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INFECTIONS
AND INEQUALITIES: by Paul
Farmer, M.D., Ph.D. (Partners in Health / Harvard Medical School) Thank
you for inviting me to discuss the need for increased attention to infectious
diseases, in particular, tuberculosis and HIV. I know that I come today
with what’s termed a “hard sell.” I’ve been told, by colleagues here and
abroad, that it will be much harder to promote the idea of greater U.S.
investment in global health equity after what happened in this country
on September 11, 2001. But
failure to make an investment commensurate with the gravity of these epidemics
would be a terrible mistake, in my view as a physician and as an American.
The fact that untreated infectious diseases continue to cause a majority
of poor children’s deaths is a scandal, because we have strategies that
could change all this. Also shameful is that tuberculosis, thought by
some to be a scourge of the past, could remain, until recently, the leading
single infectious cause of adult death. Again, we have the tools necessary
to find and cure almost every single case of tuberculosis. The fact that
tuberculosis has been surpassed by another infectious pathogen, HIV, is
yet another scandal. It’s not that tuberculosis deaths are falling: it’s
rather that HIV deaths are rising rapidly. How
many scandals can we contemplate at once? We hear about “compassion fatigue”
and yet we have scarcely begun to turn our powerful medical and public-health
capacity to bear on the real causes of suffering in much of the world
today: poverty and untimely death from infectious diseases. As conditions
improve in some parts of the “global village,” they worsen in others,
setting the stage for deepening inequalities of outcome and the strife
they engender. The
numbers are well known, and have been presented to Congress many times;
indeed, some members of Congress and their staff are already involved
in responding to these challenges. Last year, AIDS caused perhaps 2.7
million deaths; tuberculosis killed an estimated 1.7 million; over a million
people perished from malaria. Most of these deaths occurred,
of course, among the poorest 20% of the world’s population. The cost in
human terms is incalculable. But
it has been estimated that if it were not for malaria, Africa’s GDP would
have been $100 billion higher than it was last year. HIV has had an even
more cataclysmic impact. I
traveled here directly from central Haiti, where I have worked for the
better part of two decades. During that time, we have put in place a hospital
and community-health program designed to serve the very poorest. We’ve
done this entirely with private donations. We have seen the immense power,
in individuals’ lives, of medical technology when used properly and where
needed most. We are privileged to see, in our daily practice there, the
cure or alleviation of many afflictions. In
recent years, however, we’ve been overwhelmed by the sheer number of patients
and by the gravity of their problems. We continue to enjoy victories,
certainly, but these will become more rare if there is not a massive public
effort to take on the diseases of poverty. Private philanthropy cannot
hope to turn the tide, not for those who must contend with both sickness
and poverty. Unfortunately
for the unfortunate, public investments in health and in research are
skewed away from the global burden of disease. It’s been noted that the
amount spent in the United States each year on pet food far exceeds that
spent on the treatment of major infectious killers in the developing world.
The list goes on. There’s far more money available for research on bioterrorism—
a form of terrorism that’s exceedingly hard to document— than there is
for treatment of those with anthrax or other infections alleged to be
bioweapons. Two decades into an epidemic that makes the newspapers every
day, it’s difficult to point to a single donor-funded AIDS treatment program
on the continent hit hardest by HIV. There has been no new antituberculous
drug developed in the last 30 years. Our
National Institutes of Health are well funded compared to other countries’
research establishments, but in a way that reflects national epidemiology:
last year, $3.9 billion went to cancer research; $74 million to tuberculosis
research (the latter figure is a huge leap over previous years). Many
feel that this is appropriate, since cancer, and not tuberculosis, is
what kills U.S. taxpayers. I am not here to take on nationalist arguments,
but rather to make a medical and moral one: the NIH and other U.S. health
institutions, including the Centers for Disease Control and Prevention,
are the largest, and best, in the world. We could and should be doing
more to promote global health equity. Indeed, our increased involvement
will determine whether or not many global health initiatives succeed. Others
have already briefed you on why this is in the national interest, and
I’m more comfortable arguing, simply, that such expenditures are in the
interest of humanity. There are also epidemiological reasons to spend
more resources on the leading infectious killers, regardless of how rare
they may be in one congressional district or another. Allow me to give
an example from our own experience. In addition to working in Haiti, I
also work in both Boston and Peru. I work in Peru because one day a patient
showed up in a Harvard teaching hospital with disseminated tuberculosis.
