Dr Mario Raviglione is the director of the World Health Organization's (WHO) Global Tuberculosis Programme. He spoke to EurActiv's Henriette Jacobsen.
We are seeing that in Africa the numbers of people with AIDS and HIV, and the number of related deaths, are going down in many countries. The same can be said about tuberculosis. However, at the same time we are witnessing in Eastern Europe and former Soviet states that the rates are going up. Why are we seeing this development?
When it comes to Africa, overall the HIV epidemic is coming down. It has peaked in terms of annual incidents in the early 2000s. The tuberculosis epidemic was also growing quite dramatically in Africa during the decade of the 1990s, driven by HIV/AIDS. When you are infected with HIV your immune system doesn’t work. The CD4 cell doesn’t work and then you allow mycobacteria, which cause tuberculosis, to grow unchecked. But the tuberculosis epidemic has nothing to do with HIV/AIDS for the vast majority of it. Nearly 90% of tuberculosis cases in the world, around nine million new cases per year, have nothing to do with HIV. Only around 12% of the cases are related to HIV. So these cases would probably not happen if there wasn’t an HIV epidemic.
During the 1990s, there was this major increase in tuberculosis in Africa, linked to HIV/AIDS. When the HIV/AIDS epidemic peaked in Africa around 2000 in the sub-Saharan countries, then the tuberculosis epidemic followed two years later. We are now saying that the tuberculosis epidemic in Africa is slowly coming down, meaning the number of cases per year is slowly being reduced.
As a result of this, since Africa counts for overall about 24% of the global tuberculosis cases. Since the epidemic in Africa started going down about 10 years ago, the global tuberculosis epidemic is also coming down now [at] around 2% per year. That’s the picture in Africa. There is a decline and you see the decline especially well in some countries that have been monitored or have had monitoring systems in place which work - for example Kenya, Zimbabwe and Malawi.
Several of them show a very clear decline in the number of cases which is obviously very good. The burden remains big and the rate per capita in Africa is the worst in the world, but the annual number of cases is now coming down.
When it comes to Eastern Europe, the situation is similar. During the 1990s, the two big cases, Africa and Eastern Europe, were where the cases of tuberculosis really went up. The increase in Eastern Europe, however, was not linked to HIV, though there has been an HIV epidemic there, as well in Ukraine - which is a good example - and Russia.
But in reality the tuberculosis increase we saw in the 1990s in this part of the world was linked to the socio-economic conditions, with rapid deterioration of the public health systems and the rapid impoverishment of the population. When you have a situation like this, then tuberculosis flies. What happened there was that those patients that had tuberculosis could easily transmit the infection to others because they were living in congested places, such as two families living in one apartment. When one person got sick, the others would also get infected.
We estimate that one-third of the human population is affected. We’re talking two billion people affected, but the vast majority of them will never develop tuberculosis.
So if you have a situation like in the former Soviet Union with rapid impoverishment with people living in congested places or outside, the transmission goes on. Once you get infected, you are malnourished, an alcoholic, you are stressed. This is exactly what was happening over there.
Then you develop this infection and eventually the disease. This went on rapidly and on top of this, the public system that was part of the former Soviet Union and in basically all of the socialist countries, which were pretty well-developed systems … deteriorated rapidly.
I visited myself Russia, Kyrgyzstan and Kazakhstan in 1994-1995, so I remember very well what was happening there. They did not have drugs anymore, or they only had one or two of the four recommended drugs. The spreading also included forms of tuberculosis that became multi-drug resistant. In essence, when you treat tuberculosis with one drug, instead of the normal four, because you don’t have access to the other three, which was exactly the case over there in this very critical phase of transition between the socialist-communist system into a market economy… What happened was they didn’t have access to drugs so they were treating patients with what they could; they were treating with one drug.
That’s the situation when you develop resistance and that’s why they have an enormously high level of multi-drug resistant tuberculosis in that part of the world, the highest in the world.
Is it accurate to say that the HIV virus began to spread when the isolated nations behind the Iron Curtain began to open up?
It may be possible HIV was introduced somewhere from the outside because it came much earlier in the outside world than in the former Soviet Union and in socialist countries. But it localised there in the beginning among drug users and among sex workers. In the case of HIV, it also spread very much in prisons because of some of the old practices - you can imagine.
