Going Public: Pharma’s Commitment to Public Health

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Elisabeth Pena Villarroel

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By Elisabeth Pena Villarroel

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The pharmaceutical industry’s commitment to public health is at the core of its very existence; the mission and work of the industry’s companies are to create, develop, and bring to market lifesaving and life-enhancing medicines. A natural extension of this mission is the industry’s participation and sponsorship of myriad public-health initiatives around the world (see box page 20). From donating medicines and providing funding for health initiatives to helping with pandemic planning, responding in crisis situations, and providing education, the pharmaceutical industry’s contributions to, and its role in, the public-health arena are varied. With a lingering public-perception problem among consumers, the industry has to take a leading role in communicating in the public-health forum. Key Issues Funding, insurance, education, and access to medicines rank among the top public-health issues of concern to the pharmaceutical industry. DeBuono. Pfizer. Meshing the research agendas of public health and the pharma industry is a challenge. As research and development of new products that impact lifestyle continues, for instance obesity drugs, there are many goals shared by the industry and the public-health community. If we could combine forces to come up with a research agenda to address whether those interventions are having an impact on the public’s health, that would be a great opportunity for partnerships. Another area for coordination is the healthcare reform agenda; both the public-health community and the pharma industry have a vested interest. Public-health groups are interested in providing access to care and coverage for the underserved and for children, and the pharma industry wants to ensure that people have access to medicines as well as the latest therapies. There is a need to more effectively communicate their collective agenda. Mello. Harvard School of Public Health. The two public-health issues for the industry that are foremost in the public’s mind are its interface with the academic medical establishment around research and the issue of pharmaceutical access and pricing. Whyte. Discovery Health Channel. The number of uninsured Americans is an issue that affects all aspects of the U.S. healthcare system. In the United States, cost is the main barrier to pharmaceutical access, and many patients, even with Medicare Part D, cannot afford the medications they need for optimal treatment. Pharmaceutical companies face the challenge of developing innovative and affordable products. Increasing access to these medications will continue to be a public-health challenge for the industry, especially as the American population continues to age. The industry has pharmacy assistance programs, and lately companies have been communicating these messages around the country, for instance with Montel Williams. At the same time, there is the broader issue that people forget: drug development and drug discovery cost a lot of money. Allsop. AstraZeneca. Personalized medicine is one of the scientific advancements moving the industry away from treatments that offer health benefits to very broad populations of patients and toward more targeted treatments that will offer benefits to specific subpopulations of patients. This presents us with several challenges, including cost of development and developing or leveraging proper diagnostics to identify patients who will benefit from drugs. Frain. GlaxoSmithKline. A lack of resources — too few dollars, too few people, and too few facilities, particularly in the developing world — to deal with public-health issues is a key problem. The World Health Organization has estimated that to supply a basic package of medicines it would cost $34 a year per person, and 35 of the 46 African countries spend less than $12 a year. This is a key issue for the pharmaceutical industry, and it should be a collective responsibility for the countries and international groups involved. Howe. Project HOPE. The two top public-health issues facing the life-sciences industry are professional healthcare education and access to medicines. Over the years, the pharma industry has developed and produced new treatments with dramatic results, but emerging nations may not be aware of these new treatments. Through the partnership of Project HOPE and the pharmaceutical industry, we are able to address this need by providing educational opportunities and training to physicians and other healthcare workers. For example, in the late 1990s the president of China came to us and described an epidemic facing his country, which was diabetes. His concern was that less than 20% of people with diabetes knew they had the disease before developing a complication. We addressed this need for education through a train-the-trainer program. Additionally, in the past few months we have trained more than 200,000 healthcare workers, including almost 37,000 doctors and nurses in all of the country’s provinces. BD, Eli Lilly, and Roche were the major supporters of this initiative with Project HOPE. Colatrella. Merck. Sustainability of public-health programs, particularly in the developing world, is a key issue that we are all facing and trying to address. For Merck, one of the ways that we have tried to ensure that these programs and healthcare systems are sustainable is by not trying to do it alone. We bring to the table all the partners who are essential in making sure medicines don’t sit on the shelf