Dr Frieden, Dr Castro, colleagues at CDC, ladies and gentlemen,
The theme for World TB Day this year is On the move against tuberculosis: innovate to accelerate action. This reminds us of the urgent need to scale up efforts and continue to seek new and innovative ways to stop TB.
On this day, let me welcome your ambitious new plan to eliminate TB in this country, subtitled Together we can. Let me welcome this very American can-do and inclusive approach. Let me welcome the special focus on reaching society’s most vulnerable groups.
The plan is itself an innovation on a World TB Day that calls for innovation. If a low-burden country like the US can eliminate TB, you will set a precedent and start a momentum that will draw other countries into its sweep. As we all know, determination and momentum to reach a goal spark further innovations, both high-tech and low-tech. All countries will benefit from your experience.
With progress to date, and the expertise gathered here in CDC and in health departments across the country, elimination is an appropriate, inspiring, and feasible goal. Yes, you can!
This year marks the halfway point, from 2006 to 2015, for the Global Plan to Stop TB, a plan to which you contributed so much as our partner. The worldwide control of TB is largely a success story. Many attribute this success to a strong public health model with a standardized approach to diagnosis and treatment.
Following the advent of curative drugs in the late 1940s, approaches to TB control gradually discarded the earlier social and environmental interventions. “Prevention starts with cure” became the new mantra. The next big step forward came with the DOTS approach, which focused on the detection of the most infectious people with TB and on ensuring treatment until they were cured.
Since 1995, when DOTS was introduced, more than 36 million people have been cured, according to internationally recognized standards of care, and about 6 million deaths have been averted. These are big numbers, and this is big progress. Without question, DOTS works.
But there are other big numbers and big causes for concern. Last year, TB still claimed a staggering 1.8 million lives, making it the second biggest infectious killer of adults worldwide. Rates of new TB cases are falling slowly in all regions, but not yet in all countries. The rate of decline in cases and deaths is far slower than needed, and far slower than what is possible.
In this day and age, no one should die of TB, and certainly not nearly 2 million people in a year.
Inadequate diagnosis and care, in the private and public sectors, drive the rise of multi-drug resistant and extensively drug-resistant TB. Both are far more costly and difficult to treat, and extremely difficult to diagnose, especially in the low-resource settings where most cases are concentrated and where laboratory capacity is vastly insufficient.
As we know very well, the emergence of resistant forms of TB represents the failure of the entire health system in which TB programmes operate. It is a failure of policies on social protection, laboratories, drug quality and rational use, infection control, and surveillance.
Drug-resistant TB creates enormous additional demands and pressure on components of the health system that are already weak. In other words, drug-resistant TB severely strains and erodes the very capacities needed to prevent its emergence in the first place.
Co-infection with HIV is another major concern. Between 2007 and 2008, 1.4 million TB patients were tested for HIV, representing an increase of 200,000 from the previous year. Of those who tested positive for HIV, one-third benefited from life-prolonging antiretroviral therapy and two-thirds were enrolled in chemo-prophylactic therapy to prevent the risk of fatal bacterial infections.
In people living with HIV, screening for TB and access to preventive therapy for TB more than doubled. Again, we see progress, but once more, the numbers are still far too low.
Ladies and gentlemen,
For so many diseases today, problems that were once worldwide in their prevalence are now largely confined to the poorest people living in poor places. As one argument goes, many of these diseases, like TB, like leprosy or hookworm infections, like childhood pneumonia and diarrhoeal disease, will gradually vanish, all by themselves, as economic and social conditions improve.
Partnerships such as Stop TB were launched because the international community chose not to wait, but to act in a concerted, collaborative, and urgent way. Such initiatives have a built-in sense of urgency, and they also express the heart of the equity argument. People should not be denied access to life-saving interventions for unfair reasons, including those with economic or social causes.
Today, TB is largely a disease of deprived populations. A disease that resurged with a vengeance is now being stubbornly maintained by poverty and social disadvantage.
Quite frankly, for a killer disease like TB, the pressure to treat as many people as possible, with limited resources, means that the hardest to reach may be the last ones reached. As long as this happens, we will not be doing the job right.
This is a world increasingly characterized by rapid unplanned urbanization, inequitable economic growth, widening income gaps, and the presence of large pockets of social deprivation in every corner of the world. TB thrives in this kind of a world, in rich and poor countries alike.
The long-term target for global TB elimination, set for 2050, will not be met with current strategies and tools.
Today, we find TB control turning full circle: from a pre-drug era when social and environmental interventions were promoted, to a focus on scaling up diagnosis and treatment, to a possible new era when reaching the poor with high-quality services combines with efforts to reduce the likelihood that vulnerable people will be exposed to infection and subsequently to those factors that favour disease.
In other words: primary prevention as well as cure.
We know the risk factors, and know that they are prevalent in disadvantaged groups, especially in urban settings. These are risks like HIV infection, malnutrition, diabetes, smoking, alcohol and substance abuse, indoor air pollution and, above all, limited access to basic care for the poorest people.
True, lasting, and definitive progress will depend on finding bold ways to strengthen health systems and services, aligning TB prevention and care with the broader development agenda, and addressing risk factors that are closely associated with social disadvantage.
This, then, is the dilemma facing the future of TB control. And this, too, is one of the biggest problems facing public health today.
The Millennium Development Goals promote health as part of an overarching strategy for poverty reduction. To put it bluntly: if we miss the poor, we miss the point.
Thank you.