This week at the World Health Assembly in Geneva, WHO member states are debating how to strengthen the global pharmaceutical R&D system to better meet needs in low- and middle-income countries.  Last November, governments agreed to establish a set of “demonstration projects” to test out the recommendations of a WHO expert group on how to develop more affordable, adapted medicines to address long-neglected health needs. But it remains unclear what exactly these demonstration projects should be and what they should demonstrate. A key principle is that these projects are not just pilots – they should also demonstrate new mechanisms, principles or approaches.

We should not waste precious time and money demonstrating again what the past decade has already shown. For example, we have seen that increased public and philanthropic funding can fill pipelines with candidate technologies and bring improved products to market. We have seen that not-for-profit product development partnerships can develop such improved products at relatively low-cost.  We have seen that creative approaches to managing intellectual property can reduce barriers to research and competitive drug production.  And we have seen that governments can pool their funding and jointly decide to invest in R&D (as with HIV diagnostics), and create additional market pull by financing commodity purchases (as with pediatric HIV medicines and pneumococcal vaccines). Finally, there is a long history of collaboration and capacity building between scientists from the North and South, including for basic research and clinical trials. These are all important advances for global health R&D and should be supported, but they are not sufficient.

So, what does need to be demonstrated? Attention is needed in at least two areas: new approaches to financing and to governance.

Both “push” and “pull” mechanisms have long been used in traditional approaches to R&D. One promising new approach is “open knowledge innovation,” in which a wide community of contributors works toward a shared goal, research results are rapidly shared, and access to the benefits of new knowledge are widely available. While two projects have demonstrated promise and some success with this model, many questions still need to be answered about when, where and how it could work best to lower costs and accelerate innovation. Push financing should be dedicated to testing open knowledge innovation approaches.

In terms of pull mechanisms, an important proposal to test is awarding milestone or end prizes to incentivize the development of a specific product, in exchange for monopoly rights such as those provided by patents. A key benefit of this approach would be lower prices for medicines, since competitive production could begin immediately. The size of the prize could be determined by the value of the invention, including the expected magnitude of the public health contribution, the expected cost of R&D, how well it meets the target product profile, or other factors.

Finally, new approaches to governing the global R&D system are needed, including better information on inputs, processes and outputs; better coordination and priority-setting; and reliable financing.

Governments should not squander this unprecedented opportunity to test new approaches to investing in, incentivizing and governing needs-based innovation for health.

Suerie Moon is Research Director and Co-Chair of the Forum on Global Governance for Health at the Harvard Global Health Institute. John-Arne Røttingen was the chair of the WHO Consultative Expert Working Group on Research and Development, and is Visiting Professor at the Harvard School of Public Health.

Potential competing interests: SM is a member of the Board of Directors of the Drugs for Neglected Diseases initiative-North America, consultant to the Medicines Patent Pool, and a member of the UNITAID Proposal Review Committee. JAR is the Chair of the Board of the Alliance for Health Policy and Systems Research and member of the Scientific Oversight Group of Institute for Health Metrics and Evaluation.

van de Weg CAM, Pannuti CS, de Araújo ESA, van den Ham H-J, Andeweg AC, et al. (2013) Microbial Translocation Is Associated with Extensive Immune Activation in Dengue Virus Infected Patients with Severe Disease. PLoS Negl Trop Dis 7(5): e2236. doi:10.1371/journal.pntd.0002236

This Week in PLOS Pathogens:

Wild plants interact with many other living entities such as animals, insects, other plants, as well as their physical environment. They are also often colonized by many microbes, including fungi, bacteria and viruses. In this Pearl, Dr. Marilyn Roossinck discusses plant-virus biodiversity, how plant viruses impact species invasion, interactions between plants, viruses and insects, and mutualistic viruses of plants.

Immunocompromised individuals tend to suffer from influenza longer with more serious complications than healthy patients yet little is known about the impact of prolonged infection and the efficacy of antiviral therapy in these patients. By developing an immunocompromised ferret model, Dr. Erhard van der Vries and colleagues mimicked an immune suppressive regimen for solid organ transplant recipients which provides a useful tool in the development of novel antiviral approaches.

