Dear Bill & Melinda:
I’ve just finished browsing your “Grand Challenges” website where you announce funding for ideas that will change the world for the better. You certainly use all the right words to sound like you are committed to innovation.
You say: “One bold idea. That’s all it takes.”
You also say: “Unorthodox thinking is essential to overcoming the most persistent challenges in global health. Vaccines were first developed over 200 years ago because revolutionary thinkers took an entirely new approach to preventing disease.”
And also: “Grand Challenges Explorations fosters innovation in global health research. The Bill & Melinda Gates Foundation has committed $100 million to encourage scientists worldwide to expand the pipeline of ideas to fight our greatest health challenges.”
So far, so good. So when I saw one of the topics in your latest “Grand Challenge”, I was pretty excited. I mean, “New Ways to Reduce Pneumonia Fatalities Through Timely, Effective Treatment of Children” is a pretty cool cause to support. After all, as you point out “Over 1.2 million children died from pneumonia in 2011. Ninety percent of child deaths from pneumonia occur in sub-Saharan Africa and South Asia where the proportion of deaths among children with pneumonia can reach as high as 30%.”
That’s a lot of children dying needlessly. Good for you for caring about them.
So, like you say, you’re looking for “One Bold Idea”, right?
Well, let’s just pause and catch our breath here before becoming too excited, because in the next paragraph on your “Grand Challenges” website it becomes starkly clear that you aren’t really looking for “One Bold Idea” – you’re really only interested in rather incremental ideas that fall into three narrow little boxes of pre-defined “solutions”.
I say – Merde!
You say: “We are looking for innovative ideas in the following specific areas of interest under this exploration:
1. Child friendly formulations of amoxicillin
2. Optimizing Oxygen concentrators
3. Devices for measuring oxygen saturation (or optimizing pulse oximetry)”
In other words, you will only fund unorthodox, innovative, bold ideas that fall within a conventional, and somewhat limited approach to treatment of bacterial (not viral) pneumonia. And that’s a real shame, Bill and Melinda, because I can offer you an idea that is truly innovative, bold and outrageous, that can be tested and proven with a simple, inexpensive series of trials, and that can then be implemented anywhere in the world at very low cost. Furthermore, this solution to pneumonia deaths isn’t limited to children. That’s important because while a horrible number of children die each year of Pneumonia, they aren’t the only age groups at risk. As many elderly people die from Pneumonia every year as children, but neither your charity nor your vision seems to extend that far. What you are asking for, essentially, is bold, innovative solutions that demonstrate that the world is flat, and you will not consider funding any proposal that seeks to establish that the earth is any other shape.
Further, when demonstrated to everyone’s satisfaction this idea will not just offer a new, inexpensive, safe and effective treatment for Pneumonia, it will also offer treatment solutions and cures to a wide range of diseases and conditions including Asthma, Obesity, Chronic Fatigue Syndrome, Myalgic Encephalomyelitis, Congestive Heart Failure, Depression, and possibly Alzheimer’s.
Is that Bold enough for you? I’m guessing not. But I would like to lay it on the table anyway. Please feel free to ignore it.
However, before we get to my proposal, let’s get a bit more clarity on Pneumonia itself. This from “The Lancet”, Vol. 377, Issue 9773, pages 1264-1275, 9 April 2011:
“About 200 million cases of viral community-acquired Pneumonia occur every year—100 million in children and 100 million in adults. Molecular diagnostic tests have greatly increased our understanding of the role of viruses in pneumonia, and findings indicate that the incidence of viral pneumonia has been underestimated.”
“In children, respiratory syncytial virus, rhinovirus, human metapneumovirus, human bocavirus, and parainfluenza viruses are the agents identified most frequently in both developed and developing countries. Dual viral infections are common, and a third of children have evidence of viral-bacterial co-infection.”
“In adults, viruses are the putative causative agents in a third of cases of community-acquired pneumonia, in particular influenza viruses, rhinoviruses, and coronaviruses. Bacteria continue to have a predominant role in adults with pneumonia.”