but get them to those who need them most. Pharma’s Role The pharmaceutical industry plays an important public-health role just by creating and developing medicines, but it does not stop there. Many of the industry’s companies work closely with public-health organizations to further patient care. Mello. Harvard School of Public Health. Historically, the pharma industry’s main contribution to public health has been through innovation and generating new products that are available to those who can afford them and, in the course of that innovation, providing the bulk of the funding for clinical research. Nowadays, there is a question of whether the industry’s obligations extend to acts of charity. Does the industry have an obligation to behave as a charitable organization, although historically its contributions have arisen because it has been focused on being an excellent business? DeBuono. Pfizer. One area that both the pharma industry and public-health community are knee deep in, in terms of preparedness, is pandemic planning. The public-health community is seeking out pharma for producing vaccines and drugs, such as Tamiflu, and at the same time pharma is seeking the public-health community out to get a better sense for the guidelines and recommendations around treatments. Pandemic planning is an area that the pharma industry can play a major role in. Also, Pfizer is very interested in supporting efforts to improve the public-health workforce, which includes everything from providing fellowships for young investigators in public health, to programs, such as our CDC applied epidemiology fellowship program. We also have produced several policy books and career guidebooks to celebrate and showcase leadership in public health. We are very excited about making a contribution to the field by telling stories and celebrating the experts in the field to motivate and captivate young people to go into this field. Whyte. Discovery Health Channel. The pharmaceutical industry plays a key role in public-health issues. Close collaboration with government agencies is required to make certain that adequate amounts of antibiotics and antidotes are available in case of public-health emergencies. Worldwide, the public-health issues of HIV, tuberculosis, and other infectious diseases take center stage in public-health policy. In the United States, concerns about bioterrorism also have become increasingly important. Partnerships with national, state, and local agencies on issues of disease-management and quality-improvement initiatives will be increasingly important. For instance, pharmaceutical support of patient education, like diabetes education programs or public awareness campaigns for HIV or other infectious diseases, such as malaria and tuberculosis, is an effective means of improving patient outcomes. Continued physician education is also important to improve adherence to national guidelines and evidence-based practices. Changing physician behavior is a crucial step to tackling the inefficiencies of the system. And people forget that pharma companies play a key role in drug development and discovery. Their research budget surpasses the NIH. Pharma companies play a pivotal role in translating research into practice. Allsop. AstraZeneca. Certainly pharma has a role in areas such as developing new medications that might treat high-risk conditions that occur before clinical manifestations, such as high-blood pressure or cholesterol. Also, several of us in the industry are engaged in searching for new therapies to address highly infectious diseases, such as tuberculosis, that have significant worldwide impact. The industry also can play a role in promoting greater compliance among patients with their prescribed treatments to avoid the potential negative consequences of infections or chronic diseases that are inappropriately treated because patients don’t rigorously follow the course of treatment prescribed by their healthcare provider. Colatrella. Merck. For Merck, and the industry as a whole, we see our primary role as discovering, developing, and delivering innovative medicines and vaccines that help to improve health globally. One of the key questions for us is deciding what we should focus on and sometimes that involves making tough choices. At Merck, we have decided to focus on nine primary therapeutic areas, including obesity, oncology, cardiovascular disease, diabetes, vaccines, Alzheimer’s disease, atherosclerosis, pain, and sleep disorders. The criteria we look at include unmet medical needs and our core research competencies. Guselli. InfoMedics. For the industry to play a larger role in the future of public health, pharma companies have to demonstrate that they are operating in the best interest of public health. Right now because the industry is in a defensive posture, it is very difficult for companies to be perceived as anything other than being profit driven. The industry association — PhRMA — has to be leveraged, not so much to take on these issues, but to begin to integrate the industry into the decision-making process. Howe. Project HOPE. An example of the power of a partnership between the pharma industry and a nongovernmental organization, such as Project HOPE, is exemplified in the work that we were able to accomplish in partnership with Abbott and Pfizer. Those companies supported our health worker training and mentoring program in the Hubei province of China to build HIV healthcare capacity. They trained healthcare workers in the use of antiretroviral medicines: when they should be used, how they should be used, and how they should be monitored. As a result of this two-year program, the mortality rates among HIV patients in that province