Tuberculosis
(Developing World)
(21/03/06)
John Barrett
(Edinburgh, West)
(LD): It is a delight to introduce this debate today, as world
tuberculosis day is later this week. People throughout the world will be
encouraged to think about this devastating disease, which many thought was
in the past, but which is raging throughout the world.
We can take a
snapshot of the position in, for instance,
Africa. Africa has 11
per cent. of the world's population, but it accounts for more than a
quarter of the global TB burden. Since 1990, TB rates have doubled in
Africa
overall and tripled in areas with high levels of HIV infection. In
Botswana,
more than 70 per cent. of TB patients are also infected with HIV. Those
statistics are truly sobering.
Africa may be on
the front line of the global fight against TB, but
Asia
has the highest TB burden in the world, largely due to its massive
population.
India is home to just under 2 million TB sufferers, and while often we
think of TB as a disease of the developing world—today's debate is focused
on the developing world—closer to home, 67,000 Europeans have lost their
lives to it.
David Taylor
(North-West Leicestershire)
(Lab/Co-op): The hon. Gentleman mentions outbreaks and the incidence in
Europe. Indeed, TB is starting to emerge in a worrying way in my home city
of Leicester. Perhaps he was about to deal with this, but does he agree
that in an era of international trade, travel and migration, TB control is
not confined to the countries and continents where it is becoming rife? We
have a direct interest—not just moral, but social and economic—in driving
it back to its position 40 years ago, when we thought we had virtually
eradicated it.
John Barrett:
I could not agree more. There have been several isolated outbreaks in this
country, in the hon. Gentleman's constituency and in Aberdeenshire, but,
more generally, there is a higher incidence in cities such as
London. Increased
global travel is certainly one of the causes.
People think about
whether the issue directly affects them: they are aware that people from
the UK travel
abroad to the nearer parts of eastern Europe, but large numbers also
travel on ever more direct flights to countries with a high HIV incidence.
The hon. Gentleman's point is well made.
I was about to
touch on an area relatively closer to home: the former Soviet Union has
been hit badly by the disease and it has the second-lowest treatment
success rate in the world—only marginally better than that of Africa. The
collapse of the
Soviet Union
left many countries in the region with weak health care systems and
particularly poor diagnostic facilities. The real problem is
multi-drug-resistant TB, which is more expensive to treat and a particular
problem in the
Baltic states.
TB does not respect
national boundaries or international treaties, and I would like to explain
the problem in some detail. TB is the leading form of death from a curable
infectious disease. Globally, it is second only to
HIV/AIDS
as a cause of illness and death, infecting 9 million people every year
and killing 2 million. Nearly all those people are in the developing
world.
What is more
shocking, however, is the fact that the illness is entirely preventable
and curable. That is why today's debate is so important. With world TB day
on 24 March almost upon us, we must do all we can to highlight the need to
get to grips with and eradicate the disease, which continues to claim a
life every 15 seconds.
About two weeks
ago, I was pleased to host an exhibition in the Upper Waiting Hall in this
place. I hope that many Members took the time to look at it. The
exhibition comprised a collection of photographs by Gary Hampton, a
renowned TB photographer, of TB sufferers throughout the world, including
in India,
Africa, Europe and South America. The message was simple: TB is current,
dangerous and on the increase in many parts of the world, but, despite the
scale of the problem, we have the means to cure it completely.
About 80 per cent.
of the individuals newly diagnosed with the disease each year live in the
22 most populous countries.
Andrew George
(St. Ives)
(LD): My hon. Friend makes a strong case for the Government and the
international community paying close attention to the serious problems of
TB, particularly in developing countries. Does he agree that although the
media in the west seem to be in a blind panic about avian influenza—which,
while not wishing to diminish the deaths, has killed only 90 people—the
preventable deaths of 2 million people should grab the attention of the
world and of Governments who can make a big impression on this mass
killer?
John Barrett:
I agree with my hon. Friend absolutely. One problem is that the media are
always looking for something new, and TB is not new. It has been around
for generations, and many people in this country think of it as something
from the past. It is not deemed to be a politically sexy story, but people
continue to die. The scale of the problem is massive: 5,000 people die of
TB each day. If we were to think that a disaster on the scale of that at
the World Trade Centre—about 3,000 people died in that attack—was
happening daily, what resources would we be prepared to put into dealing
with it?
TB has existed for
a long time, and many people have played a part in the fight against it. I
shall mention just a few. One who deserves particular praise is
Edinburgh's own TB
pioneer, Sir John Crofton, whom I met some time ago. He demonstrated more
than 50 years ago that TB was curable, and his work led directly to a
massive decline in TB cases. Sir John was recently awarded the Union
medal, which is the highest honour awarded by the International Union
Against Tuberculosis and Lung Disease. I am sure that all who are aware of
Sir John's remarkable achievements will agree that he is a more than
worthy recipient. I was delighted to table an early-day motion before
Christmas to congratulate him on his latest accolade, and I have been
touched by the support it received and the contact I have had with people
throughout the country who thank Sir John for playing his part in the
fight against TB.
The Department for
International Development has done much excellent work for many years. I
praise the Minister, the Secretary of State and previous Secretaries of
State for playing their part and continuing to fund worthwhile projects in
several countries even though the issue has not always been at the top of
the news agenda.
On a visit with the
International Development Committee, I saw at first hand the work that has
been done in Andhra Pradesh in
India, and in Kenya,
Malawi and Mozambique. The Department's absolute commitment for the long
term involves considerable financial cost. The DFID paper produced in
December 2005 lists sums committed in the fight against TB: £8.5 million
in Mozambique,
£7.5 million in Malawi and £20 million in Andhra Pradesh. I have seen some
of the excellent work that is being done by the Department's staff in
conjunction with local partners, and I cannot praise it highly enough.
