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file TB
HEC
ARKANSAS
Area Health
Education
Centers
October 30, 1998
Program
University Tower Office
The Honorable Hillary Rodham Clinton
1123 S. University, Suite 400
The White House
Little Rock, AR 72204
Washington, DC 20500-2000
(501) 686-2590 [Voice]
(501) 686-2585 [Fax]
Dear Hillary:
I was delighted to learn yesterday of your recent meeting regarding tuberculosis,
since we have undertaken one in Volgograd, Russia. With USAID support given
to UAMS and the Volgograd Medical Academy by the American International
Health Alliance, we have trained two young physicians from Volgograd and next
week will participate in a conference there sponsored by the Academy. Dr. Joe
Bates is the senior, distinguished member of our team. In his laboratory, Dr.
Kathy Eisenach and Dr. Don Cave are international leaders in the molecular
biology of tuberculosis. A description of our project accompanies this.
We look forward to your leadership with respect to the grave threat presented by
tuberculosis and would welcome opportunities to discuss the matter with you.
Please let me add that Ruth Remmel, Maggie Garcia, and Mary all enjoyed seeing
you a couple of weeks ago in Little Rock. We all remain solid supporters.
Sincerely,
Jin James C. Wohlleb
Assistant Director
Enc.
University of
Arkansas for
Medical Sciences
Equal Opportunity Employer
VOLGOGRAD TUBERCULOSIS CONFERENCE, NOVEMBER 1998
Background
From Tuesday through Thursday, November 3 to 5, the tuberculosis conference of the
Arkansas-Volgograd partnership (funded by AIHA) will take place at the Volgograd
Medical Academy. Originally anticipated as a national conference, its scope was altered in
June 1998 during the trip of the Arkansas team to Moscow and Volgograd. They
discovered during conversations in Moscow that another national conference was planned
at the Moscow Medical Academy in September. The Arkansas-Volgograd partners also
concluded during discussions in Volgograd that focus on improving laboratory procedures
in Volgograd might alone enhance cure rates through achieving more precise and reliable
identification of specific strains of tuberculosis.
Further, the Arkansas team sensed that an opportunity to compare management of cases
and their outcomes with open discussion might reveal why 10 per cent or more of therapies
fail. This seems more appropriately conducted in a local rather than a national forum.
On the other hand, the stature of the lecturers recruited for the laboratory sessions is
international. Desiring to continue the dialogue begun during our introductions in
Moscow, the partners also believe that participation by the leaders there would be
beneficial to long-term progress of aiding in the war against tuberculosis in Russia.
Contents of the conference
On Tuesday and Wednesday, the "consecutive case conference" proposed by Dr. Bates and
accepted in Volgograd last June will occur. Dr. Karaduta and Dr. Kosolapov will describe
approaches to tuberculosis control, procedures, and results that they have observed during
their 6 months in Arkansas. Following their lectures, we propose to stop for a half-hour
then begin presentations and discussions of 10 tuberculosis cases from Arkansas. This will
require the remainder of the day. On Wednesday, cases from Volgograd will be given and
discussed. The amount of time allotted might not be enough to hear all 10 cases from each
Arkansas and Volgograd. Participants will proceed with as many as possible within the
allotted periods of time.
Dr. Jennifer Dillaha, a fellow in infectious diseases at UAMS and the Veterans
Administration Medical Center, prepared 2-page summaries of 10 consecutive cases who
presented to clinics in Little Rock starting four years ago. Dr. Karaduta translated these
into Russian and carried them back to Volgograd two weeks before the conference.
Illustrations and graphs will be labeled in both English and Russian.
To provide the clinicians and laboratory staff with an overview of the laboratory's role in
tuberculosis control, lectures will cover this in the afternoon on Wednesday. Thursday, the
focus shifts to specific laboratory methodologies, which will be most informative to the
technicians in tuberculosis laboratories. Following is the schedule for the conference.
Sessions on Tuesday, November 3
Sessions on Wednesday, November 4
09:00 Introductions
09:00 Case Presentations
09:15 TB Control in the US, Dr. Karaduta
10:45 Break
10:00 US Lab Methods, Dr. Kosolapov
11:15 Case Presentations
10:45 Break
13:15 Lunch
11:15 Case Presentations
14:00 Role of the Laboratory in the
Diagnosis of Tuberculosis, Dr. Eisenach
13:00 Lunch
15:00 Molecular Epidemiology of TB, Dr.
14:00 Case Presentations
Cave
16:00 Summary and Discussion
16:00 Summary and Discussion
Lectures on Thursday, November 5
Lectures on Thursday, November 5
09:00 Specimen Collection and Handling;
13:30 Identification and Drug
Microscopy, Dr. Pfyffer
Susceptibility Testing, Dr. Siddiqi
10:00 Discussion
14:30 Discussion
10:30 Break
15:00 Molecular Methods for Direct
Detection and Drug Susceptibility Testing,
11:00 Specimen Processing and Culture
Dr. Eisenach
Methods, Dr. Pfyffer
16:00 Discussion
12:00 Discussion
16:30 Summary and Conclusions
12:30 Lunch
Friday, November 6
Friday, November 6
Evaluation of conference
Plan laboratory changes
Tours of laboratories
Other project plans
2
On Thursday, two family physicians from Arkansas -- the director of a residency program
and another in private practice -- will lecture and discuss cases with faculty and residents
of the new family medicine department of Volgograd Medical Academy.
As many laboratory staff as possible will attend from the laboratories of the academy as
well as from those of the oblast and city of Volgograd. This includes people who collect
and prepare specimens. Because the visiting experts will emphasize practical techniques
for achieving reliable and precise results, their instruction will lead to improvements of
laboratory performance during the next year as the partners continue communications.
This outcome of the conference is critically important to the future of the project in so far
as it will lay the foundation for advances in laboratory development and, indirectly, clinical
successes. The direction planned for the next year or more emphasizes the necessity and
achievement of reliable and precise laboratory performance. Continuing education and
monitoring operations will follow initial training. Studies of laboratory procedures in
Arkansas by visiting faculty and staff from Volgograd will continue. These will stress
quality control. With funds currently being sought, a new reference laboratory will be
constructed in space already designated for this purpose by the academy. The educational
activities in Volgograd and Arkansas will prepare staff for this reference laboratory.
The rationale for emphasis on laboratory performance is twofold. It rests on observations
of last June that faculty of the Academy are more open to instruction and improvements in
their laboratories than in their clinics. The other reason is the expectation that more precise
and reliable laboratory methods will result more frequently in appropriate medications for
patients and enhance the capacity for detecting ineffective treatments.
Because similar attitudes seemed to prevail in Moscow, and because effectiveness of
treatment appeared to be approximately the same in Moscow as in Volgograd, the partners
believe that involving leaders of tuberculosis clinics and laboratories of Moscow will
benefit national progress against tuberculosis through dissemination of technology. An
additional advantage to nationwide anti-tuberculosis actions will be increased exchange of
information and solidarity among groups of experts.
Private sector support
Becton Dickinson (BD)-Europe has agreed to support the meeting by sending Dr. Gaby
Pfyffer from the University of Zurich and Dr. Salman Siddiqi from the Maryland, USA
offices of BD Biological Systems. Dr. Pfyffer, who consults internationally on laboratory
methods, will lecture on collecting and processing specimens. Another expert on methods
in tuberculosis laboratories, Dr. Siddiqi will describe drug susceptibility testing.
Dr. Andrey Pchelkin of the DINA firm in Moscow is invited to attend with a guest and to
exhibit diagnostic kits sold be his firm for use in tuberculosis laboratories.
3
The partnership has submitted a request to BD for assistance with the construction of a
new laboratory for tuberculosis. Its intended function is as a reference resource where
technicians of the oblast will be trained, operations of other laboratories will be monitored,
and research will be conducted (in addition to its routine service of laboratory clinics).
Invited guests
The Volgograd Medical Academy and the University of Arkansas for Medical Sciences
invited the following tuberculosis leaders and officials (or their designated alternates) to
the November conference in Volgograd. Due to relatively late invitations and prior
commitments, however, most could not attend.
Alexander G. Khomenko, M.D., Director of the Central Tuberculosis Institute and member
of the Russian Academy of Medical Sciences
Vitaliy I. Litvinov, M.D., Director of the Moscow Anti-TB Center and Corresponding
Member of the Russian Academy of Medical Science (Formerly he headed the
Immunology Department of the Central Tuberculosis Institute.)
Valentina I. Golyshevskaya, M.D., and Inna R. Dorozhkova, M.D., Institute for
Phthisiopulmonology Research of the Moscow Sechenov Medical Academy
Farit A. Batyrov, M.D., Director of the Moscow Clinical Tuberculosis Hospital No. 7
Adalbert Laszlo, PhD, Consultant, WHO and IUATLD, Ottawa, Ontario, CANADA
Donald Enarson, M.D., Director of Scientific Activities, IUATLD, Paris, FRANCE
Natalia V. Voziianova, Project Management Specialist, Health Division;
George R. Oswald, Health Industry Specialist, Office of General Development; and
Nikita Yu. Afanasiev, M.D., M.P.H., Project Management Specialist for Health and
Pharmaceuticals; USAID, Moscow, RUSSIA
Victor Boguslavsky, M.D., Director, AIHA/Moscow
Alex Goldfarb, Ph.D., Public Health Research Institute, New York, NY, USA
Rick O'Brien, M.D., Kenneth Castro, M.D., and Nancy J. Benkin, M.D., Tuberculosis
Control Program, Centers for Disease Control and Prevention, Atlanta, GA, USA
(Unable to attend.)
Lee B. Reichman, M.D., M.P.H., Director, National Tuberculosis Center, Medical College
of New Jersey, Newark, NJ, USA (Consultant to this project but unable to attend.)
4
file
Tuberculosis Meeting
October 28, 1998
Briefing Book
Table of Contents
1-
-
List of Participants
2- Seating Chart
3 - - Talking Points
U.S. Government Activities
4 - Department of Health and Human Services
5 - - U.S. Agency for International Development
6- Gore/Primakov Commission
NGO/International Organizations Activities
7- - OPEN Society Institute
8 -
World Health Organization
9 -
World Bank
Al D'Amato letter?
TB Meeting
October 28, 1998
List of Participants
World Health Organization
Project 55 TB Initiative (Ralph Nader grp.)
Dr. Gro Brundtland
Christoph Lee
Dr. David Heymann
AID
Executive Director for Communicable
Administrator Brian Atwood
Diseases
Duff Gillespie
Ambassador Jonas Store
Deputy Assistant Administrator for
Executive Director
Population, Health and Nutrition
Ambassador Thomas Loftus
HHS
Secretary Donna Shalala
World Bank
Dr. James Wolfensohn
Peggy Hamburg
President
Asst. Secretary for Planning and Evaluation
Jan Piercy
State
U.S. Executive Director
Frank Loy
Undersecretary of State for Global Affairs
Dr. David de Ferranti
Vice President, Human Development
Douglas Wake
Network
Office of Assistance to the NIS
Chris Lovelace
WH/NSC
Director, Human Development Sector
Melanne Verveer
Marsha Berry
Open Society Institute
Ken Bernard
George Soros
Andrew Weiss
Dr. Paul Edward Farmer
Leon Furth
Dr. Alexander Goldfarb
Dr. Srdan Matic
TB Meeting Seating Chart
October 28, 1998 -- The Map Room
David
Amb. Jonas
Amb. Thomas
David
Chris
Heyman
Store
Loftus
de Ferranti
Lovelace
Door
X
X
X
X
X
George
Gro
James
Soros
Brundtland
Wolfensohn
X
X
X
Srdan X
x Jan
Matic
Frank X
Piercy
Loy
Alexander X
X Melanne
Goldfarb
Leon X
Verveer
Furth
X Ken
Paul
X
Bernard
Farmer
X
X
X
Brian
HRC
Donna
Atwood
Shalala
X
X
X
x
X
X
Duff
Andrew
Douglas
Peggy
Chrisoph
Marsha
Gillespie
Weiss
Wake
Hamburg
Lee
Berry
TUBERCULOSIS MEETING
OCTOBER 28, 1998
MAP ROOM
TALKING POINTS
OPENING REMARKS:
I am pleased all of you could come to take part in this
discussion of international tuberculosis control, one of the
most critical and threatening global disease issues of our
day. Looking around the room, it is clear that we have
assembled the talent to help support a coordinated strategy to
deal with TB worldwide.
We all know the statistics concerning the resurgence of this
age-old scourge: 8 million new cases per year over and over
2,000,000 deaths - that's over 5,000 deaths per day. As we
enter the 21st century, TB remains the single largest
infectious disease killer of adults. And most Americans still
believe that TB is a disease of the past.
We have recently been reminded again of how pressing this
problem has become by George, who with his seemingly unlimited
energy and commitment, has highlighted the TB epidemic in
Russia and the other countries in the Newly Independent
States.
And the epidemic in Russia is raising a new issue - multi-drug
resistant TB, which not only will make treatment far more
expensive, but also poses a serious threat outside the region
- a deadly form of disease that can cross borders as quickly
as an international plane flight.
There are no simple answers to the TB epidemic. This is not a
disease that is easily treated with a single antibiotic
prescription or injection. We must look at TB control in the
context of development of quality health care at the community
level. And we need high-level political commitment to ensure
that a "best-practices" approach to control is seen as a high
government priority.
Obviously, funding is critically important to carry out these
important control programs. Also important is the need to
develop broad-based partnerships with other concerned nations,
the private sector, academia, foundations and especially the
2
UN. With a global partnership under the expert leadership of
Dr. Brundtland and W.H.O to carry out the needed TB control,
we can, and will, move to control this killer.
Introduce other speakers:
I would like to turn at this point to Secretary Donna Shalala,
whose national and international leadership in health
promotion and disease control need no elaboration for this
group. She co-chairs the Health Committee of the Gore-Primakov
Commission, and is passionate in her support of the new
leadership of Gro Brundtland at W.H.O.
[Note: Secretary Shalala will likely speak on the
components of international TB control as learned from our
domestic experience. For Russia, she will emphasize the
critical political commitment that can be developed through
the work of the Health Committee of the Gore Commission.
She will touch on countries building a rational national
control strategies and the "Global Stop TB Initiative" of
W.H.O.]
Introduce Brian Atwood, Administrator, USAID
[Note: he will describe the USAID approach to TB
internationally concentrating on broadening the issue to
the NIS and other affected countries. He will note
institutional investments, and may mention the mission of
the Strategic Design Team leaving next month to set up
"Demonstration Sites." in Russia.]
Introduce Dr. Gro Brundtland, Director General, W.H.O.
[Note: She will discuss W.H.O.'s leadership in the "Global
Stop TB Initiative" - including the complex constraints
related to inadequate trained health personnel, inefficient
drug procurement systems, poor political will, and problems
of drug resistance. She will outline the W.H.O. actions.]
3
Introduce James Wolfensohn, President, World Bank
[Note: He will outline the World Bank's interest in the
problem, its past investments, and interests in working in
Russia and other countries with significant TB problems.]
Introduce George Soros.
[We are told that he will support W.H.O.'s lead in dealing
with the global epidemic, and will offer his assistance in
building a global consortium of major institutions and
intergovernmental organizations (such as the EU) to raise
the required funds.]
Discussion. open
CONCLUDING REMARKS:
I am gratified to hear that we seem to have the same basic
approach for dealing with the global TB epidemic. I won't
recapitulate what was said, you all are better than I at
representing your agencies and interests. We have much to do.
With regards to Russia, I encourage the joint CDC/USAID/WHO
Strategic Design Team to report back on what specific
intervention plans will work best. We must help Russia and
the other Newly Independent States develop rational and "do-
able" national plans for TB control and treatment given their
specific circumstances.
Globally, we have an important task laid out before us. Each
of us can contribute to our collective goal of controlling
this epidemic - and doing so by doing what each agency or
organization does best. But we should move forward quickly
and resolutely - working together jointly with a common ideal
of caring for and treating those who are infected, and
stopping the spread of the disease through both community and
international action.
HEALTH& )
THE SECRETARY OF HEALTH AND HUMAN SERVICES
WASHINGTON, D.C. 20201
USA.
AUG 28 1998
MEMORANDUM FOR THE PRESIDENT
SUBJECT: Tuberculosis Epidemic in Russia
Because the tuberculosis (TB) epidemic in Russia is such an important health care issue, I am
providing you with an update and background on its current status and the steps we are taking to
address this significant, world-wide threat to the public health. Also, I have attached talking
points and a brief background paper for your use should the opportunity arise during your visit
to further our recent progress made in combating this deadly disease.
As you know, I have had the pleasure of serving as a co-chairperson, together with the Russian
Minister of Health, on the Health Committee of the Gore-Chernomyrdin Commission. TB
control is a key issue for the Health Committee and many resources of the Department of Health
and Human Services, especially through the Centers for Disease Control and Prevention (CDC),
and the USAID, Department of State have been mustered to assist the Russian government in
fighting this disease. But urgent problems continue that need to be addressed.
First, although Russia has the relatively low-cost drugs that can be used to treat TB, there are
often more TB patients in the prisons and sanitoria than can be treated with the drugs available.
Also lacking is surveillance, laboratory support and the organizational systems and discipline to
see treatments completed.
Second, when the inexpensive, simple antibiotic treatments for TB are not adhered to, are
inadequate or unavailable, a Multi-Drug Resistant Tuberculosis (MDR-TB) may emerge that is
treatment-resistant and requires much more expensive antibiotics. If these are unavailable or are
used in a haphazard fashion, there is substantial risk of developing even more resistant strains of
TB and spreading an airborne epidemic beyond Russia.
We have worked with our Russian colleagues to encourage them to adopt a treatment regimen,
known as Directly Observed Therapeutic Strategy (DOTS), that has been advocated by the CDC
and the World Health Organization (WHO). DOTS entails carefully monitoring patients to
ensure that they take the full course of antibiotics prescribed to eliminate TB. This can be done
in either an in-patient or out-patient setting, but the cost savings of out-patient treatment are
substantial. It is an important world-wide strategy to treat TB that can improve the quality of
care and reduce costs without the need for prolonged institutionalization.
However, some have argued that because DOTS does not require institutionalization, drug
treatment compliance could be lower, which could lead to the emergence of MDR-TB. The
official Russian policy on TB retains the traditional approach of treatment in sanitoria. This is
especially true among local officials where the sanitoria system is a major source of employment.
Page 2 - The President
Seeing both sides of this issue, we have pushed hard, but respectfully, for reform in Russia. I am
especially pleased that the Gore-Chernomyrdin Health Committee has given us a forum to
convince the Minister of Health to adopt DOTS and to make the organizational changes
necessary for its implementation. The cost of adequate treatment of TB in Russia, including
transition to a system of DOTS, remains a challenge but HHS and the State Department are
working with our Russian counterparts to develop a short- and long-term strategy.
One example of our success stems from our convincing the Ministry of Health to adopt DOTS
which paved the way for Mr. George Soros and his grantees to implement DOTS demonstration
projects in Russia. Under this effort, Mr. Soros' Open Society Institute is providing funding to
the New York City-based Public Health Research Institute (PHRI) to implement DOTS pilot
projects in Russia with a focus on the possible emergence of MDR-TB. I would note that the
First Lady is keenly aware of the public health threat of MDR-TB and raised it during a meeting
with Mr. Soros where he was explaining his initiative in Russia
You should also be aware that Mr. Soros' grantee, PHRI, together with the Britain-based
Medical Emergency Relief International and the Belgian-based Medecins Sans Frontieres
(Medicine Without Frontiers) have sent an open letter to President Yeltsin urging that he do more
to combat the spread of MDR-TB, warning that Russia has become the "world's incubator of the
deadly disease." Some Russian conservatives consider these efforts to be a "plot" by western
drug companies to sell Russia expensive pharmaceuticals.
We would suggest a less politically confrontational, more public health approach to this
complicated issue. An approach based on the scientific evidence that DOTS can be a more
effective and lower cost approach to the treatment of TB, especially with respect to the threat of
MDR-TB. We hope that the progress that we have made with the Russian Ministry of Health,
which has made it possible for the Mr. Soros' initiative to occur, can be continued.
As I mentioned above, I am making the attached talking points and briefing paper available to
you should the opportunity arise to further our public health goals of reducing the incidence of
TB, especially MDR-TB, among the Russian people. I have also attached an informative
editorial by Harvard Professor, Howard Hiatt, who argues because of its airborne spread,
resurgent tuberculosis, and MDR-TB in particular, are an even greater threat to society than the
AIDS epidemic. Please let me know if you would like any additional information.
Donn 98hlole
Donna E. Shalala
Enclosures
Tuberculosis Epidemic in Russia
Talking Points
We share your concern about the increased incidence of tuberculosis (TB) in Russia, and
especially the emergence of a particularly dangerous form of tuberculosis, multidrug-
resistant TB (MDR-TB) that cannot be treated with conventional antibiotics.
We understand that MDR-TB is now a particular challenge in the penal system of the
Russian Federation. Prisoners released after even brief stays in crowded prisons may
have acquired the disease and become the source of infection in the community at large.
We in the U.S. have had our own unfortunate experience with drug-resistant tuberculosis.
During late 1985 and early 1990's, we had outbreaks of MDR-TB in hospitals and
prisons, much of which was associated with HIV/AIDS co-infection.
We have committed a substantial level of effort and resources to bring the situation under
control. Only after implementation of treatment methods, such as directly observed
therapy, that are recommended by the World Health Organization and our own Centers
for Disease Control and Prevention, were we able to make real progress in controlling
this persistent disease.
We are aware of the situation in Russia and applaud your recent efforts of the Russian
Ministry of Health and the Chief Administration of Execution of Punishment to
implement international standards of TB control.
We also understand the difficulties you face, both economic and social, in restructuring
the system of TB care.
However, we also are aware that there are successful pilot projects underway in Ivanovo
and Tomsk that are being carried out as part of multilateral and our own bilateral
cooperation.
Based on these experiences, we stand ready to provide technical assistance as you work
towards a nationwide program of tuberculosis control in Russia.
Russia's Health Care System and Condition
Serious shortcomings in Russia's health system and disease profile threatens the country's ability
to provide adequate public health services to the Russian people, and for some diseases, poses a
cross-border threat to the health of other nations, including the United States. While many
general health statistics have improved modestly in the last two years, including life expectancy,
alarming increases are evident in rates of STDs, HIV and TB.
Between 1990 and 1997, the incidence of syphilis has increased from 5.4 per 100,000 to 216.9
per 100,000 - an increase of nearly 5,000%. Gonorrhea is increasing rapidly as well, and what
shocks health officials and local leaders is that many of those infected are under the age of 20. In
1987, Russia had 24 recorded cases of HIV. By the first half of 1998 there were close to 8,700
cases of HIV and 300 AIDS deaths reported. Outside estimates are much higher, but even the
Russian Duma estimated that Russia can expect at least one million cases of HIV in the coming
years, with which the health and economic system will be unable to cope. The rise in TB cases
has been dramatic, with civilian notifiable cases increasing from 36 per 100,000 in 1992 to 75
per 100,000 in 1996; particularly worrisome is the level of multiple-drug resistant TB which is
estimated at 7.3% of all civilian cases, posing a distinct threat beyond Russia's borders. The TB
situation in prisons is far worse.
The health system suffers from low and underfunded health budgets, poor performance of the
mandatory health insurance program in collecting premiums, and the lack of a legal framework
for the private provision of health care despite survey findings indicating that upwards of 40% of
health expenditures are out-of-pocket. The work of medical providers suffers from a lack of
evidence-based medicine and quality improvement in all aspects of healthcare, especially
diagnosis and treatment protocols.
Nonetheless, successful dialog between U.S. and Russian health experts through the bi-lateral
commission initiated by Vice President Gore, and effective use of USAID foreign assistance
contributions are evident. Since 1992, the U.S. has provided over $95 million to address a broad
range of health issues important to Russia such as immunization, women's reproductive health,
pharmaceutical investment and quality control, environmental health, and health information and
response activities. Approaches involving partnerships between U.S. and Russian organizations
have been successful at the local level and, in one program's case, has led to U.S. private
contributions of time and equipment estimated at $45 million over the last four years. Attempts
at strengthening the role of non-governmental organizations in the delivery of public health
information and services health field requires more attention.
Tangible results are evident from the U.S.-Russian cooperation. For example, an estimated three
million Russian couples now have access to safe and effective family planning services, and U.S.
assistance has been credited with bringing down abortion rates. Yet, controversy about family
planning has increased from the political right and from some religious groups. The Yeltsin
administration wants to continue U.S.-Russian cooperating on reproductive health programs, and
expand into improvements in maternal and neo-natal health. Russia is also working with the
U.S. on a national initiative to improve the quality and access to health services, and a multi-year
strategy aimed at STD/HIV prevention and control. A design effort for USG assistance in TB
control is scheduled for Fall 1998.
More Deadly Than AIDS
Howard Hiatt
Washington Post
August 14, 1998
Many Americans think that with the discovery of streptomycin more than 50 years ago, the
tuberculosis problem was solved. But a little-noticed (in the United States) TB epidemic now
kills 3 million adults a year worldwide, more than AIDS or malaria. Even more threatening is the
increasing appearance around the globe of forms of TB that are resistant to streptomycin and
many other drugs that have been used to treat the disease.
Almost every person with the common variety of TB can be cured with two to four medications
daily for at least six months at a total cost of about $100. In recent years the World Health
Organization, with support from the World Bank, has treated drug-sensitive TB in many
countries with a very effective strategy that involves supervised administration of the drug over
the prescribed period.
But when TB sufferers are treated inadequately, that is, when they don't have all the required
drugs or don't take them long enough, mutant TB bacteria that are more resistant to the drugs
grow. Patients may feel better temporarily, but what was a curable condition can become a death
sentence. And their now multidrug-resistant (MDR) TB bacteria infect others.
MDR TB can often be cured, but at a cost eight to 80 times higher than that of treating ordinary
TB. Until a few months ago that cost led to the view that treatment of MDR TB in resource-poor
countries was not "cost-effective." But Paul Farmer and Jim Kim, two physician- anthropologists
who divide their time between work at Harvard Medical School and Brigham and Women's
Hospital, on the one hand, and the poorest areas of Haiti, Peru and Mexico, on the other, have
changed that.
In the barrios of Lima, where they have been involved in community-building for five years,
they recognized that treating only patients with drug-sensitive TB, the most prevalent kind, could
encourage the spread of MDR TB.
Even more important, they regard treatment for MDR TB as the right of all its victims. Finally,
they know well that infectious diseases respect no border and that their spread to the rest of the
world is more than a threat. In fact, an American priest who recently died of MDR TB in Boston
had come there from service in the barrios of Lima.
Therefore, they began treating almost 100 of the many desperately ill patients with MDR TB in
Lima with five or more drugs daily over a period of two or more years.
More than 85 percent appear to have been cured. Farmer and Kim ascribe a large part of their
success to their partnership with community members whom they have trained to ensure that
every patient takes every dose of every medication every day. The cost has been great (although
1
much, much less than the cost in a U.S. hospital), but they have thus far succeeded in obtaining
the needed drugs, partly by going into debt.
Earlier this year tuberculosis specialists from around the world gathered at the American
Academy of Arts and Sciences and examined and then endorsed the preliminary Lima evidence.
Subsequently, the World Health Organization decided to replicate. the Lima experiment in a few
other sites around the world that it has designated MDR TB "hot zones."
Thanks to the generosity of George Soros, the first such sites will be in Russia and Latvia, where
MDR TB is prevalent and spreading rapidly. The Soros foundations have committed to pay for
programs there. But if the worldwide epidemics are to be contained, many more groups must be
mobilized. The World Bank, national governments -- particularly those of industrialized nations
-- the pharmaceutical industry, other business leaders concerned with international trade,
scientists and others all can play crucial roles in a program to wipe out all forms of TB.
The AIDS pandemic has appropriately aroused the concerns of people around the world. The
tuberculosis pandemic requires no less. Because it is spread much more readily than AIDS -
through the air that everybody may breathe -- it represents an even greater threat.
The writer, a professor of medicine at Harvard, is director of the Initiatives for Children Program
of the American Academy of Arts and Sciences.
c Copyright 1998 The Washington Post Company
2
AID
U.S. AGENCY FOR
INTERNATIONAL
DEVELOPMENT
MEMORANDUM
TO:
WH/OFL, Melanne Verveer
FROM:
Acting AA/ENI, Donald L. Pressley Dm
SUBJECT: Tuberculosis in the ENI Region
In response to my conversations with Mrs. Clinton during our recent trip to Eastern Europe,
please find below a summary of USAID's tuberculosis activities in Europe and the New
Independent States (ENT).
Following a general decline in the incidence of tuberculosis (TB) prior to 1991, rates have
risen dramatically since then. With a continuing breakdown of the health systems in the
troubled economies of the NIS, most countries continue to follow a very cost-inefficient TB
control strategy involving active case-finding, regular chest X-rays, excessive skin testing and
immunizations, and a well-entrenched, costly sanitoria network. USAID is assisting in
reorienting the TB control effort in the region through: pilot efforts on the WHO
recommended directly observed therapy, short course (DOTS); strengthening
epidemiological monitoring and surveillance; more rational pharmaceutical management,
including appropriate prescribing practices and pharmaceutical procurement; and
strengthening health care delivery systems.
In addition, USAID awarded a first tranche of funding to the Department of Health and
Human Services (DHHS) to create an ENI regional TB working group to include expertise
from WHO, SOROS and other entities to address TB in the region. The working group will
help define the barriers to acceptance and adoption of DOTS in the NIS and will recommend
activities necessary to overcome the barriers.
A. TUBERCULOSIS IN RUSSIA
As you know, since the collapse of the ruble and the banking system in Russia, the State
Department (S/NIS/C) and the NSC have been closely tracking the TB and pharmaceutical
situation in Russia, and have discussed the possibility of humanitarian assistance to respond
to particular needs. TB in Russia, however, is not responsive to short-term humanitarian
assistance. The number of notifiable cases of TB in Russia has more than doubled over the
past six years, from approximately 35/100,000 population in 1992 to approximately
1300 PENNSYLVANIA AVENUE, N.W.
WASHINGTON, D.C. 20523
202 647 9973 P.03
USAID
ES:9T
2
75/100,000 population in 1998, according to the Ministry of Health (MOH) and WHO.
Russia's TB rates are among the highest in Europe. Rampant TB rates in prisons continue to
serve as a source of infection for the civilian population and multi-drug resistant forms of the
disease are on the increase. These two factors have emerged as major threats to successful
control of the epidemic. Mortality due to TB in the general population is about 17 per
100,000 population, while in the prison population it is estimated to be as high as 484 per
100,000 population.
Russia continues to follow outdated diagnostic and treatment practices. Efforts by the USG,
Soros and other donors to modify those practices, are showing some positive results. But TB
in Russia is a complex problem, for which there is no clear or short term fix. Progress
towards adoption of modern methods is constrained by a range of difficult economic,
political, institutional, psychological, ethical, social and logistical impediments.
In an effort to position itself to respond to the growing crisis, USAID/Moscow commissioned
a study to examine the availability of and procurement methods for first-line TB drugs in
Russia. The September 1998 report indicates that: a) the first-line anti-tuberculosis (TB)
drugs are all available on the Russian market; b) that Russian drug manufacturers increased
production of first-line TB drugs by 50% during 1997 and now claim to have sufficient
production capacity to satisfy 100% of the country's need for these first-line TB drugs for
1998; but c) chronic shortages nevertheless exist due to perpetual problems with raw
materials, procurement, distribution, affordability, and stock management. An emergency
drop of TB pharmaceuticals is not needed now and would complicate or even worsen the
situation, since the system is not prepared to properly handle a DOTS program.
Nonetheless, USAID/Moscow will continue to monitor the situation.
Programs Underway
Because of the risk of promoting multi-drug resistant TB, there is a growing recognition that
"doing DOTS badly is worse than doing nothing at all." It is absolutely critical that Russia
have in place a sensible and comprehensive plan and adequate implementation capacity to
support a DOTS program before drugs are distributed and treatment activities are initiated.
USAID and the Centers for Disease Control (CDC) are moving quickly and responsibly to
develop a plan to deal with the current crisis.
With S/NIS assistance, USAID set aside in FY98 $1.5 million of Freedom Support
Act (FSA) funding for TB efforts in Russia. In November, USAID and CDC will
begin a TB assessment and design effort to identify likely sites for a multi-year TB
program. It is envisioned that the USAID/CDC program will support pilot,
community-based activities which complement and build on the work supported by the
Soros Foundation and other bilateral donors. Because of statutory limitations, USAID
and CDC expects to focus on civilian (not prison) populations. The programs will
P.04
3973 647 202
DIASN
ES:9T
3
institute a "DOTS-Plus" strategy (including food supplements and other inputs besides
TB drugs) while tracking the prevalence of multi-drug resistant TB.¹
A one year hospital partnership (funded by USAID) between the University of
Arkansas, School of Medical Sciences and the Volgograd State Medical Academy is
initiating modern standards for tuberculosis diagnosis, treatment, and case
management in a very limited way. All new health partnerships under the American
International Health Alliance (AIHA) will explicitly include TB in the initial needs
assessment.
The American College of Physicians in collaboration with DHHS is working on a
pilot effort to integrate TB into other quality and primary care initiatives..
For other donors working on TB programs in Russia, please see attached matrix, "Summary
of Donors' Tuberculosis Programs in the Russian Federation as of October 1998.
B.
TUBERCULOSIS IN CENTRAL ASIAN REPUBLICS (CAR)
Central Asia has seen a three to four fold increase in tuberculosis since the early 1990's.
Although a number of other countries have TB rates higher than those found in CAR, the
situation is still grave because of the often incurable form of the disease multi-drug resistant
TB. USAID, Chevron and other donors, in a unique public-private partnership, are funding
a TB initiative in CAR, and the results are just beginning to surface.
Programs Underway
Chevron Munaigas funded Project HOPE to introduce DOTS at pilot sites in Kazakhstan in
1994. Chevron also delivered a TB mobile clinic to Almaty Oblast, with transportation costs
covered by the Department of State.
In 1997, USAID/CAR started its "TB Initiative", in collaboration with Chevron, building
upon on-going health reform efforts. The implementing team includes Abt Associates, Project
HOPE, and CDC - a collahorative public-private partnership which has worked extremely
well in the region. Broad objectives have been to update the existing TB diagnostic,
treatment and control practices in the region through demonstration pilot sites in Kazakhstan
and Kyrgyzstan. Activities include: developing national TB education campaigns; training
health care professionals; supporting and monitoring DOTS pilot projects in Almaty (81
patients) as a model for national expansion; strengthening TB epidemiology and surveillance;
and analyzing the cost-effectiveness of DOTS.
1 It should be noted, however, that Russian-Iran legislative directives, if enacted, will dramatically
constrain the flexibility and scope of this program both at the federal and community levels.
202 647 9973 P.05
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4
Because of USAID's TB initiative, in May 1998, the President of Kazakhstan, Mr.
Nazarbaev, signed a decree to implement DOTS nationwide. Some funding has been
allocated and momentum is apparent in the MOH. Supported by all the donors in the region,
a development plan for the National TB Control Program has been finalized to implement
DOTS at limited pilot sites which will act as centers for training for the rest of the country.
Thus far, USAID has committed $1,980,000 of FSA funding for the program. Through
collaboration with the World Bank, TB activities will be expanded to additional oblasts in
Kazakhstan and Kyrgyzstan over the next few years. In 1999, subject to availability of
funding, elements of the program will be expanded to Tajikistan, Turkmenistan and
Uzbekistan. Other organizations involved in or exploring TB-related activities in Central
Asia include AMOCO, Lutheran Ministries, Medecins sans Frontiers-Luxenburg, Philip
Morris, SOROS and the University of Wisconsin.
Although too early to measure impact, TB initiatives accomplishments in CAR to date
include: training of 385 physicians and other health workers in DOTS therapy, laboratory
methods, drug supply and logistics, and health surveillance; provision of modern laboratory
equipment and supplies for smear microscopy to three demonstration sites; initiating an
information campaign including two press conferences on TB in Kazakhstan and two TV
videos which are shown on national and Almaty TV; and ongoing policy dialogue on costs
and laws concerning TB prevention, diagnosis and treatment.
C.
TUBERCULOSIS IN OTHER AREAS OF THE ENI
Caucasus:
The Mission is currently revising their health strategy and will explore possible
TB initiatives.
Ukraine:
During the period 1990-1996, the TB rate in Ukraine increased by 45 percent
and the MOH states that the country now has 45.8 people per 100,000 infected with TB.
The Mission in Ukraine is exploring TB initiatives in conjunction with a future primary
health care strategy.
Kosovo:
USAID's Office of Disaster Assistance (OFDA) has provided about $696,000
to Doctors of the World to provide food and hygiene parcels for TB patients and their
families as incentives to increase treatment compliance in collaboration with a Swedish and
multi-donor funded screening and treatment program in Kosovo. Over 4,000 TB patients
have benefitted from this program. Initial results show a significant increase in the patient
compliance rate. As peace plans begin to take effect, USAID will continue to review the
status of TB in Kosovo especially when developments programs become more regular.
90'd 51.66 109 7.07
(THSN
DC:91 866I-97-100
LOS ANGELES TIMES
MONDAY. FEBRUARY 16, 1998
B5
An Ancient Marauder Looms Again
Tuberculosis: The fight
control programs misuse antibiotics and
which the U.S. contributes only about
ineffectively treat patients, practices that
$500,000. WHO estimates that, in addition
against it must be global as
foster drug-resistant strains. These MDR-
to commitments from developing countries,
drug-resistant strains spread.
TB "hot-zones" pose a grave threat to glo-
$100 million more is needed annually to
bal health, as international travel and
control the epidemic and prevent the
migration put all areas of the world in close
spread of MDR-TB. Surely, Americans
By RALPH NADER
contact.
would be willing to foot some portion of that
and R. GORDON DOUGLAS
Few people recognize the danger that
bill to prevent a disease that WHO's Rich-
MDR-TB poses to Americans. It is very
ard Bumgarner called "Ebola with wings"
For the first time since the introduction
difficult and expensive to contain, and the
from descending on our shores.
of anti-tuberculosis drugs in the 1950s, the
industrialized world is by no means
world faces the threat of incurable TB, a
immune. Since 1991, when these strains
Congress has approved additional money
disease that destroys the lungs, dooming its
were found in only 13 states, MDR-TB has
for the Agency for International Develop-
ment, which channels funds to WHO, to
victims to drown in their own blood. This
spread to 42 states and the District of
combat infectious diseases worldwide. If
deadly infection is airborne; it spreads like
Columbia. In September, a new strain of
only the Clinton administration would fol-
the common cold. Worst of all, highly
highly contagious TB that multiplies at
low through more comprehensively. Some
resistant strains have been discovered in 34
1,000 times the normal rate was identified
of the proposed new funding for biomedical
countries by the Global Project on Anti-TB
along the Tennessee-Kentucky border.
research and for the National Institutes of
Drug Resistance.
