Hopes rest on a new rapid diagnostic test for tuberculosis (TB)

One of the best chances of stemming the tide of tuberculosis (TB) epidemic in low- and middle- income countries is to thwart the transmission cycle – by diagnosing TB early, and treating it successfully without delay. The microscope has been around since 1882 as the key standard TB diagnostic tool, and with low sensitivity (50-60%) and other challenges in detecting TB in varying conditions and co-morbidities, it is clear that it is high time we use better, more effective and efficient tools to accurately detect TB, and neither mis-diagnose nor miss TB diagnosis in myriad settings. Read more

This was a clear thought emerging out of the 'International Symposium on Tuberculosis Diagnostics: Innovating to make an impact' (ITBS 2010), organized by the International Centre for Genetic Engineering and Biotechnology (ICGEB) in New Delhi, India (16-17 December 2010) with support from the Aeras Global TB Vaccine Foundation, Bill and Melinda Gates Foundation and Foundation for Innovative New Diagnostics (FIND).

Although high-income countries have moved on to using better and modern diagnostic tools, many low- and middle- income countries still rely principally on sputum smear microscopy.

One of the diagnostic tools that the World Health Organization (WHO) recently endorsed is a fully automated Nucleic Acid Amplification Test (NAAT) - Xpert ® MTB/RIF - a new and novel rapid test for TB, especially relevant in high TB burden countries. According to the WHO, the test could revolutionize TB care and control by providing an accurate diagnosis for many patients in about 100 minutes, compared to current tests that can take up to three months to have results. This WHO endorsement of the NAAT has come after 18 months of rigorous assessment of its field effectiveness in the early diagnosis of TB, as well as multidrug-resistant TB (MDR-TB) and TB complicated by HIV infection, which are more difficult to diagnose.

THREE-FOLD INCREASE IN DIAGNOSING DRUG-RESISTANT TB POSSIBLE
According to the WHO, evidence to date indicates that implementation of this test could result in a three-fold increase in the diagnosis of patients with drug-resistant TB and a doubling in the number of HIV-associated TB cases diagnosed in areas with high rates of TB and HIV.

But this new 'while you wait' test incorporates modern DNA technology that can be used outside of conventional laboratories. It also benefits from being fully automated and therefore easy and safe to use.

WHO is now calling for the fully automated NAAT to be rolled out under clearly defined conditions and as part of national plans for TB and MDR-TB care and control. Policy and operational guidance are also being issued based on findings from a series of expert reviews and a global consultation held last week in Geneva. The consultation was attended by more than a hundred representatives from national programmes, development aid agencies and international partners.  

75% REDUCTION IN PRICE FOR COUNTRIES MOST AFFECTED BY TB
Affordability has been a key concern in the assessment process. Co-developer FIND (the Foundation for Innovative and New Diagnostics) announced recently it has negotiated with the manufacturer, Cepheid, a 75% reduction in the price for countries most affected by TB, compared to the current market price. Preferential pricing will be granted to 116 low- and middle- income countries where TB is endemic, with additional reduction in price once there is significant volume of demand.

"There has been a strong commitment to remove any obstacles, including financial barriers, that could prevent the successful roll-out of this new technology," said Dr Giorgio Roscigno, FIND's Chief Executive Officer in a WHO communique. "For the first time in TB control, we are enabling access to state-of-the-art technology simultaneously in low, middle and high income countries. The technology also allows testing of other diseases, which should further increase efficiency."

WHO is also releasing recommendations and guidance for countries to incorporate this test in their programmes. This includes testing protocols (or algorithms) to optimize the use and benefits of the new technology in those persons where it is needed most.

Though there have been major improvements in TB care and control, tuberculosis killed an estimated 1.7 million people in 2009 and 9.4 million people developed active TB last year.

Bobby Ramakant - CNS 


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International Symposium on TB Diagnostics: Innovating to make an impact

The "International Symposium on TB Diagnostics: Innovating to make an impact" (ITBS 2010) shall soon be held in New Delhi, India during 16-17 December 2010. It is being organized by the International Centre for Genetic Engineering and Biotechnology (ICGEB). ITBS 2010 is being co-sponsored by Aeras Global TB Vaccine Foundation, Bill and Melinda Gates Foundation and Foundation for Innovative New Diagnostics (FIND). Read more

"This is the fourth meeting in the International Tuberculosis (TB) Symposia (ITBS) series that has become a regular biennial event at ICGEB, New Delhi. It is heartening to note that every meeting has attracted increasingly good number of leading TB experts from across the world as well as large number of young researchers from across India and other countries. However, tuberculosis still continues to inflict one third of the global population, causing nearly nine million new cases of tuberculosis (TB) and death of nearly 1.8 millions per year. Thanks to persistent efforts of research community across the world, Mycobacterium tuberculosis is beginning to reveal its secrets, though slowly and reluctantly. Once again it is time for us to get together, pool our resources, and form networks in order to evolve more effective intervention strategies. This Symposium is an attempt to facilitate this process" said Dr Pawan Sharma, Convener of ITBS 2010.

