2005 World Union Conference
October 20, 2005
Remarks by Dr. Helene Gayle, former director, HIV, TB, and Reproductive Health
A Bolder Notion Of What We Can Do
I am honored to give this plenary presentation and pleased to have Dr. Bertie Squire and Dr. Wilfred Nkhoma chairing this session.
In his treatise, Aphorisms, Hippocrates made several observations on what he identified as the most common disease of his day… phthisis. Today, we know it as tuberculosis.
Hippocrates correctly observed that phthisis most commonly occurs in people’s prime years, between the ages of 18 and 35. He wrote—again correctly—that its advance was marked by the discharge of blood into the lungs.
And then he made an observation that was particularly telling. He warned physicians against treating people who were in the later stages of TB, because their inevitable deaths could damage the reputations of the attending physicians.
It seems callous… or perhaps it was simply pragmatic, that the ‘father of medicine’—lacking the ability to save lives, would preach that doctors should at least save their reputations. We rarely think of medicine—even ancient medicine—deliberately denying the needs of humanity.
Two and a half millennia later, we have the ability to save lives. And yet, if Hippocrates were here today… and saw that every year we accept that millions of cases of TB go untreated… and saw that we allow this disease to take the lives of two million people—he would have to conclude that we were still taking his advice.
Two thousand, five hundred years after Hippocrates warned that it would diminish the reputations of physicians when they inevitably failed in their attempts to treat people with TB, we diminish our reputations… and we fail our fellow man when we adopt a similarly stunted notion of our ability to help.
I’m here today, and I’m honored to join you, because it is time for us to embrace a bolder notion of what we can do.
Embracing that bolder notion begins with recognizing the equal worth of every human life.
All too often, in the developed world, we see our neighbors as the people down the street, in the next community or within our national borders. As the world becomes increasingly interconnected, people have tried to expand that definition of “neighbor” by noting that when microbes can cross borders with ease we are all connected. Thus, they make the argument that the challenges of global health are economic or even national security issues.
I have no problem with that. If those are the arguments we need to make to generate attention and funding, that is fine. But to me, these are not economic issues. They are not national security issues. These are humanitarian issues. People are dying, and we can save them; and that ought to be enough.
Therefore, we need to expand our definition of neighbor to the infant in Africa, the mother in India, the farmer in Afghanistan, and the hospital patient in China. All of these people deserve a chance to live healthy and productive lives.
While the equal worth of every human life is a basic statement of our common humanity, it is a daunting starting point for all of our work—because the inequities in the world far outstrip the resources any one individual, or organization, or even government has to fight them.
However, it is even more daunting to accept as inevitable the fact that 11 million children in the developing world die before they turn five, because they were never given the vaccines or medicines that would have saved their lives. Or that one person in Africa will die every minute we are in this room from a disease that is almost entirely treatable.
When it comes to stopping TB, embracing that bolder notion of what we can do will require new tools, greater application of existing ones, and, finally and most importantly, greater advocacy, activism and action from all of us.
Right now, there are two very different stories that we can tell about the global response to TB.
The more hopeful story is one in which TB rates are decreasing in five out of the six measured regions…
… where we see that the STOP TB partnership now includes over 400 organizations…
… where we have an affordable, proven treatment for the disease, and one that has been made available to 14 million people…
… and where a confluence of committed scientists and public health professionals, research funding, and improved technology and knowledge have moved TB from the backwaters of microbiology to the cutting edge of science.
For all of this progress, there is a more harrowing story to be told, however.
While TB incidence rates are declining overall, the actual number of TB cases is still on the rise…
…We still lack an affordable and scalable response to MDR-TB…
More daunting still is that TB and HIV have become linked in a deadly synergy, with TB now the number one killer of people with HIV, and an estimated 1/3 of people with TB in Africa also infected with HIV.
Thus, those regions where we see HIV on the rise—India, the former republics of the Soviet Union, China—show us where the future battles against TB will have to be waged.
Meanwhile, as the numbers increase—and are poised to increase further—discussion of TB has decreased.
- Of the eight millennium development goals, TB is mentioned only as a sub-goal, lumped together with other diseases.
- In the G7 finance ministers’ document, which we know is a vital precursor to being part of the G8’s agenda; there was no mention of TB.
- While allocations to fight TB from The Global Fund to Fight AIDS, TB and Malaria have gone up in each round, it still represents only 13 percent of their cumulative funding.
- And at the very same WHO meeting that TB is declared an African emergency, WHO pledged additional funding for malaria and HIV/AIDS, but not for TB.
You can see that the second story—the more harrowing one—has quite a bit of evidence to support it. And where does that story lead? Ultimately, it leads to a situation where with each passing day; the tide of this disease rises faster than our ability to stem it.
We can’t allow this to happen.
That is why we need to pursue a three pronged approach not only to better treat TB, but to increase awareness as well.
First, we need greater application of existing interventions. Second, we need greater investment in and development of new and improved interventions. Third, and equally importantly, we need greater advocacy
If there is the smallest measure of hope to be taken from the current pandemic of TB, it is that nearly every death is a needless death. This disease is treatable. And, in terms of the actual cost of treatment, treatment is affordable.
