Global Health Ministers Meeting on Tuberculosis in China

April 1, 2009

Prepared remarks by Bill Gates, co-chair and trustee

Thank you, President Sampaio. Good morning, Honorable Vice-Premier Li, and Dr. Margaret Chan. And thanks to all of you here for this very warm welcome.

I am honored to be here in Beijing to announce a unique and promising partnership between the government of China and the Bill & Melinda Gates Foundation.

I want to thank the Chinese Ministry of Health for bringing us together to accelerate the global fight against TB.

I want to thank the ministers of health and representatives of more than two dozen countries who are here to write national plans to fight TB.

I want to acknowledge Margaret Chan and the WHO for their tireless work against this disease.

I also want to express my thanks to Vice Premier Li Keqiang for his leading role in China’s rising commitment to public health.

I have been fortunate enough to travel to China many times. Each time I visit, I come away impressed with the talent, energy, and creativity of the Chinese people. Today, the government of China committed these strengths to the cause of reducing TB. This is phenomenal news! If China leads in the fight against TB – developing new approaches here in China and demonstrating them to the world – we will see a dramatic drop in the number of TB deaths in the next decade.

We could accomplish something even larger, if the world’s emerging economies – Brazil, India, South Africa, Indonesia, and China – all work together to increase their commitment to public health. This would give us a much higher percentage of the world’s people applying their intelligence to these problems – and inventing and exporting solutions. That could disrupt old patterns of inequity and help remake the map of global health.

We know that more than 9 million people develop TB every year; nearly 2 million people die from it; and half a million patients a year are developing TB that is resistant to drugs that have been effective for 50 years. Some strains have shown resistance to all drugs.

Unless we do a better job of treating TB, multi-drug-resistant TB will make up an ever-rising share of TB cases – until the ratio eventually flips.

Instead of having mostly drug-susceptible TB, we’ll have mostly drug-resistant TB. Sickness and death would multiply, and – because treating MDR-TB costs 100 times more than treating regular TB – the economics would be catastrophic.

The prospect is alarming and it should galvanize us to action. But I believe we will prevent it because of the convergence of two forces: urgency and innovation.

In the history of the fight against TB, we have had periods of urgency, and we have had periods of innovation. But we have not had urgency and innovation working together.
 
In the 19th century, the urgency of the disease drove people to begin treating TB in sanatoriums. But at the time there was no serious innovation there. In the mid 20th century, we had innovation in the discovery of antibiotics, but over-confidence prevented there from being urgency, and research stalled – leading to a period of neglect, with neither urgency nor innovation.

In the early 1990s, the WHO declared TB a global emergency. Urgency returned, and we saw the scale up of DOTS around the world, including here in China, which did an impressive job in scaling DOTS up nationally. The DOTS approach was an innovation, and it saved many lives. But there was no innovation in the tools. The most commonly used diagnostic test today is more than 125 years old, the vaccine was developed more than 80 years ago, and the drugs have not changed in 50 years.

There’s a slang expression in English that we use when you are caught in a fight, but you can’t use all your advantages. We say it’s: “Fighting with one arm tied behind your back.” For centuries, the world has been fighting this infectious disease with one arm tied behind its back. That’s why we haven’t been winning.

I believe we can have a future very different from the past because we are finally entering an era of urgency and innovation together.

The rise of multi-drug resistant cases has restored a sense of urgency – and innovations are coming on line with the promise of better diagnostics, new drugs, better systems, and eventually, a new vaccine. So finally, we are starting to put our talent and energy into the fight.

Today, the most commonly used diagnostic test for TB detects only half of all cases. But coming along we have an LED microscope that detects 65 percent of cases and allows diagnoses to be made three times as fast.

Today, the most commonly used diagnostic test for MDR-TB takes at least six weeks. But right now we have a much better test – one that will give you the results in the same day. If you use the slower diagnostic, the patient can go on infecting family members for weeks. If you get the one-day diagnosis, you can begin treatment immediately and prevent new infections.

Quicker, more accurate diagnoses can make a big impact against the combination of HIV and TB. People who have HIV are more likely to get active TB. And TB is the leading cause of death for people with AIDS. If we can diagnose and treat TB in people with AIDS, we get them many more years of life to support their families, raise their children, and take care of their parents.

