Examination of Witnesses (Questions 720
- 739)
TUESDAY 22 APRIL 2008
Dr Haileyesus Getahun, Ms Diana Weil and Ms Louise
Baker
Q720 Lord Desai:
From what I gather, you are only a coordinating body and do not
do any investment. We have been told that there is a lot of vertical
investment in specific diseases to the neglect of the horizontal
investment required for local healthcare systems. What is your
view on that balance?
Ms Weil: There are a couple of major things
that we have been doing. Many members in the Stop TB community
since the 1990s, when there was quite a lot of investment in structural
adjustment and efficient health systems and there was not much
investment in disease control, (there was a disinvestment in disease
control) started documenting what was happening with disease control
programmes at that time. As you know, there was a great increase
in attention to disease programmes because of HIV, Malaria and
TB and the effects of those diseases, so we saw the creation of
the Global Fund and we have seen this great infusion of new funds
for diseases. We are now seeing the reverse, very heavy funding
of some disease programmes and, as you said, not sufficient funding
on health systems. Our community has got involved in a couple
of ways. One is that we have been very deeply involved with our
Partners and bilateral agencies in developing guidance on how
we contribute to health system strengthening through what we do,
through the disease angle, through advising the Global Fund. Many
of us were involved in a consultation with the Global Fund on
how they should invest partially in health systems in addition
to the ways that they invest today. We have been involved in documenting
how health systems power investments. Disease control can also
contribute to health systems through logistic systems, innovations,
basic capacity building and providing resources for general staff.
In TB at the service level many people work on multiple diseases,
so if you can invest in building that capacity or expanding the
number of community health workers, then that will have a follow-on
effect for other diseases. We work with Global Workforce Alliance,
the Health Metrics Network, the International Health Partnership
on health system strengthening that your Government has put the
lead on. We are all engaging in trying to define best how we strengthen
systems and learn lessons from individuals' fields. One more example
is that in TB control we have been one of the fields that has
done the most with drawing in non-public providers. So how we
do the best with private providers in the developing world where
in the past many were doing very poor practices, and many are
still doing that, but how to bring them in, engage them and ensure
they are part of the overall system for fighting diseases. We
are just coming out with a policy document on how national TB
programmes contribute to health systems. Overall, I think in the
community we share the view that there has to be a growing pot,
we need to invest more in disease control because we know that
we are getting results through disease control, and we also need
to develop much more financing and much more efficient financing
on funding health systems, particularly primary care.
Q721 Lord Desai:
Do you have a view on prevention versus treatment? What is the
balance of investment between prevention and treatment?
Ms Weil: TB is both prevention and treatment
at the same time because, if you treat infectious cases, you are
also preventing transmission, if you are finding them and treating
them fast enough. TB is not exclusively a treatment programme,
it is also prevention.
Q722 Lord Desai:
There are no pre-diagnostic things you can do to prevent the onset
of TB?
Ms Weil: There are. In the developed world we
have preventive therapy for those who are found to be infected
with TB but not having the disease, and we are trying to extend
that to those with HIV infection who are at high risk. If we catch
people early enough with their infectious disease, which is the
first step—because there are so many people with active
disease in the developing world who have not been detected, so
through new laboratory methods, getting existing lab methods out
there, we hope to find people earlier and prevent that transmission.
In terms of the research front, we believe that, if we can develop
new vaccines against TB, that would be the best scenario possible.
We are not there yet but we have many in development. At the bottom
line, the key is to be communicating across these terrains, especially
in-country, to be sure that disease programmes are communicating
with the health planners and there is a common national health
plan that incorporates interest in prevention treatment and other
infrastructure issues for health systems. But we are not there
yet in many countries. Haileyesus knows the situation in Ethiopia.
Dr Getahun: This leads to the question of the
neglect of TB research in general. We do not have any good and
best diagnostic tools to confidently diagnose TB either in an
HIV-infected or non-infected patient. We still rely on microscopy,
which is 100 years old. It is very difficult without having that
robust tool to focus on preventing TB. That is why our programme
is more a treatment programme. That is another area that really
needs critical focus.
Q723 Lord Jay of Ewelme:
We have had lots of evidence about the extent to which TB and
HIV are interlinked, but we have also had a certain amount of
evidence that sometimes at national level, sometimes at local
level on the ground, they are treated in rather separate ways
and that somebody who comes to a clinic with TB will not get tested
for HIV and vice versa. Dr Getahun, you said earlier on that you
were involved in a WHO TB/HIV programme and I just wondered what
you were doing, or what the TB Partnership were doing, to try
to ensure that on the ground the links between the two are properly
recognised.
Dr Getahun: This is an interesting question.
We are much more optimistic at the moment. Had it been three or
four years ago that statement would have been absolutely true.
I am not saying that patients are still not seen separately and
not tested for HIV when they have to be tested, but the point
in general is that changes are coming from where we stand now.
This is because WHO took the leadership in 2004 to provide countries
with clear policy and strategy clarifying what needs to be done.
