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The TB Frontier: New Strategies, HIV Linkages, Washington D.C., October 17, 2007

July 24, 2008

Jorge Sampaio

UN Secretary General’s Special Envoy to Stop TB

Former President of Portugal



“The TB Frontier: New Strategies, HIV Linkages,

Threats, and Tools – The Global Effort”



Policy Luncheon organized by the CSIS Task Force on HIV/AIDS

and The Henry J. Kaiser Family Foundation


Washington D.C.

Dirksen Senate Office Building Rm. 628

October 17, 2007

Ladies and Gentlemen,




Ø First of all, let me express my gratitude for giving me the opportunity to address this distinguished and influential audience;


Ø Allow me to start on a very personal note – you probably do not know, but as a teenager I spent an academic year in Baltimore.


Ø I retain very fond memories of that time. But I remember particularly well being totally puzzled by your interactive-oriented schooling, focused on teaching children to assert themselves by speaking and acting in a forceful way.


Ø Imagine my discomfort as a little foreign speaker with a poor English, when I was called upon to address my schoolmates on issues like human rights  


Ø Well, this is to say that I have always been fascinated by your most dynamic civil society worldwide, by your powerful public space and by the vitality of your political life. 


Ø In my view, this is something that remains at the core of your democracy and it is indeed a great asset. 




Ladies and Gentlemen,



Ø I was asked to make some introductory points on the issue we will discuss here today – “The TB Frontier: New Strategies, HIV Linkages, Threats, and Tools – stressing in particular the global viewpoint and the on-going efforts to tackle TB.


Ø In order to carry out my task, let me ask and try to answer three main provocative questions:



o   How TB control matters to human security?

o   Why making the case for global TB control remains a kind of a Catch 22 situation?

o   Why we need to move from a global to a ‘glocal’ approach to turn MDGs on health – especially TB  – into deliverables?





1.    How TB control matters to human security?



Ø As you have probably noticed, since the end of the Cold War the concept of “security” has clearly been enlarged to encompass new threats and challenges well beyond military ones. Furthermore, its scope has also expanded as globalization has generated new risks and vulnerabilities, most of them cross-border and transnational.


Ø And although “human security” means different things for different people, there is a wide acceptance that new conflicts, inter-personal and inter-community violence, international terrorism, poverty and growing inequalities, and the impact of health crises are part of a new human security agenda.


Ø Regarding the case of communicable diseases, it is therefore clear that, like international terrorism, they attack countries not at their borders but deep inside their national territory.


Ø The three biggest pandemics in our globalizing times – HIV-AIDS, TB and Malaria – therefore pose a global public threat. They are part of the everyday insecurities faced by the world’s poor and excluded, but they are also a breeding ground for instability and conflict, affecting global security.


Ø Indeed, global health matters on ethical, humanitarian and development grounds as well as for economic reasons.


Ø Health for all is a basic universal human right. Illnesses have devastating economic and social impact on all societies. A government that cannot ensure the health of its people has failed its most fundamental responsibility.


Ø Global Health is also at the heart of every agenda for human development because it is the key to stability, security and peace at local, national, regional and global level.  Our current context of new conflicts, pervasive poverty and accelerating global flows brought the health and security fields closer together.


Ø Let me focus now on tuberculosis’ threat to global security.


Ø The evidence is appalling, although most of the time ignored.


Ø Let’s recap some data: as you probably know, TB is a curable disease, but – as you probably do not know – it kills 4.500 people every day.


Ø TB is indeed a disease of poverty and, virtually, all TB deaths are in the developing world, affecting mostly the most vulnerable, the poorest and undernourished.


Ø But new drug-resistant strains of tuberculosis (as MDR-TB, Multidrug-resistant TB, a form of TB that does not respond to standard drug treatment, and Extensively Multi-Resistant TB, XDR-TB) are present in virtually every country around the world. And 450,000 new MDR-TB cases are estimated to occur every year.


Ø Let me emphasize that Multi-Drug Resistant TB (MDR-TB) arises from poorly managed treatment and that Extensively Multi-Resistant TB (XDR-TB) is entirely man-made.


Ø Furthermore, TB is a leading killer among HIV-infected people in developing countries with weakened immune systems. And a quarter of a million TB deaths are HIV-associated.


