Global Health Matters
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Global Health Matters
Test to protect: equal access to diagnostics for all
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The COVID-19 pandemic has brought a new global awareness of the accessibility of diagnostics: we need to test to protect with equal access for all. In this episode of Global Health Matters, we answer key questions such as “how available are essential diagnostics in low- and middle-income countries (LMICs)?”
Host Garry Aslanyan interviews our special guests who have a deep understanding of diagnostics and their application worldwide. Bill Rodriguez is CEO of FIND, the global alliance for diagnostics, and is also founder of his own diagnostics company, Daktari Diagnostics. Our second guest is Sikhulile Moyo who led the team that helped discover the Omicron variant in Botswana through careful cross-examination of COVID-19 tests.
Join us in this podcast episode to understand the state of diagnostic testing in LMICs and how to achieve equity in access to testing in all countries.
Guests are:
· Bill Rodriguez, CEO, FIND
· Sikhulile Moyo, Research Laboratory Director, Botswana Harvard AIDS Institute Partnership
Related documents, transcripts and other information can be found on our website at
https://tdr.who.int/global-health-matters-podcast/test-to-protect-equal-access-to-diagnostics-for-all
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Disclaimer: The views, information, or opinions expressed during the Global Health Matters podcast series are solely those of the individuals involved and do not necessarily represent those of TDR or the World Health Organization.
Hello and welcome back to our regular followers of the Global Health Matters podcast. I'm very pleased that our listenership keeps growing. For those of you who are joining us for the first time, welcome to the show. I'm your host, Gary Aslanan. In this episode, we will be exploring the importance of access to diagnostics in global health. Over the past couple of years, diagnostics have moved from laboratories into our living rooms. Many of us have had experience of performing our own COVID tests at home and waiting anxiously to see the result. Unfortunately, to have access to diagnostics is a privilege. Millions of people around the world still lack access to timely diagnosis for a range of diseases. Diagnostics play a critical role in three major global health priorities, such as global health security and antimicrobial resistance, and achievement of universal health coverage. In this episode, I'm joined by two guests, each with significant experience and who are driven to reducing the access gaps for diagnostics. Dr. Bill Rodriguez is the Chief Executive Officer of Find, the Global Alliance for Diagnostics. FIND connects health system stakeholders to enhance access to diagnostics. Dr. Sikulele Moyo is a medical virologist and the director of the Botswana Harvard HIV Reference Laboratory. Dr. Moyo has also been part of the Botswana Presidential Task Force for COVID-19. Bill and Sikulele will be highlighting the current inequities in diagnostics, reflecting on the lessons learned from the COVID-19 pandemic, and sharing some of the exciting new innovations in the field. Hi, Bill. Hi, Gary, how are you? Hi, Sikulele. Hi, Gary, how are you? Great, thanks. Bill, how has your career journey evolved to focus on diagnostics and what were some of the professional and personal motivators along that way?
SPEAKER_04Yeah, thanks, Gary. So I trained in medicine as a clinician, as an infectious disease specialist. And so I see the world as a clinician and whether focus on patient care and how do you help the patient in front of you. And so I think probably three different um aspects really in my career led me to focus on diagnostic testing. The first was my career coincided with the broad sweep of the AIDS pandemic. As a medical student, I had one 30-minute lecture on HIV. Two years later, in my first um role taking care of patients, the first five patients I took care of died of AIDS, and they were all my age in the early 20s. So that was one very formative aspect of my early training in medicine. The second was one of my early mentors was the late Paul Farmer, who's probably passed away recently. And I worked with Paul in Haiti and other other places, and his influence, the way he demanded equity, and said, we need to take care of every patient the same way we take care of any patient, you know, had a pretty profound influence. I mean, and then the third was at the time in the late 90s, early 2000s, the rapid pace of technology development that I witnessed and the impact of new technologies on high-income country diseases like cancer and heart disease was just overwhelming. And I saw how powerful those technologies could be if we could apply them to global diseases, whether they were infectious diseases or sickle cell disease, but diseases of poverty. And so those three forces, the AIDS pandemic, the influence of Paul Farmer, and the rapid development of technologies in the early part of my career really led me to see the potential for diagnostics to drive equity and um uh clinical care on a global basis.
SPEAKER_03Thank you. Sicilera, what about you? Uh, what inspired you to become a virologist? And what do you find most satisfying in your job?