Several groups and
organisations are involved. TB Alert produces easy-to-access literature to
ensure that people in this country know the basics about TB and are able
to find out exactly how they can detect infection and what preventive
measures should be taken if they are travelling to a high-risk area.
Individuals play an enormous part in the fight against TB, none more so
than Bill Gates of the Bill and Melinda Gates Foundation, which has
pledged more than $900 million over the next 10 years towards tackling the
disease. I shall come back to that.
There are also a
number of advocacy groups, including Results, which deserves particular
praise for its work on the issue—especially its lobbying of hon. Members.
Two members of its staff, Sheila Davie and Louise Holly, deserve a special
mention for having contacted several Members from all parties to keep the
fight against TB high on the agenda.
As I said, however,
the scale of the problem is truly massive. TB is curable, and we have to
ask why the problem has not been dealt with. Up to 60 per cent. of TB
cases can be detected using existing diagnostic measures, and nearly all
of them can be cured using existing treatment methods, so what are the
obstacles? One of the first that we need to overcome is the perception
that TB is a disease of our grandparents' generation. TB is not a disease
of the past, and I mentioned the sobering statistic that 5,000 people die
from TB every day, which certainly concentrates the mind.
As recently as
1993, the World Health Organisation declared TB a global health emergency,
and when we look at the figures, it is difficult to disagree. Incredibly,
it is estimated that a third of the world's population, or nearly 2
billion people, are infected with TB and that 5 to 10 per cent. of them
will deliver the active disease.
When I mentioned
this debate to my hon. Friend the Member for Mid-Dorset and
North Poole
(Annette Brooke), she said that she was unable to attend, but that she had
been a TB sufferer as a young child. More than 50 years after the
introduction of effective treatments for TB, the disease remains
unconquered. Indeed, in many developing countries—particularly those
stricken with
HIV/AIDS—the disease remains dangerously unstable.
Moreover, although
TB predominantly affects developing countries, as the title of the debate
suggests, it is worth remembering that TB is making a comeback in western
Europe. Indeed, as the hon. Member for North-West Leicestershire (David
Taylor) said, the number of TB cases in
England
has increased by 25 per cent. over the past 10 years and continues to
increase. About 7,000 new cases are reported each year, most in
London.
Although multi-drug regimes are available and cure 95 per cent. of
patients with active drug-sensitive TB, newer and better drugs are needed
because of poor compliance with the six-month treatment regime.
Andrew George:
My hon. Friend knows that I share his interest in this subject, because we
visited Kenya
with Results last September to look at TB projects. Does he not accept,
however, that the treatment regimes are pretty robust, at least in the UK,
and that the vast majority of patients will survive if they stick to those
regimes? Surely the problem is in the developing world, where
multi-drug-resistant TB is developing and the bacillus is getting stronger
because people do not stick to the regimes. A particular concentration of
effort is clearly needed.
John Barrett:
What my hon. Friend says is true for several reasons. Not only has the
medical battle been fought and largely won in this country, but TB is very
much a disease of poverty, and poverty is most clearly associated with the
developing world.
I was astounded at
the poverty that exists to this day in places such as Kibera—the massive
slum on the outskirts of Nairobi—and the general public can see that
poverty if they go to see "The Constant Gardner", which is on in cinemas
as we speak. The vast majority of people in that slum have no supply of
drinking water or sanitation and they live in cramped accommodation with
no adequate ventilation—perfect circumstances for TB to thrive in.
In this country, we
have managed to ensure that people have clean drinking water supplies and
sanitation, but we have also managed almost to eradicate poverty. Poverty
is why TB is such a problem throughout the developing world. Whether we
are talking about drug-resistant TB or one of the traditional forms of TB,
the disease is closely associated with poverty.
We must seek to
alleviate poverty through the millennium development goals and other means
of raising people's standard of living. We must improve how people live
and the quality of their accommodation to ensure that individuals with TB
do not live in cramped conditions, because that would mean the rest of
their family, their neighbours and their friends being far more likely to
contract the disease. Therefore, I entirely agree with my hon. Friend the
Member for St. Ives (Andrew George).
There has been
progress, however, and there is hope. Despite the scale and severity of
the problems, Marcos Espinal, executive secretary of the Stop TB
Partnership, has said that
"we have the
possibility to finally beat TB over the coming decades."
Indeed, over the
next 50 years, the aim must be to eradicate TB as a global health problem.
In 1991, the World Health Assembly set a target of detecting 70 per cent.
of all infectious cases of TB and curing 85 per cent. of those detected by
2005. Those targets were undoubtedly achievable, but they have not been
met. Some 80 per cent. of known cases are successfully treated, but only
45 per cent. of cases are detected.
David Taylor:
The hon. Gentleman refers to the targets that have been set. How confident
is he that the unlikely alliance of the Chancellor of the Exchequer and
Bill Gates—a commitment to double the £1.2 billion global spend on TB was
announced at Davos earlier this year—will halve the number of deaths to
which the hon. Gentleman referred? Past targets have proved difficult and
illusive, have they not? Is he confident that the new target will drive
down the number of deaths in the way the Chancellor and Mr. Gates
anticipate?
John Barrett
: I am
optimistic about the commitments that Bill Gates and the Chancellor have
made, and I look forward to the international dimension of tomorrow's
Budget being given as much importance as the domestic agenda, but I am
pessimistic about the end results. Large amounts of resources have been
poured in, but we have not dealt with the combination of factors that have
built up the environment in which TB thrives.
Although the
resources have gone in, we have seen first hand how many countries have
suffered from famine and drought—factors outwith donors' control. In
addition, there is still conflict in some countries, and other factors
mean that TB is a difficult nut to crack, even though the resources have
increased. As I said, I want to ensure that donors, funders and
organisations working on TB make the necessary commitment in the
developing world, and I can hope for the best, but time will tell how
successful we are.
As was suggested
earlier, we need a plan for the long term and a commitment to see the
issue through beyond national elections, G8 summits and Davos. The
Chancellor said:
"If 2005 was the year
of commitment then 2006 must be the year of delivery".
