Stop TB Partnership

Speech by William Foege

STATEMENT BY DR WILLIAM FOEGE, SENIOR HEALTH ADVISER,
BILL AND MELINDA GATES FOUNDATION, USA AT THE MINISTERIAL CONFERENCE ON TB & SUSTAINABLE DEVELOPMENT

THURSDAY 24 MARCH

"Investing in Health for the Long-Term"

"TB and Sustainable Development - Lessons from Other Health Programs"

We have heard repeatedly over the last two days that tuberculosis is the second most lethal agent in the world, second only to tobacco. But as Albert Schweitzer once said, "suffering is a more terrible lord of mankind than death itself". And it is this combination of death and suffering that makes us absolutely appalled at the toll of tuberculosis. A tuberculosis worker once told me, "our tuberculosis efforts are well-balanced; we have problems everywhere." As we try to figure out how best to solve this challenge, it is worth asking what lessons we have from other health programmes. To try to balance this I'll have ten lessons in ten minutes:

• Small pox, polio, infectious diseases in general, agriculture, and the environment all repeat the same lesson: we need to be globalists. Einstein once said, "nationalism is an infantile disease: our solutions will forget national boundaries".
  
• Reciprocity - forty years ago the teaching was that malnutrition made infectious diseases worse. But it was a one way theory. Now we know that infectious diseases themselves cause diarrhoea, reduced appetite, and they burn calories, so infectious diseases make malnutrition worse. The two are locked in a deadly cycle. And now we find that health and development are likewise fused in a reciprocal relationship. No problem can be understood in isolation.
  
• Using global agencies. This is different from thinking globally. This is learning to organize globally. When people complain about global agencies I remind them that we only have fifty years of experience. It took the United States over 125 years to figure out something as simple as how to allow women to vote. It took over 200 years to extend that franchise to minorities. 50 years is simply not enough time to get our global health governance right. But we have yet another chance here to improve.
  
• There is no single best approach. One size does not fit all. With smallpox, WHO took the lead and UNICEF opted out. With polio eradication, Rotary International, a service organization, was the catalyst. Guinea Worm has been promoted by an NGO. Onchocerciasis started as a coalition between the World Bank and WHO for vector control, but now mectizan distribution has been catalysed by a corporation, the Merck drug company. We have these organizations, we have GAVI [Global Alliance for Vaccines and Immunization], we have medicines for malaria. What is the point? There is no single model that fits all needs. But second, the real power is in a shared goal. And third, if we want WHO to provide the required leadership we need to give them the required budget.
  
• There is nothing as important as agreeing on the goals to be achieved. The secret of leadership is no secret at all. It is in defining shared goals.
  
• Once there is an agreement on goals there is nothing as important as a strategic plan. A plan that combines the science, the management, the political will, the resources, the interest. Repeatedly it has been shown that money follows a good plan. As Dr Heymann reminded us yesterday for tuberculosis, we need a plan that balances DOTS expansion and MDR-TB containment.
  
• We heard from Dr Brundtland on Wednesday night, seize the moment. Can you imagine what would have happened if we had not seized the moment for smallpox. What would we be up against right now with AIDS if we also had to contend with smallpox and the problems of smallpox vaccine? What could go wrong with polio if we don't finish soon? And what new problems will delays give us with tuberculosis? It has been said that unless you are serving time there is never enough of it. And that seems especially true for tuberculosis control. We simply have to speed up. We need more action. Wisdom is knowing what to do next, but virtue is actually doing it. And we have to be reminded that time goes in one direction only. The great physicist Richard Feinman once said that it takes very little energy to scramble an egg, but that science will always be incapable of reversing that simple process. Every day we are losing opportunities that can't be reversed. We must seize the moment. Where I come from people used to say, you can't make pigs by reversing the sausage machine.
  
• Public health decisions are ultimately grounded in political decisions and we need to make this a political issue in every country.
  
• Public health programmes are expensive. Tuberculosis control is expensive. But not nearly as expensive as the disease. We must be persistent in making that point. Persistence doesn't always work, but it's the only thing that does work.
  
