Gates Foundation Health Chief on Coaxing Pharma to Do Good

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it validates the question of whether we should be investing in a malaria vaccine at all. Yes, we should. If you have a good vaccine, it will make a huge difference. It will be bigger than most malaria drugs because of the way of delivering them.

X: What kinds of things have you stopped doing because of this portfolio approach?

TM: You have to ask ‘what do you know?’ A lot of things are speculative. A vaccine for malaria or HIV, these are unknown things. Everything is contrasted now with known things like bednets for malaria. There’s male surgical circumcision for HIV, which is actually cost-effective, because you avert hospitalizations and opportunistic infections. The question for any new thing that comes in is ‘should we rather be investing in the third bednet, or male surgical circumcision?’ There’s an alternative thing we could do with the resources.

I should tell you the other dimension on this matrix, as it is probability of technical and regulatory success. That’s kind of essential. Anybody who wants to formulate a great value will get huge value [in the portfolio matrix], but if the probability of success is incredibly low, then we should be skeptical of that. In biotech or pharma, you can easily spend for 10 years and get nothing. So you need to have some balance.

For example, look at visceral leishmaniasis in northern India and some parts of East Africa. We’ve looked hard at what kind of vaccine would be needed, and the likelihood we’d get a vaccine. We’ve shifted into a much earlier research space with those vaccines. And drugs are also very tough for that. So we refocused our efforts there on vector control, and away from drugs and vaccines. It’s because vector control has been proven to work, and it’s here and now.

I don’t want to give the impression that we use this system rigidly, because the uncertainty around these things is considerable. It brings me to the second set of things I wanted to mention related to this matrix.

To do it, you have to actually know the state of the world. Our way had been through IHME, the Institute for Health Metrics and Evaluation—Chris Murray’s group at the University of Washington. They published the 2010 Global Burden of Disease (GBD) report last year. It is great. It’s the first time there’s been this total accumulation, trying to fit everything—all the deaths from important conditions—into a single envelope about everyone who dies on the planet. It’s a fantastic enterprise. They have got the biggest analytic capacity of anybody in the world addressing burden of disease globally. The problem is it publishes every couple of years. It’s every decade for the full thing, with some updates on particular topics every couple of years. That’s too infrequent to drive real measurement. At the end of the day, we’d like to be able to say this malaria intervention is effective, because we’ve seen the burden of malaria drop year by year in the region we’re working in. But there’s no way the data can support that now. So we’ve invested in the GBD 2.0, which is to bring them online in real-time. When new data sets come in, we want that whole GBD recalculated on the fly, without waiting a couple years.

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