“Presence of viral epidemics in the community, patient’s age, speed of onset of illness, symptoms, biomarkers, radiographic changes, and response to treatment can help differentiate viral from bacterial pneumonia. However, no clinical algorithm exists that will distinguish clearly the cause of pneumonia.”
“No clear consensus has been reached about whether patients with obvious viral community-acquired pneumonia need to be treated with antibiotics. Apart from neuraminidase inhibitors for pneumonia caused by influenza viruses, there is no clear role for use of specific anti-virals to treat viral community-acquired pneumonia. Influenza vaccines are the only available specific preventive measures. Further studies are needed to better understand the cause and pathogenesis of community-acquired pneumonia.”
“Furthermore, regional differences in cause of pneumonia should be investigated, in particular to obtain more data from developing countries.”
So it seems that Pneumonia can be caused either by viruses, or by bacteria, or by both. Hmmmmm. And it also seems that the “incidence of viral pneumonia has been underestimated.” Double Hmmmm. And “a third of children have evidence of viral-bacterial co-infection.” Triple Hmmmm.
Well, I suppose I could go on and belabor more of the problems of treating Pneumonia in children as simply a bacterial problem, but I’m sure you catch the drift. I would rather turn now to the three categories where you are willing to fund “Bold” and “Innovative” ideas.
Area #1 – Child friendly formulations of amoxicillin
You say “Amoxicillin is an effective beta lactam antibiotic with activity against the pneumococcus. The World Health Organization recommends amoxicillin dispersible tablets as the first line antibiotic for outpatient treatment of children with pneumonia. However, the availability and use of this formulation as treatment for pneumonia in high burden countries remains limited. Many countries only have the capsule and powder for suspension formulations on their licensed medicines register, while others continue to recommend cotrimoxazole as front-line treatment.”
“The capsule is difficult to administer to children, while the suspension is bulky, requires clean water to reconstitute, is costly, and may require refrigeration in locations with extremely high temperatures. Also, liquid dosage forms, such as syrups and suspension are usually not amenable to long-term storage or transport under high temperature conditions common in many low and middle income countries and must be consumed once opened or reconstituted. Dispersible tablets have improved shelf life and cost but continue to have associated challenges including time to dispersal and requirement for clean liquid.”
“The ideal oral pediatric dosage form is tasteless/taste-masked and orally dissolvable or easy to swallow. We are looking for innovative ideas on dosage formulation of amoxicillin for children between birth and 5 years of age (the most affected age group). Ideas such as orally disintegrating tablets (not requiring dispersal in liquid prior to consumption), or transdermal patches will be accepted. While established techniques exist for disintegrating tablets including freeze drying, molding, spray drying, sublimation, direct compression, cotton candy process, mass extrusion, and melt granulation, we are looking for formulations that are user friendly, simpler than dispersible tablets, and of equivalent or lower cost to current amoxicillin formulation.”
OK Bill & Melinda –You’re ignoring the fact that a very significant % of Pneumonia isn’t caused by bacteria at all, but by viral infections, and you’re looking for a better formulation for a standard antibiotic. That’s all you’re interested in funding. Wow, that’s bold! (a little snarky, I know – sorry)
So how about area #2 – Optimizing Oxygen Concentrators
Here you say “Oxygen is a life-saving intervention, yet many hospitals and health centers do not have access to reliable oxygen supply. Cylinders are costly to refill and logistically challenging to transport especially to rural areas with poor road access. Therefore, many low resource settings rely on oxygen concentrators, where facilities have access to grid power or reliable backup power. In settings where electricity is not reliable however, current oxygen concentrators are less suitable.”
“We are looking for innovations that would improve the adaptability of oxygen concentrators to low resource settings including improving power or maintenance requirements of the equipment. Power supply is a major known challenge, and we are therefore looking for systems that have low power needs, increased storing capacity or are able to operate continuously from grey power or alternative energy sources. Other improvements to reduce maintenance needs are also encouraged as are improvements to system efficiency.”
