Speech by Mr Andre Roberfroid

STATEMENT BY MR ANDRE ROBERFROID, DEPUTY EXECUTIVE DIRECTOR, UNICEF AT THE MINISTERIAL CONFERENCE ON TB & SUSTAINABLE DEVELOPMENT

THURSDAY 24 MARCH

"Tuberculosis - Women and Children Can No Longer Wait"

It is my great pleasure today to be present at this historic opportunity in the global battle to overcome tuberculosis. In UNICEF’s opinion TB has become one of the most seriously neglected and underestimated health, human rights and poverty problems of our era. It is indeed appropriate and timely that we begin to address collectively and multi - sectorally this dreadful scourge at the beginning of the new Millennium.

Urgent Threat

No one can deny that TB is reemerging in many regions of the world as the next Millennium’s gravest threat to global health and well-being. In particular its synergistic relationship with HIV/AIDS makes it a double burden on those populations that we know are already suffering the devastating social, economic and health impacts of HIV/AIDS. While Asia has the greatest number of TB cases, Africa has the highest rates of TB primarily due to rampant HIV/AIDS. In all parts of the world the urgent danger of inaction is the potential threat of an explosive increase in multi-drug resistant TB.

Extensive Impact on most socially and economically vulnerable

The impact of tuberculosis on overall health status and socio-economic well-being especially of the most-vulnerable is extensive. TB surpasses all other causes of women deaths. It infects roughly 4 million women annually and kills over 750,000. It already is estimated to be the major single cause (40%) of premature death amongst AIDS cases. New research is pointing to the devastating impact TB illness and death has on the well being of young children and the family in general. Evidence obtained by the Asian Development Bank (ADB) shows that at least half of the financial crises in poor Asian families are triggered by a catastrophic illness especially TB. When coupled with the already high costs of HIV, many families and countries are facing a double burden of significant scope

The Consequences of Inaction

Of even greater concern to UNICEF is the cost of inaction or inadequate action. In Asia, it has been estimated by WHO that if India, a high-burden TB country, were to reach the recommended STOP TB Initiative target of 85% DOTS (Directly Observed Treatment Short-course) coverage today, it would take 50 years of sustained effective action to eliminate TB. Furthermore, if we allow the proliferation of inadequate TB-treatment services, unsupported family care practices and incorrect self-treatment, a real possibility in Asia, we face an even greater humanitarian and epidemiological disaster in the rise of multi-drug resistant TB (MDR-TB). We cannot be complacent. It has been shown by experience in other parts of the world facing multi-drug resistant TB that it costs, on average, $US 50,000 to successfully treat one MDR-TB patient.

Solutions already at hand

Yet the solutions are well within reach. Whilst the cost to treat one drug resistant TB case is enormous, it costs as little as US$11 for a six months supply of drugs to effectively treat a regular case of TB. However, the biggest saving is that the $11 treatment can prevent the much more costly and deadly multi-drug resistant TB (MDR-TB). The choice for action is clear. Establish an effective worldwide DOTS system today for as little as $11 per patient, or risk a virtually uncontrollable MDR-TB future.

Why UNICEF should help

The case for UNICEF’s involvement in stopping TB is also clear. TB is a major threat to the rights of the child, adolescents and their families. Its potential negative impact on the survival, growth and development of our mandated populations is, without question, extremely grave. The social impacts affect our mandated population disproportionately – the stigma faced by TB infected women and young people (a rapidly growing affected group) is devastating. Stigma disenfranchises the deeply affected and adds to the grave potential risks from inadequate treatment.

UNICEF also needs to be involved because there has been insufficient attention focused on the direct and indirect impact of the disease in children. There must be more research done to identify the epidemiology of TB in children especially in the context of rising HIV/AIDS. Our suspicion is that TB in children is underestimated due to the difficulty of diagnosis in the young child compounded by difficulties of dealing with HIV/AIDS. In terms of indirect impact on children living in families affected by TB and HIV/AIDS, we see evidence of a negative impact on school attendance. Evidence for this identifies that approximately 300,000 children in India drop out of school due to the social and economic impact of TB in the family. In Kenya we see very clear evidence that TB and HIV/AIDS in the family has very serious negative effects on child survival due to increased impoverishment of the family and a subsequent decline in adequate family care practices on the part of ill and overwhelmed family care-givers. In other words the disease renders ineffective the taken-for-granted family coping mechanisms that have been the foundation of community and family care systems for generations. There also needs to be more TB and HIV/AIDS research that identifies the special risks to children in conflict situations, children who are refugees, children who are trafficked and children who are generally in conflict with the law.

