Poverty and lung health

Abstract

The International Union Against Tuberculosis and Lung Disease (The Union) held its 40th World Conference on Lung Health in Cancun, Mexico, between 3 and 7 December 2009. It was attended by over 2000 delegates from 104 countries around the world. The conference featured four stimulating plenary sessions and an extensive selection of scientific symposia. A total of 1125 abstracts were also presented from five broad categories: clinical trials and TB basic science, clinical research for treatment and care, epidemiology, education, advocacy and social issues, and policy and program implementation. In addition, the conference was preceded by a series of well-attended postgraduate courses and workshops.

Tuberculosis & poverty

The theme of the conference held in Cancun, poverty and lung health, was relevant on several levels. The mission of the International Union Against Tuberculosis and Lung Disease (The Union) is to bring innovation, expertise, solutions and support to address health challenges in low- and middle-income populations. The focus of The Union’s efforts is, and always has been, poor and vulnerable populations. The needs of these marginalized populations have been heightened by recent global economic challenges. Refocusing the attention of the global TB community to the needs of the poor is both necessary and timely.

The link between poverty and TB has long been apparent [1]. However, the knowledge of such an association does not, in itself, lead to concerted action. Until recently, global TB control efforts were focused broadly and generally on those countries most affected by the disease. In some circles, special attention to subgroups within theses countries, such as the poor, remained ‘unnecessary’ since most TB patients were in great need and that need was so widespread. A turning point in this mindset was the release of ‘Addressing Poverty in TB Control: Options for National TB Control Programs’ [2]. This 2005 publication – a joint effort by the WHO and the Stop TB Partnership – aptly highlights in its introduction that ‘because a TB program operates in a poor country does not necessarily mean that it is adequately addressing poverty’. The guide provides a stepwise approach to focusing efforts on the poor within the programmatic setting. An equally important advancement in the efforts to increase the awareness of the need for special efforts focused on the poor was the establishment in 2005 of a sub-working group within the DOTS Expansion Working Group of the Stop TB Partnership. The TB and poverty subgroup (previously the TB Poverty Network for Action) has made great efforts to ensure that all activities of the partnership are viewed with a ‘pro-poor’ lens. These advancements, although noteworthy, have not necessarily led to the same achievements in the field in many countries. The challenge of the next decade will be to translate the knowledge, guidance and successful experiences to date into effective action to better serve impoverished TB patients, their families and communities.

Two conference presentations in Cancun were particularly germane in this effort to refocus our efforts on the poor. The opening session of the conference featured a presentation by Abdo Yazbeck, Health Sector Manager for Europe and Central Asian Region at the World Bank. Drawing from his book entitled ‘Attacking Inequality in the Health Sector: A Synthesis of Evidence and Tools’, Yazbeck highlighted the disparities in health outcomes between rich and poor populations [3]. More revealing was the presentation of data suggesting that our health systems – even when publicly financed – are more likely to serve the well-off than the poor and therefore actually increase the inequalities in health outcomes. Yazbeck provided country examples to highlight six practical rules to ensure programs and services are truly effective in reaching the poor. Yazbeck’s presentation was followed by a presentation by S Bertel Squire (Liverpool School of Tropical Medicine, UK) entitled ‘Health solutions for the poor – reflections from program delivery’. Using the analogy of a series of hurdles that poor populations must overcome, Squire effectively emphasized the challenges that are faced by vulnerable populations in their everyday search for accessible and effective TB diagnosis and care. Moreover, using the example of the front-loading of sputum microscopy examination, the potential impact of pro-poor program modification was highlighted. It is these surmountable obstacles that must be confronted to successfully implement TB control among the poorest populations.