Malaria parasites kill up to a million people around the world every year, yet emergence of resistance to drugs remains a key obstacle against elimination of malaria. Dr. Jennifer Guler and colleagues reveal a population-based genomic strategy for mutagenesis that operates in human stages of P. falciparum to efficiently yield resistance-causing genetic changes at the correct locus in a successful parasite.

This Week in PLOS NTD:

Approximately 680 million people worldwide are at risk of infection with food-borne trematodes, including Opisthorchis viverrini (OV) that was suspected of significantly contributing to kidney pathology, plus bile duct fibrosis and cancer in humans. Detailed in this paper, Dr. Prasert Saichua and colleagues confirm the link between OV and these conditions, pointing out the need for a urine-based assay that could indicate both renal and bile duct pathology from OV infection.

Sand fly saliva contains different potent, biologically active proteins that can either induce host antibody production to protect against cutaneous leishmaniasis or exacerbate an infection. In this article, Dr. Tatiana de Moura and colleagues outline their work to identify and catalog the secreted proteins of sand fly saliva, including the isolation of one protein form Lu. intermedia that protects mice against Leishmania braziliensis infection.

The pathogenesis of severe dengue virus (DENV) infections is still not fully understood, but the cause is hypothesized to be an immunostimulator lipopolysaccharide-promoted cytokine storm, as is described in severe sepsis. In this study Dr. Cornelia van de Weg and colleagues seek to confirm a previous finding that microbial translocation occurs in DENV infected patients, and discovered cytokines that may contribute significantly to the cytokine storm.

Image Credit: Mista Stagga Lee, flickr

In addition to strengthened background checks, one of the proposals in the failed measure was to establish a 12-member National Commission on Mass Violence to conduct a comprehensive factual study of incidents of mass violence. Interestingly, one of many areas that the commission would have been tasked with investigating was “the availability and nature of firearms, including the means of acquiring such firearms, and all positive and negative impacts of such availability and nature on incidents of mass violence or in preventing mass violence.”

Thanks to the twitter feed of Prof. Simon Chapman (the Keith Richards of Public Health minus the cigarettes etc.) I’ve been following a fascinating set of reports on this same question. While the topic of gun violence isn’t funny, arguments against gun control are increasingly incoherent and farcical, which is why the set of reports on gun control by comedian John Oliver for The Daily Show are some of the most informative reporting on gun control that I’ve seen. The advantage The Daily Show has over mainstream news is that as a satirical news show it does not feel obliged to offer the false balance of allowing firearm advocates to assess the evidence on the effectiveness of gun control measures without question.

In the first of three reports John Oliver interviews Philip van Cleave of the Virginia Citizens Defence League. This quote from Oliver sets the tone of the interview: “What if gun control could work? Which obviously it can’t, so we know that it won’t, so that’s not a problem. But what if it could, due to that time that it did … Australia.” It is easy to laugh at the hapless van Cleave, who, while struggling to respond to Oliver, tries to shrug off Australia’s gun control efforts by saying “woopty doo” and eventually outwits himself while trying to explain why there are high numbers of gun deaths in the United States.  However, Oliver’s Australian case study is an intriguing one because since 1996 when Australia’s Conservative Prime Minister, John Howard, introduced sweeping gun control laws in response to a mass shooting there have been no gun massacres; in the 18 years before 1996 there had been 13 mass shootings. The measures included a gun buyback scheme and the banning of semiautomatic long guns and pump-action shotguns, and Howard also explains to Oliver that the homicide rate involving guns have declined since 1996 along with the incidence of youth suicides.

In his report Oliver briefly flashes up a Harvard Bulletins report from 2011 which was produced by the Harvard Injury Control Centre and aimed to summarise the evidence on the effect of Australia’s gun buyback scheme in 1996.  The report highlights several articles, which support assertions that the buyback scheme reduced gun deaths, even though deaths due to firearms were already falling in the early 1990s. The report also highlights two articles that found little evidence for an effect of the law; the authors of the Harvard Bulletins report noted that the design of the two studies made it almost impossible to find an effect and one of the articles was authored by Australian gun lobby members. The report concludes that there are probably three reasons why gun buybacks in the United States have apparently been ineffective, that is the buybacks are relatively small in scale, guns are surrendered voluntarily, and so are not like the ones used in crime; and replacement guns are easy to obtain. More recently Simon Chapman and Philip Alpers have published an excellent opinion piece in the Annals of Internal Medicine discussing Australia’s efforts to control gun violence in light of the Sandy Hook Elementary School shootings in America.