TB-HIV/AIDS – Duel threat and double tragedy

The combined stigma of HIV/AIDS and TB represents virtual ostracism for those concerned. None of us can afford to ignore this gross violation of the right to health and the right to a just livelihood. Yet parents with HIV/AIDS who become sick with TB can actually extend both their longevity and quality of their lives with proper TB treatment, postponing their children's orphan hood. The social and economic impacts of this joint disease scourge will drive many into new poverty and more deeply impoverish those already marginalized and vulnerable amongst our mandated populations. In Cambodia, for example, amongst ordinary people there is a growing perception that the two diseases are one and the same affliction. In other words as far as ordinary people are concerned, if you have HIV/AIDS, you therefore have TB and if you have TB you therefore have HIV/AIDS. This is double jeopardy at its worst. Separate services that deal with patients and potential patients as separate entities cannot easily address the duel stigma and the social, economic and medical consequences of the duel stigmatization. It is understandable but not logical to see why HIV/AIDS services and TB services might be afraid of the cross-stigmatizing effects of the two disease burdens on their individual services but the more we separate the two issues the longer it will take and the greater the ultimate suffering on the affected populations. People have a right to the cure for TB, the right to care when they have HIV/AIDS and the right to be protected from duel stigmatization as the antithesis of health.

Practical ways forward

DOTS is cost effective
It seems redundant to say that we have within our means today a high cost effective strategy and effective technology to fight this problem. Let us not forget that the World Bank has identified DOTS as cost effective a strategy as EPI, and we all know that even the poorest of countries has managed to maintain effective EPI for many years now. Already effective national TB programmes in low-income countries prove that we can do it today – Viet Nam, Cambodia, Kenya and Tanzania. But we have not done enough and the future remains in jeopardy. People have a right to the cure afforded by DOTS but DOTS must be strengthened so that it can be effectively accelerated and serve national, community and individual needs and cultural practices and thereby go to scale in the way that is required required if we are to to meet global coverage and cure targets.

National Investment Plans crucial
UNICEF is of the opinion that there must be strong national investment plans for TB to complement the global investment plan being prepared by the STOP TB Initiative. These national investment plans must be multisectoral and involve a broad partnership going beyond the health systems and including civil society, private sector, NGOs and the community. On the Government side, there must be a multi-sectoral government partnership and not just Ministries of Health who already must carry many burdens in an increasingly curtailed financial environment.

Better Drug Supply and New family and people-friendly technologies imperative
There can be no doubt that there needs to be a greatly improved supply of existing drugs. That this is not available opens up the way for sometimes-dangerous private health care sector involvement and disastrous self-care. While the private sector can be a potent force for good in terms of TB control at present it is more of a liability when in fact it should be an asset At the family and community-level there is an urgent need for better and more family-friendly and community-appropriate approaches and technologies. All the research and anecdotal evidence shows that families and individuals seek care no matter how bad or how good it is – the strong desire to be healthy and TB free is an under-recognized family asset in the battle against TB. It is not that patient won’t comply with proper treatment it is more often the case that the treatment is both culturally and technologically unfriendly and sometimes unfriendly in the extreme. UNICEF therefore urges new research that will help identify and create new vaccines and help create new people and community "friendly" approaches.

Political Will our Richest Asset
The TB community has rightly indicated that political will is our most potent asset. Yet alas it remains underutilized in the face of this growing scourge. Without a political commitment to fighting TB all the other assets that will be brought to bear – financial, technological and social – will not succeed in defeating TB and reducing HIV/AIDS. It is political will that will mobilize other sectors of society. It is political will that will ultimately empower the private sector, communities and all sections of Government to fight this problem. UNICEF understands the power of politics very well. It lauds the political will that has enabled EPI to succeed over great odds. Political will has defeated the scourge of Vitamin A deficiency. Political will has overcome iodine deficiencies! But we must not underestimate the complexity of fighting TB – it will require a level of stability of political will that we know is possible but which remains untested. I urge all of us on behalf of the millions of people already suffering and the millions under potential threat from TB not to fail in our commitments and our duty in fighting the devastating scourge of TB and related HIV/AIDS.