- The Washington Times - Sunday, April 2, 2006

Washington Times special correspondent John Zarocostas recently interviewed Christopher Dye, coordinator for tuberculosis (TB) monitoring and evaluation at the World Health Organization (WHO), in Geneva about efforts to control the deadly disease. Mr. Dye, 49, has a doctorate in zoology from Oxford University in England and is the lead author of the new WHO report “Global Tuberculosis Control, 2006,” issued to coincide with World TB Day on March 24.

Question: The report shows that in 2004, the last year for which records are complete, there were 8.9 million new cases of TB and 1.7 million deaths worldwide, despite the fact that there have been treatments for decades.

Answer: Well, the first thing to say is that the rates of tuberculosis are still increasing, but they’re not increasing anything like the rate they would be increasing if we hadn’t already achieved what we have under the [Direct Observed Treatment, Short-Course] strategy — the core public-health approach to controlling TB. It consists of the prompt diagnosis of patients, the correct drugs for treating those patients, a recording and reporting system for knowing what’s going on, and mechanisms for building political commitments.

Under the DOTS strategy, over the last 10 years that we’ve been gathering information, we’ve treated over 20 million TB patients, and that treatment has undoubtedly dramatically reduced the death rates in those parts of the world where DOTS has become available. And it has almost certainly reduced transmission and slowed the rate of which TB is increasing around the world. There have been many achievements of the DOTS strategy, even though this report makes it clear what we have achieved so far is not enough.

Q: Some regions, and some very poor countries, are doing very well in controlling TB, but some not so well. How do you explain the discrepancy?

A: … We do see variations in performance. The explanation for that variation in performance is different in different countries. Some countries have not made the political commitment at the highest level, which we know is extremely important.

If we take a country like Peru, which had spectacular successes in TB control during the 1990s, that was in large part because there were strong political commitments not only for TB control, but also for improving public health in general. That really worked, and we have the evidence to show that it worked.

Similarly, China, with strong political commitment backed by the necessary technical mechanisms, introduced the DOTS strategy in half the country during the 1990s, and we’ve shown very clearly that there has been a substantial reduction in TB prevalence as a result of that. So, when there is the right mix of political commitment with the right level of technical capacity on the ground, we can show that TB control will make a difference.

Q: The report indicates that some regions — like the Americas, Southeast Asia and the Western Pacific are likely to meet the targets that WHO set for 2005, which was to have 70 percent of all new TB cases detected and 85 percent successfully treated. But other regions such as sub-Saharan Africa, Eastern Europe and the Middle East fall short by a wide margin. Why is that?

A: Again — different reasons for different parts of the world. Of the regions that are not likely to meet the targets, Eastern Europe and sub-Saharan Africa are the most important as far as the epidemiology of TB is concerned. In sub-Saharan Africa, we talk first about the relationship between TB and the spread of HIV/AIDS, and, of course, that would be at the front end of the problem, if you like.

Of course, Africa suffers from tremendously chronically weak health systems. So, even where there has been a will in Africa to improve TB control and to put in place the right mechanisms — and some countries have demonstrated commitment to do that — it has been very difficult for them to succeed rapidly in TB control because they’re working off some very low base.

That is why we, with African health ministers last year, declared the TB problem to be a continentwide emergency. And some countries are responding to that. In the last few days, Kenya declared that it has an emergency plan for dealing with TB, and we’ll be working with them to try to ensure that plan is put in place.

In Eastern Europe, the other important area of the world, the problem is not so much about patients’ going to health services. It’s really about the quality of treatment they’re being given in the face of widespread drug resistance to TB. Now that multidrug resistance to TB has accumulated over many years — particularly in the countries of the former Soviet Union — those patients are very difficult to treat successfully, because they have multidrug-resistant TB.

Not only because the bug itself is resistant to drug treatment, and the proper drug treatment is complex and expensive, but the patients who suffer from multidrug-resistant TB are themselves very hard to manage, if I can put it like that. They are commonly unemployed; they are commonly homeless, people in prison, drug users; and they are infected with HIV/AIDS.

