MSF statement at the New Delhi STOP TB Partners' Forum, March 25th 2004, by Rowan Gillies, President, MSF International
Mr chairman, ladies and gentlemen,
We've heard a lot about TB control today. Let’s now talk about TB care and why Médecins Sans Frontières (MSF) thinks new TB tools are desperately needed.
The pharmaceutical industry is making some efforts to cover R&D for TB. This is important work and we welcome it. But it is a small part of what is required.
At MSF we have been confronted for the past 30 years with the challenge of TB treatment; we have seen the DOTS strategy been put in place; and have implemented it ourselves.
We know it works in stable countries with a low HIV prevalence.
However the majority of the 20,000 people we treat for TB each year don't live in such places.
They live in Malawi, a country with high HIV prevalence.
They live in Afganisthan and Sudan, chronically unstable countries.
We have programmes that are specifically adapted to their circumstances, but without a revolution in TB care, they will remain the privileged few.
Example:
I met a 33-year-old lady, Elizabeth, in Liberia. She presented emaciated, short of breath and had the classic hollow stare of tuberculosis. On examination we found out that a tuberculose abscess had eroded through her chest wall. All I could do was relieve her breathing for a short time by draining two litres of pus from her pleural cavity. She died over the next three days.
I got to know her over that time. Her story was a familiar one: she had four children. Two were with her, one other was dead, the other missing. She had fled the fighting, moving from one refugee camp to another for over a year. During that time she had presented three times to temporary camp clinics, she even had a sputum test which was negative. She died having been diagnosed too late and never treated for TB.
This is the reality.
I was in Malawi last month at our TB/HIV programme. The frustration of TB treatment was obvious. The concerns of the clinicians were different from the concerns of the patients. The doctors are faced with sick patients with HIV and AIDS, they are faced with the dilemma of a negative sputum and unreliable clinical diagnosis. Do you treat for TB?
Knowing that if they don't have TB the patients will deteriorate whilst you give potentially the wrong treatment. Or do you assume they are negative, and not treat a curable disease?
For the patient, once they have a diagnosis, they have their own dilemma: committing to directly observed treatment, disrupting harvest or planting time, or perhaps leaving their seasonal jobs. Or, instead, make the choice of living and perhaps dying with untreated tuberculosis.
This is the reality.
Lets look at the facts: where are we now?
We rely on a 19th century diagnostic tool.
It doesn't detect paediatric, extra pulmonary or smear negative TB.
We are using medications that work but are old, require 6 months treatment to which resistance is spreading.
We have a vaccine with uncertain efficacy.
All this for a disease that kills 2 million people every year.
DOTS is holding back the tide but for how long?
For us there is a dangerous asymmetry between the magnitude of the problem and the response. We must start refusing this status quo.
We need modern, effective tools to make an impact on the disease.
We need more resources for developing new TB tools – for existing ventures but also for new initiatives.
We need to boost development and validation of new diagnostic tools for resource-poor settings.
And let’s be honest about the involvement of the pharmaceutical industry: they have disinvested themselves of antibacterial R&D and are unlikely to guarantee the development of a TB drug from A to Z.
It is dangerous and naïve to rely on market forces to respond to the TB problem.
Governments should insist that companies make compounds with potential TB activity available to those who are willing to develop them into drugs, and that companies share their know-how and capacities with these ventures.
But in the end governments themselves are responsible for global crises -- and there is no doubt that this is one.
I feel we are at a crossroads in TB treatment now. With the global alliance, the find initiative and other such programmes there is some impetus for change.
What is missing is the urgency.
There was urgency for SARS, with a diagnostic test developed last year in only four months. TB is a different bug, but this shows what is possible, with political commitment and resources.
Why do I call for urgency?
We feel tuberculosis in 2004 is an emergency. Two million deaths a year is a horrifying statistic. What is more horrifying is watching a fellow human being like Elizabeth who survived pillaging by soldiers, the birth of four children, and living a subsistence existence -- only to slowly expire, breath by breath, through decades of neglect. All this in 2004.
As her doctor I am ashamed. We should all be ashamed.
In summary: DOTS is not the only answer to TB.
I have 2 final points to make:
1) improving DOTS is essential with new diagnostics and drugs.
2) we must attempt to treat patients currently excluded from DOTS.