Speech by Dr Donna E. Shalala

STATEMENT BY DR DONNA E. SHALALA, SECRETARY OF HEALTH AND HUMAN SERVICES, USA AT THE MINISTERIAL CONFERENCE ON
TB & SUSTAINABLE DEVELOPMENT

THURSDAY 23 MARCH

"Meeting the Threat of TB: The Case of New York City"

It’s an honor to join all of you at this "Ministerial Conference on Tuberculosis and Sustainable Development," and I want to recognize the remarkable leadership--and foresight--of Dr. Gro Brundtland, Mr. James Wolfensohn, and the Dutch government--in organizing this event.

I can think of no better place to meet than in Amsterdam. It’s not just that the Netherlands has already given so much to the international community—from Van Gogh and Vermeer, to Spinoza and Erasmus. It’s not just that the "Royal Netherlands Tuberculosis Association"--a recognized leader in the fight against TB--works with national programs in 10 countries that have cured over one million TB cases in the past decade. It’s that during Amsterdam’s "Golden Age," intrepid Dutch mariners and merchants took the lead in charting new courses around the globe. In their wake, they laid down some of the very first global lines of communications and drew the world closer together.

Fellow Ministers: That is also very much our task. If we want to lift the shadow of tuberculosis that falls across our nations, then we must also chart new courses...harness global communications...and come together to design a global strategy. This conference gives us that opportunity. It gives us the opportunity to learn from one another…to share with one another... to address our common problems in common cause.

When it comes to addressing TB, we cannot afford to delay. As we're all aware, one-third of the world's population is already infected with TB...and up to 50 million may be infected with multi-drug resistant tuberculosis. TB is a leading killer of women...and the leading infectious killer of youth and people living with HIV/AIDS. TB claims a life every 15 seconds. But--as the STOP TB Initiative reminds us--this global epidemic is more than a health problem. TB attacks the body and assaults the spirit...It hinders economic development...It holds the poor in the grip of poverty and disease. And none of our nations--north or south, east or west--are immune from its threat.

Since we all share in the problem, we must all share in the solution. That is why we are here in Amsterdam. Today--as we struggle to address our common TB problem--I'd like to share with you how New York City dealt with a dramatic resurgence of TB in the 1980's and early 1990's. Then I want discuss the lessons we can all draw from that episode.

New York City has long been a center for both tuberculosis--and its control--in the United States. At the turn of the century, charity groups moored old battleships and ferries in the harbor to house TB patients. To combat the disease, City officials created an extensive public health system. But as living conditions and hygiene improved--and especially when effective medication became available in the 1940's--the number of TB cases dropped dramatically. As they did, officials--and the public--became complacent. Despite the high rates of TB that persisted in some of New York's poorest communities, most people believed that modern medicine had defeated this ancient enemy once and for all. Funding was slashed. By 1988, staff at the city's TB control bureau had been decimated...two-thirds of New York's chest clinics were disbanded...and 1,000 hospital beds for TB patients were eliminated.

Unfortunately--after decades of decline--TB skyrocketed in the 1980's because of AIDS; increasing homelessness; greater poverty; over-crowding; and other factors. Between 1979 and 1992, the number of patients with tuberculosis tripled...and the percentage of such patients with multi-drug resistant TB more than doubled. In central Harlem, TB cases reached an alarming 222 per 100,000 persons--20 times the national average--and higher than in many developing nations. With an epidemic on their hands, in 1991 officials from an array of City agencies--led by the Health Department and its remarkable Commissioner, Dr. Peggy Hamburg-- committed their wills and their wits to the battle. They pledged the necessary human and fiscal resources. And they designed one of the most comprehensive, sustained, integrated TB control plans of any U.S. city.

At its crux, the plan had three goals: To increase the treatment completion rate; to impede the spread of TB in institutional settings; and to prevent future cases of active TB. To help achieve these goals--to help ensure that the epidemic was contained, efforts were sustained, and progress maintained--the federal government rallied to aid the city.

With support from the Centers for Disease Control and Prevention--as well as the city and state governments of New York--the TB Control Bureau increased its staff from 144 to 600 between 1988 and 1994. Many of these new employees were outreach workers who visited TB patients in their homes and workplaces--and treated them with "Directly Observed Therapy." Armed with an understanding of their communities, they worked with the infected on a daily basis. The workers met them on city streets, under bridges, in homeless shelters and subway stations to ensure that patients got the treatment they needed. Their efforts to treat and beat the disease were particularly successful when partnerships were formed with people from the local community. By 1994, more than 1200 patients were receiving "Directly Observed Therapy," as compared to only 50 in 1983.

Other Health Department initiatives complemented this work. For example: TB screening was implemented in city jails, and a state-of-the art "Communicable Disease Unit" was created at Rikers Island--the largest prison in the U.S.--to ensure that inmates with TB got appropriate treatment and care. Infection control activities were improved at local hospitals. And to ensure accountability, every TB case in New York was reviewed on a quarterly basis. A parallel development was the downsizing of large, single-adult homeless shelters. This move decreased the opportunities for exposure to infected individuals.

Thanks to all of these initiatives, New York City began to dramatically turn the tide and bring down the curtain on its TB epidemic. In 1993--only one year after the program began in full-force--TB cases were down 15 percent from the year before--the first substantial decline in 15 years. By 1997, over 95 percent of TB patients completed treatment--compared to only 50 percent five years earlier. And between 1992 and 1998, there was a 59 percent decrease in TB cases--and an astounding 91 percent decrease in multi-drug resistant TB. Tomorrow, the New York City Health Department will be releasing new numbers that show this downward trend is continuing.