"It is perhaps the most opportune time to address issues in TB Diagnostics. With the largest pipeline of new drugs and drug combinations in place, 'potentially effective against all forms of disease in all patients' (TB Alliance), and a similar pipeline of TB vaccines in various stages of clinical trials, it is only imperative to devise point-of-care diagnostic methods, which are not only sensitive and specific but also time-effective and cost-effective. This Symposium provides an opportunity to take stock of deliverables in the area of TB diagnostics against the backdrop of advances made in the basic biology of the disease. I hope that this meeting offers a platform for national and global policy-makers, academia, industry and funding agencies to come together and take stock of the current status of TB diagnostics and find ways for translating research results into reliable point-of-care methods for diagnosis, and to develop more robust strategies for epidemiology studies. At this juncture, India being home to the largest number of TB patients in the world, presents a challenge and an opportunity to emerge as a global leader in the area of TB diagnostics" added Dr Sharma.

The ITBS 2010 Symposium will provide a platform for these deliberations in the following scientific sessions:
- Pathophysiology of Tuberculosis and the Challenge of Diagnosis
- Trailing the Bug: TB Diagnostics Today & Tomorrow
- Changing the Landscape of TB Diagnostics in India
- Diagnostics Innovations from India: View from Industry and Clinic
- Diagnostics Innovations in India: Enablers and Barriers

Bobby Ramakant - CNS

Breaking silos: Tuberculosis (TB) and poverty

Tuberculosis (TB) continues to affect society's most vulnerable - those who live in abject poverty, are marginalized or economically and socially isolated. The poor and vulnerable people are much more likely to suffer from TB due to socioeconomic factors. The poor face significant costs and delays in accessing TB services and treatment outcomes are more likely to be adverse, said Rachael Thomson from Liverpool School of Tropical Medicine (LSTM) who was nominated by the TB and poverty sub-working group of Stop TB Partnership to speak at the Biennial Conference of Irish Forum for Global Health (IFGH) held in Maynooth, Ireland (29-30 November 2010). The IFGH meet was organized by IFGH with support from Combat Diseases of Poverty Consortium (CDPC), Irish Aid and National University of Ireland Maynooth (NUIM). Read more

"In urban Malawi poorer patients face costs six times their monthly income to access a diagnosis from 'free' facilities, and in rural Malawi this cost rises to ten times" said Rachael.

New TB case detection in many countries is low because the poor people are least likely to access TB care services. The process of accessing care is impoverishing making the people accessing care even poorer, said Rachael.

The lack of adequate diagnosis, treatment and cure means the burden of TB in poorer communities continues to increase.

Not surprisingly, the poor people have higher risk of infection, higher prevalence of disease and worse outcome of disease too. Moreover the poor people have greater health care needs, said Rachael.

Social and economic determinants at individual, household and community levels affect a person's vulnerability to TB.

Special situations such as massive population movements - the displacement of people and refugee flows - and living or working in vulnerable conditions also increase the risk of a person contracting TB. In developed countries, ethnic minorities and other marginalized communities are at a greater risk of contracting the disease.

There is a need to combat TB by addressing the barriers faced due to poverty such as infrastructural, housing, employment, educational and nutritional deficiencies.

Rachael explained that poverty is more than economic poverty (living on less than USD 1.25 per day) and encompasses lack of opportunities, voice and representation, and is a major determinant of vulnerability to disease - especially TB.

One of the major steps forward in addressing poverty and TB will be to put health on the poverty agenda and poverty on the health agenda, said Rachael.

Rachael gave an overview of the TB and poverty sub-group of the Stop TB Partnership. TB and poverty is the sub-group of the DOTS Expansion Working Group (DEWG) of the Stop TB Partnership and is a network of individuals and organisations interested in the needs of poor and vulnerable populations with respect to TB. Since September 2010, the secretariat of the TB and Poverty sub-working group of the Stop TB Partnership is housed in the south-east Asia regional office of The Union in New Delhi, India.

A two-days consultative workshop of the TB and poverty sub-working group was also held in Gurgaon, India on 29-30 October 2010 which brought together the national TB programme managers from India, Nepal and Thailand, state TB officers from eight poorest states of India, and partners from various other organizations like WHO, the World Bank, World Vision, GFATM Round 9 members, media (CNS, Asia Tribune), National Partnership for TB care and control in India among others, said Rachael.

Bobby Ramakant - CNS/ member on-site IFGH Key Correspondent team 


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Private-private partnership delivers affordable eye care

An Irish non-profit, Right to Sight (RTS), partnered with a NGO – Lions Aravinda Institute of Community Ophthalmology (LAICO) and a private-for-profit company, Shalina, to deliver quality, affordable and sustainable eye care in Democratic Republic of Congo (DRC), shared Keerti Bhusan Pradhan, who was speaking at the Biennial Conference of Irish Forum for Global Health (IFGH) in Maynooth, Ireland (29-30 November 2010). This meet is being organized by IFGH with support from Irish Aid, National University of Ireland Maynooth (NUIM) and Combat Diseases of Poverty Consortium (CDPC). Read more

Right to Sight (RTS) had raised USD 200,000 to jump start this private-private partnership (PPP) model based initiative which eventually mobilized more than USD 1.5 million from a private company and a range of other contributions and expertise to make the eye care service sustainable and affordable in a long run in DRC, said Keerti during his interaction at the Health Systems and Services (HSS) parallel session at the IFGH meet.

These three private partners got together to establish an eye-care health centre in Katanga, DRC which began operations in 2007. There was a considerably small user charge for people accessing eye care services from this centre to meet operational costs and make the initiative sustainable. “By end of first year (2007-08), this eye care health centre broke-even by meeting the operational expenses,” said Keerti. More than 35,000 outpatients were seen and 2000 surgeries conducted in the first year of operations at this centre.

