to find ways to harness the incredible energy and thoughtfulness and interest in these kinds of global health equity problems with the people to do them. Because at Partners in Health we get so many inquiries every day from people who want to do this kind of work—and they don't know exactly what it is. We're a service-based organization, which is fine because I see it as part of the work. But we now have to spend a lot of time helping people channel their careers.

And if I were going to start again I would start an organization that did just that. For example, a bench scientist came up to Paul Farmer the other day and said, "I went to your talk. I don't want to leave bench science but I'd like to do your kind of work." And he said, "You can do our kind of work, this kind of work, just by making sure that whatever it is you're developing, whatever it is you're working on—ask who are you developing it for? Is it just going to be for the affluent people in the world or can you make sure, using your own influence, or can you get involved in some way to make sure that the drug you're developing is going to be available to other people?" That's idealistic, I know, but there are different ways to do it. And I would love to start an organization that said, "I don't know what your skills are, but whatever your skills and interests are…" and put you with the right organization or indeed start a new organization that was able to do that.

Jack Higgins: At the same time that we suggest possibilities for things that are hot now or maybe hot in the near future, I want to point out that there are literally hundreds or thousands of different career paths you could take that could end up contributing to global health. And it's probably equally important to looking at trends and our predictions to do what you feel you can do well and what interests you and then maybe apply that to making changes in the world that are for good.

And you may even decide to drift off someplace out of global health and into something else in the process. But if you're really good with numbers or you're really good with bench science but somebody tells you the only way you can help is to be a doctor and you go spend eleven years doing medical school and residency and then decide you hate it, you're not going to do what you could have done had you stayed at the bench or stayed crunching numbers or working with IT or whatever you might have done.

So listen to suggestions, but at the same time really follow your heart in terms of what feels good to you as a career path. And then look at how you can take that career path in the direction you want it to go.

Judith Justice: Thank you. I'm going to take advantage and also contribute. I'm going to build on what Tony said. I was not a Peace Corp volunteer but I have to say I always regretted it—because whether it's the Peace Corp or another volunteer type of group, opportunities where you can be at the grassroots, where you can live in communities and understand people's lives every day and the problems they face, what they do when they're sick—remember, this is my bias; I'm an anthropologist speaking. I learned this through my anthropology work. But I feel that kind of experience—really understanding people, whether it's this country or other countries, in their day-to-day lives and their challenges and what contributes to their decisions when they're looking for healthcare and what's acceptable and available to them—has served me well in all my years of policy work and talking about other kinds of interventions.

But it's a kind of basic thing that doesn't even have to be health-related—just when you have these opportunities. But I always encourage our students to take whatever opportunity they have to go to other countries and to try to learn in the best way that they can. I think with each experience you take something away that you can then apply to your own interests and your own discipline.

Were there any of the other panelists from the other panels who'd like to contribute something? Do we have one or two minutes? Because we didn't have a chance this morning and I think at the later panel we probably won't again. Anyone else?

Nzeera Ketter: I'm Nzeera Ketter from the International Aids Vaccine Initiative. And I wanted to offer some suggestions of things people can do to begin their careers in this kind of work.

We have field sites all over Africa and India and we are doing very high-tech research in a low-tech environment. And there are lots of opportunities, from information technology to laboratory work to community work out in the field. And many of our initial people who begin to work with us actually go, interns affiliated with one of our larger grantees, and spend a year or two in the field learning from other people and then finding what it is that really turns them on, that really makes them excited about what they're doing.

And it's amazing. You know, unless you go there and do it yourself you really don't find those opportunities. And thinking outside the box when you're in the field makes you think about how to use less firewood so that there is less deforestation and it may be completely unrelated to HIV vaccine research that I do, but it's staring you in the face and it demands some innovative thinking.

So there are ways to connect with people who are already doing something and then tack on your innovative thinking to theirs.

Vikram Kumar: I wanted to add just a couple more ideas. Another hot area is social networking—what Friendster was a couple of years ago. If you look at transmission of HIV, some people infect more than others. So mathematicians in the audience might start looking at that data—the patterns of transmission—and figure out: what are those nodes? And in a resource-poor environment where you have to just give drugs to several people you give them to those highly-infected nodes.

So it's another example of a place where you take a technical skill of statistics or math and you find the guy who has the data set you need. And that might take you a year—it's very difficult to get that data. But then you've actually written a paper on it and figured out that this is the way we can totally change the way we treat these people.

Bruce Walker at the MGH had this great idea of treating HIV/AIDS in a different way—treat them up front and kill the virus early. Those sorts of approaches are—we're starting in many of these areas from scratch. There's very little to lose, so you might as well be crazy about what you think about.

Related Links

2005 International Development Conference

Remarks by the Conference Panel on Funding Innovations

Remarks by the Conference Panel on Medical Innovations

Remarks by Dr. Debrework Zewdie