Transmission of tuberculosis can occur
Health also should be channeled into TB
If tuberculosis were a newly emerging
anywhere, from planes to schools to neigh-
research. Furthermore, the U.S. must pay
disease rather than an ancient marauder, it
borhood bars. In 1994, a South Korean
its dues to the United Nations if WHO is to
would be making headlines almost daily.
woman with MDR-TB infected four Amer-
be effective in fighting TB and other such
However, in the four years since the World
icans on a plane.
deadly diseases. Unless this funding is sus-
Health Organization declared TB a global
The importation of TB across interna-
tained over the long term, TB programs will
emergency, there has been little interna-
tional borders is very common. In this
be ineffective, treatment of patients will be
tional alarm. Inexpensive, generic medica-
country, 37% of TB patients are foreign-
incomplete and our temporary good inten-
tions have long existed to cure tuberculosis,
born, 25% of them from one of four "hot
tions will only fuel the spread of drug-
yet 3 million people die each year, making
zones": India, Korea, Vietnam and the
resistant strains.
TB the greatest infectious killer world-
Dominican Republic. In the Dominican
wide, responsible for one-fourth of the
Republic, where 9% of TB cases are MDR,
The only way to protect Americans
world's preventable deaths.
one out of every seven residents has
against multi-drug-resistant tuberculosis is
In October, an unprecedented report
obtained a visa for travel to the U.S.
to support effective treatment and control
released by top U.S. and international
The U.S. learned a harsh lesson when the
programs that prevent MDR-TB from
health agencies issued the ultimate warn-
dismantling of TB control infrastructure in
developing. It is a war that must be fought
ing: Multi-drug-resistant strains of tuber-
the 1980s led to sharp increases in tubercu-
internationally, before this country
culosis (MDR-TB), which can be virtually
losis. According to New York City's director
becomes a primary TB battleground.
untreatable, have emerged worldwide and
of TB control, the explosion of MDR-TB
threaten to overwhelm the public health
required more than $700 million between
Ralph Nader and Dr. R. Gordon Douglas
systems of India, Russia, Latvia, Estonia,
1992 and 1996 to quell the outbreak.
are on the steering committee of the Prince-
Argentina, Ivory Coast and the Dominican
The World Health Organization spends
ton Project 55 Tuberculosis Initiative of
Republic. In these countries, poor TB
$11 million annually on TB control, of
Princeton University's Class of 1955.
21/oct/98
Health
IV
TUBERCULOSIS
GARE-PRIMIKOV
Summary of Situation
In Russia, as in much of the former Soviet Union, tuberculosis (TB) cases have increased
dramatically in recent years. In addition, multi-drug resistant (MDR) TB which does not
respond to conventional treatment has emerged. MDR-TB has spread in environments
such as prisons and hospitals, and threatens TB control efforts since the costs for treating
MDR-TB are 100 fold-higher than for treating non-resistant TB ($3000/case versus
$30/case). The problems have emerged because of unstable drug supplies and reluctance
of the medical establishment to use the simple, effective strategy known as DOTS that
consists of five elements that include government commitment, appropriate methods of
TB diagnosis, an adequate supply of quality drugs, supervised administration of these
drugs, and careful monitoring of treatment outcomes. This approach is used in the U.S. as
well in more than 100 other countries. Unless the TB problem in Russia is dealt with
immediately, drug resistance due to poor treatment practices will continue to develop and
spread in the community, making TB virtually untreatable.
U.S. Activities to Date
TB has been considered as an important disease by the Health Committee of the Gore-
Primakov Commission. At the request of the Department of Health and Human Services,
CDC has participated in the committee's TB activities, which until now have been limited
because of availability of resources and resistance at the national level in Russia to institute
meaningful changes in national TB policies. CDC activities to date have included a series
of visits to Russia in which meetings were held with national counterparts for the purpose
of discussing possible collaboration. In addition, CDC planned and hosted a U.S. study
tour of TB experts from the leading TB institute in Russia in February 1997 to see the
U.S. TB strategy in action in a variety of settings. Although CDC has been involved in a
number of TB projects in the Central Asian Republics and the Baltics, direct involvement
in Russia has been limited. Recently, however, USAID in Moscow has recognized the
importance of the problem and is planning on providing mission funds for a three year
period to CDC for the development of one or more pilot projects.
PHRI/Soros Activities
In September 1998 CDC staff conducted a joint visit with members of the Public Health
Research Institute/Soros Steering Committee to examine their activities in the civilian and
prison populations in the Tomsk Oblast and a TB prison in the Kemerovo Oblast.
Public Health Research Institute (PHRI) of New York City has received a $12 million
grant from the Soros Foundation (Open Society Institute, OSI) to undertake projects
aimed at reform of tuberculosis control in the Russian Federation (RF). Dr Alex Goldfarb,
9
a senior scientist in PHRI, serves as the director of the project. After one year of
operation, PHRI has joined DOTS demonstration projects in the civilian sectors in
Ivonova (initially supported by WHO) and Tomsk (supported by the British NGO,
MERLIN), strengthening laboratory capacity and entering into contracts with local
authorities to achieve cost savings by reducing the number of TB hospital beds and of
unproductive TB screening activities. For assistance in training, project monitoring, and
surveillance/reporting, PHRI is working with the Central TB Research Institute (Prof
Alexander Khomenko) in Moscow. PHRI is also supporting a DOTS project initiated by
MSF/Belgium in a TB prison in Mariinsk (Kemerovo) and has begun DOTS projects in
four other prisons (Tomsk, Ivonova, Mari-El, Vladimir and Nidzy-Novgograd). Based on
information available to CDC, it appears that the DOTS projects in the civilian sectors,
where rates of initial MDR-TB appear to be relatively low, are succeeding. However,
failure rates has high as 40% have been found in the Mariinsk prison, likely because of an
equivalent rate of MDR-TB in new patients beginning treatment. Clearly, in such a setting
a DOTS-alone approach may be inadequate. As a next step, PHRI intends to implement a
DOTS-plus project in Tomsk (both the civilian and prison sectors). With project funds
now fully committed, PHRI is looking for other partners and funding sources. to expand
DOTS-plus programs in regions where it is working and extend DOTS implementation to
other regions in RF.
U.S. Planned Activities
Beginning November 15, CDC will detail a public health advisor to Moscow for a 4 to 5
week period to assist the USAID Mission in the development of a TB in Russia
Background/Strategy Document.
In late November, a joint CDC-AID team will visit Russia to perform an assessment of
three areas to determine which area would be most suitable to serve as a demonstration
site for CDC-guided TB control project activities. This multi-disciplinary team will
consist of a senior epidemiologist, a TB laboratory specialist, a senior public health
advisor and an experienced program management officer. One of the sites to be visited,
the Kemerovo Oblast in Siberia, has expressed a strong interest in introducing the basic
DOTS strategy in the civilian population (Medecins Sans Frontieres, Belgium is already
working successfully in the main prison). The second site, the Ivanovo Oblast near
Moscow has been used as a pilot area by the World Health Organization and has one of
the two most developed DOTS programs in Russia. In this oblast, the U.S. contribution
would be the development of a strategy to identify and cure the MDR-TB patients who
are not cured by the routine DOTS approach. The third area under consideration is the
Novgorod Oblast which is said to have a progressive governor and chief TB doctor, and
has allegedly indicated it's willingness to provide an adequate supply of required TB
drugs. If successful, a demonstration project would serve as model for other oblasts in the
country. It is hoped that if success is demonstrated in various oblasts, the other oblasts
10
which are still expressing considerable reluctance to abandon old treatment strategies will
be willing to change to the DOTS approach.
Major Obstacles
1.
The amount of money that is being made available at the USAID mission is
inadequate to fully support the proposed activities.
2.
Current U.S. government restrictions on the ways in which money can be spent in
Russia may limit the usefulness of available monies. At least part of the potentially
available mission funds cannot be spent on activities benefitting the national,
oblast, or local governments or on salary support for Russian nationals).
3.
For these projects to be conducted successfully, USAID money must be spent (or
other sources must be located) to pay for drugs. Although the need for the
expensive MDR TB drugs may diminish over time if the program is successful, the
need for basic TB drugs will remain, and it appears unlikely that the oblast or
national governments will be able to bear these costs in the next several years.
4.
Sustainability of efforts beyond the duration of the project may be difficult unless
the financial situation of the country undergoes dramatic improvement.
Coordination Meeting on TB in Russia, 15 October, 1998
At a meeting convened last week (15 October, 1998) by the Office of the Coordinator for
NIS Assistance, the group, including Drs. Hamburg and Eisenberg, explored several ideas
that were later discussed with Dr. Helene Gayle at CDC. The demonstration projects
described above will be most effective in the long run, if they are combined with the
following initiatives:
1.
The setting of a national framework and establishment of an environment for
broader adoption of improved care patterns (especially if the demonstrations can
show the effectiveness of "best practices"). This would likely be done with Russian
TB leaders, oblast leaders, medical education and professional leaders, and
political leaders. This should be linked with the American International Health
Alliance (AIHA) and American College of Physicians (ACP) projects, and
integrated with the Health Committee's quality and primary care initiatives.
2.
The building of capacity to care for patients with TB outside sanitoria and prisons.
This means upgrading the ability of hospitals and polyclinics to care for TB
patients, especially once they have been successfully started on treatment and can
be sent into community-based DOTS programs (more difficult, obviously, with
11
MDR-TB).. This can be done in conjunction with the ACP project, perhaps with
other Health Committee efforts to help upgrade primary care and polyclinics.
3.
The building of capacity in laboratories for testing TB sensitivities and for assisting
clinicians in the selection of appropriate treatment, combined with laboratory
support for a more extensive surveillance system to identify the disease burden and
to characterize the epidemic better. Dr. Hamburg emphasized this as having been
very important in New York City's success in reducing MDR-TB.
4.
The identification of the Russian drug availability situation. Funds should be
considered to assist the broader distribution and delivery of drugs, some of which
are already in Russia but are not being used. A combination of the lack of money
to buy pharmaceuticals, poor health sector organization for their distribution to the
areas most in need, and the lack of knowledge or commitment to use the drugs
appropriately, as well as other factors, contribute to this problem.
These efforts will be very expensive, but the Health Committee should take advantage of
the attention this is getting to emphasize that one can't do demonstration projects without
building reform of TB care into the public health infrastructure, improving the
community-based care, and paying attention to quality of care. Depending on the
intervention, these could be done either in the demonstration regions, in the nation as a
whole, or as part of other donor and collaborative programs (eg, the Access to Quality
Care Initiative, AIHA). It should also be linked with the Soros initiative, of course.
The challenge is how to do the demonstrations with the little money available to the
Health Committee, and to have concrete and near-term products and achievements, yet
offer a broader scope of ideas that focuses those who may direct more funds toward the
program on the full spectrum of components of the initiative if it is to be long lasting.
V
MATERNAL CHILD HEALTH
The USAID Women's Reproductive Health Project
This project has continued its roll-out and institutionalization activities. A team recently
left Russia after developing a strategy for the next 3-4 years which will expand current
work in the area of women's reproductive health to Women's and Children's Health. New
efforts will include work in policy development, NGO development; research; and
information, education, and communication activities.
1.
To date, six of the eight roll-out sites have received contraceptive technology
update trainings and four have received contraceptive shipments. Training in the
12
cc Melame
OPEN SOCIETY INSTITUTE
S
I
GEORGE SOROS
Chairman
20th August 1998
ARYEH NEIER
President
Mrs. Hillary Rodham Clinton
The White House
Washington D.C. 20500-2000
Dear Hillary,
You told me at our last meeting of your interest in the problem of tuberculosis in Russia.
As you noted, explosive prison epidemics in Russia are fueling the larger national epidemic;
these outbreaks are, of course, not contained by national boundaries. I am very pleased that
Dr. Gro Brundtland of the World Health Organization has underlined the importance of U.S.
leadership in addressing this global emergency.
We have started a program to address TB in Russia through the WHO-endorsed control strategy
of directly observed therapy or "DOTS" which cures sensitive TB and prevents new multiple
drug-resistant TB from developing. We have received requests to support programs from our
foundations in such countries as Kazakhstan, Kyrgyzstan, and Azerbaijan which are currently
under consideration.
Since we initiated this work a year ago, we have discovered that the problem is considerably worse
and more difficult than we imagined. My concerns fall into two main areas: MDR-TB, and other
impediments to the adoption of the DOTS approach.
First, the situation is greatly complicated by the multidrug-resistant strains of TB which are not
effectively treated through the DOTS approach. The World Health Organization last month
endorsed a "DOTS-Plus" strategy which addresses drug resistant treatment in circumstances such
as those found in Russia. Since we met, I have directed our TB team to adopt this expanded
approach in order to save lives and halt epidemics already underway.
This enhanced approach is significantly more costly than the simpler "DOTS" approach. This
expansion will require additional funding, though far less than the cost of ignoring these drug-
resistant strains. While I am prepared to commit some additional funds to TB, I have become
convinced that the problem can be addressed only with the coordinated and solid financial
commitment of a wide range of international, bilateral and private donors.
Second, as our programs develop in Russia, we have encountered a range of economic, political,
social, and logistical impediments to the adoption of the WHO/DOTS strategy. Similar
impediments exist in other countries as well. We appreciate that failure to overcome these issues
could jeopardize our investments in TB control, but simple solutions are not readily available.
This is an issue you may want to raise in connection with your visit to Russia in September.
400 West 59th Street, New York, New York 10019
Phone: 212. 548. 0600
Fax: 212. 548. 4679
Website: http://www.soros.org
Hillary Rodham Clinton
20th August 1998
Page 2
I understand that the WHO is currently considering undertaking a global TB program. I have
written Dr. Brundtland a similar letter, and would like to find ways to work with them. A handful
of key players-yourself, Dr. Brundtland, Jim Wolfenson of the World Bank, for example-could
make all the difference if we act promptly. It is my hope that we can join together in calling for the
sustained international attention and funding that could contain outbreaks in the former Soviet
Union and elsewhere. The United States has a critical and new role to play in confronting public
health threats outside of its borders. I look forward to hearing from you on this important issue.
Yours sincerely,
George Soros
Fax :212-2627580
Sep 23 '98 15:08
P. 03/14
OPEN SOCIETY INSTITUTE o
S
GEORGE SOROS
20th August 1998
Chairman
ARYEH NEIER
President
Dr. Gro Brundtland
World Health Organization
Geneva, Switzerland
Dear Dr. Brundtland:
I understand that the WHO is currently considering undertaking a global program to address the
problem of tuberculosis. As you may know, my foundations have started a program to address
TB in Russia through a DOTS based approach. We have received requests to support programs
from our foundations in such countries as Kazakhstan, Kyrgyzstan, and Azerbaijan which are
currently under consideration.
Since we initiated this work a year ago, we have discovered that the problem is considerably worse
and more difficult than we imagined. My concerns fall into two main areas: MDR-TB, and other
impediments to the adoption of the DOTS approach.
First, as you are well aware, the situation is greatly complicated by the multidrug-resistant strains
of TB. We were very pleased to learn that the WHO last month endorsed a "DOTS-Plus" strategy
addressing drug resistant treatment in circumstances such as those found in Russia. I have since
directed our TB team to adopt this expanded approach in order to save lives and halt epidemics
already underway.
Unfortunately, we realize that this enhanced approach is significantly more costly than the simpler
"DOTS" approach, and will require additional funding, though far less than the cost of ignoring
these drug-resistant strains. While I am prepared to commit some additional funds to TB, I have
become convinced that the problem can be addressed only with the coordinated and solid financial
commitment of a wide range of international, bilateral and private donors.
Second, as our programs develop in Russia, we have cncountered a range of economic, political,
ethical, and logistical impediments to the adoption of the DOTS strategy. Similar impediments
exist in other countries as well. We appreciate that failure to overcome these issues could
jeopardize our investments in TB control, but simple solutions are not readily available.
I am hopeful that the WHO will decide to undertake a global plan to control TB. I would like to
find ways to work together in addressing this public health emergency, I have spoken with Hillary
Clinton about this problem, and have written her a similar letter. A handful of key players--
yourself, Hillary Clinton, Jim Wolfenson of the World Bank, for example--could make all the
difference if we act promptly. 1 look forward to discussing this important matter with you in the
near future.
Personson Yours sincerely,
George Soros
400 West 50th street, Ngw YOUR. New York 1000
Phone 211. 548. 11600
Tax 212 518 16/9
Withhite hip I/www
Fax :212-2627580
Sep 23 '98
15:09
P.04/14
OSI-LED INITIATIVE TO ERADICATE
TB
AUGUST 1998
"The two largest TB NGOs, KNCV in The Netherlands, and the International
Union Against TB and Lung Disease, have a combined budget for fighting TB of
just over $10 million. Last year, the Wellcome Trust announced it could provide
over $2 million to determine the complete sequence of the genome of the tubercle
bacillus. Unfortunately, most of the largest foundations, such as Ford,
Rockefeller, Kellogg and Pew, and the largest health and development NGOs,
such as CARE, Save the Children and Oxfam, remain conspicuously absent in the
battle against TB."
BASIC TENETS OF THE OSI-TB INITIATIVE
Tuberculosis remains the single largest infectious contributor to adult
mortality in the world today.
Increasing globalization of economies demands a global response to the TB
pandemic.
An effective and concerted response demands not only the leadership of the
medical and scientific communities, but also the full participation of the
private sector, including international trade and finance.
JUSTIFICATION FOR OSI INVOLVEMENT IN GLOBAL TB CONTROL
George Soros is the single largest individual donor to. TB control in the
world today.
The regions in which the Network of Foundations is established- from the
former Soviet Union to South Africa- are those in which TB is endemic or
recrudescent; these regions are particularly hit hard by drug-resistant TB.
The OSI brings two critical and previously missing components to TB
control: a human-rights approach and new leadership from the business
OSI-TB INITIATIVE
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sector, previously a minor player in the TB community. Furthermore, the
geographical reach of the Network of Foundations is unparalleled and the
OSI would bring significant experience to the containment of prison-related
outbreaks.
OSI-TB INITIATIVE
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JUSTIFICATION FOR CHOICE OF PARTNERING INSTITUTIONS AND
COMPOSITION OF ADVISORY BOARD
The organizations identified as potential partners in an OSI-led TB eradication
effort are the major participants in global TB control. The Advisory Board
would bring together the leaders of these organizations, as well as key players in
international public health. Others will no doubt be identified.
PROPOSED ORGANIZATIONS
PROPOSED ADVISORY
BOARD REPRESENTATIVE
AMERICAN ACADEMY OF ARTS AND SCIENCES
HOWARD HIATT
CARTER CENTER
WILLIAM FOEGE
CENTERS FOR DISEASE CONTROL AND PREVENTION
HELENE GAYLE
HARVARD MEDICAL SCHOOL
PAUL FARMER
INTERNATIONAL UNION AGAINST TUBERCULOSIS
NILS BILLO
AND LUNG DISEASE
KNCV, HOLLAND
KITTY LAMBRECHT
LONDON SCHOOL OF HYGIENE AND TROPICAL
JOHN PORTER
MEDICINE, UK
MEDICAL RESEARCH COUNCIL, SOUTH AFRICA
BERNARD FOURIE
NATIONAL JEWISH MEDICAL AND RESEARCH
MICHAEL ISEMAN
CENTER
NATIONAL TUBERCULOSIS CENTER &
LEE REICHMAN
PUBLIC HEALTH RESEARCH INITIATIVE
RESEARCH INSTITUTE OF TUBERCULOSIS,
AMAN ZHANGIREEV
KAZAKSTAN
OSI-TB INITIATIVE
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PARTNERS IN HEALTH
JIM YONG KIM
ROCKEFELLER FOUNDATION AND THE
LINCOLN CHEN
HARVARD SCHOOL OF PUBLIC HEALTH
UNIVERSITY OF ALABAMA
MICHAEL KIMERLING
WORLD HEALTH ORGANIZATION
ARATA KOCHI
OSI-TB INITIATIVE
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WHAT ARE THE GOALS OF OSI-TB?
OSI-TB would not seek to replicate existing TB-control structures, nor would it
seek to act alone in inaugurating new TB treatment and control efforts. Rather,
OSI-TB would seek to fill in gaps:
Leadership gaps must be filled if truly global efforts are to progress. OSI-TB
would have a special focus on leadership from business sectors, including
international finance, the pharmaceutical industry, and philanthropies; the
human-rights community would also be engaged.
Gaps in political will must be filled if government support for national
DOTS-based programs, including "DOTS-Plus," are to have real impact on
the global TB pandemic.
Gaps internal to the TB community have neglected critical developments-
MDRTB and prison-centered outbreaks of TB- that threaten the hard-won
gains of global TB control.
Funding gaps will be filled not through direct OSI contributions, but rather
through coalition building to channel new resources into priority TB-
control efforts.
How WOULD OSI-TB WORK?
OSI-TB can make have an enduring impact on global TB control through a
four-step process:
1.
Forge a powerful consortium of actors and institutions, led by an expert
Advisory Board.
2.
Convene a meeting of Dr. Gro Brundtland (WHO), Jim Wolfensen
(World Bank) George Soros, the U.S. Surgeon-General Satcher, and leaders
of the global TB community to launch a worldwide campaign to bring new
resources to TB control.
3.
This campaign will have as its centerpiece a drive to secure an
unprecedented commitment of public and private resources- the Global
Trust for TB Control- targeted to Board-approved projects.
OSI-TB INITIATIVE
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4.
Identify TB "hot zones" where new public-private partnerships, funded
through the Trust, can contain deadly epidemics and promote the primary
goals of modern TB control.
OSI-TB INITIATIVE
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LILLY
PHRI
OTHER PARTNERS
HMS/HU
OSI
CDC
PIH
KNCV
ROCKEFELLER
WHO
IUATLD
OSI-TB ADVISORY BOARD
PROJECTS
OSI-TB INITIATIVE
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PROGRAM IN INFECTIOUS DISEASE AND SOCIAL CHANGE
DEPARTMENT OF SOCIAL MEDICINE, HARVARD MEDICAL SCHOOL
641 HUNTINGTON AVENUE, BOSTON, MA 02115
PH. (617)432-3715, FAX: (617)432-2565
PAUL FARMER AND JIM YONG KIM. DIRECTORS
To:
ARYEH NEIER & GEORGE SOROS
OPEN SOCIETY INSTITUTE
FAX: 212-548-4608
FROM: PAUL FARMER, M.D., PH. D.
DATE:
17 SEPTEMBER 1998
During the week of 6-11 September, I traveled with a fact-finding mission to investigate the state of
tuberculosis (TB) control in Russia, with a particular interest in assessing the problem of TB in
prisons. We also evaluated the OSI-funded TB control initiative conducted by the Public Health
Research Institute (PHRI). Our team included representatives of the World Health Organization
(WHO) and U.S. Centers for Disease Control, as well as clinical and research specialists in
tuberculosis control. This group, which serves as the advisory committee to the PHRI projects,
counts decades of experience in TB control and research. I myself acted as special consultant on
TB epidemiology and treatment to the OSI.
For a number of reasons, we expected the TB situation in Russia to be grim. Several of us had
previously visited regional TB facilities; all of us were familiar with reports, in the Russian and
foreign popular press, describing large outbreaks of TB and high case-fatality rates. These
outbreaks, in tandem with the dismantling of the public-health infrastructure, have led to a rapid
rise in national case rates. In 1990, TB incidence in Moscow was estimated at 27 per 100,000
population; by 1993, it had almost doubled, to 50 per 100,000. The situation is significantly worse
in Siberia, where incidence went from 43 to 94 per 100,000 during the same period. By March
24th, 1998, it was possible for the WHO to announce that TB incidence in Russia had risen
another 50% between 1994 and 1996. About a quarter of a million new cases were detected in 1996
alone.
We were also concerned about multidrug-resistant tuberculosis (MDRTB). Most members of the
committee had read the recent WHO/IUATLD report, which suggested decreased cure rates and
significant levels of resistance to first-line antituberculous drugs in the region surveyed. Finally, we
knew that the epidemic was particularly affecting, and amplified within, the prison system. In the
space of the last few years, TB has become the leading cause of mortality among Russian prisoners
and detainees, accounting for 40-80% of all prison deaths in some facilities. National TB mortality
among Russian prisoners was recently pegged at 484 per 100,000- among the highest in the
world.
P. FARMER/REPORT TO OSI, 17 SEPTEMBER 1998
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In the light of these unwelcome trends, the OSI-funded initiatives were deemed particularly
welcome both by many Russian officials and by the broader, global TB community. The PHRI has
initiated work in both the civilian and prison populations of Tomsk, and has recently expanded its
support of key reforms to the neighboring oblast, Kemerovo. Similar efforts are also underway in
Vladimir, closer to Moscow.
I have visited all of these regions. On this most recent trip, however, the mission visited Siberian
facilities only. What we found disturbed us greatly. A PHRI-led public-private coalition- linking
foreign NGOs, including Médecins Sans Frontières (MSF) and MERLIN UK, with both prison
and civilian health authorities- has already led to substantial improvements in aspects of TB
control ranging from case detection to the standardization of record-keeping and program
evaluation. Furthermore, this coalition has been able to substantially reduce improper TB-control
practices, which are the root cause of increased rates of treatment failure and increased rates of
acquired resistance to the best and least expensive drugs. The committee was unanimous in
deeming these reforms central to any effort designed to avert further disaster.
These reforms, however, come late. When the OSI-funded initiative was planned and funded, the
contribution of drug resistance to low cure rates was unknown, but MDRTB was estimated to
represent no more than 5% of incident cases. What we found, however, was a rate of MDRTB
many times in excess of this estimate, and we suspect that drug resistance helps to explain the very
low cure rates seen inside a number of the institutions in which standard TB-control practices have
been implemented.
The case of Penal Colony 33, in Mariinsk, Kemerovo, gives an idea of both the gravity and extent
of the problem. For the last few years, the Belgian branch of MSF has worked inside the Colony
with close cooperation, obviously, from prison officials. Treatment has been standardized, and
case detection, treatment protocols, and record-keeping are now in keeping with WHO-endorsed
TB-control practices. And yet, preliminary cohort studies have revealed cure rates of less than 60%
even though the standardized regimen has been bolstered by a fifth drug, and all doses are directly
observed. Although complete drug-susceptibility data are not available, preliminary testing in
Belgium suggests that a majority of treatment failures are due to drug resistance. Patients who fail
therapy now constitute an increasingly large proportion of those detained in Colony 33; they are
eventually isolated from other prisoners. Since Russian law does not permit indefinite detention,
however, these prisoners, still infectious, are simply released into the community at the end of their
term. A majority of the group- 80% by some estimates-are lost to follow up after release,
underscoring the need for close coordination of prison and civilian TB control.
Rapidly rising TB case rates elsewhere in Kemerovo Oblast are further proof of the relationship
between prisons and the surrounding community, as is the fact that fully a third of all civilian TB
diagnoses are made in those with a history of imprisonment. Finally, the highest extramural rates
are registered among prison guards and others working in close association with TB-affected
prisoners.
Equally disturbing, and again suggestive of the increasing contribution of drug resistance to poor
outcomes, are data showing that, between 1987 and 1997, as rates of TB skyrocketed, cure rates
went from an already-low 67% to a sobering 44 %. (See Figure 1). Death rates among those
treated also increased, from 9% to 30%. Note that rates of abandonment and death due to other
causes during treatment remained constant.
P. FARMER/REPORT TO OSI, 17 SEPTEMBER 1998
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15:13
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Figure 1.
Trends in TB treatment outcomes, 1987 and 1997
Kemerovo Oblast, civilian population
1987
16%
cure
8%
TB deaths during treatment
deaths from other causes during
9%
TB treatment
67%
transferred out
1997
16%
10%
44%
30%
After meeting with both civilian and prison officials from Kemerovo, the fact-finding mission met
with the state governor and leading health officials. We urged the governor to declare tuberculosis
an "emergency," and he assured us of his strong and unconditional support for the institution of
P. FARMER/REPORT TO OSI, 17 SEPTEMBER 1998
3
202 331 9097
WHO
NSC
INIL
HEALTH
10/23/98
11:43
NO. I
WHO's Response to the Global Tuberculosis Emergency
1. In 1993, the World Health Organization declared TB a global emergency. It took this
imprecedented step as TB was claiming the lives of 2-3 million people each year, making it the
eading infectious killer of youth and adults. Increasingly, the disease was becoming resistant to
currently available medicines because of careless TB treatment practices. (Drug resistance can
levelop when patients get the wrong drugs, drug supply is irregular or patients stop taking their
nedicines too soon because they feel better). And yet, in spite of these dangers, the world's
response to the epidemic was minimal
WHO defined the enormous size of the global TB problem through expanded monitoring and
surveillance. For example, it determined that TB had become the leading cause of death among
HIV positive people. The disease also orphans hundreds of thousands of children each year and is
the single biggest killer of young women.
3. WHO also determined that TB is a major contributor to poverty. Eighty per cent of TB patients
are in the most economically productive years of their lives. TB sends many self-sustaining
funilies into poverty. If the breadwinner of a family is not properly diagnosed or treated, he or she
will lose, on average, a full year of work
4. WHO developed an effective TB control strategy known as DOTS. DOTS is the most effective
rategy available for detecting and curing TB. It was developed from two decades of testing and
best practices. DOTS requires direct observation of treatment to ensure that patients take the
edicines; and it also requires government commitment, microscopy services, reliable drug supply
and monitoring systems. DOTS can help any country rich or poor -- to achieve high cure rates.
COTS achieves cure rates as high as 95 per cent even in economically devastated or war-torn areas.
Besides achieving high cure rates, DOTS has a number of important advantages:
The strategy can be integrated successfully within general health services to achieve
widespread coverage.
DOTS does not require hospitalization or isolation. Parients can remain at home and
return to work in a few short weeks.
DOTS is as effective in curing TB in both HIV-positive and HIV-negative people, and
is one of the most affordable ways of extending the life of a HIV-positive person.
5. WHO and the World Bank determined the cost effectiveness of DOTS. DOTS helps prevent
In ultidrug resistance; which is often fatal and up to 100 times more expensive to treat. The World
Bank considers DOTS as one of the most cost-effective health strategies available. A six-month
course of drugs for DOTS costs between $10 to $20 per patient in most developing countries.
DOTS is a sound economic investment for any government. For example proper use of DOTS in
TI riland could save the country $2.3 billion over 20 years.
6. Ite Organization promoted the global implementation of DOTS. WHO developed the
DO essary tools, guidelines, training materials and policies to promote the implementation of DOTS.
A.T the same time, WHO embarked on major advocacy and intensified technical assistance to over
50 countries, focusing on big countries with largest TB burdens. These efforts have made DOTS
Date of the fastest expanding health interventions of this decade. Today, nearly 2 million people are
being cured with DOTS.
Inc icator
1990
1998
Number of countries using DOTS
10
110
cent of TB patients being treated by DOTS
Under 1 percent
15 percent
Drug costs per patient
$40-60
$10-20
E-- emal donor aid to TB control
$16 million
$70 million
10/23/98
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0202
331
3001
RBV
WHO's Challenge Ahead
1. WHO has identified the main constraints that are preventing further progress against the TB
epidemic. These are 1) lack of political commitment; 2) lack of human and financial resources; 3)
unavailability of affordable and secure supplies of anti-TB drugs; 4) increased multiple-drug
resistant TB (MDR-TB); and 5) the HIV epidemic, which is partly fueling the global TB epidemic.
$ global strategy is needed to address these constraints, particularly in high-burden countries.
2. WHO's new Director General - Dr Gro Harlem Brundtland - has identified TB as a priority concern
or the "renewed" WHO.
3.
froundwork must now be established among global partners for a major initiative on TB. The
Stop TB Initiative will lay out and prioritize the steps needed to overcome current constraints to
2 ction and provide the basis for a significant expansion of global efforts against TB.
4. The Stop TB Initiative will serve to command increased attention and resources for further
i uplementation of DOTS; swiftly establish solutions to sustained global access to anti-TB drugs;
lentify cost effective options for addressing MDR-TB and frame a long term vision for a TB
desearch and development agenda to include new tools - most importantly an effective vaccine.
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THE GLOBAL TUBERCULOSIS EPIDEMIC
Burden of disease
- There were an estimated 8 million new cases of TB in 1997, including 3.6 million
cases of infectious pulmonary disease, and 16.1 million existing cases of disease.
- An estimated 2.0 million people died of TB that year, about 1 in 4 cases. TB
causes more deaths than any other single infectious agent.
- Roughly 1 in 3 people carry the M. tuberculosis bacterium (MTB), i.e. 1.8 billion
people.
- Countries in South East Asia had the largest number of new cases (3.0 million) in
1997), but the rate per head was highest in sub-Saharan Africa (257/10⁵ persons).
- 22 countries had 80% of all incident cases. The leading five together accounted
for over half the global total. They were all in Asia: India (1.9 million), China (1.4
million), Indonesia (583,000), Bangladesh (292,000) and Pakistan (261,000).
- 1 in every 500 people was infected with both TB and HIV. Three-quarters of a
million TB cases (8%) were infected with HIV. The highest rates of co-infection
(over 1 in 50 people) were in southern Africa, but India had the largest number of
co-infected individuals (1.9 million) and the largest number of HIV-infected TB
cases (190,000).
- Surveys suggest that about 1 in 10 TB cases is resistant to at least one drug; about
1 in 50 cases is multi-drug resistant (to at least isoniazid and rifampin)
- The huge scale of the problem is explained mainly by poor control and population
growth in south Asia and sub-Saharan Africa, and high rates of MTB/HIV CO-
infection in some African countries.
Trends
- Without greater control effort, annual TB incidence is expected to increase from
about 8 million cases/year in 1997 to 11 million cases/year by 2020.
- Reaching WHO targets of 70% case detection and 85% cure by year 2010 could
save about 1 in 4 cases (approx. 50 million) over the next two decades.
- The incidence of disease is increasing most quickly in African countries that have
high levels of HIV (e.g. Malawi, Kenya, Tanzania). It is also increasing quickly in
countries where control programmes have broken down (e.g. Russian Federation).
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Control
- Only about half of infectious cases are treated and cured. The cure rate in DOTS
Programmes is much higher than average, typically about 80%.
- Approximately half of all countries have now adopted the WHO DOTS strategy.
Twenty-one of the 22 highest-burden countries have DOTS Programmes, but most
with low rates of case finding and cure.
- At present, about 1 in 10 infectious TB cases is cured in DOTS programmes
- Among high-incidence countries, the best control programmes are in Peru,
Tanzania and Viet Nam, though programmes in Bangladesh and China have
expanded rapidly during the 1990s.
- Progress in TB control is very slow in the majority of high-burden countries,
notably India, Indonesia, Nigeria, Pakistan, Philippines and Russia.
NSC INTL HEALTH 007/010
11:45
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WHO
10/23/98
No. 2
Briefing Points for the Director-General's 28 October meeting at the
White House With Mrs H Clinton, Mr J Wolfensohn and MrG Soros
The Tuberculosis Problem
Each year there are about 8 million new TB cases, with about 2 million deaths.
Multidrug-resistant TB (MDR-TB) has emerged as a major threat to TB control in some
countries, including Russia and the Baltic States.
In 1997 an estimated 8% of TB cases were attributable to HIV, the burden falling mainly
on sub-Saharan Africa and increasing in other regions, especially the Indian sub-
cominent.
11
TB is the biggest single killer of women aged 15-44 world-wide, is the major cause of
death among the HIV infected, and is a significant brake on socio-economic development
in poor countries as it affects mostly young adults.
#:
The global response to TB has thus far been inadequate: many poor countries are failing
to control it; rich countries are not doing enough to support TB control in the poor
countries and, as a result, the prevalence of TB globally remains unacceptably high, and
MDR TB is being created and spread internationally.
The Current Solution to the TB Problem
The DOTS strategy has been shown by the WHO in collaboration with the World Bank to
be one of the most cost effective health interventions.
Proper case detection and curc of infectious cases are the comerstone of the TB control
strategy.
Successful implementation of such strategy achieves high cure rates (e.g., 95% cure
among a quarter of a million TB patients annually in China).
Existing Constraints to the Solution
0
The DOTS strategy is labour intensive, requires direct observation of treatment and strict
patient monitoring.
Where the prevalence of MDR-TB is high or where HIV infection is widespread, control
measures in addition to the DOTS strategy are necessary.
Although 97 countries have adopted the DOTS strategy, only 15% of TB patients globally
are treated under DOTS because only few countries have achieved full coverage.
Governments of high prevalence countries have shown insufficient political will and
leadership, and have not allocated adequate financial resources.
There is 3 lack of trained human resources and of secure, quality controlled drugs.
Inefficient drug procurement systems in most countries result in an increase in the cost of
drugs and produce shortages of stocks.
BCG vaccine is ineffective to prevent infectious forms of TB, thus it cannot interrupt TB
transmission.
10/23/98
11:46
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Recommended Actions
The current global TB control situation is similar to that of vaccine preventable diseases in
the mid 1980s. EPI has successfully progressed to achieve the global targets in the early
1990s through global coalition building and country specific social mobilization. Even
hough TB control and the implementation of DOTS may be more complicated than EPI
operations, through global coalition and country specific social mobilization, DOTS coverage
can be expanded to allow achievement of the global targets of 70% case detection and 85%
were rate by 2010. Therefore, we recommend the following:
WHO, the World Bank and various US agencies and private charitable interests such
as the Open Society Institute commit themselves to work together and combine efforts
to analyse constraints, prepare, appraise and finance projects that provide solutions
and assist countries with high quality technical implementation of TB control.
2.
WHO, in partnership with the World Bank, various agencies throughout the world,
and other private and public interests will establish a Stop TB Initiative which has
the following four components:
A global charter for advocacy and commitment to TB control and elimination of MDR-
TB.
A global action plan to coordinate interaction among international partners to ensure
effective TB control
A mechanism to swiffly establish global access to anti-TB drugs.
A global research agenda balancing short and long-term vision.
!. successful Initiative will ensure the following:
TB activities at WHO and worldwide are facilitated.
Expanded effective TB control in high burden priority countries.
Expanded global surveillance of drug resistance and new interventions to treat MDR-TB
focusing on Russia and other high MDR-TB burden countries.
A global drug facility or direct drug funding to countries in need to ensure the sustained
supply of quality, fixed-dose, combination TB drugs.
Coordinated approaches to the care and prevention of TB and HIV, especially in Sub-
Saharan Africa
Improved tools to deliver effective TB control services as an integral part of primary
health care.
Development of new tools, such as rapid diagnostic tests, drugs and vaccines.
,
The World Bank's Current Activities in Tuberculosis Control
The World Bank is fully committed to fighting the global tuberculosis epidemic. The
World Bank's contribution is twofold: through the policy advice it provides to
countries, and through country-specific lending.
In pursuing TB control activities, the Bank collaborates closely with WHO, NGOs,
bilateral and technical agencies. For example, a current Bank project in Latvia will
be financing improved TB treatment and surveillance, with technical assistance
provided by the U.S. Centers for Disease Control. The Bank is also working closely
with partners regarding potential interventions for improved TB control in Russia.
The Bank has provided nearly US$ 300 million in financing for tuberculosis control
programs since 1989, making it the largest single source of external funding for
tuberculosis control in developing countries.
About twenty countries are using World Bank financing to implement the WHO-
recommended TB control strategy (DOTS). Several new projects are under
preparation. Some projects are tuberculosis-specific, but a majority address TB
control within broad health sector development and health sector reform projects.
The two largest Bank-supported TB control projects are in China and India. These
countries are home to more than one third of the world's estimated 8 million new TB
cases each year.
The project in China was initiated in 1992 and has demonstrated dramatic results with
the DOTS strategy: half of the country's population is now covered, and over one
million infectious cases have been cured to date. The challenge now is to expand this
success to the rest of China and to achieve financial sustainability.