Although their war against TB is far from over, New York has won the battle against the epidemic. When we examine what happened in New York City, I believe we can find six lessons...Lessons that are also challenges for every nation...And challenges we all must meet before we can usher TB off the world stage for good.

Our first challenge is that we can't wait any longer. After all, TB is a nineteenth century disease...a nineteenth century specter. But it returned to haunt us in the latter part of the twentieth century simply because we had neglected, ignored and overlooked it. If New York City had established a TB control program much earlier--when pockets of the disease persisted in its poorest neighborhoods--it could have avoided an epidemic, and it could have saved itself over one billion dollars in health care and other costs. Similarly, if we don't act now to address serious pockets of TB around the globe, we'll be in a much more serious--and dangerous--situation in the coming decades.

Of course, any TB control program must be both comprehensive--and accountable. That's our second challenge. As we saw in New York, such a program can work--and work quickly. A piecemeal approach will do more than fail. It will make the problem worse because inadequate treatment can lead to an increase in multi-drug resistant TB.

When designing a comprehensive program, we must commit adequate resources--and that includes the necessary political and social will. That's our third challenge. Above all, a stable, adequate funding base is needed. I realize that when a nation is struggling with a range of pressing health, social and economic problems this isn't easy. But it is cost effective. When New York City tolerated crippling compromises in its public health system, it had to devote enormous resources to subdue a disease that--as I noted earlier--could have been controlled years before--at a far lower cost. And we know that in the developing world, Directly Observed Therapy--the effective mainstay of any TB control program--only costs about 11 U.S. dollars a patient. But therapy for multi-drug resistant TB which--as I noted a moment ago--is often a byproduct of inadequate treatment, can run as high as 4,000 dollars or more...not to mention the human costs.

With the TB epidemic growing around the globe, we must also encourage the development of new weapons for our fight--and that means a renewed commitment to research. That's our fourth challenge. Research is the firm foundation on which all of our TB efforts are built--so it must never become the forgotten step-child of tuberculosis control strategies. We need operational research fully integrated into national TB programs. We need to research new drugs that can reduce the length of treatment to less than three or four months. We need to discover new diagnostics--including a more rapid test for multi-drug resistant TB.

 And, of course, we need to develop a TB vaccine that will be available, affordable and effective everywhere. The United States is prepared to make substantial investments in vaccine research. That's why the Clinton Administration's Fiscal Year 2001 budget for the National Institutes of Health includes a sharp increase for AIDS, malaria and TB vaccine research.

And that's why President Clinton has also proposed a ten year, one billion dollar tax credit for pharmaceutical and biotechnology companies to accelerate vaccine development. Under his plan, every dollar that a qualifying non-profit spends to purchase a new vaccine would be matched by a dollar of tax credits for the developer of the vaccine. By doubling the purchasing power of the non-profits, this tax credit will significantly expand the market for new vaccines...It will provide a powerful incentive for vaccine development...And it will help move new vaccines out of the halls of science and into the hands of those who need them. But let me caution: While we search for a vaccine, tomorrow...we already have reliable, proven and inexpensive TB medicines that work, today.

Our fifth challenge is to improve the social and economic environments of our most vulnerable citizens--and eliminate those conditions that allow TB to survive and thrive. We saw that when New York downsized its homeless shelters, it also decreased the opportunities for TB transmission. We cannot really address TB unless we also address the broader conditions of a person's life.

Our sixth and final challenge is the challenge of working together. As we're all aware, tomorrow is World TB Day--and this year's theme is "Forging New Partnerships to Stop TB." Just as the work in New York was most successful when it included community partnerships, we must continue to form global partnerships that include governments, world health organizations, the private sector and academia. That's why the United States is committed to the STOP TB Initiative--through which individuals, organizations and governments are working together to hasten international progress against TB. That's why the U.S. is providing more than 20 million dollars this year--through the United States Agency for International Development--to help you, and other governments, strengthen and expand TB control programs. That's also why President Clinton--in his speech to the United Nations last year--called on foundations, pharmaceutical companies, international agencies and other governments to join us in an international crusade against infectious disease. And that's why the Declaration of this Ministerial Conference--a declaration that calls for accelerated world action against TB--is so important.

As I alluded to earlier, in our increasingly interconnected world, no nation can hope to fight TB in isolation. TB respects no national border...no national flag...no national community...no narrow domestic walls. One case of TB--anywhere in the world--can turn into TB cases everywhere in the world. Because TB recognizes no borders, in our fight against it, neither can we. Or as Dr. Brundtland has said, when it comes to public health, "solutions, like problems, have to be global in scope."

This conference is an excellent start to formulating that global solution. And as we've seen, time and time again, when we do work together, we win. In 1977, we eradicated smallpox from every nation on earth. And we've almost reached that point with polio. If we employ a similar global strategy...a similar global commitment...a similar global response--and with the outstanding leadership of Dr. Bruntdland and WHO staff--then we'll also be able to write the final chapter on TB. We can do it: And remove TB from the headlines. We must do it: And consign TB to the history books. And we will do it: But only if we follow the example of those intrepid Dutch mariners and chart a common course in our common cause.