By Stephen Lewis
Durban, South Africa, July 17, 2016
Allow me to set a context for these remarks. Everyone in this room knows more about TB than do I. I can’t pretend to expertise; I merely have observer status. You’ve had an extraordinary array of break-‐outs and plenaries of scientific and academic excellence that I can’t begin to rival. But what I think I can do, hope I can do, is to provide some personal reflections on some selected issues, based in part on the work on HIV, and in part on life experience. I shall leave out a great many things, choosing instead to settle on those where I feel I have something to contribute.
Curiously, I stand before you utterly perplexed. I have spoken to a goodly number of people, and read a great deal of material, and I’m not at all sure I understand what, exactly, is required to get past the incremental response to TB.
My perplexity was further accentuated by the report issued by UNAIDS on the eve of the conference, titled “The Prevention Gap”.
Many of the findings were ominous. Having paraded the self-‐ congratulatory chorus of “Ending AIDS by 2030”, presumably in large measure to attract donor funding, suddenly the alarm bells are ringing: prevention has stalled at an average level of
1.9 million new infections every year since 2010 … no single region of the world has recorded a significant drop, and some—take Eastern Europe/Central Asia for example—have recorded astronomic increases; further, a full 35% of new infections are rooted in Key Populations; among adolescents in sub-‐Saharan Africa, age 10 to 19, seventy-‐five percent of new infections occur in girls—an astonishing commentary on our failure for 35 years to address gender inequality … if rhetorical extravagance of monumental proportions meant anything, there’d be a zero infection rate amongst girls; and finally, the money from international sources is falling dramatically … from roughly $10 billion in 2013 to $8 billion in 2015. We are in crisis mode.
Now why do I raise this frontally in this speech? Because nowhere—I repeat, nowhere—in the narrative text is the word tuberculosis mentioned. I was stunned.
However, stunned turned out to be as nothing when I received, this morning, a copy of UNAIDS latest report, just released, titled “90-‐90-‐90: On the Right Track Towards the Global Target”. In 54 pages of text, TB is mentioned three times, entirely in passing, as though it were utterly inconsequential. I verged on cardiac arrest. What was I missing? Isn’t it accepted knowledge, everywhere, that you can’t get to 90-‐90-‐90 without defeating tuberculosis?
Let me elaborate on my apparent naivete and perplexity. When I started in the role of Envoy in 2001, virtually every hospital I visited in the high prevalence countries told me that the co-‐ infection rates were a scary ten to fifteen percent. By the time I left the role at the end of 2006, it was commonplace to hear of co-‐infection rates of 30 to 50 per cent rising, on occasion, to 70 per cent (in Lesotho at one point it reached 92%). So in my understanding of the pandemic, AIDS and TB were inseparable.
I remind you of the words of Dr. Motsoaledi: quote “We will not end AIDS without ending TB. We will either succeed or fail together, so walking alone is not an option … In South Africa we are ensuring that every person who receives an HIV test is also tested for TB, and every person with TB, is tested for HIV”, end quote. How much clearer can you be?
So wouldn’t you think that any report on HIV/AIDS, whatever its rationale, treatment or prevention, would ring in some reference to TB? Wouldn’t you say—I don’t think this is intellectual innocence on my part—that UNAIDS is a logical repository to drive the response to tuberculosis; if the two are stitched so relentlessly together, and TB is now a greater killer than AIDS, would you not think that the entity charged with the international institutional responsibility for AIDS, would be the protagonist in the fight against TB?
Let me admit that I haven’t discussed this with Michel Sidibe. But he would be well within his rights to say ‘Look Stephen, we’re not an agency, we coordinate the joint UN Program on HIV/AIDS, involving eleven participating UN agencies … it would take forever to get their approval if we ever got it at all. And then we have our PCB, our Program Coordinating Board, who would make us jump through an eternity of hoops.’
He would be right, but look what it leaves us with: there’s no international organization, equivalent to UNAIDS, driving the response to TB. That’s something I want to return to later in this speech. I should add of course that WHO is deeply committed to eradicating the scourge of TB, but WHO is a specialized agency with particular scientific competence, and it simply doesn’t have the people on the ground to lead the fight. We all know that.
Nor do I mean for a moment to diminish the STOP TB Partnership, and the same of course for The Union. But these are not powerful international entities, rooted in the United Nations, and with vast budgets at hand.