Today, the most commonly used medicines come in the form of loose pills, and patients have to take as many as 13 pills a day. But we have fixed-dose combinations that can bring the pill burden down from 13 to just four, or even three or two. This would make it much easier for patients to complete the treatment, cure their disease, and stop transmission.

In coming years, we should be able to replace these tests and treatments with tools that are even more effective.

Within the next two years, we could see a nucleic acid based diagnostic with 98 percent accuracy that tests for drug resistance at the same time. This would attack a top cause of TB – the patients whose TB is missed by the test, and don’t get treated, and who keep spreading the disease, including MDR-TB.

Within this decade, we also hope to introduce new drugs that the bacterium has never seen before, and does not resist. These new drugs could be standard first-line treatment for everyone with TB, whether they have MDR-TB or not. That would simplify treatment of even drug-resistant cases.

Eventually, however, the bacterium would develop resistance to the new drugs as well – which is why it is so important to continue work on the drug pipeline at the same time as on a new vaccine. Over the next four years, we’ll have results from trials that could give us a more effective vaccine – and that would be a very important advance in the fight against TB.

There is a great future of innovation ahead of us. But if we don’t keep spending on research, that future won’t happen. It can be hard to make investments, especially in this economic climate. But we have to weigh the investment against the return. My commitment to research comes from my experience in computers and software – and I’m convinced the lesson there applies here as well. Some of the best money ever invested – whether by a corporation, a government, or a foundation – is in finding inexpensive ways to prevent costly problems. The return can be astronomical.

Our foundation’s fight against infectious disease came out of a question Melinda and I began to explore ten years ago. We asked ourselves where a dollar of funding can have the biggest impact in saving and improving people’s lives. We believe that TB – given the scale of the problem, the rising urgency, and the opportunities for innovation– is one of the best investments in the world today if you want to improve people’s lives.

Of course, one foundation’s effort is never enough. You have to find many partners who feel the same way.

I am honored to announce today that the Chinese Ministry of Health has begun a new project here in China – in partnership with our foundation – to develop, demonstrate, and scale up new innovations to fightTB.

The rise of tuberculosis around the world has had a powerful impact here in China. The WHO estimates that China has 15 percent of the world’s TB cases, 1.3 million new cases a year, and more than 200,000 deaths annually. In addition, China has more than 20 percent of the world’s drug-resistant cases, the second-highest rate in the world.

This is at a time when the government of China is intensifying its commitment to public health. In January, as the Vice Premier said, the government announced a $130 billion initiative to improve health care in China.

Because of its skill, its scale, its TB burden, its love of innovation, and its political commitment to public health, China is a perfect place for proving out large-scale use of new tools and delivery techniques to fight TB.

As part of this project, the Ministry of Health and our foundation will introduce new diagnostics, new forms of treatment, new approaches to help patients complete treatment. This will all align with the new delivery systems as part of the health reform already being planned in China.

At first, we will test these new tools and systems in a population of 20 million people. After two and a half years, we will scale up the most effective approaches to 100 million people by the end of the fifth year. At that point, we’re hoping the partnership will have demonstrated how to slash the incidence of TB and MDR-TB here in China and that these techniques will be scaled up not just in China but around the world.

The partnership is based on a clear premise: The alarming threat of drug-resistant TB is rising because of gaps and mistakes in the way we treat TB. If we improve basic TB prevention and control, we will cut off MDR-TB at the source.

The Chinese Ministry of Health is committed to using the diagnostic tools I’ve described that let us know in hours, not weeks, if patients have TB or MDR-TB. This can dramatically reduce the number of people who pass on the disease during the six-week gap that exists today between diagnosis and treatment.

We’ll also be changing the systems, because if we don’t change systems, even the best tools may do no good, because they may never get to the people who need them. One of the great benefits of partnering with the Chinese Ministry of Health is its commitment to simultaneously try new tools and modify systems. This is a key reason I have such high confidence in this project.

Second, the Ministry of Health will make it a priority to purchase and deliver fixed-dose combinations to reduce the number of pills patients have to take. As you know, if patients don’t complete their course of treatment, they’re far less likely to recover, and the strain of TB that comes back is more likely to be drug resistant. So everything that can be done should be done to make it easier to take and complete the course of medicine.

