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TB Notes 1, 2000
Introduction
Where We've Been and Where We're Going: Perspectives from CDC's Partners in TB Control
Changes I've Seen
TB Control in New York City: A Recent History
Not by DOT Alone
Baltimore at the New Millennium
From Crickets to Condoms and Beyond
The Denver TB Program: Opportunity, Creativity, Persistence, and Luck
National Jewish: The 100-Year War Against TB
Earthquakes, Population Growth, and TB in Los Angeles County
TB in Alaska
CDC and the American Lung Association/ American Thoracic Society: an Enduring Public/Private Partnership
The Unusual Suspects
The Model TB Prevention and Control Centers: History and Purpose
My Perspective on TB Control over the Past Two to Three Decades
History of the IUATLD
Thoughts about the Future of TB Control in the United States
Where We've Been and Where We're Going: Perspectives from CDC
Early History of the CDC TB Division, 1944-1985
CDC Funding for TB Prevention and Control
Managed Care and TB Control - A New Era
Early Research Activities of the TB Control Division
The First TB Drug Clinical Trials
Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC)
TB Communications and Education
TB Control in the Information Age
Field Services Activities
TB's Public Health Heroes
Infection Control Issues
A Decade of Notable TB Outbreaks: A Selected Review
International Activities
The Role of CDC's Division of Quarantine in the Fight Against TB in the U.S.
The STOP TB Initiative, A Global Partnership
Seize the Moment - Personal Reflections
 
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This is an archived document. The links are no longer being updated.

TB Notes 1, 2000

The Unusual Suspects

by Lee B. Reichman, MD, MPH
Professor of Medicine,
Preventive Medicine and Community Health
Executive Director,
New Jersey Medical School National TB Center
A Founding Component of the International Center
for Public Health

TB people have always been an "in" group. They always tend to talk to each other, and meet at their own meetings such as the International Union Against Tuberculosis and Lung Disease, the American Thoracic Society, and the National Tuberculosis Controllers Association. Before 1992, if you went to meetings of other groups (the Infectious Diseases Society of America, the American Public Health Association, the American College of Physicians, the European Respiratory Society to name a few), there was precious little TB, if any, on the program.

But TB docs aren't the only ones who treat TB, and since TB remains a serious global problem, they shouldn't be the only ones concerned about TB.

TB in the United States is now in a downward spiral. Even though TB in the world remains rampant, in the United States TB rates are down 7 years in a row including 1999. But, paradoxically, during this period of decline, interest in TB seems to have markedly increased, and such interest apparently has increased outside the parochial TB community. This to my mind is the factor that is reinvigorating TB and TB control worldwide. It leads me, on the basis of present evidence, to humbly suggest that the salvation of TB control in the world as well as in the United States will only occur when the players are no longer exclusively from that "in" group. The new outside players could be characterized as unusual suspects.

In the past I've been very publicly critical of the WHO's ex-Global Tuberculosis Programme staff for all too often going it alone, but I'd like to now commend them and their successes, tentatively at least, for adopting and leading more of a team approach to deal with worldwide TB. And their leadership in the "Stop TB" Initiative, which necessarily requires partnerships, will hopefully be one more important (if seriously overdue) example. There is now increasing evidence that they have reached out to many other "unusual suspects." In March 1998 WHO called together an Ad Hoc Committee on the Global TB Epidemic (the London conference). This certainly isn't big news. However, the Ad Hoc Committee of 19 consisted not only of physicians; more importantly, it included several unusual suspects: the Commissioner of the Securities Commission of Jordan, an economist from Zambia, a civil service administrator from India, a nonphysician university professor from Indonesia, and others. When this group called on heads of state, parliamentary leaders, finance, planning, and health minsters, as well as the Director General of WHO, each to exercise his or her own pivotal role, it certainly carried more weight than the opinions of a cadre of self-serving TB doctors and nurses, TB controllers, or TB researchers. And when the committee called upon governmental leaders to address TB as an issue outside the health sector which, if not dealt with properly, must increase costs for the labor force and reflect negatively on tourism and foreign investment, it also carried important influence. When they suggested that TB should be handled as a defense program rather than a social program, such a theme stood a better chance of success than if broached by the usual interested parties.

For several years many in the TB community have pleaded with USAID to get involved in international aspects of TB control, if only because of the realization that this is the best way to control TB in the United States, where increasing numbers of cases (now 42% in 1998) are in the foreign-born. But it wasn't until Ralph Nader's Princeton Project 55 (unusual suspects, to say the least) got involved, that USAID made a commitment to worldwide control of TB and properly made the United States a significant donor nation in the global fight against TB.

