Interview with Dr Mario Raviglione, Director of the Stop TB Department, WHO
Dr Mario Raviglione, Director of the Stop TB Department since 2003, has worked on TB control issues for two decades. He talked about past and future challenges from his office in Geneva.
John Donnelly Q: What is your main concern in TB control overall?
Dr Mario Raviglione A: My concern is that people don’t fully understand the basics of TB control. In our enthusiasm to fight XDR-TB (extensively drug-resistant TB) and MDR-TB, many are thinking that we have to deal with these 1,000 MDR cases in country X, while forgetting about the 100,000 normal TB cases in that country. Those 100,000 cases all have to be treated properly or we will get more MDR cases. We should never withdraw from the notion that MDR has to be taken care of. But we must make sure we prevent MDR cases in the first place.
Q: In the early 1990s, WHO recommended DOTS [the basic package that underpins the Stop TB Strategy] to treat TB. At the end of the decade, an argument unfolded over treatment of drug-resistant cases. What happened?
A: There was a big debate between the purists who backed DOTS only and those who wanted the treatment of drug-resistant TB. One side believed the basic thing had to be implementing basic TB control. Others, including Paul Farmer and Jim Kim at Partners in Health, said we had to also address those with MDR, that it was an issue of basic human rights as well as controlling these difficult to treat cases. You have to remember that we were talking at a time when a couple of hundred thousand dollars for TB control in a country was considered a big success and thus the priority was basic DOTS only. But then we held a meeting in Cambridge in April 1998. It was an amazing meeting, there was a lot of enthusiasm, and we reached an understanding. At the end, we had a direction. We realized the first step was to make sure we had the TB drugs available for MDR-TB, and so we conceived the Green Light Committee in the following few months. That, we hoped, would create a demand for the drugs, lower the price, and oversee the use of the drugs.
Q: What were the lessons learnt from that meeting?
A: What I learned was if WHO doesn’t pursue a solution that benefits everyone, the whole world can suffer. The strong collaboration with Harvard and Partners in Health allowed us to move forward. At that meeting, it was just a few people, perhaps 45 of us. We had started a plan to treat those with drug-resistant TB.
Q: Why hasn’t the world made greater progress in the past decade to treat MDRTB?
A: We certainly have persuaded a bunch of countries to do it, including some that were very reluctant. Why is it not done everywhere? It’s extremely difficult to deal with. You need a laboratory to detect it. You need access to drugs. You need money. If you write a proposal to the Global Fund, it takes six months to put together, another three months to get approval – it ends up take a year to a year and a half to get the money. But we’re also well aware of those bottlenecks and we are working to make it an easier process.
Q: What was the impact of the discovery of extensively drug-resistant TB, and naming it XDR-TB?
A: This hugely accelerated the process of making people aware of the dangers of TB. ‘The X underlines the urgency of the problem.” The outbreak in Kwa- Zulu Natal (where 52 of 53 people died of XDR-TB) really shocked people.It showed how scary this could become. After it happened, we called a meeting in Geneva (Switzerland) and named the first XDR-TB Task Force. During this period there was a lot of attention around the world. Everyone now knew that this was one of the worst possible diseases you could get and named it the first XDR-TB.
Q: What do you hope happens next?
A: I want health ministers around the world to say, `My goodness, I didn’t know this was so scary. I must do something.’ Then you hope the next day they call the national TB program manager and says they want them to face this thing as a top priority. I want them to put more money in their budget toward this and to apply for a grant from the Global Fund. I want them to upgrade their labs immediately, introduce the new technology that identifies MDR- and XDR-TB in 24, 48 hours, not four months. I want them to make sure the drugs are of proper quality, make sure the physicians are trained right away on what needs to be done. They should get outside experts to come to their country and teach them how to do these things, and they should develop a national plan to fight TB.
Q: Couldn’t the global financial crisis impede progress?
A: This is an emergency. There is no choice. Money can be mobilized. If people get more ambitious, they can get the money and get this done. When people decide to do things, they can do it. In Brazil, in the 1990s, they gave antiretroviral drugs to everyone who had AIDS. No one else in the developing world did it, but they showed you could do it. If there is political will, then the possibility is there.