An interview with Anthony Mbewu, President of the Medical Research Council, South Africa and next Executive Director of the Global Forum for Health Research

Q: South Africa is currently considering acquisition of a high-throughput screening (HTS) facility that would allow it scale up the screening of natural compounds. At this stage in the development of its biotechnology platform, do you think an investment in HTS is appropriate?

A: I think there is a role for HTS along with other sorts of high-tech technology. What we have done in South Africa in terms of looking for the molecules is to take the approach of looking at natural compounds. The mistake we made in the past was we said, Well there are 2,000 plants that are unique to South Africa; we put them all through HTS and we found nothing. Now, you know, it really doesn’t work that way. So since 1997, South Africa has followed a twin track: one, the classical drug discovery route of taking a plant, getting alcohol and water extracts, putting it through HLPC and trying to find the compounds. But then also having a parallel approach of saying let’s look at the medical folklore, African traditional medicine, where these plants have been used for centuries, often in combination. And let’s get clues from that.

For instance, the clue for one antimalarial that we have characterized came from a plant that was used as an antipiretic. And so we guessed that if this was used as an antipiretic in Kwa Zulu Natal, where malaria was once endemic, perhaps it’s an antimalarial. And behold, we were able to extract three molecules from the plant, and characterize them by NMR. And of course the problem now is how to commercialize them, because we don’t have the funds. The venture capital is not there.

The other thing we realized was that perhaps when these drugs are used in combination, they act more as biologic drugs than chemical entities that follow the ‘Lipinski Rule of 5. ‘And indeed, we found for instance in plants used by traditional healers compounds that are active against mycobacterium tuberculosis, but when you try and extract them and isolate them they fall apart. They’re large molecules, they don’t obey Lipinski’s rules, how they work we don’t know. But clearly studying them is a whole new discipline.

Q: Cuba has been very successful in developing a biopharmaceutical industry despite limited resources. Has it served as a model for South Africa?

A: Yes, President Mbeki sent me as part of a delegation back in 1998. The question was if Cuba could do this in ten years, why can’t South Africa?

Well, one problem is venture capital. I’m a trustee of the only biotech venture capital fund in South Africa, Bioventures. We’ve had a successful first round. But there isn’t money for a second round.

And then the most important single factor is human resources. We don’t have an educated population, we don’t have the PhDs and post docs that you need for a national biotech industry.

Q:There are some innovative approaches to drug development taking place in South Africa. One of them is iThemba Pharmaceuticals, a biotech startup with a high-volume, low-margins approach to developing and commercializing new treatments. Without venture capital, can iThemba or any such effort ever be successful?

A: I think it depends on where you are along the value chain. You need VC at some point because although you can do preclinical Phase I and II without major funding, when you get to Phase III it can be very expensive. It costs between $100 and $500 million in the West. In South Africa, we could probably do Phase III clinical trials for about $50 million. So it’s cheaper, but it’s still hugely expensive, and you have to have venture capital to pay for it.

Q: Without HTS, South Africa must rely on pharma to screen its natural compounds, the therapeutic potential of which is unknown. Does this pose a risk to the country’s intellectual property?

Yes, but the South African government has passed legislation with regard to IP rights. So the latest act stipulates that if the R&D has been done in South Africa, the IP can not be sold overseas. One thing that has done is force pharma to forge collaborations with South African R&D institutions, so rather than simply taking the compound back to a lab in New Jersey, they have to work with a company like iThemba Labs and take the molecule to the market together.

Integrating different knowledge systems has been a recurring theme at this conference. In a session yesterday on climate change and health equity, Dziedzom de Souza of the Noguchi Memorial Institute for Medical Research in Ghana offered up an intriguing idea to make the most of data gathered via geographical information systems (GIS).
De Souza wants to see GIS data integrated into health information systems. This seems obvious, but many countries don’t do this. Countries like the USA are top of the list in using such data when looking at how climate change affects the health of the poor, but regions like West Africa are barely using GIS data in this way at all.
Why does this matter? 80% of health data is intricately linked to geography, de Souza said. This has implications for health generally, but especially when we look at how climate change affects disease. For example, tropical diseases vary with climate variations in terms of their intensity and spread. Climate change is also altering the geographical spread of vector-borne diseases. Countries in West Africa, for instance, will much more vulnerable to these shifts in disease patterns than the USA.
None of this has to cost poor countries a lot of money. There is a wealth of free GIS data available in WHO’s Health Mapper and Google Earth, for example. Developing countries will need all the data they can get to fight climate change. It’s time they start making use of these tools.