decreased 72%. This example shows that pharma companies bring expertise, research, development, and the distribution of lifesaving medicines to the on-the-ground experience and expertise of groups such as Project HOPE. That chemistry results in a profound impact on people; HIV patients in Hubei province are living examples of this chemistry. Frain. GlaxoSmithKline. The whole movement of public-private partnerships is critical to being part of the solution. Companies in the industry have chosen different ways to participate in public health, but as an industry our primary role is clearly to do what we are best at, which is to discover and develop more medicines and to make sure they can be supplied to the people who most need them. At GlaxoSmithKline we have two approaches: we donate medicines for short-term treatments to organizations such as Project HOPE, and we make HIV and malaria medicines available at cost for the 64 least-developed countries — to their governments, as well as employers, and nonprofit organizations in these countries. Going Beyond the Doctors’ Offices Whether the pharma industry is helping out in crisis situations or tackling some of healthcare’s underlying social issues, many companies play a public-health role that extends beyond clinics and doctors’ offices. Allsop. AstraZeneca. The pharmaceutical industry already plays a role in disseminating disease and well-being information to both patients and the public through Websites and other forums. This information, however, is often viewed as added value that comes from our research into diseases. Pharmaceutical companies should not be seen as the major source of information on disease but rather as one partner among others, including healthcare providers, academia, and governments, contributing to a public-health discussion. Colatrella. Merck. While the key role of pharma companies is to make sure that we are producing innovative medicines and getting them to those who need them, we also have a lot to offer in terms of management and technical expertise. For example, during the 9/11 tragedy, the role Merck played was quite different from other disaster situations. Our primary role wasn’t to provide medicines to hospitals; rather we provided our helicopters and our ambulance services, and our plant locations supplied construction gloves, goggles, cots, and bedding. We have logistical experience in terms of moving medicines through a delivery system in a crisis situation, and we have management and technical expertise, which are also very useful in terms of preparedness. Frain. GlaxoSmithKline. I believe that the most effective industry contributions can be made when the activity is closely related to the business; we try to target most of what we do on health and healthcare education to some extent. We have a program called PHASE, which stands for Personal Hygiene and Sanitation Education, and the goal of this program is to educate children about the importance of washing their hands after using the latrine and also educate communities on the importance of having well-maintained latrines. The results from this program have shown that children are absent from school much less because they don’t have diarrheal disease and, because they are out from school less, their grades are better and they are better educated. So in the end, these types of programs do help underlying causes of some public-health problems and contribute to bringing people out of poverty. Whyte. Discovery Health Channel. Pharmaceutical companies should demonstrate good corporate citizenship. Partnerships with government and nonprofit agencies are certainly methods to start addressing these large-scale issues. But just like any large social change, the best and most effective ideas start at the ground level. If individual doctors and patients buy into an initiative, they will help generate momentum and move the idea forward. In contrast, large-scale initiatives that are passed down to physicians and patients are often viewed with skepticism. Also, the pharma industry can help tremendously in preparedness. Companies have great infrastructures to connect with physicians’ offices through their detail representatives and other personnel, and they have connections to the pharmacies. They can play a critical role in dealing with issues of preparedness, especially issues that could relate to bioterrorism and other public-health emergencies. People forget that pharma companies can play a role in these areas. But one industry or one person cannot do everything, and pharma should focus on what it does well and not extend too far at the beginning of the health continuum, which isn’t an area of expertise. DeBuono. Pfizer. A good example of public-health efforts that go beyond the doctor’s office is our work in health literacy, helping the public and patients understand health information clearly and effectively so that they can make decisions. Pfizer has been committed to this for more than 10 years. All of our patient education materials are written at a 5th and 6th grade reading level, a reading level that is understandable to the majority of the public. We feel our role goes beyond the development, distribution, and selling of medicines and the doctor-patient interchange; we really believe that as a company we can focus on larger public-health issues. As we introduce our products and programs, we have to introduce other elements that lead to better health. One such element is training on basic public health. We are beginning to take a larger worldview of our mission, which is beyond merely the discovery and distribution of medicines and looking at how we fit into the larger health agenda. Guselli. InfoMedics. In