Although I
wholeheartedly support those sentiments, it will take more than a year. We
are all in this fight for the long haul. Tomorrow's Budget is the ideal
opportunity for the Chancellor to confirm that the commitment to further
spending will be high up the agenda.
At the beginning of
the 21st century, TB has been declared a full-blown global emergency, and
a global emergency requires a global plan of action. Thankfully, we have
one in place. The Stop TB Partnership provides a platform for
international organisations, countries, donors and governmental and
non-governmental organisations. It recently launched its new stop TB
strategy whose objectives are to achieve universal access to high-quality
diagnosis and patient-centred treatment; reduce the human and
socio-economic suffering caused by TB; protect the most vulnerable groups
from TB, HIV and multi-drug-resistant TB; and support the development of
new tools in the fight against TB.
The components of
that strategy include the high-quality expansion of DOTS—the directly
observed therapy short-course scheme—which is often used in the fight
against TB and which, I am glad to see, has been successful. The strategy
must be collaborative to meet the challenges of TB and HIV control, along
with multi-drug-resistant TB.
We must help to
strengthen health systems—I am aware that DFID has been involved in that
work as well. We must engage aid providers and agree international
standards for TB care while empowering those with TB and those communities
that are badly affected by the disease. We must also help to promote and
sustain research. The global plan, finalised just two months ago, aims to
break the back of the global TB epidemic and to eliminate it as a global
problem by 2015.
David Taylor:
The hon. Gentleman is most generous in giving way once more. He mentioned
research, but one difficulty is that there is no significant commercial
market in developing countries for drugs that tackle the diseases of
poverty. Does he hope that the Minister will refer to the possibility of
pharmaceutical companies lowering the prices of their drugs that are
designed to tackle the diseases of poverty, of which TB is but one?
John Barrett:
As I mentioned, the film "The Constant Gardener", which many members of
the public have seen, deals with the issue of the price that drugs
companies charge to deliver effective treatment. Clearly there is not
money to be made in the commercial world by supplying very poor people
with drugs that will save their lives. We await the Minister's reply on
that. It is in all our interests—not just morally, but economically—to
help the poor nations of this world, which are often the sub-Saharan
nations, to improve their economic growth and start trading their way out
of poverty. They will benefit financially and we will also benefit.
Andrew George:
I am sure that my hon. Friend accepts, however, the need for early
intervention and proper treatment before the TB bacilli become
multi-drug-resistant. If patients are caught early enough and the
treatment is followed through fully, it costs only $10 to cure someone and
prevent a death. Surely that is $10 extremely well spent.
John Barrett:
My hon. Friend is one step ahead of me. I was aware that he was a keynote
speaker at the launch of the global plan. Without a doubt, few things are
better value for money than $10 that can save a person's life. As he said,
one problem is that successful treatment can be started, but if it is not
maintained for the full six months of therapy, patients might feel better
and stop taking the drugs, which might allow drug-resistant TB to develop.
In certain areas,
drugs are not available or people have to pay, and in countries of extreme
poverty paying for drugs can often be the barrier between life and death.
That is why I am pleased that some of the many projects funded by DFID
ensure that drugs are freely available and that cost is not issue. Access
and maintaining the course for six months might be issues, but the cost of
treatment is not in many countries.
The global plan for
2002-15 builds on the partnership's first global plan for 2001-05. It
supports the need for long-term planning and for action at regional and
country levels. The plan provides a consensual view of what the Stop TB
Partnership can achieve by 2015, provided that we mobilise the resources
to implement the stop TB strategy, according to the steps laid out in the
global plan.
The global plan will
help to stimulate political commitment, financial support, effective
intervention, patients' involvement, community participation, and research
and development. All those will be central planks of the overall strategy
to tackle TB.
The cost of the
global plan is $56 billion, which represents a threefold increase in
funding as compared with the first global plan. Although that is a
significant increase, any doubts that anyone might have should be dashed
when we consider what we get for that $56 billion. The estimated funding
gap is $31 billion, which must be met because the rewards are high. Full
funding would save 14 million lives at a cost per life saved of $157,
which is much less than the average economic productivity per person per
year, even for the poorest individuals.
Even under such a
crude economic calculation, the economic benefits far outweigh the costs.
When we consider the amount of money spent post-9/11, this is a small
price to pay. If averaged out, it is $5.6 billion a year, which is what
the US spends
in Iraq every month. The figure is three days' global military spending
and the amount spent each month is estimated at $58 million—more than the
total 10-year cost of the global plan.
What will be
achieved if we implement the global plan? Implementation of the stop TB
strategy will expand access for all to quality TB diagnosis and treatment.
About 50 million people will be treated under the strategy and 14 million
lives will be saved. The first new TB drug for 40 years could be
introduced in 2010, with vastly improved diagnosis.
By 2015, we will
have a new, safe, effective and affordable vaccine available if all goes
according to plan. Targets could be met, such as the global achievement of
the millennium development goal to halt and begin to reverse the incidence
of TB, and the TB partnership's 2015 targets to halve prevalence and death
rates from 1990 levels.
What else can we
all do, in the House and elsewhere? As I mentioned, the exhibition in the
Upper Waiting Hall was one small attempt to raise awareness while today's
debate will generate coverage, interest and column inches. Those
interested will be able to follow it and know that hon. Members are facing
up to the problem. TB is not a disease of the past, and we must remind
people of that.
The decline in the
incidence of TB in the developed world has been accompanied by a fall in
the commercial incentive to develop and invest in new anti-TB drugs. The
DOTS programme has revolutionised the treatment of TB across the world,
but it is 50 years since its introduction, and treatment and detection
rates have remained constant since 1995—still far below the rates and
targets set out in the MDGs. To contain the disease properly, new drugs
and vaccines are needed to tackle multi-drug-resistant TB. Despite the
undoubted success of the DOTS expansion, most countries look unlikely to
meet the MDGs for TB by 2015. Further innovation is crucial if,
ultimately, we are to tackle TB.