In India, the TB control project, which began in 1997, has also achieved excellent
results with DOTS in several pilot regions. It has established the foundation for the
Revised National TB Control Program, and is providing the impetus for an 8-12 year
process of extending the approach nationwide. Political commitment, assured drug
supply, health worker training and supervision, patient education and motivation, and
operational research are critical to the progress of these projects.
The Bank is supporting implementation of the DOTS strategy in countries as diverse
as Bangladesh, Cambodia, Cote d'Ivoire, Egypt, Haiti, Krygyzstan, Morocco, Niger,
Philippines, Romania, and Vietnam.
In some countries, tuberculosis control is
intimately linked to prevention and control of HIV/AIDS, and the strengthening of
collaborative interventions, education, and referral is critical.
2 d 3561964233 11:00/17 86 26 '01 (NOW)
FROM WB EXC
7142
ALFONSE D'AMATO, NEW YORK, CHAIRMAN
COMMISSION ON
CHRISTOPHER H. SMITH, NEW JERSEY, Co-CHAIRMAN
SECURITY AND COOPERATION IN
Ben Nighthorse Campbell, Colorado
John Edward Porter, Illinois
EUROPE
Spencer Abraham. Michigan
Frank R. Wolf, Virginia
234 FORD HOUSE OFFICE BUILDING
Conrad Burns, Montana
Matt Salmon, Arizona
WASHINGTON, DC 20515-6460
Olympia J. Snowe, Maine
Jon Christensen, Nebraska
(202) 225-1901
Frank R. Lautenberg, New Jersey
Steny H. Hoyer, Maryland
Harry Reid, Nevada
Edward J. Markey, Massachusetts
FAX: (202) 226-4199
Bob Graham, Florida
Benjamin L Cardin. Maryland
E-MAIL: [email protected]
Russell P. Feingold, Wisconsin
Louise Mcintosh Staughter, New York
EXECUTIVE BRANCH COMMISSIONERS
JOHN SHATTUCK, DEPARTMENT OF STATE
(Vacant). DEPARTMENT OF DEFENSE
(Vacant). DEPARTMENT OF COMMERCE
October 9, 1998
-
MICHAEL R. HATHAWAY, CHIEF OF STAFF
DOROTHY D. TAFT, DEPUTY CHIEF OF STAFF
To: K.BERNAI
The Honorable Madeleine Albright
Secretary of State
FYI.
Department of State
2201 C Street, NW
Washington, DC 20520
Dear Madame Secretary:
We are writing to focus your attention on the growing threat of Multiple Drug Resistant
Tuberculosis (MDRTB) in the Russian Federation, as outlined in the attached information. We would
appreciate learning what initiatives have been undertaken by the United States to help contain and defeat
this biological threat. Like the Y2K problem, the MDTRE problem can become a crisis if not addressed
in a timely and effective manner.
With easy international travel and limited means of protecting people from an airbome pathogen,
the incubation and spread of MDRTB in Russia also poses a threat to the health of the U.S. population.
Moreover, as the world has seen before in this century, the spread of disease, whether influenza after
World War I or AIDS in Africa, can threaten and even upset social, political, and economic structures
necessary for peace and security.
This medical threat must be addressed now, while it may still be possible to limit the consequences.
Given Russia's economic troubles and political uncertainty, a concerted international effort to help the
Russian authorities contain the spread of this disease and treat its victims appears to be urgently necessary.
Currently, the Open Society Institute of the Soros Foundations is funding a $12 million program to combat
TB and MDRTB in Russia. Other NGOs, such as Doctors Without Borders, Medical Emergency Relief
International, and the New York Health Research Institute, have already begun studying the issue and have
raised the alarm. But the problem is genuinely global in scope and will require assistance from
governments.
We understand that George Soros is planning in the near future to discuss this troubling matter with
Mrs. Hillary Rodham Clinton and World Bank President James Wolfensohn, and to emphasize the
necessity of governmental involvement. The United States should certainly take the lead in coordinating
the activity of medical experts, foreign capitals, international organizations and NGOs to assess the risk and
PRINCETON PROJECT 55 INC.
file
5/15
Tuberculosis Initiative
Ralph Nader
P.O. Box 19312
Washington, DC 20036
May 27, 1998
First Lady Hillary Rodham Clinton
The White House
1600 Pennsylvania Avenue NW
Washington, DC 20500
Dear Mrs. Clinton,
In your recent speech before the World Health Assembly in Geneva, you provided an
excellent account of the severity and urgency of many global health crises. We are
particularly pleased by your emphasis on the prevention and treatment of infectious
diseases like tuberculosis.
Major public addresses such as yours are exactly what is now required to revive this
nation's awareness of these profoundly neglected health causes. TB is one of the most
disproportionately unheeded pandemics, yet it is the world's number one infectious killer
and the death toll is rising every year. Few people in this country are aware of the
enormous burden TB exacts from the citizens of developing countries, and the clear and
present threat that drug resistant strains pose to the health and national security of the
United States. TB kills more women than all causes of maternal mortality combined, yet
most Americans consider it a disease of the past. The yearly death toll from land mines is
matched by TB every single day, however many journalists and even public officials
believe we have won the war against tuberculosis.
You have the unique capacity to refocus America's attention on health issues of major
global importance, and this speech was an exemplary first step. Now, as you said, "We
must put our hearts, our minds, and our resources in action." In South America, you
witnessed the unprecedented successes that can be achieved through the use of directly-
observed treatment for tuberculosis patients. As you saw, the WHO-recommended
regimen, Directly-Observed Treatment, Short-course (DOTS) is a very simple system, that
the World Bank determined to be one of the world's most cost-effective health
interventions. Successful application of DOTS has produced cure rates above 85% in
places as diverse at New York, Peru, China, Tanzania, and Bangladesh. In most
countries, the overall effect of DOTS on the primary health infrastructure and the incidence
of infectious diseases has been remarkable.
For the health and stability of developing nations, and to protect Americans from multi-
drug resistant TB (MDR-TB), it is time for the U.S. to make a significant investment in
DOTS for the most severely affected nations of the world. USAID's new infectious
disease initiative is a good beginning, but this pilot project must be expanded to other key
regions of the world. MDR-TB is already threatening to overwhelm the public health
systems of "hot-zones" such as Latvia, Estonia, Russia, the Dominican Republic,
Argentina, and the Ivory Coast. Unless we ensure the rapid application of DOTS in these
and other countries, epidemics of MDR-TB will become commonplace in many more
countries.
A global assault on TB will also require significant commitments from the WHO, and from
developing nations. The U.S. should make use of its diplomatic influence to encourage
endemic nations to dedicate resources to the control of TB within their borders.
Additionally, the U.S. should help to accelerate the introduction of WHO Secretary
General-Elect Gro Harlem Brundtlandt's "Roll Back Malaria" and "Roll Back TB"
initiatives. Currently the WHO Global TB Programme's total annual budget for the
application of DOTS is a paltry $11 million. Dr. Brundtlandt should be supported in
significantly increasing funding for the TB program, in accordance with its prominence
among causes of death globally.
Finally, with the introduction of the President's "Research Fund for the 21st Century,"
now is the time for the U.S. to make a meaningful investment in research on the infectious
diseases of major global health importance identified by USAID's new initiative. DOTS
can make a significant impact on the global disease burden, but without an effective TB
vaccine, we will not be able to control TB over the long-term. Now that scientists have
read the entire genetic code of the TB microbe, the potential for the development of new
drugs, diagnostics, and vaccines has never been better. This March, a working group of
TB and vaccine experts, convened by Secretary Shalala, met to formulate a national
"Blueprint for a Tuberculosis Vaccine," which sets the course for accelerated development
of a TB vaccine, but without new funding, this initiative cannot get under way.
Thank you, Mrs. Clinton, for your dedication to the health of the world's population. We
hope that you will work with us to significantly increase U.S. commitments to global
health.
Sincerely,
Ralph Nader
Steering Committee
Enclosures: informational packet
cc: Mr. Sidney Blumenthal, Dr. Laura Efros, Mr. Tom Friedman, Mr. Leon Fuerth, Mr.
David Halperin, Mr. Chris Jennings, Dr. Donald Jordan, Dr. David W. Kampt, Mr. Peter
Rundlet, Mr. Eric Schwartz, Mr. Michael Waldman, and Mr. Joel Wilson.
I
file TB
THE WHITE HOUSE
WASHINGTON
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[
PRINCETON PROJECT 55 INC.
Tuberculosis Initiative
Project Managers
Celine Gounder
Scott Regenbogen
1600 20th Street NW
Center for Civic Leadership
Washington, DC 20009
32 Nassau Street
(202)588-7748
Princeton, NJ 08542
fax: (202)588-7798
(609) 921-7812
[email protected]
fax: (609) 921-2712
[email protected]
HOW IS PRINCETON PROJECT 55
A FINAL WORD
PRINCETON PROJECT 55
FINANCED?
We are Democrats, Republicans, Independents and
and its
none of the above. We are liberals, conservatives and
Princeton Project 55 is financed primarily by
some of each. We are doctors, lawyers, businessmen,
contributions from members of the class, their families
CENTER FOR
accountants, ministers, writers, educators andjust about
and friends. Some funding has been obtained from
everything else. Whatever we are we have much in
CIVIC LEADERSHIP
grant making foundations.
common:
Contributions to Princeton Project 55 are tax
We came of age together.
deductible. A copy of the 501(c)(3) ruling is available
upon request.
"Mobilizing Princeton alumni,
We are the beneficiaries of an exceptional educa-
tion and opportunities in life that are not available to
students and others to strengthen
everyone. With this privilege goes responsibility.
national institutions and values,
HOW CAN I PARTICIPATE?
to provide civic leadership, and to
By virtue of knowledge and experience developed
over many years, we have much to offer.
implement solutions to critical
If you are a member or spouse of the Princeton
national and global problems."
Class of 1955 and haven't already done so, JOIN
We are in it together. There is much to be done.
PROJECT 55 NOW!
Volunteer to work on one of our programs. You
Please join us.
need not be a member of Project 55 to help on our
projects - many of our best volunteers have no
connection with Princeton or the Class of 1955.
Propose and develop a project of your own.
Make a tax deductible contribution to Princeton
Project 55. We need your help.
Join or help form a public service program with
your own classmates, friends or alumni association.
Call or write us for help or information.
PRINCETON PROJECT 55
THE CENTER FOR CIVIC LEADERSHIP
32 Nassau Street
32 Nassau Street
Princeton, New Jersey 08542
Princeton, New Jersey 08542
Phone (609) 921-8808
Phone (609) 921-8808
Fax (609) 921-2712
Fax (609) 921-2712
PRINCETON PROJECT 55 is a non-partisan, nonprofit tax
WHAT IS PRINCETON PROJECT 55
Mentoring. Project 55 has instituted highly regarded
exempt organization established by the Princeton
mentoring programs for at-risk inner city students in
University Class of 1955 to provide an outlet for men and
DOING?
Trenton, New Jersey and Southern Connecticut, and
women of our generation to become more effectively
Project members are in the process of organizing or
involved in solving the problems facing our nation and to
Princeton Project 55 focuses its efforts on strengthening
supporting similar programs in other areas. Project 55's
inspire our children's generation and others to join in that
civic organizations and initiating projects to find and
programs involve a greater commitment of time and
effort on the part of both mentor and mentee than
effort.
test systemic solutions to critical problems affecting the
public interest. To be considered by Project 55, a
other programs, and as result of the combined efforts
of the mentoring and character education projects,
THE CENTER FOR CIVIC LEADERSHIP coordinates and
project must:
the character education curriculum has been
supports public interest projects approved by Princeton
introduced or is under consideration in schools in both
Project 55. Its recently expanded office space and staff
address important societal issues
areas. The leaders of these programs see mentoring as
are available to assist other public interest projects on a
focus on systemic change rather than treating
a "foot in the door" for a variety of interventions designed
shared cost basis. By locating in Princeton, the Center
symptoms
to re-instill hope and accomplishment in the lives of our
benefits from the intellectual resources of the University
inner-city children.
hold promise of significant impact
and its students and faculty.
Service Exchange Program. The Service Exchange
encourage and utilize community participation
Program enables citizens in impoverished areas to
provide opportunities for substantial involvement by
provide needed services to each other on a barter
Princeton students and alumni
basis. Every hour of service given by a participant
Princeton Project 55 was born of the realization that there
entitles that participant to an hour of service in return.
is a vast untapped resource, available for the public
be non-partisan
For example, a resident who does shopping for an
good. among women and men of our generation. We
elderly person who is incapacitated might receive
are prepared to devote a larger share of our time and
The Public Interest Internship Program places
babysitting servicesi return. All ecords are maintained
energy to preserving and improving a world from which
Princeton students and recent graduates in summer
in a central computer, and the program is administered
Internships and full-year Fellowships with public interest
we have received so much. We believe that the
by a local agency. The program not only provides
organizations across the country. Interns and Fellows
needed services, it also rebuilds a sense of community
knowledge and experience we have accumulated can
work for groups selected by Project 55 for the quality of
among the participants. PP55 has organized three
be used to find new solutions to difficult problems.
their work and their emphasis on finding systemic
service credit programs in New Jersey and is working to
solutions to the problems they address. Project 55
establish another in Atlanta.
We believe that in a society that has recently been
members and other Princeton graduates serve as
characterized by so much greed and self-interest, many
mentors, orienting Interns and Fellows to the
Outreach. Project 55 has encouraged and assisted
of the young men and women who are now graduating
communities where they work and meeting with them
the formation of similar projects by other alumni groups
on a regular basis during their service.
both from Princeton and other colleges and universities.
from Princeton and other colleges and universities across
the country are seeking guidance and opportunities to
The Public Interest Program has been hugely
Representatives of over 50 other universities have
successful. The number of applicants and placements
attended PP55 conferences. The Princeton Club of
contribute to the public good. We believe we can
have increased dramatically since the program began
Chicago has launched a major educational effort in
respond to their needs.
in the summer of 1990. The program both helps the host
an inner-city high school and co-sponsored a three-
organizations and introduces increasing numbers of
day seminar on urban problems. The Harvard Law
Princeton Project 55 and its Center for Civic Leadership
Princeton graduates to public interest work. Asignificant
School Class of 1958 has formed Project Appleseed to
are our effort to transform these beliefs into reality.
number of participants have decided on a public
organize centers for public interest law. ReachOut 56
service career as a result of their experience. Many
has been established by the Princeton Class of 1956,
more will be motivated to participate in public service
and Yale has formed its own Project 55.
on a volunteer basis while pursuing other careers. It is
Program Development. Project 55's Program
"You're going to be saying something that is profoundly
the goal of the Public Interest Program to provide a
Development Committee evaluates additional
relevant to American life at this moment. This is an era of
meaningful public interest experience to 10 percent of
program proposals against the criteria described above
non-commitment. You will be saying that commitment
each Princeton graduating class by 1995.
in light of such factors as cost, practicality, and the
matters. This is an era of self-preoccupation. You will be
presence of a "passionate leader" whose devotion
Character Education. Princeton Project 55 took the
saying that self-absorption is not enough. This is an era of
and enthusiasm are essential to the success of any
leadin organizing The Character Education Partnership,
disintegrating values. You will be saying that we do have
project. The committee also provides program
a nonpartisan, nonprofit coalition of individuals and
shared values worthy of commitment, even sacrifice.
development assistance and support.
organizations, including prominent national education
You will be saying that shared effort to solve our problems
associations. The Partnership encourages schools
Princeton Project 55 is not a grant-making foundation.
is not a hopeless venture."
throughout the United States to initiate or strengthen
Its resources are used to maintain the Center for Civic
K-12 character education. By stressing such commonly
Leadership and provide coordination, assistance and
John W. Gardner
held values as honesty, responsibility, perseverance
seed money for its projects. With the exception of a
(Addressing Princeton Project 55)
and respect for self and others, character education
small paid staff, the time devoted by members and
has proved successful in (a) reducing student violence,
associates to Princeton Project 55 programs is donated.
pregnancy, substance abuse and disrespect, (b)
Many projects will require additional funding from
improving academic performance, and (c) preparing
outside sources, and it is the responsibility of each
young people to become responsible citizens.
project team to raise those funds from independent
public or private sources.
file TB
October 6, 1997
Melanne Verveer, Chief of Staff
Office of the First Lady
The White House
Washington, D.C., 20500
Dear Melanne:
That was an encouraging telephone conversation we
had about the First Lady possibly engaging the scourge
of tuberculosis worldwide and its drug resistant strain.
A number of Administration officials made the suggestion
that Hillary Clinton could make a major contribution to
raising the visibility of that challenge within the govern-
ment and the general public. As I mentioned, the entire
area of global infectious diseases and the increasing
resistance that these organisms are displaying should be-
come a new and major pillar of American foreign policy.
Just TB and malaria are taking five and one half million
lives a year. With more international travel, even
nations with well developed public health systems are
becoming more vulnerable, according to recent studies.
So, for starters, I am enclosing a very concise
and readable collection of materials on TB prepared by
Princeton Project 55 (also described herein) and the
Project Managers--Celine Gounder here in Washington and
Scott Regenbogen in Princeton, New Jersey. It would
be useful if the First Lady were to spend a few minutes
perusing these fact sheets.
Please let me know if any action is forthcoming
or any interest is incubating. Her trip to Central
Asia takes her to a region where TB is all too pre-
valent.
Ralph
Ralph Nader
PO Box 19312
Washington, D.C., 20036
Enclosure--TB packet
WORLD REPORT
tough, lodging itself within the lung,
Fighting TB: a second
where it is contained indefinitely by the
body's immune system or, for an unlucky
10 percent, breaks out into active, infec-
tious tuberculosis. With the drugs found
chance to do it right
at midcentury, TB mortality in developed
countries dropped sharply. In the United
States, TB deaths fell from almost 20,000
in 1953 to below 2,000 in the 1980s.
But the foe now includes 'Ebola with wings'
Many richer nations, including America,
considered TB defeated and began cutting
research and treatment funds.
GILBERT-SYGMA
But the disease continued to thrive in
the developing world, where incomplete
treatments were common. From a public-
health standpoint, faulty treatments-in
which some patients would neither die
nor be cured-turned out to be worse
than no treatment at all. Statistically, if
10 people were left untreated, 5 died and
2 remained uncured and infectious (the
other 3 were cured by their own natural
defenses). But of every 10 on an incom-
plete drug regimen, only 2 died while 4
remained uncured and infectious. One in-
fectious person typically would infect 10
to 15 additional people in a year. Thus in-
adequate treatments tended to double the
rate of transmission. They also created
drug-resistant strains. The calamity, says
Dr. John Sbarbaro of the University of
Colorado, has been "a global failure of
politicians, a failure of public health, and
a failure of physicians."
Today, the WHO estimates that 50 mil-
The new campaign is aimed at curing millions of TB victims like this man in Somalia.
lion people carry the extraordinarily du-
rable form of tuberculosis known as MDR,
Last week, the World Health Organiza-
or multidrug-resistant TB. The several
BY TIM ZIMMERMANN
tion urged the expansion of an anti-TB
million in the developing world who get
ollywood screenwriters might favor
strategy that has the potential to cure
active MDR-TB will be as good as dead.
H
newer and more exotic bugs. But
nearly every person treated, except for
Elsewhere, even in good hospitals, MDR
the infectious disease that ranks as
those with the new superbugs. Known as
treatment can cost $250,000 a patient,
the world's deadliest is very old and
DOTS-Directly Observed Treatment,
and still some 40 to 50 percent will
very familiar, a plague spread by mere
Short-course-the approach relies upon
die. "It's like Ebola with wings," warns
coughing and sneezing. Hippocrates
the careful monitoring of patients for six
Richard Bumgarner, deputy director of
called it phthisis ("shriveling and wasting
to eight months as they take a daily dose
the WHO's Global TB Program. "And once
away"). Victorians called it consumption.
of four different drugs. The hope is that 7
that MDR epidemic is created outside our
In 1900, not long after people began call-
of every 10 TB victims will receive the
borders, there is no way to protect
ing it tuberculosis, it accounted for 1 in 7
treatment over the next decade and that
the U.S."
deaths in America and Europe. But when
10 million lives thus will be saved.
A brief resurgence of TB in the United
a drug-based remedy emerged at mid-
DOTS isn't new. More than 70 nations
States caused by the AIDS epidemic has
century, the scourge suddenly seemed
have used it this decade, and data now
been brought under control. But the Cen-
doomed-only to bounce back.
show its effectiveness in places as differ-
ters for Disease Control and Prevention
Today, the TB microbe is harbored by
ent as New York City and Peru. But the
says outbreaks of MDR continue.
up to 2 billion people, about a tenth of
approach is being used for only 1 in 10 TB
If this were Greek tragedy, there would
whom will become sick and infectious.
sufferers worldwide. The WHO initiative
be no second chance. But decades after
Each year, TB claims nearly 3 million
targets 13 countries-including Russia,
researchers developed the drugs neces-
lives-which is more than all other infec-
China, and Mexico-that harbor three
sary to treat tuberculosis, DOTS repre-
tious diseases combined. Worse, shoddy
fourths of the world's estimated 20 mil-
sents a cost-effective strategy to redress
treatment has spawned drug-resistant
lion active TB cases. The additional cost
the policy failures of the past. Whether
strains that are virtually incurable. "It's a
would be about $100 million a year.
the strategy is widely implemented is a re-
scary story," says John Crofton, an Edin-
Lung wrecker. DOTS may be a therapeu-
peat test of global priorities for the politi-
burgh clinician who 40 years ago helped
tic breakthrough, but the history of ef-
cians. Whether the right antibiotics to
prove that a cure was at hand. "And what's
forts to stamp out tuberculosis is a tale of
treat multidrug-resistant TB can be found
so tragic is that it is preventable."
hubris. The TB bacillus is insidious and
is yet another test for the scientists.
U.S.NEWS & WORLD REPORT. MARCH 31, 1997
45
The Washington Post
June 24, 1997
Controlling Infectious Diseases
David Brown ably chronicles specif-
the health and economic well-being of
ic progress made against infectious
Americans is immense, but we are
diseases such as leprosy and river
not doing nearly enough to control
blindness but overall paints too rosy a
them. It is particularly appalling that
picture of the future ["The Long
there is no global system for surveil-
March Toward Stamping Out Infec-
lance and control of infectious disease
tious Diseases," news story, June 2).
outbreaks. The patchwork of uncoor-
New evidence is beginning to sketch a
dinated agencies and programs should
truer and more frightening picture.
be linked with a global information
Ln the 1970s, with the eradication
network. and public health systems
of smallpox and the discovery of the
should be greatly boistered in coun-
polio vaccine, it seemed that infec-
tries where potentially catastrophic
tious diseases would be eliminated by
diseases such as AIDS and the Ebola
the year 2000. Since then the medical
virus originate.
world has identified some 30 new
diseases, and multidrug-resistant
The government and the pharma-
forms of TB. malaria and other dis-
ceutical industry need to work togeth-
eases once thought to be under con-
er. While firms such as Merck have
trol threaten to overwhelm fragile
donated drugs to fight river blindness,
health systems in many countries.
corporate generosity is not a substi-
Infectious diseases today kill 17 mil-
tute for creating the financial incen-
lion people each year. With 2 million
tives for developing new drugs and
people crossing international borders
building the local infrastructure for
every day, stopping these microbial
distributing them in needy countries.
threats at our borders is not a realis-
PATRICK LEAHY
tic option.
U.S. Sentor (D-Vt)
The dangers these diseases pose to
Washington
FINANCIAL TIMES
MONDAY MARCH 24 1997
Action on TB would bring big
economic returns, says WHO
By Clive Cookson,
TB worldwide: DOTS can turn the tide
lowing every dose and moni-
clear evidence even 10 per
Science Editor
tors his or her progress until
cent use of DOTS has led to
TB cases (m)
the disease is cured.
a levelling off of the world-
Effective tuberculosis
8
This strict supervision is a
wide TB epidemic after
control programmes would
Without DOTS
striking contrast to what
decades of growth. "We now
bring huge economic returns
happens today in India and
know that if we use DOTS
as well as health and social
many other developing coun-
more widely, we can send
6
benefits. according to a
Current
tries: doctors prescribe anti-
the epidemic into decline
report released by the World
DOTS impact
biotics in a haphazard way
and can save many millions
Health Organisation
and they make little effort to
of lives in the next 10 years,"
today. World TB day.
4
ensure that the patients take
he says.
Tuberculosis kills an esti-
the whole course. As a
The WHO's target is to
Impact If DOTS
mated 3m people a year
is used more widely
result, people stop taking the
raise the DOTS treatment
more than any other infec-
drugs when they feel better
rate from one in 10 to seven
2
tious illness.
but before the TB bacillus
in 10 patients worldwide.
The first detailed eco-
has been eliminated from
That could halve the number
nomic study of TB treatment
their body.
total of new TB cases, Dr's
has been carried out for
0
Then, after a while, the
1990
95
2000
05
10
15
20
Kochi says.
WHO in India, where about
disease returns - sometimes
The world's governments
30 per cent of the world's
Source WHO
in a drug-resistant form
and aid agencies would need
tuberculosis cases occur. It
more difficult to treat.
to spend an additional $500m
shows that. if the Indian
carried out the Indian study
account between them for
At present DOTS is used
a year to achieve a 70 per
government spent $200m a
with Professor Ravindra
over 40 per cent of the
for no more than 10 per cent
cent DOTS treatment rate.
year on an effective control
Dholakia and colleagues at
world's TB.
of the world's TB patients,
says Dr Almeida an insig.
programme. the tangible
the Indian Institute of Man-
WHO's recommended con-
although the latest WHO sta-
nificant amount compared
benefits to the economy
agement, Ahmedabad.
trol strategy is DOTS
tistics show that it is far
with the projected economic
would he worth at least
A similar study, soon to be
(directly observed treatment
more effective than other
gains from having millions
$750m a year and might be
published for Thailand, will
short-course). This requires
approaches.
of people working healthily
much greater.
show a larger benefit per
each patient to take a com-
It typically achieves cure
instead of sickening or dying
Comparable benefits for
patient there than in India
bined dose of four powerful
rates of 80 to 90 per cent,
from TB. The Indian study
the world as a whole would
because average income is
antibiotics every day (or on
compared with about 40 per
shows economic benefits
run to billions of dollars a
higher. Dr Almeida says.
alternate days) for six to
cent for unsupervised treat-
would justify spending as
year and could exceed $20bn
The same would apply) to
eight months.
ment.
much as $750m a year on TB
a year. says Dr Joel Almeida,
other rapidly industrialising
The main feature of DOTS
Indeed Dr Arata Kochi,
control in India, assuming a
medical officer at the WHO
Asian countries such as
is that a health worker
director of the WHO global
"discount rate" as high as 16
global TB programme. who
China and Indonesia, which
observes the patient swal-
TB programme. says there is
per cent.
Herald
INTERNATIONAL
Tribune
PUBLISHED WITH THE NEW YORK TIMES AND THE WASHINGTON POST
TUESDAY, MARCH 18, 1997
Russian Prisons Breeding Drug-
Resistant Tuberculosis, Officials Warn
By Barry James
which will be made public in Berlin on
fore they are sentenced because of over-
International Herald Tribune
Wednesday.
crowding, poor hygiene and lack of de-
"The recent dramatic increase in TB
cent nutrition in holding prisons.
Russian prisons and labor camps have
cases is a clear reflection of the eco-
Dr. Kluge said that from a public
become incubators of virulent, drug-res-
nomic turmoil and social upheaval in the
health point of view it was better not to
istant tuberculosis that is spreading
Russian Federation since 1990," the re-
treat the infected prisoners and allow
through the region as prisoners are re-
port says.
them to die, rather than give them partial
leased, officials in Moscow and at the
Figures given by Alexander Khomen-
drug treatment that built up resistance to
World Health Organization said
ko, director of Russia's central research
the disease and spread it among the
Monday.
institute of tuberculosis, indicate that the
population.
The Moscow Center for Prison Re-
rate of TB in the general population may
Doctors Without Borders runs a treat-
form said 2,481 of every 100,000 pris-
almost have tripled between 1991 and
ment program at the Mareensk special
oners contract TB, but at some labor
1996 to 70 cases for every 100,000
TB camp in central Siberia based on
camps the question is almost not whether
people in the Russian Federation.
multiple drug therapy. but Dr. Kluge
prisoners will catch the disease but
This is between four and seven times
said sputum samples sent to Belgium for
when.
higher than the figures reported in most
analysis indicated that some prisoners
Russia has a prison population of
Western countries, where the disease is
had acquired resistance to the entire
more than one million.
largely controlled by multiple drug ther-
panoply of drugs.
The situation is even worse in some
apies but is nevertheless becoming an
The Mareensk program reaches only
other regions of the Commonwealth of
increasing public health hazard. In 1995,
400 of the 2,000 prisoners at Mareensk,
Independent States. The International
the last year for which figures are avail-
but Dr. Kluge said he was trying to
Committee of the Red Cross, which ad-
able. the United States reported 8.7 cases
persuade authorities to expand it to pre-
ministers a treatment program in Baku,
of TB per 100,000, a total of 22,860
vent continual reinfection. The camp,
Azerbaijan, reported recently that there
cases, of which 4.1 percent were in cor-
built for 700, is so overcrowded that
were 4,667 cases of TB for every
rectional institutions.
prisoners sleep in shifts. and some rent
100,000 prisoners - 50 times higher
Dr. Hans Kluge, Moscow coordinator
out their beds by the hour. Nevertheless.
than in the general population with a
for Doctors Without Borders, said that in
prisoners consider they are better off
25 percent mortality rate.
some regions, 60 percent of TB patients
there than in the labor camps and de-
In Kazakstan. the government last
were former prisoners.
liberately avoid taking medication or
year released about 56,000 prisoners un-
If we want to break the chain of
fake their sputum tests in order to avoid
der an amnesty, many of them suffering
transmission, we have to tackle the prob-
being sent back.
from drug-resistant tuberculosis, ac-
lem at the root, in the prisons,¹ he
It is a disaster." Dr. Kluge said. "In
cording to the Global TB Education
said.
January and February this year, 115 pa-
Fund in Washington.
Nick Banatvala of Medical Emer-
tients died. It's a real cemetery."
The fact that prisoners are spreading
gency Relief in London, which operates
He said that hundreds of TB victims
the disease among the general popu-
a TB treatment program among the gen-
were awaiting admission to Mareensk,
lation after their release is one reason
eral population, said there was a "tre-
and in the meantime spreading the dis-
along with the collapse of medical ser-
mendous need" for good work in the
ease in other camps. The problem was
vices and general poverty - why "TB
prisons, where the disease was mostly
compounded by homosexuality and
rates are climbing back to levels of 20
affecting young male adults.
promiscuity in the camps, he added.
years ago, spawning the highest mor-
Valeri Sergeyev of the Moscow Cen-
A principal means of spreading the
tality rates in Europe and taking the lives
ter for Prison Reform said many pris-
disease. Dr. Kluge said, were prison
of those in their most productive years.
oners can expect to contract TB. which is
trains where detainees were crammed 30
according to the WHO's 1997 TB report.
spread by an airborne bacillus, even. be-
into a compartment.
FRONTIER POST
Pakistan
Monday, March 24, 1997
World TB day being observed today
The scourge that kills
100,000 in Pakistan annually
By Dr. KHABIR AHMAD
years later. the effective tools and
infectious cases. so that they can
PESHAWAR - Tuberculosis -
medicines discovered long ago for
be cured.
assumed by many as a disease of
fighting TB. are not being put to
2. The patients must be OB-
the past. poor and poets - has
proper use." he said.
SERVED and recorded swallowing
become the world's leading infec-
This year. the core theme of
each dose of their medicines by a
tious killer, claiming nearly three
the day IS "Use DOTS more wide-
health worker
million people in 1995 and likely
ly" DOTS (Directly Observed
3- TB patients must be provid-
to kill at least 30 million people in
Treatment Strategy) which was
ed treatment within a system that
the next 10 years. If the current
endorsed by the WHO in 1993
ensures that they are being cured
trends continue.
when It declared TB as a global
4- The correct dosage of anti-
According to World Health
emergency, involves health work-
TB medicines - known as
Organisation (WHO). one-third
ers or family members watching
SHORT-COURSE chemotherapy
the world's population - about 2
patients take each dose of anti-TB
- must be used for the right
billion people - have already in-
drugs and monitor patients'
length of time.
fected with tuberculosis.
progress until the patients are
5- Governments must support
"Someone IS infected with TB
cured This supervision must con-
the DOTS strategy emphatically
every second. Left untreated, one
tinue every day for the first two
and make TB control a high prior-
person with active TB will in fact
months and, ideally. for all SIX
ity
10 to 15 people in a year's time.
months of treatment
As far as Pakistan IS con-
Like the common cold. TB
Dr Kochi said that DOTS cur-
cerned. "TB is back with a
spreads through air and by rela-
rently covered only about 10 per
venguance, claiming 100,000 lives
tively casual contact." says WHO.
cent of the worlds population
every year." says Dr M.A. Barzgar,
The World TB Day. being ob-
"DOTS has doubled cure rates
WHO representative to Pakistan
served worldwide today reminds
in Tanzania. China and New York
Talking to The Frontier Post by
is the fact that more than 40
City. Many other countries have
Telephone. Dr Barzgar said: "At
years after the discovery of drugs
also started adopting the DOTS
least 15 million people are al-
that can wipe out TB, the disease
strategy and are also achieving
ready infected with TB to which
continue to kill more people than
higher cure rates" he said
400,000 new cases are added ev.
ever. It reminds us that the TB
adding that the DOTS strategy
ery year."
epidemic IS still out of control.
was able to cure as mucn as 95
"If we don't take appropriate
The day. according to Dr Arata
per cent of all TB patients -
measures, the TB epidemic could
Kochi. the WHO director of global
twice as many as any previous
only get worse," he warned
TB programme. gives us an op-
anti-TB strategy. TB medicines
According to Dr Barzgar, the
portunity to help break this SI-
can cost as little as $11.
day IS aimed at generating public
lence and stop the spread of tu-
DOTS strategy of the WHO has
awareness that TB today IS a
berculosis
five main elements.
problem that will not wait. The
This day IS the anniversary of
1- The first priority for every
TB, he said. was frustrating killer
the discovery of the cause of TB
programme must be to DIRECT
and stressed the need for adopt.
in 1882. "Ye!, over one hundred
attention toward identifying sick.
ing the DOTS strategv
The Indian Express
SATURDAY, APRIL 5, 1997
Tuberculosis time-bomb
Fight it globally, fight it at home
I
T is tuberculosis more than any other disease
maturely and get saddled with multi-drug-resistant
that underlines John Donne's pragmatic obser-
TB. Thirdly, there has been a general failure of
vation that no man is an island. The time-bomb
diagnosis. For this, both patients and medical per-
ticks, not just for some forgotten hill tribe, but for
sonnel have to blame. Social prejudice has meant
the residents of New York and London, Chennai
that those afflicted by TB present themselves to
and Dacca; not just for the refugee from regions
medical attention only in the later stages of the dis-
that exist below the poverty line, but for the well-
ease. Even then their condition could remain unde-
heeled and well-fed. Today this 19th century mala-
tected because of tardy data-collection. A proper
dy, that once went by the romantic term 'consump-
sputum examination is the only way to diagnose
'tion', is killing more people in the world than ever
TB accurately, yet many doctors continue to
before. What is worse. it has combined with late-
depend on X-ray reports emanating from faulty
20th century killers like AIDS to wreak further
equipment. Thus valuable time is lost, even as more
damage. A person afflicted by AIDS is ten times
people are exposed to the contagion.
more likely to contract TB than others.
The battle against the disease world-wide has to
The roller-coaster ride of this centuries-old dis-
be waged particularly hard in this country, which
ease may appear strangely out of sync with the
has an estimated 14 million TB patients. Every
promise of modernity. The hopes raised by the
year at least five lakh Indians die of it. It is an unre-
identification of the TB bacillus by Robert Koch in
lenting epidemic that few speak about, an epidem-
1882 and the discovery of rifampicin as an effective
ic that hasn't been controlled in these 50 years of
drug against the disease in the late 1960s seem to
independence. The National Tuberculosis Control
have been belied. There are three main reasons for
Programme and its recently revised version have
this. The first, of course, is the highly contagious
often been a charade of simulated sputum samples,
nature of the disease and the close proximity with
broken-down X-ray equipment and a severe short-
which human beings live and work together in a
age of medicines. If there is a glimmer of hope in
world where an estimated one-third inhabitants car-
all this it is the internationally recommended
ry the TB bacilli. The second, even more tragic,
breakthrough in TB control known as Directly
aspect is that the battle against the disease the world
Observed Treatment Short-course or DOTS. The
over has been an extremely half-hearted one. Time
strategy here is to merge conventional multi-drug
and again, once the obvious symptoms of the dis-
therapy with a new management system that
ease like bouts of coughing disappear, patients
ensures the monitoring of each TB patient until he,
imagining they are cured give up medication pre-
or she is certified as cured.
INTERNATIONAL
Herald
Tribune
PUBLISHED WITH THE NEW YORK TIMES AND THE WASHINGTON POST
London. Thursday, March 20, 1997
WHO Hails Advance in
Tuberculosis As Milestone
TB: World Health Organization Hails a
Treatment That Could Save Millions of Lives
By Alan Cowell
health radar screen" in the 1960s and
and asphyxiation. Patients also display
New York Times Service
1970s amid widespread assumptions it
wasting as muscle tissue is eaten away.
was under control.
According to the World Health Or-
GENEVA - Claiming "the biggest
Only in the early 1990s, when "huge
ganization, the disease dates back about
health breakthrough of this decade,'
increases" in tuberculosis cases began
6,000 years and was once known as the
the World Health Organization forecast
to be identified in New York City, did
"white plague."
Wednesday that millions of lives could
health officials focus anew on the dis-
It was so much part of the fabric of
be saved over the next 10 years through
ease, Dr. Nunn said.
19th century European society that it
a tuberculosis treatment that has been
He added that tuberculosis claims 2 to
inspired poets and musicians in works
field-tested in such disparate places as
3 million deaths per year from a re-
including Puccini's opera "La Bo-
New York City and rural Tanzania.
ported 6 to 8 million cases.
heme.
