Examination of Witnesses (Questions 1066
- 1079)
TUESDAY 20 MAY 2008
Dr Nils Billo
Q1066 Chairman: Dr
Billo, thank you very much for coming here today and for your
time. We are the Intergovernmental Organisations Select Committee
of the House of Lords. Our interest, as you know, is in the intergovernmental
organisations but also the non-governmental organisations and
the way they co-ordinate and co-operate to deal with contagious
diseases. We are primarily interested in the structure of the
intergovernmental organisations and the machinery rather than
the diseases themselves, although obviously we have to have some
knowledge of that. The events today are being recorded. You will
see a record of that in draft form for you to make any corrections
of a factual nature that you wish to make. After this event, if
anything occurs to you that you feel you left out or would like
to add or elaborate on, please feel free to write. Our purpose
is essentially to get as much information as possible for our
report, so please feel free to elaborate as and when you wish.
First of all, I think I should compliment your organisation. You
have been around for a very long time, founded in Paris and with
an impressive record. Perhaps, as we have some understanding of
that, I can go directly to the first question, which concerns
the Directly Observed Treatment Short Course—a fascinating
title, if I may say so, and one which has received a lot of praise.
We have also heard from Target TB that "the implementation
of what is called DOTS in TB control ... is sometimes seen to
be too prescriptive from the top. What is prescribed by international
organisations is not always easy to implement at a local level,
so perhaps there is not a sensitivity to local conditions".
What would your view of that be?
Dr Billo: This strategy was developed by our
organisation and was called DOTS by the WHO. The term DOTS is
a little bit confusing because it means Directly Observed Treatment.
Obviously this is an important issue because very often, if patients
do not take this medication, then the risk of developing drug-resistance
is imminent. That is why we believe it is really important that
this is implemented properly. If a programme is not implemented,
we face those risks, and we have seen problems especially in sub-Saharan
Africa and former Soviet Union countries where this strategy has
not been well-implemented. The strategy, by and large, if we compare
it with other strategies on Malaria or AIDS, has done a lot of
good and many millions of patients have benefited. The criticism
of being a programme which is top-down rather than implemented
in the healthcare structure is not correct, because I believe
there needs to be a mixture between a vertical and horizontal
component. If you do not have a central co-ordination point—and
that is true not only for TB but AIDS or any other disease of
public health importance—then you have a chaotic situation
at the periphery. This co-ordination is critical at national level
but also at regional and local level, the peripheral level, where
this needs to be integrated into the health system. Obviously
this is a challenge in many countries where the issue is a deficient
healthcare system, where there is a lack of infrastructure, a
lack of medication, a lack of well-trained personnel, a lack of
very basic management skills, and sometimes that impedes the proper
implementation of such a programme. Tuberculosis can take the
credit for having achieved quite a lot over the last 20 years.
Before that, tuberculosis was not given proper attention and many,
many people died unnecessarily. One other issue is that people
ask why is the number of cases still going up. First of all, we
did not find the cases in the past because the programmes were
not efficient enough and, secondly, we have the AIDS epidemic,
which diminishes the immunity of TB patients, or patients who
are infected with TB, and because their immunity is down they
will develop the disease. That is one of the complications of
the two epidemics, they are so closely linked that they influence
each other. To get back to your question about is it too much
top-down that it does not reach the periphery, that may be true
in some cases but, by and large, I would say the programme is
well-implemented and the DOTS programme is now implemented in
almost all the countries that have a big problem with TB.
Q1067 Chairman:
Let me ask you, what happens in a country where the basic health
service is very deficient? Would you not introduce DOTS there
because, presumably, if you could not do the directly observable
bit, it would not be appropriate? Is that right or not?
Dr Billo: It is true in a certain way. I would
need to specify and this becomes a little more technical. There
are two phases in TB. The first phase is where you get four drugs,
and in the next phase you only have two drugs. If possible, those
drugs should be associated because that reduces the risk of the
development of drug-resistance. Especially in the first month,
one really needs to make sure that Directly Observed Treatment
is being applied: otherwise, as I said before, there is a risk
that patients only take the red tablet and not the other one,
and this may cause them problems. One of the big problems we have
seen, especially in countries where the health system was not
sufficient and the drugs were not available,—one example
was former Soviet Union countries like the Baltics—was they
did not have the drugs, so they took what they had and that created
a big mess and the situations we now have in those countries.
