Speech by Dr E. Borst-Eilers

OPENING STATEMENT BY DR E. BORST-EILERS, MINISTER OF HEALTH, WELFARE AND SPORT, THE NETHERLANDS AT THE MINISTERIAL CONFERENCE ON TB & SUSTAINABLE DEVELOPMENT

THURSDAY 23 MARCH

Tuberculosis control - a dynamic process in a low-burden country

Dr Brundtland, Dear Colleagues, Honoured Guests, Representatives from various organizations, Ladies and Gentlemen,

First of all I want to extend a warm welcome to you all. I hope that this is going to be a fruitful conference that will provide you with both inspiration and practical ideas.

I would like to use my 10 minutes to discuss the way in which the Netherlands dealt with the problem of tuberculosis in the previous century. Truth be told, we have had mixed results in fighting this disease. But that is precisely why this story could be so enlightening for us all.

Until the middle of the last century, the Netherlands, too, was a high-burden country with respect to tuberculosis. Around 1900 TB mortality was about 2 per 1000 people in the Netherlands. That is 100 times higher than the deathrate from AIDS, when this disease was at its peak in the Netherlands.

Until World War I, TB-control was mainly in the hands of the private initiative. Only when the number of TB patients kept increasing, the government got involved.

An extensive network of privately run TB clinics was set up. Equally important, since the 1930s much more attention was paid to reducing poverty. After all, poor housing and lack of a balanced diet were the primary causes of TB.

Despite the enormous efforts on the part of the government and numerous private organisations, we failed to get rid of TB, because an effective treatment was simply not available.

As we all know, in the wake of World War II, the situation improved dramatically. Anti-tuberculosis medication was developed, which for the first time allowed us to cure patients. Large-scale screening programmes aimed at schools and companies were introduced. Moreover, the BCG vaccine had become available. Lastly a campaign against bovine tuberculosis also proved to be of great importance. As a result, the incidence of TB and the deathrate from this disease in the Netherlands fell dramatically.

These successes prompted us to scale down the role of the TB clinics, even many were closed. The Netherlands thought that it had almost eradicated TB: one of the big killer diseases in the previous century. It seemed to be just a matter of time before TB would vanish from the face of the earth.

We know now, that that was a big mistake. TB did not disappear. Tuberculosis is no longer an endemic disease in the Netherlands. Instead, TB manifested itself in the form of small outbreaks at particular locations, such as schools, sports clubs, pubs and disco’s. Moreover, TB began to affect primarily groups of people who are more difficult to reach and influence, such as the homeless and illegal immigrants. Also, people who have reduced resistance, such as HIV infected persons, appeared to be particularly vulnerable. Finally, many TB-cases proved to be imported from abroad. In short, we were facing a new situation that required health services specifically geared towards the new threat.

We integrated TB-control into the Municipal Health Services to ensure that the disease could be tackled efficiently and effectively. Beyond that, we developed tailor-made programmes for risk groups. For instance, since the 1980s all foreigners from countries where TB is endemic have to be screened and treated before they can settle down in the Netherlands. Similarly, children whose parents regularly go back to countries where TB is endemic are required to be vaccinated at the Municipal Health Services.

When TB patients are not able to comply with their treatment regime, we can opt for DOTS - short for Directly Observed Therapy.

Last but not least, practical guidelines have been developed to monitor treatment-outcome.

If you now think that we're on top of the situation, I must disappoint you. The biggest pitfall in addressing infectious diseases like TB is to think that you're winning the battle and can finally ease up.

Good-quality primary health care and good quality public health services that are easily accessible are of vital importance. Prevention, early recognition and adequate treatment of TB must remain an integrated part of our health care system. All doctors must constantly be aware of the fact that TB is not an uncommon disease in the Netherlands. They should be especially alert when they are dealing with immuno-compromised patients, patients from other countries or patients from the population of the homeless.

Ladies and Gentlemen, I have told you how we have dealt with the problem of TB in the Netherlands over the years. The fight against TB has been conducted with varying degrees of intensity, depending on the perceived seriousness of the situation.

Of course, the conditions in the Netherlands cannot possibly be compared to those in your countries. Some of the countries represented here, particularly African nations, have a population severely affected not only by TB but also by HIV/AIDS. As if that weren't enough, many of their inhabitants are poor and lack good-quality primary health care. These countries are truly carrying a double burden. Political instability can further exacerbate these conditions.

It is our duty to look beyond our national borders and to address this issue on a world-wide basis. We therefore very much welcome the recent initiative to establish the GAVI - short for the Global Alliance for Vaccines and Immunization. As a member of the GAVI Board I'll do my utmost to ensure that vaccines will be made available at prices all countries can afford.

In the meantime, we simply cannot afford to sit on our hands. Until effective vaccines are developed, we will have to concentrate on treatment. For TB, the DOTS method, developed by my compatriot Karel Styblo, has proved to be highly effective in several countries, for instance in India.

It is of paramount importance that anti-tuberculosis drugs become available to the entire world population. I applaud the WHO's approach of engaging the pharmaceutical industry and relevant organisations on this point. But crucially, the distribution and administration of medicine and vaccines should be underpinned by effective public health services. One of the top priorities therefore is to strengthen the public health services in the high-burden countries. There is much work to be done. I hope that you will take back home with you, the knowledge and experience gained here to use it in your own country.

By telling you the Dutch story, I hope I have shown the importance of investing in TB control. The fight against tuberculosis is a dynamic process that needs to be adjusted continuously. The moment you think you can sit back and relax, TB will rear its ugly head again. I am looking forward to seeing the results of your discussions.

Thank you for your attention.