the long run, the pharma industry would be better off trying to get actively involved in the public-health forum by being perceived more as an asset than as a liability. While companies can get some mileage from, and have been effective with, patient-assistance programs and with making HIV and AIDS drugs available around the globe, these give companies marginal credibility. I am talking about infiltrating the public-health decision-making forum. The industry could make a better effort to assert itself in a productive and constructive way to address fundamental public-health issues on local, state, and federal levels. Mello. Harvard School of Public Health. There is an inherent conflict of interest in asking a company to help ameliorate the health conditions that generate a market for its products. One obvious example is obesity. There are many ways pharma can support the efforts of communities, health plans, and employers to try to curb obesity, but pharma also is very interested in developing anti-obesity drugs. Howe. Project HOPE. The best way for the pharma industry to have an impact outside the doctor’s office is to partner with organizations such as Project HOPE that are working day in and day out to make a difference in the health of people around the world. For example, last summer, the Navy deployed its 1,000 bed hospital ship, The Mercy, to Southeast Asia, and Project HOPE volunteers, along with Navy counterparts, provided care and humanitarian aid to people at 10 stops along the way. Several pharma companies, including Abbott, Baxter, J&J, Merck, and Wyeth complemented this effort by contributing pharmaceuticals and financial resources. Because of their support, volunteers took care of almost 61,000 patients aboard the ship and on shore, performing more than 1,000 surgeries, giving more than 11,000 immunizations, filling more than 41,000 prescriptions, as well as conducting more than 6,000 training courses that included CPR and emergency obstetric procedures. This is an example of the pharma industry coming together with Project HOPE in a far away region of the world and truly making a difference. Public Health and the Industry’s Perception Communication of the industry’s role in public-health improvements and successes could contribute to improving the industry’s public image, however, experts say there is a fine line between informing people about the good deeds and using these actions for promotion. Colatrella. Merck. It is crucial to raise awareness and get the information out there so that people have a very comprehensive view of what we stand for as an organization. The hope is that if they are aware of Merck’s commitment to public health it will help to differentiate Merck and raise awareness of the company and lead to all around better feelings about the industry in general. But this is a tightrope that we have to walk. While we have a desire to get information out there to educate and inform the public, unfortunately this information is sometimes perceived as promotional rather than educational as it was intended. Allsop. AstraZeneca. In my opinion, much of the criticism comes from people not understanding the tremendous contribution the pharmaceutical industry has made to medical research and improving health and healthcare. I won’t speculate on what the next five years could bring, but I will say I believe the greatest impact we can have on public perception is to lead with our science. We need to discuss and deliver new and better ways of treating life-threatening and chronic disease. DeBuono. Pfizer. Public-health leaders understand that good communications around a crisis are absolutely critical to solving that crisis. When there is an outbreak of a disease or a pandemic, a public-health leader has to communicate the best ways of prevention and treatment. In many ways the pharma community is facing an image and perception problem and can learn lessons from the public-health community about the need for good, open, transparent communications early on. Whyte. Discovery Health Channel. Americans have become increasingly critical of any large corporation, and the pharmaceutical industry has not been free from that scrutiny. Continued support and development of public-health initiatives would certainly help to offset this negative perception. With continued reports of “secret payments” to physicians and some lingering negativity from Vioxx, pharmaceutical companies will have to take an active role in improving perception in the next five years. Like other for-profit corporations, pharma companies have a commitment to their shareholders. Balancing this commitment with an altruistic commitment to the patients who benefit from their medications is a challenge. Mello. Harvard School of Public Health. The industry is rightly looking for ways to make amends in areas where it is has been perceived to have, in some cases, acted inappropriately or in ways that did not match public expectations. Efforts to provide greater access to medications are lauded by the public-health community, but to address some of its public-perception problems the industry has to tackle areas where the problems occurred. For example, prescription-access programs are useful in addressing critiques that the industry prices its drugs at a premium or out of the reach of many populations. But there is a whole other set of perception issues around nondisclosure of safety information and secrecy in the industry. To address these issues, the industry has to make public-health outreach efforts that specifically pertain to the conduct of research and provide transparency around those areas. Howe. Project HOPE. Participation in public-health initiatives