What are the greatest opportunities as we look at ending tuberculosis?
There is finally a global commitment to end TB. We have a Global Strategy, endorsed by the World Health Assembly, which speaks about ending TB. We have the Sustainable Development Goals, that clearly puts a line for ending TB, as well as HIV and malaria, and we have the Global Plan, which lays out the right path to end TB.
We are also engaging on a different way with the communities and the people affected by TB, looking at issues like gender and human rights to make sure we are not leaving anyone behind. We also have new drugs and new tools. We are learning more about innovation and service delivery.
What are the greatest challenges?
Despite all our efforts, TB has not succeeded in getting the visibility of HIV. TB has been around for 2,000 years and HIV has been around for 30-34 years, yet it is only now that we speak of ending TB.
If we really want to end TB, we need a paradigm shift, a change in the way we fight TB at every level, in every community, in every health facility, in every country. This means changing the way we think of TB, adjusting our packages, policies and guidelines and putting people at the centre of our interventions, so we reach all the people that need them.
Another challenge is financing. The Stop TB Partnership Global Plan, a five-year investment plan that represents the roadmap to accelerating impact on the TB epidemic and reaching the targets of the WHO End TB Strategy, has a total cost of US$65 billion globally.
What are the main areas the global community needs to focus on to achieve progress?
The global decline in TB has slowed over the past decade to a 1.5 percent annual reduction in global incidence. This is an outrage. We got used to TB. TB kills quietly and kills the people who are not necessarily the most visible. They are the very poor people and belong to vulnerable groups. It is not a spectacular disease like Ebola. It is a shame on humanity that we have a disease that is curable and costs US$40 for 6 months of treatment and is now the biggest killer among infectious diseases.
For a long time, TB programs have been very vertical. We were floating in our own world, extremely medical, mainly doctors discussing between themselves, therefore our terminology, engagement and reach was very limited. We did not interact very well with the private sector, which plays an extremely important role in terms of TB care. We did not interact very well with people from the health systems and we thought of TB as in a separate corner, with its own systems and its own procurement system.
We need to work with a set of prioritized countries, the high burden ones, and bring down the numbers in these big reservoirs. This is not feasible without a very strong commitment of the country’s government and a sustained financial commitment. There are solutions and we can do it, by focusing interventions on the right places and by going with the right combination of tools. With TB, we initially prioritized the smear positive cases, which are the most infectious cases, and we failed to take care of the smear negative and extra-pulmonary cases, which are less infectious. Time has proven that we can have the right vision and the right dialogue with the private sector and communities, but unless we look at TB in all its forms and resistances and adjust our policies and regulations it won’t fly.
How important is building stronger systems for health to end TB?
You cannot address any infectious disease without a proper system in country. Otherwise, we will keep running in circles. You see that with Ebola. We should all try to create a solid ground force at the community level that is capable of coping and is resilient in addressing any form of public health threat. In TB you cannot think of diagnosis, monitoring and evaluation or reaching people without a good health system in place. We cannot go ahead without a proper integration in health systems.
If you want to measure a successful health system or universal health coverage, TB can be a very good indicator of success. Every year there are 3.6 million people missing, and they are the most vulnerable, who for whatever reason do not have access to the service and are not being reached or enrolled or kept in treatment.
How serious a challenge is multidrug-resistant TB?
We are sitting on a time bomb. More than half a million people develop multidrug-resistant TB each year, according to WHO, and these are new cases. We are neglecting those who relapse and interrupt their treatment. We have turned MDR-TB into something so difficult and so special that we are treating MDR-TB as a separate part of the program. The scale-up is not really happening and we need to change that mind-set. We have countries that are enrolling 50 patients a year when the burden is in the thousands. This is not chemotherapy or a life-long treatment. It is a very difficult treatment, but it is two years and if properly done it is curable.
We need to look at where transmission is happening and look at the entire MDR-TB problem , making sure cases are identified like any other drug resistance in a routine way and making it part of a normal treatment.
How important is promoting human rights to end TB?
TB affects the vulnerable groups, and among them we have migrants, refugees and people who use drugs. To really get to the roots and properly address human rights you need to interact in a meaningful way with those whose rights are not being respected. That means sitting on the table with the most vulnerable groups together with people from the Ministry of Justice and Ministry of Health and understand each other where we are. Over the last several years we are trying to push this not only on the global agenda but it should be understood at the country level and understood by governments and by everyone. All these conversations are now starting. We still have a bottleneck in some of the big global institutions to push vulnerable groups, key populations and people affected by TB to have a place in the table in a meaningful way.
What is the most inspiring moment you have lived through in your career to help those affected by TB?
I feel I am pulling teeth all the time and pushing walls, but you get up again and not give up. For me, these moments are my interactions with people living with TB. I am always amazed by their stories and their courage. I come from a poor village in Romania so I understand very well when you come from a group that is not the elite and the difficulties of going through the system. Many years ago in Moldova I met a mother, father and their one-year-old baby. They all had MDR-TB. The father had infected the family and despite that he kept interrupting his treatment because he needed to go to his work as a brick-layer and bring money to the family. It is really about luck. I feel a great responsibility to give back.