Global Health Challenges & Personalised Medicine Antoni Plasència, MD, MPH, PhD

1. Global Health Challenges & Personalised Medicine Antoni Plasència, MD, MPH, PhD Deputy Director (antoni.plasencia@cresib.cat) Parlament de Catalunya. October 23, 2012 Leading research at:

3. Leading research at: Multidisciplinary and translational health research

4. Leading research at: Mission: “To improve global health through research and training”

5. Our Global Presence Leading research at: collaborations with more than 100 institutions from 40 countries in the five continents.

6. Leading research at: A Centre committed to translate research into action

7. Leading research at: Outline • The Global Health vision • Progress & Challenges in GH • The role of research in GH • The potential for personalised medicine • Why GH R & D in H2020? • Concluding remarks

8. The Global HealthVision Global Healthis «PublicHealthwithoutborders» • Better health for all –particular attention to the needs of the most vulnerable; health as a human right • Global perspective on scientific inquiry and on the translation of knowledge into practice • Scientific approach to health promotion and disease prevention, examining broad determinants of health, including, but not limited to, medical care • Interdisciplinary approach and collaborative team work- population problems analyses • Multilevel systems-based interventions: society, governance, corporate responsibility, environmental, behavioural and biological risk factors • Comprehensive frameworks for financing and structuring health policies and services supporting community-based and clinical prevention integrated with health-care delivery Adaptedfrom : Fried LP, Bentley ME, Buekens P, Burke DS, Frenk JL, Klag MJ, Spencer HC. Lancet 2010; 375: 535-37.

9. Leading research at:

10. Leading research at: Global health: A majorchallengefacinghumanity Closingtheunnaceptablehealthequity gap: Thattoday, in thetwenty- firstcentury, yourlifeexpectancyisdeterminedbywhereyou are born

11. Gapminder

12. Leading research at: Theworld in the mid-20th century

13. Leading research at: Theworld at theend of the 20th century

14. Leading research at:

15. Leading research at: Under-five year mortality by World Region 1955-1999 300 250 200 Africa 150 Under-five mortality rate (per 1000 live births) S E Asia E Med 100 W Pacific 50 Europe Americas 0 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99 Estimate at five-year intervals

16. Leading research at: A prodigious century • Smallpox eradication • Not far from polio and measles eradication • Decreasing overall mortality • Life-expectancy at birth has increased by a mean of 25 years • Mean individual wealth has increased like never before • Technology revolution

17. Leading research at: A prodigious century ? • About 1200 million people, 1/5 of the world population, lives with less than 1 dollar /day • Communicable diseases continue to cause 59% of deaths and 64% of DALYs lost among the poorest 20% of the world population

18. “The biggest problem facing humanity in this century is that of poverty“. World Bank, 2001 Percentage population living on less than $1.25 per day 2009.

19. Leading research at: “Little imaginationisrequiredtovisualisethegreatincrease in theproduction of food and rawmaterials, thestimulustoworldtrade, and abovealltheimprovement in living conditions, withconsequent social and cultural advances, thatwouldresultfromtheconquest of tropical diseases”. General George C. Marshall, US Secretary of State, OpeningAddresstothe 4th International Congresseson Tropical Medicine and Malaria (Washington, DC, May 1948)

20. Epidemiologic & behavioral transition: growing burden of NCD on top of the ongoing hazards of undernutrition and CD (1/3)

21. RF largely amenable to environmental interventions

22. (Lack of) equity in theprovision of servicesand global health

23. The role of research in global health

24. Leading research at: The role of research in global health • If used more widely, existing medicines and prevention tools for these diseases could save millions of lives - however none of them can completely eliminate HIV/AIDS, TB or malaria. • Research and development into new drugs, vaccines and commodities is a crucial component for building up effective ammunition against diseases that keep people in poverty • Of the 1233 new drugs that reached the market between 1975 and 1997, only 13 were for tropical diseases that primarily affect the poorest

25. The “10/90 gap”… • Since its foundation in 1998, the Global Forum advocated effectively around the “10/90 gap”… • In the meantime, the landscape of health research for development has changed in important ways: • global expenditure on health research has more than quadrupled to over US$ 125 billion in 2003 (US$ 160.3 billion in 2005); • there are many more actors engaged in funding or conducting health research relevant to the needs of low- and middle-income country populations; • but the epidemiology of diseases has shifted substantially, so that many low- and middle-income countries are now experiencing high burdens of injuries and noncommunicable diseases such as cancer, diabetes, heart disease and stroke, as well as continuing high burdens of infectious diseases. Investment studies by the Global Forum for Health Research continue to demonstrate that health research applied to the needs of low- and middle-income countries remains grossly underressourced in many areas and the term “10/90 gap”, while not representing a current quantitative measure, has become a symbol of the continuing mismatch between needs and investments.