Researchers said the benefits of the
In an interview, Dr. Nunn said that
In the early 20th century, richer pa-
system. known as Directly Observed
several factors explained the worldwide
tients were confined to sanatoriums
Treatment Short-course. or DOTS, have
upsurge in the ailment in the 1990s.
such as the institution depicted in
become apparent only in the past few
These included the spread of the HIV
Thomas Mann's novel, "The Magic
months as a mass of new data has shown
virus resulting in reduced natural im-
Mountain."
dramatic increases in the numbers of
munity, immigration from developing
These days. Dr. Nunn said, tuber-
people cured as a result of the regi-
to developed countries and the break-
culosis claims more lives than AIDS. He
men.
down of health-care systems in Russia
said a full one third of people stricken
The new treatment and management
and parts of Eastern Europe following
with the HIV virus - and thus sus-
regime is based on close monitoring of
the collapse of communism.
ceptible to infection - die from tuber-
tuberculosis patients to ensure that they
The epidemic "has been running un-
culosis.
fully complete a course of powerful
abated in most of the world's countries
An assessment by the World Health
medication lasting six to eight months.
and has even begun to worsen in Eastern
Organization published Wednesday
In the past, said Dr. Paul Nunn, the
Europe and parts of Western Europe,"
called the disease the "leading infec-
head of the World Health Organization
said Jaap Broekmans, an official who
tious killer of youths and adults' in the
Tuberculosis Research and Surveil-
helped in the development of the DOTS
world, claiming most of its victims
lance Unit here, patients who failed to
strategy. According to Mario Ravigli-
among economically active people pre-
complete such courses ended up gen-
one, a medical officer at the World
dominantly in the Third World.
erating drug-resistant and incurable
Health Organization, recently compiled
The DOTS program centers on the
strains of the disease.
data from surveys of 98 percent of the
use of four established, low-cost tuber-
The new system - in use in 70 of the
global population show that the new
culosis drugs - isoniazid, rifampicin,
world's 216 countries and territories -
treatment and management system pro-
parazinamide and either ethambutol or
differs markedly from other forms of
duces cure rates of 77 percent, com-
streptomycin - taken in conjunction.
treatment where the therapy regimen is
pared with 41 percent from other pro-
An advantage of the system, Dr. Nunn
not standardized or where tuberculosis
grams to combat tuberculosis.
said, is that the full course of treatment
treatment centers on mass scanning of
The highest rate using the new system
can cost as little as $11. much less than
the population by X-ray and institu-
was recorded in the mid-1990s in China,
other cures.
tionalization of infected patients, re-
Dr. Nunn said, in a project where 95
Under the new system, health officers
searchers said.
percent of 114,000 people infected with
must physically witness a patient taking
The development was revealed si-
tuberculosis were cured.
a full course of medication.
multaneously at the World Health Or-
Hiroshi Nakajima, the director-gen-
"The most important thing is to hold
ganization headquarters in Geneva and
eral of the World Health Organization,
on to the patients,' Dr. Nunn said.
at the institute in Berlin named for
said in a statement that the new system
"People take drugs for a month and feel
Robert Koch, the German physician
was 'the biggest health breakthrough of
much better and think, 'Why should I go
who announced his discovery of the
this decade, in terms of the lives we will
on seeing this health worker?'
In
fact.
bacilli causing tuberculosis on March
be able to save."
by breaking off a course of treatment.
24. 1882.
Dr. Nakajima said the organization
Dr. Nunn said, patients encourage drug-
Since then. the disease has killed un-
anticipated that "at least 10 million
resistant, incurable tuberculosis.
told millions of people, said Dr. Nunn.
deaths" would be prevented in the next
The DOTS program is billed by the
but ``completely fell off the public
10 years "with the introduction and
World Health Organization as a break-
extensive use" of the new strategy.
through in part because other research
Tuberculosis is an infectious disease
has not so far produced a vaccine to
almost always transmitted through air-
prevent tuberculosis.
borne bacteria from an infected person.
"Prevention lies in the cure," Dr.
It destroys the lungs. leading to bleeding
Nunn said. "If you cure patients, you
prevent them from transmitting the dis-
ease.
Newsday
March 20, 1997
WORLD'S TB EPIDEMIC COULD HIT 9 MILLION
by Laurie Garrett, Staff Writer
The world's tuberculosis epidemic will top nine million active cases annually within 20
years if governments fail to swiftly change the way they handle the disease, according to a report
released yesterday by the World Health Organization.
In countries using appropriate TB control measures - called Directly Observed Therapy -
TB is leveling off and the incidences of drug-resistant forms are at manageable levels. Currently,
there are 7.5 million active cases of TB worldwide.
But several countries refuse to use the labor-intensive DOT to treat what Richard
Bumgarner, WHO's TB deputy director, calls "ebola with wings." The reference is to TB's
airborne contagion and 50-percent lethality if untreated. The refusal seems part economic, part
philosophic.
For example, Russian authorities insist that TB's spread is due to poverty and poor
housing rather than to improper treatment. And, they say, the appropriate cure involves months or
years of quarantine in sanitoriums, where patients are given a succession of antibiotic treatments.
"The patients are charged for everything, including the drugs. When they run out of
money, they're kicked out of the institutions," Bumgarner said.
Under DOT, properly medicated patients can live at home because the medication renders
them noncontagious. The DOT system of daily monitoring to ensure proper use of four antibiotics
proved its worth in New York City. Through DOT, and at a cost of about $1 billion, New York's
early 1990's epidemic was controlled by 1994.
The incidence of TB in Russia in 1995 was 6 1/2 times that of the United States. Several
other Eastern European countries have even higher rates. Latvia, Lithuania and Moldova report TB
rates that are 7 1/2 times greater than in the United States and Romania's TB rate is nearly 12 times
greater, according to WHO.
In the short run, Bumgarner said, persuading governments to switch to DOT could not
only save lives, but prevent the otherwise inevitable spread of drug-resistant TB into Western
Europe.
TB Weekly
April 1, 1996
Epidemiology TB Rates in U.S. Drop but Authorities Fear Complacency
The renewed fight against tuberculosis (TB) in the U.S. is yielding results, with the
number of cases dropping for the third consecutive year, but experts said another lapse in
complacency could be lethal.
According to statistics released by the U.S. Centers for Disease Control and Prevention
(CDC), there were 22,812 new TB cases in 1995, a six percent drop from 1994. The rate per
100,000 people fell to 8.7 from 9.4.
The goal remains elimination - less than one case per 100,000. But several barriers
remain, according to doctors and public health experts at a conference in Washington, D.C.,
marking World Tuberculosis Day.
Tuberculosis killed three million people and made eight million sick in 1995, the World
Health Organization (WHO) said. WHO projected it would take $500 million a year to bring the
epidemic under control globally.
In an age of international travel and migration, no single country can wipe it out alone,
experts from the CDC, American Lung Association and Pan-American Health Organization said.
Perception is part of the problem. Effective drugs have been available to fight TB for 50
years and health authorities had begun to think of the lung disease as a vanquished enemy, a
problem of the past.
But as soon as they let their guard down, TB re-emerged as a serious health threat. The
problem was exacerbated by the AIDS epidemic because AIDS patients are particularly vulnerable
to TB.
"The 20 percent resurgence of TB in this country from 1985 to 1992 after more than three
decades of steady decline clearly demonstrates the high price of complacency," Dr. Kenneth Castro
of the CDC told a news conference. "To be successful in this battle we must refrain from
premature declarations of victory, which lead to complacency."
Doctors are also alarmed that there are more strains of TB resistant to standard drugs and
they fear that if lowered vigilance results in another surge of cases, drug resistance will be an even
more treacherous problem the next time around.
INDIANAPOLIS STAR
Indianapolis, IN
Thursday, March 20, 1997
TB epidemic exploding in Russia
Global threat of disease
leveling off due to better
Return of tuberculosis
treatment, but Eastern
Tuberculosis claims as many as 3 million lives each year. Thirteen countries are
Europe headed for 'crisis.
home to nearly 75 percent of the world's TB cases.
By Paul Geitner
ASSOCIATED PRESS
Russia
BERLIN - Better treatment
Pakistan
China
has stabilized the spread of tuber-
Mexico
culosis worldwide for the first time
Ethiopia
The Philippines
India
in decades, but U.N. health offi-
Zaire
Brazil
Bangladesh
cials said Wednesday that a grow-
Thailand
ing TR epidemic in Russia is
South
Indonesia
threatening Europe.
Africa
The global TB epidemic has lev-
Source: World Health Mization
eled off because health care work-
ers are being trained to make sure
Associated Press
patients take the full, six-month
losis explosion there.
Although effective and afford-
course of medication. World
Since 1991, Russia has seen a
able drugs have been available
Health Organization officials said
70 percent rise in TB cases and'a
since the 1950s. they generally
at a news conference.
90 percent jump in TB death
must be taken for six to eight
They said widespread use of the
rates. said Richard Bumgarner.
months. Many patients, especially
new "DOTS" - or Directly Ob-
deputy director of the WHO's
in poorer countries, stop taking
served Treatment. Short-course
Global TB Program.
them as soon as they begin to feel
- method could cut the number
Lethal drug-resistant strains
better because of the inconve-
of TB cases in half over the next
account for 6 percent of the TB
nience or to save money.
decade. saving 10 million lives. as
cases in the Baltic country of Lat-
That allows the stronger TB
well as prevent the development of
via, 14 percent in Estonia and 18
germs that resisted the initial drug
drug-resistant strains.
percent in Lithuania, he said.
onslaught to reproduce. making it
But the method is still not being
"Make no mistake," Bumgarner
harder. if not impossible. to cure
used in Eastern Europe. and eco-
said. "Europe has been heading
later.
nomic and social upheaval in Rus-
slowly but surely to another TB
Fully adopted in the United
crisis."
sia and other former Soviet bloc
States and elsewhere since the
countries since the end of commu-
Tuberculosis. the world's top
early 1990s. the DOTS method
nism has contributed to a tubercu-
infectious killer. is spread through
involves better identification of TB
coughing and sneezing and can be
cases and training of people to
highly contagious.
administer medication.
Attachment 5
Foreign Operations Subcommittee Hearing
"Combating Infectious Diseases"
May 15, 1997
Witnesses
Dr. Barry Bloom, Investigator, Howard Hughes Medical Institute; Professor of
Microbiology and Immunology, Albert Einstein College of Medicine
Dr. David Heymann, Director, Division of Emerging and Other Communicable
Diseases Surveillance Control, WHO
Dr. Nils Daulaire, Chief Health Policy Advisor, USAID
Dr. Gordon Douglas, President, Merck Vaccines
Dr. John Sbarbaro, Professor of Medicine and Preventive Medicine, University of
Colorado Health Sciences Center
Dr. Barry Bloom discussed three major infectious diseases that he felt most needed to be
addressed in developing countries: tuberculosis, AIDS, and malaria. Dr. Bloom suggested that
three major WHO extrabudgetary programs be considered for increased financial support,
including the WHO Global Program for Tuberculosis (GTB). In Africa, he noted, TB is the most
common cause of death among those infected with HIV, killing 30% of AIDS patients there. In
addition, multi-drug resistant strains of tuberculosis are now emerging, as seen recently in New
York. Unless drug treatment is properly supervised, tuberculosis becomes rapidly resistant to the
only drugs available. Directly observed treatment prevents emergence of resistance and leads to
cures in over 85% of tuberculosis patients, rendering them non-infectious within a month. In the
long-term, efforts should be made to develop an effective vaccine.
Dr. David Heymann outlined a global framework for surveillance and control of infectious
diseases, which WHO is putting in place. Dr. Heymann noted that within a year, there have been
27 infectious disease outbreaks in addition to the heavy burden of underlying diseases. Included
among these is TB, the spread of which is now facilitated by HIV infections. Dr. Heymann
emphasized the need for strengthening public health infrastructure. He explained that WHO's
programs should be empowered to help in strengthening national capacities to detect and control
infectious diseases. He also stated that the WHO's existing infectious disease monitoring
networks and computerized information systems should be expanded.
Dr. Nils Daulaire noted that in FY 1996, USAID devoted approximately $320 million to
infectious disease programs. USAID's approach to infectious diseases consists of four elements:
basic prevention through changing the conditions that allow infectious diseases to spread and
flourish; secondary prevention by improving health systems so that they can prevent and control
infectious diseases; targeted prevention and control through specifically tailored programs that
focus on high priority diseases; and, response to emergency situations. USAID's principal efforts,
outside childhood BCG immunization (which provides modest protection against new TB
infection), have been in support of programs aimed at developing a rational approach to managing
TB among people with HIV infection. "It is clear that the resource needs of a truly global effort to
address TB are enormous, in all likelihood dwarfing today's AIDS control efforts. This is
unquestionably the biggest unmet need among infectious diseases today." Dr. Daulaire maintains
that before a global TB program can be launched, greater efforts should be made to improve health
infrastructures in developing countries.
Dr. Gordon Douglas explained that the US needs a comprehensive public policy that addresses
issues ranging from research initiatives to health care delivery infrastructure, and whose
implementation depends on strategic partnership efforts between government and other segments
of society, such as the private sector. Dr. Douglas noted that the failure to use TB drugs
appropriately has led to widespread emergence of TB strains that are resistant to existing
antibiotics. Dr. Douglas also observed that the HIV/AIDS pandemic is further fueling emergence
of multi-drug resistant tuberculosis. Dr. Douglas outlined barriers to increased involvement of the
private sector in infectious disease control efforts: inadequate protection of intellectual property;
parallel trade in patent-protected medicine (when different prices are set by governments among
price-controlled markets); government price and profit controls; black market sales; lack of quality
assurance and the willingness to compromise on quality to achieve cost savings; inadequate
resources for countries to acquire effective therapies and newer vaccines; lack of epidemiological
data; and the lack of health system infrastructures that can support rigorous treatment regimens.
Dr. John Sbarbaro began by saying, "I was asked to come up with a disease that exemplified
all the points my colleagues have made. The obvious answer is tuberculosis." Dr. Sbarbaro noted
that the WHO approach to TB, DOTS, is a highly effective approach to controlling tuberculosis.
According to Dr. Sbarbaro, little advancement in health infrastructure is necessary to apply DOTS
because all that is required is the participation of primary health care workers and village health
workers. Dr. Sbarbaro believes that USAID should become a leader on global tuberculosis control
by putting more money into WHO's DOT program. The WHO uses its funding as seed money to
start programs that governments find so effective that they then fund it themselves. Dr. Sbarbaro
also noted that WHO should be encouraged to make TB a higher priority, and that the World Bank
should be encouraged to lend money for controlling TB.
Attachment 2
Tuberculosis Fact Sheet
United States Statistics
In 1996, a total of 21,337 cases of tuberculosis were reported to the CDC from the 50
states, the District of Columbia, and New York City (8.0 cases per 100,000
population). This represents a 6.7% decrease from 1995.
During 1996, a total of 29 states reported fewer TB cases than in 1995, and 21 states
and DC reported no change or more cases in 1996 than in 1995.
Data indicates a decreased number of TB cases among U.S.-born persons and an
increased number among foreign-born persons. During 1996, TB cases reported
among persons born outside the U.S. accounted for 36.6% of total reported cases,
compared with 34.7% in 1995. In 1996, the number of TB cases among foreign-born
persons decreased 2.9%, representing the first decreases among foreign-born persons
since 1986 (the first year such data were collected).
Homeless populations in big cities are reservoirs for tuberculosis: some estimates show
that as many as 30% of the homeless population of San Francisco may beinfected with
the TB bacillus.
In 1990, it is estimated that $700 million was spent to treat the 26,000 U.S. cases of
TB that year.
SOURCE:
CDC. (1996) "Tuberculosis Morbidity - United States, 1995." MMWR.
45: 365-370.
(1997) "Tuberculosis Morbidity - United States, 1996." MMWR.
46: 695-700.
Global Tuberculosis Statistics
In 1995, more people died of tuberculosis than in any other year in history.
There are 8 million new TB cases annually. Of these, only 5 million receive any form
of treatment at all, and only 500,000 receive DOTS.
TB causes more deaths than any other infectious disease. It kills 3 million people every
year. Of these, 1 million are women.
The WHO estimates that 180 million children less than fifteen years of age were
infected with tuberculosis as of 1995.
In 1994, there were about 23 million refugees worldwide. As many as half of them
may be infected with the tuberculosis bacillus, as refugee camps present prime
conditions for the spread of tuberculosis.
TB is the leading killer of HIV-positive people worldwide.
The American Lung Association estimates that improvements in TB control could
increase economic output in developing countries by more than $24 billion annually.
SOURCE: WHO web site, http://www.who.ch/programmes/gtb/tbrep-96/tbreport.htm.
696
MMWR
August 1, 1997
Tuberculosis - Continued
TABLE 1. Number of reported tuberculosis cases, percentage change in number of
cases, and case rates*, by state and year - United States, 1995-1996
No. cases
Case rate
% Change from
State
1995
1996
1995 to 1996
1995
1996
Alabama
420
423
+ 0.7%
9.9
9.9
Alaska
81
96
+18.5%
13.4
15.8
Arizona
319
282
-11.6%
7.6
6.4
Arkansas
271
225
-17.0%
10.9
9.0
California
4,677
4,313
- 7.8%
14.8
13.5
Colorado
95
104
+ 9.5%
2.5
2.7
Connecticut
139
138
- 0.7%
4.2
4.2
Delaware
56
43
-23.2%
7.8
5.9
District of Columbia
102
139
+36.3%
18.4
25.6
Florida
1,556
1,417
- 8.9%
11.0
9.8
Georgia
746
790
+ 5.9%
10.4
10.7
Hawaii
193
200
+ 3.6%
16.3
16.9
Idaho
14
15
+ 7.1%
1.2
1.3
Illinois
1,024
1,060
+ 3.5%
8.7
8.9
Indiana
199
202
+ 1.5%
3.4
3.5
lowa
72
70
- 2.8%
2.5
2.5
Kansas
89
74
-16.9%
3.5
2.9
Kentucky
327
259
-20.8%
8.5
6.7
Louisiana
476
420
-11.8%
11.0
9.7
Maine
28
21
-25.0%
2.3
1.7
Maryland
370
319
-13.8%
7.3
6.3
Massachusetts
330
262
-20.6%
5.4
4.3
Michigan
424
443
+ 4.5%
4.4
4.6
Minnesota
156
131
-16.0%
3.4
2.8
Mississippi
271
251
- 7.4%
10.0
9.2
Missouri
244
224
- 8.2%
4.6
4.2
Montana
21
19
- 9.5%
2.4
2.2
Nebraska
24
22
- 8.3%
1.5
1.3
Nevada
115
137
+19.1%
7.5
8.5
New Hampshire
23
21
- 8.7%
2.0
1.8
New Jersey
848
820
- 3.3%
10.7
10.3
New Mexico
85
89
+ 4.7%
5.0
5.2
New York
3,066
2,588
-15.6%
16.9
14.2
North Carolina
519
554
+ 6.7%
7.2
7.6
North Dakota
5
8
+60.0%
0.8
1.2
Ohio
280
301
+ 7.5%
2.5
2.7
Oklahoma
237
201
-15.2%
7.2
6.1
Oregon
156
190
+21.8%
5.0
5.9
Pennsylvania
674
583
-13.5%
5.6
4.8
Rhode Island
50
35
-30.0%
5.1
3.5
South Carolina
334
348
+ 4.2%
9.1
9.4
South Dakota
28
19
-32.1%
3.8
2.6
Tennessee
465
504
+ 8.4%
8.8
9.5
Texas
2,369
2,103
-11.2%
12.7
11.0
Utah
48
58
+20.8%
2.5
2.9
Vermont
4
4
-
0.7
0.7
Virginia
359
349
- 2.8%
5.4
5.2
Washington
278
285
+ 2.5%
5.1
5.2
West Virginia
71
57
-19.7%
3.9
3.1
Wisconsin
117
114
- 2.6%
2.3
2.2
Wyoming
5
7
+40.0%
1.0
1.5
Total
22,860
21,337
- 6.7%
8.7
8.0
* Per 100,000 population.
DOTS: A PROVEN STRATEGY
The most effective way to control TB is to stop its spread at the source - curing
sick patients. The secret to treating TB is as simple as making certain that
patients regularly swallow the right medicines until they are cured. This
supervision is the cornerstone for the
World Health Organization's (WHO)
Short-Course Chemotherapy
recommended TB control strategy:
directly-observed treatment, short-
Initial Phase of Treatment
course (DOTS).
(Daily for 2 months)
Isoniazid
300 mg
Rifampicin
600 mg
DOTS is the only viable method for
Pyrazinamide
2000 mg
reducing TB transmission and death
Ethambutol
1200 mg
worldwide. It has been successful in
Continuation Phase of Treatment
such diverse locations as New York
(3 times a week, 4 months)
City, Tanzania, Peru, Guinea,
Isoniazid
600 mg
Bangladesh, and China.
Rifampicin
600 mg
DOTS Is an Effective Cure & Prevents New Infections
DOTS is a strategy that provides a standardized combination of the most effective medicines;
ensures through direct observation that these medicines are taken regularly until patients are cured;
and monitors patients' overall progress. This three-pronged approach is key to saving lives and
stopping the TB epidemic.
DOTS uses a specific combination of four anti-TB medicines - isoniazid, rifampicin,
pyrazinamide, and ethambutol (or streptomyecin) - in a treatment known as short-course
chemotherapy. When patients take these drugs consistently for the required six months, they are
more than 95% effective.
In addition to providing the right medicines, ensuring that patients regularly take all the drugs in
their treatment is one of the most vital aspects of TB control. Direct observation of treatment is one
of the most vital aspects of TB control. Direct observation of treatment is one important element of
the DOTS strategy and is necessary because the most serious impediment to controlling TB is that
patients often interrupt or stop their treatment, sometimes because they mistakenly believe they are
cured or because the medicines cause side effects. In addition, in some countries, drugs are not
available continually. The DOTS strategy addresses these problems by making it the responsibility
of the health worker - not the patient - to ensure that treatment is complete and the patient's
progress is monitored carefully.
DOTS Prevents Multi-Drug Resistant TB
The DOTS strategy also prevents TB from becoming multi-drug resistant. Many patients fail to
take all their medicines consistently because of the extended treatment period or because they no
longer have any of the outward symptoms of the disease. In addition, many doctors and health
workers prescribe the wrong drugs or the wrong combination of drugs. This inconsistent or
partial treatment is the primary cause of multi-drug resistant TB.
By providing the right combination of medicines, supervision, careful evaluation and monitoring
of a patient's progress, the DOTS approach successfully prevents multi-drug resistance by
ensuring full treatment of a sick patient until they are proven cured.
DOTS Has Been Successful Around the World
Tanzania, China, Guinea, Peru, Bangladesh, Mpumalanga (South Africa), and New York City
have used the DOTS approach and seen their cure rates skyrocket. For example in:
New York City: Using the DOTS approach, New York City has achieved a 36% decrease
in the number of TB cases between 1992 and 1995 and cut the MDR-TB rate by 75%.
Bangladesh: In 1993, the government of Bangladesh adopted DOTS to cure its widespread
TB cases. By 1995, as many as 80% of the TB patients treated were being completely cured in
the parts of the country using the DOTS strategy.
China: Since DOTS was implemented in 1991, the TB cure rate in participating provinces of
China has improved dramatically from less than 50% to over 90% among new cases.
Peru: From 1991-94, the treatment and cure of contagious cases is estimated to have
prevented 1.5 million new infections.
South Africa: DOTS is currently being tested in Mpumalanga District with good results.
Over 80% of TB patients have been successfully treated in the Mpumalanga demonstration
project.
Other countries who are just beginning to use the DOTS strategy are also witnessing significant
results. In India, pilot projects in New Delhi, Gujarat, and Bombay are using the DOTS strategy
and are tripling their previous cure rates.
But More Countries Need To Implement DOTS
The DOTS strategy needs to be put into effect in many countries plagued by TB. Of the 8 million
people who develop active TB each year, only about 500,000 have access to a DOTS based
approach. If the DOTS strategy were used consistently throughout a dozen large countries - such
as Bangladesh, Brazil, China, Ethiopia, India, Indonesia, Mexico, Nigeria, Pakistan, Russia,
South Africa, Zaire - nearly three-fourths of the world's TB cases could be cured. As of 1995,
only five of these twelve countries had aggressively committed to establishing and expanding TB
control based on the DOTS strategy.
The disease already is endemic globally. Russia and Eastern Europe have seen reports of TB cases
surge upwards, with some regions experiencing high rates similar to those found in Africa.
Industrialized countries are not exempt; cities such as Montreal, Milan, Amsterdam, Dallas, and
Paris have seen TB rates rise in recent years.
Multi-Drug Resistant TB: An Incurable Disease?
Recent Outbreaks of MDR-TB
New, multi-drug resistant strains of
New York City
tuberculosis are threatening to make
London
TB incurable again, as it was before a
Milan
India
cure was found in 1952. Multi-drug
Thailand
resistance is a man-made phenomena
South Africa
and is created by inconsistent or
Estonia
Pakistan
partial TB treatment. Multi-drug
resistant strains of TB spread as
Source: WHO Global TB Program
quickly as regular TB and have
emerged in cities all over the world.
Humans Are Breeding Multi-Drug Resistant TB
Inconsistent or partial TB treatment is the primary cause of multi-drug resistant strains of
tuberculosis - it does not occur naturally. Many patients do not take their medicines for the entire
six-month treatment period or stop treatment because they no longer have the outward symptoms
of the disease.
In addition, many doctors and health workers prescribe the wrong combination of drugs. The
World Health Organization estimates that nearly two-thirds of those who are prescribing TB
medication are putting people at risk to drug-resistant TB.
A standardized four-drug regimen of anti-TB medicines taken consistently for six months offers a
95% cure rate for TB. But when treatment is inconsistent or not properly administered, some TB
bacteria may not be killed. They will be weakened, but not dead. If treatment continues
haphazardly, or is simply repeated when a patient begins to feel sick again, the bacteria could
become resistant to some, or all, of the drugs. They can then multiply, creating millions of copies
of themselves, all drug resistant.
Multi-Drug Resistant TB Is Too Costly to Cure
Strains of multi-drug resistant TB are just as contagious as the regular TB bacteria, but in many
cases, they cannot be cured with available and affordable drugs. Multi-drug resistant TB can raise
the cost of treating tuberculosis 100 times.
The mutant TB strains may be resistant to one, two, three, or even up to nine different anti-TB
drugs, making treatment more difficult and costly to administer. In developing countries, people
with multi-drug resistance usually die because effective treatment is impossible in a poor nation. In
wealthy countries, approximately 50% of patients with MDR-TB die because of the difficulty of
treating the disease.
Multi-Drug Resistant TB is Spreading
Researchers estimate that as many as 50 million people may already be infected with TB that is
resistant to one or more common anti-TB drugs - and that number is growing.
Although no one knows exactly how far multi-drug resistant TB has spread, it exists in both the
developing and industrialized world. A 1995 study of regions in Pakistan showed that 75% of TB
patients were resistant to at least one drug, and over 40% were resistant to more than three drugs.
In the United States, New York City has seen a 36% decrease in the number of TB cases reported
between 1992 and 1995 - but, new drug resistant strains of TB persist. A new study documents
the transmission of a TB bacteria resistant to seven drugs from New York to metropolitan areas in
Florida, Nevada, Georgia, and Colorado. These cities have a combined population of 7.1 million
and are hubs for air and auto travel.
DOTS Can Prevent Multi-Drug Resistant TB
Failure to adhere consistently and completely to the standardized combination of anti-TB drugs can
cause multi-drug resistance to an effective cure. Because of this phenomenon, the most vital aspect
of TB control is not the choice of drugs available today, but the measures taken to ensure that
patients regularly take all the drugs in their treatment.
The World Health Organization's recommended strategy of treatment - directly-observed
treatment, short-course - meets that challenge. DOTS is a strategy that provides a standardized
combination of the most effective medicines, ensures through direct observation that these
medicines are taken regularly until patients are cured, and monitors patients to ensure their overall
progress. This three-pronged approach is the key to saving lives and stopping the TB epidemic.
If adequate funds are spent to attack the TB problem at its source - in sick patients - we could
cure more than 85% of those infected with TB in developing countries, stop the spread of the
disease, and prevent the creation of MDR-TB in the first place.
The World Bank has called the DOTS strategy one
of the "most cost-effective of all health interventions."
Figure 3.2 Benefits and costs of forty-seven health interventions
Increase in DALYs (log scale)
100
Chemotherapy for tuberculosis
10
Vitamin A
supplementation
1
0.1
$1/DALY
Treatment of
leukemia
0.01
$10/DALY
Greater
effectiveness
Environmental
0.001
Lower
control of dengue
$100/DALY
cost
$10,000/DALY
$1,000/DALY
0.0001
10,000
1,000
100
10
1
0.10
Cost per intervention or per intervention-year (dollars, log scale)
Target:
Children under age 15
Adults age 15 or older
Note: DALY, disablility-adjusted life year. Interventions are specific activities intended to reduce disease risks, treat illness,
or palliate the consequences of disease and disability; an intervention-year is an intervention repeated throughout the year
rather than provided only once.
a. Includes some interventions that benefit all age groups.
Source: Jamison and others forthcoming; World Bank data.
SOURCE: The World Bank. 1993. Investing in Health: World Development Indicators. New
York: Oxford University Press. p. 62.
Projected Change in the Rank Order of Disease Burden
for 15 Leading Causes, Worldwide 1990-2020
1990
Rank
2020
Disease or injury
Order
Disease or injury
Lower respiratory infections
1
Ischemic heart disease
Diarrheal diseases
2
Unipolar major depression
Conditions arising during perinatal period
3
Road traffic accidents
Unipolar major depression
4
Cerebrovascular disease
Ischemic heart disease
5
Chronic obstructive pulmonary disease
Cerebrovascular disease
6
Lower respiratory infections
TUBERCULOSIS
7
TUBERCULOSIS
Measles
8
War
Road traffic accidents
9
Diarrheal diseases
Congenital anomalies
10
HIV
Malaria
11
Conditions arising during perinatal period
Chronic obstructive pulmonary disease
12
Violence
Falls
13
Congenital anomalies
Iron-deficiency anemia
14
Self-inflicted injuries
Protein-energy malnutrition
15
Cancers of trachea, lunch, and bronchus
NOTE: Disease burden is measured in disability-adjusted life years (DALYs), a measure that
combines the impact on health of years lost due to premature death and years lived with a
disability. One DALY is equivalent to one lost year of healthy life.
SOURCE: Murray, C. J. L., and Lopez, A. D. 1996. Global Burden of Disease and Injury,
Vol. 1. Boston: Harvard University Press.
MEMORANDUM
DATE: October 2, 1997
TO:
Eric Schwartz, Richard Ragan
National Security Council
FROM: Ralph Nader
Steering Committee, Princeton Project 55 Tuberculosis Initiative
RE:
global tuberculosis control activities
ATTACHMENTS:
1. Princeton Project 55 brochure
2. Tuberculosis fact sheets
3. Media coverage of tuberculosis
4. Congressional interest in increasing funding for TB programs
5. Senate hearing on infectious diseases
The mission of the Princeton Project 55 Tuberculosis Initiative is to encourage United States leadership of
effective and innovative tuberculosis prevention and treatment programs, and to raise public awareness about
tuberculosis. We are a public service interest organization, and the steering committee of the PP55 Tuberculosis
Initiative includes myself, Dr. Gordon Douglas (President of Merck Vaccines), Dr. Myron Freund, Bill Shafer,
and Pete Milano, all members of Princeton's Class of 1955. The Project Managers of the Tuberculosis Initiative
are Celine Gounder and Scott Regenbogen.
Tuberculosis is the single greatest infectious killer in the world, causing 8 million illnesses and 3 million deaths
every year. Like the common cold, TB is spread through the air by casual contact. The primary cause of this
epidemic is ineffective treatment and prevention strategies, which fail to identify infected individuals, and poorly
address infectious cases. The HIV/AIDS epidemic is now fueling the TB epidemic and threatens an explosion of
TB, especially in Asia, Eastern Europe, and the nations of the former USSR.
Yet an extremely cost-effective treatment and management system has proven to effectively control TB in all parts
of the world. This strategy is known as DOTS (Directly Observed Therapy Short-course). DOTS ensures that
each patient's treatment and cure is monitored and documented, and that action is taken if progress is not made.
As part of the strategy, health workers watch their patients take their medication, and monitor them until they are
cured. DOTS has achieved cure rates of greater than 85% in places as different as New York City, Peru, China,
Tanzania and Bangladesh. The World Bank has called the DOTS strategy one of the "most cost-effective of all
health interventions." This comprehensive therapy can cost as little as $11 per patient in developing countries.
DOTS is essential because when patients do not take all of their medications, they produce strains of the bacteria
that are resistant to anti-TB drugs. Some strains have become resistant to the whole arsenal of drugs, making
them virtually incurable. These especially dangerous multi-drug resistant forms of tuberculosis (MDR-TB) can be
prevented by ensuring that patients take their medicines.
MDR-TB is the most serious infectious disease threat for the early 21st century for three reasons: i) it is virtually
incurable and highly fatal in the developing world; ii) it is transmitted by casual contact, through the air; and iii) it
is already widespread, and is poised to break out of the "hot-zones" which have been identified as areas of
particular danger.
The world stands at a crossroads for mobilizing international action. Effective TB control would protect US
public health well into the next century. It is imperative that an effective program be installed, and that
commitments be sustained.
Attachment 4
Congressional Interest in Tuberculosis
The Princeton Project 55 Tuberculosis Initiative has been in contact with all senators and
congressmen on the Foreign Operations subcommittees of the Appropriations committees. Both
Foreign Operations subcommittees have discussed appropriations to USAID for the purpose of
combating infectious diseases.
In the Senate subcommittee, Sen. Patrick Leahy (D-Vermont) has been a strong proponent of
increasing funding to infectious disease programs. In May, the Foreign Operations subcommittee
held a hearing - "Combating Infectious Diseases" - on behalf of Sen. Leahy. Sen. Daniel
Inouye (R-Hawaii) is also interested in TB control because Hawaii has the second highest case rate
of tuberculosis in the country. Others supportive of increased funding to tuberculosis programs
include: Sen. Tom Harkin (D-Iowa), Sen. Frank Lautenberg (D-New Jersey), and Sen. Patty
Murray (D-Washington). No senators expressed opposition to increasing funding available for
tuberculosis control programs.
In the House subcommittee, Rep. Rodney Frelinghuysen (R-New Jersey), Rep. Nita Lowey (D-
New York), Rep. Sidney Yates (D-Illinois), Rep. Nancy Pelosi (D-California), Rep. Esteban
Torres (D-California), and Rep. David Obey (D-Wisconsin) are most strongly supportive of
increasing funding to tuberculosis control programs. Rep. Frelinghuysen will be taking the lead
during the conference committee on the Foreign Operations Appropriations bill to insert report
language advocating funding of the Global Tuberculosis Initiative. No congressmen expressed
opposition to increasing funding available for tuberculosis control programs.
Other senators and congressmen have a record of supporting tuberculosis programs:
Rep. James Walsh (R-New York) had tuberculosis himself, and is a strong supporter of increased
funding to tuberculosis control programs.
Rep. John Dingell's (D-Michigan) father had tuberculosis and the congressman is supportive of
TB control initiatives. In 1995, he requested a report from the General Accounting Office on the
incidence of tuberculosis in the United States.
In 1994, Sen. Frank Lautenberg (D-New Jersey) supported a measure allotting $500,000 to
support two demonstration projects whose focus was to be on collaborative approaches to
controlling the spread of TB.
In 1994, Rep. Tony Hall (D-Ohio) called upon USAID to make tuberculosis a priority, and if it
failed to do so, he called upon Congress to earmark funding for tuberculosis programs.
In 1992, Sen. Edward Kennedy (D-Massachusetts), Reps. Henry Waxman (D-California), and
Edolphus Towns (D-New York) jointly requested a congressional Office of Technology
Assessment report on the rise of tuberculosis cases in the United States. In 1994, Sen. Kennedy
and Rep. Dingell requested a follow-up study.
In 1992, Rep. Waxman and Rep. Charles Schumer (D-New York) proposed that $100 million be
spent for special testing and drug programs to fight drug resistant tuberculosis.
In contrast, Rep. Lamar Smith (R-Texas) said in 1993 with regard to tuberculosis prevention,
"You know, prevention is always best. But I look upon prevention a little bit differently. To me,
prevention means that we have more border security, a better border patrol."
PRINCETON PROJECT 55 INC.
file
TB
Tuberculosis Initiative
Ralph Nader
P.O. Box 19312
Washington, DC 20036
May 27, 1998
First Lady Hillary Rodham Clinton
The White House
1600 Pennsylvania Avenue NW
Washington, DC 20500
Dear Mrs. Clinton,
In your recent speech before the World Health Assembly in Geneva, you provided an
excellent account of the severity and urgency of many global health crises. We are
particularly pleased by your emphasis on the prevention and treatment of infectious
diseases like tuberculosis.
Major public addresses such as yours are exactly what is now required to revive this
nation's awareness of these profoundly neglected health causes. TB is one of the most
disproportionately unheeded pandemics, yet it is the world's number one infectious killer
and the death toll is rising every year. Few people in this country are aware of the
enormous burden TB exacts from the citizens of developing countries, and the clear and
present threat that drug resistant strains pose to the health and national security of the
United States. TB kills more women than all causes of maternal mortality combined, yet
most Americans consider it a disease of the past. The yearly death toll from land mines is
matched by TB every single day, however many journalists and even public officials
believe we have won the war against tuberculosis.
You have the unique capacity to refocus America's attention on health issues of major
global importance, and this speech was an exemplary first step. Now, as you said, "We
must put our hearts, our minds, and our resources in action." In South America, you
witnessed the unprecedented successes that can be achieved through the use of directly-
observed treatment for tuberculosis patients. As you saw, the WHO-recommended
regimen, Directly-Observed Treatment, Short-course (DOTS) is a very simple system, that
the World Bank determined to be one of the world's most cost-effective health
interventions. Successful application of DOTS has produced cure rates above 85% in
places as diverse at New York, Peru, China, Tanzania, and Bangladesh. In most
countries, the overall effect of DOTS on the primary health infrastructure and the incidence
of infectious diseases has been remarkable.
For the health and stability of developing nations, and to protect Americans from multi-
drug resistant TB (MDR-TB), it is time for the U.S. to make a significant investment in
DOTS for the most severely affected nations of the world. USAID's new infectious
disease initiative is a good beginning, but this pilot project must be expanded to other key
regions of the world. MDR-TB is already threatening to overwhelm the public health
systems of "hot-zones" such as Latvia, Estonia, Russia, the Dominican Republic,
Argentina, and the Ivory Coast. Unless we ensure the rapid application of DOTS in these
and other countries, epidemics of MDR-TB will become commonplace in many more
countries.
A global assault on TB will also require significant commitments from the WHO, and from
developing nations. The U.S. should make use of its diplomatic influence to encourage
endemic nations to dedicate resources to the control of TB within their borders.
Additionally, the U.S. should help to accelerate the introduction of WHO Secretary
General-Elect Gro Harlem Brundtlandt's "Roll Back Malaria" and "Roll Back TB"
initiatives. Currently the WHO Global TB Programme's total annual budget for the
application of DOTS is a paltry $11 million. Dr. Brundtlandt should be supported in
significantly increasing funding for the TB program, in accordance with its prominence
among causes of death globally.
Finally, with the introduction of the President's "Research Fund for the 21st Century,"
now is the time for the U.S. to make a meaningful investment in research on the infectious
diseases of major global health importance identified by USAID's new initiative. DOTS
can make a significant impact on the global disease burden, but without an effective TB
vaccine, we will not be able to control TB over the long-term. Now that scientists have
read the entire genetic code of the TB microbe, the potential for the development of new
drugs, diagnostics, and vaccines has never been better. This March, a working group of
TB and vaccine experts, convened by Secretary Shalala, met to formulate a national
"Blueprint for a Tuberculosis Vaccine," which sets the course for accelerated development
of a TB vaccine, but without new funding, this initiative cannot get under way.
Thank you, Mrs. Clinton, for your dedication to the health of the world's population. We
hope that you will work with us to significantly increase U.S. commitments to global
health.
Sincerely,
RalyMander Ralph Nader
Steering Committee
Enclosures: informational packet
cc: Mr. Sidney Blumenthal, Dr. Laura Efros, Mr. Tom Friedman, Mr. Leon Fuerth, Mr.
