George Soros, thank you for hosting this discussion and for sustaining the momentum from last year’s White House meeting on the global tuberculosis crisis.
Two out of every three premature deaths in low-income countries are the result of an infectious disease or inadequate maternal or neonatal care – with tuberculosis (TB) one of the major causes.
The enormous infectious disease burden – now mostly avoided in wealthy countries – is a significant obstacle in preventing low-income countries from escaping abject poverty. Infectious diseases are also a powerful force in pushing self-sufficient families into destitution and dependency. A recent study indicates that one TB case alone can lead to 20-30% loss of household income in developing countries. The world will not be able to achieve the poverty reduction targets set by the G8 for the year 2015 if it does not make a renewed effort to tackle tuberculosis and the other major high-burden diseases such as malaria, diarrhoeal diseases, pneumonia, AIDS, measles and maternal mortality.
We have the life-saving drugs to cure TB, and the cost-effective strategy for their use. By using the DOTS strategy fully, most of the 2 million tuberculosis or tuberculosis and AIDS deaths that occur each year could be prevented. It is hopeful to note that the number of countries adopting the DOTS strategy has increased from 10 in 1991 to 110 by 1997, and that the cost of TB drugs has come down from $40-$60 per patient to $10-$20 during this time. WHO is very appreciative of the contribution made by the World Bank and bilateral donors – some of whom are around this table – to work with WHO to achieve this progress.
The fact remains however that today only 20 percent of the world’s TB patients are being treated through the DOTS strategy. And though the cost of TB drugs has decreased, seventy percent of DOTS implementation costs are still related to the purchase of TB drugs. We know that inability to purchase TB drugs is a major obstacle to DOTS expansion for NGOs and the world’s poorest countries. The drugs for DOTS are not rolling off the production lines and making it into countries in quantities necessary to accomplish what is now technically and operationally possible.
So, now is the time to go to scale with the DOTS strategy. WHO and its partners in the Stop TB Initiative, are actively looking for the best way to remove the obstacles created by the lack of anti-tuberculosis drugs, and we hope to be able to suggest how to concretely accomplish this at the ministerial-level conference on TB and Sustainable Development in Amsterdam next March.
It is not acceptable that we cannot make sufficient supplies of anti-TB drugs available in a world where the usefulness of DOTS is well recognized, and where a critical mass of health workers have been trained to use DOTS effectively. At the same time the world has also been forced to take on the new challenge of curing multi-drug resistant TB (MDR-TB), as so clearly described in the Harvard report. WHO is deeply appreciative that George Soros and the Open Society Institute, Harvard University, and the many other partners here today are rising to meet the challenge of MDR-TB. The work now underway that will lead to the development of the DOTS Plus strategy will provide us with much better ways of managing MDR-TB in hospitals in countries such as the former USSR, the Dominican Republic, and parts of China and India.
The emergence of multi-drug resistant tuberculosis around the world could threaten TB control using the DOTS strategy. Multi-drug resistant TB is clearly contagious, and it is associated with high rates of treatment failure. MDR-TB is the result of failure to use the cost-effective DOTS strategy, while state-of-the-art treatment of MDR-TB is prohibitively expensive. We therefore must recognize the vicious circle of bad TB treatment and MDR-TB. We must place it squarely at the centre of our thinking about controlling TB. Bad TB control programmes can create more new cases of MDR-TB faster than DOTS Plus strategies will be able to cure them.
We cannot afford NOT to remove the obstacles to rapid expansion of DOTS. If we fail, efforts to cure MDR-TB cases will be an endless task making merely a cosmetic impact on the global burden of TB. It is equally tragic when an African woman cannot afford the $20 drugs to cure her non-resistant TB as it is when a Russian prisoner will perish because $2,000 is not available for his anti-MDR-TB drugs. In all instances, ensuring low price, high quality and widespread availability of anti-TB drugs is one of our most important challenges.
As increasing amounts of funds are devoted to containing MDR-TB in a few "hot spots" around the world, we must ensure that resources are not siphoned away from implementing and expanding DOTS world-wide. A distorted approach to TB funding may cause confusion in priorities at the country level. Securing second line drugs for individual MDR-TB patients is important, and so is strengthening basic TB control, continued surveillance of MDR-TB, and continued research and development on new anti-tuberculosis drugs. Only a balanced approach can prevent a global MDR-TB epidemic in a cost-efficient way while preventing the greatest number of deaths.
In summary, the TB epidemic today is actually several different epidemics throughout the world. There are hot spots of MDR-TB where MDR-TB levels are above 5%. These include several countries of the former USSR, but also the Dominican Republic and Cote d’Ivoire, and the areas in these countries where MDR-TB has reached these levels must be considered as international public health emergencies. At the same time, levels of resistance in the majority of countries are much lower, and rapid expansion of DOTS can prevent these levels from rising. This is the basic thinking of the STOP TB partners as they work on the concrete solution to combat TB globally.
