"An ounce of prevention is better than a pound of cure" -Ben Franklin
From the global banking system to the control of the deadliest diseases in the world, preventing a problem in the first place is the Holy Grail to mitigating some of the world's greatest challenges. If you are thinking 'duh' when you read this, I challenge you to read on and ask yourself why it is that so many preventable, or potentially preventable, and costly issues in the world today are being dealt with only as catastrophes after the fact? From fiscal cliffs and bank bailouts to emerging superbug epidemics, did we not see these things coming? And if we did, who is responsible for making the decisions that got us here, and who makes the decisions on how to get us out? And, why is it that hindsight always 20/20?
Today, there is a growing field of study around the art and science of decision making among prominent business schools that teach on judgmental heuristics and the biases they produce. Heuristics often refer to the mental shortcuts we take when problem solving, discovering or learning. Some common heuristics include the confirming evidence trap, anchoring bias and escalation of commitment. There is also the pervasive phenomenon called groupthink, a peer pressure mechanism that can have a deleterious impact on businesses and society when we overvalue consensus building. Hindsight often uncovers these heuristics and bias, giving us that 'ah hah' moment in situations like the financial crisis and the Iraq war. In these cases, and thousands of others like them, it wasn't the fact that the data wasn't there to begin with, rather, it was the way the data was analyzed and presented to the decision makers, and the choices they made when faced with conflicting or ambiguous data and competing agendas.
To put it simply, they failed to question the answers. In the age of Big Data, choosing to see what one wants to see in order to prove that an original decision, idea or strategy was the right one in the first place, can result in poor decision making that leads to lost lives and billions in levies.
Today, we face a tremendous challenge in achieving TB elimination. Contagious and airborne, it is a resilient and highly adaptable microorganism that has survived and thrived alongside its human host for centuries. Historically described as the "Great White Plague," TB was the cause of more deaths in industrialized countries than any other disease during the 19th and early 20th centuries. By the late 19th century, 70-90 percent of the urban populations of Europe and North America were infected with the TB bacillus, and about 80 percent of those individuals who developed active TB died of it. Today, more than 2 billion people, almost a third of the world's population, are infected with the same TB bacillus, and this number will continue to grow without effective preventive measures.
While reviewing the comprehensive World Health Organization's Global Tuberculosis Report 2012, one can easily see that there is conflicting data in regards to how successful our efforts have been at mitigating this epidemic. On the one hand, no one can deny the tremendous success of control programs that have reduced deaths by more than 40 percent over the past twenty years. On the other hand, there are nearly a million more cases of TB in the world today than when the World Health Organization (WHO) declared TB a global emergency 20 years ago, with 7.8 million cases in 1990 and 8.7 million cases in 2011. And despite progress in reducing TB-related deaths, it remains second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent, killing 2-3 people around the world every minute.
In addition, TB has evolved to be more challenging to cure, as evidenced by increasing cases of drug-resistant TB strains now present in almost all countries surveyed worldwide. Alarmingly, recent reports from India and South Africa of apparently untreatable cases, referred to as totally drug resistant, are raising international concerns around the emergence of a manmade superbug, with higher mortality rates being reported than the more publicized Ebola and SARS viruses. Drug-resistant TB threatens to halt overall progress, given that treatment for these strains can be as much as 1,000 times more expensive, require two or more years of continuous therapy and have much lower cure rates than drug-sensitive TB.
Finally, while historically a disease of the poorest and most vulnerable, TB is poised to spread through migration and urbanization as evidenced by a highly publicized London TB hotspot adjacent to the home of some of Europe's largest banks, and the recent outbreak in downtown Los Angeles. Situations like these are waking up policy makers to the fact that there is no way to adequately protect those who are exposed to a contagious individual from becoming infected with the TB bacillus.
Recently, efforts to raise awareness and support for TB control and elimination efforts have led to the launch of a new Zeros Declaration -- zero new deaths, zero new infections and zero suffering from TB. While I applaud efforts to push for more ambitious targets and to be aspirational in nature, there is a danger in setting these targets in front of the less well informed decision makers who might be tempted to think that we have this epidemic under control. Yes, we need adequate funding, and budgets should be fully supported, but it is more complicated than that.
Ultimately, it is innovation that will drive progress across the entire value chain from delivery science, operational research and R&D in vaccines, to drugs and diagnostics. Already there have been some tremendous breakthroughs with the approval of GeneXpert, a new rapid diagnostic, and bedaquiline, the first new antibiotic for TB approved in 50 years. However, these successes are not enough.
There is an equally pressing need to stick to the basics of good infection control measures, and to ensure that the highly curable drug-sensitive cases are both found and treated. Today, it is estimated that as much as a third of the 8.7 million new cases of TB last year went undiagnosed and untreated, confounding efforts to stop the spread of a disease.
However, the most effective way to stop the threat of TB is to prevent the spread of TB. New vaccines sit at the center of future TB elimination efforts. Like every other major infectious disease in the history of mankind, prevention through vaccination has been the most cost-effective tool in eradicating and controlling these diseases.
Significant scientific progress in vaccine R&D is well underway. Investments of more than $600 million over the past decade have resulted in a robust global TB vaccine portfolio comprised of more than 25 early stage discovery leads and preclinical candidates, and a dozen candidates for which clinical trials are underway. New capacity in high disease burden countries to manage complex, large-scale efficacy trials has been established, and historical clinical trials offer crucial insights into the biology of TB.
Questions raised by Richard Anthony of the Royal Tropical Institute in a recent Financial Times article regarding whether or not scarce resources should be invested in TB vaccine R&D versus drugs and diagnostics miss the point. The Wright Brothers didn't have aspirations to fly to the moon on their first flight in Kitty Hawk in 1903. If innovation had stopped there, I would not be in Cape Town attending the 3rd Global Form on TB Vaccines this week.
In science we don't deal with certainty, we deal with probability, and there is a high probability we will have a new vaccine within the next 10-15 years. While that may seem like a long way off, the consequences of delay would be significant. A preventative adolescent and adult vaccine with 60 percent efficacy, delivered to a mere 20 percent of the population at risk, could avert up to 2 million new cases of TB a year. In addition, by implementing a highly efficient portfolio management approach, it is estimated that less than $1 billion would be required over the next 15 years to successfully introduce at least one new vaccine.
These costs pale in comparison to the WHO's Global TB Report 2012, which cites that an estimated $8 billion a year is required to provide tuberculosis treatment and care, with an annual need of at least $1.6 billion in international funding to close the gap. During these challenging economic times, it is critical not only to adequately fund TB control programs, but also to take into consideration the future costs to society.
We are at risk of committing a moral hazard if we limit our focus on the here and now of TB control. Future generations will pay the price for each year we are delayed in making new TB vaccines available for the world. Austerity measures demand that we invest in longer-term strategies that will ultimately save billions in treatment costs, while protecting future generations from one of the longest lasting and deadliest epidemics of mankind.
For now, we need an honest dialogue around what is working and what could be working better and how scarce resources are invested to support control efforts and R&D, lest we create a Tower of Babble for TB. This week experts, global leaders and civil society groups are gathering in Cape Town, South Africa to participate in the TB Vaccines 3rd Global Forum. We know the dialog and collaborative efforts can't stop here, we must take it globally and include colleagues in TB control and drug and diagnostic R&D. We can, and we must come together as honest brokers to help the world understand how to better control and one day eliminate this disease.
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