26. Leading research at: Potential for Personalized Medicine in Global Health ? We are much more genetically similar than different, but… generalizability of findings? The end of the “one-size-fits-all” approach? Early development stage Evidence-based medicine and comparative effectiveness research Real benefits for LMIC populations?

27. Leading research at: Role of Personalized Medicine Research in Global Health ? • Betterortargetedinterventions? (vaccinesordrugs) • Diagnostic, screeningorpredictivetests? • Needforinstalledresearch and carecapacities (laboratorygenomics, biobanks, epidemiologiccohortstudies, clinicalstudies, RCT, gene-basedtechnologies, etc.) • Collaborativeresearchinvolvinginvestigatorsfrom LMIC and HIC, includingmultidisciplinarypartnerships • Needfor training and education of theworkforce • Ethical and legal frameworks • Equity (of access) From: Khoury MJ. Current Pharmacogenomics and Personalized Medicine 2009;7:158-163.

28. Leading research at: Personalized Medicine in LMIC: a priority ? • Most of the targets for public health interventions will be on the environmental side (including economic, social & political) • Predominance of risk factors that are amenable to environmental modification • Important challenges to equitable provision of health services • Global justice and human rights approach « A major challenge is to generate an evidence base that can demonstrate that a genomics approach is at least as safe, effective and cost-effective in these settings, as other more traditional approaches, such as modifying environmental o social determinants.» From: Burke W et al. Genetics in Medicine 2010;12:785-791 • Areaswithclearlyestablishedevidence of clinicalutility(prenatal/neonatal detection of certaininheriteddiseases) • Areaswithlow-costsolutionsavailable (more systematic use of familyhistoryinformation) • Areaswithscopefor target innovativetechnicalsolutions(prevalentinfestiousdiseases)

29. Leading research at: Need for a public health genomics approach(for all countries) • Select evidence-based applications • Maximizing health benefits and reduce inequities • Reducing harms and unnecessary health care expenditures (premature or inappropriate use) • Evaluating public health interventions • Fostering capacity building in research and clinical care

30. Research centers as a developmentstrategy Programa de colaboración Ministerio da Saude - Faculdade de Medicina (UEM) Fundacio Clinic de Barcelona – Agencia Española de Cooperación Internacional

31. Poverty-related and neglected diseases (PRNDs) in the next Research Framework program (HORIZON 2020) • Market forces alone will not lead to the development of sufficient, affordable, and appropriate new technologies and goods for these diseases. Public support and public financing are required when public goods are under-supplied by the market. • Horizon 2020 presents an opportunity for the European Union (EU) to step in as a leader in addressing this market failure and stimulate innovation. • Crucial need to raise awareness and mobilise MEPs and EU policy makers on the crucial need for stronger EU investment and commitment (both political and financial) to the fight against PRNDs through R&D tools in the Horizon 2020 package. • to educate MEPs and EU policy makers on the cost-effectiveness of investing in R&D for global health and how it can strengthen and boost Europe’s Research leadership

32. Why Global Health R & D in H2020?Summary of Key Reasons Leading research at: • Strengthening the EU’s economy through support for a key but challenged area of European innovation • Providing competitive advantage for European industry and research • Improving health for Europeans and globally, with resulting positive effects on health systems, employment and global health security • Sustaining EU credibility with regard to commitments made across a range of EU policies, including those on health, economic growth, social inclusion and development • Facilitating global health and science diplomacy, knowledge sharing and common solutions to problems

33. Leading research at: “Who indeed could afford to ignore science today? At every turn we have to seek its aid... the future belongs to science and those who make friends with science.” JawaharlalNehru India’sfirst Prime Minister(1889 - 1964)

34. Thank you! La statue du Passe muraille, réalisée par Jean Marais en 1989. Place Marcel Aymé, Paris.  

35. www.cresib.cat www.isglobal.org Leading research at:

38. ThePublicHealthPyramid From: Frieden TR. Am J Public Health 2010 ;100:590–595.