Another important aspect of this initiative that needs a mention is that it had built capacities and competencies of local healthcare providers in DRC to run this eye care centre. The expat-to-local human resource ratio has been 1:6 with 5 expats to 30 DRC citizens who are part of the team at this centre and considerable knowledge transfer and sharing of skills take place between them, said Keerti.

RTS worked with the Aravinda Eye Care System (AECS) which is the largest eye care provider in the world with a renowned service delivery model, a facility for manufacturing high quality ophthalmic products at low cost - Aurolab and an institute for teaching and training – Lions Aravinda Institute of Community Ophthalmology (LAICO). They brought in another partner, Shalina Laboratories, a pharmaceutical company in DRC, to support this initiative through corporate social responsibility (CSR) initiatives. And that is how the eye care health service centre was built and started functioning towards end of 2007, said Keerti.

The DRC-based private-for-profit partner of this initiative, Shalina, plans to expand this private-private partnership model of eye care delivery to 18 African countries with six centres planned in DRC as well, said Keerti.

Although not connected directly to eye-care health services, yet in terms of similarity between the partnership approaches, it will be worthwhile to mention that a participant from Irish Aid said a similar project is also taking place in Tanzania on addressing issues related to disability.

These examples of private-private partnerships give hope – particularly to countries like India and Cambodia for example - where the first clinic most of the population visits with initial symptoms is most likely to be in private sector. If people can access quality healthcare without delay it is likely to have a very positive outcome on public health. In same HSS session at IFGH meet, another speaker Una Lynch from Queen’s University, Belfast, shared how strengthening primary healthcare services in Cuba had such pronounced positive outcomes in terms of public health.

Bobby Ramakant - CNS/ Key Correspondent at IFGH 


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Strengthening Health Systems: Global Health Financing

A new research report "Financing Global Health 2010: Development assistance and country spending in economic uncertainty", by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, indicates that despite the worst global economic crisis in decades, public and private donors continue to donate generously to global health, though at a slower rate. The report documents the continued rise in health funding and the effects of that funding on spending for health by governments in developing countries. The commitment to health in the developing world has grown dramatically over the last twenty years, with the  developing countries' governments increasing their spending on health. Read more

 The research shows that development assistance for health has grown 375% in the last decade-- from $5.66 billion in 1990 to $26.87 billion in 2010. Thailand, for example, has seen its health assistance explode from $2.3 million in 1990 to $67.9 million in 2008-- a staggering increase of nearly 3000%. But, when we look around the region, we find countries that receive far more aid than Thailand per person, including the Philippines, Cambodia and, most strikingly, the small island nations. Micronesia, for example, receives $161 per person, while Thailand receives only $1 per person.

However, IHME’s preliminary estimates show that the growth rate is slowing. Between 2004 and 2008, assistance grew by an annual average of 13%. But between 2008 and 2010, the rate of growth was cut by more than half to 6% annually. The government and private donors in the US made up one-half of all funding in 2008. But the economic downturn has hit US-based NGOs hard, and the amount of health funding spent by them decreased by 24% from 2009 to 2010.

Most health funding has gone to the countries with the greatest need, but researchers found striking anomalies, including the fact that 11 of the 30 countries with the highest number of people suffering from disease and high mortality receive less health funding than countries with stronger economies and lower disease burdens.
Dr. Christopher Murray, Director of IHME, feels that, “Everyone in the global health community is worried about how the economic crisis is going to affect giving. Research has shown that economic downturns don’t usually have an immediate effect on charitable giving, but we were still surprised to see sustained growth through 2010.”

Spending on HIV/AIDS programs has continued to rise at a strong rate, making HIV/AIDS the most funded of all health focus areas. Dr Murray feels that this could partly be due to the fact that, "Advances in medications to combat HIV were among the main reasons that donors and NGOs started to rally together to form what we know today as the global health community. The legacy of the early fight against HIV has maintained a strong commitment to funding for HIV-related efforts, and this includes the U.S. President's Emergency Plan for AIDS Relief, the single largest amount of funding to combat HIV."

Funding for maternal, newborn, and child health received about half as much funding as HIV/AIDS as of 2008. Again, funding for non communicable diseases represents just 0.5% of all development assistance for health.

Both, malaria and tuberculosis receive far less funding than AIDS: $1.19 billion for malaria in 2008 and $0.83 billion for tuberculosis. Funding for malaria and tuberculosis also appears to go to countries that do not have large groups at risk for these diseases. For example, of the 30 countries that receive the most malaria health funding adjusted for disease burden, only three – Eritrea, Sao Tome and Principe, and Swaziland – are located in sub-Saharan Africa, where malaria is most acute. Instead, the countries that receive the most money in proportion to their malaria burden include Georgia, Sri Lanka, Azerbaijan, Uzbekistan, Nicaragua, Kyrgyzstan, Tajikistan, Honduras, and Guatemala. All of these countries received more than $2,000 per disability-adjusted life year, or DALY, between 2003 and 2008.

Why is it so? Dr Murray feels that “in part it’s because health assistance decisions are not made entirely based on need but also reflect longstanding economic and political ties between countries, some of which go back to colonial days.”

In countries whose governments receive significant donor funding, development assistance for health appears to be partially replacing domestic health spending instead of fully supplementing it. Conversely, in countries that receive health funding mainly through NGOs, government health spending appears to increase.

The researchers indicate that the intensified focus on certain health issues – such as maternal, newborn, and child health, non communicable diseases, and health sector support – is likely to magnify the competition for limited resources and exacerbate the effects of any downturn in development assistance for health.

