versão impressa ISSN 0042-9686
Bull World Health Organ vol.83 no.3 Genebra Mar. 2005
WHO reinvigorates role to fight 'big three' diseases
Never has the combined toll of the 'big three' diseases been so high and the risk to global health so great. In 2004, an estimated three million people died of HIV/AIDS, two million of tuberculosis (TB) and one million of malaria, and the number of deaths is increasing in the poorest regions as each disease feeds off the other. In this Bulletin interview, Jack C. Chow, WHO's Assistant Director-General for HIV/AIDS, Tuberculosis and Malaria, talks about the challenges in fighting the three diseases.
Q: HIV/AIDS and TB have drawn huge attention. Is malaria being neglected?
A: One of the themes of my stewardship has been to advance the concept of the compounding effect of the three diseases. I am particularly concerned about the confluence of these in resource-limited settings, their depletion of the health workforce and the economic cost to societies alike. More attention is being focused on malaria, on the practical low-cost and no-cost solutions that can reduce morbidity and mortality in malaria. The Roll Back Malaria Partnership and WHO's Roll Back Malaria Department have been very proactive in promoting a number of critically needed interventions, like the long-lasting insecticide-treated bednets and the new generation of ACTs (artemisinin combination therapies) medicines which are transforming malaria treatment, and we are very encouraged by the response that we have seen. For example, the UK recently dedicated US$ 74 million (£40 million) for malaria bednet distribution, and at the World Economic Forum meeting in Davos in January a call for personal donations for malaria garnered about a million dollars.
Q: Donors are pledging a lot of funds for HIV/AIDS, but less for TB and malaria, how do you ensure each disease gets adequate resources?
A: We make clear that WHO's role is in articulating public health strategies on how to support countries and implement programmes. We are very heartened that the Dutch Government has allocated a very significant extra-budgetary contribution to malaria and we also welcomed donations for HIV/AIDS and TB, particularly the Canadian '3 by 5' contribution and their ongoing contribution to TB control. My mission is to make clear the benefit of investment in WHO. If we do our job right at country level for our Member States the resources will follow. Again, like all challenges, it's an ongoing need because each of the three diseases is unfortunately rampaging.
Q: What are the challenges in the fight against TB?
A: Regrettably, TB infects nearly one-third of the world's population generating nine million active cases per year and killing two million people every year. WHO's technical support and operation of the Global Drug Facility has expanded the worldwide implementation of DOTS and contributed to solid progress in detection and treatment success goals. We are invigorating our TB work in collaboration with the Global Fund and by confronting the challenges of TB/HIV co-infection (see feature on pp.165166) and multi-drug resistance. Of the six WHO regions, five have TB incidence that is falling or stable, but Africa has an incidence that keeps increasing at almost 10% per year, offsetting the gains in the rest of the world. There needs to be special focus on Africa, while maintaining TB control programmes in the rest of the world.
Q: Other organizations have taken up the cause of the 'big three': UNAIDS and the Global Fund To Fight AIDS, Tuberculosis and Malaria, to name two. Has WHO's central role been undermined?
A: We have reinvigorated our mission to provide timely, accurate and robust advice for governments and civil society to implement the strategies of prevention, treatment and care. We welcome the advent of the Global Fund and the vigorous efforts of UNAIDS. I view the work in confronting the three diseases as a chain of concerted action with three links: finance, expertise and implementation. WHO and UNAIDS are in the middle link of providing the expertise, blueprints and strategies that can be financed by The World Bank, Global Fund and bilateral donors, and implemented at country and community levels through governments, NGOs, the private sector and individual citizens. We have always had this role.
Q: How have you reinvigorated WHO's mission?
A: The '3 by 5' is a fresh campaign. We have stronger partnerships, like the Stop TB Partnership and the Roll Back Malaria Partnership, we are finding ways to strengthen those and sharpen the vision and the mission. For TB, for example, there has been significant progress on the goal to detect 70% of existing cases and successfully treat 85% of those that get treatment. So far countries have reached a detection rate of about 43% and treatment success rate of 83%. We are also spotlighting new interventions: the long-lasting insecticide-treated nets and ACT medicines for malaria.