David Halperin, Mr. Chris Jennings, Dr. Donald Jordan, Dr. David W. Kampt, Mr. Peter
Rundlet, Mr. Eric Schwartz, Mr. Michael Waldman, and Mr. Joel Wilson.
cc: melanne
from
FACSIMILE
WORLD HEALTH ORGANIZATION
Tel: +41 (22) 791.2711
CH-1211 Geneva 27 - Switzerland
Fax: +41(22) 791.
Telegram: UNISANTE GENEVA
Email: [email protected]
Telex: 415416
WWW: http://www.who.ch
Message No.:
Page 1
of
2
pages
Date: 5 November 1998
From: Office of the Director General
To: Office of the First Lady of the United States of
HQ Geneva
America
Fax No.: (1 202) 456 2883
Our ref.: GTB/T9-370-30
Subject:
PERSONAL MESSAGE FROM THE
DIRECTOR-GENERAL FOR KIND
TRANSMISSION TO THE FIRST LADY,
MRS HILLARY RODHAM CLINTON
Dear Mrs Clinton,
Dear Hillary
Thank you for hosting the meeting on Tuberculosis at the White House on 28 October 1998.
1 was strongly encouraged by the clear level of commitment among US agencies, the Open
Society Institute and the World Bank to accelerating the fight against TB. Strong support and
leadership from these institutions, including the National Institutes of Health (NIH), US Agency for
International Development (USAID) and Centers for Disease Control and Prevention (CDC), and of
course also a number of other partners, are critical to renewed global efforts to combat this
preventable disease.
The situation of the present TB control effort is very similar to that of child immunization in
the mid-1980s. Basically, technical knowledge existed, a critical mass of people were being trained
to implement Expanded Programme on Immunization (EPI) and many countries, mainly small and
mid-size, were making good progress. But the progress was very slow in large countries, resulting in
a low global immunization coverage.
However, child immunization has achieved the global target in the early 1990s by adding
coalition building at global level and country specific social mobilization to the ongoing effort. I
believe we can drastically expand coverage of the directly observed treatment, short-course (DOTS)
strategy, as well as pursuing new and innovative approaches, by following a similar path.
As we discussed during our meeting, WHO is prepared to give its fullest attention to a
renewed attack on TB globally, including a special focus on the situation in the Russian Federation.
I have instructed my staff to accelerate the careful preparation of a Stop TB Initiative which will
serve to galvanize a broad global coalition of important partners, and to initiate social mobilization in
the target countries. As such, WHO welcomes the opportunity to lead this effort. I am delighted that
Mr Soros and Mr Wolfensohn have committed to participate in and support this Initiative.
cc:
Mr George Soros, Soros Foundation, New York (Fax 1 212 974 0367)
Mr James Wolfensohn, World Bank, Washington (Fax 1 3031)
1948
1998
WORLD
MEALTH
ORGANIZAT
ORGANISATION MONDIALE ps LA LINTE
A
66 It T6L +4122 PAX T : : LT NHL 86, TT/90
Office of the First Lady of the United States of America
page 2.
5 November 1998
A critical first step is a meeting of potential Initiative partners on 28 November 1998 in
Bangkok to begin planning for the expansion of the partner base in the fight against TB. This will be
important in order to achieve the level of political and economic commitment needed to reverse the
grip of this disease in the 22 countries which account for 80% of the world's TB. WHO staff will be
working with representatives from the CDC, the World Bank and others to identify appropriate
collaborators and secure expanded commitment to this Initiative.
In early 1999, a second meeting of partners is planned. This meeting will serve to build
global consensus regarding strategy and direction of the Initiative.
I am confident that by working together through a Stop TB Initiative we will make a
difference in mobilizing worldwide commitment required to adequately confront the global TB
epidemic. I thank you again for hosting the important meeting last month, your continued interest in
global health issues, and the particular support you are giving to WHO and to myself.
Yours sincerely,
Ero
Gro Harlem Brundtland, MD, MPH
Director-General
WHO/GTB/GVA
66 11 T6L +1112 PAY T:21 NHL 86, TT/90
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
Q
file WHO/TB
Téléphone Central/Exchange: +41(22) 791.2111
Direct: 791.2963
Direct fax: 791.4199
Mrs Hillary Rodham Clinton
E-mail: [email protected]
First Lady of the United States of
America
In reply refer to: STB-T9/370/30
The White House
Prière de rappeler la référence:
1600 Pennsylvania Avenue, NW
Washington, DC 20500
USA
27 April 1999
Dear Hillary
Further to our recent meeting and communications regarding the global tuberculosis
epidemic, the STOP TB Initiative and specific efforts to assist the government of the Russian
Federation to improve the TB control situation, I would like to brief you on the results of recent
WHO activities in these areas.
Following our meeting at the White House in October 1998, WHO, on behalf of a growing
coalition of partners, launched the STOP TB Initiative. Over the past few months, through generous
support from USAID, CDC and others, a Secretariat based in Geneva consisting of staff seconded
from WHO and various external partners has been laying the foundations of a global campaign to
STOP TB. Its aims are to create greater public demand for action against TB and to stimulate the
political leadership necessary to mount an effective response - with special focus on the 22 highest
burden countries which account for 80% of the global burden of disease.
To build momentum and draw high level political attention to this campaign, a stream of
activities is planned for 1999-2000. These events will serve to bring new partners, including donor
agencies, foundations, industry and academia, into the Initiative, and in a stepwise fashion establish
the foundation for expanded global action against TB. This includes a "Ministerial Conference to
STOP TB" which will be co-organized by STOP TB and the Government of The Netherlands and
will be held in The Netherlands in March 2000. This conference will bring together the Ministers of
burden Health as well as Finance, Development or Planning from the highest burden countries to set the
stage for expanded country action against TB across sectors of government and society.
An All Partners' Forum is slated for the spring of 2000 with the aim of bringing in a wider
range of players into TB control and strengthening the co-ordination between the internal and
external TB control organizations working in high TB prevalence countries.
I have welcomed the World Bank and the Soros Foundation as partners in this Initiative and
have requested the support of Mr Wolfensohn and Mr Soros for several of these activities. In
addition, I have invited the participation of Ms Carol Bellamy (UNICEF) and Mr James Gustave
Speth (UNDP) in the STOP TB Initiative in order to ensure wider participation of UN system
agencies in the fight against TB.
./2
cc:
Mr G. Soros, Open Society Institute, New York
Mr J. Wolfensohn, World Bank, Washington, D.C.
1211 GENEVA 27-SWITZERLAND Telegr.: UNISANTE-GENEVA Telex 415416 OMS Fax 791.07.46 1211 GENEVE 27-SUISSE Télégr.: UNISANTE-GENEVE
Our joint efforts to assist the Russian Federation have also progressed since we last met. In
early March 1999, a WHO delegation, led by Dr David Heymann, Executive Director of
Communicable Diseases, visited Moscow and met with officials at the Ministry of Health, the
Russian Academy of Medical Science, the health committee of the DUMA and the Russian Red
Cross. During these meetings, an agreement was reached to establish an interdisciplinary group, led
by the Ministry of Health and WHO and comprised of Russian and international TB experts, with
the objective of developing the best strategy for the control of TB in the Russian Federation.
I was particularly happy regarding this agreement, as it shows significant progress by the
government of the Russian Federation in their concern for and political commitment to TB control.
We have suggested that the USAID, CDC, the Soros Foundation's Open Society Institute, the World
Bank, and other donors assisting the government of the Russian Federation in TB control be invited
to join this working group. We are currently in the process of finalising the terms of reference with
the Russian Ministry of Health.
I am confident that this working group will facilitate the improvement of TB control in the
Russian Federation, make it more cost effective, more accessible to larger populations and provide
recommendations on areas such as TB in prisons and the management of drug resistant forms of TB.
Regarding the issue of multiple drug resistance (MDR-TB) in the Russian Federation and
other heavily impacted areas of the world, in January 1999 WHO convened a meeting to plan and
coordinate a rational, evidence-based approach to this emerging issue. Meeting participants, which
included USAID and CDC, agreed to strengthen collaboration on MDR-TB work between
institutions and affected communities. WHO was called upon to serve as the coordinating institution
to establish a global working group of experts and interested parties, and to serve as the negotiator to
facilitate the implementation of pilot projects in settings where MDR-TB is firmly entrenched. It is
anticipated that the results from these projects will provide the necessary evidence for policy
recommendations to WHO member states facing this complicated health issue.
I thank you for your continued interest in and leadership on global health issues and look
forward to communicating more progress on these and other important activities in the months to
come.
Yours sincerely,
hno 11.Bundtled
Gro Harlem Brundtland, MD, MPH
Director-General
file TB
OPEN SOCIETY INSTITUTE
S
I
GEORGE SOROS
Chairman
ARYEH NEIER
President
March 3, 1999
Mr. J. Brian Atwood
Administrator
Agency for International Development
1300 Pennsylvania Avenue, N.W.
Room 6.9
Washington, D.C. 20523
Dear Mr. Atwood,
I want to congratulate you on the decision of US AID to fund a DOTS-Plus pilot project
on treatment of multi drug resistant TB in Russia, to be carried out by a team from the
U.S. Centers of Disease Control and Prevention.
I was particularly pleased to learn that the city of Ivanovo was chosen as the project site.
As you know, a TB control program of the Public Health Research Institute (PHRI),
supported by OSI, has been operational in Ivanovo for nearly a year. PHRI has prepared
the groundwork for the CDC project and will continue to maintain the infrastructure to
support and interact with the CDC team, thus significantly increasing the chances for
our joint success.
The complimentary effort by PHRI and CDC which is funded, respectively, by OSI and
US AID is a perfect, albeit rare, example of public/private collaboration to address
pressing issues of global public health. And it appears to be the first concrete outcome of
the meeting that we had last October at the White House. I am looking forward to
continued work with you.
Yours)sincerely,
George Soros
CC: Hillary Clinton, Donna Shalala, Gro Brundtland, James Wolfensohn,
John Eisenberg, Margaret Hamburg
400 West 59th Street, New York, New York 10019
Phone: 212. 548. 0600
Fax: 212. 548. 4679
Website: http://www.soros.org
09/08/95
09:54
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STATE LEG AFF.
002
H8542
CONGRESSIONAL RECORD-HOUSE
September 6, 1995
gentlemen, the government is begin-
and the need for responsible behavior by
port of that country, protections
ning to govern and Congress has little.
every member of the International community
against discrimination.
if any. control over the FBI, the ATF.
to confront the oppression that afflicts millions
I am very pleased to say that at the
and IRS.
of women.
request of myself and the gentlewoman
Shame Congress. Clean hands? My as-
With the assistance of the U.S. Ambassador
from California [Ms. WATERS] about 70
sets.
to the United Nations, Madeleine Albright, Mrs.
Members of this House have joined in
Clinton has laid the important groundwork for
sending a letter to Mr. Mugabe object-
continued dialog between Secretary of State
ing strenuously to his bigoted attack
WHAT I LEARNED ON SUMMER
Christopher and the Chinese Foreign Minister
on people who simply have a different
VACATION
in their upcoming meeting.
sexual 'orientation, noting that this
(Mr. HAYWORTH asked and was
Hillary Clinton deserves our gratitude for her
kind of denunciation of people who are
given permission to address the House
efforts which engage China while steadfastly
decent citizens is contrary to the re-
for 1 minute and to revise and extend
advocating the need for advances in human
spect for human rights that we had
his remarks.)
rights which are necessary for China's genu-
hoped Mr. Mugabe would show.
Mr. HAYWORTH Mr. Speaker, we
ine integration in the international arena.
I am including at this point in the
might entitle this, "What I Learned on
RECORD the letter and the list of signa-
Summer Vacation." The fact is, going
tures, as follows:
back home, we reorient ourselves to
OUR COMMITMENT TO GET THE
His Excellency ROBERT MUGABE,
the great and good common sense of
JOB DONE
President. Harare. Zimbabwe.
the American people.
(Mr. BASS asked and was given per-
DEAR MR. PRESIDENT: We were distressed
mission to address the House for 1
to read your attack on people who are gay
Did I hear uniformity among the con-
and lesbian.
stituents of the Sixth District of Ari-
minute and to revise and extend his re-
As Members of Congress dedicated to pro-
zona? Of course not. Good people can
marks.)
tecting the human rights of all people. we
disagree, but overwhelmingly the peo-
Mr. BASS. Mr. Speaker, I am proud
believe that you are gravely mistaken in
ple of the Sixth District of Arizona told
to say that today the House Repub-
your denunciation of people based on their
me. "Stay the course, stick to your
licans are ready to finish the job we
sexual orientation and your assertion that
started 8 months ago. We are ready to
they should be excluded from the protection
principles, work hard to reform this
balance the budget for the first time in
of their "individual freedom and human
government."
rights."
Indeed, we have heard today already
a generation, to help save this country
When individuals are mistreated by gov-
broad bipartisan consensus, and so in
for our children and our grandchildren,
ernment because of some basic characteris-
that spirit of bipartisanship, I extend
and we are ready to pass a. plan that
tic of their nature, human rights are vio-
my hand to my friends on this side of
will protect. preserve, and strengthen
lated. Attacking docunt individuals who are
the aisle, saying the problems we
Medicare for our senior citizens.
fully respectful of the rights of others. who
confront are too great for politics as
We are willing to take the heat on
are productive and responsible citizens, but
this controversial issue to save a bro-
who happen to be gay or lesbian is wrong. As
usual.
ken system that three, I repeat, three
strong supporters of the struggle of the peo-
Let us get about the business of gov-
of President Clinton's own Cabinet sec-
ple of South Africa against the oppressive,
erning America.
dehumanizing apartheid system, WB wel-
retaries say needs to be dealt with im-
comed the inclusion in the Constitution of
mediately. We are ready to pass a plan
South Africa of recognition that discrimins-
FIRST LADY DESERVES OUR
that will help end our country's wel-
nion based on an individual's sexual orients-
PRAISE
fare system that creates poverty, de-
tion is wrong. We strongly urge you to re-ex-
(Mr. RICHARDSON asked and was
pendency, destitution, breaks up fami-
amine this issue and to follow the example of
lies. and discourages people from work-
the new government of South Africa in re-
given permission to address the House
specting the human rights of all people.
for 1 minute and to revise and extend
ing.
BARNEY FRANK,
his remarks.)
We are committed to ending a system
Member of Congress.
Mr. RICHARDSON. Mr. Speaker, the
that has created debt and has rewarded
MAXINE WATERS,
First Lady deserves credit. first for
inefficiency.
Member of Congress.
going to China, and second for speak-
We are not afraid to take on the spe-
COSIGNERS OF THE LETTER TO PRESIDENT
ing out so forcefully for human rights
cial interests and the status quo here
ROBERT MUGABE OF ZIMBABWE
and women's rights.
in Washington. In fact, the only ones
Noil Abercrombie, MC; Xavier Becerra,
The First Lady spoke out eloquently
interested in preserving the old ways
MC; George Brown, MC; Ronald Del-
against forced abortions and forced
are the defenders of the old order who
lums, MO; Lloyd Doggett. MC; Anna
sterilizations and other women's rights
live and breathe inside Route 495 in
Eshoo, MC; Elizabeth Furse. MC: Ste-
abuses common in other countries,
Washington, DC. and if we learned any-
ven Gunderson. M,C; Alcee Hastings,
thing during this August recess, it is
MC: Steny Hoyer. MC; Patrick Ken-
such as rape, mutilation, and domestic
that the American people want us to
nody, MC; Zoe Lofgren. MC; Edward
violence. She also stressed the impor-
stay the course and continue with this
Markey, MC: Marty Meehan. MC:
tance of women to families and the
George Miller, MC; Joseph Moakley,
need for setting new standards for
revolution in 1995.
MO; Eleanor Holmes Norton. MO:
women's health, economic welfare.
Frank Pallone, MC; Jack Reed, MC:
family planning, and the status of
Martin Sabo. MC; Charles Schumer,
PROTECTING HUMAN RIGHTS OF
MC; Gerry Studds, MC; Melvin Watt.
women in general.
ALL PEOPLE
MC: Sidney Yates, MC; Gary Acker-
Mr. Speaker, the First Lady showed
guts and commitment in China, and
(Mr. FRANK of Massachusetts asked
man, MC; Howard Berman, MC; WIl-
and was given permission to address
liam Clay, MC; Norman Dicks, MC:
she deserves our praise.
Richard Durbin, MC: Sam Farr. MC;
Mr. Speaker, the First Lady has worked
the House for 1 minute and to revise
Sam Gejdenson, MO; Luis Gutierrez,
continuously on issues related to women, chil-
and extend his remarks and include ex-
MC.
dren, and families for the past 25 years. This
traneous material.)
Sheila Jackson-Lee, MC; Tom Lantos.
week she has combined her skills and experi-
Mr. FRANK of Massachusetts. Mr.
MC; Nita Lowey, MC: Jim McDermott,
ences with the role of diplomat.
Speaker, sadly, just before we left for
MC; Carrie Meek. MC; Norman Mineta,
Amidst tenuous United States-Chinese rela-
recess, the President of Zimbabwe,
MC; James Moran, MC; John Olver,
tions, the First Lady has walked a fine line in
Robert Mugabe, engaged in an unjusti-
MC; Nancy Pelosi, MO: Lucille Roybal-
Allard. MC; Bernard Sanders. MC;
Beijing-balancing the urgent need for worth
fied wholly prejudicial attack on gay
David Skagga, MC; Edolphus Towns,
en's rights and the administration's policy of
men and lesbian citizens of his coun-
MC; Henry Waxman, MC; Thomas
constructive engagement with China.
try.
Barrett, MC: Sherwood Boehlert, MC:
Mrs. Clinton has successfully pointed out
The attack was in sharp contrast to
Peter DeFazio, MC; Julian Dixon. MC;
the need for a forum of openness of free
the leadership of, for instance, Nelson
Ellot Engel. MC; Thomas Foglietta,
speech in Beljing. Her remarks underscore the
Mandela, who has included in the Con-
MC; Henry Gonzalez, MC; Jane Har-
magnitude of the U.N. Women's Conference
stitution of South Africa. with the sup-
man. MC: Maurice Hinchey, MC; Eddie
09/08/95
09:55
202 647 2762
STATE LEG AFF.
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September 6, 1995
CONGRESSIONAL RECORD-HOUSE
H8543
Berrice Johnson, MC; John Lewis, MC;
to Dut together anything that we
minute and to revise and extend her re-
Carolyn Maloney, MC; Cynthia McKin-
could. because these issues are very,
marks)
ney. MC: Kwelui Miume. MC; Patsy
very critical.
Ms. DELAURO. Mr. Speaker, over the
Mink., MC; Jerrold Nadler, MC: Major
There will not be another inter-
August break. I had a chance to meet
Owens, MC. Charles Rangel. MC: Bobby
national meeting. for 10 years, and to
with my constituents to discuss the
Rush, MC: Patricia Schroeder. MC;
Louise Slaughter. MC; Nydia
have allowed China to play with it this
Republican plan to cut Medicare in
Valánquez, MC; Lynn Woolsoy. MC.
way is outrageous.
order to finance a tax cut for the
I think the House leadership owes
wealthy. The people I represent want
American women also an apology, be-
me to bring a message back to the Re-
INTRODUCTION OF THE MOTOR
cause the delegation sent from this
publican leadership: Medioare 18 a trust
SPORTS PROTECTION ACT
body to the women's meeting could not
fund, not a slush fund.
(Mr FUNDERBURK asked and was
have a woman chair. A woman could
Now, I know that my Republican ool-
given permission to address the House
only be a cochair. They had to send a
leagues were also back home wying to
for 1 minute and to revise and extend
male along, too, and one who does rot
sell themselves as the true protectors
have a good record on women's issues.
of Medicare. But, the American public
his remarks.)
I find that very troubling. and the
isn't buying this GOP makeover. The
Mr. FUNDERBURK. Mr. Speaker. as
message from all of this 15. "Women.
public 18 skeptical about the sketchy
you know. North Carolina is the home
of professional auto racing and it is on
our time scill has not come yet." When
GOP plan that claims private insur-
will be treated as first-class rather
behalf of thousands of North Caro-
ance companies will offer seniors more
than the second-class citizens the Unit-
linians and millions of NASCAR,
for less. With suoh fantastic claims,
NHRA and INDY racing fans across
ed Nations relegated us to as we see
it's no wonder that a recent poll found
America that I introduce the Motor
this meeting in Beling proceed?
71 percent of Americans have little
Sports Protection Act today.
trust in the House Republicans to han-
dle Medicare.
Mr. Speaker. Bill Clinton 1s waging
1220
For 30 years Republicans have wart-
war or the tobacco family. He has
threatened the livelihood of thousands
CAL RIPKEN, JR.'S MANY
ad to privatize Medicare. In fact, the
ACHIEVEMENTS
current majority leader has said that
of tobacco farmers across the South
he would have no part of Medicare in a
and he 18 now or the verge of destroy-
(Mr. EHRLICH asked and was given
free world. Does that sound like a
ing professional automobile racing as
permission to address the Rouse for 1
WE know it.
party that wants to protect Medicare?
minuts and to revise and extend his re-
The Funderburk bill, which Richard
marks.)
Petty says all race Cans can rally
Mr. EHRLICH. Mr. Speaker. today I
THERE IS MORE TO DO
around, will stop Bill Clinton before he
rise in tribute to a constituent whose
(Mr. RADANOVICH asked and was
crosses the finish line. It prevents Big
achievement 18 tho talk of the Nation.
Brother agents from slapping advertis-
given permission to address the House
Tonight Cal Ripken, Jr. a native of
for 1 minute.)
ing restrictions on the tobacco spon-
Aberdeen, MD. will play his 2,131st con-
Mr. RADANOVICH. Mr. Speaker. this
sors of pro racing. Mr. Speaker. each
secutive game with the Baltimore Ori-
104th Congress now moves forward
NASCAR alone pumps over $2 billion
oles, breaking a longstanding record
from the Contract With America. And.
into the southern economy. Racing
held by the legendary Lou Gehrig It is
"move" must be the operative word.
fans are hard-working, law-abiding
fitting that Cal 18 the only player ever
The lesson learned in our August re-
Americans. They deserve better than
to accomrlish this feat, because he
cess is that the public wants action not
to be used as pawns in Bill Clinton's
uniquely represents the qualities for
words. Everywhere I went, men and
shell-game. Lets send him a message
which Lou Gehrig will always be re-
women said, "Congresaman, we'd soon-
right now: Bill Clinton keep your
membcred-sportsmanship. fair play.
er have you moving ahead * even if
hands off racing.
and sheer love of the game.
the path is rough and you stumble 00-
Support the Funderburk Motor
Fans across the Nation have started
casionally * don't let Congress just
Sports Protection Act
calling Cal the Iron Man. But endur-
stand there."
ance is only one aspect of his success.
America bought in to our program.
He was Rookie of the Year in 1982: MVP
WOMEN STILL TREATED AS
They approve our commitment to a
in 1983 and 1991; and played in 13 con-
SECOND-CLASS CITIZENS
balanced budget. They like outting
secutive All-Star games. He has hit
tack the bureaucracy. They commend
(Mrs. SCHROEDER asked and was
more home runs than any shortstop in
term limits.
given permission to address the House
major league history.
Most of this we delivered in this
for 1 minute and to revise and extend
DesDite his fame. Cal Ripkes takes
House. Yet, there is more to do here on
her remarks.)
precious time before and after every
the Hill, and I urge the Senate to heed
Mrs. SCHROEDER. Mr. Speaker. the
game to sign autographs, pose for pic-
the call.
United Nations owes the women of the
tures, or simply to chat with his fans-
Let us get down to business, but let
glebo a great apology.
the way Babe Ruth. Lou Gehrig. and
118 make sure it 18 dealing with unfin-
Every 10 years. there is an inter-
Jackie Robinson once did. At a time
iehed business, not business AS usual.
national U.N. Women's meeting. and
when many fans are disillusioned by
the United Nations could have carod
the big-business approach to baseball.
less about what the host d'd to make
Cal's sincere passion for the sport re-
REPUBLICANS TAKING THE CARE
this meeting as inconvenient and as
minds us of a time when baseball was
OUT OF MEDICARE
swful as possible. In fact. the Secretary
what it was always meant to be-a
(Mr. ENGEL asked and was given
Ceneral of the United Nations could
game.
permission to address the House for 1
not even bother to come. He predicted
I urge all my colleagues to join with
minute and to revise and extend his re-
he W&B going to have a fever all 12 days
me and the citizens of Maryland as we
marks.)
that this meeting was going to be
salute Call Ripken. Jr. His accomplish-
Mr. ENGEL. Mr. Speaker. I rise
going on.
ment 13 a timely illustration of what is
today on behalf of my mother, Seroy
Now, the message that sends to all
best about our national pastime.
Engel. and the millions of mothers. fa-
countries 18 that the United Nations 18
thers. sisters. and brothers throughout
Dutting thie on only because it is po-
our Nation whose lives depend on Medi-
litically cerrect, but they do not really
NOW 71 PERCENT OF AMERICANS
care. In the next few weeks this legisla-
care. and the Secretary General cannot
DO NOT TRUST REPUBLICANS TO
tive body is going. to have to make
really bother to come.
HANDLE MEDICARE
some tough decisions. The question
I find that tragic. and I am very
(Ms. DELAURO asked and was given
will be will we let the Republicans take
grateful the First Lady went and tried
permission to address the House for 1
the care out of Medicare. I say, "No."
09/08/95
09:56
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STATE LEG AFF.
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H8550
CONGRESSIONAL RECORD-HOUSE
September 6, 1995
bill. If we are going to vote, to put Con-
that shey made at the U.N. Fourth
The First Lady reaffirmed and BUD-
gress first and make sure Congress does
world Conference on Women. Mr.
ported the conference's main themes of
not have to shut down and take tho
Speaker, I rise as one who opposed
economic and educational opportunity.
same lumps that the rest of the Fed-
Beijing as the venue for this important
health care. and protecting women
sral Government and the rost of the
conference. I still think it was a most
against violence. Again. the First Lady
public does, at jeast give the public
unfortunate choice.
and the Ambassador did not mince
lobby reform. Let us vote on lobby re-
I rise as one who does not think that
words of protest over repression. igno-
iorm today. It 19 very easy and it 18
the United Nations has been strong
rance. abuse, and torture while the
very. very simple. Ban the trips. ban
enough in enforcing its own rules in
Chinese Government looked on. We
the gifts. ban the free meals.
terms of open participation for women
have been told that the Chinese Gov-
Mr. Speaker. I have taken the lobby
in the conference. The United Nations
emment has not reported on the First
reform pledge. I have voluntarily taken
did not do enough, whether we are
Lady's speech. but we do know that the
on and agreed to abide by the provi-
talking about the accreditation of
word will get out.
sions of the lobby reform package. even
women from Taiwan and Tibet, or
As one who has opposed the First
though it is not the law. This House
women who are concerned about wom-
Lady's attendance. I want to commend
can do the same thing today. There-
en's and human rights in those coun-
her for her outstanding courage for
fcre, I would just call upon the Repub-
tries. The United Nations did not do
breaking the silence on human rights
lican leadership and the Speaker. first
enough in regard to people that the
in China. for breaking the silence on
of all, to schedule something else. Get
Chinese just did not want into that
sterilization and forced abortion in
some other bills moving that mean
conference because their countries rec-
China. There are many in this body
something to the public besides Con-
ognize Taiwan; for example. the ren
who opposed the conference itself. I do
Gress' appropriation.
resentatives from Niger.
not include myself among them. be-
The second thing. If we are going to
However. Mr. Speaker. what I really
cause I believe that the conference 18 a
bring Congress appropriation to the
want to oal! to the attention of our ool-
very important one. I think that some
floor today. please put lobby reform on
leagues are the strong statements
of those who opposed the conference
LC. End the free trips, end the junkets,
made by the two leaders of our delega-
and opposed the First Lady's attend-
and the meals, end the guasts. end the
ance did so because of China's forced
tion. I strongly supported a high-pow-
bad perception. Bring some reform to
ered delegation to the Beijing con-
abortion policy.
this Congress.
I look forward to working with those
ference I strenuously opposed the at-
Finally. third, if I could just set time
colleagues. as some of us have been
for 026 more, Mr. Speaker, could we do
tendance by First Lady Hillary
working together in the Subcommittee
Rodham Clinton. I did so because I
campaign finance reform? we have
on Foreign Relations of the Committee
thought it W&B not possible for her to
heard a lot of calk about it. There was
on Appropriations and in other com-
attend the conference and make the
a great handshake out there in New
mittees of this House. to improve the
Hampshire 8 to 10 months ago; but how
strong statement that she made.
lot of the women in the world by im-
about real campaign finance reform to
Indeed, Hillary Rodham Clinton's
proving their health. The First Lady
make it easier for challengere? ! volten-
statements, are the strongest state-
talked about women's health. she
carily agreed to limit the campaign
ments made on human rights in China,
talked about violence against women,
spending that I do. I voluntarily take
in Asia, and in the world by this ad-
she talked about child survival, ahe
the voluntary campaign pledge that
ministration to date. I am very, very
talked about the spread of AIDS and
our Secretary of State in West Virginia
proud that the women of the Clinton
how rapidly it is spreading among
administration are taking such a
issues every election seasor. Congress.
wonten in the developing countries.
though, ought to be willing to Dase this
strong stand on this very important
I look forward to continuing my
issue.
for the entire country. and so make it
work with our colleaguee on this sub-
easier for challengers, make it easier
The First Lady, in Beijing. very cou-
ject, and certainly working with the
for the public, and make sure that the
rageously. stood up and broke the si-
Clinton administration on those areas
money ohase ends.
lence on sterilization and forced abor-
where more common ground has now
Finally. Mr. Speaker, let me just
tions in a country where that is the
been laid by the First Ledy. and where
urge the Members today, do not make
policy. Therefore, I say in the spirit of
more opportunity has been presented
the Arst thing Congress does when it
commendation to the First Lady and
by this very important conference
corres back into session to passits own
to Ambassador Albright that when
which called attention to these issues.
bill for its own appropriation to feather
they said they would not mince words
With that, Mr. Speaker. I am very
its own nest. If we are going to do that.
when they went to China, that they
proud to place into the RECORD the two
Mr. Speaker. I would urge, please lot us
would make the statements that would
statements, by First Lady Hillary
have lobby reform: End the tripe. end
be necessary. they. indeed. did. I com-
Rodham Clinton to the United Nations
the jurkets, end the free meals. and II-
mend them-for that.
Fourth World Conference on Women.
nally begin to restore some faith in
IE 18 shamen!. : think, that such an
and the remarks before the World
this congressional system. and particu-
important conference on the rights of
Health Organization, as well as the
larly, in this House of Representatives.
women and the economic future of
statement of our Ambassador to the
women and families was held in a coun-
United Nations, Ambassador Madeleine
try with such an appalling human
Albright. She was a sreat participant
COMMENDING HILLARY CLINTON
rights record. The strong statements of
in the conference, she represented our
AND MADELEINE ALBRIGHT FOR
these members of the U.S. delegation
country very excellently. as she.always
STRONG
STATEMENTS
ON
made 10 clear that our Nation must not
does. I am very pleased to put Ambas-
HUMAN RIGHTS DURING THE
waiver from its commitment to per-
sador Albright's very strong statement
U.N. FOURTH WORLD CON-
sona! and political freedom to equal
on human rights. indeed, basic free-
FERENCE ON WOMEN
rights and equal opportunity -
doms for all people. men and women, in
The SPEAKER pro tempore. Under a
The First Lady, in her remarks, was
the RECORD of this Congress.
previous order of the House. the gentle-
eloquent in her defense of the prin-
The material referred to follows:
woman from California [Ms. PELOSI] is
ciples of women's rights and human
AMBASHADOR MADEL.EINE K. ALBRIGHT. U.S.
recognized for 5 minutes:
rights. and she spent a great deal of her
PERMANENT REPRESENTATIVE TO THE UNIT-
ED NATIONS-REMARKS TO THE FOURTH
Ms. PELOSI. Mr. Speaker. I appre-
time talking about how advancing
WORLD CONFERENCE ON WOMEN
clate the opportunity to address the
women's rights would strengthen fami-
BEIJING INTERNATIONAL CONVENTION CENTER.
House on this very important day. I
lies throughout the world. She empha-
BEIJING. CHINA, SEPTEMBER 6. 1996
rise to commend First Lady Hillary
sized how that strengthening families.
Honored guests, fellow delegates and ob-
Clinton and our Ambassador to the
building families. was what was impor-
servers. I am pleased and proud to address
United Nations. Ambassador Madeleine
tant in strengthening sooieties
this historic conference on behalf of the
Albright, for the strong statements
throughout the world.
United States of America
09/08/95
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STATE LEG AFF.
005
September 6, 1995
CONGRESSIONAL RECORD-HOUSE
H8551
My government congratulates the thou-
Second, in accordance with recently-ap-
Let us be clear. Freedom to participate in
sands who have helped to organize the con-
proved law, the Department of Justice will
the political process of our countries is the
ference, to draft the Platform for Action. to
launch a six-year. $1.6 billion initiative to
inalienable right of every woman and man.
inform the world about the subjects under
fight domestic violence and other crimes
Deny that right, and you deny everything.
discussion here and to encourage wide par-
against women. Funds will be used for spa-
It 18 unconscionable, therefore, that the
ticipation both by governments and NGO's.
cialized police and prosecution units and to
right to free expression has been called into
We have come here from all over the world
train police, prosecutors and judicial person-
question right here, at a conference con-
to carry forward an age-old struggle: the
nel.
ducted under the auspices of the UN and
pursuit of economic and social progress for
Third. our Department of Health and
whose very purpose is the free and open dis-
all people, based on respect for the dignity
Human Services will lead a comprehensive
cussion of women's rights.
and value of each.
assault on threats to the health and security
And it is a challenge to us all that so many
We are here to promote and protect numan
or women-promoting healthy behavior. in-
countries in so many parts of the world-
rights and to stress that women's rights are
creasing awareness about AIDS, discouras-
north. south, west and east-fall far short of
neither separable nor different from those of
ing the use of cigarettes, and striving to win
the noble objectives outlined in the Platform
men.
the battle against-breast cancer.
for Action.
We are here to stop sexual crimes and
And, as Mrs. Clinton made clear yesterday,
Every nation. including my own, must do
other violence against women; to protect ref-
the United States remains firmly committed
better and do more-to make equal rights a
ugees, SQ many of whom are women; and to
to the reproductive health rights gains made
fundamental principle of law; to enforce
end the despicable notion-in this era of con-
in Cairo.
those rights and to remove barriers to the
niots-that rape is just another tactic of
Fourth. our Department of Labor will con-
exercise of those rights.
war.
duct a grassroots campaign to improve con-
That is why President Clinton has made fa-
We are here to empower wornen by enlarg-
ditions for women in the workplace. The
vorable action on the Convention to Elimi-
ing their role in making economic and politi-
campaign will work with employers to de-
nate Discrimination Against Women a top
cal decisions, an idea some find redical, but
velop more equitable pay and promotion
priority. The United States should be a party
which my government believes 18 essential
policies and to help employees balance the
to that Convention.
to economic and social progress around the
twin responsibilities of family and work.
And it is why we will continue to seek a
world; because no country can develop If half
Fifth, our Department of the Treasury will
dialogue with governments-here and else-
its human resources are de-valued or re-
take new steps to promote access to finan-
where-that deny to their citizens the rights
pressed.
cial credit for women. Outstanding U.S.
onumerated in the Universal Declaration
We are here because we want to strengthen
microenterprise lending organizations will
In preparing for this conference. I came
families. the heart and soul of any society.
be honored through special Presidential
across an old Chinese poem that is worth re-
We believe that girls must be valued to the
awards and we will improve coordination of
calling. especially today. as we observe the
same degree as boys. We believe, with Pope
(ederal efforts to encourage growth in this
Day of the Girl-Child. In the poem. a father
John Paul II. in the "equality of spouses
field of central importance to the economic
says to his daughter:
with respect to family rights". We think
empowerment of women.
Sixth. the Agency for International Devel-
We keep a dog to watch the house,
women and men should be able to make in-
formed judgments 8.8 they plan their fami-
opment will continue to lead in promoting
A pig is useful. too.
lies. And we want to see forces that weaken
and recognizing the vital role of women in
We keep a cat to catch a mouse.
families-including pronography. domestic
development. Today, we announce important
But what can we do with a girl like you?
initiatives to increase women's participation
Fellow delegates, lot us make sure that
violence and the sexual exploitation of chil-
in political processes and to promote the en-
question never needs to be asked again-in
dren-condemned and curtailed.
forcement of women's legal rights.
China or anywhere else around the world.
Finally, we have come to this conference
There is & seventh and final commitment
Let us strive for the day when every young
to assure for women equal access to edu-
cation and health care, to help women pro-
my country 18 making today. We, the people
girl, in every village and metropolis, can
and government of the United States of
look ahoud with confidence that their lives
tect against infection by HIV. to recognize
America. will continue to speak out openly
will be valued, their individually recognized,
the special needs and strengths of women
and without hesitation on behalf of the
their rights protected and their futures de-
with disabilities, and to attack the root
human rights of all people.
termined by their own abilities and char-
causes of poverty. in which so many women.
My country is proud that, nearly. a half
acter.
children and men are entrapped,
century ago. Eleanor Rooseveit, a former
Let us reject outright the forces of repres-
We have come to Beijing CO make further
First Lady of the United States. helped draft
sion and ignorance that have held us back:
progress towards each of these goals. But
the Universal Declaration of Human Rights.
and act with the strength and optimism
real progress depend not on what we say
We are proud that, yesterday afternoon, in
unity can provide.
here, but on what we do after we leave hur.
The Fourth World Conference for Women is
this very hall, our current First Lady-HII-
Let us honor the legacy of the heroines, fa-
lary Rodham Clinton-re-stated with memo-
mous and unknown who struggled in years
not about conversations; it 18 about commit-
rable eloquence our national commitment to
past to build the platform upon which we
ments.
that Declaration.
now stand.
For decades, my nation has led efforts to
The Universal Declaration reflects spir-
And let us heed the instruction of our own
promote equal rights for women. Women in
(tual and moral tenets which are central to
lives. Look around this hall, and you will see
their varied roles-as moshers. farm labor-
all cultures. encompassing both the won-
women who have reached positions of owner
ers. factory workers, organizers and commu-
drous diversity that defines us and the com-
and authority. Go to Huairou, and you will
nity leaders helped build America. My gov-
mon humanity that binds us. It obliges each
see an explosion of energy and intelligence
ernment 18 based on principles that recognize
government to strive in law and practice to
devoted to every phase of struggle. Enter
the right of every person to equal rights and
protest the rights of those under its jurisdic-
any community in any country, and you will
equal opportunity. Our laws forbid discrimi-
tion. Whether & government fulfills that ob-
find women insisting-often at great risk-
nation on the basis of sex and we work hard
ligation is a matter not simply of domestic.
on their right to an equal voice and equal a.c.
to enforce those laws. A rich network of non-
but of universal, concern. For it 18 R funding
ccss to the levers of power.
governmental organizations has blossomed
principle of the United Nations that no gov-
This past week, on video at the NGO
within our borders. reaching out to women
ernment can hide its humar rights record
Forum. Aung San Sun Kyl. said that "it is
and girls from all segments of society. edu-
from the world.
time to apply in the arena of the world the
cating, counseling and advocating change.
