What does it actually mean to cure a disease?

Opinion: vaccines are considered the gold standard in healthcare and if delivered correctly would lead to eradication of hepatitis C, so why hasn't it happened yet?

By Jamie Sugrue, Trinity College Dublin

Research is often focused on developing a cure or a therapy for a disease. The definition of both these words centres around relieving or healing a person of their disease state or condition. Access to these cures or therapies is rarely discussed and often society is not one which easily facilitates access for everyone suffering from a particular condition.

Is it enough to fund development of a cure or therapy without continuing to work to properly ensure adequate dissemination of aforementioned treatment? Can we truly call a cure a cure if access is difficult and therefore the ability to cure some is negated? What if the cure or treatment we have developed is only 60-70% effective? It is unlikely that time and money would continue to be invested in tackling this condition further - is that fair? All these questions ultimately lead to the bigger question of what does it actually mean to cure a disease in the modern world?

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From RTÉ Radio 1 Drivetime, Catherine Byrne, Minister of State at the Department of Health discusses the launch of a new vaccine alliance

The story of the hepatitis C virus (HCV) is a useful narrative in exploring these questions further. HCV was discovered in 1989, and initial therapies weren't good: they had a success rate of about 50%, needed to administered over the course of a year and had awful side effects. Since 2010, a drug that has a 95% cure rate once taken has been 'available’. These drugs, known as Direct Acting Antivirals (DAAs), target HCV specifically.

How many times can we afford to treat any one individual?

HCV requires blood to blood contact to spread, so people most often affected include recipients of contaminated blood products, or individuals who inject drugs. As HCV infection is a progressive disease that slowly causes liver damage over a period of 20-30 years, many people who are infected go a long time without being diagnosed. The most recent estimates from the World Health Organisation (WHO) indicate that there are 71 million people chronically infected with HCV worldwide, though only 20% of those have actually been diagnosed, and though DAAs have been available for about a decade, only 2.9% of people infected have been treated.

From RTÉ One News, Women exposed to blood product contaminated with Hepatitis C in late 1970s asked to volunteer for study

365,000 people still die from HCV related illnesses annually. The WHO hopes to eliminate HCV by 2030, an ambitious target that many reports suggest is unlikely to be met given the current regime. Therefore, despite the availability of a cure for HCV significant work around diagnosis and dissemination is still required.

One contributor to the reality that the WHO target is unlikely to be met is that therapies directed against HCV do not prevent reinfection, therefore without adequate accessibility, we will likely have a continuous cycle of treatment and reinfection for many individuals. At €50,000 per treatment, this is not a model that can be sustained by any healthcare system, and will lead to difficult new questions about how many times can we afford to treat any one individual?

We need to keep in mind that 'curing' a disease often isn’t sufficient

In light of this, perhaps continued funding should be focused on vaccine development for HCV, which prevents infection in the first instance, thus rendering null the need for therapeutic interventions. Vaccines are considered the gold standard in healthcare and if administered correctly would lead to the eventual eradication of HCV, as we have done with polio and smallpox.

The big question of course is why the proposals above are not the reality, and inevitably the answer is centred around economics and money. Ireland, as with most other countries across the globe, has a significant shortfall in funding scientific research. As a scientist with some experience in applying for research funding, this is not a particularly profound statement, but it is perhaps a fact of which everyone is not aware.

From RTÉ Archives, Government is set to establish a £120 million compensation tribunal for those infected with contaminated blood (1995)

Ireland's expenditure on research and development as a percentage of GDP is just 1.18% (2016), while the EU average is 2.03%. As a country, this means that not every project deemed worthy of funding by a review body will actually receive the funding they have requested. In one sense, this is a nod to the quality of work being done by scientists in Ireland, in another sense, it’s incredibly disheartening.

In light of this unfortunate reality, funders are required to make tough decisions and focus funding on projects with perhaps more obvious applications, and areas which they deem to be of priority for the state. This trend towards funding projects with high potential for application, be it in developing a new therapy or policy is one which the scientific community at large is concerned about.

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Funding more of these types of projects takes more and more away from the finite budget of that funding institution, meaning less money can be spent on blue skies research (more fundamental research) or areas with more subtle application, such as dissemination or access to medication, or the development of strategies for diagnosis.

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Given the finite budget, should a disease be deemed cured, work centred around that disease is very unlikely to be funded in subsequent funding calls. We therefore need to keep in mind that ‘curing’ a disease often isn’t sufficient and that continued work in that area can lead to new and exciting results with broader applications as well as ensuring proper access to that therapy.

Jamie Sugrue is a PhD Candidate at Trinity College Dublin who is researching resistance to viral infection in a unique cohort of women exposed to hepatitis C virus contaminated medication in the 1970s.

The views expressed here are those of the author and do not represent or reflect the views of RTÉ

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