Unfortunately, the two areas where we have most of the problems
are in former Soviet Union countries with all these immigrants
that may come over and cause problems in our countries, where
we thought TB had been eliminated. I would like to say something
about that because we forgot to invest in TB in many, many countries
and that was a big fault. The Directly Observed Treatment is important
to make sure that patients do not take a wrong or deficient treatment.
Q1068 Chairman:
I understand that and understand the very great importance, not
just for the sake of the patient but the danger of creating greater
resistance, if the drug regime is not adhered to, but what I am
struggling with a bit is, is the success of DOTS as it has been
described because you only introduce it where you think the regime
can be made to work? Or do you make a clear choice that you cannot
deliver the Directly Observed Treatment system and, therefore,
you will not introduce it there?
Dr Billo: Obviously if you do not have any health
structure at all, then nothing is possible.
Q1069 Chairman:
So you do not do it then?
Dr Billo: It is not feasible. You pilot a DOTS
programme, or any public health programme, if possible in a difficult
area, to see that it works. If it is too complex, then it is not
going to work anyway. The DOTS strategy is not complicated. It
demands organisation. It does not demand a lot of technology,
but it demands some basic services. It demands a basic management
unit in a district hospital or health centre, where patients can
come and get their treatment and get supervised, and that is critical.
The strategy will work less well in a situation where you have
hardly any health system or health centre available, where it
has to be done in the community somewhere. It can work but it
is more complicated to monitor. To briefly summarise the strategy,
it needs political commitment, the drugs, the microscopy network,
the treatment observation and, very importantly, the monitoring
and evaluation part. If patients travel around, it is much more
difficult to get that information. As you said, it is critical
that to have a good programme you need the infrastructure and
that is a problem in many, many countries, there is no question
about that.
Q1070 Chairman:
In summary, what you are saying is that you do need an element
of top-down here unless you have got a very good system on the
ground, because the only way you can be sure of not making the
problem worse, by having the drugs not used appropriately, is
having some way in which you can be confident that the proper
use of the drugs is adhered to. Is that right?
Dr Billo: I absolutely agree with you, and that
is what I always say: "If you are not able to guarantee a
good programme, do not start, because you may create harm".
Unfortunately, this has happened in some countries where drugs
are being distributed without any proper programme available,
and then some drug resistance has occurred. The health system
is critical.
Q1071 Lord Avebury:
Can we apply this reasoning to sub-Saharan Africa, where you said
there were problems. We did hear from the International HIV/AIDS
Alliance that our Department for International Development does
acknowledge the needs of marginalised populations but continues
to invest a large proportion of its AIDS resources in intergovernmental
organisations and governments that are unable or unwilling to
respond to the HIV epidemics amongst marginalised populations.
We wonder whether the same is true of TB and whether you could
illustrate that by looking at the problems in southern Africa
where there are marginalised populations. I am thinking particularly
of the Zimbabweans and South Africa, who are much in the news
at the minute. If those people are not being treated for HIV/AIDS,
then presumably they are not getting any treatment for TB either,
and this is not apparently a matter of much concern to DFID, which
channels all its aid through governmental agencies that are discriminating
against these marginalised populations.
Dr Billo: I really think that, in order for
any AIDS, TB or public health programme to work, you need to support
governmental organisations, governmental institutions, but also
the communities and NGOs. In my opinion, it is a mixture. I can
illustrate that. Our organisation works very closely with the
WHO and we have many working groups where we are together, so
we really co-ordinate our work well. Obviously, if you channel
money to a government, it will depend how the government is organised.
You mentioned South Africa, which is a very unfortunate situation.
South Africa is probably the richest country in the sub-Saharan
area but, unfortunately, I am sorry to say, they have a very deficient
TB programme. AIDS, as you all know, is difficult for some peculiar
reasons at the top level, where there is a lack of commitment.
