Interview
Treat now while we have the drugs
To find out more about the technical and economic options now apparent for infectious disease control, the Bulletin's Robert Waldgate talked to David Heymann, WHO's Executive Director for Communicable Diseases.
Q. Your Infectious diseases report 2002, prepared with several other UN agencies, says that this is a truly unique moment a moment of heightened awareness and commitment, and that this is the time to respond to it with practical programmes.
A. That's right. It is a unique opportunity to respond. We have the necessary tools, and now we have a commitment not just to prevent disease, but to treat those already infected. The six major illnesses that are responsible for 90% of infectious disease mortality are acute respiratory infections, diarrhoeal diseases, AIDS, malaria, TB and measles. Measles is the only one of these diseases where infection can be prevented by a vaccine. However, perceptions of the importance of vaccines are shifting. In just the past three years the international development community has understood that we can no longer limit our public health programmes to a strict focus on vaccination or prevention we must also treat people. We must cure them, bring them out of sickness so they can work, contribute to their economies, and release themselves from poverty. This commitment is increasingly evident. Development agencies are now providing resources in the form of a Global Fund with almost US$ 2000 million of pledges to provide developing countries with the drugs and other commodities needed to control AIDS, TB and malaria.
Q. You don't think that this political commitment has been finally disappointing, in that Kofi Annan, Secretary General of the UN, was asking for US$ 710 000 million a year but only US$ 800 million will be disbursed in the first year; while the President of the USA can ask Congress without a blink of an eyelid for US$ 50 000 million for war?
A. I see encouragement on several fronts. The G8 group of industrialized countries is committed to reducing the burden of infectious diseases. The Global Fund was set up just last month, and the initial pledges are encouraging. If the international community continues to build on this momentum, and if results can be demonstrated, then financial support for the fund will grow. Far from being disappointing, this is a very exciting time in public health. The paradigm for health development has been broadened to include treatment, and the bilateral and other development agencies have shown their willingness to support this broadened mandate with funds.
Q. And are programmes and governments in developing countries ready to deliver on this?
A. Governments are ready to deliver if they can diversify their health systems sufficiently and show good stewardship. This means letting nongovernmental organizations, the private sector, and other potential partners work with them to improve access to drugs and other interventions, and not keeping them exclusively in restricted government health facilities.
Q. The report of the Commission on Macroeconomics and Health, and the Infectious diseases report 2002, talk about extremely large sums of money to turn health systems around US$ 66 000 million a year. That's not realistic in the short term, is it? So what will be going on in the short term?
A. As I said earlier, we have the necessary tools. In the short term there is great urgency to use these tools to the maximum. Existing drugs are gradually becoming ineffective as antimicrobial resistance spreads. We have seen simple antibiotics for simple infections become unusable. This forces us to resort to much more expensive antibiotics with many more side-effects. We face a situation of great urgency to do the job now with as many partners as possible. We are confident that if the proper mix of health services governments, civil society, NGOs, the private sector is made within countries, much can be done to scale up immediately. What Jeffrey Sachs [Chairman of the Commission on Macroeconomics and Health] sees as needed is US$ 66 000 million per year. Of that, governments are expected to commit about a third. They are expected to contribute to disease control by committing resources in the form of staff and other essential activities. They must be, and are becoming, active players. Since the declaration of commitment to reducing malaria by African Heads of State in Abuja, Nigeria, two years ago, for example, several countries have eliminated import taxes on essentials such as insecticide-treated bednets to prevent malaria. Now is the unique moment for the international community to support developing countries if we are to get results in a cost-effective manner. If we wait we will have to pay more for second line antibiotics. In some instances we may run out of antibiotics altogether unless industry increases its rate of research and development.
Q. What specific diseases are you thinking of?
A. The three major killers. With AIDS, we can prolong life with antiretrovirals (ARVs), but even so, resistance is developing. For TB and malaria, resistance is already a major problem and growing.
Q. Is there a risk of anarchy developing in ARV sales and distribution, with Africa becoming an engine of resistance?
A. WHO is currently collecting all available evidence on the use of ARVs in preventing mother-to-child-transmission of HIV, and also in treating persons with AIDS. That evidence is being collected and analysed as the basis for sound public health policies. Those policies are not yet universal, and it is not yet completely understood what can and can't be done in sub-Saharan Africa. What is clear is that TB, which is an opportunistic infection in AIDS, can be successfully treated. We have the evidence and a strong medical model. We also know that if you treat TB in AIDS patients you can prolong lives. You also prevent transmission of TB to other people. So TB treatment in AIDS patients is a very cost-effective means of prolonging life and halting transmission one of those necessary tools we have right now and need to use with the greatest urgency. 