SPEAKER_05Uh that's a good one. I started seeing a lot of people dying from HIV, and it was very close to me because uh I lost some family members, uh, two brothers and my sister then. And I realized that uh uh the pandemic was on us, and uh, you remember there was no cue at the time, and there was very little hope. And at that time, I met a man uh who was a virologist, and and I got interested because of the passion to see uh how to help. And as a virologist, I realized that they were looking at uh new tools of diagnostics for HIV, and that really inspired me that you can do basic science that translates to so much impact in public health. So that really started my passion uh for research and also for diagnostics. And I trained under him, and it really gave me a passion to pursue a career in virology. So my passion now is to see timely diagnostics that that impact patient outcomes and public health response. That's an intersection of my career and anything that I can do either to promote improvement of access to diagnostics, uh, research that informs public health, that really changes uh how I look at things.
SPEAKER_03So both of you have really reflected on how the inequities in terms of access to diagnostics have impacted various health issues. So, Bill, the current pandemic clearly exposes a lot of fragilities when it comes to diagnostic systems. So, can you tell our audience what they are, especially in low and middle-income countries?
SPEAKER_04Yeah, I think there's a saying that's come up again and again in the past years that pandemics don't create any new problems in society, they just reveal all the existing ones. And I think that's been extremely clear when it comes to testing and diagnostic systems in um in low and middle-income countries. You know, in the past 20 years, we've invested heavily in HIV testing. We have uh centralized laboratories that do uh high volumes of viral load tests and can turn around tests in 24 hours. We've invested in tuberculosis testing, malaria testing, and we have strong systems there. And selectively in a few other areas like uh uh human African phantosombiasis or has a very targeted program that applies testing to eliminate that disease. But pandemics, almost by definition, are community-based diseases. Um SARS-CoV-1 or SARS-CoV-2, they spread person to person in communities, and that's has become pandemic. And we've realized now that we fail to invest in community-based testing systems, platforms that can be used as primary healthcare centers, community health workers as testers, um, and that that failure to invest in a more community-based platform instead of a vertical approach, even for HIV, which is a broad disease with impact at the primary healthcare level, is it's revealed that um there's a major gap in our ability to respond to pandemics, and it's just played out over the past years with COVID. We've really been behind in trying to get testing out to communities through community-based testing programs because we failed to invest in those, and we didn't realize it until COVID uh you know really emerged and made it quite clear.
SPEAKER_03And Sikivela, in Botswana, where you work, what are some of the gaps that still exist in bringing the diagnostic capacity to communities?
SPEAKER_05Yeah, that's an important one. I think the systems have grown uh vertically, and when COVID came, it exposed that some models of centralizing care uh are detrimental to uh to making sure that people access health. Ozona has moved a lot in terms of increasing access to diagnostics, especially in in urban areas or peri-urban areas. And some of the gaps are really uh increasing access to very remote areas. Uh, and that has been very, very important. Uh making sure that diagnostics are efficient, the timely reporting, uh, so that the access that is given at least allows for timely response. And I think just focusing on infectious diseases alone is also a time bomb because probably uh because of the nature of the funding, focusing on HIV and TB to the detriment of looking at uh what should we do for NCDs, for example. Uh, but in terms of our response, uh, we need to make sure that we close those gaps because the uh the COVID pandemic has really shown us that we need to be ahead of the game uh in terms of diagnostics. We are used to lab-driven testing uh and properly maybe nurse-driven testing, but the pandemic quickly showed us that the health system was overwhelmed uh and there was not enough people to test. Uh, you had the testing equipment, but not enough people to do the test. And that really helped us to see, okay, we need to be innovative here. How can we use the community? How can we train lay workers? How can we repurpose lay workers uh to really expand the testing? And that was an opportunity, for example, uh to expand the testing and really increased uh uh testing rates by more than 200 to 300 percent, uh, just by repurposing different codes to increase access to testing. And I think that lesson should be important uh as a lesson for uh any pandemic that may come in, that we need to reduce complexity in testing.
SPEAKER_03So both of you mentioned the um fragilities of the system that have been exposed due to pandemic and the experience we had with COVID. So, Bill, is there any action that has been catalyzed on global or other levels towards equity in diagnostics, both in terms of future pandemic preparedness, but also for all the other health inequity issues that uh you already uh both reflected on?
