A Discussion with Bernhard Liese, Chair, Department of International Health at Georgetown University School of Nursing & Health Studies

With: Bernhard Liese Berkley Center Profile

October 19, 2009

Background: Bernard Liese has focused over a long career on global public health issues. In this discussion the focus is on tuberculosis but reaches beyond to broader issues of international engagement on priority public health. He describes the “rediscovery” of tuberculosis in the 1980s and 1990s, as it had largely disappeared from view in wealthier countries. New challenges include: powerful evidence of high TB HIV/AIDS co-infection and drug resistant TB. The remarkable performance of the Stop TB Partnership stands out among global health partnerships. He touches on issues around advocacy (limited effective advocacy for the disease plus stigma explain in part low funding of TB programs), regulation of private sector treatment of the disease, and the special challenges for TB of the demanding close and long term monitoring of patients that is essential.

Following on our reviews of faith work on HIV/AIDS and malaria, we are focusing now on faith connections with tuberculosis and seek your ideas and counsel. You were recently involved in an evaluation of World Bank TB programs. What directions might that suggest for our enquiry?

The world of TB, at least on the international level, is one of the better-organized ones in the health constellation. Despite the fact that the TB community is quite heterogeneous, these days the Stop TB Partnership includes 900 plus partners which work generally quite well together. The Partnership does useful and quite effective work, and there is relatively little conflict in that group. This is despite the fact that the experience and focus of the participating institutions is very varied. Some organizations have long traditions of working with TB, for example CDC, KNCV in the Netherlands, and the Union, while others have a more recent engagement. The Stop TB website is superb. You can find whatever you need, and you can find all kinds of information on countries, disease trends, expenditure trends, etc. They are very well organized and a wide range of information is readily available there. This is no small achievement.

I am not aware of any specific engagement from the church side, but I can explore that when I meet with [the] leaders of the Partnership in the near future. I will ask specifically about the role of religious organizations. I suspect that it is not very prominent, unlike, for example, leprosy, where religious organizations have played very central roles.

What are the main issues facing global efforts to address TB today?

The question of monitoring a TB patient’s compliance with treatment remains central. When the program started, we feared that you could not really do DOTS for a longer period of time because people would drop out, that it would be difficult to find somebody to supervise them, and so on. Experience has shown that indeed that is not true and the story is rather more complicated. Generally, DOTS has worked very well yet issues of compliance remain. Most programs I know of have experimented with family members, teachers or health volunteers providing the direct observation. I am aware that churches are major partners providing services under Government contracts i.e. the Church Associations of Zambia or Lesotho (CHAZ/CHAL) but I have no personal knowledge in working with the Churches , which may be related to the fact that I have largely worked in Asian countries, where churches are not that powerful. In China or Vietnam, you would be unlikely to work with church partners.

Looking at Africa, you have very few really structured control operations. If you look at the World Bank’s record there, it is rather limited and there are only a few viable programs. An institution that knows very well what is going on in Africa is the South African Medical Research Council (MRC). They have a good idea of what’s happening because they are THE reference laboratory for drug resistant TB in Sub-Saharan Africa (XDR and MDR).

If the range of partners is so much deeper for tuberculosis than on the other diseases, why has overall funding been less than for malaria or HIV/AIDS? What’s the connection between the strength of the partnership network and overall funding by disease?

I truly don’t know; it’s a question we are asking ourselves. I just did a paper on Neglected Tropical Diseases (NTDs). NTDs represent 0.6 percent of overall development assistance going to disease control. They are not that much less important than AIDS, TB or malaria, but advocates of the latter diseases have been far more successful in advocating for them.

If one looks at HIV/AIDS, there’s no obvious reason why it should attract 35.6 percent of the overall development assistances for health. You can look at it from two perspectives. You can say, well, this shows that if a group effectively advocates for a disease you can raise considerable additional funding from the international community; that’s a positive effect. You can, however, look at it from another side which assumes that HIV/AIDS is driving out other diseases and that we really are only reallocating funding within an existing fixed donor envelope. But if you look at the issue of growth rates for different types of diseases, then our analysis shows that over the last seven years, support for all disease control programs has been growing; for the big three a lot and for the others very slightly. The only area where there was a drop has been support for general health services programs.