In Oliver’s subsequent reports for The Daily Show he highlights that introducing gun control laws in Australia wasn’t straightforward because, like in the United States, there was substantial resistance to the measures. One of the key differences appears to be that Australian members of parliament, such as Rob Borbidge, were prepared to vote through legislation despite the negative impact that the legislation might have on their political careers. In contrast high profile lobby groups in the US, such as the National Rifle Association, would appear to have a disproportionate influence on the political debate in the United States.

Chapman and Alpers’ recent commentary was published before the vote on the Manchin-Toomey bill but ends optimistically. “Interventions similar in intent and design to those that successfully reduced the toll of guns on the lives of Australians may, perhaps, take hold in the United States.” Unfortunately, in light of the negative outcome of recent efforts to introduce gun control in the US this seems less likely. While this is a disappointing outcome the potential public health gains of controlling access to machines that are designed with the primary purpose of maiming and killing should ensure that gun control won’t fall off the political agenda in the US any time soon.

Image Credit: Flickr snre

The following new articles are published in PLOS Medicine this week:

Continuing with the series providing a global perspective on integrating mental health, Sylvia Kaaya and colleagues discuss the importance of integrating mental health interventions into HIV prevention and treatment platforms. Clinical depression, alcohol abuse, and HIV-associated neurocognitive disorders are highly prevalent in people living with HIV and have negative consequences for treatment outcomes and cost of care.

The prognosis and treatment for colorectal cancer depend on five pathological stages (0–IV), each of which has a different treatment option and five year survival rate. Pierre Laurent-Puig and colleagues present a novel transcriptome-based classification of colon cancer associated with prognosis that is based on molecular subtypes, clinical and pathological factors, and common DNA alterations. These findings could help classify colorectal cancer into six robust molecular subgroups that might help identify robust prognostic genetic signatures, new prognostic subgroups, and targets for future drug development.

Jennifer Yeh and colleagues examine how changes in Helicobacter pylori and smoking trends in the last few decades contribute to past and future incidence of gastric cancer (specifically intestinal-type noncardia gastric adenocarcinoma, NCGA). Combined with a fall in smoking rates, almost half of the observed fall in rates of intestinal-type NCGA cancer in US men between 1978 and 2008 was attributable to the decline in infection rates of H. pylori. The full benefits will take several decades to be realized, and further discouragement of smoking and reduction of H. pylori infection should be priorities for gastric cancer control.

David Sinclair and colleagues discuss their experience at the Ghana National Drugs Programme’s review of the international evidence base for five priority pediatric medicines. The authors report that applying the global recommendations to Ghana was not straightforward for any of the five medicines, despite evidence of important clinical benefits, because of the unproven effect of the drugs in African settings and the scant information on cost effectiveness and the supply chain. This project demonstrates why transparent information on the evidence supporting global recommendations on pediatric medicines should be easily accessible to policy makers.

Remember you can comment on, annotate and rate any PLOS Medicine article and see the views, citations and other indications of impact of an article on that articles metrics tab.

Mysore K, Flannery EM, Tomchaney M, Severson DW, Duman-Scheel M (2013) Disruption of Aedes aegypti Olfactory System Development through Chitosan/siRNA Nanoparticle Targeting of semaphorin-1a. PLoS Negl Trop Dis 7(5): e2215. doi:10.1371/journal.pntd.0002215

The following new articles are publishing in PLOS NTDs this week:

There is not yet a vaccine for schistosomiasis and treatment presently relies on a single drug, praziquantel, which has shown cases of reduced efficacy in certain areas, raising serious concerns about the need to develop a new therapy. In this paper, Dr. Mathieu Vanderstraete and colleagues have investigated the possibility of fighting Schistosoma mansoni by targeting key receptors involved in the parasite’s glucose uptake, metabolism and reproduction.

