[00:01] Speaker 1: Ladies and gentlemen, please welcome Bill Steiger of Malaria No More, Dr. Lutz Hegemann of Novartis, and Dr. Jessica Virgin of Myesha Meds.
[00:10] Speaker 2: Good morning.
[00:26] Speaker 3: Thanks for joining us. My name is Bill Steiger. I'm Chief Executive Officer of Malaria No More, and I'm pleased to be joined by 2 very distinguished guests: Dr. Lutz Hegemann, President of Global Health at Novartis, one of the world's most innovative pharmaceutical companies, and Dr. Jessica Vernon of Maisha Meds, one of the most innovative NGOs working on the private sector delivery of healthcare in Africa. It's pretty hard to follow Elmo.
[00:51] Speaker 4: So, we have an unenviable task.
[00:53] Speaker 3: I promise that we won't make you wiggle, but I'm pretty sure we will make you think. And the through line from the 2 panels this morning, I think, is going to be children and what can we do to support children and families around the world.
[01:07] Speaker 5: You heard about some challenges here in the United States.
[01:11] Speaker 4: Now, I'll turn to the 2 of you.
[01:12] Speaker 5: We're in New York, the US.
[01:14] Speaker 3: We haven't had malaria for a long time, since the 1950s.
[01:17] Speaker 5: That's right.
[01:18] Speaker 3: Why should we in the Global North care about malaria?
[01:21] Speaker 4: What challenges do you see now about the disease, and what gives you hope that these are challenges we can solve?
[01:27] Speaker 6: Well, thank you very much, Bill, for having me, and good morning to you all.
[01:32] Speaker 7: I think when we talk about malaria, we need to realize that it is one of the oldest, but also one of the deadliest diseases that is known to mankind, and it still kills about 600,000 people every year, which is a staggering number and has a profound impact on communities in Africa and beyond.
[01:54] Speaker 6: And as you said, Bill, it's predominantly children under the age of 5 who are implicated and who suffer from malaria.
[02:02] Speaker 7: But then, in addition to that, we also see the disease pattern changing as a consequence of changing climate patterns, forced migrations, and It was just a few weeks ago that 2 people died of malaria at the Frankfurt Airport, baggage handlers in Germany, which you wouldn't expect. So we shouldn't be thinking of malaria as a disease that's far away, but it is in fact on our doorsteps.
[02:28] Speaker 8: To reinforce that, economic growth is one of the— so economic growth is often reduced by malaria incidence.
[02:43] Speaker 9: So, people who are—
[02:47] Speaker 8: economic growth is a big factor that is affected by malaria. So, people who have malaria often cannot work as hard, cannot go to school, cannot pay as much attention in school because they're sick.
[03:03] Speaker 9: And as a result, you see reduced growth in certain parts of the world where there is higher rates of of malaria.
[03:09] Speaker 8: In addition, resistance is emerging and could come to regions with—
[03:17] Speaker 9: that don't currently have malaria.
[03:19] Speaker 8: As Liz said, the map is changing and the drugs are not working as well as they used to.
[03:25] Speaker 9: And so, it's something that we should all be thinking quite a bit about.
[03:27] Speaker 4: So, Liz, I'll turn to you. Jess mentioned this issue of resistance.
[03:32] Speaker 3: I think a lot of people don't know that the parasite that causes malaria that mosquitoes transmit to us and between us is now becoming resistant to many of the first-line medications that we typically use to treat the disease. So how is Novartis innovating to meet that challenge?
[03:49] Speaker 6: I mean, first of all, we shouldn't be surprised that resistance against current antimalarials is rising, and I would say it's even remarkable that it's taken us 25 years since we introduced the current class of malaria antimalarials to now see resistance rising, because that has happened over time to every other antimalarial medicine that was ever in use, because the parasite is a clever fellow and they, of course, try to adapt to the ecosystem and try to survive as much as we want to kill it.