Therefore, it should be a source of global shame that DOTS has only been made available to 14 million people of the 28 million who need it.
We should be pushing for greater access to treatment. Still, we need to ask – why are people not seeking or receiving a treatment that can save their lives?
The first reason is that they don’t know what the warning signs of TB are, or, if they do know the warning signs, they fear the stigma of being identified as a TB patient.
Overcoming that hurdle requires greater education and outreach.
The second reason is that treatment for TB is long and intensive.
I recently saw a video of a “graduation ceremony” from a DOTS program. The graduates were wearing the distinctive red t-shirts with the “Stop TB” logo on them. It was clear from the images that there was a sense of joy, and of relief. Both of these feelings were justified—but I couldn’t help but think: it should not require putting your life or livelihood on hold to free oneself from disease. And you shouldn’t have to celebrate treatment of a disease that’s largely treatable.
Yet, in too many cases, that’s exactly what happens.
I know this plenary is focused on the interrelation between TB and poverty, and the truth is while poverty is often a risk-factor for TB, poverty is also frequently exacerbated by the demands of TB treatment.
I was particularly taken with the research conducted by Dr. Squire in Malawi, which he presented a couple of years ago. He found that for the urban poor, getting to care cost about three and a half US dollars. The number of work days lost in receiving care was 22 days, which amounted to about four and a half US dollars in lost income.
That may not sound like a lot, but what it means is that the act of receiving treatment for a life-threatening disease costs 40% more than the average monthly income.
For the rural poor, the commitment presents an even greater burden. Rural patients found that they had to visit three separate government facilities before receiving a diagnosis—a process on which the average Malawi spent $5.70—the equivalent of 54 days of income. Once treatment began, the average admittance time was 21 days. Two thirds said their harvest was affected due to the time they lost on the farm while seeking care. As a result, up to one quarter of the rural residents seeking care engaged in an impoverishing activity, such as selling an asset or borrowing money.
Those numbers add up to this: receiving TB treatment, for many, is a choice between life and livelihood.
Again, it shouldn’t be that hard to get treated.
We know that most people who are being treated for TB will become asymptomatic after two months—their fevers and coughs will be gone, though their treatment will not be complete. Thus, daily observed therapy and monitoring and supervision are pillars of DOTS for a good reason.
However, Dr. Squire’s work has shown us that the length of DOTS and the distance many people must travel for treatment not only present barriers to treatment, but are major contributors to poverty.
We need to look at creative ways to expand DOTS in a way that meets people’s needs. That includes self- and community-based administration.
I read with interest a story out of rural Ethiopia, in which communities formed TB clubs. People would monitor each other, and then take the bus, once a month en masse for checkups. The treatment rate in the affected communities grew from 45 percent to 95 percent.
Let’s remember that DOTS, in and of itself, is not a goal. Getting people treated and cured is. Therefore, dogged adherence to a particular strategy should not get in the way of meeting our goal. As Nietzsche wrote, “Many are stubborn in the pursuit of the path they have chosen, few in pursuit of the goal.”
It is, however, possible to advance the goal by improving the path. Many of you have seen the draft paper currently being circulated describing a strategy to build on and enhance DOTS.
These new pillars include care for all—which means addressing the challenges presented by TB when it appears in conjunction with HIV, as well as the challenge of MDR TB.
They also include a commitment to strengthening health systems, enabling and promoting research, and empowering patients and communities through advocacy.
All of these steps will make DOTS an even better architecture for TB therapy in the future.
As we work to broaden the availability and increase the ease of DOTS treatment, we also need to invest in newer, better interventions. Consider this: we still use a diagnostic test for TB that predates the age of flight. We use a vaccine that predates television. And the last time there was a new drug for TB, the majority of people currently living on earth had not yet been born.
As a result, we’re using a 100 year old diagnostic test that misses half of all cases.
Even though one in six TB deaths is a child, there are no real diagnostic tools for children.
We need faster, better, easier, more broadly effective tests, combined with faster, easier, and cheaper treatment. And we need better vaccines.
At the Gates Foundation, we operate under two beliefs. The first is that every life has equal value. That belief fuels our work to make sure that we do more to make sure that existing interventions reach those who need them.
The second belief is that technology offers us the opportunity to solve problems that may seem intractable. That belief explains why we’re currently investing in the development of 70 different products—new or improved vaccines, medicines, and diagnostic technologies—in the hopes of a breakthrough.
And we recognize that breakthroughs—particularly when it comes to combating TB—have been far too long in coming.
That is why today I’m proud to bring several pieces of good news about progress in fighting TB
First, we recognize that any work we do to improve and expand treatment programs will still face a bottleneck if advances aren’t made in diagnosis, and so I am pleased to announce that the Foundation for Innovative New Diagnostics recently collaborated with Eiken Chemicals to develop a rapid and simple test for the detection of active tuberculosis particularly suited to HIV infected patients.
Under this agreement, FIND will be developing a test that will quickly detect TB DNA directly from clinical samples without the need for complex instruments.
