Marcel Tanner ~ Full interview

Director of the Swiss Tropical Institute in Basel

1.  What are in your view the most urgent problems in the field of health?

In the field of global health the problem is not so much one single specific disease but the health systems that can not cope with the disease problems that we face in different areas of the world. Now the biggest problem is not the focus on one or the other disease, but that we have weak systems. That is actually in global health and health development one of the most urgent problems that we have to tackle.

Nowadays, within each country we have certain health systems. By health systems I do not distinguish between the public or the private. I mean all partners contributing to better health. So it is the public, traditional, private and charitable system as well as civil society. This is where we see the mismatch. Poor health systems do not recognize the disease problems. Sometimes it is because they are not very well developed or on the periphery. Or there is no good collaboration between the different service providers.

So it is not only a question of money. The different health systems of our world are faced with many differing problems. If you look carefully at health systems in the world you see relatively rich countries that have poorly performing systems. Like the US that is investing quite a lot of the GDP into health, but the system is not performing very well. Indicators such as mortality rate and lower life expectancy are for some areas of society similar to those in developing countries.

It is not only the organisation of a health system that is responsible for identifying priorities, allocating resources and really pursuing the implementation of health plans. It is also the structural and functional status of health systems which I think are the most critical issues of this world.

2.  What kind of solutions do you see?

One of the solutions is to introduce a more systematic approach. In health planning many people are focusing on an epidemiological approach by looking which are the most important diseases. It is important that we tackle pandemics like HIV, but if you tackle it in a mechanistic, ‘magic bullet’ approach, then you will not succeed if you do not have a system to carry it through.

An important problem of weak health systems is the human resources. If you really look at for instance the Millennium Development Goals, where everybody is focusing on 2015, and you calculate what you need in terms of people working in the health sector on different levels (medical doctors, directors, etcetera) you will find that most countries have substantial deficiencies in human resources - preventing them from reaching these noble goals. So, even the best plans will not work when human resources are not available.

3.  What in your view are the necessary conditions for successful solutions?

The necessary condition is to have a comprehensive approach to health and disease, and health and wellbeing. Too many countries are very much focused on disease problems as a means of achieving good health and less on health systems that can provide the available tools like vaccination for the population. It is a paradigm shift that I will explain to you with a very simple comparison. Too many people talk about ‘magic bullets’ to treat diseases. What you need is the magic gun. And the magic gun is a functional health system. If you want to have long term success, this change is necessary.

Short term success by way of reducing a disease, having an impact through prevention, that is always possible. But it is not a recipe for the long term success of a system that cares for the health and well being of a population.

4.  If you would set short term goals, which goals would you set?

Assure that in each geographical setting (north, south, west, east) that the health system can deal with basic treatment and prevention. Emphasise vaccination to ensure treatment at the centre and at the periphery. You will not get the commitment of a population if you work for health issues on the long term, whilst ignoring the immediate, basic needs. If your emergency system does not work, if the vaccination for the children is not working, you can never achieve desired goals in the long term.

Vaccination is one of the most important basic needs on the prevention side. On the treatment side we are turning back to what we tried in many resource poor countries: to formulate essential programmes, so that at the peripheral health facilities you can diagnose and treat a common disease pattern. That is very important and these systems have broken down in many countries where minimal essential treatment kits disappeared from the periphery and can only be found in central health units. By reinstalling these basic, minimal essential kits common disease problems can be diagnosed and cured.

5.  Can biotechnology play any role in these solutions and problems you just mentioned?

Biotechnology can play an important role. But not with the single philosophy that biotechnology will be that magic bullet. You still need the magic gun, the health system. Biotechnology can play an important role, particularly on the diagnostic front for instance, at the site of care diagnostics. Biotechnology can do a lot of good.

For example, a big diagnostic problem in many countries is to distinguish the origin of different fevers. Because many viral infections spread to new areas. We have to make the right diagnosis at an early stage; for example with stick-tests at the point of care. Such rapid diagnostic tests are very important for rapid and correct diagnosis and care. Even if you have no treatment for a particular disease you must exclude some diseases.

6.  Do you think biotechnology solutions should be placed higher on the agenda?

In some circles biotechnology is rated high. I think you can only look to biotechnology in specific situations. In resource poor settings the biotechnology from the peripheral point of care, diagnostic for an example is absolutely crucial and should have a very high priority. We should not forget our systematic approach, this would be totally wrong.

With regard to diseases of poverty, for a large majority of our world there is still not enough investment, because it is not profitable for companies. That is the sad situation. But companies may underestimate the value of a new point of care such as HIV resistance testing for instance. We treat thousands, even millions of people but we should monitor the behaviour of the virus and resistance development and we really need the technology to do this. Not in the university hospital but at the point of care where we have to ensure regular, continuous treatment.

Companies do not realise, that although patients won’t buy these expensive drugs, nowadays there are large global initiatives that could buy or subsidize the development of treatments for diseases of poverty. Companies could actually get good returns on investment. This thinking has not yet sunk in.

We can promote this thinking by getting it on the international agenda, bring it into the circles including the WHO (World Health Organisation), PDP (new Product Development Partnerships) or charities like the Bill & Melinda Gates Foundation. There are now many players for investments into health.

7.  What in your view will the field of health look like in 20 years?

We will have an important moment in 2015 when we discuss whether we have achieved the millennium goals. I fear we will realize that in many countries we have not reached these goals because the systematic approach was or is lacking. If you have only the technological developments you will not really make big steps. You will have isolated wonderful solutions, but not the systematic approach that really will help improving health in a sustainable way.

8.  If we talk about biotechnological solutions, do you think there will be public debate about this?

There must be a public debate about how sick our health systems are. You will see that technology has an important role to play in fixing health systems. But it is not just adding a little bit but really doing this in a comprehensive way. And not only with the people who invent technologies, but also with the users.

9.  Do you have any other remarks that you like to add to this subject?

My important point is that we have a fragmented approach to health and well being. We made good, secure steps, but never made progress in reducing inequalities in quality of life. Good health systems not only have medical components, but have equally strong social, cultural and economic components.