[04:30] Speaker 7: So we now see those signs of resistance and they become very prominent. We see resistance now being documented and becoming a public health issue in at least 4 or 5 African countries, with suspected resistance in more countries, and we've long seen it in the Greater Mekong area, that resistance exists. So we need to use our best science to be step ahead of the parasite, and that's what we've been doing now for many years by doing targeted drug discovery to develop that next generation of antimalarial, which is now in regulatory approval process, and we are confident and hopeful that it can be deployed in time before the spread of resistance becomes more widely and more deadly So, a medicine, especially a new medicine like the one that you're working on, which we can call Ganloom—
[05:32] Speaker 3: you will tell us the scientific name of the compounds—
[05:36] Speaker 5: is only as good as access to it.
[05:40] Speaker 3: If we can't provide access to patients, to providers, that innovation is a false promise. So, what needs to happen from now forward to make sure that we can get this new medicine and the ones that will follow into the hands of the people who need it?
[05:54] Speaker 7: I think it's fair to say that, having not had a new innovation in malaria treatment for 25 years, I think the world has lost a bit its organizational memory, how to bring those innovations to patients in need quickly, and that's why we need to start discussing very broadly with all stakeholders involved How we can accelerate that process, how we can make sure that the unique features of those innovations are being used in the most appropriate way. What we have classically done in a sequential way— first completing clinical trials, then waiting for regulatory approval, then talking to WHO, then changing guidelines, then establishing supply chain—
[06:41] Speaker 6: takes way too long in the current situation.
[06:44] Speaker 7: So we cannot do this sequentially. But we have to mobilize all stakeholders in this ever more complex ecosystem to make sure we reduce timelines, we work in parallel, and we are ready as soon as we feel comfortable that the medicine can be deployed at scale. And then we also need to be very precise in how and where we deploy those medicines so that we don't overuse them at the same time, because we want them to be used in patient populations that benefit the most, And here, in the face of resistance, I see saving lives for individual patients who otherwise would not be treated, and at the same time blocking the transmission of the disease from one patient to the next patient.
[07:29] Speaker 6: And those are 2 features that Ganaplastic lumefantrine will offer to the medical community.
[07:35] Speaker 3: And one day, when it gets regulatory approval, we'll have a catchy name for the drug, right?
[07:39] Speaker 6: Yes, we're working on that.
[07:40] Speaker 10: Good.
[07:41] Speaker 3: That will help me out.
[07:42] Speaker 5: So, Jess, one of the things I've learned from you is that the first stop for many patients with malaria or who think they might have malaria is a private pharmacy.
[07:52] Speaker 4: So, those are the institutions with which you work in 4 African countries.
[07:56] Speaker 3: Tell us why patients choose to go to pharmacies first in many cases, and what's the important role of the private provision of healthcare for malaria and more broadly in sub-Saharan Africa?
[08:06] Speaker 8: Fantastic.
[08:07] Speaker 9: So, we work with about 6,000 pharmacies, clinics, and drug shops across 4 countries in Africa. And one of the things that I learned as a medical doctor working in western Kenya many years ago is that a lot of patients are going to the private sector first because it's more convenient, because oftentimes it has drugs that the public sector might not have in stock.
[08:27] Speaker 8: It's often closer, and they're often waiting less time.
[08:29] Speaker 9: So, they're willing to pay a very small amount of money usually about $1, in order to speed up that process and get the drugs that they need. This has become a norm across the region. About half of all patients are accessing care and accessing malaria care in private sector.
[08:44] Speaker 8: And one of the things that's been really interesting as the resistance is starting to emerge in some of these regions is that we're seeing that patients are actually going in to buy different drugs already. So, they're buying drugs that they think or they know will work better.
[09:00] Speaker 9: than the ones that are currently first-line in these regions. So, we've been able to work with them to help kind of speed up that process already and help them get these different drugs. And then we're really excited about a lot of these new innovations that are coming online that will be able to help improve that access where they need it, based on the kind of targeted individual, like, understanding of the maps of where different drugs might be needed.
[09:25] Speaker 3: So, one of the things that I know you do with your pharmacies is work to make the quality of the care that pharmacists are delivering to patients better. How are you doing that?
[09:36] Speaker 8: So, we have used a lot of kind of very boring economic literature and a lot of understanding of how health systems work in other parts of the world. So, a lot of patients in Africa are not insured.
[09:48] Speaker 9: They're paying out-of-pocket for their care, but they would be willing to work within models that feel a bit like health insurance, where they go in and pay a copayment for drugs. So, we build clinical decision support.