Ø Now, the paradox is that people under anti-retroviral treatment of a non-curable disease eventually die from a curable disease. This is an unbearable situation!


Ø You may recall the case of this Atlanta lawyer, Mr. Andrew Speaker, who, this summer, has helped to splash the acronym XDR-TB across headlines….


Ø Indeed, he was not the first to travel with TB since, according to WHO and CDC records, many other TB patients have traveled and, in some cases, there has been transmission of the infection to other passengers.


Ø But this is really a wake-up case from which we can to draw some lessons.


Ø The question we need to raise is not, in my view, “what more can a country do to protect its citizens from exposure to TB?”, because, unlike people, diseases do not need a passport or visa to travel and to spread around and therefore we can not build staunch walls against outside disease threats.


Ø To my mind, critical questions are “what more can we do at global level to improve diagnosis, treatment and prevention of this curable disease?”, “What more can we do to save more than a million lives each year ?”


Ø As a global pandemic, TB generates risks that that have security implications. As it is an affordably-curable disease, these risks are unnecessary and avoidable. Why therefore make our citizens and societies vulnerable to undesirable and volatile crises? How can we afford to do nothing ?


Ø Indeed, one can argue that epidemics have ever shaped world history.  Black Death, smallpox, measles, syphilis, tuberculosis, AIDS…


Ø So…What is different now?


Ø WHO estimates that more than 40% of the 56 million deaths each year are avoidable, given the existing knowledge, technologies and resources. This makes a big difference.


Ø Secondly, there is a permanent risk of global pandemics. Because of globalization and the interconnection of international system. Because travel time between remote corners is measured in hours, flow of goods, services and finance is transnational, and information travels in fractions of a second.


Ø Just as the outbreak of an epidemic in one corner of the world ultimately affects us all, so it is linked directly or indirectly to all the other major world issues, such as conflicts, economic imbalances, the rich-poor gap, population growth or the environment.


Ø Therefore global TB control matters to human security because TB everywhere is TB anywhere.




2.    Why making the case for global TB control remains a kind of a Catch 22 situation?



Ø In the early 1990s, an outbreak of drug-resistant TB in New York City cost US$ 1 billion to contain.


Ø Unfortunately, obvious lessons were not learned and future outbreaks such as XDRTB were not prevented.


Ø Research and development by G8 and other high-income countries of new tools to fight TB effectively has been neglected and under-funded over more than 40 years.


Ø The Stop TB Partnership Global Plan to Stop TB (2006-2015) has identified an annual research funding shortfall of US$ 900 million to deliver urgently needed new diagnostics, drugs and a vaccine.


Ø Moreover the recent Global Response Plan launched by WHO and its partners a few months ago calls for an additional 170 million US$ a year in this biennium if new tools to face XDR-TB are to be developed quickly.


Ø At present, according to WHO figures, the total cost of the Global Plan to Stop TB for the ten-year period (2006-2015), inclusive of the additional new component to face XDR-TB,  is estimated at US$ 67 billion, of which US$ 25 billion is currently available, leaving a funding gap of US$ 42 billion.



Ø Although this is a big gap, let us bear in mind that it has to be filled both by donor countries and by endemic countries.


Ø The Global Plan contains a blueprint for a series of actions to be implemented by endemic countries in order to reach the MDG of halting and starting reverse incidence of TB as well as the Stop TB Partnership targets of halving prevalence and mortality with regard to 1990 baseline.


Ø In my view, it is obviously more affordable to fill this gap than to pay for the economic and social loss produced by the epidemics.


Ø However, advocacy for global TB control seems sometimes like a Catch 22 situation.


Ø To claim that TB poses risks that have security implications we need to recognize TB as a health emergency; but to recognize TB as a health emergency, we need to acknowledge TB as a threat to human security.


Ø This vicious circle makes political support to global TB control a restless battle.


Ø On the one hand, because there are many other global issues, competing to be highly placed on the global agenda; on the other hand, because among global health issues, the white plague, as TB was called in the past, does not achieve “iconic status”.


Ø This is why, in my capacity as the UN Special Envoy to Stop TB, apart from carrying on several contacts with decision and opinion makers, I have insisted on the need for significant scaling-up of advocacy, communication and social mobilization for TB.


Ø We need to generate political, social and behavioral change at every level, we need to create social pressure and political accountability to shape policy agendas and mobilize US$ 67 billion for the period from 2006 to 2015 for TB control.