The non-profit
organisation Global Alliance for TB Drug Development, which is supported
by the Bill and Melinda Gates Foundation and the Rockefeller Foundation,
has brought badly needed new focus and leadership for drug development. In
the short term, six new drug candidates for TB are now undergoing clinical
trials. Indeed, Bill Gates has already pledged $900 million over the next
10 years towards tackling the disease.
However, action
from above must be matched by renewed and improved action on the
ground—the front line of the battle against TB. The DOTS strategy has
helped not only to cure millions of people worldwide, but to strengthen
public health care capacities. Indeed, it has been argued that the
greatest legacy of DOTS to the overall health of developing countries
might be not in control of TB alone, but in helping to build the basic
infrastructure of a public health system. For example, in
India, where the
public health system is weak, more than 422,000 health workers have been
trained during the expansion of DOTS. DOTS plus is the first step in
moving beyond DOTS.
We must also be
aware of the problems of HIV that are associated with TB. Although
originally they were largely considered separate diseases, co-ordinated
planning and implementation of TB and HIV programmes will lead to more
effective prevention and treatment of TB among patients infected with
HIV/AIDS.
In countries with high levels of AIDS, the scale of the challenge posed by
TB simply exceeds control capacities. As a result, DOTS, or any other
programme focusing on one disease, will always fall short. TB symptoms are
often the reason for accessing the health care system.
Andrew George:
My hon. Friend makes an extremely strong case for giving the challenge of
the global plan up to 2015 a much higher priority. Given that TB killed
more people than all the wars, earthquakes, floods, armies, air accidents,
terrorist attacks and murders worldwide last year, and following on from
his comparison between the money needed for the global plan and military
spend, does he believe that Ministers should use that comparison and take
a fraction of the defence budget, for example, to fund the global plan?
Should we not use such rhetoric to up the ante and get the plan the
priority it deserves?
John Barrett:
My hon. Friend knows exactly where I stand on that. I have never thought
that the amount spent in Iraq is particularly good value for money. The
amount of money spent on—
Mr. Bill Olner
(in the
Chair): Order. I think that the hon. Gentleman is straying way off the
point.
John Barrett:
I stand corrected Mr. Olner. I may have been inadvertently led into that
by my hon. Friend.
I shall draw my
remarks to a conclusion. Our efforts need not be focused on simply
managing this disease. TB can be cured and consigned to the history books
within the next 50 years if we are determined to tackle it in other
countries the way that we have tackled it here. The fight against TB must
be a marathon, not a sprint. It requires sustained action and attention
from the international community. Just as the DOTS treatment is effective
only if patients follow the full course of treatment, we will fulfil the
aims of the global plan only by committing to it for the long haul.
I look forward to
hearing from the Minister and hope that the Government also confirm that
they will continue to play their part in the battle against TB.
Susan Kramer (Richmond
Park) (LD):
I did not want to interrupt your line of sight earlier by stepping
forward, Mr. Olner. I thank you for the opportunity to follow my hon.
Friend the Member for
Edinburgh, West (John
Barrett).
Obviously, the case
has been laid out exceedingly powerfully, and I very much want to
associate myself and my party with the World Health Organisation and the
stop TB strategy. It is not my goal to repeat the facts and figures that
have been laid out so eloquently this morning. I wanted to speak in this
important debate because world TB day is an opportunity to remind all of
us that no matter what medical advances we pursue in our own country and
the developed world, basic diseases continue to devastate much of the
globe. It is also an opportunity to recognise that the developing world
pays a double penalty by being affected by poverty and disease, which so
often go hand in hand.
I want to draw
attention to some aspects of WHO's strategy, and to pick up on the
research provided by the African Medical and Research Foundation, which
works extensively in this area. Through many of its studies in
Africa, the foundation
draws attention to the frequent difference between what appear to be
effective TB strategies at national level, and the difficulty of
delivering those strategies on the ground.
Many hon. Members
will be aware that many African countries, as they develop their health
systems, focus on managing TB in a hospital environment, and on diagnosis
and prescription. But there is comparatively little penetration and effort
to tackle the disease within the communities where people live. If one
considers the poverty of the individuals involved, the difficulty in
accessing more sophisticated aspects of health care and the way in which
the disease impacts on mothers and children and undermines entire
communities, looking at the disease in a community context is typical.
I draw hon.
Members' attention to AMREF's research in the
eastern cape
of South
Africa, in the designated homelands, which is where millions of black
South Africans were forcibly removed during apartheid. It is therefore one
of the poorest communities in South Africa. The research showed that
health personnel did not have an adequate understanding of TB management;
that on the ground, locally, within the community, there were insufficient
supplies of TB drugs; and that testing was slow, so it sometimes took up
to two weeks to get results. The situation was made worse by the fact that
TB patients did not understand prevention, the cause of the disease, or
why they needed to take medication for six or eight months to eliminate
the disease from their systems permanently.
As a result of that
health study, approaches to the problem are changing in the
eastern cape. Nurses
are being trained in TB management and public transport is being provided
to ensure that sputum specimens can be delivered to laboratories and back
to clinics with results within 24 hours. That is completely changing the
way in which that community is experiencing and tackling the disease. It
falls well within the DOT—directly observed therapy—strategy that has been
structured and underpinned by WHO, and which has been so effective
generally in furthering TB management worldwide.
An issue that has
been touched on but not developed, and is, presumably, the risk that we
face most viscerally in the future, is the link between TB and
HIV/AIDS.
Many people will be aware that that is a growing arena for TB as a
disease. We are aware that it affects the developing world powerfully, and
that it is beginning to take hold in our communities.
The presence of HIV
results in a high degree of multiple-drug-resistant TB. Not only do TB
drugs have a tendency to be ineffective on people with HIV, but it is much
harder to diagnose TB in people with HIV, especially in its early stages.