SPEAKER_04Yeah, you know, one thing that we shouldn't underemphasize is um how relevant testing has become in this pandemic. You know, we we may not remember all the way back to two years ago, but in the early days of the pandemic, we were acutely aware of how important testing was and and how little access we all had to it everywhere in the world. And of course, that's the daily experience of most people for the test they need in lower and middle-come countries, but even wealthy countries and wealthy people realize I can't access the test on anywhere. And I think that relevance has persisted for two years. People are very aware of the role of testing in their own health across the globe. Political leaders, Dr. Kendrick on a daily basis, has to state on a weekly basis, um, from President Biden to President Ramaphosa, are talking about testing for the public. And I think that's really essential because now people understand, hey, this is a critical part of our health system, and we need to um make sure it's it's available. So that that then raised the information in a new way, I think, on a global basis. And so equity in crypto testing became a cornerstone of a global response. And this awareness we just talked about is how hard it is to deliver testing to fragile systems, um, everyone became acutely aware of that. So I think that's and that's an important piece because now testing is on the agenda the way it has been before, and equity is a core principle. I think a few things that we've seen and realized are critical to delivering equity. One is WTO leadership. You know, I think the WHO gets criticized uh sometimes for its response to emergencies. And I think the WHO has been um uh just absolutely essential and and and I think that that the power of the WHO to deliver that message, I think, is is critical and something we need to recognize and maintain when we move out of the pandemic. The other issue that I think has been really clear is manufacturing you know, most tests for most of these is the the factories and the equipment that make the test kits and the regions are in the global north. And that created problems, and it also made a lot of countries realize how critically they are dependent on things well outside of their control politically. And so the effort that's grown over the past 12 months or a year and a half is okay. We need manufacturing for diagnostic tests in the global south, in Latin America, in West Africa, in South Africa, and we're building those factories. That's going to support equity, probably not in time for the pandemic when it was needed last year, but for the future, for future pandemics, for tuberculosis, for tests that manufacturers in the global north don't really pay as much attention to. And that I think is a critical legacy of COVID is to identify this sort of niche issue of hey, where the pests are produced is really essential for equity, especially in Africa, but across the global thousand. I think that's something we'll look back at and realize as a critical moment in the pandemic.
SPEAKER_03I can see Sigileli, you wanted to add something to this.
SPEAKER_05I think he raised uh very important points uh around the need to be able to produce kids uh and and supplies within our region. And we've seen it as well, is rolling not only to testing kids, but it's also rolling out to vaccines and also several testing products that we need uh to increase access as well as probably innovative ways of testing. Uh, some people tried innovative ways like food testing uh or different algorithms to expand testing and scale up testing. Uh, and I think that has become very, very important. Uh well-safe Bill.
SPEAKER_03So, Siklele in 2021, uh late 2021, uh, you and your colleagues and scientists that work with you uh were the ones who sounded the alarm around the Omicron variant. Uh to me, this means that Botswana had a very good early warning and detection system supported by diagnostic capacity. Maybe you could tell our audience a little bit more about that experience and how that uh unfolded.
SPEAKER_05The discovery of Omicron in Botswana was not an accident. I think it was a result of a strategic intent to increase access to detecting what is going on in the population. Unique diagnosis. So testing, testing, testing, testing. So Botswana decided to make sure that there's access to testing in all its dispatches and increasing access using COVID zones where in each of the catchment areas there's a PCR lab and also using the infrastructure from HIV, the sample referral system, you were able to refer samples to the next PCR lab. And we developed now a surveillance strategy that was going to be able to be built on that, that if we get a positive, we are going to sample it. And our strategy was made of so many uh pillars. First of all, we wanted to know what is coming in into the country, surveillance of our points of entry. So if there's a new virus coming in, we were there trying to see that and sample. We're also interested to see what is happening in people who are being hospitalized who have the fast disease progression. Uh so we were there, death cases, we were also sampling those. We were also looking at generally in the population. We couldn't sequence everyone, but what is the representative way of sampling across these areas that will give us a meaningful data to estimate what is happening in the population. So this strategy allowed us to be on a weekly basis accumulating representative samples uh that cut across these uh different objectives. And that was very, very important. Um uh we received a lot of support uh from organizations like uh Find and Pilent Melinda and the Minister of Health in terms of setting up our systems uh and also enhancing the testing. Uh the 11th of November we received these unique samples. Uh and they were they were tested in one of the labs, and they noticed that we monitor what we call cyto threshold values. It's a measure of how concentrated the virus is. So this one was very concentrated and was like, oh, we've never seen such a concentration of viruses. And they brought it in because we were sequencing weekly, uh, we got those