Ø Experience shows that celebrities and public icons can do a lot to engage public support, to mobilize people and to raise awareness.


Ø This is why, for example, I am most happy that international soccer player Luis Figo has agreed to be a TB speaker. I very much hope that we can display a massive worldwide campaign for TB to mobilize political, social and financial resources, led by him.


Ø We need to break the vicious circle that makes TB a neglected disease. TB is an affordably curable disease, but it still kills 1.6 million people annually, far more than the number killed in the natural or man-made catastrophes that make headlines.



3.    Why we need to move from a global to a ‘glocal’ approach to turn MDGs on health – especially TB – into deliverables ?



Ø In spite of spectacular progress in health achieved during the 20th century, good health is inequitably distributed. Moving into the 21st century, we need to recognize that half of the world’s population has been left behind, carrying a vast burden of preventable diseases.


Ø But can we avoid or at least reduce it? Can we do more? Can we do better?


Ø Yes, we can, we should, we must do more, faster and better.


Ø For technical/security reasons – because we live in a world of open borders where new strategies of risk-control and management are needed to protect our citizens against external shocks;


Ø For efficiency arguments – because it is a good investment, it “pays” from a cost-benefit viewpoint.


Ø For political reasons – because global health security is increasingly recognized as a public and indivisible good, which needs to be a top priority on the global agenda.


Ø For ethical reasons – because protecting the health of humankind and reducing unsustainable health disparities require international cooperation and shared responsibility.



Ladies and Gentlemen,


Health and human security are central matters of human survival in the 21st century.


Ø As the risk of pandemics is global, we need to energize global health as a human security priority.


Ø We  need urgent additional action to meet health-related MDGs, as well as improved international cooperation to meet specific HIV-AIDS, TB and Malaria targets.


Ø In my view, we need indeed to think globally. But to deliver we need to act locally.


Ø Therefore, a results-oriented approach of global health challenges and threats requires a glocal strategy.


Ø By glocal I mean: a people-centered approach, a focus on empowerment and ownership.


Ø Even if TB-control has to be seen as a Global Public Good for Health, comprehensive TB control rests on the ability of national TB programs to successfully identify and treat patients.


Ø Therefore adequate coordination between international input and domestic action and policies is a critical point in achieving global TB control.


Ø To making progress, it is crucial sustained country leadership and ownership for TB control in the context of the “three ones” principle – one national plan, one authority and one monitoring and evaluation system.


Ø I will leave to the WHO experts more technical explanations on the elements of the Stop TB Strategy, which underpins the Global Plan to Stop TB. This Strategy builds around DOTS, the case management approach promoted internationally for over a decade and that remains  the fundamental approach to TB treatment.


Ø But I could not finish without stressing two additional critical points:


Ø Firstly, the need to improve coordination in the fight against AIDS and TB as a critical point in improving health worldwide. It is sobering to recognize that only 0.5% of estimated HIV patients are currently tested for TB and only 7% of TB patients are tested for HIV worldwide – this is a shockingly dramatic shortcoming, isn’t it?


Ø To control TB in high HIV settings far more collaboration between TB and HIV/AIDS programs must be implemented.


Ø This is why I would like to put forward a proposal for a meeting of the influential stakeholders – such as the G8 countries, the European Union, the World Bank, the Global Fund, UNAIDS, WHO, USAIDS, OGAC, foundations, companies, associations, NGOs and Governments of high-burden countries – to lay down concrete steps for global coordination of TB and HIV activities.


Ø Secondly, the need to strengthen health systems worldwide is a key issue in achieving most of the health-related Millennium Development Goals. This requires improving infrastructures, investing in laboratories and addressing the lack of health workers facing many developing countries. Without prompt and coordinated action, the shortage will worsen.


Dear Friends


Ø We need to develop new and more effective capabilities to address health security priorities. This requires strong political leadership, appropriate financial resources, new partnerships, and a glocal strategy.


Ø Investing in TB control as a pilot case pioneering the emergence of a new paradigm of human security will contribute to reducing fears and to generating public confidence.


Ø In my view, it will be a win-win cooperation strategy, providing clear leadership to the first-mover. To my mind, this is a natural role to be played jointly by the USA and the European Union, as a way of strengthening transatlantic cooperation.



Many thanks