That is one reason why it is crucial that research in this area does not
stand still. Although there are effective therapies for the more
traditional variants and versions of TB, the HIV-related strains of the
disease are not well understood or managed in almost any community. It is
crucial, therefore, that the funding that is necessary for new diagnostics
to enable efficient testing for HIV and TB in health facilities is
available to communities not only in London, but in poor and rural areas
across the globe.
TB is a disease of
the poor. In the era in which we live, in which we have made the
commitment to make poverty history, we must, by definition, also make TB
history. I highly commend what has been said today, and I look forward to
hearing what the Government have to say about the support that they will
give the programme. I note that when my hon. Friend the Member for
Edinburgh, West asked the Minister a question on this issue recently, the
Government were unable to identify how much funding goes into TB work. I
wonder whether they now have a clearer idea of how that money is being
used. I appreciate the opportunity to associate myself with this debate.
Mark Simmonds
(Boston and Skegness)
(Con): I start by congratulating the hon. Member for Edinburgh, West (John
Barrett) on securing this important debate, particularly considering that
world TB day is coming up, which he rightly highlighted. He summarised
well the totality of the issues surrounding TB, and made the significant
point that it is not only developing nations that suffer from TB; it
affects the developed world as well, albeit, thankfully, to a
significantly lesser extent. None the less, we can ensure that we
constantly monitor that situation.
The hon. Gentleman
is right to highlight and confront the perception that TB is a historic
disease. Statistics and personal stories clearly demonstrate that that is
not the case. The whole world community—both developing nations and
donors—needs to ensure, both bilaterally and through multilateral
institutions, that TB is at least stopped in its tracks, if not
eradicated, as quickly as possible.
I also welcome the
hon. Member for Richmond Park (Susan Kramer). I congratulate her on her
new position and I am sure that she will enjoy the role. We look forward
to significant contributions such as that which she has made today. She
was right to draw attention to the disparity between national strategies
in many developing nations and delivery on the ground in communities. I
will say a little more about that later. The hon. Lady was also correct to
draw attention to the link between
HIV/AIDS
and the prevalence of TB. I want to ask the Minister some questions about
the cross-availability of antiretroviral drugs to enable both diseases to
be eradicated.
As hon. Members
will hopefully be aware, the Conservative party is supportive of much of
what the Government are doing in this area. We support the Global Fund to
Fight AIDS, Tuberculosis and Malaria and we acknowledge and support the
Government's commitment to double the amount of UK taxpayers' money that
has gone into that fund. However, we acknowledge, as I am sure that the
Minister will, that there have been problems of delivery through the
global fund to date.
We support the
international finance facility for immunisation and also world TB day
later this month. We hope that it will raise the profile of that
debilitating and dangerous disease in developing nations, not only in the
traditional areas of sub-Saharan Africa but in those areas where the
disease has significant and growing prevalence, such as Asia and the
ex-Soviet republics, and where the problem has been ignored for far too
long.
We welcome the
recent announcement of £6.5 million of funding to the Global Alliance for
TB Drug Development and the commitment from the Chancellor of £41.7
million to tackle TB in India. We also agree with the G8 Africa
communiqué, which said that people should have
"access to basic
health care (free wherever countries choose to provide this)".
Alongside the
Government, we want to encourage countries to drop user fees, which limit
access to health care and are a major deterrent in developing countries,
particularly for those who find themselves in poverty.
Like the hon.
Member for Richmond Park, I do not wish to bore the Chamber by repeating
the statistics that the hon. Member for Edinburgh, West gave in his full
and articulate speech. However, I would like to add two statistics that
struck me, which I do not think he used. One person per second catches TB.
That is a staggering statistic. Also, between 8 million and 10 million
people per annum become infected with TB. The problem is not growing in a
small way; it is a significant and accelerating disease, and we need to
ensure that we tackle it across the international community.
As the hon.
Gentleman rightly pointed out, effective treatment is inexpensive. A
six-month course costs between $5 and $10, depending on which medical
people one talks to. He was absolutely right to highlight the fact that TB
is a totally curable disease. We need to ensure—through such debates in
the UK Parliament, and in our constituencies—that we highlight the fact
that the disease is not historic, but is growing and is more greatly
prevalent in all parts of the world than people's perceptions would allow
them to believe.
Having said that, in
Africa 45 per cent. of people with infectious TB have access to
life-saving treatment. However, an untreated person can infect 10 to 50
people a year, which tends to happen in the workplace and through the
adult population. That can have a very debilitating impact on the economic
performance of communities, giving rise to greater exacerbation rather
than alleviation of poverty. The treatment of TB can take up to eight
months, during which time a person is unable to work and falls deeper into
poverty, as do their dependants if they are an adult. The World Bank
estimates that TB costs the average patient three or four months of lost
earnings, which can represent up to 30 per cent. of annual household
income.
The millennium
development goals made specific reference to stopping the prevalence of
diseases such as TB by 2015. The international community is a significant
way off that. Tackling TB will go a long way to making a significant
contribution to many of the other millennium development goals, such as
access to education. Fewer children will drop out of school because of
infection, to care for relatives or because they do not have teachers any
more because they are suffering from TB or, in particular, from HIV.
The hon. Member for
Richmond Park rightly made a point about the correlation between TB and
HIV/AIDS,
which is one of the issues that I want to highlight today. Since 1990,
overall TB rates across Africa have doubled, and they have tripled in
areas with high levels of HIV. The hon. Member for Edinburgh, West
mentioned the fact that in Botswana 79 per cent. of TB patients also have
HIV. It is our view that there needs to be significantly better
collaboration between TB and HIV programmes, as that will vastly improve
the control of both diseases.