And that leads to another reflection. There is no separate financial machine behind TB as there is with PEPFAR for AIDS and the President’s Malaria Initiative for Malaria (although it must be noted that PEPFAR has sunk over a billion dollars into TB in recognition of the integrated relationship). TB is overwhelmingly funded by the Global Fund; without it, there would be a vacant pipeline. As has been noted, some 77% of funding for TB in Africa comes from the Global Fund … however, only about 17% of the Fund’s resources go to TB … some 53% to HIV and 30% to malaria. Tuberculosis is the impoverished cousin … a matter of some consternation since it’s the infectious disease that has ascended to the status of the engine of death. One and a half million annually, and not a single death necessary. What in God’s name is wrong with the world?
I want to say something about this funding crunch, because all of us know that resources are desperately lacking.
Everyone is looking towards the pledging conference in Montreal, Canada, this fall.
The Global Fund target is $13 billion, and I think they’ll make it, largely because the Canadian Government is exercising intense diplomatic pressure on the donor community. Canada has a new Prime Minister, the darling of the G7, and he is putting his name on the line for the pledging conference. That’s a great thing. In fact, it wouldn’t surprise me if we exceeded the target.
But that prompts another thought, heretical though it may be. The Board of the Global Fund is far too hesitant, too timid, too cautious about asking for money. There would have been no risk in going for $14 billion with the extra billion designated for tuberculosis. I understand the visceral competing interests of refugees and terrorism, but the international community simply can’t allow a curable infectious disease to rob the world of more lives in one year than all of the competing conflicts taken together.
Please don’t give me any lectures in realpolitik. This is a world I know. I’ve spent more than fifteen years as an elected member of a legislature, I was Canada’s Ambassador to the UN, I was a Deputy at UNICEF headquarters responsible for global programming and, incidentally, for overseeing the raising of money for that remarkable organization, and I reported to Kofi Annan for five and a half years as his Envoy on HIV/AIDS in Africa. I don’t usher in that biographic stuff to seek to impress. I do it to say that I learned, over the years, that timidity and passivity are the authors of misfortune.
This room is filled with principled advocates and activists who would move heaven and earth to defeat this disease, but the collective efforts are compromised by indifference in high places, by an absence of political leadership, and by strangulated shortfalls in resources. All of it is unconscionable; all of it is indefensible.
So because I wanted to make a couple of useful recommendations during this speech, rather than just a prolonged rhetorical spasm, let me share a thought about resources.
Last Thursday, while here in Durban, I phoned Jim Kim, President of the World Bank. I spoke to Jim, not simply because he holds an exalted position in the world of international finance, but because in his early days, he and Paul Farmer, when creating Partners in Health, focused significantly on tuberculosis from Russia to Peru. I know that for Jim Kim it’s a living and burning issue, and I also know that the World Bank has done some work on tuberculosis that is highly regarded.
We talked at some length, he the mentor, I the student, and at the end he said to me: “Stephen, you can tell the audience that we talked, and you can tell them that I told you that I would be willing to sit down with a representative group to discuss, concretely, innovative forms of financing to fund tuberculosis”.
I suggest you take him up on it. If some of you have done it before, then do it again. The invitation was serious. MSF, Partners in Health, STOP TB, the IAS, WHO, the Treatment Action Group, The Union, Results, TAC … whomever, take a stab at it.
I’ve spent much of my adult life excoriating and eviscerating the World Bank. In my mind the Bank will never be able to atone or compensate for the wanton, savage damage it did to Africa with Structural Adjustment programs. That was financial colonialism run berserk, and Africa is still paying the price. But Jim Kim is a different kind of President of the Bank. Unlike his predecessors he truly believes in the elimination of poverty, and recognizes that TB is the disease of poverty. More, I recall that when Jim headed the HIV program at WHO, he launched the famous 3 by 5 initiative which, though it wasn’t entirely successful, unleashed the roll-‐out of treatment for much of the African continent. This is a man to take seriously. I urge you to do so.
So is Dr. Aaron Motsoaledi. I read his speech of yesterday morning, and thought it a cogent and powerful contribution to this meeting. Inevitably, he raised MDR-‐TB and the urgent necessity to summon every fibre of our collective being to extinguish this growing menace that now ravages half a million people a year.
As we all know, in considerable measure, it’s a matter of drugs. As Dr. Motsoaledi said, South Africa has the largest number of people in the world on bedaquiline. But many many more need the treatment. There is also growing hope around delaminid, but as you know, the drug company, Otsuka is not being cooperative in the provision of significant quantities of the drug at all, let alone at prices that countries can afford.
