Biomedical Innovation and World Health

BIOMEDICAL INNOVATION AND WORLD HEALTH PAUL F. BASCH* The methods of biotechnology are expected to generate many new diagnostics, vaccines, and other products of potential benefit to human health. While the advantages of such products are clearly evident to their developers and enthusiasts, the fact is that the transfer, dissemination , and adoption of innovations constitute a relentlessly Darwinian process. Whenever and wherever it is introduced, each biomedical innovation will survive, perish, or evolve as a consequence of natural selection in the epidemiologic, economic, and logistic marketplace. Many factors determine the eventual success of biomedical innovations . The product must fill a need, of course, but even though health ministries spend billions of dollars to define and fill health needs, it remains difficult to specifyjust what that means. One developing country 's government thought that a health center was needed in a certain village, but the people preferred to walk an hour to the existing health center in another town where they could also shop and catch up on the news and do other things that they needed to do. Epidemiology is also a big factor: 10 years ago nobody needed a drug against AIDS; 10 years from now a billion people may need a vaccine against the highly fatal trimillennial syndrome. In some cases the need may precede, or stimulate, development of the innovation. For decades some people have coveted, or needed, or thought they needed (which is the same thing) a replacement for a diseased heart, or a vaccine against hepatitis A or malaria, and technologists have striven to accommodate, with varying success. Conversely, innovations engender needs: many people did not know that they needed a VCR or liposuction until those things became available. Innovations are situational in place and time: the costly diagnostic instrument so admired in Atlanta may be useless in Uganda through lack of reliable electric power, or trained personnel, or spare parts, or ?Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California 94305-5092.© 1990 by The University of Chicago. AU rights reserved. 003 1-5982/90/3304-0685$0 1 .00 Perspectives in Biology and Medicine, 33, 4 · Summer 1990 | 501 maintenance, or because nobody can afford to use it, or because even if it works perfectly the condition that is diagnosed cannot be treated anyway , or maybe because the disease that it is designed to find does not happen to occur there. The perishability of innovations is as inevitable as the decay of isotopes. As the passage of time diminishes novelty, it is the fate of innovations to become routine, or to be forgotten, or to evolve into something else. Innovations are not really alive at conception. The distance between the idea for a potential innovation and its actual application to anything in the real world is so great that many, perhaps most, clever inventions never survive the rigors of development and implementation. Even so, some worthless or counterproductive innovations conceived in intellectual obscurity can manage to hang on for years—for example, X-ray machines for fitting children's shoes, or routine tonsillectomies. Some are so deeply entrenched that it might be considered innovative to stop doing something considered normal but probably not cost-effective, such as the annual physical; or probably harmful, such as the excessive number of caesarean sections performed in many areas of the world. In many minds there exists a conviction that the efficiency and effectiveness of health services can be improved with additional innovation: if not, what is the point of biomedical research? Indeed, biotechnologic innovation translates into industrial production that, with economies of scale, can make available more diverse products, produced ever less expensively on a unit basis. However, their introduction will result in more decisions about which products and dosages to use for which application , with more things to check, more chances for error, and an increased possibility of iatrogenesis, such as adverse reactions to new immunizations or therapies. More sensitive and specific tests can uncover more presumed irregularities and signal them earlier. Many slight conditions that would normally disappear by themselves would now demand some sort of medical attention. New methods of monitoring and follow-up may be required. Therefore, while...