I want to ask the
Minister what progress the Government and DFID have made in expanding the
collaborative TB and HIV strategy. What steps is DFID taking to ensure
that developing nations co-ordinate TB and HIV programmes, that those
infected with HIV are screened for TB, and that those infected with TB are
screened for HIV? That would ensure the provision of antiretroviral drugs
to all who need them, not just those who may require them on a superficial
basis.
I want to highlight
three particular issues: drug development, drug resistance and drug
availability. I have some questions that I hope the Minister can answer.
There have been some successes. We should not think that TB is on the
rampage unchecked. The most notable success has been in Vietnam, where 76
per cent. of all infectious cases in the past year have been cured. That
can be done with commitment from the international community and the
Governments in the respective countries.
The hon. Member for
Edinburgh, West rightly highlighted that there has been no new drug for TB
in the past 40 years. The Global Alliance for TB Drug Development aims to
have developed a new drug by 2010, but current estimates are not
optimistic. It has been estimated that there is only a 5 per cent. chance
of that. The cost of producing successful drugs in that time scale is
estimated at about $400 million.
As well as research
on new drugs, steps must be taken towards new methods of diagnosis and
vaccination. I would welcome any explanation from the Minister of exactly
what progress is being made not only towards the treatment of TB but
towards its prevention. There also needs to be predictable and sustainable
funding, particularly to assist research and development. What steps is
the Minister's Department taking to ensure predictable and effective
funding flows for those research bodies, so that they can come up with new
drugs and vaccinations?
Multi-drug-resistant TB has been identified in 91 countries and is
widespread in many populous countries, including China, India and the
former Soviet Union. What steps are the Government taking to fund the
development of treatments for MDR-TB? It is clearly more challenging and
requires greater on-the-ground monitoring as people become resistant to
the initial programme of drugs.
The hon. Member for
Richmond Park also mentioned drug availability. It is important that DFID
and other relevant institutions do more to encourage the pharmaceutical
industry to allow the manufacture of generic drugs for use in the
developing world. The former director-general of the World Health
Organisation's HIV programme suggested the designation of humanitarian
corridors, which would allow leading drugs manufacturers to produce drugs
at low prices for modest royalties, giving greater access to those with
limited resources in developing nations. What action is the Minister
taking to ensure that TB drugs can be accessed in developing nations? He
will be aware that some developing nations have placed tariffs on certain
health care products. Some of those tariffs have been reduced, but not
sufficiently to ensure the free access of drugs in the developing nations
where they are needed most.
Can the Minister
also say what steps his Department is taking to ensure collaboration
between all the different interest groups—public sector, private sector
and non-governmental organisation initiatives? Also, what improvements in
collaboration are proposed between all the interested parties in the
developed world and the developing nations to ensure the maximum impact of
the inevitably limited resources that can be put into controlling TB? Are
TB control mechanisms included in the respective countries' poverty
reduction strategies? If not, why not? And if not, I hope that they will
be included in future.
It would also be
helpful if the Minister explained what supportive role the Government will
play in implementing the Stop TB Partnership strategy. The 58th World
Health Assembly took place in 2005, where all countries made a commitment
to ensure the availability of sufficient resources to achieve the
millennium development goal relevant to TB, but there is currently a $31
billion funding gap. What is the Minister doing to encourage the UK
Government and other countries to fulfil their international commitments,
particularly those made at the 58th World Health Assembly?
For strong health
care provision to flourish, there must also be political stability.
Corruption plays a role; I have debated that with the Minister at other
times, and I do not intend to go into it again now. Suffice it to say that
economic growth is impossible if a country's population are sick and
dying. That is particularly the case in respect of TB, which
disproportionately affects adults in the work force. We must encourage
schemes that include civil society, NGOs, regional Governments, donor
country Governments and the communities on the ground if we are to see
progress towards the millennium development goal of halting and beginning
to reverse the incidence of major diseases such as TB by 2015.
I want to repeat
something that the hon. Member for Edinburgh, West said in respect of the
campaign against TB, because it succinctly summarises what the global
community needs to do. It needs to
"stimulate political
commitment, financial support, effective intervention, patients'
involvement, community participation and research and development."
If the UK Government are supportive of that strategy and programme, they
will find Opposition Members supportive of them.
The
Parliamentary Under-Secretary of State for International Development (Mr.
Gareth Thomas):
I join other hon. Members in paying due tribute to the hon. Member for
Edinburgh, West (John Barrett) on securing this debate on tuberculosis.
Given its timing just days before world TB day, he has done the House a
particular service. TB places an unnecessary burden on the developing
world in particular—TB causes 2 million deaths a year—and the House has
benefited from the opportunity to discuss these issues again. I should
also pay tribute to the hon. Gentleman's continuing advocacy on this
topic; he has not come to it fresh today. I know through his work on the
Select Committee on International Development and his visits to our
programmes in Andhra Pradesh and Kenya that he has followed this issue for
some time.
I also congratulate
the hon. Member for Richmond Park (Susan Kramer) on her elevation to her
current position. She is fortunate to have in her constituency arguably
the greatest professional rugby club—London Welsh. That makes her almost,
but not quite, as privileged as I am in terms of the constituencies that
we represent. She raised a number of issues, as did the hon. Members for
Edinburgh, West, for St. Ives (Andrew George) and for Boston and Skegness
(Mark Simmonds) and my hon. Friend the Member for North-West
Leicestershire (David Taylor). I will try to do justice to their
contributions.
As all hon. Members
said, there is a huge challenge before us because of the number of people
who die or become infected as a result of TB. It is, however, a challenge
that the international community, supporting developing countries, could
rise to. There is already an internationally agreed strategy for TB
control—directly observed short-course treatment programmes or DOTS—which
we know has considerable impact. I understand that later this week the
World Health Organisation will announce that in 2004 DOTS programmes were
able to detect 53 per cent. of TB cases worldwide, and to treat
successfully 82 per cent. of them. That is encouraging, but those figures
also reveal the scale of the challenge that remains. We need to build on
that success and do more.