puts the industry in a different light, a light that illustrates a caring and compassionate side of the people who choose to work in the industry and make a difference every day in the health of people around the world. The beneficiaries of our programs throughout the world, whether they are health professionals who have been trained or patients who have been treated, are very grateful for the training and the care, and with that comes a feeling of appreciation for our pharma partners. So as the industry looks for ways in which it can participate in doing good, this is one in which the act of reaching out and making a difference in people’s lives makes patients better. It also changes the perception of the industry. It is truly a win-win situation. Frain. GlaxoSmithKline. Instituting programs in developing countries isn’t enough; we have had these programs for many years. For instance, our HIV program was the first industry program for the disease back in 1992, but that hasn’t stopped us from receiving criticism or protected the company. The people we work with know that we are not only interested in the sales of our products, but that we are interested across the whole spectrum of healthcare, right down to how communities work and what they need to do to protect themselves from diseases. We need to raise awareness around these efforts with the public. PharmaVOICE welcomes comments about this article. E-mail us at feedback@pharmavoice.com. Dr. John Whyte Discovery Health Channel CME is an area where pharma companies can play a vital role in helping to educate physicians in the latest technologies and interventions. This is an area that most public-health agencies don’t have the funds to address. Brenda Colatrella Merck We certainly have a role to play in addressing broader social issues. The challenge is figuring out where to focus to make an impact and to engage in projects where we can play an integral part rather than engaging in transactional philanthropy. Dr. Michelle Mello Harvard School of Public Health There are a variety of roles that the pharmaceutical industry could play in public-health promotion, but there is an inherent conflict of interest in asking a company to help ameliorate the health conditions that generate a market for its products. Thought Leaders Aileen Allsop, Ph.D. VP, R&D of Science Policy, AstraZeneca, Wilmington, Del.; AstraZeneca is an international healthcare business engaged in the research, development, manufacture, and marketing of prescription pharmaceuticals and the supply of healthcare services. For more information, visit astrazeneca-us.com. Brenda d. Colatrella. Executive Director of Global Health Partnerships, Merck & Co. Inc., Whitehouse Station, N.J.; Merck is a global research-driven pharmaceutical products company. For more information, visit merck.com. Barbara DeBuono, M.D., MPH. Senior Medical Advisor, U.S. Public Health and Policy, Pfizer Global Pharmaceuticals, Pfizer Inc., New York; Pfizer discovers, develops, manufactures, and markets leading prescription medicines for humans and animals as well as many of the world’s best-known consumer brands. For more information, visit pfizer.com. Justine Frain. VP, Global Community Partnerships, GlaxoSmithKline, Philadelphia; GlaxoSmithKline, one of the world’s leading research-based pharmaceutical and healthcare companies, is committed to improving the quality of human life by enabling people to do more, feel better, and live longer. For more information, visit gsk.com. Gene Guselli. CEO, InfoMedics Inc., Woburn, Mass.; InfoMedics helps pharmaceutical companies and managed-care organizations improve the quality of communications between patients and their physicians. For more information, visit infomedics.com. John P. Howe III, M.D. President and CEO, Project HOPE, Millwood, Va.; Project HOPE (Health Opportunities for People Everywhere) is an international healthcare education and humanitarian assistance organization that works to make healthcare available for people around the globe, especially children. For more information,visit projecthope.org. Michelle M. Mello, J.D., Ph.D. C. Boyden Gray Associate Professor of Health Policy and Law, Department of Health Policy and Management, Harvard School of Public Health, Boston; the Harvard School of Public Health’s mission is to advance the public’s health through learning, discovery, and communication. For more information, visit hsph.harvard.edu. John Whyte, M.D., MPH. VP, Continuing Medical Education, Discovery Health Channel, Discovery Communications Inc., Silver Spring, Md.; Discovery Communications is a nonfiction media company that reaches more than 1.5 billion people in more than 170 countries. For more information, visit discovery.com. Dr. Barbara DeBuono Pfizer We are at a juncture between what I would consider the public-health arena’s need to articulate its vision for a healthier world and pharma’s need to identify itself publicly as an industry committed to a vision for health. Dr. Aileen Allsop AstraZeneca Pharmaceutical companies should not be seen as the major source of information on disease but rather as one partner among others, including healthcare providers, academia, and governments, contributing to a public-health discussion. Project HOPE ince 1958, Project HOPE (Health Opportunities for People Everywhere) has worked to make healthcare available for people around the globe — especially children. The international healthcare education and humanitarian assistance organization has trained more than 2 million healthcare professionals and provided more than $1 billion in pharmaceutical products and other healthcare products to emerging countries around the world. The organization began