Speaking in Thursday’s plenary session, the author Laurie Garrett raised the point that when the U.S. embargo comes down—“and it will during the Obama administration”—Cuba’s primary health care system will be threatened as never before. “Hundreds of U.S. and Canadian health care providers are going to swoop down to grab up Cuba’s doctors,” she said. Garrett also said that in addition to poaching Cuban doctors, U.S. medical tourism to Cuba could siphon medical talent from the country’s primary health care system and into cosmetic surgery.

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In Thursday’s plenary session, Dr David Samuels of the University of the Western Cape argued that poor countries’ loss of human resources to richer ones should be compensated by the latter. “More than 60 percent of health systems spending is on human resources, and in Africa the ratios are just abominable,” Samuels said. “We’re losing human resources in the brain drain, and it amounts to unfair trade. People shouldn’t be restricted from moving, but the countries that receive the professionals should reimburse the sending countries.”
Samuels added that while capacity building is imperative to stem this loss, “you can’t do that in the long run without rebuilding the training institutions.” Over the past couple of decades, African training institutions have suffered from ill-informed policies and economic crises. “For instance, the World Bank, 15 or so years ago, said that countries should not invest in tertiary education, only in primary. And actually we need investment in both. Right now, we don’t have the basis to actually build capacity. So all this talk of money going into capacity building, we’re not seeing it in African universities.”
One reason for that, he said, is that much of the money spent on capacity building is absorbed by the actors conducting the transaction. “PEPFAR claims to be spending $3 billion on capacity building, but how much of that is going to U.S. contractors, who come to Africa to run short training courses and then leave? That money should go directly to the African institutions. We can have partnerships with U.S. contractors, but as it is, the great majority of that money returns to the U.S.”

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What if a patient in rural Gujarat could see a doctor in downtown New Delhi without waiting in line? Without leaving her village? And what if it only cost her $1.00? According to Al Hammond, Senior Entrepreneur in Residence at Ashoka, that isn’t just the future of health care distribution in remote rural areas. It’s the present. “These things are beginning to be put on the ground right now in rural India,” he said in a plenary session speech on Wednesday. “And they’re all driven by social entrepreneurs.”
Hammond was talking about telemedicine—new technology capable of linking medical professionals with patients in areas plagued by chronic shortages of health care personnel. “It’s not widely understood that within 5 years rural broadband will be available practically everywhere there is cell phone coverage,” he said. “That will allow for video links between a doctor and a patient.” It would also allow for so-called telepharmacy, a potential solution to the lack of licensed pharmacists and the abundance of counterfeit drugs in many rural areas.
“Machines that dispense pills in an automated fashion already exist in many developed world hospitals,” said Hammond. “They’re called ‘Med Stations.’ We need to develop the Internet controlled rural version of these devices that can reliably dispense medicines under the control of the pharmacist from any urban center.”
It’s just the kind of cutting-edge technology that many people associate with the word innovation, a flick-of-the-switch gadget that promises to sweep away the problems of the past. But is it the right innovation for the rural poor?
Claudio Schuftan of the People’s Health Movement in Vietnam doesn’t thinks so. “I want to congratulate Mr. Hammond for bringing high tech equipment to rural areas where there is no electricity, and no way to repair the equipment that has broken down,” he said. “And last but not least for creating a system of dependency in an environment where most of us sitting in this room are trying to resolve the problems of health distribution from a completely different angle.”
Hammond replied that Ashoka is aware of the hostility from some quarters to private sector approaches. “But we want to emphasize that this work is being carried out by social enterprises, which have been launched by NGOs. It uses market techniques, because that’s how you get efficiency in the distribution system.”
Ashoka has carefully surveyed the families participating in the pilot study, Hammond added, “and they like the service. They think it treats them better than the other services available to them, and they consider it very affordable.” Perhaps more important, he said, was the fact that, on the basis of the pilot study to date, the Indian government has requested 600 additional units.
No innovation is a panacea. But if telemedicine is truly able to bridge the urban-rural divide, it would address an issue at the heart of health care in the developing world. Should it be implemented? Is it sustainable? And who should decide?
We invite your comments…