samples into our patch. Uh, when we got them into our patch, we noticed that when we compared them with others, they were sitting in their own tree. When you put two a tree of virus, a family tree of viruses, what we call phylogenetic analysis, we realized that these four clustered together. And boom, what is this going on? Uh, when we looked at them initially, as a virologist, you think there's an error. So we went back to the lab. So we could have reported this data as early as the 18th of November, but we went back to the lab. Uh, and and by the 19th, we were sure that we saw exactly what we saw. And on the 22nd of November, we notified the Minister of Health, we made the data available, and that was a Monday. And by Tuesday, we got a call from uh an independent group that saw our sequences and they said, Oh, we've seen something similar. So, two independent labs identifying a lineage. So, for us, when we reported to the Minister of Health, we say, Oh, we've identified an unusual lineage. I still have that email, I'm framing it for future because it it changed the world. Uh, an unusual lineage. We didn't know that it's a variant, we didn't know it's a variant of concern. Uh, so when we notified uh Minister of Health and South Africa as well, then we realized that this is worth reporting to the World Health Organization. And then as Bill said, uh, WHO has played a very critical role. They formed a technical working group. And on the 26th of November, they classified this unusual image, uh, a variant of concern, now called the Omicron. Uh and and I think for me, I was fulfilled as a scientist to report something like that. Uh, but also uh it was a roller coaster of emotions because the the way the world reacted uh with travel bans. Uh and I think we have learned a lot over the past two years that I think that reaction was unfortunate. Uh, economies were damaged, uh, the even the medicines and the vaccines that we're expecting were delayed. Uh, a lot of businesses were closed. There was a lot of lockdowns unnecessarily. So the cost implications were huge. And uh uh some of us got um calls about what you have done, uh, you scientists with your big mouth, it was a holiday season coming up. And uh, why didn't you keep quiet until we come back from Christmas? Uh and when you look back, while we went through that rough time, I feel even more strongly that data transparency, data should be shared transparently and should be used to improve public health.
SPEAKER_03Bill, uh, beyond the developments you mentioned related to COVID-19, what are the other exciting and disruptive innovations in diagnostics that are emerging? And how could they apply to other diseases to TB or other neglected issues, especially in low and middle-income countries?
SPEAKER_04Yeah, Gary, I think I'll highlight two really exciting developments that are on the near-term or medium-term horizon. One is actually sequencing. Sikolelli told a really powerful story about the identification of Omicron and the consequences, but the commitment to sharing data and transparency. And so we we what we've seen under COVID is um literally every country in the world now has the capacity to do sequencing of pathogens and turn that information or information around, share it publicly, and incorporate into a global response. And what that means for disease surveillance is potentially transformative. Um we will be able to track variants of every pathogen, the major viruses, uh HIV, TB, and to apply that not only for epidemiologic purposes to monitor diseases in much something much closer to real time than we've ever been able to do before, but also potentially for clinical applications in TB drug resistance, in antimicrobial. Microbial resistance more generally in HIV management. So that capacity and the cost of sequencing has come down dramatically. So that's a really powerful technology that we rarely had no access to in LMICs until COVID. So that's one really disruptive innovation that has come about. The second is um uh at a technical level in in what's referred to as multiplex molecular point-of-cure platforms. What does that mean? So the first generation of these were instruments like the expert platform for tuberculosis that really were made a difference in making uh tuberculosis diagnosis uh simpler, faster, less expensive. Instead of taking days or weeks to culture um T B, we can now use a molecular test to identify the the DNA in an hour and and and know that this is TB. And that changes patient care dramatically. But those systems are expensive. You can just say, is this TB? And if the test is negative, well then what do you do? So COVID has has led to the accelerated development of multiple platforms. We're tracking over a hundred companies, 45 in late development, five that are already on the market that can do multiplex molecular testing. So that disruptive innovation that's very likely going to transform primary healthcare across the world, and especially in uh low and middle-income countries that really have not had access to this kind of powerful technology because it was too expensive, too complicated. And we'll see those systems enter the market in 2023, 24, 25, and likely be transformative as we enter the end of this decade.
SPEAKER_03And what about you, Sikilele? How does that play out in Botswana in terms of innovative diagnostic approaches and future?
SPEAKER_05It has really opened up uh avenues for multi-pathogen diagnosis. And a lot of these platforms that were uh enhanced through COVID are now uh open platforms that will be able to cover uh other pathogens. And I think this is very, very important that now we can will be able to do things cheaper. And I think other than just that, we've also seen an innovative way of some digital solutions that could help us to accelerate uh uh availability of data. And if we can enhance these uh uh mobile uh apps uh to make sure data is available at a central level to enhance decision uh making very faster, I think that is very, very, very important. I think that will drive uh quality of care. We can put these tools uh near patient care. I think that will really, really help.