Fixed-dose combinations have been available for 30 years, but I’m stunned that still only 15 percent of patients around the world take them. A number of barriers have blocked more widespread use. It is hard to assure the quality of FDCs, and that increases the cost. There have been no high-volume purchasers, so the incentive to reduce the costs hasn’t been there.

I think the thing that has really been missing is commitment by the global community to make FDCs the standard of care.

The government of China – by switching to FDCs, doing the quality assurance, and guaranteeing large purchases – will break through the barriers that have kept FDCs so underused. If every country represented here today would also commit to using FDCs, we could, in the next five years, see more than half the world’s patients on FDCs, which would lead to much better compliance and a reduction in the spread of TB.

Finally, the partnership with China includes financial incentives for monitoring patients will be improved. Right now, health care workers at the township and village level are expected to monitor patients to make sure they are taking their medicine. But the financial incentives are low, so the workers often do other clinical work that pays more.

Research shows that in some areas a small minority of patients have trouble complying with the treatment. If we can take that 25 percent and focus on incentives, we can quadruple the amount of money available for monitoring each case, and that makes the financial incentive high enough to have an impact.

So the partnership will use technology – such as mobile phones and medicine monitors – to help people comply, identify the patients who don’t, and let doctors move them to more intensive case management.

Melinda and I saw the importance of all these initiatives last summer when we visited a rural village in Hainan and met a mother with TB. It was in some ways a sad visit. She had been on TB treatment for months – taking 13 pills at a time. But she was still very thin, she was still coughing, and she was unable to work.

We learned that it was the second time she had TB. Perhaps if she had had FDCs the first time or great monitoring–she would not have become sick again. She most likely had MDR-TB, but it wasn’t known, because she didn’t have the diagnostic test. If she did have MDR-TB, then she wasn’t taking the proper medicine, and it’s possible she would transmit MDR-TB to other people.

New diagnostics, more FDCs, new technology and incentives to ensure compliance, and new systems to accommodate new tools – these innovations will attack this disease at the points that give it strength: the patients who are misdiagnosed, the cases that aren’t followed up, and the people who are given the wrong medicine or don’t complete their treatment. These are the changes that can save people like the woman from Hainan and her children.

But the most promising element in this project may be this: we won’t need a decades-long effort to bring the results of the project to the attention of someone who can take it to scale. The Chinese government is doing the demonstration, and the Chinese government – with the right proof - can take it to scale. Melinda and I have often talked about the importance of partnerships in philanthropy. It’s hard for me to think of a better illustration of what we mean than the partnership being announced today.

As we look ahead to the next decade, the leading indicators in the global fight against TB will be the actions of the world’s emerging economies represented here. It is here that urgency and innovation that need to come together – not only at the same time, but in the same country.

Five countries represent forty-five percent of all TB cases – and 60 percent of MDR-TB cases. These countries have the TB burden that generates great urgency, and they have the talent and resources to use the best innovations – and also find new ones.

I was very pleased at Brazil’s announcement by their health minister last week that they are committed to ending their status as a high-TB burden country, and also to helping the fight against TB in Africa.
 
India has the capacity to make and export FDCs and second-line drugs that would make a big impact in promoting compliance around the world.

South Africa is dedicating its research capacity to host important clinical trials of new vaccines, drugs, and diagnostics.

The world has lost many lives to infectious disease because the urgency has often been on one side of the world while the capacity for innovation was on the other.

I think that era is ending. Every country should feel the urgency, whether it is suffering from TB or not. Every country is capable of innovation, whether it has a high-tech economy or not. And every country can adapt its systems to use the best innovations of others. Where a 6-month course of treatment is available, the 8-month course should be abandoned. When FDCs are available, loose pills should be abandoned. When a new test is available that can diagnose MDR-TB in hours, not weeks, every country needs it as part of its national plan.

I hope each one of you makes the most of your authority to give your people the best innovations in the world, and I urge you to develop innovations of your own. Not just for your country, but for the world. If every government has the sense of urgency, and innovation comes from every country, we will get the upper hand against tuberculosis– and finally turn this fight in favor of human beings. Thank you.