• Take responsibility. Frederick the Great was once touring a prison and all the prisoners got down on their knees and protested their innocence, except for one man. Frederick asked, "why are you here", and he said, "for robbery". Frederick said, "did you actually commit the robbery", and he said, "I did". He said, "I'm going to give you a pardon. I don't want you here corrupting all these innocent people". Take responsibility and then provide the best management possible. The difference between a body of scientific knowledge improving health or not improving health comes down to management. And the management cannot be limited to tuberculosis. It must figure out how to manage our own response to tuberculosis in the midst of all the other health problems. But it cannot even be limited to health; it must figure out how to do this, taking into account education, employment, poverty, the environment, politics. We need generalists as well as specialists. But we need also for all of us to become generalists and specialists, to know how our daily activities fit in to the whole of life.
  

And finally, we are not engaged in charity. Being involved with equity is not the same as charity. Instead, we are all in this together, trying to join our knowledge and our experience to improve the world and its future. To collectively solve a problem. A friend of mine from CDC was on his deathbed. He was a very organized man and so even in those final hours he asked a colleague to write his obituary for him. And then he said goodbye to friends and family and slipped into a coma. And then a miraculous thing happened. He came out of the coma, resumed conversations, lived another year. And he told me that while this was marvellous, the nicest thing of all was the chance to edit his obituary.

We are editing our obituaries every day. And how we solve the problem of tuberculosis is one more edit. The Vice-President of the World Bank invited us in her moving statement yesterday to look into our pasts. The Minister from Thailand invited us to ask how will the future see us. And there are the lessons in a nutshell. Use every lesson and experience of the past to face our descendants. The vast majority of the public that you serve has not yet been born. And we want to face that future public with pride, saying, "with tuberculosis we succeeded in being good ancestors". Thank you."

(Plenary Discussion/Moderator) Any concrete plans, based on the discussion today, on how to go forward? Hearing about what the developed world should be doing to help. Hearing about the fact that money is necessary and has to be found. Puts Foege on the spot] and asks him to be specific and pick up on what Brazil has raised in terms of research: What would make the Gates Foundation want to take part in a specific programme?

Foege:

You probably know I don't speak for Bill Gates. This has first of all been a fascinating discussion, because what has come out now are the real problems: that this requires an extraordinary coalition of public/private resources; of public health and clinical medicine; of pharmaceutical companies and so forth. Dr Brundtland started with the idea of how do we get the right balance. Obviously there are some things we all have to agree to, such as the goals - whether we are talking about federal or state or local level. There are things that we need to agree to on strategic plans, but the delivery will always be local. And then we have to figure out how the financing is mixed.

But what we have heard this morning is, do not underestimate the challenge of doing this. I was happy to hear health insurance come up and the people saying, don't expect this to answer the question. Let me go a step further and say, do not look to the United States for how to finance medical care. We are in an absolute mess and I can tell you that the outcome of this has to be the conclusion that the market place is not the way to deliver health. Once profit becomes the bottom line, you lose so many other things. It is just not the way. And yet I don't see the way out in the United States. We have gone so far that it is not going to be easy to correct this.

But back to the issue here. I agree that the global community has to look at how to improve the vaccine, how to improve drugs, how to improve diagnostic abilities. The Gates Foundation has already put US$ 25 million into the development of new vaccines and is now pledging an equal amount of money for the development of new drugs. It is true there has not been a new drug for thirty years. When you look at what the market should be it is enormous, but it is a poor market and therefore the pharmaceutical companies say they cannot invest the required US$ 350 million and satisfy their stockholders. And so we are looking for ways to get a public/private mix so that the research can be paid for in some other way and the companies do not have to therefore get a profit that replaces the research money.

Let me finally say, we have to be careful all the time to look for what are the big points so that we do not miss the point. I know a man that went on two diets because he couldn't get enough food with one diet. Well that misses the point of going on a diet. And the point we have to make here is that equity is absolutely essential. No one gains if there is a segment of the population that is left out because they are too poor. And that this is what protects the entire programme. Equity is the bottom line.