SPEAKER_03Final question to both of you, Bill and Siculeri. What promise does improving access to diagnostics hold for achievement of public health systems in countries such as Botswana and obviously in other uh settings in low and middle-income countries?
SPEAKER_04Yeah, Gary, it's a great question. I would say um we're really we're really at the cusp of a transformation in testing um as part of basic healthcare services on par with treatments and vaccines. And so I think we're we're really entering a new era where disease surveillance and clinical management are going to be much more data-based, based on available tests that are widely used on a regular basis. Whereas in the past, a lot of what we've done has not been data-based. It's been based on best guess and empiric approaches and mass drug administration, things that were effective for their time. But now this is much a much more targeted approach that's going to make healthcare more efficient, more economic, and lead to better outcomes. And I don't want to overpromise what testing can do, but we've seen that potential now begin to transform um public health surveillance and clinical case management in what was otherwise a pretty horrible two-year period of this pandemic. That's the one legacy that I think um um we'll look back on and say, well, at least there was one positive impact from this virus and this pandemic on a global basis.
SPEAKER_05I'll also say that uh this has provided a unique opportunity uh that is accelerating research efforts globally and locally as well, and has highlighted other things like uh engaging communities and leadership in the response. Uh, we see uh novel platforms coming up. It means that disease diagnosis is going to be faster. Uh, and in the in the era of overlapping epidemics, we see an opportunity to extend uh cross-disciplinary research and diagnostic into integrated service delivery for HIV, for TB, for malaria. We see that there's opportunities uh for integration. And also it brings other opportunities in digital data systems uh because now you have you're generating a lot of data in a very short space of time. So you need to manage that data. Uh so solutions for making sure that this data moves very fast. Uh, you're real near real-time reporting to public health and alerts and emergencies and data analytics, making sure this data can provide uh uh reasonable uh clinical decisions, but also public health decisions is becoming uh a very good opportunity. And also we see that the diagnostic industry for manufacturing diagnostics is really, really looking up to say how can we develop these technologies here? And there are tests developed, for example, in in Dhaka, in Senegal, uh they develop their own uh COVID rapid tests. So I think the future is holding on to if I mean someone said we should not waste a crisis. So we should utilize the opportunities that uh COVID has brought us uh to advance uh public health.
SPEAKER_03Thank you both for this exciting discussion and for joining our podcast.
SPEAKER_05Thanks, Gary. It was a pleasure.
SPEAKER_03Thank you, thank you, Gary Bill and Sikulele hold a deep passion for their work, and this was reflected in what they shared with me. I was struck by Bill's quote saying that pandemics don't create new problems in a society, they just reveal the existing ones. As we have heard not only in this episode, but also from so many of our guests I've spoken in the last year, this indeed is true. The COVID-19 pandemic has cast a spotlight on many failures in global health. However, the efforts from countries like Botswana and the experience of virologists like Sikulele gives me really great hope. This shows that it's indeed possible for countries to effectively respond during an emergency, not only safeguarding the health of their own people, but also to share their knowledge with the whole global health community. I want to commend Sikulele and his team yet again for their skilled work in discovering the Omicron variant in Botswana. I feel there is a lot to be optimistic about with so many new diagnostic innovations biming on the horizon. Hopefully, they will reduce the gap and assist in achieving greater diagnostic equity for all.
SPEAKER_00Gary clearly set the stage for Dr. Zagnas and Catherine to speak their truth, which is necessary if we are to hope that the field of global health will transition from the historic power imbalances, inherent racism, and patronizing programming, toward what beloved Dr. Paul Farmer taught us, which has much more to do with being allies to one another.
SPEAKER_03I totally agree with you, Margaret. We must never lose sight that we are all allies in this quest for health globally. Be sure to join the Global Health Matters podcast again next month for yet another inspiring episode. Thank you for listening, subscribing, and sharing the podcast with others who may be interested.
SPEAKER_01Global Health Matters is produced by TDR, an infectious diseases research program based at the World Health Organization. Gary Aslanian, Lindy Van Niekerk, and Maki Kitamura are the content producers, and Obadiah George is the technical producer. This podcast was also made possible with the support of Chris Koes, Elizabeth Adesti, Isa Suder Dayao, Norin Ogalaer, and Chembe Collaborative. The goal of Global Health Matters is to produce a forum for sharing perspectives on key issues affecting global health research. Send us your comments and suggestions by email or voice message to idrpod at who.int and be sure to download and subscribe wherever you get your podcasts. Thank you for listening.