He died shortly thereafter of what turned out to be multidrug-resistant
tuberculosis, which had not been seen in Boston in years. A U.S. citizen,
the patient was a relief worker who’d been living and working in a slum
in Peru. When we later traveled there to look for other cases— as you
know, tuberculosis is an airborne infection, and “contact tracing” is
important— we found hundreds of people living and dying with untreated
multidrug-resistant tuberculosis. These city-dwellers were untreated following
international recommendations, which then argued against treatment because
the drugs needed to treat these patients, though long off-patent, were
prohibitively expensive. It was thus not "cost-effective" to
treat multidrug-resistant tuberculosis in resource-poor countries. Such
logic did not take into account the fact that such epidemics are transnational.
As in Western Europe, a majority of all Massachusetts’ tuberculosis cases
are diagnosed in the foreign-born. And it is possible to trace the recent
spread of multidrug-resistant tuberculosis across the globe. Certainly,
we need analytic tools such as those weighing costs and benefits of medical
interventions. Such tools are useful in, say, deciding whether to continue
a vaccination program long after the disease in question has been wiped
out; whether or not to build a new neonatal intensive care unit in a city
well endowed with similar units; whether public funds should be used for
a new treatment claimed to have slightly fewer side effects when a comparable
treatment is already available. The list of decisions requiring careful
consideration— not all health programs merit public funding— is a long
one. This is a heavy burden for policy makers; I do not envy you. But
HIV and tuberculosis do not belong on this list. They are global
public health emergencies. And we have not yet treated them as emergencies.
Assessments to the contrary would have to explain why, if they’ve been
addressed as emergencies, HIV and tuberculosis have managed to wreak such
havoc in recent years. In the past two decades, some 22
million people have died of AIDS, a disease unknown in 1981. Over
36 million are living with HIV as we speak, and new infections continue
apace. More than 10 million children have been orphaned in Africa alone
and some believe that number will reach 40 million within the next decade.
Indeed, it is no exaggeration to argue that HIV is the greatest threat
to humanity since the bubonic plague of the 14th century. But
this is not the 14th century. We have effective tools for the treatment
and control of both tuberculosis and HIV. In the area around our clinic
in Haiti, for example, there are high rates of tuberculosis (incidence
is around 400 cases per 100,000 population, the highest in the hemisphere).
But deaths from the disease are exceedingly rare because treatment is
effective and free of cost to the patient. Nor is AIDS necessarily synonymous
with a death sentence. In the United States, the impact of antiretroviral
therapy for HIV has been profound. Mortality has plummeted over the past
few years, as data from the Centers for Disease Control and Prevention
suggest. Can
complex therapies ever be delivered in settings of great poverty, where
the burden of disease lies most heavily? There are several examples to
suggest that drugs and vaccines can indeed be delivered effectively if
there is adequate political will and well-functioning, international coalitions
that can rise to new challenges. For example, the Global Alliance for
Vaccines and Immunization (GAVI) already provides vaccines and logistical
support to 36 countries; the Mectizan Donation Program provides ivermectin,
an effective therapy for river blindness, to 22 million people each year;
the International Trachoma Initiative provides azithromycin to treat another
blinding illness, trachoma. All of these are public-private partnerships
that involve philanthropy, government support, and international and local
expertise. Many
of you will note that treating river blindness and providing vaccines
are far easier than the treatment of tuberculosis or HIV, which call for
multi-drug regimens over long periods of time. But other initiatives show
that this can also be achieved. A new Global TB Drug Facility already
provides “first-line” antituberculous drugs to five countries in which
modern TB control methods are followed; the number of participating countries
is expected to rise sharply this year. Finally, the WHO’s Green Light
Committee for Multidrug-Resistant Tuberculosis helps procure high-quality,
low-cost “second-line” antituberculous drugs to programs able to demonstrate
that these agents— the same ones not deemed cost-effective a couple of
years ago— will be used correctly. I have seen this latter program go
from an idea to a major effort involving, soon enough, a dozen countries
and many NGO partners. The impact of pooled procurement (and ending “monopsonies”)
on drug prices has been profound. But
what about AIDS? In Haiti, we have pioneered a small project to deliver
antiretroviral therapy to some of the poorest people in the hemisphere.
Although this is a small project with fewer than 100 patients receiving
“triple therapy,” it also provides AZT to any pregnant HIV-positive woman
who wants it, counseling to all who are tested (and the number of patients
asking to be tested has risen sharply since we introduced antiretroviral
therapy), and social assistance to HIV-affected families. The project
is a success and has improved morale among our staff, who were sick of
diagnosing HIV infection and not having the tools to treat it. Our “HIV
Equity Initiative” could be replicated, we are convinced, on a much larger
scale. That,
of course, is why I’m here today: not to plead for funding for our project,
but rather to plead for funding for the global efforts that will not take
off until they have solid and generous backing from the United States.