Q: What are the major challenges facing the '3 by 5' campaign, to get ARVs to three million people in developing countries by the end of 2005?
A: The treatment numbers went from about 300 000 to 700 000 in a year. We are very encouraged by this progress but much more needs to be done. The stories of several countries show that when a confluence of factors come together this goal can be attained. For instance, in Uganda political leadership, investment of the country's own resources and investment by external donors working with societal partners helped to deliver health care and HIV/AIDS care and de-stigmatize the illness. The top-line story is that when you make treatment available and abundant at low cost people are much more willing to seek testing, counselling and treatment for HIV/AIDS. When access to treatment is scarce and the price is high people are discouraged. We are seeing that in Uganda. We are encouraged also by what we see in Zambia. Botswana is one country that has already attained the 50% goal to deliver treatment, and there are several countries in South and Latin America that have made ARVs universally available. The challenge is making treatment more available in big countries, such as South Africa, India and Nigeria because of their size and the number of people with the virus.
Q: Even if WHO and its partners achieve the '3 by 5' goal, how sustainable is this treatment and what happens after December 2005?
A: '3 by 5' has a time-limited goal, but the mission is much longer term. Building health systems, training and educating the health workforce, and promoting community action are among the key things that need to happen.
Q: How do you persuade donors to make that long-term commitment?
A: It's been made very clear that the present therapy is lifelong. That implies a logic of having ample supplies of medicine and a long-term financial commitment by the global community, as well as having a sufficient numbers of doctors nurses, community workers and counsellors who can confer clinical judgement, manage care, and treat other primary and secondary illnesses. WHO and others are striving to say that with the benefit of ARVs people can live longer and be productive members of the workforce. AIDS care has economic value and is socially indispensable.
Q: How is the global community helping governments to fill the huge shortage of health workers needed to scale up ARV treatment in sub-Saharan Africa?
A: That's the emerging story. In public health as well as in development human resources are the critical pillar. We need to make a robust investment not only in the health workforce but in getting communities involved in health care. WHO is rolling out a number of products and projects to help train and educate the health workforce. One is the IMAI, the Integrated Management of Adult and Adolescent Illness package,
which is a module which can be rolled out at country and community level to train health workers in HIV/AIDS care. It's the challenge of promoting what I call 'skill' and 'will': 'skill' is the tasks that can be done through education and learning by doing, but even more important is 'will'. How do you motivate people to provide health services or to educate patients amid very difficult circumstances? We are thinking about economic incentives as well as morale boosting actions through role models and group discussions so that people feel connected to a greater cause and that they are contributing to their neighbourhoods and countries.
Q: Can this approach to health-care delivery be applied to other diseases?
A: The story is emerging, and we absolutely hope the lessons of '3 by 5' will be studied and applied to treating other infectious diseases or other primary health-care needs.
Q: Why are generic medicines important to your work with the 'big three' diseases?
A: We value both generic and research-based medicines because HIV is a very powerful mutator and we need fresh, innovative generations of ARVs that can stay ahead of drug resistance, have fewer side-effects and could eventually contribute towards a curative treatment. At the same time, HIV is penalizing the poor disproportionately and generics are valuable because they are effective and low cost. I don't see it as an 'either' 'or', it's about promoting a strong armamentarium to offer people with HIV in developing and developed countries.
Q: Was the switch in WHO's drug recommendation to ACTs last year a setback for the malaria cause?
A: WHO has articulated the value of ACTs and worked assiduously with countries to change their policies in favour of these drugs, which are highly curative when applied properly. The old line of medicines, chloroquine etc., have encountered parasite resistance. They were inexpensive but didn't work so any expense on them is too high. We are heartened that at least 20 countries in Africa have adopted ACTs as part of their first-line regimen and we are working with the private sector, and countries such as China to grow more of the plant that provides the raw ingredient for ACTs.