“More than 300,000 mothers still die every year, and more than 7 million children die before the age of 5. Chronic diseases need more attention, and countries need better health care infrastructure,” Dr. Murray said. “All of these pressing health issues require funding, and it is becoming increasingly difficult to balance competing needs.”
Whatever the compulsions of funding agencies/beneficiary governments be, Dr Murray believes that 'when a program is started it should include an evaluation component so that everyone will have a detailed understanding of whether the program is improving health. This is gives developing country governments guidelines for how to best target their limited resources, which is actually the most important factor in health spending. Spending by governments on their own health programs on the whole far outweighs spending by donors.'


Shobha Shukla - CNS
(The author is the Editor of Citizen News Service (CNS) and also serves as the Director of CNS Diabetes Media Initiative (CNS-DMI). She has worked earlier with State Planning Institute, UP.  Email: shobha@citizen-news.org, website: www.citizen-news.org)  


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Thailand Shares Successful Experiences on Universal Health Coverage

Dr. Viroj Tangcharoensathien, the Director of International Health Policy Program, MOPH Thailand and the winner of Edwin Chardwick Medal Award, shared the successful experiences of Thailand over 27 years to achieve full Universal Health Coverage at the First Global Symposium on Health Systems Research (HSR), 16 – 19 November 2010, Montreux, Switzerland. Read more.

“By 2002 Thailand achieved full population coverage, which helps people to be able to access health services without pushing them to poverty because Thai government subsidized payments. Today all 650 districts were covered by a district hospital.” Dr.Viroj announced.

The key factors which helped Thailand to contribute to universal coverage includes political decision making and leadership, extensive trust base networks, policy networks, research networks and linkages among them.

Government effectiveness in its capacity to translate policy intention into actual implementation also contributed to success. In addition, Civil society involvement which included agenda setting on various policies: ART, renal replacement therapy for example. Health Service platform is vital otherwise Universal Coverage is a ‘citizen right in paper’ and Knowledge management: application of tacit knowledge, Health Systems Research also contribute to the achievement of universal coverage.

Thailand initially offered a favorable health package to low income group of 30 THB (US$ 0.7) and later on patients were not asked to pay anything. The Thai government contracted service providers and paid a certain amount to cover a certain number of people per year, instead of free choice fee for services reimbursement model.

Thailand still faces some serious challenges and these include:

1. How to sustain efficiency, equity and quality achievement while strengthen capacity to address new challenges through evidence.
2. And the demand for research outpaces the capacity in generating evidence.
3. Also demographic and epidemiological transition for example Chronic long term care versus hospital acute care, effective coverage of interventions and primary prevention of risk factors.
4. Non-health sector actions against determinants of ill-health such as Tobacco, alcohol, transfat, obesity, physical inactivity, safe environment and injury prevention.
5. Institutional capacity to generate evidence on ICER, fiscal impact, equity and ethical considerations of new medicines, interventions.

“We have to maintain a sustainable model and continue to develop our research,” Said Dr.Viroj.

“We have to prepare the longer term care and ensure that our aging people are healthy and it would be better to encourage them to stay at home with family instead of in the health care centre and links between home care and the health sectors need to be established,” he said.

“Due to the increasing of cost related to health issues we should formulate policy which is related to long term care. On the benefit package we need to improve and strengthen of new intervention and new medicine.” he added.

Jittima Jantanamalaka - CNS
(The author is the Managing Director of Jay Inspire Co. Ltd (JICL), produces radio programmes in northern Thailand and writes for Citizen News Service (CNS). She is also the Director of CNS Diabetes Media Initiative (CNS-DMI) in Thailand. Website: www.jay-inspire.com, Email: jittima@citizen-news.org) 


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Right To Sight (RTS) committed to eliminate avoidable blindness

Three-quarters of all blindness can be prevented or treated. Avoidable blindness poses an enormous challenge to healthcare system, particularly in low- and middle- income countries. There are nine million people in Africa alone with preventable blindness, out of which 50-75% people are blind due to cataract and 5% due to glaucoma, says Keerti Bhusan Pradhan (Right To Sight) who is heading to Ireland to present his work in Africa at the Irish Forum for Global Health (IFGH) biennial conference next week (29-30 November 2010). Read more

Although blindness in 50-75% people is attributed to cataract, the health response has been appalling. According to the World Health Organization (WHO), cataract surgery is one of the most cost-effective treatments that can be offered in developing countries. It can allow people to increase their economic productivity by up to 1500% of the cost of the surgery during the first post-operative year.

According to WHO, about 314 million people are visually impaired worldwide, 45 million of them are blind. Most people with visual impairment are older, and females are more at risk at every age, in every part of the world. About 87% of the world's visually impaired live in developing countries.

The leading causes of chronic blindness include cataract, glaucoma, age-related macular degeneration, corneal opacities, diabetic retinopathy, trachoma, and eye conditions in children (including those caused by vitamin A deficiency). Age-related blindness is increasing throughout the world, as is blindness due to uncontrolled diabetes. Three-quarters of all blindness can be prevented or treated.

Keerti represents the Right To Sight (RTS) which is dedicated to eradicate preventable blindness through the use of proven techniques in cost recovery, training and surgical practice. One of the major landmarks of Keerti is his contribution to improving eye care and preventing avoidable blindness in India as well as many countries in Africa.

