It is well recognized that in the conventional medical practice, the process does not work effectively if the doctors are treating patients like shooting in the dark. It is always important to identify the disease problem before embarking to the treatment process. This process of knowing what might be the disease and its cause, is called Diagnosis. Diagnosis, as Pai Madukar like many other global health experts mentions in his Forbes article, has been neglected for many years as if it was not important then not worth investing in as a health system. That is why we have been having for instance the WHO essential drug list from decades ago and waited for very long to have a list of essential diagnostic tests. Today diagnostics can be discussed with a little more precaution than when discussing drugs. This is because when you talk about diagnostics, it is well clear to understand the role of other factors such as infrastructure and training than when you discuss drugs. You can easily deploy a new drug to a new place, but you cannot just deploy a new diagnostic method to a new place if you do not take enough consideration of other factors that in the eyes of many do not sound relevant or worth bringing to the table of discussion.
The gaps in diagnostics cannot be seen as a new challenge to the developing and developed world. This has been well highlighted even before, mainly during global health issues such as HIV/AIDS, Malaria and tuberculosis. Most of us are familiar with the 90/90/90 roadmap of the UNAIDS and other partnering institutions. The ideas behind this policy were put together by statisticians who were able to convince the world that we can eliminate HIV despite the challenge of having no cure yet, if we make sure that 90% of the HIV positive population know their status, of whom 90% have access to viral load suppressing treatment, and of whom 90% successfully get a viral load that is lower than detectable. If this is possible, then HIV can be eliminated after a certain time that can be predicted if all assumptions remain true such as not transmitting HIV once you have undetectable viral load. But this means just one thing: A strong diagnostic capacity. Since this beautiful idea has been agreed upon, we have not seen much going on in availing needed diagnostic capacity even much has been done so far in availing treatment capacity. This can remain subject to argument. The big question here is, why treatment and why not diagnostic first? The answer is simple: Neglect.
Speculations can be made around this remarkable neglect in the world of diagnostics. Either it is that it does not present a good business opportunity or whether it does not present pressure to systems since these systems have ways to go around it and achieve part of what they call success in disease control. I do not want to bring back the old debate about “prevention or cure” but I would like to argue that the issue is both. Some time back, it has been argued whether countries should focus on disease prevention or whether they should focus on disease treatment. The same debate was a big deal in the big world institutions such as World Bank whether financing primary health care is necessary even in countries that present low economy back then. That is why, the World Bank during round the 70s, and even now there is a limit to how much dollars a country should invest in the health of its population based on its GDP. This poses a tradeoff to what needs to be funded versus what needs to be ignored, at least for a while.
Now, we have 3 competing priorities:
preventive measures such as vaccines and others,
diagnostic capacity that includes methods most of which rely on the current infrastructure and personnel,
treatment interventions such as drugs which may only be relying on predeveloped treatment protocols that require simple adoption process by countries.
With this, it is paramount to recognize that most of the decisions must be taken by individuals who do not need to necessarily understand how these things work. It is obvious in developing and developed countries that the most priority be posed by treatment interventions not simply because these are not more expensive than the rest but because they solve a problem which is easy to measure and they give results which are easy to measure as well. Prevention success is hard to measure and diagnostic capacity outcome is always looked at less going for, since for most disease conditions, you diagnose many and you find less with the disease of interest.
Today we can learn a lesson thanks to COVID19. It is starting to be clear that the more you have working diagnostic system, the more prone you are to be successful in managing an outbreak. Let’s look at countries that are affected the most so far and try to discern what they have in common and what their differences are. Looking at the attached graph, the countries which started early mass testing have experienced remarkably reduced numbers of deaths.
It can be deduced from the available data that the earlier these countries are able to diagnose, the more people are diagnosed per week, the less threatening this pandemic becomes. This can be confirmed by many other disease conditions such as HIV, TB, and most types of cancers. The impact of HIV reduces as the condition is earlier diagnosed. The same with Tuberculosis. For this to happen, infrastructural capacity development should start earlier than the pandemic.
And as we build the infrastructures, we should not look at one disease condition but rather use the integration approach as we design, plan, implement and even evaluate any diagnosis capacity development project. “The infrastructure countries have put in place for TB has dual-use purposes for addressing other respiratory diseases. Health workers trained to respond to TB understand infection control, contact tracing and other measures we need for ending the COVID-19 pandemic. The diagnostic platforms widely used for TB in developing countries, called GeneXpert, can now be used to test for COVID,” said Jose Luis Castro, Director of the International Union Against Tuberculosis and Lung Disease.
By Jean Pierre Musabyimana
Biologist and Global Health activists