In the area of improving TB treatment, the Global Alliance for TB Drug Development has announced a partnership with Bayer Healthcare to coordinate a clinical trial to evaluate the potential of an existing antibiotic to shorten the standard 6-month TB treatment.
Preliminary studies have showed that moxifloxacin—which is already approved in dozens of countries to treat bacterial respiratory and skin infections—may reduce treatment time to four months or less.
When an additional month of treatment can mean the difference between subsistence or poverty for an individual, and thus the difference between seeking or declining treatment entirely, this partnership could present a major step forward in the near-term.
This trial will span four continents, enroll 2,500 patients, and is backed up by a commitment—should the trial prove successful—of making this drug affordable for those who need it most.
Both of these announcements could lead to important advances in the diagnosis and treatment of TB.
In the area of vaccine work, I’m proud to share that the Aeras Global TB Vaccine Foundation is announcing a new partnership with GlaxoSmithKline Biologicals to bring GSK’s promising vaccine candidate to phase II clinical trials in Africa and other locations.
Already, this vaccine has been shown to produce high levels of cellular immunity against TB in early-stage clinical trials, and our hope is that this cooperation between the public and private sector will accelerate the development, testing, and, ultimately, the delivery of an effective vaccine to those who need it most.
While I’m heartened by this good news, we recognize that each of these advances still faces a long road ahead of it, and that none may yield a silver bullet. However, a dramatically different world is not reliant upon a perfect drug, a perfect test, or a perfect vaccine. In fact, incremental improvement in each of these can—in conjunction—fundamentally change the trajectory of the epidemic. Therefore, what we need is for any progress we make to be matched by the flexibility to make the most of it.
This is easier said than done. Some of you have devoted a life’s work to impose the rigor necessary for well-functioning public health systems. Our challenge now is to retain that rigor, while incorporating new advances. We need to make sure that any new seeds of hope land on fertile soil.
We also need to recognize that even if the developments I just mentioned lead to the breakthroughs we seek, none of us alone has the resources to make our work reach all our neighbors in need and all our neighbors not yet born.
That work can only be accelerated and brought to scale by governments and markets.
Governments and markets, in turn, can only be moved by people. And that is where you come in.
Many of you have dedicated your lives and careers to confronting this disease, and the world is lucky you have chosen to do so.
As I said at the beginning of my remarks, though, now is the time to embrace a bolder notion of what we can do.
And that means adoption a more aggressive approach to outreach.
I have spent much of my career working on HIV/AIDS. In the early years of the AIDS epidemic there was a real ambivalence about the importance of this new, strange disease, and thus the resources weren’t nearly commensurate with the needs.
And then, communities affected by HIV began to speak up. They called for more funding. They enlisted public health leaders, politicians, governments, activist communities, the research community, celebrities, and forced the global health challenge into the global consciousness. People were passionate and unwilling to take no for an answer. They chained themselves to offices, they protested, they strategized and made demands. Ultimately, they got results.
Today, the National Institutes of Health spends $2.9 billion on HIV research, and $100 million for TB. That difference is not because the TB is unimportant, or because the needs for research are not pressing. And it’s not because HIV is getting too much money. It’s because the HIV community demanded those resources.
I’m not advocating that we march in the streets… although that might not be a bad idea. I know this is a polite community. But what is clear is that we do need more activism and more advocacy and to generate greater momentum for action, and the next year will present opportunities to do just that.
It our collective belief in what is possible—a bolder notion of what we can do—that should compel us to action.
In July 2004, at the Bangkok AIDS conference, Nelson Mandela proclaimed, “The World has made defeating AIDS a top priority and this is a blessing. But TB remains ignored… we can’t fight AIDS unless we do much more to fight TB as well.”
He was right. We are in a race to stem these diseases, and we can’t win one without winning the other.
Nelson Mandela’s important statement in Bangkok was followed by the declaration of an African TB emergency by WHO and African health ministers… who then turned to the finance ministers… demonstrating how the strength of one voice can be amplified by many others, and can ultimately change the fate of millions.
One of the largest opportunities will come in January, when the Stop TB Partnership will be introducing Global Plan II—a clear description of the problem, what we need to do to address it and what resources will be needed to do so.
Right now, this plan is nearing the end of the draft stages. Already, you can see that this plan will outline steps for each of us—whether we are governments, researchers, philanthropies, or public health activists.
I know that many of you have added input to make sure that the plan is improved. Once it goes final, we all have a role to play in making sure it gets enacted.
Some of you may feel that it is not a perfect document. No document ever is. What is important is that we make it a living document, a true catalyst for concerted action.
If we do that, we will be able to meet again at this conference next year and look back with pride on a year of unprecedented progress.
And if we can do these things every year, we will hasten the day when we will have relegated TB—which has been with humanity for so much of human history—to the annals of history.
I began by sharing the writings of Hippocrates, who—two thousand five hundred years ago—advised physicians to deny their sense of common humanity in order to save their reputations.
Today, by embracing a bolder notion of what we are capable of doing, we can embrace our common humanity, and save something more valuable than a reputation—we can save lives.