Well Bill & Melinda – I have to give you a tiny thumbs-up on this one. You’re close. Getting oxygen to the lungs is indeed critical to saving the lives of pneumonia victims. Their lungs are so inflamed and filled with mucous that they are literally drowning in their own body fluids. So – limited kudos here. You see the problem, but your vision for the solution is to improve on existing technology. I suppose some might call that bold, but I’m afraid that I can’t agree. It’s just a search for a slightly better mousetrap – not for a solution to the underlying problem. But good for you – you’re trying. I suppose. After all, that approach has worked for MicroSoft – kinda.
OK – onwards – Number Three area where you’ll fund Bold and Innovative solutions: Devices for measuring oxygen saturation (or optimizing pulse oximetry)
I can understand why you are big believers in Technology Bill and Melinda – technology has been very, very good to you. So let’s see why you think this is an area for bold innovation.
“Hypoxemia (low oxygen level in the blood) is associated with mortality. Identifying children with hypoxemia is a key step to provision of life saving oxygen supplementation. Hypoxemia is difficult to detect using clinical signs alone because they lack sensitivity. The primary method for measuring oxygen saturation at the point of care is pulse oximetry, however its availability is highly limited in the developing world due to cost. The initial investment is considerable, and the maintenance costs have been reported to be as high as 50% of the initial capital costs on an annual basis2. The low longevity and high costs of parts particularly the finger sensors constrain their use in low resource settings.”
“The last few years has seen innovations around mobile devices that can potentially measure oxygen saturation. Examples of such devices are limited, and remain costly. We are looking for innovations that will deliver reliable devices or tools for measuring and monitoring of oxygen saturation in children with pneumonia in low resource settings. These innovations should be of lower cost than existing devices, require less frequent and affordable maintenance, and be usable with limited or no training by non-professional health providers. The ideal device would have a long sensor life without disposable parts and be able to communicate with or integrate into a mobile technology (cell phone) platform.”
OK – so you’re looking for technology that offers a better way to monitor children who are dying of pneumonia – presumably so that they can be treated more effectively. And how are they going to be treated more effectively? Please see Bold Solutions #1 and #2 above.
What a nice, neat little package. You’re looking for a better antibiotic, a better machine to pump oxygen into little lungs, and a better machine to see how well the antibiotics and oxygen pumps are doing. And you’re focused like a laser on young children in Sub-Saharan Africa and parts of Asia. I guess old people dying of Pneumonia in nursing homes in the US just aren’t as photogenic as little brown and black babies cuddling in Melinda’s loving arms while hubby Bill looks on admiringly. Too bad Grandma – no Big, Bold solutions for you.
Then of course on your Grand Challenges website there’s a long list of proposed solutions that you won’t fund – too long to list here. Suffice it to say that if a solution doesn’t fall directly under 1, 2 or 3 you aren’t interested. Even if it is a real, safe, effective, simple, and inexpensive solution – one for which there are reams of historical evidence that it will work, because it used to work pretty well, before it was lost and forgotten for the past hundred years or so.
And it won’t take millions of dollars to prove this solution to every clinician’s satisfaction and then get it into the field and start saving lots of those little lives. And my guess is that it will address a huge part of the risk to life of both bacterial and viral Pneumonia – the inflammation in the lungs and the clogging of those lungs with cement-like mucous, which of course cuts off the oxygen supply.
Readers of this blog have already guessed precisely where I’m going with this, haven’t you? I’m betting that a simple tonic made from pure, natural, high quality Coca Leaf will do the trick. Certainly not the entire trick – you will still want to be able to treat the underlying bacterial and/or viral infection, but throughout the 1800s doctors in Europe and America who of course had no recourse to antibiotics or high technology routinely treated cases of Pneumonia and other lower respiratory tract diseases with Coca Leaf tonic. Of course they weren’t always successful – plenty of people were carried away into death in spite of having their pulmonary inflammation reduced and their lungs cleared of mucous by Coca Leaf treatment. I am sure that today’s doctors could do better, given the anti-bacterial and anti-viral medicines and the technologies available.