with a hospital ship that traveled the world. In 1958, Dr. William B. Walsh, a Navy medical officer, persuaded President Eisenhower to donate a U.S. Navy hospital ship, the U.S.S. Consolation. With $150, a dream, and the support of corporations and individuals, the ship was transformed into the S.S. HOPE, and the organization known as Project HOPE was born. Today, with more than 70 programs ongoing in 32 countries around the world, the organization’s main focus is to develop long-term sustainability in the areas where they serve. “We don’t look to just drop in and deliver medicines and leave; we look to reestablish the healthcare infrastructures,” says John P. Howe III, M.D., president and CEO of Project HOPE. He cites the group’s work in Indonesia following the tsunami, noting that Project HOPE still has people on the ground helping to rebuild its hospitals as well as train nurses and doctors. Project HOPE works closely with the pharmaceutical industry to help further its mission of providing healthcare around the world. Recently, the organization honored five global healthcare companies — Genzyme Corp., GlaxoSmithKline, Johnson & Johnson, Merck & Co., and Wyeth — which have each contributed more than $100 million in gift-in-kind and financial support to the organization’s programs worldwide. Brenda Colatrella, executive director of global health partnerships at Merck, says the wide-ranging reach of the organization’s initiatives is one reason Project HOPE makes such a terrific partner for the industry. “We have six primary partners in terms of medicine donations, and Project HOPE, which serves 78 countries, is one,” she says. “During the past 10 years we have donated close to $2 million to support Project HOPE’s programs and about $200 million in medicines and vaccines; one of the key areas in which we have worked with Project HOPE is immunization programs.” Dr. John Howe Project HOPE Sound Bites From the Field Anshal Purohit is Director, Strategy and New Business, at Donahoe Purohit Miller Inc., Chicago, a full-service healthcare agency offering strategically creative advertising, market research, and education. For more information, visit donahoepurohitmiller.com. “Corporations that have been most successful in repairing the industry’s damaged image, along with their own, are those that have taken an active and meaningful role in shouldering their responsibility to domestic and global public health. Monetary and/or intellectual investments in orphan drug development, contributions in support of public-health issues, and a willingness to support legislation in favor of global access to essential medicines are all activities that demonstrate a genuine commitment to the core industry mission of delivering health and well-being to all people and simultaneously serving to further the industry’s rebranding efforts.” Lynn O’Connor Vos is CEO and President of Grey Healthcare Group, New York, a global healthcare communications network that provides an extensive array of integrated services in support of brand acceleration and sales. For more information, visit ghgroup.com. “Social networking promises to be one of the best tools we have for helping the public understand and build confidence in our industry. As consumer-generated online content continues to grow, industry leaders must use its power to nurture lasting relationships that advance the public health and trust. By sponsoring or mediating online discussions, companies can affirm their position as actively engaged, caring partners by helping to create online communities where people can solve problems together. These communities can have a measurable impact on improving patient care and our industry’s image. And those companies that understand how to become custodians of this online dialogue will reap the benefits of stronger consumer and physician relationships and deeper public trust.” PharmaVOICE asked experts what tactics or best practices have been most successful in helping to repair the industry’s image and how public-health efforts can contribute to repairing the image. Gene Guselli InfoMedics When talking about public health, building durable relationships with patients, or understanding the patient-support needs of physicians we need to discuss changing the paradigm and redesigning the industry’s core business model. Justine Frain GlaxoSmithKline One of the key activities we can do to improve public health is to be an employer and provide business opportunities, because those initiatives can help address poverty and related issues. As an employer we also can play the role of corporate citizen as our local employees do community work with schools and hospitals. Public-Health Initiatives Many pharmaceutical companies have an extensive list of public-health initiatives, some of which are highlighted below. GlaxoSmithKline n African Malaria Partnership — The GlaxoSmithKline African Malaria Partnership (AMP) was established in 2001 to support effective community-focused responses to improve the prevention and treatment of malaria in sub-Saharan Africa. In 2005, the company launched Mobilizing for Malaria, an advocacy initiative to help increase the world’s attention on the problem. GSK also supports education and behavior-change programs in Africa through partnerships with nonprofit organizations by encouraging effective prevention and prompt treatment. n Global Alliance to Eliminate Lymphatic Filariasis — GSK is a key member of the Global Alliance to Eliminate Lymphatic Filariasis, a 20-year program to break the transmission cycle of this mosquito-borne disease. GSK donates its antiparasitic medicine albendazole, which is given once a year together with one other treatment. Also