Keep Taking the Meds: Solving the World’s Biggest Drug Crisis | Dr. Peter Small

Keep Taking the Meds: Solving the World’s Biggest Drug Crisis | Dr. Peter Small


That wasn’t a sedative to keep me calm through my talk. That was medicine that I
should have taken this morning and I’ll bet that I’m not alone because one thing that I learned over my career is that it’s really hard to take pills, a problem that’s known as “medication nonadherence.” As a doctor in San Francisco at the dawn of the AIDS epidemic I saw patients die because they didn’t take their pills. And as a scientist at Stanford my laboratory studied the molecular mechanisms by which bacteria become resistant to antibiotics when they’re not taken as prescribed. And during my work in global health I have gone to great lengths including flying medicine to remote villages in Madagascar and Nepal with drones. And as a son I have struggled with the frustration of watching my mother take her pills as she would say “just when she needed them.” Medication nonadherence is so common that we have become complacent with it, and yet it’s a really big deal. I’m not oblivious to the other big drug crises that we’re facing;
the opioid epidemic and the overuse of antibiotics. But as a clinician I have seen the power of pills to improve health and to prolong lives… If they’re actually taken.
In the United States forty percent of medicine is not taken as prescribed. And there are lots of reasons for this. The most common is simple forgetfulness
but some patients grow weary taking pills and others develop side effects. The impact of medication nonadherence is shocking. In the United States it results
in a 125 thousand premature deaths each year and costs the health system 300 billion dollars. The impact on global health, which is my real passion, is simply staggering.
Each year the world takes about 4 trillion doses of medicine. Let me say that again. Let me say that again. Four. Trillion. Doses of medicine. And to support that we invest massively in strengthening health systems and training healthcare workers and building supply chains to get those pills what we like to call the last mile to the people who need them.
And yet none of that matters if we cannot get the pill the last eighteen inches from the pill to the patient’s mouth. We simply cannot ignore the last eighteen inches of
our healthcare delivery system. This problem is poised to get much worse. Humanity is experiencing a tsunami of noncommunicable diseases.
Conditions like diabetes and heart disease for which many people will have to take a pill a day for the rest of their lives. We have a global drug, prescription drug problem
brewing that we simply can’t ignore. Medication adherence is particularly problematic for tuberculosis patients, patients who have been the focus of my work for more than
thirty years. TB infects about 10 million people a year and it kills more people than any other infection including HIV/AIDS. The vast majority of cases occur in low
and middle income countries where accessing healthcare is a challenge. And because it’s airborne, TB anywhere can easily become TB everywhere. The stakes are so high for Tuberculosis that about twenty-five years ago the world health organization endorsed a strategy called “directly observed therapy” which includes among other things having the patient’s pill consumption directly observed. Frankly it’s just not working. It’s a huge burden on a patient to go to the clinic everyday
just to have their pill consumption observed and it’s an inconvenience for the clinic as well. We need a better way to support the ten million patients who will develop TB this year.
How are we going to help those millions of patients? With this: a smart phone. Two out of every three humans alive on the planet today have a phone in their pocket
and sixty percent of those phones are smartphones. I believe that access to smart phones in low and middle income countries has crossed a tipping point where we can
start to consider them as a workhorse for delivering healthcare. In India they already are. A few years back I helped to launch a partnership that uses
smartphone technologies to help TB patients take their medicines. The partnership included the National Tuberculosis Program and Wisepill,
a company that makes this smart pill box, which both reminds patients that it’s time to take their pills, and has inside of it the guts of a cell phone that automatically calls
the clinic to let them know that they have. Knowing in real time that people are taking their pills is a game changer, but it’s the easy part of the solution.
Helping those who are struggling to do so is where the real value lies. To make this happen, we need to understand why people are struggling and tailor
our interventions to each. In India we’re learning that forgetful patients respond well to a simple text message. Patients who are weary of taking their meds need a phone
call to remind them the importance of doing so. And people who are having bad side effects need to come in and see the doctor. The lesson is clear: Simple, personalized
interventions can help people stay on their medicines. In January of this year I had the opportunity to see the progress that’s being made in India first hand. I traveled down a very long and very bumpy road in the northern state of Bahar where I met Pudja, who was diagnosed with Tuberculosis shortly after giving birth to her son. Pudja had spent so much money seeking healthcare that she had to sell her house. She was there with her treatment supporter and on their
phones I could see that Puja was taking her medicine regularly and she didn’t need to take time away from her busy life as a new mother to go to the clinic each day
to watch her pills consumed. Pudja is just one of 270 thousand TB patients in India today who are getting cell phone base support in taking their medicines.
The government of India is so impressed with this program that they have now mandated that all of their patients, two-and-a-half million people a year, will be
getting similar support in the coming years. And yet because a government mandates this doesn’t mean it’s going to happen because at its core taking pills is very personal.
To go the last eighteen inches we have to go beyond a program that’s mandated by the government to one that is embraced by the patients themselves.
To really go these last eighteen inches we need to engage the power of cellphones in their pockets. Cell phone companies and technology companies have made
very powerful tools and if people were as engaged as taking their pills as my in their pockets. Cell Phone companies and technology companies have made
these very powerful tools and if people were as engaged as taking their pills as my screenage daughter Tessa is in snapchatting with her friends the medication
adherence problem would go away. The power of these phones is really phenomenal at targeting specific messages to specific people and doing it at the right time and doing it at great scale. There are differently disturbing aspects to this technology’s ability to entrance, and persuade and to track us, but I for one cannot
walk away from the potential of this technology to help people around the world technology’s ability to entrance, and persuade and to track us, but I for one cannot
walk away from the potential of this technology to help people around the world technology’s ability to entrance, and persuade and to track us, but I for one cannot
walk away from the potential of this technology to help people around the world technology’s ability to entrance, and persuade and to track us, but I for one cannot
walk away from the potential of this technology to help people around the world technology’s ability to entrance, and persuade and to track us, but I for one cannot
walk away from the potential of this technology to help people around the world take their medication. These companies have come under fire for using their powers
primarily for profit. Profits that are so enormous they’re being compared to the industrial trusts of the gilded era. Now is the time for these companies to channel some of that
power and small sliver of those profits to helping people take their pills. For the companies For the companies themselves, taking on medication adherence will help them to answer questions that are of fundamental importance for all of the work that they’ll be doing in low and middle income countries. How do they adapt their technology to settings
with less data? How do they work transparently and ethically in different political systems, and how do they employ the lean approaches that have been so effective in Silicon Valley
to improve lives in villages? Do I really think that we can go from helping a few hundred thousand TB patients in India to helping hundreds of millions of people around the
world take their medicine? I believe we can. And I know that if we do we will improve billions of lives in the coming decades. If we choose to walk away from this challenge the
investments that we’re making in health systems and health workforces and supply chains will be largely lost. We have the tools to help people take their medicine.
These companies can help us to do so at scale. Now is the time to come together and take our healthcare that last eighteen inches.
Thank you.

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