In addition, it depends on the political system available. In
South Africa you have a federal system, so the federal government
probably has difficulties co-ordinating among the different states
and provinces of South Africa to really get things done. Unfortunately,
especially for TB, they were not able to create an efficient programme
and it is correct that, because of that, a lot of the marginalised
populations have not been able to benefit from infrastructure
which is there but is not well-organised. I always say that we
make a big mistake by saying we do not have the technology, we
do not have the science; we have the science and we have the technology
but what is lacking is the management. In many countries basic
management is deficient: how to organise a trip from A to B takes
a huge administrative burden and that hampers the proper functioning
of many things, including health systems. Again, I think it is
critical to support governments, to support the WHO, but it is
also very critical to support efficient community-based organisations
and NGOs on the spot. It is the synergy between the two that will
make for a good programme. There are many examples where, for
instance, the government structures are weak and NGOs are very
strong and it works then. An instance would be in Bangladesh,
where we have a very weak government system but a very strong
NGO system and the TB programme works extremely well. Then we
have India, where you have a very strong government system, a
little bit top-down, very controlled, and they struggle a little
bit with getting more NGOs involved, but they are doing it as
well. It is a mixture of both and to bet on one side only would
be a mistake.
Q1072 Lord Avebury:
Since you mentioned Bangladesh as an example of good practice,
can you say anything about the minority populations there? They
do have a substantial but reducing population of Hindus in Bangladesh
and they also have a large population in the Chittagong Hill Tracts,
which is separate from the majority ethnically in terms of religion.
Are you sure that Bangladesh is applying the same treatment to
minorities as it does to the majority?
Dr Billo: First of all, I do not know Bangladesh
in detail, so I cannot answer your question accurately, but what
I know is that Bangladesh has a very weak government system and
BRAC, the NGO that works there, has been able to do a good job.
I am not saying they are able to catch all the people with little
access. I can probably come in here with an experience we had
in the Union. We got a grant from the Canadian International Development
Agency to look at poor populations and improve access to innovative
new ways, for instance with wall paintings, to really tell the
poor people, if they cannot read, that if they have a cough they
need to go and get examined. This project, which we implemented
in China, India, Indonesia, Bangladesh, Pakistan and other countries,
showed that through innovative ways you can improve access for
the poor. Unfortunately, TB is a disease of the poor and marginalised.
It is very difficult to get these people to the treatment centres.
Their first worry is not the disease, it is getting food for their
families, so the last thing they do when they are almost dead
is they go to get treated and very often the prognosis is not
so good. There needs to be an holistic approach if you want to
give better access to marginalised and poor people. You need to
offer them some incentives to come to the treatment centres, and
that is true not only for TB but for HIV and any other diseases.
Their worry is not the disease, it is daily survival. The whole
system needs to be looked at and that is why we think non-governmental
organisations that can give food, give incentives, are important
in that sense to complement the services of governmental organisations.
Q1073 Lord Desai:
We have had a number of people telling us about the problem of
co-ordinating HIV/TB infections. How are the HIV and TB programmes
operated? Are they co-ordinated nicely or are there problems?
Dr Billo: This is a very good question and I
would say that for many years, unfortunately, this has been a
challenge. It is improving, but it is improving slowly. If I can
criticise WHO, the fact is that for many years they have had trouble
talking to each other, the HIV department and the TB department.
Q1074 Chairman:
Within the WHO?
Dr Billo: Within the WHO and also WHO with UNAIDS.
WHO is part of UNAIDS but this has been a problem and translated
into some co-ordination issues in countries as well. Obviously
it is very easy to say that TB and HIV are very common, they need
to look at things together; but it is not so obvious because very
often there are different funding streams that go to the programmes
and everybody is basically guarding their turf and that can hamper
the collaboration. Many organisations are realising that this
has been deficient. Also PEPFAR, the initiative of President Bush,
which paid very little to TB and HIV, is now putting much more
money into this and facilitating this co-ordination in many countries.
Our organisation has taken up this challenge and we have several
projects, for instance in Myanmar, DR Congo, Zimbabwe, where we
have tried to get over this barrier. For instance, we have the
TB programme as an entry point for HIV as well; so, when a TB
patient comes, we also facilitate the HIV test to make sure we
do not miss a person with TB who may have HIV as well. As you
may have heard, TB is very often the first infectious disease
that pops up for a patient infected with HIV who otherwise has
no symptoms. It is very important that this is addressed strongly.