Closely related to tuberculosis, Mycobacterium africanum is less likely to stimulate the host immune system or progress to active disease. Here Dr. Florian Gehre and colleagues describe the fundamental genomic and phenotypic differences between M. tuberculosis and M. africanum to better understand the virulence mechanisms that make the former one of the most successful bacterial pathogens, and to discover potential strategies to interfere with mycobacterial pathogenicity.

Dr. Keshava Mysore and colleagues analyze development of the Aedes aegypti olfactory system, a tissue of vector importance which is critical for recognition of human blood meal hosts, among other essential behaviors. Utilizing small interfering RNAs (siRNAs) delivered through chitosan nanoparticle feedings to larvae to target the axon guidance gene semaphorin-1a (sema1a) a variety of larval and pupal olfactory system defects were introduced.

The following new articles are publishing in PLOS Pathogens this week:

Survival of infection with Ebola virus (EBOV) depends on the ability of the host to mount early and strong immune responses, however, given that EBOV cases are associated with 40%– 90% human mortality, EBOV has developed intricate solutions to human immunological defenses. Drs. Jonathan Cook and Jeffrey Lee discuss the current structural understanding of the functions of envelope entry glycoproteins in immune evasion using EBOV as an example.

Rhesus monkey rhadinovirus (RRV) is a gamma-2 herpesvirus that is a close homolog of the human Kaposi’s sarcoma-associated herpesvirus (KSHV; HHV-8), but RRV is able to use a broader range of both A-type and B-type Eph receptors. Drs. Alexander Hahn and Ronald Desrosiers show that the gH/gL glycoprotein complex of rhesus monkey rhadinovirus binds to and mediates entry of virus into target cells via cellular Ephrin receptor tyrosine kinase proteins.

Neisseria meningitidis is a human pathogen that can cause life threatening meningitis and sepsis in humans; however the key processes that dictate the transition from carriage of the bacterium in the airway to invasive disease are undefined. Dr. Freda Jen and colleagues report that the receptor for this pathogen on airway epithelial cells is the platelet activating factor receptor (PAFr), an immunomodulatory molecule shown to play a role in promoting bacterial sepsis.

In the middle of 2012, I took on the task of Collection Editor for the PLOS Collection Measuring Coverage of Maternal, Newborn, and Child Health. But what did coverage measurement mean and why should it matter? These last nine months have opened my eyes to the importance of the topic and the challenges that are faced. They have made me realise how much more those who work in high-income countries can learn from those who work in other settings around the globe.

As an academic obstetrician, I am sadly used to presenting shocking statistics on maternal deaths, over 99% of which happen in low- and middle-income countries; as a researcher into complications of pregnancy in a high-income country, we must constantly question how our work will make a difference where it matters most.

Our triennial confidential enquiry process has examined every death in England related to pregnancy in the last 50 years, assessed standards of care, and produced lessons to be learned. When the reports repeatedly showed deaths from pulmonary oedema in women with pre-eclampsia, we became much more restrictive with fluid management in such cases, and deaths fell. We can generate hospital-level statistics on the proportion of women who have a caesarean section, and have great debates on what the ‘right’ proportion should be. If we introduce a new intervention, such as anti-retroviral drugs for prevention of mother to child HIV transmission, I am confident that delivery of the programme will be high, estimates of the impact reasonably accurate, and sustainability good. For some years, perinatal acquisition of HIV has been less than 1% in our hospital – a figure of which to be proud. We don’t really have to stop and think about whether we can access those data. They may not always be perfect, but we have plenty to work with. So how do we translate those numbers to make a difference in a global setting?