Investing in preventing avoidable blindness is not only a public health imperative but also a smart investment as it saves costs for countries and donors, says Keerti. According to a research done by Frick and Foster, the estimated cost of global blindness and low vision was USD 42 billion in 2000. Without a decrease in the prevalence of blindness and low vision, it was projected that the total annual costs would rise to USD 110 billion by 2020. However, if avoidable blindness is eliminated, this projected cost will be reduced to only USD 57 billion in 2020, says Keerti.

There are many challenges to initiatives that aim to eliminate avoidable blindness and two major ones are inconsistent quality of care and shortage of healthcare workers in Africa, says Keerti.

One of the novel approaches Right To Sight brings in is using private public partnership (PPP) to engage private sector in public health. Most of the healthcare in sub-Saharan Africa is in public sector and Keerti envisions a growing role of private sector in meeting public health needs in the region. According to a research study, USD 20 billion of additional investment is needed for healthcare in private sector to improve health outcomes in Africa.

Keerti believes that operational ownership of eye hospitals by the private sector partners is vital. Right To Sight, a non-profit, works in partnership with Shalina Laboratories which is a pharmaceutical company in Democratic Republic of Congo (DRC). Shalina plans to expand Right To Sight's PPP model of eye care delivery to 18 African countries with six centres planned in DRC in phases.

This pilot would provide road map for many private partnerships to have eye care services in Africa leading towards the goal of eliminating avoidable blindness by 2020 says Keerti.

Preventing avoidable blindness mandates a stronger response at all levels and from all stakeholders. Let's hope that the forthcoming biennial conference of Irish Forum for Global Health (IFGH) next week will be a game changer for evoking the warranted response to eliminate avoidable blindness.

Bobby Ramakant - CNS 

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Will access to essential asthma medicines be on NCD Summit agenda?

Asthma is the most common chronic disease. Since 2000, some areas of public health, such as tuberculosis (TB), have gone from being deprived of resources for decades to having significant amounts of funding. While important gaps remain, this “dream come true” has also revealed that spending better is equally necessary as spending more. Ms Cécile Macé, Pharmacist and Coordinator, The Union's Asthma Drug Facility (ADF) said at the 41st Union World Conference on Lung Health in Berlin, Germany that "ADF improves affordability of essential asthma medicines in developing countries." Read more

It is not only important for the countries, particularly low- and middle- income countries to have access to affordable asthma medicines but quality is important to monitor as well. The Asthma Drug Facility (ADF) is a mechanism to improve access to affordable and quality asthma medicines where they are needed most, said Cécile Macé.

Lack of adequate skilled healthcare providers to manage asthma care is also a critical impediment to the response. Improving skills of healthcare personnel by the development of guidelines and training packages, is another key priority to improve response to asthma in low- and middle- income countries, said Cécile Macé.

Assessing quality of asthma care by regular monitoring, is another key challenge, said Cécile Macé.

Policy makers and economists need to understand that asthma care is a smart investment –because costs increase manifold when asthma is either not treated at all or incorrectly treated. So a wise strategy and to make the best use of every resource available, it is vital to manage asthma in the right way and provide standard treatment and care, said Cécile Macé. We need to reduce the unnecessary expense of emergency asthma, said Cécile Macé.

Due to sustained advocacy, one of the outcomes is that there is more financial support available for asthma programmes. Around 30 countries received funds through the Global Fund to fight AIDS, TB and Malaria (GFATM) under their tuberculosis (TB) application to implement the Practical Approach to Lung health (PAL) strategy, which is a part of the WHO Stop TB Strategy, which also includes among others, an asthma care component. Other health financing mechanisms need to consider supporting asthma care as well.

One of the methods for financing medicines is a revolving drug fund (RDF) in which after an initial capital investment, medicine supplies are replenished with monies collected from the sales of medicines. We should encourage donors to support the purchase of asthma medicines through initiatives like Revolving Funds. Revolving fund is a sustainable solution for asthma response, said Cécile Macé.

It will be strategic opportunity for the forthcoming United Nations (UN) Summit on non-communicable diseases (UN Summit on NCDs) in September 2011 to also address this need to ensure access to essential asthma medicines in low- and middle- income countries.

Bobby Ramakant - CNS 


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Canada endorses the Declaration on Right of Indigenous Communities

As the 41st Union World Conference on Lung Health in Berlin, Germany was going on, another development took place in Canada – which will surely impact public health including tuberculosis (TB) and lung health among indigenous communities. Canada endorsed the Declaration on the Rights of Indigenous Communities. Wilton Littlechild, Regional Chief, Assembly of First Nations, has been a powerful advocate demanding this endorsement from Canada since years. Four states had voted against the declaration initially, New Zealand, Australia, United States of America and Canada. However, New Zealand and Australia had changed their position and endorsed the declaration earlier. Now Canada too have endorsed the declaration, thankfully. Read more


"Indigenous people around the world have sought recognition of their identities, their ways of life and their right to traditional lands, territories and natural resources. However throughout history, their rights have been violated" said Chief Littlechild.

Chief Littlechild gave an overview of significant milestones in demanding policy change and responses to the human rights of indigenous communities.

In 1923, Haudenosaunee Chief Deskaheh had travelled to Geneva to speak to the League of Nations and defend the right of his people.

1925 Ratana first travelled to London with a large delegation to petition King George, but he was denied access.

The International Labour Organization (ILO) Convention 169 (1991) Article 3 states that indigenous peoples must fully enjoy fundamental human rights without obstacles or discrimination.

The ILO Convention 169 Article 2 gives governments the responsibility for ensuring that all indigenous people have the same rights and opportunities as non indigenous peoples.