For instance, in Myanmar we have had very good success, where
with very little money we were able to get those two programmes
together, but it is a constant dialogue that needs to be had from
the TB programme to the AIDS programme and vice versa. Because
historically the AIDS programme has been very strong, they always
have a lot of money, and even before the era of anti-retroviral
treatment they had a lot more money compared with the TB programme;
they feel they have more muscle and do not feel the need to collaborate,
but this is happening more and more. Also, very importantly, the
AIDS activists play a crucial role. For many years the struggle
was to get more money for prevention, for drugs; but now they
realise that TB is a big issue they are pushing very hard. We
had our World Conference in Cape Town last year and we had about
5,000 activists who asked for better TB treatment for HIV-infected
individuals. We need to push that movement much more. We need
to sensitise the HIV community about tuberculosis in order to
improve that collaboration that you rightly mention.
Q1075 Lord Desai:
Just to go further with that, even the UK has not got a proper,
good co-infection strategy. As you say, AIDS is much more politically
glamorous than TB.
Dr Billo: Yes.
Q1076 Lord Desai:
Are you and your partners doing something to raise awareness of
TB as being equally important?
Dr Billo: We are trying to do that, but it is
very difficult. Just as an example, when the WHO Secretary-General,
Margaret Chan, talks about big challenges, she talks about HIV,
Malaria and many other things, and TB gets forgotten, and we have
a problem with that. It is something that we need to improve on.
We have made a lot of progress, but still AIDS is much more glamorous,
it affects populations which are very strong in terms of advocacy,
whereas TB affects mostly poor people and they do not have a lobby.
That is one of the big issues. They do not go out onto the streets
in South Africa, or very seldom, it is the HIV people who go on
the streets and shout that they want something. TB people are
poor, marginalised, and very often it is more difficult to raise
their point.
Q1077 Lord Howarth of Newport:
Can I just press you for a moment to elaborate a little bit on
what you have been saying about the WHO and Margaret Chan? Do
these problems of different departments that need to talk to each
other and collaborate still persist? Or are they being addressed?
Dr Billo: They are being addressed. It is much
better than it used to be. It is very much on the right track
now. The activists have played an important role. They are pushing
for this collaboration at all levels, including within the WHO,
and this is much better. We have a TB/HIV Working Group and a
liaison person who was delegated from the WHO TB Department to
UNAIDS, so these links are much better. We had a press conference,
for instance, here in Paris, where we looked at the major challenges
and invited somebody from UNAIDS to give a talk. These things
are much better co-ordinated now but, as we know, it is not enough
to have this recognised at the top level. We always make the mistake
or the assumption that, if WHO does it, it will happen everywhere,
but this has to be translated through a policy transfer mechanism
to the governments of countries, and that is often not enough,
because it stays there, is discussed in a committee and it is
not sub-national. It needs to go to all levels and that takes
a long time. We have seen that with the DOTS strategy. For many
years the strategy has been known by WHO, by the major NGOs; but
still, if you ask somebody at the lower level "What is the
DOTS strategy?", they would have trouble saying what it is.
Q1078 Lord Howarth of Newport:
The budgetary processes are crucial, are they not, because if
people are funded to do one thing and not another they will do
the one thing?
Dr Billo: Yes. This is an important point. When
you fund programmes in an isolated way, you may run the danger
that they only look at their area of interest and not look in
a lateral way. DFID has quite a good reputation in addressing
that issue and not just funding programmes, they like to have
a more holistic approach.
Q1079 Lord Avebury:
Since you have mentioned DFID, I have in front of me this report
from Results UK which is entitled An Inadequate Response,
where they say: "of the 18 high burden countries in which
DFID has a bilateral presence, only two country officers reported
that they were providing any direct support for TB/HIV collaboration
activities". Can you verify that? Why do you think it is
that DFID has such a creditable record in the face of this criticism?
Dr Billo: To be honest, I do not have a detailed
overview of what DFID is funding. I know that DFID has given a
lot of support to many countries. I am not 100 per cent familiar
with the way in which they give support, but I know they claim,
at least, that they try to support holistic approaches where they
say they will fund TB, HIV and Malaria and, if you make a proposal,
you have to send a package which includes all important areas.
The reality probably is still not as it should be, but I would
say DFID has supported TB in a very substantial way, especially
in India and other countries in Asia, and it is one of the development
agencies that has done a lot for TB and supported the Global Fund
in a meaningful way. Among all those agencies, I would think DFID
has done quite a good job compared with others. There is always
room for improvement, of course.
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