Yet some of the advocates, particularly from the HIV/AIDS community, will argue that these programs are indeed strengthening health systems; that they are providing many services. Frankly, I doubt it.

So we should appreciate that there is irrationality around these allocation issues. The advocates for malaria have also been effective in making their case. Malaria is a much more prevalent disease, and much more visible than TB; child mortality is high, particularly in Africa. There’s real, immediate mortality associated with malaria, which is a feature easy to market. Disabling diseases, leprosy and so on, are much harder to advocate for.

Tuberculosis is a special disease. People are scared about tuberculosis. It’s something which you surely do not want to get. But the mortality is not that high, it is stigmatizing, and the process of treatment is lengthy. Tuberculosis has a tint of a mental disease, and people think it is a disease of the past.

Can you tell us about your experience with tuberculosis control?

When I first started to work for the World Bank in 1976, I was asked to work in the Philippines on irrigation projects. We visited the Ministry of Health in connection with irrigation-related health issues. I noticed a sign in the building pointing to a unit dealing with tuberculosis control. I realized that there was a tuberculosis program, something I had not seen before. I got to know the manager, and learned that the program and treatment were largely hospital-based and that this very program was actually one of the few ongoing tuberculosis programs in developing countries.

Tuberculosis was a forgotten—not a neglected—a forgotten disease until basically the early 1980s because it no longer constitutes a major problem in our countries. The antibiotics used to fight TB were quite effective, so tuberculosis was rare, and occurred in isolated pockets, for example among alcoholics and in prisons. Consequently, the anxiety about the disease had disappeared. I recall in medical school there would be talks about it, but we had no direct contact with patients. It was an unimportant disease.

This picture changed totally when the magnitude of the worldwide TB problem was rediscovered. Data from the Philippines and other countries showed that TB was a highly prevalent disease in developing countries. The WHO established in the mid-eighties a division dedicated to TB; Dr. Arata Kochi was the unit’s most effective manager. The objective was to put TB back on the agenda and to start control using the DOTS strategy.

The World Bank played an important role here. Sometimes we tend to overstate the Bank’s involvement, but in tuberculosis the Bank played an important role. We were doing a study on effective disease control organizations in China and other parts of the world; the study was funded by the Edna McConnell Clark Foundation. During the field visits, we came to Beijing to wrap up the China part of the research study, which was on schistosomiasis control. Suddenly we were confronted with a group of colleagues from the Chinese Ministry of Health, Tuberculosis section. My Bank colleague and I looked at each other, asking, “What is this?” The Chinese talked about the serious issues they faced with their tuberculosis program, and their desire to move ahead. It was basically a forceful pitch for WB assistance. For us, it came totally out of the blue. Back to Washington, I talked with Dean Jamison, who was in charge of health then, suggesting that we needed to follow up, and also with the country director for China. They agreed and we did.

The China program took off very well. When it was fully implemented, it covered half of the country using the DOTS strategy; there are several publications about the program and detailed evaluations—a good summary one in the Lancet. It is one of the real success stories. So, by the mid-nineties, the disease, tuberculosis, was on the agenda again. A control strategy, DOTS, was available that worked and had been used on a large scale in China. That had a tremendous signal effect.

In the nineties, I worked in Vietnam on malaria and tuberculosis control. The program was well organized and technically supported by KNCV with financial support from the WB. The big problem was the need for continuous availability of anti-tuberculosis drugs or what they call in the trade “stock outs.” Stock outs in DOTS projects in the nineties were a real issue, and they happened again and again in Vietnam and in China and in other projects. The procurement practices of governments simply did not work in the case of tuberculosis, where staggered and reliable deliveries were essential. If you have a program where you have to guarantee continuous treatment, you must guarantee continuous drug supplies or you face serious problems. Many programs suddenly had to airlift drugs in because regular procurement was unworkable. This was a real problem worldwide; it has little to do with the incapacity of a particular country. It was simply that the procurement system and pharmacy management systems were unsuited for TB programs.