First, we need to be able to measure what is happening. The statistics with which I am familiar are incredibly hard to generate accurately when the healthcare systems lack the infrastructure that I take for granted. There are few local, regional or national databases in low- and middle-income countries that can tell us which women are receiving appropriate antenatal care, what the quality of that care is, and whether it translates into improved outcomes for mother and baby. So the population-level surveys that are used in low- and middle-income countries (such as DHS and MICS) are vital for providing this type of information. This collection provides a guide that should be readable for the uninitiated and thought-provoking for those more familiar, on use of these surveys, highlights important issues relating to survey error , discusses how to consider health inequalities and gives an overview of how the indicators were chosen.

And are the metrics valid? Original research papers present work on validation of some of those indicators, and demonstrate that we should be more cautious in assuming that the indicator measures what we think it does. For example, using hospital-based data as their reference standard, a study concluded that labelling a caesarean section as being an emergency could not be recommended for use in surveys as it could not be validated. Progress is being made on providing anti-retroviral drugs to pregnant women with HIV, but another paper reports that using data from a health facility may over-estimate the true proportion of infants exposed to HIV that received such drugs during pregnancy and breast-feeding. Other research papers in the collection tackle topics relating to maternal, newborn and child health in Mozambique,  China, Zambia, and Pakistan and Bangladesh.

The collection will no doubt be useful to those who work in this area, but I would encourage others who are less familiar with the field to dip into it too. During my time handling the papers I learned plenty that is useful to me as an academic in the UK, but more importantly gained a timely reminder to keep my horizons wide when considering where our research could and should have an impact.

Dr. Lucy Chappell is Clinical Senior Lecturer in Maternal & Fetal Medicine and Honorary Consultant in Obstetrics at King’s College London. She is a Freelance Associate Editor at PLOS Medicine.

The Measuring Coverage of Maternal, Newborn, and Child Health Collection was produced with support from the Child Health Epidemiology Reference Group (CHERG). Financial support for CHERG is provided by The Bill & Melinda Gates Foundation through their grant to the US Fund for UNICEF.

Read the collection: http://www.ploscollections.org/measuringcoverageinmnch

Sputum microscopy, the method used by Koch, continues to be the most widely used test for TB in endemic countries.
Image Credit: Madhukar Pai

Tuberculosis is one of the oldest human diseases and remains to this day one of the world’s top killers. The WHO reported nearly nine million new cases of tuberculosis globally in 2011, with 1.4 million deaths worldwide. Even today, in India alone, nearly 1000 patients die of tuberculosis every day. Clearly, this is one ancient plague that continues to take a toll on humanity.

The WHO millennium development goal for tuberculosis is to achieve a 50% decrease in tuberculosis mortality by 2015. Recently, a Global Thematic Consultation on Health concluded with more ambitious post-2015 targets: zero new tuberculosis infections, zero tuberculosis deaths, zero tuberculosis suffering and zero tuberculosis stigma and discrimination.

Although much progress has been made in the past 20 years, there remains an enormous burden of disease and many countries are not on track to meet even the modest 2015 goal. In the past year, tuberculosis has received significant media attention, highlighting positive developments in our fight toward elimination, such as the roll-out of a rapid molecular test for TB, approval of the first new drug for tuberculosis in over 40 years.

But the media has also highlighted setbacks such as the emergence of ‘totally drug-resistant’ strains of Mycobacterium tuberculosis in countries like India and South Africa, and failure of the first novel tuberculosis vaccine since BCG. Several roadblocks still stand in the way of reducing the burden of disease, including challenges in early diagnosis of the disease, before transmission occurs in the community, as well as in providing effective shorter and more effective treatment regimens.

Spitting Blood by Helen Bynum is released at a pivotal time in the history of tuberculosis, where renewed efforts are being put into the control of this rampant illness. In her book, Bynum presents an in depth exposé on the history of tuberculosis, taking the reader through the medical, cultural and societal implications of the disease through time, highlighting just how much it has shaped history, and been shaped by socioeconomic development.

Starting the book by recounting George Orwell’s experience with tuberculosis and how it influenced not only his work but most of his life, Bynum draws in the reader and arouses curiosity while providing, through the narrative of Orwell’s life, basic scientific facts regarding tuberculosis. This is one of the book’s strengths, where the microbiological and medical concepts are not glossed over but rather fully explored with the help of clear, simplified yet accurate explanations. This will allow the book to reach a much wider audience.