The ILO Convention 169 Article 5 recognizes and protects the social, cultural, religious and spiritual values and practices of these peoples.

The ILO Convention 169 Article 7 specifically refers to the obligation that states parties have with regard to the improvement of the conditions of life work, levels of health and education as a matter of priority in national plans.

The ILO Convention 169 Articles 14 and 16 guarantee the rights of ownership and possession of land by indigenous peoples and the right not to be displaced.

"No health without land for indigenous people," rightly said Chief Littlechild.

"The declaration on the rights of indigenous people was adopted by the general assembly on 13 September 2007. The declaration is the most comprehensive statement of the rights of indigenous peoples ever developed, giving prominence to collective rights to a degree unprecedented in international human rights law" said Chief Littlechild.

The drafting of the declaration began in 1985 and the first draft was completed in 1993. In 1995, the commission on human rights set up its own working group to review the draft adopted by the human rights experts of the working group and the sub-commission, said Chief Littlechild.

"There are many steps that should be taken to apply indigenous rights’ lens to TB programmes" said Chief Littlechild.

Countries like Bolivia, Colombia, Ecuador, and Mexico, have all written multiculturalism into their constitutions to ensure that their country’s legislation conforms with convention obligations and international human rights guidelines related to the highest attainable standard of health.

"The ministers of health and policymakers should be trained on the obligations from international human rights conventions to which their government is a party. If national health policies, plans, and programmes, do not align with these obligations, efforts should be undertaken to revise them so as to make them consistent with those conventions and standards" said Chief Littlechild.

Policy makers can build and expand databases from national and sub-national sources to measure and monitor the impact of ethnicity on the exercise of human rights and fundamental freedoms related with health and the right to health per se, said Chief Littlechild.

The national TB control programmes (NTPs) can systematically monitor TB trends among indigenous populations to determine ways to improve healthcare. NTPs can also investigate the ways in which health is determined by outside factors, and the extent to which the government can remedy problems of infrastructure, said Chief Littlechild.

The NTPs, NGOs and civil society should also build networks of national and sub-natoinal research institutions that focus on health or other issues of importance to indigenous populations.

The minister of health can encourage the dissemination of culturally appropriate health information materials in local languages, the inclusion of traditional leaders, healers in health promotion, said Chief Littlechild.

Outlining the unique social determinants that affect health of indigenous communities, he listed: colonization and colonialism, residential schools in some schools TB rates were so high that they were locally referred to as TB schools), language and culture, indigeneity, geographical locale, racism and self determination.

Victoria Tauli-Corpuz, Chairperson, of Permanent Forum on Indigenous Issues, had once said: "Actions taken to reach the MDG [millennium development goals] health goals cannot be measured solely in terms of improving average health outcomes. They must also be evaluated in terms of their consistency with a human rights based approach which emphasizes participatory, non-discriminatory and accountable actions to improve the health of indigenous peoples."

Endorsing of the declaration on rights of indigenous communities by Canada and other nations shall go a long way in not only reducing diseases like TB among indigenous peoples but also improving quality of life and conditions that respect human rights.

Bobby Ramakant - CNS  


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Irish Forum for Global Health calls for protecting health aid funding

"Current economic crisis threatens to reverse much of the progress made in developing countries"
The Irish Forum for Global Health (IFGH) is concerned at the further cuts to the overseas aid budget in the Government's four-year plan. It urges the Government to protect aid funding for health and HIV programmes in developing countries and to keep its promise to increase aid to 0.7% of Gross National Income (GNI) by 2015. The current economic crisis threatens to reverse much of the progress made in developing countries over recent decades and UNESCO estimates that the economic downturn will cause between 200,000 and 400,000 additional child deaths each year between now and 2015. Urgent measures are needed to protect the poor and vulnerable. Read more


Ireland has a responsibility to help address the health needs of developing countries. While health in Ireland has steadily improved, the gap has widened between Ireland and the least developed countries.
External aid for health has proven to be effective. For example, more than 5 million people are now on anti-retroviral treatment for HIV in developing countries, compared to just 300 thousand in 2002. There has been a dramatic reduction in malaria deaths due to the distribution of insecticide-treated bed nets. Aid for health has also been good for economic development as tackling major diseases such as tuberculosis (TB) and malaria makes people healthier and more productive.

Developing countries are dependent on external aid to provide even the most basic healthcare. Cuts in aid budgets make it harder for governments to invest in critical service developments, such as recruiting new health workers, provision of emergency obstetric care and safe delivery services, and expanding immunisation programmes. Some of these effects will reverse hard-fought gains and have long term consequences for health in these countries.

Ireland's aid budget was reduced from €920 million in 2008 to €722 million in 2009. European Commission President José Manuel Barroso has said "The recession must not, cannot, will not be used as an excuse for going back on aid promises." Other European countries, including the UK, have managed to maintain aid levels despite recession.

Ahead of his Keynote Speech to be delivered at the Irish Forum for Global Health Biennial Conference 2010 taking place at the end of November, Professor Father Michael Kelly, well known and respected Irish Jesuit priest, researcher and author who has lived in Zambia for over 50 years gave his view on Irish foreign aid for health "Maintaining levels of aid, especially for health, makes economic sense, is the right, just and decent thing to do, and is something that even in the current difficult economic climate the majority of Irish people would want. Reducing the level of aid would bring only minor relief to the Irish budget but would mean major budgetary and human setbacks in recipient countries."