A number of things
need to happen if poor people are to get better access to effective TB
care. Simply put, they are threefold: there needs to be much greater
political commitment to this challenge, more money needs to be allocated,
and we need to make better use of the existing money that is available.
Let me start with that
last point. Making better use of the money means working in partnership
with developing countries, donor partners, those in research institutions
and NGOs that specialise in this field. I join other hon. Members in
paying tribute to the campaigning work of Results UK, TB Alert and the
African Medical and Research Foundation—AMREF—not least for their efforts
to enlighten the House further by calling a meeting later this week. The
Department for International Development is familiar with all those
organisations because of their work in this area. The House owes them a
debt of gratitude for their lobbying, campaigning and informative work..
Secondly, we need
to ensure that we spend more of the money that is available on research,
and make better use of the existing facilities. We also need to ensure
that the systems are in place for the money to get down to health care
services in the most remote areas and the most marginalised communities.
The hon. Member for Richmond Park rightly alluded to that. We need to
ensure that people who want to access the drugs are able to do so,
wherever they live and whatever their circumstances.
The hon. Member for
Boston and Skegness rightly alluded to the Commission for Africa's
underlining how critical TB is to the health and development agenda. He
will be aware that a similar message was highlighted by the Gleneagles
communiqué, the United Nations world summit, and the European strategy on
development—that consensus was agreed towards the end of last year. All of
them committed the global community to do more on TB.
All hon. Members
have also referred to the excellent global plan to stop TB, which was
launched by my right hon. Friend the Chancellor of the Exchequer, with
Bill Gates and President Obasanjo of Nigeria. As hon. Members said, that
global plan sets out a clear picture of what we need to do to achieve the
millennium development goal on communicable disease. That plan makes it
clear that it is possible, with greater commitment and more money, and by
using money more wisely, to halve deaths from TB by 2015. We now need to
move from those commitments in the global plan and the various communiqués
of last year to implementation on the ground.
Hon. Members who
follow the issue will know that last year the Department held a
consultation on TB and malaria, in which we reviewed our spend to date and
considered whether we needed to increase our spend and how to make better
use of the resources available. As a result of that consultation, we
doubled funding for the Global Fund to Fight AIDS,
Tuberculosis—crucially—and Malaria for 2006-07. We increased our funding
for country programmes; that is the direct bilateral support to which the
hon. Member for Richmond Park alluded. As the hon. Member for Boston and
Skegness rightly said, the Chancellor announced funding of just over £41
million for TB drugs in India, through partnership with the World Health
Organisation. We also committed some £5 million to the global Stop TB
Partnership. Those are examples of our work on TB and Malaria. We intend
to continue to expand such support later this year.
All the hon.
Members who spoke raised the issue of finance. The hon. Member for Boston
and Skegness highlighted the current $31 billion gap in the plan and
pointed out that $56 billion would be needed through to 2015. Some $25
billion is already available and, as I said, we must ensure that that is
well spent. I accept that there is a major gap in resources, and we cannot
pretend that it will be closed if it is a case of business as usual. We
need to maximise commitments from developing country Governments and
donors, and we need to work on the commitments made last year.
Crucially, we must
explore new sources of finance. Critical to that is ensuring that TB is
recognised in developing countries' own health plans—a point made by the
hon. Member for Boston and Skegness—and that Ministries of Health are
supported in making the case to Ministries of Finance for more funding for
health care in general and TB specifically, so that that money is locked
into poverty reduction strategies. Of course, we do advocacy work in areas
where our country programmes are strong and where we have identified
particular problems.
The global fund
needs to be supported if it is to maintain its share of the growing
response to TB. Hon. Members who follow the progress of the global fund
will know that in June there is to be a mid-term review of the global
fund's performance to date, and of how the replenishment has gone. That
will provide an opportunity to encourage new donors, in particular the
oil-producing countries and the private sector, to play their part in
supporting the effort on all three poverty diseases.
Even with the new
resources that have been pledged, that $30 billion gap is a considerable
challenge. Hon. Members will know that this year the international finance
facility for immunisation began its work. We hope that that does
considerable good in its own right, but also serves to encourage other
nations to support a full international finance facility, delivering new
resources for work on TB—and health care generally—more quickly.
The hon. Member for
Edinburgh, West, knows that I cannot prejudge what my right hon. Friend
the Chancellor will say in the Budget tomorrow, but he will be aware of
the commitment made last year by the Chancellor and my right hon. Friend
the Prime Minister to spend 0.7 per cent. of national income on aid by
2013. I am sure that the hon. Gentleman will want to praise this
Government for trebling spending on international development assistance
since we were elected.
The hon. Member for
Richmond Park asked for more information on how much we have already spent
on tuberculosis. Perhaps it would help if I explained that although we
fund TB control directly through a number of specific bilateral projects
in the focal countries where we operate, we also increasingly fund broader
health sector development plans for developing countries through
multilateral agencies, including the World Bank, the European Commission
and the Asian Development Bank. It is not always possible to draw out
exactly what is spent on TB, because money that goes into health sector
budgets helps to fund action on a range of other health conditions, too.
Let me give some
additional examples of the direct, bilateral support that we provide. In
Nepal we committed some £5.4 million from 2001 to the end of next year to
helping with effective diagnosis and treatment for all TB patients who
come to existing primary care facilities. In South Africa we are providing
assistance on TB to KwaZulu-Natal, the province with the highest HIV
prevalence and the worst treatment outcomes.
Hon. Members have
referred to the often considerable links between HIV infection and TB
infection. In Pakistan, one of the seven national health programmes
supported by our sectoral spend of £60 million is a national TB programme.
In Uganda we are providing direct support to strengthen the health system
and to strengthen our response on implementing the DOTS programme at
community level.
One or two hon.