[10:00] Speaker 8: So, we make sure that they're following kind of the right care checklist in order to access malaria care.
[10:09] Speaker 9: We make sure that they get testing before treatment and then quality-assured treatment only if the test is positive. And then we build the financial incentives to do that.
[10:17] Speaker 8: So, they're paying this copayment that's often the same amount or less as they would be paying for less good drugs.
[10:23] Speaker 9: And then we're also reimbursing the pharmacy for them to be able to provide this higher-quality care.
[10:29] Speaker 10: We believe that this will build the building blocks of health insurance long-term.
[10:32] Speaker 9: But in the meantime, it's also just providing really great care to patients who need it.
[10:35] Speaker 3: So, one of the things that, to an advocacy organization, is very intriguing about your model is that you have access to a lot of data that that other organizations, including the public sector, might not have.
[10:49] Speaker 4: So, talk about the data that you are collecting and what you're seeing that your patients are telling you.
[10:53] Speaker 9: So, we're seeing about 35 million patient encounters every year. About 12% of those are malaria.
[10:59] Speaker 10: So, it's a very large dataset that we're able to work with.
[11:03] Speaker 9: And we're seeing really interesting trends that aren't, I think, being surfaced elsewhere. So, first of all, in the public sector, 90% of the drugs that are being used are high-quality or WHO-prequalified qualified. In the private sector, it's only about 10%. So, 90% of the drugs are not necessarily going through that process to make sure that they're really good before they reach patients. Secondly, we're seeing that there's a lot of differences in how patients are accessing care based on region. So, injectable artesunate, which has the potential in some cases to cause greater resistance, is being used quite a bit in certain regions.
[11:41] Speaker 8: Of areas that we would kind of expect based on resistance maps. So, South Sudan and some other regions, and it's increased about 10x over the last 10 years. So, there's—
[11:50] Speaker 9: this is a big and emerging problem. And then we're seeing the drugs that are kind of the precursors to Ganloom that are already being used in a lot of the regions where resistance is emerging. So, we're able to target where where drugs should be used based on the data we're seeing around consumption.
[12:09] Speaker 3: So, in this era of reduced resources for malaria, many people might know that many external donors have reduced their funding to malaria. There's an ongoing transition that the U.S. government has started in African countries through a series of memoranda of understanding to gradually transition programs to national financial and managerial ownership, but we don't have, in many cases, in malaria programmes exactly the same amount of money as perhaps they used to have. How does innovation play a role in allowing both the private sector and national governments to do more with less, and what are some of those changes that you've seen that are most effective around microtargeting, data, innovations in private delivery?
[12:55] Speaker 6: I think for a long time we have looked at malaria as a homogeneous disease entity, which is not quite true. It was probably true many years ago when we had a very high prevalence and a very high disease burden in many countries, but in today's world it's a lot more differentiated. We have countries that are nearing elimination and we have seen countries actually eliminate malaria in recent years, and then we still have high burden situations, we have outbreaks For instance, in zones of conflict, in other crisis situations.
[13:32] Speaker 7: It may be interesting to say that in the current Ebola outbreak in DRC, Congo, it is estimated that more people die from malaria than from Ebola. So we see that whenever there is turmoil, there is disorder, we see malaria on the rise and we need more precise tools. It's not one silver bullet, but we need a whole toolbox that can be deployed in a data-driven and locally-led approach to precisely address the need of that population at the time.
[14:05] Speaker 6: And if we do that— and here my organization is also not stopping now at this one innovation, but using that as a platform for further innovation— then I do believe, by, in a more deliberate way, in a more targeted way, deploying that innovation, that indeed we can do more with less.
[14:26] Speaker 8: So, I think this is one of the most exciting times in terms of the innovations that are coming online: genapicide, lumefantrine, the spatial emanators that SC Johnson is putting out, some new bed nets, and other things.
[14:40] Speaker 9: It's also a time where there's a lot of headwinds in how we fund these things. We are excited to be able to provide some of the targeting and support to make that happen. And we see there's a lot of other groups that are able to provide kind of much more nuanced understanding and direction on where different innovations should be used. And then finally, these pharmacists are there. They didn't stop providing care when things kind of changed last year. And they're wanting to take a lot of these innovations and support them to come to scale because they see them being useful for the communities and patients that they serve.