Case detection: past, present & future

The detection rate of new smear-positive cases of TB has long been an indicator chosen to represent the progress of global TB control [4]. Until recently, the longstanding target of 70% global case detection of incident smear-positive cases has been a seemingly unreachable goal. Several years ago, as case–detection rates increased slowly at levels far below the cited target, initiatives to accelerate global case detection were implemented. The Fund for Innovative DOTS Expansion Through Local Initiatives to Stop TB (FIDELIS) was one example of this intensified case-finding effort [5]. Funded by the Canadian Government through the Canadian International Development Agency and managed by The Union, FIDELIS implemented 51 case-finding projects in 18 countries between 2004 and 2009. Several presentations at the Cancun conference examined the results of this global initiative, as well as the lessons learned. While the absolute numbers of additional cases detected throughout the FIDELIS project sites was impressive, the ability to evaluate individual strategies and approaches was limited.

The conference delegates were also presented with the impressive achievement of global case detection and treatment outcome in more recent years. A short update to the 2009 Global TB Control report was unveiled at the conference, highlighting an estimated case–detection rate of 61% in 2008 [6]. Although still short of the 2008 target of 71%, this represents a significant increase compared with detection rates observed earlier in the decade. At the same time, a treatment success rate of 87% was reported among patients in the 2007 cohort – representing the first time that the 85% treatment success indicator has been surpassed. Consistent with this progress, the WHO presented an expanded framework for case detection that moves beyond the 70% target. Citing the need to detect all TB cases, the WHO’s new emphasis on universal case detection and more aggressive case-finding approaches are both welcome and necessary.

Included in the universal case-detection vision is the mandate to increase access to multidrug-resistant TB (MDR-TB) diagnosis and care. MDR-TB has received increasing attention in recent years. Global meetings, including a high-profile ministerial meeting in Beijing in 2009, have raised awareness of the importance of this issue and the urgency for action [7]. Despite these vocal efforts, progress on the ground remains extremely limited. The most recent data indicate a great gulf between notified and estimated cases of MDR-TB globally. The 2008 notification total of approximately 30,000 cases [6] is extremely small, given that half a million MDR-TB cases were estimated to have occurred in 2007 [8]. Moreover, only 6000 cases were treated under projects known to be receiving treatment according to international guidelines (i.e., through the Green Light Committee). Therefore, the vast majority of MDR-TB cases remain undetected or are in receipt of care of unknown quality.

Appropriately, several postgraduate courses, workshops, symposia and abstracts were devoted to this critical topic. One particularly well-attended symposium was entitled ‘Research for optimized treatment of MDR-TB: update on recent developments’. The interest in the symposium, as well as the topics discussed, reinforced the primary role that research will have in advancing this previously neglected area of TB care. A related symposium entitled ‘Update on clinical trials for MDR-TB’, was sponsored by a group called Research Excellence to Stop TB Resistance (RESIST-TB). RESIST-TB is a movement to promote and conduct research on the treatment and prevention of drug-resistant TB and the session highlighted the staggering investments that are crucial to propel the research movement forward. As an important first step, RESIST-TB has developed several protocols for clinical trials on MDR-TB in anticipation of the availability of new medicines in the near future [101].

Year of the lung

The year 2010 is an important year for TB control. As highlighted, attention turns to refocus efforts on equitable access, universal detection of all TB cases, including expanded access to MDR-TB care. Appropriately, at the Cancun conference, the Forum of International Respiratory Societies (FIRS) declared 2010 as ‘the year of the lung’ – a multifaceted campaign that aims to raise awareness about the importance of lung health.

2010 in Berlin

As we enter a new decade of TB control, it is also clear that new and innovative approaches are needed to further advance the important gains achieved during the first decade of the 21st Century. The 41st Union World Conference on Lung Health will explore this important topic. ‘TB, HIV and lung health, from research and innovations to solutions’ will be held in Berlin, Germany between 11 and 15 November 2010. It is sure to be a notable event in an already significant year for TB and lung health in general.

Financial & competing interests disclosure

The Union is the host of the Annual World Lung Health Conference and all three authors were involved in the planning of various conference components. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.