Dr David Weakliam, of the Irish Forum for Global Health (IFGH), stated: "Health is a vital part of the Government's overseas development programme. The further cuts in aid in the four-year plan will undoubtedly have a negative impact on the health of people in the poorest countries. They will also damage the excellent reputation Ireland has earned for its assistance to the underprivileged in developing countries."

The Irish Forum for Global Health (IFGH) opposes further cuts in the aid budget in order to protect the health of the world's poorest and most vulnerable people.

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Communities' demand can drive development of new TB tools

Berlin, Germany: Louder voices and more demand for new tools against tuberculosis (TB) from people and communities are needed to push the fight against the airborne disease, participants of the 41st Union World Conference on Lung Health in Berlin, Germany (November 11-15) stressed. Read more


"Governments don't support TB research and development enough. We have to empower communities with more knowledge on TB issues to move governments to do something," Lucy Ghati, Community Representative to the Stop TB Partnership's Working Group on New TB Vaccines and Program Officer of the National Empowerment Network of People Living with HIV and AIDS in Kenya remarked at a press briefing on the state of TB vaccine development. "Without being pushed governments won't do anything," she added. "But we need new commodities to address TB and HIV: new diagnostics, better drugs and – if we want to have a long term solution – new vaccines."

The current diagnostics, drugs and vaccine against TB are outdated and not efficient enough. Peg Willingham, Senior Director External Affairs at the Aeras Global TB Vaccine Foundation, presented the example of TB vaccines in a separate media meeting held to brief journalists on key issues on the conference agenda. BCG, the only currently available vaccine against TB, is partly effective against severe forms of childhood TB but fails to prevent the most prevalent form, pulmonary tuberculosis in adults. Researchers around the world are working to develop new, more effective and safe vaccines, which will be affordable and available worldwide.

"It is important that the community is involved in the research. Therefore, our clinical trial research partners in the countries where we test new vaccines do a lot of community outreach," Willingham explains in an interview with CNS, citing different ways to engage and inform people such as through radio programs, outreach to schools, and comic books.

It is also essential to consider the perspectives of the decision makers at national levels who will play the leadership role in rolling out future new vaccines.  "We want to make sure that what we are doing is what countries want," Willingham said. Aeras works to involve communities at all levels of society, as demonstrated by a recent market study done among national-level decision makers in high TB burden countries.  The study, still in preliminary form, showed that TB is considered a significant health problem that does not get the attention it deserves.

"It would be a kind of a virtuous circle if people from the community said new vaccines are something they want," said Willingham, explaining that community engagement helps build demand for vaccine research and development, and it fosters clinical trial recruitment.  Local involvement and demand is essential to building government support for research.

An added challenge to building demand for vaccines is that prevention is often overlooked.  As Willingham explained, vaccines administered in childhood that have worked in preventing illness are quickly forgotten.  The cause and effect relationship of vaccines and the disease they prevent are not immediate, as with medication that quickly provides relief.

Stigma surrounding people with TB and the lack of advocates willing to add their voices to public calls for new TB vaccines also contributes to the lack of awareness about the inadequacies of BCG and the need to improve or replace it.

"People are always surprised to hear still two million people die of TB every year," Willingham says. "More people need tell to their personal stories and provide the face of people with TB. We have to figure out a way to reduce that stigma, figure out how to get people to feel safe and brave to speak up because otherwise people will keep dying quietly, behind closed doors, and it will never get any better."

Joris Vandeputte, Senior vice president advocacy and resource mobilization at TuBerculosis Vaccine Initiative (TBVI) reaffirmed the need to deal with stigma at the TB vaccines  press briefing. "Stigma has consequences for advocacy efforts and resource mobilization for TB as well," he said, at the same time acknowledging the achievements made with the (limited) funding available. "There are currently 12 vaccine candidates ready to be translated into vaccines that are globally accessible as well as promising diagnostics and treatment avenues. We have to work hard to translate these into products ready to be used in the field. For vaccine candidates to be translated, financial resources must be multiplied by 3 to 4 compared with the present effort. To overcome this huge challenge, we will have to be innovative."


Babs Verblackt - CNS
(The author is a freelance journalist, a Fellow of CNS Writers' Bureau and Associate Communications at TuBerculosis Vaccine Initiative – TBVI)

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Big Tobacco undermines health policy as treaty meetings face similar abuse: Report

Uruguay proposes resolution calling for unity in face of tobacco industry interference
PUNTA DEL ESTE, URUGUAY: A new investigative report by the International Consortium of Investigative Journalists exposes a wide range of tactics employed by the tobacco industry to undermine advances being made by the global tobacco treaty. Threats to health policy include aggressive lobbying and legal intimidation, to charitable donations and even outright payoffs. Read more


Even as Parties meet to discuss how to overcome such obstacles – the primary threat in advancing a treaty the World Health Organization projects could save 200 million lives by 2050 – industry tactics have followed countries to this week’s treaty negotiations in Uruguay.

Not only are dozens of tobacco industry representatives crowding the halls of the negotiation each day, industry is also playing a role in the seating of delegates in attendance. These delegates are the eyes, ears, and voice piece of an industry that has otherwise been prohibited from directly participating in the negotiations and health policy under a core provision of the treaty.

One such example is Zimbabwe, a non-Party observer. Despite being cash strapped, the country somehow mustered the funds to send 10 delegates to Uruguay days after a prominent tobacco industry front group disparaged guidelines being negotiated this week to the Wall Street Journal. To put this in perspective, more than 35 ratifying countries were unable to send even a single representative. Worse, though the treaty requires that health policies and negotiations be protected from “commercial and other vested interests of the tobacco industry,” Zimbabwe’s delegation includes representatives from the Tobacco Industry Marketing Board, as well as ministries whose priority is either trade or agriculture.