These are people who are typically not compliant with treatment of any kind of health condition, and TB is particularly difficult to treat, and all these problems are compounded in Eastern Europe. The outcome of that is relatively low treatment success rates — well below our targeted 85 percent cure.

Q: In Russia, even though its government has doubled the amount of funds to combat TB, the detection rate is extremely low, at only about 45 percent.

A: That’s partly a function of the way we at WHO express our statistics. We put emphasis on diagnosis of TB through a process called smear microscopy — that is, we want physicians at the point of diagnosis to take a sputum smear sample and to examine that under a microscope slide, because that is a quick and certain way to diagnose TB.

Now, the tradition in Russia and other former Soviet Union countries is to put much greater reliance on clinical diagnosis and use of X-rays. But clinical and X-ray diagnosis are ambiguous; that’s why we support X-ray diagnosis as a backup. But we also want to see these countries do smear microscopy.

Q: The report highlights that the TB problem is aggravated by a lack of coordination between detection and treatment of TB and HIV/AIDS, given the high prevalence in sub-Saharan Africa.

A: We set out quite clearly in our WHO guidelines what needs to be done. These are guidelines essentially on the way TB and HIV/AIDS control programs need to work together, which they must do increasingly, and they are … But there are somewhat different cultures of operation in TB and AIDS-control programs, so there are these hurdles to be overcome. Specifically, what’s needed for TB in sub-Saharan Africa is routine testing for HIV among the TB patients. And so those patients who are HIV-positive need to be given, along with their TB treatment, antiretroviral therapy, because there’s no point curing TB if your patient is going to die of an other, AIDS-related illness shortly afterward. … We have 41 countries that have relatively high rates of TB associated with HIV.

Q: The report estimates that the world will need $56 billion in the next 10 years to control TB. Is that achievable, and what are the outlays at the moment for TB detection and treatment?

A: We know quite accurately now how much is spent on TB control each year, both by the most effective countries and by the international donors. As things go on, we will have about $20 billion of that, leaving a $30 billion gap. Now you ask: “How is that gap going to be filled?”

The answer is that it must be filled by a combination of the countries affected and by external donors. But I must say external donations will not fill that extra gap of $30 billion. It simply is too much money for external donors. So what we need is a combination of careful external support for TB control though mechanisms like the [Global Fund to fight AIDS, TB and Malaria]. We also need the most affected countries to take seriously the problems of TB themselves.

Q: The report says that among the 22 high-burden countries that together account for 80 percent of all new TB cases, some are doing very well and are close to achieving 100 percent treatment rates — such as China, India, Cambodia, Vietnam. But at the same time you have some others, like Nigeria, where the problem is big.

A: The countries that are doing poorly among those 22 heavily burdened countries are doing so for different reasons. If we look, say, at Afghanistan, the problem is clear. The infrastructure is very poor; domestic revenue is virtually nonexistent; and external donors are still reluctant to provide support for health care, including TB control.

Now, if you come to another country like Nigeria, there are many fewer excuses. It is one of the richest countries in Africa, and, frankly, it’s scandalous how little they spend on TB control. There are political problems in Nigeria that need to be overcome with attention to developing a coherent national strategy. What I mean is, the states within Nigeria have a great deal of independence, or autonomy, to decide how they handle health themselves.

Q: What about the TB situation in rich countries in Europe and North America?

A: Five years ago, we can say, people forgot about the TB problem in rich countries. But now they have very little excuse, because WHO and other bodies concerned with international health have widely advertised the fact that TB has not gone away from the rich countries.

Some rich countries have been ambivalent in their response. Some have responded well; some have responded moderately; while others have not responded at all.

Q: What about the United States?

A: The U.S., as in most things to do with international aid and health, in terms of total amount of money spent, beats anybody else because they have a substantially larger economy. And, indeed, we are hugely grateful to the support we get from [the U.S. Agency for International Development], because they provide core support and provide an anchor for many of the programs we run in WHO. But external funds provided are often tied to particular interests and certain countries in certain parts of the world. So it’s not untied aid.

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