Money isn't the issue; it's (still) political will
Money isn't the issue; it's (still) political will
Bumgarner defends non-treatment of MDR strains
Political will - pegged as the missing ingredient in countries where tuberculosis incidence rates are not improving, or even getting worse - sometimes sounds like a commodity as elusive as the Holy Grail.
At the two-day London meeting convened last month by the World Health Organization (WHO) during the week preceding World TB Day, political will was the subject of much discussion, says Richard Bumgarner, deputy director of WHO's Global Tuberculosis Programme.
The conclusions? With all other things being equal, information is the key starting point. "Clearly, there must be normal governance at work before such an item can be discussed," says Bumgarner. "If you're war-torn or in the midst of a revolution, neither officials nor the body politic can act upon political will. But if people don't know about a problem, they can't very well act upon it."
Part of the problem boils down to image. In country after country, officials and citizenry still tend to regard TB as a disease of the past, he adds. "There is a widespread belief that TB is a relic of the Victorian era."
The report the London committee issued was surprising for its candor. It called by name countries where the chief problem was not revolution, lack of money, or other factors beyond the control of officialdom but simply a lack of will. Although the WHO report states that economic aid probably will be needed in some countries, Bumgarner was quick to downplay the significance of that finding.
"For the majority of countries faced with a TB epidemic, money is not the problem," he says. "No new money is needed because there is money already available; tragically, that money is not yet being obligated to fight TB. It could be very effectively re-obligated."
There are exceptions for "the very poorest countries," he says. "There, outside help is appropriate, especially for the purchase of drugs. Clearly, you can't cure TB without the proper drugs." But even in the poorest countries, where lack of money is part of the problem, "it isn't the main problem," he says. Bumgarner singled out for criticism those who advocate treatment for multidrug-resistant (MDR) patients.
Until recently, WHO's policy on treat ing MDR-TB has been that such treatment should not be attempted because efforts to do so pull money away from efforts to strengthen treatment programs for drug-sensitive patients, whose mismanagement has led to MDR-TB in the first place. (For information on how those policies may be changing, see story, p. 3 of TB Monitor International.)
"If one concentrates on the most medically interesting cases - that is, those who have become drug-resistant - it risks failing to spend enough money to turn off the tap that created drug resistance in the first place," he says. "It's interesting to try to figure out what to do about that. But MDR-TB is a man-made phenomenon; we need to get back to the cause, the misuse of powerful antibiotics."
Critics of WHO policy on MDR-TB say it is inhumane as well as impractical and dangerous from the standpoint of public health. Chief among critics of WHO policy is Paul Farmer, MD, PhD, director of Partners in Health, a Cambridge, MA-based public charity that is trying to persuade WHO to soften its stance, both on humanitarian and practical grounds.
Countries that, for whatever reason, cannot do the right thing at least should back away from using the most powerful drugs, in case they lose them, Bumgarner says. "If you cannot do [effective] TB control, then you should back away from using these four powerful drugs, and go back to relatively safe chemotherapy, for example, with isoniazid and thiacetazone," he says. "That allows you to treat people humanely and responsibly and to cure some cases without creating a monster you cannot control."
Many states in India have adopted this approach, he adds.
That leaves the future to consider. WHO's conclusion that its goals for the year 2,000 cannot be met doesn't mean people should despair, says Bumgarner. "Had action been taken sooner, the world would be in a better state than it is. But what about 1998? Are people going to take this seriously now?"
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