At the heart of the Universal Declaration
wisdom and experience" women have gained.
The United States is a leader, but leaders
18 a fundamental distinction between coer-
Let us all agree; it 18 time. It is time to
cannot stand still Barriers to the equal par-
cion and choice.
turn bold talk into concrete action.
ticipation of women persist in my country.
No woman-whether in Birmingham. Bom-
It is time to unleash the full capacity for
The Clinton Administration is determined to
bay. Beirut or Beijing-should be foreibly
production, accomplishment and the enrich-
bring those barriers down.
sterilized or forced to have an abortion.
ment of life that 1s inherent to us-the
Today. in the spirit of this conference, and
No mother should feel compelled to aban-
women of the world.
in the knowledge that concrete steps to ad-
don her daughter because of a societal pref-
Thank you very much.
vance the status of women are required in
erence for males.
every nation, I am pleased to announce the
No woman should be forced to undergo gen-
FIRST LADY HILLARY RODHAM CLINTON-RE-
new commitments my government will un-
ital mutilation, or to become a prostitute. or
MARKS FOR THE WORLD HEALTH ORGANIZA-
dertake:
to onter into marriage or to have sex.
TION FORUM ON WOMEN AND HEALTH SECU-
First. President Clinton will establish a
No one should be forced to remain silent
RITY
White House Council on Women to plan for
for rear of religious or political persecution,
BEIJING, CHINA, SEPTEMBER 5, 1995
the effective implementation within the
arrest, abuse or torture.
Thank you, Dr. Nakajima.
United States of the Platform for Action.
All of us should be able to exercise control
Dr. Nakajima, Dr. Sadik. Gertrude
That Council will build on the commit-
over the course of our own lives and be able
Mongella, delegates to the Fourth U.N. Con-
ments made today and will work every day
to help shape the destiny of our communities
ference on Women, and guests from all cor-
with the nongovernmental community.
and countries.
nors of the world, I am honored to be here
09/08/95
09:58
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STATE LEG AFF.
006
H8552
CONGRESSIONAL RECORD-HOUSE
September 6, 1995
this morning among women and men who are
around the world die in childbirth Most of
the physical integrity of a woman's body.
committed to improving the health of
those deaths could be prevented with basic
leaving a lifetime of physical and emotional
women and girls everywhere.
primary. reproductive and emergency obstet-
scars.
I commend the World Health Organization
rio health care. In some places, there are
HIV, AIDS, and sexually transmitted dis-
for making women's health a top priority
175,000 motherless children (or every one mil-
eases threaton more and more women-and
and for eatablishing the Global Commission
lion families. Manv of those children JON'T
experts predict that by the end of this decade
on Women's Hoalth.
survive. And of those who do. many are re-
more than half of the people in the world
I am proud that in the preparatory meet-
cruited into a life of exploitation on the
with HIV will be women. AIDS, which
ing for this Fourth world Conference on
streets of our world's cities. subjected daily
threasens whole families and regions. de-
Women, the United States took the lead in
to abuse, indignity. disease. and the specter
mands the strongest possible reeponse. Gov.
highlighting the importance of a comprehen-
of early death.
ernments and the international community
sive approach to women's health. That ap.
Thero must be a renewed commitment to.
must address head-on the growing number of
proach. builds on actions taken at previous
improving maternal health. The WHO
women who are being infected.
women's- conferences and the recent con-
launched in 1987 a Safe Motherhood Initia-
More than 700,000 women worldwide face
ferencee at Cairo and Copenhagen, whose
tive to halve maternal mortality by the yeur
breast cancer each year-and over 300,000 die
goals to promote the health and well-being
2000. To reach that goal. more attention
of it. It's the leading cause of death for
of all people were endorsed by 180 nations.
must be Daid to emergency medical care as
women in their prime in the developed world
Cairo was particularly significant us gov.
well as primary prenatal cure. Providing
In the time I speak to you today. 25 women
ernmental and non-sovernmental partici-
emergency obstetric care is a relatively
around the world will die of breast cancer. In
pants worked together to craft of Program
choap way of saving lives-and 2:0ng with
my own country. it is hard to find a family.
for Action which, among other things. calls
family planning services is among the most
an office. or a neighborhood that has not
for universal access to good quality repro-
cost effective interventions in even the poor-
been touched by this disease. My mother-in-
duotive health care services. including safe.
595 of countries.
law struggled against breast cancer for four
effective. voluntary family planning. greater
The commitment of the WHO and its Glob-
years before losing her battle.
access to education and health care: more re-
at Commission on Women's Health to make
Tobacco use is the number one preventable
sponsibility on the part of men in sexual and
childhenring and childbirth a safe and
cause of death. Ninety percent or women who
reproductive health and childbearing; and re-
healthy period of ovory woman's life deserves
smoke began to smoke as adolescents-lead-
ductiono wasteful resource consumption.
action on the part of every nation res
1016 to high rates of heart disease, cancer.
Here at this conference. improving girls
resented here.
and chronic lung disease later in life.
and women's health 18 A priority of the draft
One hundred million women cannot obtain
As the WHO points out. we also need to
Platform for Action. It includes such goals
or are not using samily planning services be-
recognize and effectively address the fact
as:- Access to universal Drimary health caro
cause then are poor, uneducated or lack ac-
that women are far more likely to be exposed
for all people-a goal not yot schieved in
casa to care. Twenty million of these women
to work-related and environmental health
many countries, including my own. The pro-
will seek unsafe abortions-some will dic.
hazards. Policies to alloviate and eliminate
motion of breast feeding. The provision of
some will De disabled for life. A growing
such health hazards associated with work in
ferinking water and sanitation. Research
number of unwanted pregnancies are occur-
the home and in the workplace demand a.c-
in and attention to wornen's health issues,
ring among young women, barely beyond
tjon.
including: environmental hazards, Dreven-
childhood chemselves. As we knew. when
Research also indicates that certain com-
don of HIV/AIDS and other sexually trars-
children have children. the chances 21
municable diseases affect women in greater
mitted. diseases. encouragement for adolos-
schooling. jobs, and good health is reduced
numbers. Tuberculosis. for example. 18 re-
cents to-postpone sexual activity and child-
for both Durent and ohild. And our progress
epcnaible for the deaths of one million
bearing. and discouragement of cultural tra-
as a human family takes another step back.
women each year and those in their early
ditions and customs that deny food and
The Cairo document recogDizes "the basic
and reproductive years are most vulnerable.
health care to girls and women.
right of all couples and individuals to decide
When health care systems around the
Goals such BA these illustrate 8 new com-
*sely and responsibly thu number. spacing
world don't work for women: when our moth-
mitment to the well-being of girls and
and timing of their ohildren and to have the
ers. daughters, sisters, friends and coworkers
worden and E belief in their rights to live up
information and means to do BO." Women
are denied access to quality care because
to their own God-given.potentials.
should have the right to health care that
they are poor. do not have health insurance.
At long last, people and their governments
will enable them to go safely through preg-
or simply because they are women, It 18 not
overywhere are beginning to undorstand that
nancy and childbirth and provide them with
just their health that is put at risk. It is the
investing in the health of women and girls is
the bust chance of having a healthy infant.
health of their families and communities as
as important 00.thn prosperity of nations as
Women and men must also have the right
well.
investing in the development of open mar-
is make those most intimate of all decisions
Like many nations. the United States
kets and trade. The health of women and
!ree of discrimination. coercion and violence.
brings to this conference A serious commit-
girls cannot be divorced from progress on
particularly any coeroive practices that
ment to improving women's health. We bring
other economic and social issues.
force women into abortions or sterilizations.
with us a series of initiatives which reg-
Scientists: doctors. nurses, community
On these issues, the U8 supports the provi-
resent the first steps to carrying out this
leaders and women themselves are working
sions in the Boijing Platform for Action that
Conference's Platform for Action.
to improve and safeguard the health of
realizm consensus language that was agreed
We are continuing to work for health care
women and families all over the world. If we
to at the Cairo Conference about a year ago.
reform to ensure that every citizen has ao-
Join together as a global community. we can
It deolared that "in no case should abortion
cess to affordable. quality care.
lift up the health and dignity of all women
be promoted as a method of family plan-
We are proposing a comprehensive and co-
and their families in the remaining years of
ning." The Platform asks governments "to
ordinated plan to reduce smoking by chil-
the 20cD century and on into the next millen-
strengthen their commitment to women's
dren and adolescents by 50 percent.
nium.
health, to deal with the health impact of un-
We art working to address the many fac-
Yet, for all the promise the future holds.
safe abortion as a major- public health con-
tors that contribute to teanage pregnancy,
WB also know that many barriers lio in our
cern and to reduce the recourse to abortion
our most serious social problems, by encour-
way. For too long. women have been denied
through expanded and improved family plan-
asing abstinence and personal responsibility
400668 to health care. education. economic
ning services."
on the part of young men and women: im-
opportunities, legal protection and human
Violence tigainst women remains a leading
proving access to health care and family
righta-all of which are used as building
cause of death among girls and women be-
planning services; and supporting health
blooks for 2 healthy and productive life.
tween the ages of 14 and 44-violence from
education in our schools.
In too many places today. the health of
ethnic and religious conflicts. crime in the
WE are pursuing a public policy agendu on
women and families 18 compromised by Inad-
streets and brutality in the home. For
HIV/AIDS that is specific to women. adoles-
equate, inaccessible and unaffordable medi-
woman who survive the violence. what often
cents. and children.
cal care, lack of sanitation, unsafe drinking
awaits them is a life of unrelenting physical
We are continuing to fund and conduct
water. poor nutrition. insufficient research
and emotional Dain that destroys their cn-
contraceptive reaearch and development.
and aducation sbout women's health issues.
pacity for mothering. homemaking or work-
Wo are addressing the health needs of
and cosrcive and abusive sexual practices.
ing and can lead to substance abuse, and
women through initiatives such as:
5 too many places. the status of woman's
even suioide.
The National Action Plan on Breast Can-
health is a pioture of human euffering and
Violence against girls and women goes be-
cer-a public, Drivate partnership working
pain. The faces in that Dicture are of girla
yond the beatings, rape, killings and forced
with all agencies of government. the media.
and women who, but for the grace of God or
prostitution that arise from poverty. wars
ecientific organizations. advocacy groupe
the accident of birth. could be ue or one of
and domestic conficts. Every day, more
and industry to Advance breast health and
our sistars, mothers or daughters.
than 5.000 young girls are forced 30 endure
eradicate breast cancer as a threat to the
Today, at least fifteen percent of prognant
the brutal practice of genital mutilation.
lives of American women.
woman suffer life threatening complications
The procedure is painful and life-threaten-
An Expansion of the National Breast and
and more than one-half million women
ing. It is degrading. And it is a violation of
Cervical Cancer Early Detection Program-
09/08/95
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STATE LEG AFF.
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September 6, 1995
CONGRESSIONAL RECORD - H
H8553
which wili ensure that women w!lo need reg-
human rights and participate fully in the Do-
much or the work we do 18 not valued-not
ular screening and detection services have
litical life of their countries.
by economists. not by historians. not by pop-
access to them, and that those services meet
There are some who question the reason
ular culture. not by government leaders.
quality standards.
for this conference. Let them listen to the
At thie very moment. as we s!t here.
The inclusion of women in clinical trials
voices of women in their homes. neighbor-
women around the world are giving birth.
for research and testing of drugs or other
hoods. and workpilaces.
raising children. cooking meals. washing
interventions that probe specific differences
There are some who wonder whether the
clothes. cleaning houses. planting crops.
between men and women is batterns or dis-
Ilves cr women and girls matter to economic
working or assembly lines. running compa.
ease and reactions to therapy.
and political progress around the
nies. and running countries.
The special health needs of older women
klobc Lil them 100k at the wonnan
women also are dying from diseases that
will be addressed through educational cam-
gathered here and at Heirou
the
nome-
should have been provented or treated. they
paigns about osteoporosis. oancer and other
makers. nurses. teachers. lawyers. policy-
are watching their children succumb to mal-
diseases.
makers. and women who run thoir own busi-
nutrition caused by Doverty and economic
And the US is conducting the largest clini-
nesses.
deprivation: they are being denied the right
cal research study ever undertaken CO exam-
It is conferences like this that compel gov.
to Ko to school by their own fathers and
the the major causes of death; disability and
ernments and peoples everywhere to liston.
brothers: they are being forced into prostitu-
frailty in post-menopausal women.
look and !ace the world's most pressing prob-
tion. and they are being barred from the bal-
Women's health security must we a prior-
lems.
lot box and the bank lending office.
ity of all people and governments working
Wasn't 10 after the women's conference in
Those of us who have the opportunity to be
together. Without good health. a woman's
Nairobi ten years ago that the world recused
here have the responsibility to speak for
God-gives potential can never be realized.
for the first time or the crisis of domestic v.°
those who could not.
And without healthy women. the world's pc-
olence?
As an American. I want to speak up for
tential can never be realized.
Earlier ecday, I participated in B World
women in my own country-wort.en who are
So let us Join together to ensure that overy
Health Organization forum. where govern-
raising children on the minimum wage.
little boy and girl that comes into our world
ment officials. NGOs. and individual citizens
women who CAN't niford health care or child
18 healthy and wanted, that every young
are working on ways to address the health
care, women whose lives are throatened by
woman has the education and economic on-
problems of women and girls.
violence. including violence in their own
portunity to live a healthy life; and that
Tomorrow, I will attend a gashering of the
homes.
every woman has access to the health care
United National Development Fund for
I want to speak up for mothers who are
she needs throughout her life to fulfill her
women. There. the discussion will focus on
!ighting for good schools. safe neighbor-
potential in her family, her work, and her
local-nnd highly successful-prostams that
hoods. clean air and clean airwaves
for
community.
give hard-working women access to credit x0
older women. some of them widows, who
If we care about the futures of our daugh-
they can Improve their own lives and the
have raised their families and now find that
ters, our sons. and the generations that will
lives of their families.
their skills and life experiences are not val-
follow them. do nothing less.
What WB are learning around the world is
ued in the workplace
for
women
who
are
Thank you for the work you do every day
that, :! women are healthy and educated
working all night AS nurses, hotel clerks. and
to bring better health to the women. chil-
their families will flourish. If wornen are free
fast food chefs 90 that they can be at home
dren. and families of this world. Thank you
from violence, their families will Nourish. If
during the day with their kids and for
for helping governments and citizens around
women rave a chance to work and card as
women everywhere who simply don't have
the world understand that we cannot ta.k
full and equal partners in societ.v. their fami-
time to do everything they are called upoc
about equality and social development with-
lies will flourish.
to do each day.
out also talking about health care.
And when families Nourtsh, communities
Speaking to you today. I speak for them.
Most of All, thank you for being par. of
and nations will flourish.
:USC as each of us speaks for women around
this bietoric and vital discussion which
That is why every woman. every man.
the world who are denied the chance to RO to
holds 80 much promise for our future.
overy child. every family. and every nation
school. or see a doctor. or OWD property. or
cn our Dlanet bas u stade in the discussion
have a say about the direction of their lives,
FIRST LADY HILLARY RODHAN! CLINTON-RE-
that takes place here.
simply because they are women.
MARKS FOR THE UNITED NATIONS FOURTH
Over the past 25 years. I have worked per-
The truth is that most women around the
WORLD CONFERENCE ON WOMEN
sistently on Issues relating to women. chil
world work both inside and outside the
dren and familes. Over the Past two-and-1-
home. usually by necessity.
BELJING, CHINA, REPTEMBER 3. 1996
hair years. I have had the opportunity to
He need to understand that there is no for-
Mrs. Mongella. distinguished delegates and
learn more about the challenges facing
mula for now women should lead their lives.
guests:
women in my own country and around the
That is why we must respect the choices that
I would like to chark the Secretary Gen-
world.
each woman makes for herself and her :am-
eral of the United Nations for invitime me to
I have met new mothers ID Jojakarta. In-
11y. Every woman descrves the ohance to re-
be part of the United Nations Fourth world
donesia. who como together regularly in
alize her God-given potential.
Conference on Women. This is truly a cole-
their village to discuss nutrition. family
We a:so must recognize that women will
bration-a celebration of the contributions
planning. and baby care.
never gain full disnity until their human
women make in every aspect of life: in the
I have met working parents In Denmark
rights are respected and protected.
home. on the job. :n the!r communities. as
who talk about the comfort they fcol in
Our goals for this conference. to swength-
mothers, wives, sisters, daughters, learners.
knowing that their children can be cared for
en families and societies by empowering
workers. citizens and leaders
in creative. ea!e. and nurturing after-school
women to take greater control over their
It is also a coming together, much the way
centers.
own deetinies, cannot be fully a.chioved un.
women come together every day to every
I have met women in South Africa who
less all governmenta-bare and around the
country.
helped land the struggle to end apartheid and
world-accept their responsibility to protect
We come together in fleids and in sac-
are now belping build a now democracy.
and promote internationally recognized
wries. In village markets and supermarkets.
I have me: with the leading women of the
human rights.
In living rooms and board rooms.
Western Hemisphere who are working every
'rhe international community has long ac-
Whether it 18 while Diaying with our chil-
day to promote interacy and better health
knowledged-and recently affirmed at V1-
dren in the park. or washing clothes in a
care for the children of their countries.
enna-that both women and men are entitled
river. or taking a break at the office water
1 have met worr.en in India and Bangladesh
to a range of protections and personal Tea-
cooler. we nome together and talk about our
who are taking out small loans to huy milk
doma. from the right of personal security to
aspirations and concerns. And time and
cowg. Mckshaws. thread and other materials
the right to determine freely the number and
again. our talk turns to our children and our
to create a livelihood for themselves ADD
spacing of the children they bear.
families.
their families.
No one should be forced to remain silent
However different wc may bc. there 16 far
I have met doctors and nurses in Belarus
for !ear of religioue or political persecution.
more that unites us than divides us. We
and Ukraine who are trying to keep children
arrest. abuse or torture.
share a common future. And we are here to
alive in the aftermath of Chernobyl.
Trasically, women are most often the Ones
find common ground 80 that we may help
The great challenge of this conference !a to
whose human rights are violated Evon !n
bring new dignity and respect to womun and
give voice to woman everywhere whose expe-
the late 20th contury. the rage of women
girls all over the world-and in so doing.
riences zo unnoticed. whose words go un-
continues to be used as an instrument of
bring new strength and stability w families
heard.
armed conflict. Women and children make
as well.
Women comprise more than half the
up a large majority of the world's refugees.
By gathering in Beljing, we are focusing
world's population. women are 70 percent or
Ana when women are excluded from the DO.
world atten On issues that matter most
the world's poor, and two-thirds of those who
litical process. they become even more vul-
in the lives of women and their 'amilies: ac.
are not caught to :ead and write.
nerable to abuse.
cess to ecucation. health care. jobs. and
Women use the primary caretakers for
I bolieve that. on the eye of a new millen-
credit. the chance to enjoy basic legal and
most of the world's children and alderly TAC
nium. it 18 time to break our silence. It is
09/08/95
10:01
202 647 2762
STATE LEG AFF.
008
H8554
CONGRESSIONAL RECORD-HOUSE
September 6, 1995
time for us to say here in Beijing. and the
If WO take bold stops to better the lives of
into Kuwait, three R-2's interdioted IT,
world to hear. that it ta no longer acceptable
women we will be taking bold steps to better
dropped the sensor-fused wea.pons. and
to discuss women's rights as separate from
the Ilves of obildren and families too. Fami-
were able to knock out 46 percent of
human rights.
lies rely on mothers and wives for emotional
These abuses have continued because, for
support and care; families rely OD women for
the mechanized vehicles including
too long, the history of women has been R
labor in the home: and increasingly. families
tanks in that division. That. Mr.
history of allence. Even today, there are
rely on women for income needed to raise
Speaker. is a revolutionary conven-
those who are trying to ailence our words.
healthy children and care for other relatives.
tional capability.
The voloes of this conference and of the
As long as discriminacion and inequities
The problem is that every study that
women at Hairou must be heard loud and
remein so commonplace around the world-
has been done on the B-2 indicates that
clear:
as long as girls and women are valued less,
having only 16 of them 18 simply not
It is & violation of human rights when ba-
red less, red last. overworked, underpaid, not
bies are donied food, or drowned. or surro-
enough. The Rand study and the study
schooled and subjected to violence in and out
cated. or their spines broken. simply because
of thoir homes-the potential of the human
that was done by Gen. Jasper Welch,
they are born girls.
family to create a peaceful. prosperous world
stated that somewhere between 40 and
It 18 & violation of human rights when
will not be realized.
60 are needed. I in fact asked General
women and-girle are sold into the slavery of
Let this conference be our-and the
Powell what he recommended to Dick
prostitution.
world's-jall to action.
Cheney, and he said. "I recommended
It 18 a violation of human rights when
And let us heed the call BO that we can cre-
50."
women are doused with gasoline, set on fire
ace & world in which every woman is treated
In my judgment. this is the most 1m-
and burned to death because their marriage
with respect and disnity. every boy and girl
dowries are deemed too small.
is loved and cared for equally, and every
portant defense decision we will be
It is a violation of human rights when indi-
family has the hope of a strong and stable no-
making in this decade. Seven former
vidual women are raped intheir own commu-
turs.
Secretaries of Defense wrote President
nities and when thousands of women are aud-
Thank you very much.
Clinton urging him to procure addi-
Jected to rape 6.B a tectic or prize of war.
God's blessing on you. your work and all
tional B-2's. We have spent $11.4 billion
It is a violation of human rights when a
who will benefit from st.
to develop the technology for the B-2
leading cause of death worldwide among
bomber. We are now able to get an ad-
women ages 14 to 44 is the violence they are
ditional 20 B-2's for about $15.3 billion.
subjected to in their own homes.
THE B-2 BOMBER AND AMERICA'S
It is a violation of human rights when
In my mind. that 18 affordable. If we
READINESS
young girls are brutalized by the painful and
shut down the line. and if we come
desrading practice of gonital mutilation.
The SPEAKER pro tempore (Mr. Ev-
back to it in 5 or 10 years and say. "My
It La a violation of human rights when
ERETT). Under a previous order of the
gosh. we do not have the bombers we
women are denied the rights to plan their
House. the gentleman from Washington
need for the future." it will cost $10 bil-
own families, and that includes being forced
[Mr. DICKS] is recognized for 5 minutes.
lion just to open the line and we get
to have abortions or being sterilized against
Mr. DICKS. Mr. Speaker, today I
nothing.
their will.
want to address the House of Rep-
My judgment 18 that there is another
If there is one message that schoos forth
resentatives in this special order on a
from this conference, it is that human rights
important issue that has been missed
are women's rights. And women's rights
very important issue that will come be-
by the press. That 18 the cost of the
are human rights.
fore the House tomorrow morning, to-
munitions on these planes. If we have
Let us not forget that among those rights
morrow afternoon, when we consider
standoff weapons, which the adminis-
are the right to speak freely. And the right
the defense appropria.tions bill. Since
tration supports, on the B-52's and the
to be hoard
1980, I have been a strong supporter of
B-1-B's, first of all, they have no util-
Women must enjoy the right to participate
the policy of former President Carter
ity against mobile targets. No. 2, is
rully in the social and political lives of their
and Secretary of Defense Harold Brown
that they cost $1.2 million per missile,
countries if we want freedom and democracy
in initiating the stealth bomber, the B-
to thriveand endure.
because you have to have long-range
It is indefensible that many woman in non-
2 program.
missiles. They also cost about $15 to
governmental organizations who wished to
In the gulf war, we saw with vivid
$20 billion for a load of them.
participate in this conference have not been
evidence the effectiveness of stealth
The cost of the wearons in the B-2 J-
able to attend-or have been prohibited from.
technology when it was decided to use
DAMS weapon 18 $320,000 for 16 of them,
fully taking part.
the F-117's against the most heavily
and in my judgment, that is a major
Let me be clear. Freedom means the right
defended targets inside Saddam Hus-
difference, one-fourth the oost of one
of people to assemble. organize. and debate
sein's Iraq. The F-117's, without the re-
cruise missile and a fraction. of the cost
openly. It means respecting the views of
quirement for jammers and other sup-
those who may.disasree with the views of
of a load of missiles. In a few days of a
their governments. It means not taking citi-
port aircraft, were able to go in and at
major conflict, you could pay for the
rens away from their loved ones and jalling
tack the most heavily defended tar-
B-2 simply by having these less expen-
them. mistreating them, or denying them
gets, using 2,000 pound precision-guided
sive weapons. either the sensor-fused
their freedom or dignity because of the
munitions. They were able to knock
weapon or the J-DAMS. I think that is
peaceful expression of their ideas and opin-
out those radars and surface to air mis-
a major difference. I also believe. 18 we
ions.
siles almost instantly, and come back
had enough B-2's. the potential some-
In my country. we recently celebrated the
without out Dilots being shot down.
day for a conventional deterrent.
75th anniversary of women's suMrage. It took
I believe that the B-2 bomber 18 Just
What If we had been able to show
150 years after the signing of our Declaration
of Independence for women to win the right
a bigger and better version of the F-
Saddam that we had this capability
to vots. It took 72 years of organized swug-
117. It allows us to go five times as far
and we could have avoided the gulf
gle on the part of many courageous women
and carry eight times as muoh conven-
war? It oost us $10 billion to move all
and men.
tional munitions and submunitions.
our forces out to the gulf, Then it cost
It was one of America's most divisive phil-
With those eame 2.000 pounds. it could
560 billion to prosecute the war, $70 b11-
osophical wars. But it was also a bloodless
carry 16, each of which would be inde-
lion was expended.
war. Summer was achieved without a shot
pendently targetable.
fired.
I think the most revolutionary thing
1330
We have also been reminded, in V-J Day
about stealth technology is its capabil-
The cold war is over, yet we still
observances last weekend. of the good that
comes when men and women join together to
ity against mobile targets. In a B-2
have threats out there. People say
combat the forces of tyranny and build a bet-
study that was done by Rand back in
there are no threats. Saddam still ex-
ter world.
1991. a simulation was used of Saddam
18ts. We have problems with Iran, we
We have seen peace provail In most places
Hussein's division, moving from Saudi
have problems with North Korea. And
for a half century. We have avoided another
Arabia into Kuwait. The B-2 was load-
in each of thoee scenarios. there could
world war.
ed up with sensor-fused - weapons. Each
be military divisions coming across the
But we have not solved older, deeply-root-
B-2 could carry about 1,400 of these
borders into a neighboring country.
ed problems that continue to diminish the
potential of half the world's population.
submunitions that looks like a puck
In my judgment, having this long-
Now it is time to act on behalf of women
with a parachute on top when dis-
range stealth bomber capability that
everywhere.
pensed. With Saddam's division coming
can go in without any other support
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PRT: FIRSTLADY
SIT: BERNARD
SIT: NSC
<PREC PRIORITY <CLAS> UNCLASSIFIED <DTG> 121529Z JUL 99
FM USMISSION GENEVA
TO RUEHC/SECSTATE WASHDC PRIORITY 6961
INFO RUCNDT/USMISSION USUN NEW YORK 5220
RUEHAT/AMCONSUL AMSTERDAM 0015
RUEHPH/CDC ATLANTA GA
UNCLAS SECTION 01 OF 04 GENEVA 005322
DEPT FOR IO
PASS TO HHS FOR OS, OPHS (LURI), OIRH, CDC, NIH, FDA
PASS TO USAID FOR GLOBAL BUREAU, AFR, PPC
PASS TO NSC WHITE HOUSE FOR DR. BERNARD
E.O. 12958: N/A
TAGS: TPHY, TBIO, WHO
SUBJECT: W.H.O. - INVITATION TO MRS. CLINTON TO
PARTICIPATE IN YEAR 2000 STOP TB CONFERENCE
1. THIS IS AN ACTION MESSAGE FOR THE DEPT. SEE PARA 15.
2. SUMMARY: DR. GRO HARLEM BRUNDTLAND, DIRECTOR GENERAL,
W.H.O. HAS INVITED THE FIRST LADY TO PARTICIPATE IN A
MARCH 2000 CONFERENCE IN AMSTERDAM ON TUBERCULOSIS
CONTROL AND THE HIGHEST BURDEN COUNTRIES. THIS MESSAGE
REVIEWS OUR UNDERSTANDING OF THE OBJECTIVES, FORMAT, AND
AGENDA OF THE CONFERENCE. END SUMMARY.
INVITATION TO MRS CLINTON
3. MISSION HAS RECEIVED A COPY OF A LETTER DATED JUNE 14
SENT TO THE FIRST LADY, HILLARY RODHAM CLINTON, FROM DR.
GRO HARLEM BRUNDTLAND, DIRECTOR-GENERAL, WORLD HEALTH
ORGANIZATION (W.H.O.) INVITING MRS. CLINTON TO
PARTICIPATE IN A MINISTERIAL CONFERENCE TO STOP TB, TO BE
HELD IN THE NETHERLANDS, MARCH 21-23, 2000. TEXT
FOLLOWS:
UNCLASSIFIED
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DEAR HILLARY,
FURTHER TO MY RECENT LETTER OF 27 APRIL 1999 REGARDING
THE TUBERCULOSIS EPIDEMIC AND THE STOP TB INITIATIVE, I
WOULD LIKE TO ENQUIRE ABOUT YOUR AVAILABILITY TO
PARTICIPATE IN A MINISTERIAL CONFERENCE TO STOP TB. THIS
CONFERENCE IS TENTATIVELY SCHEDULED FOR 21-23 MARCH 2000
AND WOULD BE CO-SPONSORED BY W.H.O., AND THE GOVERNMENT
OF THE NETHERLANDS WHICH WOULD HOST THE MEETING. THERE,
FOR THE FIRST TIME, THE SOCIAL, HEALTH AND ECONOMIC
DEVELOPMENT CONSEQUENCES OF THE EPIDEMIC WOULD BE CLEARLY
ENUNCIATED TO MINISTERS OF HEALTH AS WELL AS MINISTERS OF
FINANCE, DEVELOPMENT OR PLANNING FROM THE WORLD'S HIGHEST
BURDEN COUNTRIES. WE KNOW THAT COMBATING TB REQUIRES
SUSTAINED SUPPORT ACROSS SECTORS OF GOVERNMENT AND
SOCIETY. THE MINISTERIAL EVENT WOULD SET THE STAGE FOR
WIDENING THE RANGE OF ACTORS INVOLVED IN TB CONTROL AT
COUNTRY LEVEL.
FOLLOWING FORMAL AGREEMENT, WHICH WE ANTICIPATE SOON,
FROM THE GOVERNMENT OF THE NETHERLANDS, YOU WILL BE
INVITED TO JOIN ME AT THE MINISTERIAL CONFERENCE ON THE
EVENING OF 22 MARCH AND MORNING OF 23 MARCH. YOUR
PRESENCE AND COMMITMENT TO ISSUES SUCH AS TB WOULD LEND
STRONG CREDIBILITY TO THE PROCEEDINGS.
I LOOK FORWARD TO OUR CONTINUED COOPERATION AS PARTNERS
IN THE STOP TB INITIATIVE, AND TO A SUCCESSFUL
MINISTERIAL CONFERENCE TO STOP TB.
YOURS SINCERELY,
GRO HARLEM BRUNDTLAND, MD, MPH
DIRECTOR-GENERAL
END LETTER
OBJECTIVES/OVERALL PURPOSE
4. MISSION'S HEALTH ATTACHE DISCUSSED PLANS FOR THE
CONFERENCE WITH DR. MAARTEN BOSMAN OF THE STOP TB
INITIATIVE. THE FOLLOWING MAY BE HELPFUL TO THE WHITE
HOUSE IN DECIDING WHETHER TO ACCEPT THIS INVITATION:
A. THE OVERALL OBJECTIVE OF THE CONFERENCE IS TO BUILD,
ENHANCE AND SUSTAIN THE POLITICAL WILL OF GOVERNMENTS TO
COMMIT TO INVESTING IN AND SUSTAINING EFFECTIVE TB
CONTROL AS PART OF OVERALL HEALTH SECTOR DEVELOPMENT.
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B. THE CONFERENCE WILL ADDRESS TB AS A MAJOR CONSTRAINT
ON SOCIO-ECONOMIC DEVELOPMENT. IT WILL PRESENT TB AS A
MAJOR CAUSE OF HUMAN SUFFERING, AFFECTING PARTICULARLY
THE POOR, WOMEN AND CHILDREN, AND EMPHASIZE THE NEED FOR
GOOD TB CONTROL SERVICES AS AN INTEGRAL COMPONENT OF
EXPANDED AND STRENGTHENED HEALTH SERVICES WHICH CAN
ACCELERATE ECONOMIC GROWTH AND SOCIAL DEVELOPMENT.
UNCLAS SECTION 02 OF 04 GENEVA 005322
DEPT FOR IO
PASS TO HHS FOR OS, OPHS (LURI), OIRH, CDC, NIH, FDA
PASS TO USAID FOR GLOBAL BUREAU, AFR, PPC
PASS TO NSC WHITE HOUSE FOR DR. BERNARD
E.O. 12958: N/A
TAGS: TPHY, TBIO, WHO
SUBJECT: W.H.O. - INVITATION TO MRS. CLINTON TO
PARTICIPATE IN YEAR 2000 STOP TB CONFERENCE
C. TWO POSITION PAPERS WILL BE PRESENTED ADDRESSING THE
OVERRIDING ISSUE OF BUILDING AND SUSTAINING POLITICAL
WILL AND INVESTING IN AND SUSTAINING EFFECTIVE TB CONTROL
AS PART OF OVERALL HEALTH SECTOR DEVELOPMENT.
D. THE CONFERENCE AIMS TO ACHIEVE ITS OBJECTIVES THROUGH
THE FOLLOWING:
--DISCUSSING THE IMPACT OF THE TB PROBLEM ON THE ECONOMY
AND SOCIETY AND THE SOCIETAL AND ECONOMIC GAINS THAT CAN
BE DERIVED FROM INVESTING IN TB CONTROL;
--STIMULATING INCREASED AWARENESS OF THE GLOBAL
TUBERCULOSIS PROBLEM, THE STALLED PROGRESS IN
IMPLEMENTING EFFECTIVE TB CONTROL IN MANY OF THE MOST
AFFECTED COUNTRIES AND THE FACT THAT NEARLY 85 PERCENT OF
THE WORLD'S POPULATION LACKS ACCESS TO THE MOST COST
EFFECTIVE CURE STRATEGY;
ANALYZING EXPERIENCES, LESSONS LEARNED AND CHALLENGES
TO TB CONTROL IN THE MAJOR HIGH BURDEN COUNTRIES;
-- DISCUSSING AND ADOPTING NEW APPROACHES TO APPLICATION
OF DOTS (DIRECTLY OBSERVED THERAPY, SHORT COURSE) IN THE
CONTEXT OF SOCIETY AND THE HEALTH SECTOR AT LARGE,
INCLUDING SECTOR DEVELOPMENT APPROACHES.
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EXPECTED RESULTS
5. W.H.O. HOPES THAT THE CONFERENCE WILL YIELD A
RESOLUTION, ENDORSED BY MINISTERIAL PARTICIPANTS, STATING
THEIR COMMITMENT TO REVIEW THEIR GOVERNMENTS' CURRENT
INVESTMENTS IN TB CONTROL, REDIRECT COMMITMENT TO REVIEW
THEIR GOVERNMENTS' CURRENT INVESTMENTS IN TB CONTROL,
REDIRECT THESE RESOURCES TO MORE EFFECTIVE TB ACTIVITIES,
WHERE APPROPRIATE RAISE PUBLIC AWARENESS OF TB AND SEEK
INCREASED INVESTMENTS IN TB CONTROL TO SUPPORT SECTOR-
WIDE DEVELOPMENT.
6. COMMITMENT TO THE STOP TB INITIATIVE INCLUDING
OWNERSHIP OF THE DEVELOPMENT PROCESS FOR THE GLOBAL
ACTION PLAN AND THE GLOBAL CHARTER.
FORM AND PARTICIPATION
7. THE CONFERENCE WILL INCLUDE PANEL PRESENTATIONS AND
FACILITATE DISCUSSION OF KEY ISSUES FACED BY THE HIGHEST
BURDEN COUNTRIES. COUNTRY EXPERIENCES ON SIGNIFICANT
CONSTRAINTS TO ACTION WILL BE PRESENTED BY PARTICIPATING
DELEGATES. A CONFERENCE REPORT REFLECTING THE MAJOR
OUTCOMES OF DISCUSSIONS WILL BE PREPARED FOR ENDORSEMENT
DURING THE FINAL SESSION.
8. THE CONFERENCE WILL HAVE APPROXIMATELY 130
PARTICIPANTS, WITH AN ESTIMATED 66 OF THESE FROM HIGH
BURDEN COUNTRIES, ONE REPRESENTATIVE FROM EACH OF THE SIX
W.H.O. REGIONAL OFFICES, FIVE CHAIRS AND SPEAKERS, THE
W.H.O. TB INITIATIVE STEERING GROUP, DUTCH GOVERNMENT
DELEGATIONS.
9. COUNTRIES BEING INVITED ARE: BANGLADESH, BRAZIL,
CAMBODIA, CHINA, DR CONGO, ETHIOPIA, INDIA, INDONESIA,
KENYA, NIGERIA, PAKISTAN, PERU, PHILIPPINES, RUSSIA,
SOUTH AFRICA, TANZANIA, THAILAND, UGANDA, VIETNAM,
ZIMBABWE. WE UNDERSTAND THAT THEIR MINISTERS OF HEALTH
ARE EXPECTED TO PARTICIPATE.
10. THE OFFICIAL LANGUAGE OF THE CONFERENCE WILL BE
ENGLISH. TRANSLATION INTO RUSSIA, CHINESE, FRENCH,
PORTUGUESE AND SPANISH IS PLANNED FOR THE TECHNICAL
SESSIONS, PANEL DISCUSSION AND FINAL SESSION.
11. THE GOVERNMENT OF THE NETHERLANDS IS THE ACTUAL HOST
OF THE CONFERENCE, BUT IS ENTERING INTO A CONTRACT WITH
UNCLASSIFIED
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W.H.O. FOR ORGANIZATION AND IMPLEMENTATION.
PROPOSED AGENDA
UNCLAS SECTION 03 OF 04 GENEVA 005322
DEPT FOR IO
PASS TO HHS FOR OS, OPHS (LURI), OIRH, CDC, NIH, FDA
PASS TO USAID FOR GLOBAL BUREAU, AFR, PPC
PASS TO NSC WHITE HOUSE FOR DR. BERNARD
E.O. 12958: N/A
TAGS: TPHY, TBIO, WHO
SUBJECT: W.H.O. - INVITATION TO MRS. CLINTON TO
PARTICIPATE IN YEAR 2000 STOP TB CONFERENCE
12. THE CONFERENCE WILL BE DIVIDED INTO TWO PARTS. THE
FIRST ONE AND ONE-HALF DAYS WILL BE FOCUSED ON ACTIVE
INVOLVEMENT OF THE PARTICIPANTS THROUGH COUNTRY
PRESENTATIONS AND PANEL DISCUSSIONS. A DRAFTING GROUP
WILL SUMMARIZE THE RECOMMENDATION FORMULATED DURING THE
PANEL DISCUSSIONS INTO A DRAFT CONFERENCE RESOLUTION.