We have a 12-point policy which is simple and clear and we have
promoted that policy with advocacy. Our slogan during that time
was, "Two diseases in one patient". An HIV-infected
patient should not come on Mondays for TB and on Thursdays for
HIV. This message has got into the countries and we are seeing
encouraging things.
Q724 Lord Jay of Ewelme:
I can see it could be comparatively straightforward to produce
the plan for that. But how far is it really getting through on
the ground at national level and also at local level? Let us take
Ethiopia, as that is a country you know well.
Dr Getahun: In your folder on the second page
there are the latest figures, which have shown a significant multi-fold
increase in the last couple of years. For example, those TB patients
tested for HIV were around 20,000 in 2002, but in 2006 we were
able to test 700,000 TB patients. It is not enough, it is only
covering 12 per cent of all TB patients and still not up to the
level that it should be. The rate of increase is encouraging and
we want to keep that momentum. We are in a different phase now
to bring the HIV community particularly in to TB, and that is
where our programme really lies, especially those interventions
that are intended to save the lives of HIV-infected patients by
screening them for TB, because most of them have a higher risk
of TB even if they are taking antiretroviral drugs, and providing
them with preventive therapy to prevent TB infection when they
come for HIV care. These interventions are far below where one
would assume and our focus is to push for the HIV side to take
up these interventions. It is encouraging but we are far, far
below the targets and we need to push.
Ms Baker: I might just add something on that.
It is still the case that every three minutes somebody living
with HIV dies of TB, which is ridiculous. We have a special envoy
to Stop TB appointed by the Secretary-General of the UN, who is
the former President of Portugal, Jorge Sampaio, and, very much
in line with what Haileyesus was saying, the political push to
try and make looking at the two diseases a more integrated, more
holistic approach is coming from the Secretary-General and the
special envoy. On 9 June this year at the UN, prior to the High
Level meeting on HIV/AIDS, there will be a half-day session on
TB-HIV that the special envoy is calling that will be addressed
by the President of the General Assembly, the Secretary-General
and the leaders of the H8 agencies, so Dr Chan from WHO, Michel
Kazatchkine from the Global Fund, and Peter Piot from UNAIDS.
It is a culmination of our work on trying to attract the HIV community.
Q725 Lord Jay of Ewelme:
That all sounds great, but that does not in itself mean that on
the ground things will change, does it? Do you have a Focal Point
on the ground country-by-country trying to push this message through?
Would that be your people or the Global Fund?
Ms Weil: Part of the issue for this meeting
is the fact that in many countries you have HIV/AIDS Commissions,
which operate at a political level which is far higher than any
TB programme, which is basically in communicable diseases in the
public health authority, so they are operating at indirect levels.
For AIDS authorities, TB is one of the many issues they are concerned
about but it often gets lost in the mix. This agenda is to raise
it on the radar that you can achieve huge achievements with HIV-TB
action now.
Ms Baker: Most of the people participating in
the meeting will be at very high political level, hopefully more
than Ministers of Health, and certainly the AIDS Commissions are
responding mostly to Prime Ministers and Presidents, so it is
to try and raise the political agenda around that.
Ms Weil: For example, institutions like in the
UK and many others have produced AIDS strategies but, unfortunately,
for example, the UK strategy has very little coverage on the TB-HIV
co-infection issue.
Q726 Lord Jay of Ewelme:
That is an interesting point.
Ms Weil: That has been technically there forever,
but politically as part of the work plan it is putting it on the
agenda as being one of the key elements. That is why today our
colleagues, Mario Raviglione and Dr Paul Nunn are not here with
us because they have just travelled to Chiang Mai, Thailand, to
participate in the first ever technical day of the Programme Coordinating
Board of UNAIDS that is going to address TB-HIV for the first
time. That is a step in the right direction thanks to Peter Piot
and many other advocates in civil society who pushed for this.
Dr Getahun: What we need is political leadership
on the HIV side at country level. We believe that all of these
global efforts will really help to realise that at country level.
Q727 Lord Jay of Ewelme:
It is the HIV side, as it were, that needs to recognise the importance
of TB?
Dr Getahun: Yes, we would say that, but not
always. The TB side, particularly in Asia, should also take this
up.
Ms Baker: Failing to address TB undermines the
investment in HIV and undermines the work of the HIV community.
Q728 Chairman:
Does linking TB with HIV when you are talking to the political
leaders make it easier for the political leaders to address the
HIV issue which otherwise is a difficult one to address at times?
Ms Weil: For example, in South Africa the issues
around XDR-TB, this extensively drug resistant form of TB, probably
did wake up some of the political leaders on the issues of concern
around responding to the risks for HIV-infected people who are
seeking care and finally receiving care. I think it became a public
issue, not just for the HIV community but for the community as
a whole, because everyone was so worried about the risk of a very
lethal form of disease and the effects that had been shown and
documented in South Africa. In a way, I think it opened up the
terrain that this is not just an HIV community issue but a public
issue. Whether it helps the HIV community overall to address TB,
I am not sure.