In some ways similar to Dubos’ The White Plague, Bynum uses known cultural figures, such as John Keats and Charlotte Brontë, to better show the reader the complete hold that tuberculosis can have on a person’s life. Not limiting itself to an exposé of the European experience of tuberculosis, the book also details the scientific and cultural evolution of tuberculosis in other continents, adding a greater level of depth and providing a much broader account of historical facts. The level of detail in the anecdotes provided is truly impressive and shows the depth of research that went into creating this work.

Through the lives of artists, scientists and political figures, Bynum takes readers through the complete history of tuberculosis from the medieval period up until the 21^st century. Several critical moments of scientific discoveries are highlighted such as when Rene Laennec correlated the various granulomatous pathologies with a common etiology and when Robert Koch identified Mycobacterium tuberculosis, the causative agent.

The book also describes the evolution of the treatment for tuberculosis, until the seminal discovery of streptomycin by Selman Waksman. We learn how TB was once treated with mixtures of frankincense and myrrh, and that patients were encouraged to embark on sea voyages to warmer shores in order to aspire to a cure. We also learn that in the 19^th century, tuberculosis was commonly attributed to sedentary lifestyles and excess liquor and the author describes the emergence of the stigma associated with tuberculosis, which still exists today.

Toward the end of the book, we learn of the discoveries of the first anti- tuberculosis medications and how the drug regimens evolved to counter the threat of drug-resistant strains of bacteria. We also learn of the formulation of the DOTS strategy by the WHO – direct observed therapy, short-course – to enhance compliance and successful treatment outcomes.

Unfortunately, the portion of the book allotted to the modern challenges surrounding TB is much less extensive and detailed than the older historical accounts. There is little discussion surrounding the challenges with lack of significant decline in TB incidence despite the DOTS strategy, continued reliance on antiquated vaccines, drugs and diagnostics, the rampant use of suboptimal tests in high TB burden countries or the challenges in making newer WHO-endorsed tests more affordable.  The critical issue of declining budgets for TB control and research and development is barely discussed. A more lengthy discussion of current controversies and challenges surrounding modern tuberculosis control would have greatly enhanced the relevance of this fine book in 2013.

“Spitting Blood: The History of Tuberculosis” by Helen Bynum is published by Oxford University Press, Oxford, UK. ISBN 978-0-19-954205-5.

Jasmine Grenier is completing her medical training at McGill University in Montreal. She has worked on TB research projects and published on topics relating to TB diagnostics.

Madhukar Pai, MD, PhD, is an Associate Professor of Epidemiology at McGill University in Montreal and an Associate Director of the McGill International TB Centre. He also serves as a consultant for the Bill & Melinda Gates Foundation. Dr. Pai has previously served as co-chair of the Stop TB Partnership’s Working Group on New Diagnostics. He is also a member of the PLOS Medicine Editorial Board and the PLOS ONE Editorial Board.

The authors declare no conflicts of interest.

Books reviewed in Speaking of Medicine are independent of the book’s publisher. Reviewers do not receive a fee but are allowed to keep the review copy of the book.

The member states of the World Health Organization (WHO) will meet at the World Health Assembly later this month to discuss WHO’s follow-up of the report of the Consultative Expert Working Group (CEWG) on Research and Development: Financing and Coordination, and the follow-up report issued by the WHO Secretariat after an open-ended member state meeting in November last year.

It has long been recognized that “Market mechanisms, and also publicly-funded research, collectively result in far too little investment in research and development on diseases that mainly affect developing countries. This means that poor people suffer and die because there are no effective health technologies like medicines, vaccines or diagnostics”. Discussions on how to ensure innovation of and access to medical technology addressing diseases disproportionally affecting the poor dates back decades, and several commissions and working groups have been set down by the WHO on request from member states to examine the problem and possible solutions. Most of them have not been able to deliver a sustainable package addressing the profound market failures, until now.