DURING THE FINAL HALF DAY OF THE CONFERENCE DR.
BRUNDTLAND AND WORLD BANK, PRESIDENT WOLFENSON, OR HIS
DESIGNEE WILL ADDRESS THE PARTICIPANTS. IT WILL END WITH
A PLENARY SESSION TO DISCUSS AND ENDORSE THE CONFERENCE
RESOLUTION.
13. PROVISIONAL AGENDA FOLLOWS:
A. DAY ONE: BEGINS AT 1400 HRS.
WELCOMING STATEMENT: MINISTER A (TO BE DETERMINED)
INTRODUCTION TO THE STOP TB INITIATIVE - DR. DAVID
HEYMANN
SUMMARY REPORT OF PRE-CONFERENCE REGIONAL AND COUNTRY
WORKSHOP RESULTS AND RECOMMENDATION
SUMMARY OF POSITION PAPERS ON THE ECONOMIC IMPACT OF TB
AND HEALTH SECTOR DEVELOPMENT AND TB
PANEL DISCUSSION: INVESTING IN TB CONTROL WORKS
---THE W.H.O. RECOMMENDED TB CONTROL STRATEGY
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---PANEL PRESENTATIONS: KENYA, VIETNAM, PERU
DISCUSSION ON THE PROPOSITION: "A COST-EFFECTIVE
STRATEGY FOR DIAGNOSING AND TREATING TUBERCULOSIS
PATIENTS IS AVAILABLE"
DRAFTING GROUP SESSION
DINNER
B. DAY TWO
PROGRESS MADE AND LESSONS LEARNED IN IMPLEMENTING
EFFECTIVE TB CONTROL
-- PANEL DISCUSSION: CHANGING ECONOMICS AND THE
EFFICIENCY OF GOVERNMENT IN DELIVERING TB CONTROL
-- PANEL DISCUSSION: HEALTH SECTOR DEVELOPMENT AND TB
CONTROL
-- PANEL DISCUSSION: PARTNERSHIPS AND PRIVATE/PUBLIC MIX
APPROACHES FOR TB CONTROL
-- PANEL DISCUSSION; COPING WITH THE TB/HIV CO-EPIDEMIC
DINNER AND SOCIAL EVENT
C. DAY THREE
FINAL SESSION: RESPONDING TO THE GLOBAL TB EPIDEMIC IN
THE NEW MILLENNIUM
-- WELCOMING STATEMENT: MINISTER B (TO BE DETERMINED)
-- ADDRESS: DG W.H.O. - THE STOP TB INITIATIVE
-- KEYNOTE ADDRESS: "THE IMPORTANCE OF INVESTING IN TB
CONTROL" MR. JAMES WOLFHENSON, PRESIDENT, WORLD BANK (OR
HIS REPRESENTATIVE)
-- PLENARY: "THE AGENDA FOR INTERNATIONAL ACTION AGAINST
"TB" DISCUSSION AND ENDORSEMENT OF CONFERENCE RESOLUTION
CLOSING CEREMONY.
ROLE FOR FIRST LADY
UNCLASSIFIED
PRIORITY
UNCLASSIFIED
WHITE HOUSE SITUATION ROOM
PAGE 07 OF 07
14. ACCORDING TO DR. BOSMAN SHOULD MRS. CLINTON DECIDE
TO ACCEPT DR. BRUNDTLAND'S INVITATION, A UNIQUE ROLE
WOULD BE CREATED FOR HER. SHE WOULD BE ACCORDED
UNCLAS SECTION 04 OF 04 GENEVA 005322
DEPT FOR IO
PASS TO HHS FOR OS, OPHS (LURI), OIRH, CDC, NIH, FDA
PASS TO USAID FOR GLOBAL BUREAU, AFR, PPC
PASS TO NSC WHITE HOUSE FOR DR. BERNARD
E.O. 12958: N/A
TAGS: TPHY, TBIO, WHO
SUBJECT: W.H.O. - INVITATION TO MRS. CLINTON TO
PARTICIPATE IN YEAR 2000 STOP TB CONFERENCE
RECOGNITION IN HER OWN RIGHT FOR HER LEADERSHIP IN THE
HEALTH SECTOR AND THE SPECIAL INTEREST SHE HAS SHOWN,
PARTICULARLY IN PRIOR DISCUSSIONS WITH DR. BRUNDTLAND, IN
TUBERCULOSIS.
15. ACTION REQUEST: MISSION WOULD APPRECIATE BEING
ADVISED OF MRS. CLINTON'S ACCEPTS DR. BRUNDTLAND'S
INVITATION AND WHETHER SHE WOULD LIKE US TO PLAY A ROLE
IN ARRANGING HER PARTICIPATION.
MOOSE
<^SECT>SECTION: 01 OF 04
<^SSN>5322
<MSGID> M3955114
UNCLASSIFIED
Tuberculosis Meeting
October 28, 1998
first B
Briefing Book
Table of Contents
1-
-
List of Participants
2- Seating Chart
3 -
Talking Points
U.S. Government Activities
4 - Department of Health and Human Services
5 -
U.S. Agency for International Development
6-
Gore/Primakov Commission
NGO/International Organizations Activities
7- OPEN Society Institute
8 -
World Health Organization
9 -
World Bank
Al D'Amato letter?
TB Meeting
October 28, 1998
List of Participants
World Health Organization
Project 55 TB Initiative (Ralph Nader grp.)
Dr. Gro Brundtland
Christoph Lee
Dr. David Heymann
AID
Executive Director for Communicable
Administrator Brian Atwood
Diseases
Duff Gillespie
Ambassador Jonas Store
Deputy Assistant Administrator for
Executive Director
Population, Health and Nutrition
Ambassador Thomas Loftus
HHS
Secretary Donna Shalala
World Bank
Dr. James Wolfensohn
Peggy Hamburg
President
Asst. Secretary for Planning and Evaluation
Jan Piercy
State
U.S. Executive Director
Frank Loy
Undersecretary of State for Global Affairs
Dr. David de Ferranti
Vice President, Human Development
Douglas Wake
Network
Office of Assistance to the NIS
Chris Lovelace
WH/NSC
Director, Human Development Sector
Melanne Verveer
Marsha Berry
Open Society Institute
Ken Bernard
George Soros
Andrew Weiss
Dr. Paul Edward Farmer
Leon Furth
Dr. Alexander Goldfarb
Dr. Srdan Matic
TUBERCULOSIS MEETING
OCTOBER 28, 1998
MAP ROOM
TALKING POINTS
OPENING REMARKS:
I am pleased all of you could come to take part in this
discussion of international tuberculosis control, one of the
most critical and threatening global disease issues of our
day. Looking around the room, it is clear that we have
assembled the talent to help support a coordinated strategy to
deal with TB worldwide.
We all know the statistics concerning the resurgence of this
age-old scourge: 8 million new cases per year over and over
2,000,000 deaths - that's over 5,000 deaths per day. As we
enter the 21st century, TB remains the single largest
infectious disease killer of adults. And most Americans still
believe that TB is a disease of the past.
We have recently been reminded again of how pressing this
problem has become by George, who with his seemingly unlimited
energy and commitment, has highlighted the TB epidemic in
Russia and the other countries in the Newly Independent
States.
And the epidemic in Russia is raising a new issue - multi-drug
resistant TB, which not only will make treatment far more
expensive, but also poses a serious threat outside the region
- a deadly form of disease that can cross borders as quickly
as an international plane flight.
There are no simple answers to the TB epidemic. This is not a
disease that is easily treated with a single antibiotic
prescription or injection. We must look at TB control in the
context of development of quality health care at the community
level. And we need high-level political commitment to ensure
that a "best-practices" approach to control is seen as a high
government priority.
Obviously, funding is critically important to carry out these
important control programs. Also important is the need to
develop broad-based partnerships with other concerned nations,
the private sector, academia, foundations and especially the
2
UN. With a global partnership under the expert leadership of
Dr. Brundtland and W.H.O to carry out the needed TB control,
we can, and will, move to control this killer.
Introduce other speakers:
I would like to turn at this point to Secretary Donna Shalala,
whose national and international leadership in health
promotion and disease control need no elaboration for this
group. She co-chairs the Health Committee of the Gore-Primakov
Commission, and is passionate in her support of the new
leadership of Gro Brundtland at W.H.O.
[Note: Secretary Shalala will likely speak on the
components of international TB control as learned from our
domestic experience. For Russia, she will emphasize the
critical political commitment that can be developed through
the work of the Health Committee of the Gore Commission.
She will touch on countries building a rational national
control strategies and the "Global Stop TB Initiative" of
W.H.O.]
Introduce Brian Atwood, Administrator, USAID
[Note: he will describe the USAID approach to TB
internationally concentrating on broadening the issue to
the NIS and other affected countries. He will note
institutional investments, and may mention the mission of
the Strategic Design Team leaving next month to set up
"Demonstration Sites." in Russia.]
Introduce Dr. Gro Brundtland, Director General, W.H.O.
[Note: She will discuss W.H.O.'s leadership in the "Global
Stop TB Initiative" - including the complex constraints
related to inadequate trained health personnel, inefficient
drug procurement systems, poor political will, and problems
of drug resistance. She will outline the W.H.O. actions.]
3
Introduce James Wolfensohn, President, World Bank
[Note: He will outline the World Bank's interest in the
problem, its past investments, and interests in working in
Russia and other countries with significant TB problems.]
Introduce George Soros.
[We are told that he will support W.H.O.'s lead in dealing
with the global epidemic, and will offer his assistance in
building a global consortium of major institutions and
intergovernmental organizations (such as the EU) to raise
the required funds.]
Discussion. open
CONCLUDING REMARKS:
I am gratified to hear that we seem to have the same basic
approach for dealing with the global TB epidemic. I won't
recapitulate what was said, you all are better than I at
representing your agencies and interests. We have much to do.
With regards to Russia, I encourage the joint CDC/USAID/WHO
Strategic Design Team to report back on what specific
intervention plans will work best. We must help Russia and
the other Newly Independent States develop rational and "do-
able" national plans for TB control and treatment given their
specific circumstances.
Globally, we have an important task laid out before us. Each
of us can contribute to our collective goal of controlling
this epidemic - and doing so by doing what each agency or
organization does best. But we should move forward quickly
and resolutely - working together jointly with a common ideal
of caring for and treating those who are infected, and
stopping the spread of the disease through both community and
international action.
THUMAN SERVICES
THE SECRETARY OF HEALTH AND HUMAN SERVICES
WASHINGTON, D.C. 20201
USA.
AUG 28 1998
MEMORANDUM FOR THE PRESIDENT
SUBJECT: Tuberculosis Epidemic in Russia
Because the tuberculosis (TB) epidemic in Russia is such an important health care issue, I am
providing you with an update and background on its current status and the steps we are taking to
address this significant, world-wide threat to the public health. Also, I have attached talking
points and a brief background paper for your use should the opportunity arise during your visit
to further our recent progress made in combating this deadly disease.
As you know, I have had the pleasure of serving as a co-chairperson, together with the Russian
Minister of Health, on the Health Committee of the Gore-Chernomyrdin Commission. TB
control is a key issue for the Health Committee and many resources of the Department of Health
and Human Services, especially through the Centers for Disease Control and Prevention (CDC),
and the USAID, Department of State have been mustered to assist the Russian government in
fighting this disease. But urgent problems continue that need to be addressed.
First, although Russia has the relatively low-cost drugs that can be used to treat TB, there are
often more TB patients in the prisons and sanitoria than can be treated with the drugs available.
Also lacking is surveillance, laboratory support and the organizational systems and discipline to
see treatments completed.
Second, when the inexpensive, simple antibiotic treatments for TB are not adhered to, are
inadequate or unavailable, a Multi-Drug Resistant Tuberculosis (MDR-TB) may emerge that is
treatment-resistant and requires much more expensive antibiotics. If these are unavailable or are
used in a haphazard fashion, there is substantial risk of developing even more resistant strains of
TB and spreading an airborne epidemic beyond Russia.
We have worked with our Russian colleagues to encourage them to adopt a treatment regimen,
known as Directly Observed Therapeutic Strategy (DOTS), that has been advocated by the CDC
and the World Health Organization (WHO). DOTS entails carefully monitoring patients to
ensure that they take the full course of antibiotics prescribed to eliminate TB. This can be done
in either an in-patient or out-patient setting, but the cost savings of out-patient treatment are
substantial. It is an important world-wide strategy to treat TB that can improve the quality of
care and reduce costs without the need for prolonged institutionalization.
However, some have argued that because DOTS does not require institutionalization, drug
treatment compliance could be lower, which could lead to the emergence of MDR-TB. The
official Russian policy on TB retains the traditional approach of treatment in sanitoria. This is
especially true among local officials where the sanitoria system is a major source of employment.
Page 2 - The President
Seeing both sides of this issue, we have pushed hard, but respectfully, for reform in Russia. I am
especially pleased that the Gore-Chernomyrdin Health Committee has given us a forum to
convince the Minister of Health to adopt DOTS and to make the organizational changes
necessary for its implementation. The cost of adequate treatment of TB in Russia, including
transition to a system of DOTS, remains a challenge but HHS and the State Department are
working with our Russian counterparts to develop a short- and long-term strategy.
One example of our success stems from our convincing the Ministry of Health to adopt DOTS
which paved the way for Mr. George Soros and his grantees to implement DOTS demonstration
projects in Russia. Under this effort, Mr. Soros' Open Society Institute is providing funding to
the New York City-based Public Health Research Institute (PHRI) to implement DOTS pilot
projects in Russia with a focus on the possible emergence of MDR-TB. I would note that the
First Lady is keenly aware of the public health threat of MDR-TB and raised it during a meeting
with Mr. Soros where he was explaining his initiative in Russia
You should also be aware that Mr. Soros' grantee, PHRI, together with the Britain-based
Medical Emergency Relief International and the Belgian-based Medecins Sans Frontieres
(Medicine Without Frontiers) have sent an open letter to President Yeltsin urging that he do more
to combat the spread of MDR-TB, warning that Russia has become the "world's incubator of the
deadly disease." Some Russian conservatives consider these efforts to be a "plot" by western
drug companies to sell Russia expensive pharmaceuticals.
We would suggest a less politically confrontational, more public health approach to this
complicated issue. An approach based on the scientific evidence that DOTS can be a more
effective and lower cost approach to the treatment of TB, especially with respect to the threat of
MDR-TB. We hope that the progress that we have made with the Russian Ministry of Health,
which has made it possible for the Mr. Soros' initiative to occur, can be continued.
As I mentioned above, I am making the attached talking points and briefing paper available to
you should the opportunity arise to further our public health goals of reducing the incidence of
TB, especially MDR-TB, among the Russian people. I have also attached an informative
editorial by Harvard Professor, Howard Hiatt, who argues because of its airborne spread,
resurgent tuberculosis, and MDR-TB in particular, are an even greater threat to society than the
AIDS epidemic. Please let me know if you would like any additional information.
Donn 98hlole
Donna E. Shalala
Enclosures
Tuberculosis Epidemic in Russia
Talking Points
We share your concern about the increased incidence of tuberculosis (TB) in Russia, and
especially the emergence of a particularly dangerous form of tuberculosis, multidrug-
resistant TB (MDR-TB) that cannot be treated with conventional antibiotics.
We understand that MDR-TB is now a particular challenge in the penal system of the
Russian Federation. Prisoners released after even brief stays in crowded prisons may
have acquired the disease and become the source of infection in the community at large.
We in the U.S. have had our own unfortunate experience with drug-resistant tuberculosis.
During late 1985 and early 1990's, we had outbreaks of MDR-TB in hospitals and
prisons, much of which was associated with HIV/AIDS co-infection.
We have committed a substantial level of effort and resources to bring the situation under
control. Only after implementation of treatment methods, such as directly observed
therapy, that are recommended by the World Health Organization and our own Centers
for Disease Control and Prevention, were we able to make real progress in controlling
this persistent disease.
We are aware of the situation in Russia and applaud your recent efforts of the Russian
Ministry of Health and the Chief Administration of Execution of Punishment to
implement international standards of TB control.
We also understand the difficulties you face, both economic and social, in restructuring
the system of TB care.
However, we also are aware that there are successful pilot projects underway in Ivanovo
and Tomsk that are being carried out as part of multilateral and our own bilateral
cooperation.
Based on these experiences, we stand ready to provide technical assistance as you work
towards a nationwide program of tuberculosis control in Russia.
Russia's Health Care System and Condition
Serious shortcomings in Russia's health system and disease profile threatens the country's ability
to provide adequate public health services to the Russian people, and for some diseases, poses a
cross-border threat to the health of other nations, including the United States. While many
general health statistics have improved modestly in the last two years, including life expectancy,
alarming increases are evident in rates of STDs, HIV and TB.
Between 1990 and 1997, the incidence of syphilis has increased from 5.4 per 100,000 to 216.9
per 100,000 - an increase of nearly 5,000%. Gonorrhea is increasing rapidly as well, and what
shocks health officials and local leaders is that many of those infected are under the age of 20. In
1987, Russia had 24 recorded cases of HIV. By the first half of 1998 there were close to 8,700
cases of HIV and 300 AIDS deaths reported. Outside estimates are much higher, but even the
Russian Duma estimated that Russia can expect at least one million cases of HIV in the coming
years, with which the health and economic system will be unable to cope. The rise in TB cases
has been dramatic, with civilian notifiable cases increasing from 36 per 100,000 in 1992 to 75
per 100,000 in 1996; particularly worrisome is the level of multiple-drug resistant TB which is
estimated at 7.3% of all civilian cases, posing a distinct threat beyond Russia's borders. The TB
situation in prisons is far worse.
The health system suffers from low and underfunded health budgets, poor performance of the
mandatory health insurance program in collecting premiums, and the lack of a legal framework
for the private provision of health care despite survey findings indicating that upwards of 40% of
health expenditures are out-of-pocket. The work of medical providers suffers from a lack of
evidence-based medicine and quality improvement in all aspects of healthcare, especially
diagnosis and treatment protocols.
Nonetheless, successful dialog between U.S. and Russian health experts through the bi-lateral
commission initiated by Vice President Gore, and effective use of USAID foreign assistance
contributions are evident. Since 1992, the U.S. has provided over $95 million to address a broad
range of health issues important to Russia such as immunization, women's reproductive health,
pharmaceutical investment and quality control, environmental health, and health information and
response activities. Approaches involving partnerships between U.S. and Russian organizations
have been successful at the local level and, in one program's case, has led to U.S. private
contributions of time and equipment estimated at $45 million over the last four years. Attempts
at strengthening the role of non-governmental organizations in the delivery of public health
information and services health field requires more attention.
Tangible results are evident from the U.S.-Russian cooperation. For example, an estimated three
million Russian couples now have access to safe and effective family planning services, and U.S.
assistance has been credited with bringing down abortion rates. Yet, controversy about family
planning has increased from the political right and from some religious groups. The Yeltsin
administration wants to continue U.S.-Russian cooperating on reproductive health programs, and
expand into improvements in maternal and neo-natal health. Russia is also working with the
U.S. on a national initiative to improve the quality and access to health services, and a multi-year
strategy aimed at STD/HIV prevention and control. A design effort for USG assistance in TB
control is scheduled for Fall 1998.
More Deadly Than AIDS
Howard Hiatt
Washington Post
August 14, 1998
Many Americans think that with the discovery of streptomycin more than 50 years ago, the
tuberculosis problem was solved. But a little-noticed (in the United States) TB epidemic now
kills 3 million adults a year worldwide, more than AIDS or malaria. Even more threatening is the
increasing appearance around the globe of forms of TB that are resistant to streptomycin and
many other drugs that have been used to treat the disease.
Almost every person with the common variety of TB can be cured with two to four medications
daily for at least six months at a total cost of about $100. In recent years the World Health
Organization, with support from the World Bank, has treated drug-sensitive TB in many
countries with a very effective strategy that involves supervised administration of the drug over
the prescribed period.
But when TB sufferers are treated inadequately, that is, when they don't have all the required
drugs or don't take them long enough, mutant TB bacteria that are more resistant to the drugs
grow. Patients may feel better temporarily, but what was a curable condition can become a death
sentence. And their now multidrug-resistant (MDR) TB bacteria infect others.
MDR TB can often be cured, but at a cost eight to 80 times higher than that of treating ordinary
TB. Until a few months ago that cost led to the view that treatment of MDR TB in resource-poor
countries was not "cost-effective." But Paul Farmer and Jim Kim, two physician- anthropologists
who divide their time between work at Harvard Medical School and Brigham and Women's
Hospital, on the one hand, and the poorest areas of Haiti, Peru and Mexico, on the other, have
changed that.
In the barrios of Lima, where they have been involved in community-building for five years,
they recognized that treating only patients with drug-sensitive TB, the most prevalent kind, could
encourage the spread of MDR TB.
Even more important, they regard treatment for MDR TB as the right of all its victims. Finally,
they know well that infectious diseases respect no border and that their spread to the rest of the
world is more than a threat. In fact, an American priest who recently died of MDR TB in Boston
had come there from service in the barrios of Lima.
Therefore, they began treating almost 100 of the many desperately ill patients with MDR TB in
Lima with five or more drugs daily over a period of two or more years.
More than 85 percent appear to have been cured. Farmer and Kim ascribe a large part of their
success to their partnership with community members whom they have trained to ensure that
every patient takes every dose of every medication every day. The cost has been great (although
1
much, much less than the cost in a U.S. hospital), but they have thus far succeeded in obtaining
the needed drugs, partly by going into debt.
Earlier this year tuberculosis specialists from around the world gathered at the American
Academy of Arts and Sciences and examined and then endorsed the preliminary Lima evidence.
Subsequently, the World Health Organization decided to replicate the Lima experiment in a few
other sites around the world that it has designated MDR TB "hot zones."
Thanks to the generosity of George Soros, the first such sites will be in Russia and Latvia, where
MDR TB is prevalent and spreading rapidly. The Soros foundations have committed to pay for
programs there. But if the worldwide epidemics are to be contained, many more groups must be
mobilized. The World Bank, national governments -- particularly those of industrialized nations
-- the pharmaceutical industry, other business leaders concerned with international trade,
scientists and others all can play crucial roles in a program to wipe out all forms of TB.
The AIDS pandemic has appropriately aroused the concerns of people around the world. The
tuberculosis pandemic requires no less. Because it is spread much more readily than AIDS --
through the air that everybody may breathe -- it represents an even greater threat.
The writer, a professor of medicine at Harvard, is director of the Initiatives for Children Program
of the American Academy of Arts and Sciences.
c Copyright 1998 The Washington Post Company
2
AID
U.S. AGENCY FOR
INTERNATIONAL
DEVELOPMENT
MEMORANDUM
TO:
WH/OFL, Melanne Verveer
FROM:
Acting AA/ENI, Donald L. Pressley Don
SUBJECT: Tuberculosis in the ENI Region
In response to my conversations with Mrs. Clinton during our recent trip to Eastern Europe,
please find below a summary of USAID's tuberculosis activities in Europe and the New
Independent States (ENT).
Following a general decline in the incidence of tuberculosis (TB) prior to 1991, rates have
risen dramatically since then. With a continuing breakdown of the health systems in the
troubled economies of the NIS, most countries continue to follow a very cost-inefficient TB
control strategy involving active case-finding, regular chest X-rays, excessive skin testing and
immunizations, and a well-entrenched, costly sanitoria network. USAID is assisting in
reorienting the TB control effort in the region through: pilot efforts on the WHO
recommended directly observed therapy, short course (DOTS); strengthening
epidemiological monitoring and surveillance; more rational pharmaceutical management,
including appropriate prescribing practices and pharmaceutical procurement; and
strengthening health care delivery systems.
In addition, USAID awarded a first tranche of funding to the Department of Health and
Human Services (DHHS) to create an ENI regional TB working group to include expertise
from WHO, SOROS and other entities to address TB in the region. The working group will
help define the barriers to acceptance and adoption of DOTS in the NIS and will recommend
activities necessary to overcome the barriers.
A. TUBERCULOSIS IN RUSSIA
As you know, since the collapse of the ruble and the banking system in Russia, the State
Department (S/NIS/C) and the NSC have been closely tracking the TB and pharmaceutical
situation in Russia, and have discussed the possibility of humanitarian assistance to respond
to particular needs. TB in Russia, however, is not responsive to short-term humanitarian
assistance. The number of notifiable cases of TB in Russia has more than doubled over the
past six years, from approximately 35/100,000 population in 1992 to approximately
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75/100,000 population in 1998, according to the Ministry of Health (MOH) and WHO.
Russia's TB rates are among the highest in Europe. Rampant TB rates in prisons continue to
serve as a source of infection for the civilian population and multi-drug resistant forms of the
disease are on the increase. These two factors have emerged as major threats to successful
control of the epidemic. Mortality due to TB in the general population is about 17 per
100,000 population, while in the prison population it is estimated to be as high as 484 per
100,000 population.
Russia continues to follow outdated diagnostic and treatment practices. Efforts by the USG,
Soros and other donors to modify those practices, are showing some positive results. But TB
in Russia is a complex problem, for which there is no clear or short term fix. Progress
towards adoption of modern methods is constrained by a range of difficult economic,
political, institutional, psychological, ethical, social and logistical impediments.
In an effort to position itself to respond to the growing crisis, USAID/Moscow commissioned
a study to examine the availability of and procurement methods for first-line TB drugs in
Russia. The September 1998 report indicates that: a) the first-line anti-tuberculosis (TB)
drugs are all available on the Russian market; b) that Russian drug manufacturers increased
production of first-line TB drugs by 50% during 1997 and now claim to have sufficient
production capacity to satisfy 100% of the country's need for these first-line TB drugs for
1998; but c) chronic shortages nevertheless exist due to perpetual problems with raw
materials, procurement, distribution, affordability, and stock management. An emergency
drop of TB pharmaceuticals is not needed now and would complicate or even worsen the
situation, since the system is not prepared to properly handle a DOTS program.
Nonetheless, USAID/Moscow will continue to monitor the situation.
Programs Underway
Because of the risk of promoting multi-drug resistant TB, there is a growing recognition that
"doing DOTS badly is worse than doing nothing at all." It is absolutely critical that Russia
have in place a sensible and comprehensive plan and adequate implementation capacity to
support a DOTS program before drugs are distributed and treatment activities are initiated.
USAID and the Centers for Disease Control (CDC) are moving quickly and responsibly to
develop a plan to deal with the current crisis.
With S/NIS assistance, USAID set aside in FY98 $1.5 million of Freedom Support
Act (FSA) funding for TB efforts in Russia. In November, USAID and CDC will
begin a TB assessment and design effort to identify likely sites for a multi-year TB
program. It is envisioned that the USAID/CDC program will support pilot,
community-based activities which complement and build on the work supported by the
Soros Foundation and other bilateral donors. Because of statutory limitations, USAID
and CDC expects to focus on civilian (not prison) populations. The programs will
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institute a "DOTS-Plus" strategy (including food supplements and other inputs besides
TB drugs) while tracking the prevalence of multi-drug resistant TB.¹
A one year hospital partnership (funded by USAID) between the University of
Arkansas, School of Medical Sciences and the Volgograd State Medical Academy is
initiating modern standards for tuberculosis diagnosis, treatment, and case
management in a very limited way. All new health partnerships under the American
International Health Alliance (AIHA) will explicitly include TB in the initial needs
assessment.
The American College of Physicians in collaboration with DHHS is working on a
pilot effort to integrate TB into other quality and primary care initiatives..
For other donors working on TB programs in Russia, please see attached matrix, "Summary
of Donors' Tuberculosis Programs in the Russian Federation as of October 1998.
B.
TUBERCULOSIS IN CENTRAL ASIAN REPUBLICS (CAR)
Central Asia has seen a three to four fold increase in tuberculosis since the early 1990's.
Although a number of other countries have TB rates higher than those found in CAR, the
situation is still grave because of the often incurable form of the disease multi-drug resistant
TB. USAID, Chevron and other donors, in a unique public-private partnership, are funding
a TB initiative in CAR, and the results are just beginning to surface.
Programs Underway
Chevron Munaigas funded Project HOPE to introduce DOTS at pilot sites in Kazakhstan in
1994. Chevron also delivered a TB mobile clinic to Almaty Oblast, with transportation costs
covered by the Department of State.
In 1997, USAID/CAR started its "TB Initiative", in collaboration with Chevron, building
upon on-going health reform efforts. The implementing team includes Abt Associates, Project
HOPE, and CDC -- a collaborative public-private partnership which has worked extremely
well in the region. Broad objectives have been to update the existing TB diagnostic,
treatment and control practices in the region through demonstration pilot sites in Kazakhstan
and Kyrgyzstan. Activities include: developing national TB education campaigns; training
health care professionals; supporting and monitoring DOTS pilot projects in Almaty (81
patients) as a model for national expansion; strengthening TB epidemiology and surveillance;
and analyzing the cost-effectiveness of DOTS.
1 It should be noted, however, that Russian-Iran legislative directives, if enacted, will dramatically
constrain the flexibility and scope of this program both at the federal and community levels.
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Because of USAID's TB initiative, in May 1998, the President of Kazakhstan, Mr.
Nazarbaev, signed a decree to implement DOTS nationwide. Some funding has been
allocated and momentum is apparent in the MOH. Supported by all the donors in the region ,
a development plan for the National TB Control Program has been finalized to implement
DOTS at limited pilot sites which will act as centers for training for the rest of the country.
Thus far, USAID has committed $1,980,000 of FSA funding for the program. Through
collaboration with the World Bank, TB activities will be expanded to additional oblasts in
Kazakhstan and Kyrgyzstan over the next few years. In 1999, subject to availability of
funding, elements of the program will be expanded to Tajikistan, Turkmenistan and
Uzbekistan. Other organizations involved in or exploring TB-related activities in Central
Asia include AMOCO, Lutheran Ministries, Medecins sans Frontiers-Luxenburg, Philip
Morris, SOROS and the University of Wisconsin.
Although too early to measure impact, TB initiatives accomplishments in CAR to date
include: training of 385 physicians and other health workers in DOTS therapy, laboratory
methods, drug supply and logistics, and health surveillance; provision of modern laboratory
equipment and supplies for smear microscopy to three demonstration sites; initiating an
information campaign including two press conferences on TB in Kazakhstan and two TV
videos which are shown on national and Almaty TV; and ongoing policy dialogue on costs
and laws concerning TB prevention, diagnosis and treatment.
C.
TUBERCULOSIS IN OTHER AREAS OF THE ENI
Caucasus:
The Mission is currently revising their health strategy and will explore possible
TB initiatives.
Ukraine:
During the period 1990-1996, the TB rate in Ukraine increased by 45 percent
and the MOH states that the country now has 45.8 people per 100,000 infected with TB.
The Mission in Ukraine is exploring TB initiatives in conjunction with a future primary
health care strategy.
Kosovo:
USAID's Office of Disaster Assistance (OFDA) has provided about $696,000
to Doctors of the World to provide food and hygiene parcels for TB patients and their
families as incentives to increase treatment compliance in collaboration with a Swedish and
multi-donor funded screening and treatment program in Kosovo. Over 4,000 TB patients
have benefitted from this program. Initial results show a significant increase in the patient
compliance rate. As peace plans begin to take effect, USAID will continue to review the
status of TB in Kosovo especially when developments programs become more regular.
90'd
91.66 100 7.07
MIHSN
DC:91 8661-97-100
LOS ANGELES TIMES
MONDAY, FEBRUARY 16, 1998
B5
An Ancient Marauder Looms Again
Tuberculosis: The fight
control programs misuse antibiotics and
which the U.S. contributes only about
ineffectively treat patients, practices that
$500,000. WHO estimates that, in addition
against it must be global as
foster drug-resistant strains. These MDR-
to commitments from developing countries,
drug-resistant strains spread.
TB "hot-zones" pose a grave threat to glo-
$100 million more is needed annually to
bal health, as international travel and
control the epidemic and prevent the
migration put all areas of the world in close
spread of MDR-TB. Surely, Americans
By RALPH NADER
contact.
would be willing to foot some portion of that
and R. GORDON DOUGLAS
Few people recognize the danger that
bill to prevent a disease that WHO's Rich-
MDR-TB poses to Americans. It is very
ard Bumgarner called "Ebola with wings"
For the first time since the introduction
difficult and expensive to contain, and the
from descending on our shores.
of anti-tuberculosis drugs in the 1950s, the
industrialized world is by no means
Congress has approved additional money
world faces the threat of incurable TB, a
immune. Since 1991, when these strains
for the Agency for International Develop-
disease that destroys the lungs, dooming its
were found in only 13 states, MDR-TB has
ment, which channels funds to WHO, to
victims to drown in their own blood. This
spread to 42 states and the District of
combat infectious diseases worldwide. If
deadly infection is airborne; it spreads like
Columbia. In September, a new strain of
only the Clinton administration would fol-
the common cold. Worst of all, highly
highly contagious TB that multiplies at
low through more comprehensively. Some
resistant strains have been discovered in 34
1,000 times the normal rate was identified
of the proposed new funding for biomedical
countries by the Global Project on Anti-TB
along the Tennessee-Kentucky border.
research and for the National Institutes of
Drug Resistance.
Transmission of tuberculosis can occur
Health also should be channeled into TB
If tuberculosis were a newly emerging
anywhere, from planes to schools to neigh-
research. Furthermore, the U.S. must pay
disease rather than an ancient marauder, it
borhood bars. In 1994, a South Korean
its dues to the United Nations if WHO is to
would be making headlines almost daily.
woman with MDR-TB infected four Amer-
be effective in fighting TB and other such
However, in the four years since the World
icans on a plane.
deadly diseases. Unless this funding is sus-
Health Organization declared TB a global
The importation of TB across interna-
tained over the long term, TB programs will
emergency, there has been little interna-
tional borders is very common. In this
be ineffective, treatment of patients will be
tional alarm. Inexpensive, generic medica-
country, 37% of TB patients are foreign-
incomplete and our temporary good inten-
tions have long existed to cure tuberculosis,
born, 25% of them from one of four "hot
tions will only fuel the spread of drug-
yet 3 million people die each year, making
zones": India, Korea, Vietnam and the
resistant strains.
TB the greatest infectious killer world-
Dominican Republic. In the Dominican
wide, responsible for one-fourth of the
Republic, where 9% of TB cases are MDR,
The only way to protect Americans
world's preventable deaths.
one out of every seven residents has
against multi-drug-resistant tuberculosis is
In October, an unprecedented report
obtained a visa for travel to the U.S.
to support effective treatment and control
released by top U.S. and international
The U.S. learned a harsh lesson when the
programs that prevent MDR-TB from
health agencies issued the ultimate warn-
dismantling of TB control infrastructure in
developing. It is a war that must be fought
ing: Multi-drug-resistant strains of tuber-
the 1980s led to sharp increases in tubercu-
internationally, before this country
culosis (MDR-TB), which can be virtually
losis. According to New York City's director
becomes a primary TB battleground.
untreatable, have emerged worldwide and
of TB control, the explosion of MDR-TB
threaten to overwhelm the public health
required more than $700 million between
Ralph Nader and Dr. R. Gordon Douglas
systems of India, Russia, Latvia, Estonia,
1992 and 1996 to quell the outbreak.
are on the steering committee of the Prince-
Argentina, Ivory Coast and the Dominican
The World Health Organization spends
ton Project 55 Tuberculosis Initiative of
Republic. In these countries, poor TB
$11 million annually on TB control, of
Princeton University's Class of 1955.
21/oct/98
Health
IV
TUBERCULOSIS
Summary of Situation
In Russia, as in much of the former Soviet Union, tuberculosis (TB) cases have increased
dramatically in recent years. In addition, multi-drug resistant (MDR) TB which does not
respond to conventional treatment has emerged. MDR-TB has spread in environments
such as prisons and hospitals, and threatens TB control efforts since the costs for treating
MDR-TB are 100 fold-higher than for treating non-resistant TB ($3000/case versus
$30/case). The problems have emerged because of unstable drug supplies and reluctance
of the medical establishment to use the simple, effective strategy known as DOTS that
consists of five elements that include government commitment, appropriate methods of
TB diagnosis, an adequate supply of quality drugs, supervised administration of these
drugs, and careful monitoring of treatment outcomes. This approach is used in the U.S. as
well in more than 100 other countries. Unless the TB problem in Russia is dealt with
immediately, drug resistance due to poor treatment practices will continue to develop and
spread in the community, making TB virtually untreatable.
U.S. Activities to Date
TB has been considered as an important disease by the Health Committee of the Gore-
Primakov Commission. At the request of the Department of Health and Human Services,
CDC has participated in the committee's TB activities, which until now have been limited
because of availability of resources and resistance at the national level in Russia to institute
meaningful changes in national TB policies. CDC activities to date have included a series
of visits to Russia in which meetings were held with national counterparts for the purpose
of discussing possible collaboration. In addition, CDC planned and hosted a U.S. study
tour of TB experts from the leading TB institute in Russia in February 1997 to see the
U.S. TB strategy in action in a variety of settings. Although CDC has been involved in a
number of TB projects in the Central Asian Republics and the Baltics, direct involvement
in Russia has been limited. Recently, however, USAID in Moscow has recognized the
importance of the problem and is planning on providing mission funds for a three year
period to CDC for the development of one or more pilot projects.
PHRI/Soros Activities
In September 1998 CDC staff conducted a joint visit with members of the Public Health
Research Institute/Soros Steering Committee to examine their activities in the civilian and
prison populations in the Tomsk Oblast and a TB prison in the Kemerovo Oblast.
Public Health Research Institute (PHRI) of New York City has received a $12 million
grant from the Soros Foundation (Open Society Institute, OSI) to undertake projects
aimed at reform of tuberculosis control in the Russian Federation (RF). Dr Alex Goldfarb,
9
a senior scientist in PHRI, serves as the director of the project. After one year of
operation, PHRI has joined DOTS demonstration projects in the civilian sectors in
Ivonova (initially supported by WHO) and Tomsk (supported by the British NGO,
MERLIN), strengthening laboratory capacity and entering into contracts with local
authorities to achieve cost savings by reducing the number of TB hospital beds and of
unproductive TB screening activities. For assistance in training, project monitoring, and
surveillance/reporting, PHRI is working with the Central TB Research Institute (Prof
Alexander Khomenko) in Moscow. PHRI is also supporting a DOTS project initiated by
MSF/Belgium in a TB prison in Mariinsk (Kemerovo) and has begun DOTS projects in
four other prisons (Tomsk, Ivonova, Mari-El, Vladimir and Nidzy-Novgograd). Based on
information available to CDC, it appears that the DOTS projects in the civilian sectors,
where rates of initial MDR-TB appear to be relatively low, are succeeding. However,
failure rates has high as 40% have been found in the Mariinsk prison, likely because of an
equivalent rate of MDR-TB in new patients beginning treatment. Clearly, in such a setting
a DOTS-alone approach may be inadequate. As a next step, PHRI intends to implement a
DOTS-plus project in Tomsk (both the civilian and prison sectors). With project funds
now fully committed, PHRI is looking for other partners and funding sources to expand
DOTS-plus programs in regions where it is working and extend DOTS implementation to
other regions in RF.
U.S. Planned Activities
Beginning November 15, CDC will detail a public health advisor to Moscow for a 4 to 5
week period to assist the USAID Mission in the development of a TB in Russia
Background/Strategy Document.