“A reminder is needed that we are here to devise solutions to save people’s lives,” said Sam Ochieng of the Network for Accountability of Tobacco Transnationals and Consumer Information Network Kenya. “Progress is not possible if the long arm of industry is able to reach into and manipulate a conversation that rightly excludes Big Tobacco.”

Tobacco growing countries like Zimbabwe may be the most brazen, but are not unique when it comes to sending representatives from ministries whose objectives may be at odds with the treaty’s guiding principle that the public’s health be prioritized over trade. Of the 438 Party delegates listed in the provisional list of participants, 74 delegates represent ministries other than health. Egregious examples include Macedonia’s delegation which has no health ministry representation. Of its 19 member delegation, China sent five delegates from its state-owned tobacco corporation.

While some non-health ministries may have legitimate reason for inclusion in a delegation, such as representation from finance ministries in anticipation of discussions regarding tobacco taxation; for others such appointments further expose the primary obstacle to treaty implementation – the fact that industry has a voice it shouldn’t within government in deciding health policy.    

“This is not to say the vast majority of countries here are not acting with integrity, just that Parties must be unified in challenging tobacco industry interference for the treaty to progress,” said Corporate Accountability International’s Latin America Director Yul Francisco Dorado.

In this vein, Uruguay has proposed a resolution calling for Parties to stand together in confronting the manner of legal intimidation it and other countries are now facing from Philip Morris International.

Corporate Accountability International and its partners are pushing for the inclusion of a provision giving the Secretariat representing the Parties to the treaty a voice during legal proceedings. (CNS)

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Poverty increases vulnerability to tuberculosis (TB)

"So little attention has been given to the tuberculosis (TB) pandemic because it's a disease of the poor" had said Dr Nils Billo, Executive Director of the International Union Against Tuberculosis and Lung Disease (The Union) at the 38th Union World Conference on Lung Health in Cape Town, South Africa in 2007. In 2010, before the 41st Union World Conference on Lung Health opens next week in Berlin, Germany (11-15 November 2010), the issues around TB and poverty have only become more severe. At the consultative workshop organized by the TB and poverty sub-working group of Stop TB Partnership in India (29-30 October 2010), it was clear that TB continues to affect society's most vulnerable - those who live in abject poverty, are marginalized or economically and socially isolated. Poverty significantly increases a person's vulnerability to the disease. Read more


Social and economic determinants at individual, household and community levels affect a person's vulnerability to TB. Special situations such as massive population movements - the displacement of people and refugee flows - and living or working in particular conditions also increase the risk of a person contracting TB.

In developed countries, ethnic minorities and other marginalized communities are at a greater risk of contracting the disease. In Canada for instance, indigenous communities have a 20 to 30 times higher TB burden than majority ethnic groups, Dr Kim Barker and Dr Anne Fanning from Stop TB Canada had said to CNS during the 38th Union World Conference on Lung Health in 2007.

Factors such as social isolation, reduced access to health services, a lack of trust in the health system and lack of organized community voices exacerbate the risk of TB spreading. But by identifying these vulnerabilities to TB, control strategies can become more focussed on reaching the people most in need.

TB is transmitted more readily in conditions such as overcrowding, where there are inadequate ventilation and malnutrition. Improvements in socio-economic conditions will therefore lead to reductions in TB incidence. This should also lead to improvements in access to care, its rational use and quality of care.

About one billion people live in urban slums and over the next 30 years that number is expected to double. In the poorest countries, about 80% of the urban population lives in slums. The poor socio-economic and environmental conditions that characterize the slums facilitate the transmission of many communicable diseases including TB. The burden of TB is often far greater in these urban settings than in rural areas.

There is also increasing recognition of the fact that TB reduces people's ability to work and earn a living and that TB control programmes have the potential to reduce poverty.

Poor TB patients in developing countries are mainly dependent on daily wages or income from petty trading and have no security of income or employment. In many studies people with TB have been found to have borrowed money, used transfer payments or sold assets because of their illness.

"We have to create jobs, find income generation alternatives for those people who are on TB treatment and need financial support to sustain them through the entire treatment course," said Dr AK Jha during the TB and poverty consultative workshop in India (29-30 October 2010). The secretariat of the TB and Poverty sub-working group of Stop TB Partnership has moved now to The Union's South East Asia office in New Delhi, India since August 2010.

At this TB and poverty consultative workshop, listening to the experiences from those fighting TB on the frontlines in high burden settings like in Nepal, Thailand and India, and from five states in India, it was evident that even where Directly Observed Treatment Shortcourse (DOTS) programmes are well established, patients with TB face substantial costs prior to diagnosis. While aggregate costs for poor people tend to be lower than for those from a higher socio-economic position, the costs as a proportion of income is much higher for the poor.

Experiences from other programmes like HIV show that it was usually health-care volunteers or members from affected communities that reached the most marginalized communities, providing them with TB and HIV care and treatment services. Home-based care (HBC) experiences for people living with HIV in most hard-hit communities provide learning lessons.

Poverty has played a leading role in accelerating the spread of TB. The poor are at the greatest risk for tuberculosis because of poor housing, poor diet, poor education and risky behaviour.

Let's combat TB by addressing the barriers faced due to poverty such as infrastructural, housing, employment, educational and nutritional deficiencies.

Bobby Ramakant - CNS