Biomedical research is complex, and it is not easy to predict where we will be when looking ten years ahead. Nobody would have prioritized drugs for HIV/AIDS in 1980, but during the 1990s it became and still is a major research area, both due to the extent of the disease burden and the financial incentives for drug development. However, the world’s poor lack purchasing power and thus diseases primarily affecting them and not their richer counterparts, provide little incentive for the pharmaceutical industry to address their needs. The lack of new drugs or access to the existing ones makes it even harder to break the cycle of poverty. As R&D are high-risk, resource demanding processes, finding the right solutions that both incentivize research that are aligned with health needs and make end products available, are not easy tasks.

The CEWG took on the challenge and ended up recommending the following  as suitable solutions: Global Framework on Research and Development, Open approaches to research and development and innovation, Pooled funds, Direct grants to companies, Milestone prizes and end prizes and Patent pools. These tools cannot easily be tested and compared in randomized-controlled trials, as they all address broad and complex processes, deeply embedded in the current market economy. Still, based on the CEWG criteria; potential public health impact, efficiency/cost-effectiveness, technical feasibility, intellectual property management, degree of delinking, access promotion, transparent and accountable governance arrangements and capacity building in low- and middle-income countries, these are the most promising solutions we have.

Based on the recommendations, the WHO member states conducted national and regional discussions before meeting again in November 2012 to discuss further progress. The report of their meeting recognizes that the current system for drug development does not address the needs of the world’s poor and the urgency to address the medical research and development needs of low- and middle income countries. However, the operative points are not living up to the sustainable package approach suggested in the original recommendations. The draft resolution on the table proposes to postpone further discussions on the feasibility of a R&D Convention until 2016. Open Knowledge Innovation Mechanisms are not being promoted as a solution that can be implemented within the current R&D system and most importantly, sustainable financing mechanisms are not discussed. We find it difficult to see effective implementation of any of the recommendations, also within the tabled resolution, without additional funding.  Last, but not least, we have concerns regarding the process leading to consensus at the November meeting. Even though all member states were invited to participate, the final draft was passed behind closed doors, around 2 am the last day of negotiations, with no translators and less than 25 of the 194 member states present.  This makes us question not only the outcome of this process in particular, but also the overall decision-making procedures in global governance.

Will member states take on necessary leadership?

Though different concerns impact member states decision making within and between countries, we see few good arguments for not taking action. We do understand that the solutions suggested will demand time and resources from all countries, but underline that the solutions can potentially yield high gains in health. We need sustainable solutions in striving towards global health equity. This includes a major transformation of the health R&D system, with strengthened research coordination, improved financing mechanisms and monitoring of R&D priorities. The fragmented approaches that have been tried until now will not alone foster sustainable change.

The last years illustrate many success stories in global health. The reduction in child mortality is one of the examples of how action at national and global level together has enabled us to make health progress. In year 2000, we saw a possibility to act based on knowledge on effective interventions, and the international community responded. Though the challenges we face in drug development and delivery differ greatly, there are valuable lessons learned from the effect of global commitment and cooperation. Member states have been provided an opportunity to take responsibility and be true to their quest of improved population health. Take it.

Kristine Husøy Onarheim is co-founder of Universities Allied for Essential Medicines in Norway, and has been advocating for access to medicines since 2009. She is a final year medical student and global health researcher at the University of Bergen, and is currently a visiting graduate student at Harvard School of Public Health.

 Johanne Helene Iversen is co-founder of Universities Allied for Essential Medicines in Norway, and was previously in charge of international affairs and global health issues in the Norwegian Medical Students Association (2011-2012). She is a final year medical student at University of Bergen, and currently a visiting graduate student at Harvard School of Public Health.

Competing interests: Universities Allied for Essential Medicines is an international student organization advocating for improved access to essential medicines www.uaem.org

Image Credit: Flickr Flickr Vicki Francis & Department for International Development

This week PLOS Medicine spotlights infant and child health with new articles on neonatal mortality in rural Vietnam, M. pneumonia in asymptomatic children, and research priorities for childhood diarrhoea. The journal also continues with the ongoing Integrating Mental Health Series.

In the third article of a five-part series providing a global perspective on integrating mental health, Victoria Ngo and colleagues discuss the benefits and requirements of collaborative care models, where non-communicable disease and mental health care are integrated and provided in the primary care setting.