We must somehow come to grips with these drug companies that play fast and loose with human life. It’s important to recognize what’s going on in the larger picture. The drug companies are not operating in isolation; it’s all part of a carefully-‐orchestrated pharmaceutical plan to stall for time, regardless the human consequences, while increasing numbers of newly-‐negotiated trade agreements extend patent privileges of brand-‐name drugs far beyond the privileges provided in WTO treaties. If you think I’m a conspiracy theorist, then I urge you to read carefully the report of a panel, commissioned by the Secretary-‐General of the UN, on Access to Medicines when it is published in a few weeks time. It will, I believe, be a launching-‐pad for the necessary international confrontation with the pharmaceutical industry.
This is a life and death struggle. We need these drugs and others desperately. Even now, as you know, the End TB Project is underway, with MSF, Partners in Health and Interactive Research and Development, funded by UNITAID over the next four years. It’s hoped that, from it, there will emerge new regimens to inform the guidance of WHO. Drug companies should be falling all over themselves to accelerate the discovery and availability of new drugs and compounds to battle a disease that need not exist. If I may quote Dr.
Motsoaledi again from a recently-‐published article: “It is both a market and a moral failure when pharmaceutical companies do not invest in finding effective cures for the world’s leading infectious disease”.
As a matter of fact, let me move on from that to note a sobering conjunction of figures. In his speech yesterday, Dr. Motsoaledi pointed out that the Global Plan to End TB requires $13 billion a year in funding until 2030. That’s perfectly reasonable: apart from the treatment itself, we have an entire research and development agenda, from drugs to diagnostics, that’s starving. But the current funding levels are one-‐half of the $13 billion.
Do you hear the echo? As I said earlier, the replenishment target for the Global Fund is $13 billion over three years.
Can someone of astute, Einsteinian mathematical dexterity explain to me how we’re going to get that extra $6.5 billion, with the Global Fund currently providing just seventeen per cent of its monies for tuberculosis? Do you see how nuts the calculations are, how great is the chasm between need and delivery? And I want to make a point that is always raw for some people, but I’m so over-‐the-‐hill now that I don’t care what you might think of me. The BRICS countries where the great majority of TB is found, can summon the resources if they care to. But low-‐income and middle-‐income African countries, beset by the pandemic, have terribly limited financial capacity.
So I must ask the question that I’ve often asked before: why, in the history of the pandemic, and now with TB, are African lives more expendable? You can guess what my answer would be.
But I invoked the BRICS countries. And there is one of the BRICS countries of special disrepute: namely, India. The remarkable “Out of Step 2015” report on TB policy in 24 countries, authored by MSF and STOP TB sets out, chapter and verse, the grim disappointment when assessing the failure of so many countries in addressing TB, but India, in particular, makes tough reading … intermittent treatment instead of daily fixed dose combinations, sale of TB drugs over the counter without prescriptions, appallingly slow roll-‐out of molecular testing, a miniscule number of people on bedaquiline … all of this with 250,000 deaths a year. I would argue that it’s absolutely necessary to name and shame countries, openly, unapologetically, when their political fraudulence puts their own citizens at risk. Enough of the deference. Enough of the gentle, diplomatic niceties.
Does patience never run out?
Surely patience should be exhausted when there’s incontrovertible evidence that citizens are dying of a preventable disease because of the willful negligence of their government. The dossier on India and TB is not pretty; it’s dismal.
These wonderful NGOs, populated by individuals who scale the ramparts of social change and never give up. I’ve had the opportunity in the last few weeks to speak to Lucica Ditiu, Sharonann Lynch, Joanne Carter, Erica Lessem and many others. Sharonnan and Joanne are particularly good friends and I take their views of TB as holy writ, but—and it’s an important but—please don’t scar their reputations for any personal opinions I state in this speech.
Their commitment, as is true of so many in this room, is unflagging, and just as civil society has been instrumental in the progress against HIV, so civil society is now massing together, evermore strongly, in the effort to overcome TB. To that end, there’s a new MSF petition circulating at this conference, supported by all the excellent usual suspects, called “Step Up for TB: Sign on the Dotted Line”. It demands that all countries upgrade their responses to TB within five hundred days, noting that if the status quo continues, it will take one hundred and fifty years to achieve the goal of elimination. I urge you to join. When civil society is truly enlivened, and it sure is enlivened around TB, then the possibilities of change increase dramatically.