[15:19] Speaker 3: So, as we look forward 5 or 10 years, given that, as you say, Jess, we've seen an enormous amount of innovation— by our sense, there's more innovation in malaria in the last 18 months than in the previous 25 or 30 years. where will things stand with the disease, or where could they stand with the disease in 5 or 10 years, and what are the changes that still need to happen in delivery, in regulation, in approach to get us to the best possible outcome? Lutz, I'll start with you.
[15:52] Speaker 7: Yeah, no, I think, as we heard, the technology, both the scientific technology but also technology beyond just science in terms of availability of data, our ability to track outbreaks, our ability to diagnose patients more rapidly, is going to help us on the malaria elimination agenda.
[16:17] Speaker 6: And I am very, very confident about that and I believe that technically we are better equipped now, as you said, Bill, than we were ever before.
[16:25] Speaker 7: But we need to find a way to deploy those new technologies in a very responsible and in a very efficient way, and of course we need to sustain the basic quality and ability of a healthcare system to deliver those new innovative technologies, and that does require continued funding as well. And I am encouraged to see that more and more countries are stepping up towards local leadership, are mobilising local funding. I think we are in a transition period Currently, where the previous global health order was largely donor-funded, and now we see a diversification of funding and a lot more local engagement, which I believe is critical towards sustainability and towards long-term success.
[17:15] Speaker 6: But I remain very optimistic.
[17:17] Speaker 7: We have the tools.
[17:18] Speaker 6: Now we need to create the appropriate ecosystem, and then we'll see the populations benefit.
[17:23] Speaker 5: Great.
[17:25] Speaker 4: Efficiency, self-reliance.
[17:26] Speaker 3: What would you add to that?
[17:28] Speaker 8: I would echo much of what Lutz said.
[17:30] Speaker 9: I think we have kind of two directions to go in.
[17:32] Speaker 8: Do we want to, you know, engage with all of these amazing tools and take them to scale and make sure that they're available or, or kind of let, let some of this— the work over the many years to bring this to market, let it kind of not, not get the support it needs. I hope and I believe that there is a lot of appetite and will to make this innovation reach the communities it needs. I think, as Lutz said, the fact that local governments are wanting and empowered to engage in a way that maybe they haven't before and really think about what are the right tools for them is an incredible piece of the puzzle that's moving forward.
[18:18] Speaker 9: And I would say that, you know, we do see that there's still a lot of desire among patients to access this care, to potentially pay for it, and that there are delivery systems that can make this happen. So, we are just hoping that we're able to help support these innovations to go to the scale they need.
[18:35] Speaker 5: Great.
[18:36] Speaker 3: So, we're winding down. I have one last question for you. So, tomorrow morning, Concordia is welcoming the candidates for the position of Director-General of the World Health Organization. for a forum. If you could tell them one thing, those candidates for WHO leadership, what would it be?
[18:53] Speaker 6: That health is not a cost item but an investment opportunity to drive greater prosperity, and they should champion that.
[19:03] Speaker 3: Including working with the private sector?
[19:06] Speaker 6: Yes, definitely. That would have been my second one.
[19:08] Speaker 3: Yes, okay, I'll give you 2 then.
[19:12] Speaker 8: I would say, first of all, just listen to the grassroots and the data.
[19:17] Speaker 9: There's a lot of incredible data being surfaced that isn't necessarily driving, driving policy and decision-making.
[19:23] Speaker 8: And there are people in communities across Africa who are willing to and wanting to support them in a lot of the work that they're doing, who might not have been part of the formal system in the past and are willing to be now.
[19:33] Speaker 3: Absolutely. I will join them with one— I will add one ask of these candidates, and that is urgency. Move faster.
[19:43] Speaker 5: As new products come through the WHO for approval, for the drafting of guidelines, I hope we can move much more quickly than we have in the past.
[19:51] Speaker 3: So, I hope you'll join me in thanking Dr. Lutz Hegemann, Jess Vernon, for their insights and their commitment.
[19:59] Speaker 4: And I hope you all take away from this a sense of urgency as well, that malaria is a problem that besets many families and children around the world, but it is one we can solve and one we can solve together.
[20:10] Speaker 5: Thank you so much for being with us.
[20:11] Speaker 2: Thank you.