Lars Åke Persson and colleagues report findings from a cluster randomized controlled trial in northern Vietnam that investigates the effect of the activity of local community-based maternal-and-newborn stakeholder groups on neonatal mortality. These findings suggest that local stakeholder groups comprised of primary care staff and local politicians using a problem-solving approach may help to reduce the neonatal mortality rate after three years of implementation and at low cost.

In order to determine the possible asymptomatic carriage of Mycoplasma pneumoniae in the upper respiratory tracts of children, Emiel Spuesens and colleagues investigate the prevalence of M. pneumoniae in symptomatic and asymptomatic children at a hospital in The Netherlands. This study suggests that current diagnostic tests do not discriminate between carriage and infection, and clinicians may need to reconsider the clinical significance of a positive test result.

Zulfi Bhutta and colleagues lay out research priorities for global child diarrhoeal disease over the next 15 years, which they developed using the Child Health and Nutrition Research Initiative (CHNRI) method. In tandem with the Global Action Plan for Pneumonia and Diarrhoea, implementation research will be needed to equitably scale up already proven, effective interventions. The homepage highlights additional PLOS Medicine Research Priority papers.

In observation of International Clinical Trials Day on May 20^th, this week PLOS Medicine also features a selection of Clinical Trials.

Remember you can comment on, annotate and rate any PLOS Medicine article and see the views, citations and other indications of impact of an article on that articles metrics tab.

Once in the not too distant past, one of my co-authors on a paper suggested that we ask for comments on the paper from a person I had never met.  I wondered at the time why a British knight would take the time to comment on a paper written by a person he had never met and for which he would get no more credit than a line in the acknowledgements section.  Last week I attended the African Cochrane Indaba where I had the great pleasure of not only meeting Sir Iain Chalmers but also of dancing with him – and I get it!

Having only ever hung around the edges of the Cochrane Collaboration, it is not until this week that I really understood what this collaboration is about.  What I now know for sure is that it is indeed a collaboration founded on the values of friendship and mentoring.

 Sir Iain Chalmers and Jimmy Volmink cutting the Cochrane Collaborations 20th Birthday cake

I don’t particularly like conferences.  I find them long and boring and I have great difficulty in starting up conversations with strangers about my work and theirs.  But the African Cochrane Indaba was different.  This conference was designed around teaching and sharing skills in Cochrane methods.  While there were some “big names” doing some of the teaching, there was also a concerted effort to have African Cochranites running most of the workshops.  From my discussion with participants from Africa, this was much appreciated and a source of great pride.  The fact that these African Cochranites could do this teaching with such confidence and skill is largely, in my opinion, due to efforts on the part of people like Sir Iain Chalmers, Paul Garner, Jimmy Volmink, Justus Hofmeyr and a long host of others.  These forerunners of Cochrane not only in Africa, but in the world, give freely of their time so as to impart skills in order to ultimately save lives – and this is in my experience is “the Cochrane Way”.

African Cochrane Indaba 2013

I understand fully that lives are saved by more than evidence from systematic reviews. However, for these reviews to make a contribution they need to be conducted excellently, and that is what I saw encouraged at this Indaba.  In addition, although it was never mentioned explicitly, there was a clear message that research to address health priorities in Africa needs to be led by African researchers.  Slides shown by Paul Garner from Liverpool School of Tropical Medicine showed both that we have a long way to go to achieve this, but also that African Cochranites are increasingly influencing international health policy with the results of their research.  This is definitely something to be proud of.  There is still much more to do, including working more closely with policy makers. But no-one shied away from these issues during the Indaba.

As a feminist I do have one bone to pick though – next time I would like to see more African women, from outside of South Africa, on the podium!

For now – well done!

Karen Daniels

Karen Daniels is a specialist scientist at the Health Systems Research Unit of the Medical Research Council in South Africa.  Although originally trained as a qualitative researcher she has come to see the value of incorporating a broad spectrum of research methods in addressing health systems challenges.

Competing interests: Karen Daniels is a member of the editorial board for PLOS Medicine and a member of the Cochrane Collaboration.