You have already allocated money to the U.N.’s Global AIDS and Health
Fund, and are familiar, no doubt, with the debates regarding how much,
if any, of these resources should go towards treatment. That debate is
starting to be replaced by a wide consensus that both
treatment and prevention are necessary components of any truly effective
response to HIV. There
is consensus, too, that such projects should not be “piecemeal” or haphazard.
Although many groups are now attempting to increase access to AIDS drugs,
there is a recognized need for coherent, integrated models for the procurement
and distribution of antiretroviral agents and for monitoring their use.
There are plenty of other obstacles, as anyone who treats HIV in places
like Haiti knows all too well. Treatment regimens are technically complex,
and proper use of these drugs is not yet commonplace even in wealthy nations,
where AIDS care remains the province of specialists. Even larger obstacles
are drug procurement and supervision of therapy, which are keys to clinical
success and to preventing the emergence of resistance to antiretroviral
agents. Guided
by the experiences of previous global efforts to deliver drugs and vaccines
to resource-poor countries, new mechanisms to expand access to treatment
for AIDS and opportunistic infections (including tuberculosis, the leading
cause of death for many AIDS patients) are now being proposed. Physicians
and public-health experts have already advanced plans to establish a “Global
Program for AIDS Care and Treatment.” Global PACT, which could fit under
the aegis of the U.N. fund, could provide an essential service to patients,
national AIDS programs, donors, and pharmaceutical companies by helping
to ensure reliable and efficient procurement and monitoring of HIV drugs
and diagnostics. The
proposed plan would provide a very different “basic minimum package” than
that we see today. Right now, AIDS treatment is largely the privilege
of those living in wealthy countries. Again, cost-effectiveness arguments
have been marshaled against treatment in the very countries in which HIV
takes its greatest toll. But falling drug prices are changing the equation
rapidly. Thus the rationale of a Global PACT program includes the following
points (I’m now paraphrasing a document in preparation): 1.
There is an overwhelming need to prolong millions of productive
lives, keep families intact, and diminish HIV transmission through treatment
and through enhanced prevention activities designed to diminish risky
situations and risk behaviors. 2.
Recently lowered prices for antiretroviral drugs— concessional
prices are up to 90% less than U.S. market prices— create an unprecedented
opportunity to expand access to treatment. 3.
There is broadly shared desire— among patients and their families,
caregivers, heavily burdened countries, and industry— to see the new drugs
used more widely and effectively in resource-poor countries. 4.
Access to effective AIDS therapy has been shown to increase people’s
willingness to be tested for HIV. If the only outcome of voluntary testing
is stigmatization, ostracism, and hopelessness, people decline to be tested,
undermining counselling and prevention efforts. 5.
Access to effective treatment sharply reduces maternal-to-child
transmission of HIV and improves the survival of mothers who are then
able to care for their own children. 6.
Antiretroviral treatment lowers viral load, which has been shown
to reduce HIV transmission. As with tuberculosis, effective therapy contributes
to prevention. 7.
Although many of the medicines used to treat AIDS and opportunistic
infections are becoming available at low prices from multiple manufacturers,
their level of use in developing countries remains very limited, highlighting
barriers to access beyond price. There are almost 20 manufacturers of
anti-HIV drugs, and that number is likely to increase markedly. Serious
questions of quality control make it difficult for national AIDS programs
and other providers to procure these drugs in a cost-efficient way. In
addition, price differentials of up to 100:1 create incentives for diversion,
counterfeiting and transshipment to developed countries, which will compromise
the credibility of any program. 8.
There is a need to help manufacturers estimate their markets and
forecast future needs, establish appropriate inventories, and work with
wholesalers and procurement agencies. 9.
The entire supply chain for AIDS drugs must be improved. Warehousing
and distribution systems and national reporting mechanisms for effective
distribution and correct use of these drugs must all be coordinated. Bureaucratic
and economic barriers, including tax and tariff levels as well as cumbersome
in-country registration procedures, need to be lowered. Political will
here in the United States will be determinant in this regard. 10.
Treatment can provide hope for millions of people living with HIV,
and can motivate them to engage in prevention, including peer counselling
and participation in community activities. Expanded access to effective
therapies for HIV/AIDS, TB and opportunistic infections will also improve
the morale and performance of health professionals who serve the poor,
who too often have only been able to diagnose HIV infection and watch
helplessly as patients die. 11.
