PoliticalSpeak: DMTs in resource-poor environments

How do we get MS up the agenda in resource poor environments? #PoliticalSpeak #MSBlog #OffLabel

“Just back from a whirlwind trip to Peru, where MS is classified as a rare disease. Several neurologists spoke to me about the difficulty they have with access to treatments, particularly the more effective high-cost treatments. It reconfirms what we know already that MS is considered a rich world disease and is simply off the agenda in countries such as Peru, which is classified by the World Bank as an upper middle income country.”

“On reading this week’s NEJM the perspective article below summarises all the issues we have in terms of getting MSers in resource poor countries MS services, only it is written from an oncology perspective. Simply replace the word cancer with MS, oncologist with neurologist, pathology with MRI scanners and you will see what I mean. What can we do to help? Is our essential off-label MS DMT list sufficient? Far from it, I now realise the list as simply being an intellectual exercise to alleviate my guilt; my guilt of inactivity. What is ultimately required is not just academic ivory tower posturing and research, but activism and political will.”

Satish Gopal. Perspective: Moonshot to Malawi. N Engl J Med 2016; 374:1604-1605


….. In his 2016 State of the Union address, President Barack Obama called for a “moonshot” to cure cancer…. 

….. Drug-approval times have been shrinking, and the embarrassment of riches has renewed the focus on defining the proper sequence and combination of therapies in this field. In some instances, in fact, we have so many established or promising agents that we really don’t know what to do with them all…..

…… These advances are exhilarating not only for scientists but also for society….

…… But I now live in Malawi, a small, resource-limited country in southern Africa with a population of 17 million. From here, it can be difficult to appreciate the tangible fruits of a decades-long international war on cancer. Despite small daily victories and immense heroism on the part of patients and their families, the situation here reflects an abject failure of the worldwide cancer community. The neglect spans the continuum from awareness to prevention, diagnosis, treatment, and palliation……

…… To my constant surprise, I am often asked by clinicians, researchers, funders, and policymakers whether people get cancer in Malawi. They certainly do, as our clinics clearly attest, and the burden is rapidly increasing owing to the growth and aging of the population, as well as to the human immunodeficiency virus (HIV). Public-sector provision of antiretroviral therapy (ART) began in Malawi in 2004, and the HIV prevalence in the country is now 10%, with 67% ART coverage….. 

…… No diagnostic pathology services existed in Lilongwe, Malawi’s capital and home to more than 1 million people, until 2011, when the University of North Carolina helped the Ministry of Health build and staff a pathology laboratory…. 

…… In terms of treatment, no radiotherapy is available, and despite repeated demonstrations that cancer can be cured even here if old drugs are consistently available and properly used, we routinely stock out of generic chemotherapy medicines that were licensed in the 1960s or 1970s. There is no broad mechanism, like that in place for HIV, to ensure sustained, reliable access to either old chemotherapy medicines or newer, noncytotoxic, standard-of-care agents. Finally, palliative care often amounts to little more than a few doses of morphine that are woefully inadequate for alleviating symptoms…..

…… I find it unacceptable that the most basic, decades-old elements of oncology care are absent in Malawi, while cancer-related expenditures are skyrocketing in other parts of the world to levels that are unsustainable even in high-income countries. Allowing such disparities to persist is an ethical choice……

….. But funding cancer programs solely through research grants can have distorting effects on agendas, skewing activities toward the production of research articles rather than effective treatment or palliation for patients. “Scholarship” can sometimes amount to little more than repeated recitations of the challenges faced or shipping of tumor tissue to international laboratories for assays with little immediate relevance to local populations; however important they may be, mechanistic insights will not benefit Malawians in the short or medium term if medicines against “druggable” targets remain unavailable and the supply of even very old drugs is inconsistent. It is incumbent on us as a scientific community to generate not just citations but better outcomes for the poorest patients in the world……

……. Moreover, clinicians and scientists are not enough. Science was essential but insufficient to catalyze the international movement that transformed HIV from an existential threat in sub-Saharan African countries to a prototypical global health success story. What was ultimately required was not just research but broad civil-society activism and political will. Malawians with HIV can now live normal lives, for which we thank protesters who stormed international meetings over many decades to demand action. A similar energy now drives our moonshot dreams for cancer, but I believe we must also commit ourselves to expending a small fraction of that energy to control cancer, using proven methods, in places like Malawi. Shooting for the moon is important, but so is shooting for a world that is just and equitable……

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • Love the moonshot image…

    I dont have an answer. I wish I did. Global healthcare is a trainwreck when it comes to chronic disease or for that matter quite a bit that is not chronic.

    There is the political, geo-political, monetary not to mention the moral implications and complications globally.

    From what you have stated past India which has some 100,000 cases of MS has citizens also unable to get access.

    If Meds even off label and cost effective are placed into the hands of those in need then the people/businesses where costs skyrocket will get all concerned about their profits. If someone in Peru gets Cladribine for $100 a month lets say and its effective then others will surely scream "Why is this $50,000 here" and without the profits what drives research might come into question.

    The only forward solutions I can think of need revolve around give and take, mutually beneficial relationships and without doubt due to geopolitical diatribe would be far more complex than need be.

    People helping people. As your "Economist Espresso" stated:

    "It was not by gold or by silver, but by labour, that all wealth of the world was originally purchased"

    A global consortium of people and businesses that could buy DMT's in bulk that can be purposed towards the world ill able to afford would be a solution. Administered by some governmental or preferably not for profit entity and preferably at cost of goods. Many nations have nationalized care systems that barter for the meds. Something similar perhaps but with help in funding.

    People value money more than they value the stranger which in turn makes such individuals stranger than the perception of value to money… if that makes sense? I have MS 🙂

    History comes to mind… perhaps had colonialism been able to reach a logical albeit perhaps messy march towards the future equal access might exist? Probably not.

    You should not however feel guilty Prof. G. You did not create MS and you work tirelessly to end it. The fact you are a humanitarian and a man of science who takes what he see's outside in others and brings that inside to self means so very much to so many of us. Those of us who know something of you and millions that do not.

    God Bless You.

  • When we cure MS in the first world, then we can work on equal access. Like they say on the plane, put your own mask on first before assisting others.

  • Maybe we should work on generic cladribine. This could be achieved with abit of action by the msif. Set up a trial and give people access to treatment.won't happen because they are too afraid of pharma.

    • What HSCT centers..? There are only like 10 in the entire world.
      None in Africa or South America.
      And then the shortest time to treatment is one year wait.

    • There are many more HSCT centres that perform HSCT for cancers. I think you are referring to HSCT centres that perform HSCT for autoimmune diseases. As far as using established HSCT centres to administer treatments to MS patients – it would depend on the regulatory framework on off label treatments in each host country.


    • Interesting idea MouseDoc. Unlikely any patient association or connectee (<- New MS Word) would engage trials. But what about some of the universities? Or sized hospital systems w/ MS Centers?

      You folks already have laid all the groundwork and have data.

      I might know three entities be interested but rather dont know as the political landscape of MS is still vague to us.

      There are also smaller Pharma co's like Innate Immuno and many many others?

  • MD, Prof. G and DRK I will be resending an email to the Brazilian Association of Multiple Sclerosis (ABEM) on the health initiative MSBrain Health and the possibility of adopting in the country the use of Cladribine as an alternative to the shortage of DMTs in many cities.
    I hope that soon they get in touch with you as we face here in Brazil found similar problems in Peru.

By Prof G



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