And one further observation. I want to acknowledge the presence of Dr. Eric Goosby, the UN Envoy for Tuberculosis, admired by all. I was once an Envoy for HIV, so I know a little of Eric’s job. But there is a difference. I was one of five Envoys … two to cover Asia and the Pacific, one for the Caribbean and Latin America, one for Eastern Europe and Russia and one for Africa. Our collective task was impossible. I can’t imagine how Eric survives. Mind you, at present rates of progress, we may solve the art of cloning before we solve tuberculosis, and then we can have a cornucopia of Goosbys!
May I add to this narrative in a way that has barely been touched in the literature of TB that I’ve had the opportunity to read. If TB is the disease of poverty, about which everyone seems to agree, then please note that the most impoverished
population, certainly on this continent, are the women of Africa. And given the levels of HIV infection amongst the women, then their vulnerability is extreme.
It seems to me that this is an argument whose time has come. It’s also an argument that can be documented in human terms. The situation of women and girls figures prominently in the Sustainable Development Goals, and the vulnerability imposed on women has seemed finally to have grabbed the attention of the international community. If I were pushing donors and susceptible governments into a corner, I’d hammer home the theme of women and TB at every turn.
But let me, as I wind my way to the end of these remarks, return to a proposition I set out at the beginning. I was much struck by International Union Against Tuberculosis Executive Director Jose Castro’s speech yesterday when he rhymed off all those declarations and commitments made in good faith year after year and never honoured. He felt it might be different now … no, he felt it had to be different now. And he felt that the moment of change would come if only we all picked up the gauntlet simultaneously and hurled it in the face of tuberculosis.
It’s an attractive, compelling position. Personally, I’m ready to mount the barricades. But I think the possibility of success could be greatly enhanced if we had a United Nations agency seized of TB, and determined to give new and vital support to all of you fighting the good fight.
So bear with me and please hear me out.
The largest and best-‐resourced UN agency is UNDP, the United Nations Development Program. It’s in virtually every country, it heads the UN family in every country, and it has strong relations with the government of every country.
If UNDP were to decide to exercise significant leadership on TB, it could make a stunning impact. But hear this: as some of you may know, UNDP is already involved with TB. It actually has an extensive program testing for and treating TB in Syria. It also executes a number of Global Fund-‐supported TB programs in selected conflict countries … it has successfully treated 848 thousand cases with a very high rating from the Global Fund on the grants it receives. If we were able to turn on UNDP, it could make a world of difference.
I feel particularly strongly about it given the performance of the HIV/AIDS unit in UNDP, headed by a sublimely effective woman, who is both a lawyer and a doctor, Mandeep Dhaliwal. This is the unit that organized and wrote the report from the Commission on HIV and the LAW, and then, in exemplary fashion—actually unheard of in UN circles—followed up on the report, focusing on human rights, and activity after activity, from public meetings to judicial training, to inclusive roundtables to legislative changes in over forty countries.
More, it’s the HIV unit in UNDP that’s responsible for persuading the Secretary-‐General to appoint his Panel on Access to Medicines, and UNDP is the secretariat to the Panel.
So you see, there’s reason to believe that UNDP could be a new and powerful resource.
But I readily admit that as with all things United Nations related, it can be very difficult to predict the outcome. In this instance, much will depend on the UNDP Resident Representative in the country. If she or he is good, great things follow. If he or she is mediocre and bureaucratic then lousy things follow. The only way to overcome the mediocrity is through an edict delivered by the Administrator. The Administrator, Helen Clark is a nominated candidate for Secretary-‐General of the UN. You would have to time any overture carefully.
By the way, UNDP gets on well with WHO … a nice touch, given the rivalries within the UN system.
So let me be clear. There are obviously no guarantees, but because the possibilities are great, I think a representative delegation should approach UNDP. It became clear to me, as I absorbed the issues, that there was a coordinating instrument missing at the heart of this passionate cause celebre. A UN agency, a fund or a program, could play that role superbly if it was persuaded to do so. And then, if there was collaboration with the World Bank, for reasons of funding, we would have the best of both worlds.
And so I end. And frankly, I don’t know how to end. There’s something terribly frustrating when you see all the pieces on the chess-‐board ready for checkmate, but you just can’t figure out the next move.
I’ve tried to suggest a couple of entry points. What exhilarates me is the sense that everyone in this room, from every organization, is descending on tuberculosis, with malice aforethought, determined to remove it forever from the lexicon of infectious disease.
And you know what? That may be enough because you have so many plans in place. And the sheer force of indefatigable determination may wrestle TB to the ground.
But I’m still troubled. Why? Because like you, I can’t stand the thought of another unnecessary death. So maybe we should try one or two of my suggestions, while relentlessly pursuing our current mandates with supernatural tenacity.