Speech by Dr James Orbinski

STATEMENT BY DR JAMES ORBINSKI, PRESIDENT, MEDECINS SANS FRONTIERES (MSF), BELGIUM
AT THE MINISTERIAL CONFERENCE ON TB & SUSTAINABLE DEVELOPMENT

THURSDAY 24 MARCH

"FORGING NEW PARTNERSHIPS TO STOP TB"

Normally we meet in the field, in our health clinics, and in our hospitals. It is very much an honour to be here today and particularly to have been asked to speak to you under somewhat different circumstances. I would like to take this opportunity to look forward to the next challenges that must be confronted in tuberculosis, and particularly the challenge around research and development.

It is absolutely clear from the proceedings of the conference that TB is now on the political agenda. And that is exactly where it should be. For too long it has been a technical, medical disease. It has been a disease that has been focused on simply through technical, medical approaches and lenses. This conference more than anything else demonstrates very clearly, primarily through the level of representation from the ministers of health, the WHO, the World Bank and donor countries, this political will.

In my reading of the discussions over the last two days, it is clear that there is a consensus on technical priorities, on the need to improve, to expand, and to adapt DOTS. To improve DOTS through more research and development on diagnosis and testing and on more research and development. On increasing the efficacy of diagnostic and treatment protocols. The necessity of increasing research and development for new TB drugs. It is also clear that the necessity of expanding DOTS more widely is acknowledged and that DOTS must adapt to address the MDR-TB scourge and the TB/HIV interaction. Each of these three areas, to improve, to expand, and to adapt DOTS, is not mutually exclusive. It is clear that if any one is pursued in isolation the epidemic will only worsen.

These are technical problems or challenges that require political solutions. These solutions must rest on recognition of the right to health care of all people everywhere, on recognition of equity of access of health care of all people everywhere, on recognition of the responsibility of governments and intergovernmental organizations to ensure access to health care.

As was pointed out early in the conference, fifty years ago it was a massive and definitive public response that brought TB under control. For example, the British Medical Research Council engaged a massive research effort that led to new drug development. Sanatoriums were built, there was active tracing and case finding on the part of the public sector, and this brought the TB epidemic under control. The same is needed today.

We have seen that the most burdened countries do in fact have the political will to address TB at the national level with any and all means at their disposal. We too as MSF, within our means and within our role and within our responsibility as a non-state actor, are doing all that we can. We are working in over 20 different countries at this point specifically on TB and we are implementing DOTS in each of those countries. We very much believe and support DOTS - I want that to be absolutely clear. We are also working in conjunction with the WHO to establish a short-term procurement system for second-line drugs for the treatment of MDR-TB. This collaboration is going quite well and we expect fruitful results in the coming months.

Let us be frank. The capacity of the countries represented here is stretched to the limit. In Tanzania, for example, the annual per capita expenditure on health care is US$ 3.5 per year. There is little more that Tanzania can do to improve its efforts to develop a sustainable national TB treatment programme. With all the will in the world the countries represented here can, I believe, do little more than what they are already doing and what they have already pledged to do today.

Political responsibility also lies at the international level and not simply through bilateral mechanisms. If public health infrastructure is to be expanded, if DOTS itself is to be expanded, improved and adapted, this will require resources and interventions at the international political level. These responsibilities are simply beyond the material capacity of the high-burden TB countries. These responsibilities cannot be left in the hands of private philanthropists or NGOs, however noble their intentions. Both private philanthropists and NGOs represent in today's world a soft, if you will, informal power, and it must remain soft and it must remain informal. States, governments, must recognize and must act on their legitimate responsibility to ensure health. Nor can these issues be left to market forces. And nor, simply, to "soft interventions" or encouragements like public/private partnerships.

In the area of research and development for new TB drugs, there has been no novel or innovative treatment or therapy in the last 37 years. The market has clearly failed. And so too have governments, to ensure new antitubercular treatments. The market will not in fact provide the appropriate mechanism for developing new TB drugs. It is absolutely clear that TB is a disease of the poor. The poor have need but they do not have consumer power. That market is not a market. It will not provide a return on investment for the pharmaceutical industry. Ensuring access to new tubercular drugs means that lifesaving essential medicines cannot be treated like any other commodity, like CDs or cars; they are a public good.

Research and development is a public responsibility, requiring hard market interventions, or, singularly, public research and development initiatives. Certainly the multinational pharmaceutical industry will need to be consulted, but purely for their technical expertise. We must remember that they are accountable to shareholders and not to citizens. Any public research and development initiative must put equity of access to new TB drugs as its first goal. The drug itself and the intellectual property rights associated with its antitubercular indication must be a public good. Otherwise, access will simply be a "trickle down effect" in twenty years time when patent rights expire.

The focus should be on developing an affordable drug that shortens DOTS to less than three months with minimal dosing requirements. It should also involve a transfer of technology and a development of research and development capacity in the developing world.

We at MSF call on governments and especially the European Union and its Member States, and the United States, to play a leadership role, not just in international health forums such as this, but at other forums like the World Trade Organization, to ensure that international public health issues take priority over trade interests.

We challenge the World Bank to look at how they can fund the development of global public goods like a research and development agenda for priority global diseases. Any initiative in this area must acknowledge the clear and unequivocal leadership of the WHO in establishing a global research and development agenda for diseases like TB. Thank you.