In late November, a joint CDC-AID team will visit Russia to perform an assessment of
three areas to determine which area would be most suitable to serve as a demonstration
site for CDC-guided TB control project activities. This multi-disciplinary team will
consist of a senior epidemiologist, a TB laboratory specialist, a senior public health
advisor and an experienced program management officer. One of the sites to be visited,
the Kemerovo Oblast in Siberia, has expressed a strong interest in introducing the basic
DOTS strategy in the civilian population (Medecins Sans Frontieres, Belgium is already
working successfully in the main prison). The second site, the Ivanovo Oblast near
Moscow has been used as a pilot area by the World Health Organization and has one of
the two most developed DOTS programs in Russia. In this oblast, the U.S. contribution
would be the development of a strategy to identify and cure the MDR-TB patients who
are not cured by the routine DOTS approach. The third area under consideration is the
Novgorod Oblast which is said to have a progressive governor and chief TB doctor, and
has allegedly indicated it's willingness to provide an adequate supply of required TB
drugs. If successful, a demonstration project would serve as model for other oblasts in the
country. It is hoped that if success is demonstrated in various oblasts, the other oblasts
10
which are still expressing considerable reluctance to abandon old treatment strategies will
be willing to change to the DOTS approach.
Major Obstacles
1.
The amount of money that is being made available at the USAID mission is
inadequate to fully support the proposed activities.
2.
Current U.S. government restrictions on the ways in which money can be spent in
Russia may limit the usefulness of available monies. At least part of the potentially
available mission funds cannot be spent on activities benefitting the national,
oblast, or local governments or on salary support for Russian nationals).
3.
For these projects to be conducted successfully, USAID money must be spent (or
other sources must be located) to pay for drugs. Although the need for the
expensive MDR TB drugs may diminish over time if the program is successful, the
need for basic TB drugs will remain, and it appears unlikely that the oblast or
national governments will be able to bear these costs in the next several years.
4.
Sustainability of efforts beyond the duration of the project may be difficult unless
the financial situation of the country undergoes dramatic improvement.
Coordination Meeting on TB in Russia, 15 October, 1998
At a meeting convened last week (15 October, 1998) by the Office of the Coordinator for
NIS Assistance, the group, including Drs. Hamburg and Eisenberg, explored several ideas
that were later discussed with Dr. Helene Gayle at CDC. The demonstration projects
described above will be most effective in the long run, if they are combined with the
following initiatives:
1.
The setting of a national framework and establishment of an environment for
broader adoption of improved care patterns (especially if the demonstrations can
show the effectiveness of "best practices"). This would likely be done with Russian
TB leaders, oblast leaders, medical education and professional leaders, and
political leaders. This should be linked with the American International Health
Alliance (AIHA) and American College of Physicians (ACP) projects, and
integrated with the Health Committee's quality and primary care initiatives.
2.
The building of capacity to care for patients with TB outside sanitoria and prisons.
This means upgrading the ability of hospitals and polyclinics to care for TB
patients, especially once they have been successfully started on treatment and can
be sent into community-based DOTS programs (more difficult, obviously, with
11
MDR-TB).. This can be done in conjunction with the ACP project, perhaps with
other Health Committee efforts to help upgrade primary care and polyclinics.
3.
The building of capacity in laboratories for testing TB sensitivities and for assisting
clinicians in the selection of appropriate treatment, combined with laboratory
support for a more extensive surveillance system to identify the disease burden and
to characterize the epidemic better. Dr. Hamburg emphasized this as having been
very important in New York City's success in reducing MDR-TB.
4.
The identification of the Russian drug availability situation. Funds should be
considered to assist the broader distribution and delivery of drugs, some of which
are already in Russia but are not being used. A combination of the lack of money
to buy pharmaceuticals, poor health sector organization for their distribution to the
areas most in need, and the lack of knowledge or commitment to use the drugs
appropriately, as well as other factors, contribute to this problem.
These efforts will be very expensive, but the Health Committee should take advantage of
the attention this is getting to emphasize that one can't do demonstration projects without
building reform of TB care into the public health infrastructure, improving the
community-based care, and paying attention to quality of care. Depending on the
intervention, these could be done either in the demonstration regions, in the nation as a
whole, or as part of other donor and collaborative programs (eg, the Access to Quality
Care Initiative, AIHA). It should also be linked with the Soros initiative, of course.
The challenge is how to do the demonstrations with the little money available to the
Health Committee, and to have concrete and near-term products and achievements, yet
offer a broader scope of ideas that focuses those who may direct more funds toward the
program on the full spectrum of components of the initiative if it is to be long lasting.
V
MATERNAL CHILD HEALTH
The USAID Women's Reproductive Health Project
This project has continued its roll-out and institutionalization activities. A team recently
left Russia after developing a strategy for the next 3-4 years which will expand current
work in the area of women's reproductive health to Women's and Children's Health. New
efforts will include work in policy development, NGO development; research; and
information, education, and communication activities.
1.
To date, six of the eight roll-out sites have received contraceptive technology
update trainings and four have received contraceptive shipments. Training in the
12
cc Melame
OPEN SOCIETY INSTITUTE
S
I
GEORGE SOROS
Chairman
20th August 1998
ARYEH NEIER
President
Mrs. Hillary Rodham Clinton
The White House
Washington D.C. 20500-2000
Dear Hillary,
You told me at our last meeting of your interest in the problem of tuberculosis in Russia.
As you noted, explosive prison epidemics in Russia are fueling the larger national epidemic;
these outbreaks are, of course, not contained by national boundaries. I am very pleased that
Dr. Gro Brundtland of the World Health Organization has underlined the importance of U.S.
leadership in addressing this global emergency.
We have started a program to address TB in Russia through the WHO-endorsed control strategy
of directly observed therapy or "DOTS" which cures sensitive TB and prevents new multiple
drug-resistant TB from developing. We have received requests to support programs from our
foundations in such countries as Kazakhstan, Kyrgyzstan, and Azerbaijan which are currently
under consideration.
Since we initiated this work a year ago, we have discovered that the problem is considerably worse
and more difficult than we imagined. My concerns fall into two main areas: MDR-TB, and other
impediments to the adoption of the DOTS approach.
First, the situation is greatly complicated by the multidrug-resistant strains of TB which are not
effectively treated through the DOTS approach. The World Health Organization last month
endorsed a "DOTS-Plus" strategy which addresses drug resistant treatment in circumstances such
as those found in Russia. Since we met, I have directed our TB team to adopt this expanded
approach in order to save lives and halt epidemics already underway.
This enhanced approach is significantly more costly than the simpler "DOTS" approach. This
expansion will require additional funding, though far less than the cost of ignoring these drug-
resistant strains. While I am prepared to commit some additional funds to TB, I have become
convinced that the problem can be addressed only with the coordinated and solid financial
commitment of a wide range of international, bilateral and private donors.
Second, as our programs develop in Russia, we have encountered a range of economic, political,
social, and logistical impediments to the adoption of the WHO/DOTS strategy. Similar
impediments exist in other countries as well. We appreciate that failure to overcome these issues
could jeopardize our investments in TB control, but simple solutions are not readily available.
This is an issue you may want to raise in connection with your visit to Russia in September.
400 West 59th Street, New York, New York 10019
Phone: 212. 548. 0600
Fax: 212. 548. 4679
Website: http://www.soros.org
Hillary Rodham Clinton
20th August 1998
Page 2
I understand that the WHO is currently considering undertaking a global TB program. I have
written Dr. Brundtland a similar letter, and would like to find ways to work with them. A handful
of key players--yourself, Dr. Brundtland, Jim Wolfenson of the World Bank, for example--could
make all the difference if we act promptly. It is my hope that we can join together in calling for the
sustained international attention and funding that could contain outbreaks in the former Soviet
Union and elsewhere. The United States has a critical and new role to play in confronting public
health threats outside of its borders. I look forward to hearing from you on this important issue.
Yours
ferguar
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Sep 23 '98 15:08
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OPEN SOCIETY INSTITUTE 0 S
I
GEORGE SOROS
20th August 1998
Chairman
ARYEH NEIER
President
Dr. Gro Brundtland
World Health Organization
Geneva, Switzerland
Dear Dr. Brundtland:
I understand that the WHO is currently considering undertaking a global program to address the
problem of tuberculosis. As you may know, my foundations have started a program to address
TB in Russia through a DOTS based approach. We have received requests to support programs
from our foundations in such countries as Kazakhstan, Kyrgyzstan, and Azerbaijan which are
currently under consideration.
Since we initiated this work a year ago, we have discovered that the problem is considerably worse
and more difficult than we imagined. My concerns fall into two main areas: MDR-TB, and other
impediments to the adoption of the DOTS approach.
First, as you are well aware, the situation is greatly complicated by the multidrug-resistant strains
of TB. We were very pleased to learn that the WHO last month endorsed a "DOTS-Plus" strategy
addressing drug resistant treatment in circumstances such as those found in Russia. I have since
directed our TB team to adopt this expanded approach in order to save lives and halt epidemics
already underway.
Unfortunately, we realize that this enhanced approach is significantly more costly than the simpler
"DOTS" approach, and will require additional funding, though far less than the cost of ignoring
these drug-resistant strains. While I am prepared to commit some additional funds to TB, I have
become convinced that the problem can be addressed only with the coordinated and solid financial
commitment of a wide range of international, bilateral and private donors.
Second, as our programs develop in Russia, we have encountered a range of economic, political,
ethical, and logistical impediments to the adoption of the DOTS strategy. Similar impediments
exist in other countries as well. We appreciate that failure to overcome these issues could
jeopardize our investments in TB control, but simple solutions are not readily available.
I am hopeful that the WHO will decide to undertake a global plan to control TB. 1 would like to
find ways to work together in addressing this public health emergency. I have spoken with Hillary
Clinton about this problem, and have written her a similar letter. A handful of key players--
yourself, Hillary Clinton, Jim Wollenson of the World Bank, for example--could make all the
difference if WC act promptly. I look forward to discussing this important matter with you in the
near future.
Yours sincerely,
Corge Soros
400 West 50th Street, Ngw York. New York 10019
Phone 211. 548. 0600
Tax 211 548 44/9
Within hilp //wwww
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Sep 23 '98
15:09
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OSI-LED INITIATIVE TO ERADICATE
TB
AUGUST 1998
"The two largest TB NGOs, KNCV in The Netherlands, and the International
Union Against TB and Lung Disease, have a combined budget for fighting TB of
just over $10 million. Last year, the Wellcome Trust announced it could provide
over $2 million to determine the complete sequence of the genome of the tubercle
bacillus. Unfortunately, most of the largest foundations, such as Ford,
Rockefeller, Kellogg and Pew, and the largest health and development NGOs,
such as CARE, Save the Children and Oxfam, remain conspicuously absent in the
battle against TB."
BASIC TENETS OF THE OSI-TB INITIATIVE
Tuberculosis remains the single largest infectious contributor to adult
mortality in the world today.
Increasing globalization of economies demands a global response to the TB
pandemic.
An effective and concerted response demands not only the leadership of the
medical and scientific communities, but also the full participation of the
private sector, including international trade and finance.
JUSTIFICATION FOR OSI INVOLVEMENT IN GLOBAL TB CONTROL
George Soros is the single largest individual donor to. TB control in the
world today.
The regions in which the Network of Foundations is established- from the
former Soviet Union to South Africa- are those in which TB is endemic or
recrudescent; these regions are particularly hit hard by drug-resistant TB.
The OSI brings two critical and previously missing components to TB
control: a human-rights approach and new leadership from the business
OSI-TB INITIATIVE
1
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Sep 23 '98 15:09
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sector, previously a minor player in the TB community. Furthermore, the
geographical reach of the Network of Foundations is unparalleled and the
OSI would bring significant experience to the containment of prison-related
outbreaks.
OSI-TB INITIATIVE
2
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JUSTIFICATION FOR CHOICE OF PARTNERING INSTITUTIONS AND
COMPOSITION OF ADVISORY BOARD
The organizations identified as potential partners in an OSI-led TB eradication
effort are the major participants in global TB control. The Advisory Board
would bring together the leaders of these organizations, as well as key players in
international public health. Others will no doubt be identified.
PROPOSED ORGANIZATIONS
PROPOSED ADVISORY
BOARD REPRESENTATIVE
AMERICAN ACADEMY OF ARTS AND SCIENCES
HOWARD HIATT
CARTER CENTER
WILLIAM FOEGE
CENTERS FOR DISEASE CONTROL AND PREVENTION
HELENE GAYLE
HARVARD MEDICAL SCHOOL
PAUL FARMER
INTERNATIONAL UNION AGAINST TUBERCULOSIS
NILS BILLO
AND LUNG DISEASE
KNCV, HOLLAND
KITTY LAMBRECHT
LONDON SCHOOL OF HYGIENE AND TROPICAL
JOHN PORTER
MEDICINE, UK
MEDICAL RESEARCH COUNCIL, SOUTH AFRICA
BERNARD FOURIE
NATIONAL JEWISH MEDICAL AND RESEARCH
MICHAEL ISEMAN
CENTER
NATIONAL TUBERCULOSIS CENTER &
LEE REICHMAN
PUBLIC HEALTH RESEARCH INITIATIVE
RESEARCH INSTITUTE OF TUBERCULOSIS,
AMAN ZHANGIREEV
KAZAKSTAN
OSI-TB INITIATIVE
3
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PARTNERS IN HEALTH
JIM YONG KIM
ROCKEFELLER FOUNDATION AND THE
LINCOLN CHEN
HARVARD SCHOOL OF PUBLIC HEALTH
UNIVERSITY OF ALABAMA
MICHAEL KIMERLING
WORLD HEALTH ORGANIZATION
ARATA KOCHI
0
OSI-TB INITIATIVE
4
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WHAT ARE THE GOALS OF OSI-TB?
OSI-TB would not seek to replicate existing TB-control structures, nor would it
seek to act alone in inaugurating new TB treatment and control efforts. Rather,
OSI-TB would seek to fill in gaps:
Leadership gaps must be filled if truly global efforts are to progress. OSI-TB
would have a special focus on leadership from business sectors, including
international finance, the pharmaceutical industry, and philanthropies; the
human-rights community would also be engaged.
Gaps in political will must be filled if government support for national
DOTS-based programs, including "DOTS-Plus," are to have real impact on
the global TB pandemic.
Gaps internal to the TB community have neglected critical developments-
MDRTB and prison-centered outbreaks of TB- that threaten the hard-won
gains of global TB control.
Funding gaps will be filled not through direct OSI contributions, but rather
through coalition building to channel new resources into priority TB-
control efforts.
How WOULD OSI-TB WORK?
OSI-TB can make have an enduring impact on global TB control through a
four-step process:
1.
Forge a powerful consortium of actors and institutions, led by an expert
Advisory Board.
2.
Convene a meeting of Dr. Gro Brundtland (WHO), Jim Wolfensen
(World Bank) George Soros, the U.S. Surgeon-General Satcher, and leaders
of the global TB community to launch a worldwide campaign to bring new
resources to TB control.
3.
This campaign will have as its centerpiece a drive to secure an
unprecedented commitment of public and private resources- the Global
Trust for TB Control- targeted to Board-approved projects.
OSI-TB INITIATIVE
5
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4.
Identify TB "hot zones" where new public-private partnerships, funded
through the Trust, can contain deadly epidemics and promote the primary
goals of modern TB control.
OSI-TB INITIATIVE
6
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LILLY
PHRI
OTHER PARTNERS
HMS/HU
OSI
CDC
PIH
KNCV
ROCKEFELLER
WHO
IUATLD
OSI-TB ADVISORY BOARD
PROJECTS
OSI-TB INITIATIVE
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PROGRAM IN INFECTIOUS DISEASE AND SOCIAL CHANGE
DEPARTMENT OF SOCIAL MEDICINE, HARVARD MEDICAL SCHOOL
641 HUNTINGTON AVENUE, BOSTON, MA 02115
PH. (617)432-3715, FAX: (617)432-2565
PAUL FARMER AND JIM YONG KIM. DIRECTORS
To:
ARYEH NEIER & GEORGE SOROS
OPEN SOCIETY INSTITUTE
FAX: 212-548-4608
FROM:
PAUL FARMER, M.D., PH. D.
DATE:
17 SEPTEMBER 1998
During the week of 6-11 September, I traveled with a fact-finding mission to investigate the state of
tuberculosis (TB) control in Russia, with a particular interest in assessing the problem of TB in
prisons. We also evaluated the OSI-funded TB control initiative conducted by the Public Health
Research Institute (PHRI). Our team included representatives of the World Health Organization
(WHO) and U.S. Centers for Disease Control, as well as clinical and research specialists in
tuberculosis control. This group, which serves as the advisory committee to the PHRI projects,
counts decades of experience in TB control and research. I myself acted as special consultant on
TB epidemiology and treatment to the OSI.
For a number of reasons, we expected the TB situation in Russia to be grim. Several of us had
previously visited regional TB facilities; all of us were familiar with reports, in the Russian and
foreign popular press, describing large outbreaks of TB and high case-fatality rates. These
outbreaks, in tandem with the dismantling of the public-health infrastructure, have led to a rapid
rise in national case rates. In 1990, TB incidence in Moscow was estimated at 27 per 100,000
population; by 1993, it had almost doubled, to 50 per 100,000. The situation is significantly worse
in Siberia, where incidence went from 43 to 94 per 100,000 during the same period. By March
24th, 1998, it was possible for the WHO to announce that TB incidence in Russia had risen
another 50% between 1994 and 1996. About a quarter of a million new cases were detected in 1996
alone.
We were also concerned about multidrug-resistant tuberculosis (MDRTB). Most members of the
committee had read the recent WHO/IUATLD report, which suggested decreased cure rates and
significant levels of resistance to first-line antituberculous drugs in the region surveyed. Finally, we
knew that the epidemic was particularly affecting, and amplified within, the prison system. In the
space of the last few years, TB has become the leading cause of mortality among Russian prisoners
and detainees, accounting for 40-80% of all prison deaths in some facilities. National TB mortality
among Russian prisoners was recently pegged at 484 per 100,000- among the highest in the
world.
P. FARMER/REPORT TO OSI, 17 SEPTEMBER 1998
1
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In the light of these unwelcome trends, the OSI-funded initiatives were deemed particularly
welcome both by many Russian officials and by the broader, global TB community. The PHRI has
initiated work in both the civilian and prison populations of Tomsk, and has recently expanded its
support of key reforms to the neighboring oblast, Kemerovo. Similar efforts are also underway in
Vladimir, closer to Moscow.
I have visited all of these regions. On this most recent trip, however, the mission visited Siberian
facilities only. What we found disturbed us greatly. A PHRI-led public-private coalition- linking
foreign NGOs, including Médecins Sans Frontières (MSF) and MERLIN UK, with both prison
and civilian health authorities- has already led to substantial improvements in aspects of TB
control ranging from case detection to the standardization of record-keeping and program
evaluation. Furthermore, this coalition has been able to substantially reduce improper TB-control
practices, which are the root cause of increased rates of treatment failure and increased rates of
acquired resistance to the best and least expensive drugs. The committee was unanimous in
deeming these reforms central to any effort designed to avert further disaster.
These reforms, however, come late. When the OSI-funded initiative was planned and funded, the
contribution of drug resistance to low cure rates was unknown, but MDRTB was estimated to
represent no more than 5% of incident cases. What we found, however, was a rate of MDRTB
many times in excess of this estimate, and we suspect that drug resistance helps to explain the very
low cure rates seen inside a number of the institutions in which standard TB-control practices have
been implemented.
The case of Penal Colony 33, in Mariinsk, Kemerovo, gives an idea of both the gravity and extent
of the problem. For the last few years, the Belgian branch of MSF has worked inside the Colony
with close cooperation, obviously, from prison officials. Treatment has been standardized, and
case detection, treatment protocols, and record-keeping are now in keeping with WHO-endorsed
TB-control practices. And yet, preliminary cohort studies have revealed cure rates of less than 60%
even though the standardized regimen has been bolstered by a fifth drug, and all doses are directly
observed. Although complete drug-susceptibility data are not available, preliminary testing in
Belgium suggests that a majority of treatment failures are due to drug resistance. Patients who fail
therapy now constitute an increasingly large proportion of those detained in Colony 33; they are
eventually isolated from other prisoners. Since Russian law does not permit indefinite detention,
however, these prisoners, still infectious, are simply released into the community at the end of their
term. A majority of the group- 80% by some estimates-are lost to follow up after release,
underscoring the need for close coordination of prison and civilian TB control.
Rapidly rising TB case rates elsewhere in Kemerovo Oblast are further proof of the relationship
between prisons and the surrounding community, as is the fact that fully a third of all civilian TB
diagnoses are made in those with a history of imprisonment. Finally, the highest extramural rates
are registered among prison guards and others working in close association with TB-affected
prisoners.
Equally disturbing, and again suggestive of the increasing contribution of drug resistance to poor
outcomes, are data showing that, between 1987 and 1997, as rates of TB skyrocketed, cure rates
went from an already-low 67% to a sobering 44 %. (See Figure 1). Death rates among those
treated also increased, from 9% to 30%. Note that rates of abandonment and death due to other
causes during treatment remained constant.
P. FARMER/REPORT TO OSI, 17 SEPTEMBER 1998
2
Fax 212-2627580
Sep 23 '98
15:13
P. 14/14
Figure 1.
Trends in TB treatment outcomes, 1987 and 1997
Kemerovo Oblast, civilian population
1987
16%
cure
8%
TB deaths during treatment
deaths from other causes during
9%
TB treatment
67%
transferred out
1997
16%
10%
44%
30%
After meeting with both civilian and prison officials from Kemerovo, the fact-finding mission met
with the state governor and leading health officials. We urged the governor to declare tuberculosis
an "emergency," and he assured us of his strong and unconditional support for the institution of
P. FARMER/REPORT TO OSI, 17 SEPTEMBER 1998
3
WHO
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NU. I
WHO's Response to the Global Tuberculosis Emergency
1. In 1993, the World Health Organization declared TB a global emergency. It took this
imprecedented step as TB was claiming the lives of 2-3 million people each year, making it the
eading infectious killer of youth and adults. Increasingly, the disease was becoming resistant to
currently available medicines because of careless TB treatment practices. (Drug resistance can
levelop when patients get the wrong drugs, drug supply is irregular or patients stop taking their
nedicines too soon because they feel better). And yet, in spite of these dangers, the world's
esponse to the epidemic was minimal
WHO defined the enormous size of the global TB problem through expanded monitoring and
surveillance. For example, it determined that TB had become the leading cause of death among
HIV positive people. The disease also orphans hundreds of thousands of children each year and is
the single biggest killer of young women.
3. WHO also determined that TB is a major contributor to poverty. Eighty per cent of TB patients
are in the most economically productive years of their lives. TB sends many self-sustaining
funilies into poverty. If the breadwinner of a family is not properly diagnosed or treated, he or she
will lose, on average, a full year of work.
4. WHO developed an effective TB control strategy known as DOTS. DOTS is the most effective
rategy available for detecting and curing TB. It was developed from two decades of testing and
best practices. DOTS requires direct observation of treatment to ensure that patients take the
12 edicines; and it also requires government commitment, microscopy services, reliable drug supply
and monitoring systems. DOTS can help any country- rich or poor to achieve high cure rates.
COTS achieves cure rates as high as 95 per cent even in economically devastated or war-tom areas.
Besides achieving high cure rates, DOTS has a number of important advantages:
The strategy can be integrated successfully within general health services to achieve
widespread coverage.
DOTS does not require hospitalization or isolation. Parients can remain at home and
return to work in a few short weeks.
DOTS is as effective in curing TB in both HIV-positive and HIV-negative people, and
is one of the most affordable ways of extending the life of a HIV-positive person.
5. WHO and the World Bank determined the cost effectiveness of DOTS. DOTS helps prevent
In ultidrug resistance; which is often fatal and up to 100 times more expensive to treat. The World
Bank considers DOTS as one of the most cost-effective health strategies available. A six-month
course of drugs for DOTS costs between $10 to $20 per patient in most developing countries.
DOTS is a sound economic investment for any government. For example proper use of DOTS in
TI riland could save the country $2.3 billion over 20 years.
6. Ite Organization promoted the global implementation of DOTS. WHO developed the
DC essary tools, guidelines, training materials and policies to promote the implementation of DOTS.
P.T the same time, WHO embarked on major advocacy and intensified technical assistance to over
50 countries, focusing on big countries with largest TB burdens. These efforts have made DOTS
Dae of the fastest expanding health interventions of this decade. Today, nearly 2 million people are
being cured with DOTS.
Inc icator
1990
1998
Number of countries using DOTS
10
110
cent of TB patients being treated by DOTS
Under 1 percent
15 percent
Drug costs per patient
$40-60
$10-20
E-- email donor aid to TB control
$16 million
$70 million
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WHO's Challenge Ahead
1. WHO has identified the main constraints that are preventing further progress against the TB
epidemic. These are 1) lack of political commitment; 2) lack of human and financial resources; 3)
unavailability of affordable and secure supplies of anti-TB drugs; 4) increased multiple-drug
resistant TB (MDR-TB); and 5) the HIV epidemic, which is partly fueling the global TB epidemic.
$ global strategy is needed to address these constraints, particularly in high-burden countries.
:-
WHO's new Director General - Dr Gro Harlem Brundtland - has identified TB as a priority concern
or the "renewed" WHO.
3.
Groundwork must now be established among global partners for a major initiative on TB. The
Stop TB Initiative will lay out and prioritize the steps needed to overcome current constraints to
2 ction and provide the basis for a significant expansion of global efforts against TB.
4. ] he Stop TB Initiative will serve to command increased attention and resources for further
i uplementation of DOTS; swiftly establish solutions to sustained global access to anti-TB drugs;
lentify cost effective options for addressing MDR-TB and frame a long term vision for a TB
desearch and development agenda to include new tools - most importantly an effective vaccine.
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THE GLOBAL TUBERCULOSIS EPIDEMIC
Burden of disease
- There were an estimated 8 million new cases of TB in 1997, including 3.6 million
cases of infectious pulmonary disease, and 16.1 million existing cases of disease.
- An estimated 2.0 million people died of TB that year, about 1 in 4 cases. TB
causes more deaths than any other single infectious agent.
- Roughly 1 in 3 people carry the M. tuberculosis bacterium (MTB), i.e. 1.8 billion
people.
- Countries in South East Asia had the largest number of new cases (3.0 million) in
1997), but the rate per head was highest in sub-Saharan Africa (257/10⁵ persons).
- 22 countries had 80% of all incident cases. The leading five together accounted
for over half the global total. They were all in Asia: India (1.9 million), China (1.4
million), Indonesia (583,000), Bangladesh (292,000) and Pakistan (261,000).
- 1 in every 500 people was infected with both TB and HIV. Three-quarters of a
million TB cases (8%) were infected with HIV. The highest rates of co-infection
(over 1 in 50 people) were in southern Africa, but India had the largest number of
co-infected individuals (1.9 million) and the largest number of HIV-infected TB
cases (190,000).
- Surveys suggest that about 1 in 10 TB cases is resistant to at least one drug; about
1 in 50 cases is multi-drug resistant (to at least isoniazid and rifampin)
- The huge scale of the problem is explained mainly by poor control and population
growth in south Asia and sub-Saharan Africa, and high rates of MTB/HIV CO-
infection in some African countries.
Trends
- Without greater control effort, annual TB incidence is expected to increase from
about 8 million cases/year in 1997 to 11 million cases/year by 2020.
- Reaching WHO targets of 70% case detection and 85% cure by year 2010 could
save about 1 in 4 cases (approx. 50 million) over the next two decades.
- The incidence of disease is increasing most quickly in African countries that have
high levels of HIV (e.g. Malawi, Kenya, Tanzania). It is also increasing quickly in
countries where control programmes have broken down (e.g. Russian Federation).
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Control
- Only about half of infectious cases are treated and cured. The cure rate in DOTS
Programmes is much higher than average, typically about 80%.
- Approximately half of all countries have now adopted the WHO DOTS strategy.
Twenty-one of the 22 highest-burden countries have DOTS Programmes, but most
with low rates of case finding and cure.
- At present, about 1 in 10 infectious TB cases is cured in DOTS programmes
- Among high-incidence countries, the best control programmes are in Peru,
Tanzania and Viet Nam, though programmes in Bangladesh and China have
expanded rapidly during the 1990s.
- Progress in TB control is very slow in the majority of high-burden countries,
notably India, Indonesia, Nigeria, Pakistan, Philippines and Russia.
NSC INTL HEALTH 007/010
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WHO
10/23/98
No. 2
Briefing Points for the Director-General's 28 October meeting at the
White House With Mrs H Clinton, Mr J Wolfensohn and Mr G Soros
The Tuberculosis Problem
Each year there are about 8 million new TB cases, with about 2 million deaths.
Multidrug-resistant TB (MDR-TB) has emerged as a major threat to TB control in some
countries, including Russia and the Baltic States.
In 1997 an estimated 8% of TB cases were attributable to HIV, the burden falling mainly
on sub-Saharan Africa and increasing in other regions, especially the Indian sub-
continent.
11
TB is the biggest single killer of women aged 15-44 world-wide, is the major cause of
death among the HIV infected, and is a significant brake on socio-economic development
in poor countries as it affects mostly young adults.
4:
The global response to TB has thus far been inadequate: many poor countries are failing
to control it; rich countries are not doing enough to support TB control in the poor
countries and, as a result, the prevalence of TB globally remains unacceptably high, and
MDR TB is being created and spread internationally.
The Current Solution to the TB Problem
The DOTS strategy has been shown by the WHO in collaboration with the World Bank to
be one of the most cost effective health interventions.
Proper case detection and cure of infectious cases are the comerstone of the TB control
strategy.
Successful implementation of such strategy achieves high cure rates (e.g., 95% cure
among a quarter of a million TB patients annually in China).
xisting Constraints to the Solution
@
The DOTS strategy is labour intensive, requires direct observation of treatment and strict
patient monitoring.
Where the prevalence of MDR-TB is high or where HIV infection is widespread, control
measures in addition to the DOTS strategy are necessary.
"
Although 97 countries have adopted the DOTS strategy, only 15% of TB patients globally
are treated under DOTS because only few countries have achieved full coverage.
"
Governments of high prevalence countries have shown insufficient political will and
leadership, and have not allocated adequate financial resources.
is
There is a lack of trained human resources and of secure, quality controlled drugs.
41
Inefficient drug procurement systems in most countries result in an increase in the cost of
drugs and produce shortages of stocks.
BCG vaccine is ineffective to prevent infectious forms of TB, thus it cannot interrupt TB
transmission.
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Recommended Actions
The current global TB control situation is similar to that of vaccine preventable diseases in
the mid 1980s. EPI has successfully progressed to achieve the global targets in the early
1990s through global coalition building and country specific social mobilization. Even
hough TB control and the implementation of DOTS may be more complicated than EPI
operations, through global coalition and country specific social mobilization, DOTS coverage
can be expanded to allow achievement of the global targets of 70% case detection and 85%
were rate by 2010. Therefore, We recommend the following:
WHO, the World Bank and various US agencies and private charitable interests such
as the Open Society Institute commit themselves to work together and combine efforts
to analyse constraints, prepare, appraise and finance projects that provide solutions
and assist countries with high quality technical implementation of TB control.
2.
WHO, in partnership with the World Bank, various agencies throughout the world,
and other private and public interests will establish a Stop TB Initiative which has
the following four components:
A global charter for advocacy and commitment to TB control and elimination of MDR-
TB.
A global action plan to coordinate interaction among international partners to ensure
effective TB control
A mechanism to swiftly establish global access to anti-TB drugs.
A global research agenda balancing short and long-term vision.
successful Initiative will ensure the following:
IT
TB activities at WHO and worldwide are facilitated
Expanded effective TB control in high burden priority countries.
Expanded global surveillance of drug resistance and new interventions to treat MDR-TB
focusing on Russia and other high MDR-TB burden countries.
A global drug facility or direct drug funding to countries in need to ensure the sustained
supply of quality, fixed-dose, combination TB drugs.
Coordinated approaches to the care and prevention of TB and HIV, especially in Sub-
Saharan Africa
Improved tools to deliver effective TB control services as an integral part of primary
health care.
Development of new tools, such as rapid diagnostic tests, drugs and vaccines.
The World Bank's Current Activities in Tuberculosis Control
The World Bank is fully committed to fighting the global tuberculosis epidemic. The
World Bank's contribution is twofold: through the policy advice it provides to
countries, and through country-specific lending.
In pursuing TB control activities, the Bank collaborates closely with WHO, NGOs,
bilateral and technical agencies. For example, a current Bank project in Latvia will
be financing improved TB treatment and surveillance, with technical assistance
provided by the U.S. Centers for Disease Control. The Bank is also working closely
with partners regarding potential interventions for improved TB control in Russia.
The Bank has provided nearly US$ 300 million in financing for tuberculosis control
programs since 1989, making it the largest single source of external funding for
tuberculosis control in developing countries.
About twenty countries are using World Bank financing to implement the WHO-
recommended TB control strategy (DOTS). Several new projects are under
preparation. Some projects are tuberculosis-specific, but a majority address TB
control within broad health sector development and health sector reform projects.
The two largest Bank-supported TB control projects are in China and India. These
countries are home to more than one third of the world's estimated 8 million new TB
cases each year.
The project in China was initiated in 1992 and has demonstrated dramatic results with
the DOTS strategy: half of the country's population is now covered, and over one
million infectious cases have been cured to date. The challenge now is to expand this
success to the rest of China and to achieve financial sustainability.
In India, the TB control project, which began in 1997, has also achieved excellent
results with DOTS in several pilot regions. It has established the foundation for the
Revised National TB Control Program, and is providing the impetus for an 8-12 year
process of extending the approach nationwide. Political commitment, assured drug
supply, health worker training and supervision, patient education and motivation, and
operational research are critical to the progress of these projects.
The Bank is supporting implementation of the DOTS strategy in countries as diverse
as Bangladesh, Cambodia, Cote d'Ivoire, Egypt, Haiti, Krygyzstan, Morocco, Niger,
Philippines, Romania, and Vietnam.
In some countries, tuberculosis control is
intimately linked to prevention and control of HIV/AIDS, and the strengthening of
collaborative interventions, education, and referral is critical.
(MON) 10. 26' 98 11:03/ST. 11:02/NO. 3561964223 P 2
FROM WB EXC
7142
ALFONSE D'AMATO, NEW YORK, CHAIRMAN
COMMISSION ON
CHRISTOPHER H. SMITH, NEW JERSEY, Co-CHAIRMAN
SECURITY AND COOPERATION IN
Ben Nighthorse Campbell, Colorado
John Edward Porter, Illinois
EUROPE
Spencar Abraham. Michigan
Frank R. Wolf, Virginia
234 FORD HOUSE OFFICE BUILDING
Conrad Burns, Montana
Matt Salmon, Arizona
WASHINGTON, DC 20515-6460
Olympia J. Snowe, Maine
Jon Christensen, Nebraska
(202) 225-1901
Frank R. Lautenberg, New Jersey
Steny H. Hoyer, Maryland
Harry Reid, Nevada
Edward J. Markey, Massachusetts
FAX: (202) 226-4199
Bob Graham, Florida
Benjamin L Cardin. Maryland
E-MAIL: [email protected]
Russell P. Feingold, Wisconsin
Louise Mcintosh Staughter, New York
EXECUTIVE BRANCH COMMISSIONERS
JOHN SHATTUCK DEPARTMENT OF STATE
(Vacant). DEPARTMENT OF DEFENSE
(Vacant), DEPARTMENT OF COMMERCE
October 9, 1998
-
MICHAEL R. HATHAWAY, CHIEF OF STAFF
DOROTHY D. TAFT, DEPUTY CHIEF OF STAFF
To: K.BERNAI
The Honorable Madeleine Albright
Secretary of State
FYI.
Department of State
2201 C Street, NW
Washington, DC 20520
Dear Madame Secretary:
We are writing to focus your attention on the growing threat of Multiple Drug Resistant
Tuberculosis (MDRTB) in the Russian Federation, as outlined in the attached information. We would
appreciate learning what initiatives have been undertaken by the United States to help contain and defeat
this biological threat. Like the Y2K problem, the MDTRE problem can become a crisis if not addressed
in a timely and effective manner.
With easy international travel and limited means of protecting people from an airborne pathogen,
the incubation and spread of MDRTB in Russia also poses a threat to the health of the U.S. population.
Moreover, as the world has seen before in this century, the spread of disease, whether influenza after
World War I or AIDS in Africa, can threaten and even upset social, political, and economic structures
necessary for peace and security.
This medical threat must be addressed now, while it may still be possible to limit the consequences.
Given Russia's economic troubles and political uncertainty, a concerted international effort to help the
Russian authorities contain the spread of this disease and treat its victims appears to be urgently necessary.
Currently, the Open Society Institute of the Soros Foundations is funding a $12 million program to combat
TB and MDRTB in Russia. Other NGOs, such as Doctors Without Borders, Medical Emergency Relief
International, and the New York Health Research Institute, have already begun studying the issue and have
raised the alarm. But the problem is genuinely global in scope and will require assistance from
governments.
We understand that George Soros is planning in the near future to discuss this troubling matter with
Mrs. Hillary Rodham Clinton and World Bank President James Wolfensohn, and to emphasize the
necessity of governmental involvement. The United States should certainly take the lead in coordinating
the activity of medical experts, foreign capitals, international organizations and NGOs to assess the risk and
Secretary Albright
October 8, 1998
Page 2
work out a plan of action. Perhaps the State Department could convene a conference, along with NIH or
CDC, to look at this problem from both the Russian and U.S. ends, i.e., the potential public health mpact
on the United States, as well as the economic and political impact on the Russian Federation. Perhaps such
a conference can identify what exactly the United States can do to help combat this disease.
We are sure you share our concern about this global threat, and we in Congress would like to work
with you in averting a crisis. We look forward to hearing from you at your earliest convenience and learning
what the Department is doing to address this important issue.
Sincerely,
aljonse Dames
CHRISTOPHER H. SMITH, M.C.
ALFONSE D'AMATO, U.S.S.
Co-Chairman
Chairman
cc: Mr. Samuel R. Berger
Asst. to the Pres. For Nat'l. Sec. Aff.
Enclosure
TB Meeting
fir TB
October 28, 1998
List of Participants
World Health Organization
Project 55 TB Initiative (Ralph Nader grp.)
Dr. Gro Brundtland
Christoph Lee
Dr. David Heymann
AID
Executive Director for Communicable
Administrator Brian Atwood
Diseases
Duff Gillespie
Ambassador Jonas Store
Deputy Assistant Administrator for
Executive Director
Population, Health and Nutrition
Ambassador Thomas Loftus
HHS
Secretary Donna Shalala
World Bank
Dr. James Wolfensohn
Peggy Hamburg
President
Asst. Secretary for Planning and Evaluation
Jan Piercy
State
U.S. Executive Director
Frank Loy
Undersecretary of State for Global Affairs
Dr. David de Ferranti
Vice President, Human Development
Melinda Kimble
Network
Douglas Wake
Chris Lovelace
Office of Assistance to the NIS
Director, Human Development Sector
WH/NSC
Open Society Institute
Melanne Verveer
George Soros
Marsha Berry
Dr. Paul Edward Farmer
Ken Bernard
Dr. Alexander Goldfarb
Andrew Weiss
Dr. Srdan Matic
Leon Furth