Once you then get HIV, it’s easy to then also get tuberculosis because your immune system is weakened. Tuberculosis, contrary to HIV, spreads through the air, so in congested prisons with many prisoners in one single cell, then you can imagine what kind of public health disaster you are creating. This is exactly what happened. The issue of multi-drug resistant tuberculosis in the former Soviet Union is very much related to the form of the prisons, it has been really catastrophic.
The WHO states on its website that sometimes the statistics on infections in some countries vary a lot from official government statistics. What is the reason for that?
Not for tuberculosis because we receive the numbers from the countries and we validate, check and confirm. So in essence, the case of tuberculosis there are two levels of statistics. You have statistics that correspond to the officially notified number of cases. So when Belarus says “We have 10,000 cases”, then we take those. If we see a big difference, tuberculosis doesn’t change from one year to another very rapidly… What you have in the West is very few cases. So if you have an outbreak in one school with 20 cases and your statistics get immediately impacted.
But when you deal with bigger numbers, from those in the former Soviet Union and certainly in Africa, then on a yearly or two-year basis, you don’t see major differences. Tuberculosis is a very slow epidemic. At the moment, we really see a decline, but it’s around 2% per year.
What we do then is we validate the notifications. If we see that last year there were 10,000 cases and now they report that there are 1,000, then we go back to them and ask “What happened?”
So it could be 9,900 or 9,500, but certainly not 1,000. We validate the available statistics. At the same time on top of it, we make estimates. When a country reports 10,000 cases, in the vast majority of countries in the world, that do not have well-developed systems, in those countries you don’t necessarily have the estimate of the real number equal to what they officially notify.
For instance, they would tell you that they have 10,000 cases, but looking at some other indicators like the number of deaths to tuberculosis, several different indicators we analyse and we then go back to them and say, “Well, you are reporting 10,000 because 10,000 is what all your reports are telling you, however we at the WHO believe that you have 15,000 because of these prisons”. Then we normally we do workshops with countries and we validate every year with them what we are going to report.
So if Belarus, for example, said they had 10,000 cases, we would go back to them and say our estimates are 15,000 and 5,000 have simply not been detected or reported in the system. Then we go back and forth in the countries and when we come to an agreement, we publish the estimates.
We also publish the global level estimates. There are 9 million cases estimated globally, but only 6 million reported with a first and last name. In the case of tuberculosis, we usually agree with the governments because we discuss our viewpoints in workshops and have further discussions.
But I would also guess that tuberculosis isn’t an infection you would say is a ‘taboo’, whereas HIV/AIDS in a country, let’s say Ukraine, would be for religious reasons as it’s also a sexually-transmitted infection. Maybe the government has an interest in giving low estimates. How is this an issue for the WHO?
What you’re saying is obviously plausible. This also counts for tuberculosis, don’t worry, because there are some countries whose best interest is showing that tuberculosis is going down.
This might be an interesting philosophy because the Global Fund, which releases money for tuberculosis, malaria and HIV, will be basing its future release of money also on the estimate of the burden. So we might have, we have not seen it yet, but we might have a situation where countries will claim they have more cases because our estimates are based on a model where you can change the parameters. It’s not unexpected that some countries would actually push the numbers up in order to receive more money from the outside. This is another phenomenon that we are now watching because it could happen...
The methodology use is important before you look in the detail, but these numbers can be altered especially in the case of tuberculosis. A prevalence survey sometimes costs $3-5 million because it’s a long study and many countries have never tried doing these kinds of surveys. Without these solid types of data, you have the incidence, which is what they notify to you, but some people have not been diagnosed as they have no access to care or they have been diagnosed in the private sector and this has never been reported to official authorities.
When you have weak data from a country, people can easily change the estimates depending on the assumptions you make.
How often does it occur that you tell a government what your estimates are, and they say that your estimates are wrong and too high, and then the next year, the rates go up?
That happens … We have our mathematical models, but no one knows in the end what the right number is. Sometimes it’s a discussion and with tuberculosis we always have an open dialogue with the country. It happens every year that one to three countries disagree and ask us on what basis we’re giving the figures. Then our epidemiologist sits down with their epidemiologist and then we come to a consensus on what is the most solid set of estimates, based on the best science available.
We will not simply accept a political statement. If they don’t agree, we want them to show us why we’re wrong.