Members mentioned Russia. It is worth drawing the House's attention to
Russia's hosting of the G8 agenda this year. The Russians have shown an
interest in discussing infectious diseases in St. Petersburg later this
year. As the hon. Member for Edinburgh, West, rightly said, it is one of
the countries with the greatest burden of TB, and it has a particular
problem with drug-resistant TB, so we have been pushing for the St.
Petersburg summit to endorse support for the global plan. Indeed, when my
right hon. Friend the Chancellor launched the global plan, he made
specific reference to that.
I have mentioned
the issue of the better use of money. The hon. Member for Boston and
Skegness rightly drew attention to the need better to co-ordinate the
response to HIV with the response to TB. In some African countries—Malawi
is an example—70 per cent. of people with TB are infected with HIV, so
there is a clear case for bringing responses to the two diseases much more
closely together. In some African countries, people still need to go to
one clinic to get their TB drugs and another to be tested and get
treatment for HIV. Clearly, that is nonsense in the longer term, and we
need to support those African countries in bringing those services
together.
In 2005, the G8
committed itself to providing universal access to HIV treatment,
prevention and care. That commitment was endorsed by the UN world summit.
As part of the global steering committee that we co-host with UNAIDS, we
have been trying to make a reality of that commitment. We are drawing up
plans on how to achieve that, and on how to ensure that TB is seen as a
core element of the package of AIDS care.
In an intervention
on the hon. Member for Edinburgh, West, my hon. Friend the Member for
North-West Leicestershire rightly alluded to lack of drugs and problems
with diagnostics and vaccines for diseases. Those are major problems;
those in developed countries have considerable access to those services,
and those in developing nations have very poor access to them. We know
from international research on the issue that 10 per cent. of global
health research and development is directed at diseases of relevance to 90
per cent. of the world's population. That is a huge imbalance and a
glaring example of global inequality. That is one reason why we need to
accelerate research and development of new technologies; a second reason
is to deal with the specific issue of multi-drug-resistant TB. That is one
reason why we are supporting the WHO's tropical disease research
programme, which includes a major research project in improving TB
diagnostics, which the hon. Member for Richmond Park mentioned. If we can
get those new diagnostic methods to come on line, it will mean that we can
detect TB earlier in primary health services and we shall be able to
diagnose it much earlier in people who are also infected with HIV, where
diagnosis is often particularly difficult.
We are keen to see new
drugs developed, particularly ones that would allow for shorter and
simpler courses of treatment that reduce the burden on often fragile
health care systems. Ultimately, the goal must be to find a vaccine, if we
are genuinely to achieve long-term control.
One key way to try to
ensure that new drugs and diagnostics come on line is through
public-private partnerships, which are beginning to change the landscape
of TB research. The need for public-private partnerships will continue to
increase, particularly when embarking on expensive clinical trials. That
is why, earlier this month, I was pleased to announce UK funding of some
£6.5 million over the next three years to the global alliance for TB drug
development. However, that does not preclude the point that my hon. Friend
the Member for North-West Leicestershire made, which was that we need to
see, and should continue to encourage, the major pharmaceutical companies
in their programmes of research into diseases in developing countries. We
should try to ensure that they have effective differential pricing regimes
in place to charge higher prices in developed nations and recognise the
unaffordability of those prices for poorer nations and bring in cheaper
prices there. I have already made it clear that this is a particular issue
for second-line antiretroviral drugs to fight the
HIV/AIDS
epidemic, but, more generally, it is one that developing countries are
facing.
The hon. Member for
Boston and Skegness also mentioned access to drugs. He will be aware of
the flexibilities in the legislation on trade-related aspects of
intellectual property—TRIPs—which has only just come into force in general
terms and is not in force for the least developed and very poorest
countries. We are working with a number of developing countries, including
Ghana, to ensure that they can take advantage of the flexibilities in the
TRIPs regime.
The hon. Gentleman
said that many developing countries impose tariffs on drugs and it is
difficult to see the sustainability of such tariffs, given the huge public
health burden faced by many of those countries. Nevertheless, he will
recognise that Finance and Health Ministers and Parliaments in developing
countries must consider that in the round. As I said in answering the
point made by the hon. Member for Richmond Park about our spend on TB
directly, we put considerable resources into financing health systems to
help with the fight against TB and more broadly.
My right hon.
Friend the Secretary of State has, in various speeches to generate debate
on our forthcoming White Paper, referred to the need for us to increase
access to basic health and education services. It is worth pointing out
that the WHO estimates that it would only cost approximately £20 per
person to provide an essential package of health services. Many Ministries
of Health in low-income countries typically spend less than £5 per person,
which indicates the scale of the challenge that we face and just how much
of a step change we need to see in funding from domestic budgets in
developing countries and from international aid.
I draw hon. Members'
attention to Malawi, where we are providing £100 million of support to its
health sector budget, as part of the health sector plan, which is
specifically supporting the Government of Malawi to try to double the
number of nurses and treble the number of doctors that they recruit over
the next six years. That is being done partly by tackling many aspects of
the poor conditions in which people in the health service in Malawi have
to operate, partly by raising their pay by just over 50 per cent., an
increase that only came on line in April. Early indications are that a
significant increase in recruitment is beginning to happen.
The hon. Member for
Boston and Skegness rightly mentioned user fees for health care services.
We have made it clear that user fees can deter people from accessing the
health care services that are needed, that we support the elimination of
health care fees and that we will put resources behind efforts to
eliminate such fees. In Zambia, when the Minister of Health recently
announced her intention to abolish health fees for those in rural areas,
my right hon. Friend the Secretary of State announced additional funding
for Zambia to help compensate for the loss of those user fees.
In conclusion, I
congratulate the hon. Member for Edinburgh, West on securing this debate.
I hope that world TB day receives considerable media and parliamentary
attention; it certainly needs to. We in the Department for International
Development intend to continue scaling up our work on health care services
in general and, through that, our response to the fight to tackle
tuberculosis. I look forward to working with the hon. Gentleman and other
hon. Members to continue the campaign on this issue.
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