You can check out the arguments regarding efficacy in Pneumonia, and the references, at one of my recent posts: Coca Leaf, Cannabis, Consumption, Pneumonia & HIV/Aids
But wait – Bill & Melinda are focused on sick children in poor countries where there often is no technology, and where the antibiotics are primitive and limited, and anti-viral treatments (which Bill & Melinda don’t seem to have as a priority) are likely to be unavailable. So why not give at least some thought to the contribution that a simple, natural medicinal plant could make in many of those 1.2 Million children who are dying every year in God-forsaken places of the earth.
The answer is easy. Because that particular idea doesn’t fit into one of Bill & Melinda’s three little boxes. Well, hell, even with their zillions of dollars Bill & Melinda can’t be expected to fund every Bold and Innovative idea that comes along, even really, really simple and inexpensive ideas that could easily make a difference in the life or death of millions of people every year – not just children, but the elderly, who are the group most at risk next to young children, and many, many others.
Now, I may sound like I disrespect Bill & Melinda, but I don’t. They at least give the appearance of trying to make a positive difference in the world, and they actually do some good work. I guess what I do disrespect, and resent, is self-anointed big shots and their sycophants who toss around words like “Bold” and “Innovative” and then turn out to be interested only in the sound of their own voices, praising themselves for qualities of mind and imagination that, upon close inspection, they so clearly do not have.
So what would I do if I had even a tiny fraction of your resources, Bill & Melinda?
If I had $100,000 available to me to address the terrible issue of Pneumonia (and not just in children), here is what I would do.
I would go to Peru, and probably also Bolivia, and network with doctors and indigenous healers who already know how to treat respiratory disease (not just Pneumonia) with Coca Leaf. I would find out from them how they use Coca Leaf – as a tea, or as a tonic, or a syrup, or a lozenge, or perhaps in other ways like a solution in a vaporizer or nebulizer. I would interview these people and document the interviews on video, and I would post these videos where the world could have access to them. My good friends at Wiracocha have offered to introduce me to their extensive Peruvian network of indigenous healers, shamans, and natural medicine practitioners, so I wouldn’t simply be wandering around the mountains looking for people to interview.
Then I would use some of the money to fund one or more small but first-class and methodologically sound studies in Peru – and, again, probably Bolivia – comparing the efficacy and safety of Coca Leaf treatments of comparable respiratory disease in every age group. With credentialed scientific and medical people, as well as respected indigenous healers, as authors of the findings these results would find a peer-reviewed journal where they could be published.
Finally I would work with Peruvian and Bolivian food chemists to investigate how to make tonics and syrups and other medicinal Coca Leaf products that would be highly palatable, especially to children, and would be shelf-stable for long periods without refrigeration, and that could be manufactured inexpensively using all-natural ingredients.
And finally I would work with the Governments of Peru and Bolivia and with the leadership of the indigenous Coca-producing communities in both countries to ensure that these Coca leaf medicines would be readily available to Pneumonia patients in any country that would allow them – and I would work to ensure that any country that denied access to these Coca Leaf treatments for its people with Pneumonia and other respiratory diseases – was prominently and endlessly shamed in public for their callous disregard for human life.
Oh, and let’s not forget, as I mentioned earlier, that this simple treatment might very well also benefit people with Asthma, Obesity, Chronic Fatigue Syndrome, Myalgic Encephalomyelitis, Congestive Heart Failure, Depression, and possibly Alzheimer’s – among other scourges of humankind.
All for $100,000 to prove ( actually re-introduce the concept to this generation’s medical community) the concept and then perhaps $1 Million to see it rolled out to clinics and treatment centers in whatever countries would accept them.
Is that Bold and Innovative enough for you, Bill & Melinda?
I didn’t think so. I think I’ll just put this project up on a CrowdFunding website and see if there are some people out there who are actually willing to support real, simple, bold, innovative and almost certainly effective solutions that don’t necessarily have to fit into some tiny, pre-designed little box.
In the meanwhile, dear reader, you can use the “donate” button on this blog to let me know that you support this idea. You can also contact me at firstname.lastname@example.org if you know of any sources of potential support for this project.
And good luck with those Grand Challenges, Bill & Melinda, which in truth seem more like Grand Standing to me. But hey, you’re rich and famous, and surrounded by high-priced experts, so what the hell do I know?