If the numbers go down too much for a government, there is another danger there. Sometimes they would say the right estimate is not 10,000 but 15,000 because they need to maintain a lot of visibility so it’s more convenient. Especially, if those responsible are not at risk of being fired. But we don’t buy that kind of argument. This is done unscrupulously I would say.
Talking about the people who are living in, for example, Belarus or Ukraine and have an infectious disease such as tuberculosis or HIV… Are there a lot of people who live in those countries who are unaware of them actually being ill because of their governments not really doing anything in terms of prevention or just in general discussing these issues in the media?
That’s quite possible. In some of these countries… I would say Ukraine has been in the past… Now there has been in the last two years much more willingness to really collaborate, but as an example in the past, we have had a hard time with Ukraine. It was difficult to convince the constantly changing governments and particularly the ministers for health.
You may establish a relation with a minister of health and convince this minister to do a certain type of intervention and then that minister is gone before the necessary interventions start. Then you have to resume the discussion with a new minister and run into new problems. Ukraine has been quite a problematic country in the past for these types of things. Their response to the tuberculosis epidemic has not been satisfactory. That’s why it’s considered one of the top priorities in the world, not just in the European region.
How has the global financial crisis affected the healthcare systems in these countries?
I’m not so sure that the global economic crisis has affected the Eastern European countries a lot. It has affected the Western countries a lot and therefore the potential donations, grants, money that they make available...
For example at the WHO, we see that some of the donors, the traditional donors for the WHO, have been hesitating in putting money there for obvious reasons. But I think that the majority of these countries were also considered eligible to apply to the Global Fund when it came to tuberculosis or HIV. So they applied to the Global Fund and some of them have become eligible in the meantime over the past 4-5 years, although the majority is still today ineligible …
Now they [the Global Fund] are undergoing the process of replenishment with a replenishment conference at the end of this year. They are the ones, when it comes to tuberculosis, that are vastly responsible for external aid, 85% of the aid for tuberculosis comes from the Global Fund, so only 15% comes from other sources.
If the Global Fund doesn’t get enough money, the international community will not be able to help the former Soviet countries to react. The reality is that for external sources, the Global Fund doesn’t have enough money and there’s an absence of other major donors internationally and internally for their own allocations of money. I don’t have evidence that they have reduced domestic funding dramatically, for tuberculosis at least.
The EU is a large donor in Africa. What should be changed when it comes to aid when Eastern Europe - including some EU countries like Romania and Bulgaria - see rates going up for some infectious diseases such as HIV?
It’s a very difficult question. I came to Brussels a few years ago several times to brief commissioners and people working in the various departments. We are always focusing on two types of big programmes. One is for the developing countries. That is the one dealing with Africa in particular and Asia. And the other one is about neighbouring countries. They deal with, for example, Ukraine and Belarus. Our argument was while the low-income countries in Africa and Asia obviously deserve a lot of attention because they are the poorest among the poor. They are the ones that should receive increasing resources externally from for example the EU.
The neighbouring country policy also must incorporate a clear plan of action vis-à-vis these diseases and in particular for tuberculosis. We have told commissioners that they have multi-drug resistant tuberculosis at the highest levels in the world next door. Belarus is the top in the world with 35%, more than one-third of the cases in the Minsk region being multi-drug resistant from the start.
If you have a person with tuberculosis in Belarus, there’s one chance out of three that this person today has multi-drug resistant tuberculosis. This is a major threat for people because 50% of them will probably end up dying because of this disease. You are dealing with a disease which is actually incurable.
Secondly, there’s a major damage to the economy. You let these things spread and the cost of treating a patient in the West would be enormous. It was estimated in the past that 400 cases in New York City cost billions of dollars. So the disease is expensive, you have to make follow-ups for two years, you have to provide constant care, and most of these people come from economically and socially non-privileged groups so they even need special assistance.
Without a proper reaction and help to these former Soviet Union countries, you can expect trouble in the future because infectious diseases, such as tuberculosis, do not stop at the border. I came to Brussels two or three times to deliver this message, but I have not seen - frankly - a particular reaction from the EU in terms of mobilising special resources or creating special initiatives for this issue.
However, the EU has put a lot of money into the Global Fund which has also gone towards reaction and response to HIV, tuberculosis and malaria.