Expanded access to antiretroviral agents can help mobilize governments
and communities to adopt fair and effective AIDS policies and enable them
to leverage additional resources for AIDS prevention. Such a climate would
likely lessen both AIDS-related stigma and also discrimination. 12.
Successful pilot projects should be evaluated rapidly and “scaled-up”
as quickly as is possible and prudent in areas most affected by HIV. Most
international public-health leaders are now behind efforts to treat HIV
disease in a responsible manner, one coordinated with stepped-up prevention
efforts. UNAIDS and WHO believe that, with the right strategy and adequate
funding, five million people living with both poverty and HIV could receive
antiretroviral therapy by 2006. But we must make sure to base access to
these drugs and technical assistance on the basis of need rather than
on political considerations. Surely it is ironic, and also a scandal,
that our recently proposed AIDS assistance plan for the Caribbean did
not include a penny for the one country with the majority of the region’s
cases of HIV infection. That is because Haiti is currently under an aid
embargo that is unfair, deadly, and one of the chief reasons that we are
so overwhelmed in our clinic. I
have focused here on AIDS, but a “Global Plan to Stop TB” for intensifying
the struggle against tuberculosis has also recently been elaborated. The
goal would be to bring effective tuberculosis therapy to all those who
need it. A similar coalition of experts— a blue-ribbon panel, if I may
be so bold— has recently pegged the cost of this effort at over $9 billion
over the next several years, of which half is already pledged by heavily
burdened countries and donors. Efforts to “roll back” malaria and vaccine-preventable
illnesses also deserve unstinting support. This
is the richest and most powerful nation on the face of the earth, now
or ever, and you are among its most important stewards. I’m here today
to argue for a new way of engaging in global public health. We need to
avoid nationalism and isolationism within medicine and public health.
We need, too, to abandon the hangdog mentality that has us surrendering
so early in the fight. How many times have you heard, for example, that
it’s impossible to treat AIDS in impoverished countries? How many times
have the leaders of our bureaucracies been cautioned to be “reasonable”
when the question of AIDS treatment was raised? (Indeed, it has so far
been considered “reasonable” to withhold HIV care for the poor). How often
do we end conversations about these topics by invoking the concept of
“limited resources”? These expressions are central to the lexicon of our
times, which call instead for a new vision of equity and excellence in
global public health. I
would like to close by keeping a promise to a colleague and friend who
directs the World Health Organization’s efforts against tuberculosis.
When he heard that I’d be briefing you, he gave me a book, The
Making of the Atomic Bomb, adding, simply: “read about the copper
shortage.” I
found the relevant passages. Brigadier General Leslie R. Groves, a leader
of the Manhattan project, wrote that one of his predecessors, Colonel
Kenneth Nichols, had been charged with addressing “one serious problem
of supply.” I quote from Richard Rhodes’ book: The
United States was critically short of copper, the best common metal for
winding the coils of electromagnets. For recoverable use the Treasury
offered to make silver bullion available in copper’s stead. The Manhattan
District put the offer to the test, Nichols negotiating the loan with
the Treasury Undersecretary Daniel Bell. “At one point in the negotiations,”
writes Groves, “Nichols . . . said that they would need between five and
ten thousand tons of silver.” This led to the icy reply: ‘Colonel, in
the Treasury we do not speak of tons of silver; our unit is the Troy ounce.’”
Eventually 395 million troy ounces of silver— 13,540 short tons— went
off from the West Point Depository to be cast into cylindrical billets.
. . . The silver was worth more than $300 million. I
hope this is not an unseemly reference, since what I am pleading for are
new instruments of mass salvation, rather than weapons of mass destruction.
But imagine if the can-do mentality and scientific sophistication that
gave us, in short order, a weapon of mass destruction were to be turned
to the promotion of global health equity. Imagine a Manhattan Project
for the diseases of the poor. The
war against the major infectious killers is also the war against poverty
and social inequalities, which are bad enough within our borders and scandalous
beyond them. The ways to address social ills are contested bitterly. But
we do know how to prevent or treat the diseases that kill tens of thousands
each day. Let us respond with increased investment in the basic sciences,
in clinical investigation and new drug development, and in the effective
distribution of the fruits of this research to all those who suffer. Let
us unleash our power in a novel way: reaching out across boundaries of
state and ethnicity and language in order to make common cause with those
who bear the microbial burdens of poverty. Thus would we strike a major
blow against poverty and social inequality, very often the cause, themselves,
of discontent in the modern world.
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