In a similar vein, the Public Health Research Institute of New York and the Open Society Institute (the George Soros Foundation) again, at least for TB, unusual suspects were able to get Russia to mount significant TB involvement in Russian prisons, which will necessarily require prison as well as civilian DOT, something that WHO and CDC had been unable to do for years.

The recognition that DOTS works in drug-sensitive cases but may amplify already existing drug resistance and that MDR TB can be effectively treated by tailored second-line regimens was made not by TB physicians, but by Partners in Health, a group from Harvard University specializing in anthropology and human rights, and which has led to acceptance by WHO of the so-called DOTS Plus movement (tailored treatment of MDR TB).

We stand at a crossroads. Some of the players have now acknowledged that teamwork and partnerships are needed to realistically deal with TB. A fresh look at a thorny problem by unusual suspects can have lively and useful results.

In 1992 at the National Commission on AIDS, Joseph A. Califano, Jr., who had been President Jimmy Carter's Secretary of Health, Education and Welfare, warned that the conjoined epidemics of AIDS, TB, and drug addiction form the most frightening threat to public health America had ever faced. He likened the link of the three epidemics to Cerberus, the mythological three-headed dog guarding the gates of Hell!

Mr. Califano, another unusual suspect as far as TB is concerned, would likely be pleased to know about the progress made in TB domestically since introducing his metaphor, but global TB still remains a major problem.

I'd like to suggest that the proper approach to dealing with the global TB epidemic is also three-headed; however, not a Cerberus, but a three-headed or three-pronged thrust into the 21st century, reflecting a new collaboration between usual and unusual suspects.

I think we all must agree that government, whether it be WHO, CDC, or individual ministries of health, cannot do the job alone, and it is hoped that they will continue to reach out meaningfully both for advice as well as assistance. Nongovernmental organizations such as IUATLD, ALA/ATS, or KNVC (Royal Netherlands TB Association) cannot do this job alone either, and need to include academe and foundations, which are unusual suspects. But the third prong, previously totally neglected except as a source of donations and therefore a very unusual suspect as far as TB goes, is commercial industry!

Industry is the one potential player that has usually demonstrated the ability to create and maintain an infrastructure, motivation, expertise, and perhaps most importantly, an ability to get things done. They get things done, to my mind at least, because they are in it for profit, and profit still seems to be a stronger motivation than "doing good."

In 1996 at the Lancet conference and then in 1997 at the IUATLD annual conference in Paris, I castigated industry. I asked why, currently, the most widely used diagnostic test for TB infection was introduced in 1880. I also asked why there was essentially only one drug company trying at that time to license a new drug with admitted TB indications.

At that time I stated that drug companies don't sit with us at the TB table because as public corporations they must ask, "What's in it for us?" To a great extent, if we want them with us, there must be something in it for them beyond "doing good," a virtue that shareholders and financial analysts probably understand less well than even politicians.

I'm not the only one suggesting this. In Business Week, April 6, 1998, the cover story stated: "Still, TB, like malaria, attracts fewer resources than other infectious diseases. And it's not hard to figure out why. . . There's been the least effort to develop new anti-infectives (against these diseases) because of the inability of the population in the most affected areas to pay. That's just one reason the war with microbes may never be fully won. Companies and nations need to launch and maintain effective campaigns not only against strep and flu but also against the scourges that ravage far too many of the world's people. Only then would we have a chance of relegating these killers to the pages of our history books."

So in response, we need to define strategies to allow drug and technology companies to be full prospective players, along with government and nongovernment organizations, academe and foundations. Let's find out what they need and want, and then let's provide them with incentives and enablers; let them promote their wares as well as promote our needs. And let's let them earn a fair and proper profit for what they do.

Many years ago, the IUATLD Council (I think it was 1979 in Brussels) held an extensively prolonged discussion over whether the Bulletin of IUATLD, the predecessor to the International Journal of Tuberculosis and Lung Disease, would be irreparably corrupted if it accepted paid advertising. But TB control is too fragile and important to attack with only the usual suspects. Adding unusual suspects as full participants, such as nongovernmental organizations, academe, foundations and industry, is the only way we can ever implement and carry out the global plan, rectifying the continuing worldwide embarrassment and danger of TB.

In 1955, soon after the introduction of widespread use of TB drug therapy, Professor James Waring at Colorado pointed out in JAMA that TB was unique in that, essentially, it stayed around and spread until it was properly treated. In other words, it doesn't go away.

The global situation with TB reminds me of the man who advertised FRAM Oil Filters on television several years ago. In that commercial, a scruffy garage-mechanic type approached the camera holding an oil filter in one hand and a burned out car engine in the other. He stated: "Last week the owner of this car could have had a new FRAM Oil Filter for $4.95. He decided not to buy it. Today he has to buy a new car engine for $1,275.00.

"You can pay me now. . . or you can pay me later."

 


Released October 2008
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