It was against that background of the real issue of “stock outs” that WHO worked out a solution—the Global Drug Facility and that the Stop TB program was formally created. There was agreement that a partnership was needed, initially to make sure that drugs were available.

And that is how the Global Drug Facility came to be. Thus, the Drug Facility was a driving force behind the formation of the Stop TB Partnership. Today, the Global Drug Facility, which is a major part of the Stop TB program, has an annual budget of $50 to $70 million. It is basically grant-funded, but a certain percentage represents contracts from the countries. The problem of stock outs has largely disappeared, which is tremendous. There are still a few problems; drug procurement financed by the WB still cannot use GDF, but that is being worked on and I hope it will soon be history.

What has emerged as a further important issue in recent years is the challenge of maintaining full coverage in the highest burden countries. This is what the Stop TB Partnership is now addressing. For people in the high-burden countries, national coverage has come a long way and is reported as full coverage. Yet if you drill down, there are still a lot of lapses and white spots, and non-compliance issues; there are also issues around quality of treatment.

One reason for quality of treatment issues is that no country has actually been able to regulate and harmonize treatment in the private sector effectively as far as tuberculosis is concerned. Physicians often use their own way of treating TB. Let me give you a very recent example from China. The tuberculosis treatment there is free, though for everything else in China these days, you have to pay. TB treatment is provided by the former anti-epidemic stations, now called CDCs. In Shanghai, the CDC’s provide a cash incentive to the physicians in the hospitals or health centers to send tuberculosis patients over to them, so that they can then register there and be provided with free treatment and follow a DOTS schedule. It makes sense. However, you have still a considerable number of people who seek treatment by other means. The doctors may tell a patient, “You can go to the CDC, but if you stay here and take some medication it may be a bit more costly but it is better.” You find that happening all over the place. It has been very difficult to regulate the private sector, in terms of treatment protocol.

What is special about TB programs in this area?

What is special is that you have a longer treatment, and so there will almost inevitably be a certain part of non-compliance. So it’s a huge education task. Countries are trying, but as you can imagine, it’s not the easiest task.

The second special issue relates to the topic we discussed earlier, the advocacy of the HIV/AIDS lobby. They have been very effective in ensuring ARV treatment for AIDS patients and making HIV/AIDS a development issue. But the role of TB in HIV/AIDS has not been well appreciated.

If you are a normal citizen, who is not infected with HIV, your lifetime risk of developing tuberculosis after being infected might be about 10 percent. In summary, the risk is not that high. But if you are infected with HIV/AIDS, your annual risk of developing active tuberculosis is roughly estimated at about 5 to 10 percent—note that this is annual risk. ARV treatment seems to offer some very limited protection as the CD4 count is normally higherI took a trip with my daughter a couple of years ago to Botswana. A game warden there looked a little thin, and I said to him, “what’s up?” He said, “I nearly kicked the bucket.” I answered, “What do you mean, you nearly hit the bucket?” He answered that he was HIV/AIDS positive, that he got very sick with TB, got treated, and now he was fit again. That can indeed happen if you get proper treatment, but the problem is that several month later you might get reinfected again, and you might get yet another active TB, even if treatment is administered properly. You can constantly get reinfected.

You can imagine that in such cases drug resistant tuberculosis has become a real pain. Not only are such cases very costly to treat, but the number of drugs available for treatment is quite limited. We have not done much research in the TB drug area looking for new antibiotics. And there are now new forms of TB.