known as elephantiasis, LF is a disfiguring parasitic disease found mainly in tropical countries. n Personal Hygiene and Sanitation Education (PHASE) — Established in 1988, PHASE is a low-cost education program that helps to reduce diarrhea-related disease by encouraging school children to wash their hands. PHASE currently operates in eight countries — Bangladesh, Kenya, Uganda, Zambia, Nicaragua, Peru, Mexico, and Tajikistan — reaching more than 375,000 children and their extended families. n Positive Action — This program was set up in 1992 to support the communities affected most by HIV/AIDS. Positive Action projects strengthen the responses to the epidemic and enable greater involvement of people living with HIV and AIDS at all levels. Merck & Co. n The African Comprehensive HIV/AIDS Partnerships (ACHAP) — This is a partnership among Botswana, Merck and The Merck Company Foundation, and the Bill & Melinda Gates Foundation to support and enhance Botswana’s national response to HIV/AIDS through a comprehensive approach to prevention, care, treatment, and support. n China-MSD HIV/AIDS Partnership — This is a public-private partnership with China’s Ministry of Health to provide HIV/AIDS prevention, patient care, treatment, and support. n Merck Childhood Asthma Network Inc. (MCAN) — A nonprofit, 501(c)(3) organization, MCAN was established in 2005 to address the complex and growing problem of pediatric asthma. n The Merck Mectizan Donation Program — Since 1987, Merck has donated its drug Mectizan for the treatment of onchocerciasis (river blindness) to all who need it for as long as necessary until the disease is eliminated as a public-health problem. In 1998, Merck expanded its commitment to include the prevention of LF in African countries where it co-exists with river blindness. The program reaches more than 100 million people each year. n The Merck Vaccine Network-Africa (MVN-A) — Launched in 2003, MVN-A is a multiyear initiative to help increase the capacity of immunization programs to effectively deliver vaccines in Kenya and Mali through the training of national and regional healthcare workers in vaccine management and immunization services. n Nursing Libraries for Refugee Health — Launched in February 2006, the initiative is a collaboration of the International Council of Nurses, United Nations High Commissioner for Refugees, and Merck to provide healthcare information and training to nurses and health workers serving refugee populations in Africa. n Romania-Merck Partnership — Merck has worked with the Romanian government since 1997 to increase access to treatment and care for thousands of its children and adults living with HIV/AIDS. n U.S. Patient Assistance Program — Merck established the Merck Patient Assistance Program 50 years ago, making it one of the first such programs in the industry. Today, hundreds of thousands of patients in the United States without prescription drug coverage receive free medicines through this program each year. Pfizer Inc. Alliance for a Healthy Border/Alianza por una Frontera Saludable — This partnership is designed to improve care for and prevention of diabetes and cardiovascular disease in the U.S.–Mexico border region. Ask Me 3 — This program model was designed to improve patient-provider communication by focusing on three key health questions patients should ask their providers in any healthcare interaction. What is my main problem? What do I need to do? Why is it important for me to do this? Clear Health Communications — Developed in partnership with leading health literacy experts Leonard and Cecilia Doak and Pfizer, the initiative provides guidelines for creating health information that is accessible to a broad consumer audience. Diflucan Partnership Program — Pfizer created the program to provide Diflucan, an antifungal that treats two fungal opportunistic infections associated with AIDS, free of charge to governmental and nongovernmental organizations in developing countries. Global Health Fellows — This program sends Pfizer colleagues on three- to six-month assignments to work with nongovernmental and multilateral organizations addressing HIV/AIDS, tuberculosis, malaria, and other devastating diseases in developing countries. Infectious Diseases Institute — Pfizer partnered with the Academic Alliance Foundation and other experts to establish the Infectious Diseases Institute (IDI), a regional training, research, and treatment center with headquarters at Uganda’s Makerere University. International Trachoma Initiative — Developed as a public-private partnership, the ITI is dedicated to eliminating trachoma, the world’s leading cause of preventable blindness. The ITI to date has given more than 44 million treatments of Pfizer’s antibiotic, Zithromax, and trained thousands of healthcare professionals who, in turn, have completed 252,000 surgeries to treat advanced cases of trachoma. Pfizer Malaria Partnership — To help close critical gaps in malaria treatment and education, Pfizer has committed $15 million over five years to support pilot programs in Ghana, Kenya, and Senegal. Through partnerships with health organizations and health experts, this initiative will develop and support pilot efforts that engage and educate treatment providers and patients to improve the use and effectiveness of malaria treatment and patient adherence. Southern HIV/AIDS Prevention Initiative — In the United States, 46% of all new HIV/AIDS cases occur in the South. From 2004 to 2006, the Pfizer Foundation funded 23 innovative HIV/AIDS prevention programs and strengthened the capacity of community-based organizations to reach and serve their communities.

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