Improving access to medicines for 4000 children with cancer in Malawi

It is estimated that up to 90 per cent of children diagnosed with cancer in Sub-Saharan Africa die1. Last year, Teva announced a partnership with Global HOPE and Direct Relief to supply medicines used to treat cancer in Malawi, one of the world’s poorest countries. We look back at the first 12-months of the program, as a global pandemic made an immensely complex logistical exercise even more difficult.

‘Seriously, how difficult can it be to get medicines from where they are to where they need to be?’

This is a question often asked – quite reasonably – about supplying drugs to parts of the world where they are desperately needed, particularly when there is a vulnerable group seeking care or crisis to be averted.

The answer is: ‘Very difficult indeed’.

“To start with, you need a sustainable supply of medicines and training so people can transport, store and administer drugs properly,” says Damon Taugher, Vice President, Global Programs, at humanitarian assistance organization, Direct Relief. “Then there are global production variables, humanitarian shipping routes and times, customs clearance, local issues, and a whole lot more."

“You’ve got lawyers, operational staff, pharmacy staff, and local medical staff, all having to work together to make it happen,” he adds. “On top of all that, there’s a global pandemic to consider as well.”

If all these people and logistics do not align the results can be disastrous.

“When you don’t have a well managed project, it can easily fall apart,” says Kristi Wilson-Lewis, Director of Administration and Planning at Global HOPE (Hematology-Oncology Pediatric Excellence), a program of Texas Children’s Hospital that organizes and runs pediatric hematology-oncology programs in sub-Saharan Africa.

“In the past, I’ve seen $1 million-worth of medicines ready to go that didn’t make it to the children and that’s heart-breaking.”

One-in-ten chance of survival

Teva’s partnership with Global HOPE and Direct Relief is one example of the challenges inherent in doing what is clearly the right thing. Happily, it is also a testament to what can be achieved – and the lives that can be changed – if we work together for the greater good.

Under this innovative partnership, Global HOPE determines the specific volumes and quantities of medications identified for current patient needs at its clinical sites. Teva then provides essential medications for treating cancer and blood disorders in children to Direct Relief, who in turn ensure the efficient shipping and delivery of the donated medicines, in coordination with Global HOPE facilities across Sub-Saharan Africa.

Ultimately, this is about saving lives in a place where survival is never taken for granted – or even expected. Currently, it is estimated that up to 90% of children diagnosed with cancer in Sub-Saharan Africa die1. This compares to approximately 20% in the US2.

Teva’s donation, part of our commitment to increasing access to medicines, will support treatment plans for almost 95% of Global HOPE’s chemotherapy patients. Over the next five years, Global HOPE aims to diagnose and treat close to 4,000 new pediatric cancer patients in Malawi.

Months of complex analysis’

At the outset the prize was clearly great but a huge challenge faced the new alliance. On top of all the issues set out above, this multi-partner approach was new to all the participants and there was the added complication that the drugs involved required a cold storage supply chain.

This meant the medicines needed to stay within a two-to-eight degrees Celsius range – from initial delivery by Teva, all the way to Malawian clinics – to ensure safety and efficacy.

Getting this immensely complex logistical equation right all started with some equally complex mathematics.

“I spent a lot of time doing math ahead of all this,” says Brooke Bernhardt, Director of Pharmacy at Global HOPE. “To make this happen, we needed to understand which medications could be used, how many patients might be treated, the range of patient ages and body sizes as this determines the dose, how we want to treat each patient, how many vials are needed to ensure everyone is treated… It goes on and on – months of complex analysis.”

This was complicated by the fact that no single cancer drug could be a panacea.

“This isn’t like malaria or tuberculosis, where there are a limited number of medications commonly used,” Brooke says. “In pediatric oncology there are a lot of different cancers and we want to be able to treat them all. How can you choose between them? Why is the child with cancer in room one any different or more deserving from the child in room two?”

If that wasn’t difficult enough, the treatment also requires supplementary medicines, like antibiotics, to ensure the patient has the greatest chance of recovery.

Fortunately, Teva was well-equipped to meet this added complexity, as the world’s largest manufacturer of generic medicines, including 73% of essential cancer treatments on the World Health Organization’s Essential Medicines List (EML). In addition to oncology medications, Teva also provides many of the related treatments needed to treat patients, such as antibiotics.

Drugs in a cold climate 

The range of drugs involved required Direct Relief to expand its cold supply chain, which started in its specialist 2800 square foot cold storage warehouse in California, where Teva’s drugs first arrived on their journey across the world. 

“It takes a lot more effort to make a cold supply chain work,” says Derek Brown, Project Manager for Facilities Planning & Development at Global HOPE. “You need special packaging, thermometers, warning systems.”

“When it arrives in Malawi, you need to get it through customs as quickly as possible,” he adds. “When it gets to the clinics in Malawi it has to get straight into a cold room and you have to confirm temperature was maintained throughout the journey.”

But it all worked, a fact that Damon from Direct Relief says marked this partnership out as “really special”.

“To make an international supply project successful there are three things you need: deep trust, a good plan and lots of communication, because even the best plan is going to have to be changed,” he says. “This had all of those things and it worked really well.”

Giancarlo Francese, Head of Access at Teva, echoes this. “It’s made me really proud how we’ve worked together – it’s been like an orchestra” he says. “In an incredibly short time we’ve done something unique.”

Coming back alive

But what of the difference on the ground, where the heart-breaking human stories make the story of how the medicines got to where they needed to be a mere footnote?

Firstly, now that drug supply is regular and predictable, last minute trips to local pharmacies for drugs (that may or may not be available) are becoming a thing of the past.

“Medication adherence with chemo is really important,” says Global HOPE’s Brooke. “For some medications that are used as maintenance therapy for remission in children with leukaemia, once usage drops below 90% of what it should be the risk of relapse goes up considerably.” 3

“We fight all the other issues – getting children to make it to clinic on foot, on bikes, in taxis, however – before we start persuading the children and their families that they should take the medicine. If we get them to do that we must be able to deliver for them.”

The quality of the medication is also crucial.

“We often don’t know what we’re getting in the local market,” Brooke says. “As a pharmacist, Teva is like Adidas or Nike is in athletics. It’s the brand you know and you know you can trust the quality”.

Global HOPE believe that this combination of quality and regularity of supply is starting to have a wider impact.

“Local healthcare workers and local healthcare leadership are now seeing that cancer can be cured,” says Global HOPE’s Kristi. “A child coming in, getting treated and coming back alive, was new to them. It’ll take a long time to get the message out but every time we have another success we show people these things are really achievable.”

Such is the success of the partnership that it is set to be expanded to another eight countries. But that’s another story… and another challenge.


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Footnotes

[1] ‘A Focus on Children and Non-Communicable Diseases (NCDs)’ by The NCD Alliance, P46, https://ncdalliance.org/sites/default/files/resource_files/20110627_A_Focus_on_Children_&_NCDs_FINAL_2.pdf 

[2] Statistic taken from Texas Children Hospital’s website https://www.texaschildrens.org/departments/global-hematology-oncology-pediatric-excellence-hope-0/challenge

[3] ‘6MP adherence in a multiracial cohort of children with acute lymphoblastic leukemia: a Children's Oncology Group study’ https://pubmed.ncbi.nlm.nih.gov/24829202/ 

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