Q729 Chairman:
Help recognition. South Africa is a good example that is in denial
on the problem of HIV in a sense, so it seems to me it is easier
to talk about TB-HIV than just HIV, is that right?
Dr Getahun: Particularly in sub-Saharan Africa,
where up to 50 per cent of HIV positives die of TB, that needs
to be considered. There is not much leadership in HIV. With the
expansion and the scale-up of antiretroviral treatment, which
gives protection from developing TB disease, that was their intention,
"If we scale-up antiretrovirals, we should not have to worry
about TB treatment". The fact is that, despite patients taking
antiretrovirals, the risk of TB is increasing, it is not going
down. In a way, that sends a message to the HIV community that
on top of the XDR issues they have to consider TB. We are not
there yet.
Q730 Lord Jay of Ewelme:
Could I ask one completely different question. These are fascinating
documents, which I look forward to reading, but there is one which
one says: "The TB target for 2015 UN Millennium Development
Goal is to have halted and begun to reverse incidence. Current
assessment on target in all regions except Europe", which
is quite surprising.
Ms Weil: As a region as a whole we have to say
in Europe, but in reality it is Eastern Europe which is behind.
In Western Europe you are right on course and well beyond, moving
rapidly.
Q731 Chairman:
That is a relief, I can tell you!
Ms Weil: In Eastern Europe the biggest challenge
has been that there has been a dramatic increase in TB since the
fall of the Soviet Union, so to reverse incidence again we have
now stabilised, but in terms of decline we are not documenting
that decline yet. There is a very severe problem in Eastern Europe
because it is not something that you can turn around quickly,
particularly when it has penetrated some of the most difficult
parts of the population—the prison population, the poor,
alcoholics, drug abusers—and where you have seen this very
rapid emergence of drug-resistant disease. It is not an easy turnaround.
We had this Berlin Declaration that the UK Government was involved
in and we had a meeting of 46 governments with high-level delegations,
and they produced a very strong Declaration. I cannot say necessarily
that we are totally convinced that the response since that Declaration
has been up to that enthusiasm, but there was a strong recognition
that something needed to be done, particularly with domestic financing,
as many of the Eastern European governments have more of their
own financing available as well as ongoing concern from the development
community for the poorer countries.
Ms Baker: One of the things we have been doing
is working with the European institutions on developing a plan
and in the 27 Member States of the European Union region there
are five Member States of the EU which are classified in the WHO
list for the whole of the European region as being high priority
countries. The countries of the Baltics, Romania and Bulgaria
continue to have a major problem with multi-drug resistant TB.
There is an action plan at EU level, but TB does not respect those
borders and those borders are not that tight.
Lord Jay of Ewelme: There is free movement,
of course, which has implications for the rest of us. Thank you
very much. I am sorry to have interjected.
Chairman: No, that was useful.
Q732 Baroness Whitaker:
I would like to explore the relationship with WHO, which I think
you call your host?
Ms Baker: Yes.
Q733 Baroness Whitaker:
It is really a question of what influence or control they might
have and how it works.
Ms Weil: She has to speak honestly in front
of us because we are WHO!
Q734 Baroness Whitaker:
In so doing, could you explain why you are not, in fact, a straightforward
bit of WHO, an agency, a grouping?
Ms Baker: It actually works remarkably well
in TB. I know that is not necessarily the case for all of the
partnerships, but in TB it works reasonably well. Administratively,
we are housed by WHO, so that is the technical way of describing
it. We follow all of WHO's rules on HR recruitment, procurement.
Q735 Baroness Whitaker:
Do they do your accountancy and legal advice, personnel and all
that?
Ms Baker: Yes.
Q736 Baroness Whitaker:
So it is common services, as it were?
Ms Baker: Yes. We follow those rules and are
very much in line with all of those.
Q737 Baroness Whitaker:
That is for the "housekeeping".
Ms Baker: Yes. I am WHO staff, so my loyalty
is to the organisation, but I have a political loyalty as well
and that is to the Coordinating Board. There is administrative
responsibility, loyalty and efficiency to WHO and political instruction,
if you like, comes from the Coordinating Board of the Partnership.
Q738 Baroness Whitaker:
If the WHO Board thinks you should be emphasising something slightly
different, what do they do with their opinion?
Ms Baker: WHO is a permanent member of the Coordinating
Board.
Q739 Baroness Whitaker:
So they are one among several?
Ms Baker: One amongst 34, but they are very
clearly recognised as an important Partner, certainly more than
one among equals, let me put it like that. They are an important
player on the Board. It has not ever actually happened that WHO
has vetoed anything on the Coordinating Board, but WHO voices
its opinion very strongly and Partners take that seriously. Again,
coming back to the plan—I sound repetitive—we went
through a long process of agreeing the direction that we would
all go in and that has certainly helped. In terms of the housing
arrangements it works relatively well. WHO is very much part of
the political decision-making as well.
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