As you know well, the most worrying trend is the almost treatment-resistant XDR tuberculosis. The matter was really brought home in KwaZulu Natal in South Africa, where we had a limited XDR epidemic. The community woke up and said, “Wait a minute, it’s not only that the people die; they might infect other people before they die.” Suddenly, the question of “What are we going to do?” became relevant. Because diagnosis of MDR and XDR tuberculosis take time, there is a lag that is dangerous. We don’t have a simple quick test and in many countries we do not have laboratory facilities to actually run the tests. This is a real issue. So now people are looking at strengthening laboratory facilities as an intermediate step. Then the question arises, who will run the test sites? That is a current issue. MDR and XDR tuberculosis are real issues in the Africa region, particularly in areas where you have relatively high HIV/AIDS, thus the southern part of Africa. But that is also prevalent in the former USSR.

We understand that some governments are resisting to even start addressing MDR TB because it is in a sense an admission of failure of a conventional TB program.

Certainly it does represent a failure, but there’s no alternative to addressing the problem. It is not an option to just let it go. From a pure transmission control perspective, the only way would be that if you have any suspect of MDR, XDR TB, to totally isolate him or her, which is not feasible. These are not only difficult epidemiologically, but there are also legal and human rights challenges. So what do we do in the immediate future?

The Stop TB Program has created what is called the Green Light Committee, which is an innovative undertaking. There’s a committee at WHO in Geneva, which basically advises the governments on how to treat MDR and XDR cases, and it provides almost individual prescriptions, plus drugs for it. Unfortunately, the estimate is that the Green Light Committee deals presently with about 10 percent of all MDR cases worldwide. In summary, this is an enormous issue for the tuberculosis community.

Returning to this exploration of where religion might come into the picture, it would be interesting to elaborate on the narrative of how global organizations became involved with TB. One that we have heard is that religious institutions in communities were pioneers in showing that community monitoring was feasible (Partners in Health, Peru).

I believe the credit should go to Dr. Styblo, a Dutchman. He was director of KNCV. He came up with the basic idea for community monitoring, and that was basically the origin of the DOTS program. The DOTS strategy has changed over time because it was a bit rigid and we realized that we need to allow a little bit more flexibility. Paul Farmer, from what I understand, was among those who helped operationalize DOTS in the context of community-based organization. I’m not familiar with the Haiti program.

Who are key actors in the Stop TB program today?

There are several working groups established by the Stop TB partnership, they are its engine; the DOTS expansion working group, the HIV/TB working group, the Laboratory WG, and three working groups located outside the Geneva hub: the vaccine, diagnostic, and drug development working groups. The TB program works largely through these working groups. There is a well organized mechanism by which you become a member of the working group. The major countries supporting TB are the U.S., Canada, UK, Italy, and Japan.

When we get to the point of discussing our findings on TB, who would be good partners?

There will be no problem as the Partnership is open to such exchange. It would be good to engage someone within the WHO like Diana Weil, who is now the second-in-command on the WHO side. She was at the Bank for five or six years, seconded by the WHO, but she is back in Geneva now. She is very knowledgeable about who does what, where, when, and how.

Any further thoughts on what we might look at in terms of situating the discussions of faith and health?

If you look at the history of Europe, or just look at Germany, we had many faith-based hospitals. Today what we see is a very pluralistic hospital-owner structure that has evolved from the largely faith-based origins. The services changed gradually over time. Today, the faith-run institutions are very similar to government run facilities in terms of quality, cost etc.

I think the same process is at work in African countries. If you go to Ghana, the Catholic Mission Board today employs government nurses, which means that a majority of their staff is basically government staff and it is paid with government funding. I see no reason why the government-paid nurse should provide a different service in the context of a clinic with a faith label than a nurse in an entirely publicly-operated hospital.

The assumption that quality of service is better in faith-based institutions stems from the fact that from the fifties through the seventies, particularly in East Africa, the mission hospitals were essentially it. We lived in the early seventies in Cameroon. We had three mission hospitals in the province and two government facilities. It was the mission hospitals that provided most of the frontline hospital care and quality of care was clearly of a better standard than at the government hospitals because the faith-based hospitals had personnel, drugs, etc. Today, I would not say that that is still the case. I returned to my former work place in Cameroon about five years ago and the situation was very different. The government hospitals are larger today and their quality is quite good. I think there has been considerable development.

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