High Level Meetings, high level expectations
‘No more calls for action, we need commitment’
On September 26th something truly historic should be happening in the world of TB – a High Level Meeting (HLM) on the topic of TB at UN Headquarters in New York. This meeting is certainly going to happen, there’s no doubt about that, but exactly how historic it will be right now is uncertain – and this will all depend on whether any of the member nations (many of which have really serious TB epidemics) approach in the spirit of real commitment.
Two things will show whether this is the case. One is whether heads of states turn up (or whether they delegate this responsibility and thus reveal their true attitude towards 2 million human beings unnecessarily dying every year. (This adds up to a mortality rate of nearly one in five TB cases in a disease that today really should be seeing only one-in-a-hundred dying). The other is whether these same heads of state commit their countries to trying to meet real concrete targets to properly support the existing global commitment to see TB defeated by 2035 (because that’s already been agreed by these same countries’ health ministries at the World Health Assembly back in 2014, and was rubber-stamped by the more recent 2017 Moscow Declaration to End TB). President Putin should certainly be showing up in September given that he personally led the call on the latter occasion (when the then new Director General of the WHO added: “The UN HLM on TB is the moment we have all been waiting for …No more calls for action, we need commitment.”)
There’s a bunch of dedicated TB-focused people who have since come together and have worked tirelessly not just to see this meeting happen, but to see that it has real meaning in the coming years – to once more turn the tide on mankind’s oldest infectious enemy (because the tide did turn in the last century, and then was allowed to flood back in again as a result of shameful neglect). Many of these people are TB survivors and know just how tough recovering from this disease can be. They deserve our respect, our gratitude and most of all our support.
Any UN high level meeting is open to all 193 national delegations. Such HLMs are usually attended by these countries’ Ambassadors to the UN, but they could be added to by their national ministries, or sometimes by their Heads of State. In this respect it was particularly important that the TB HLM should take place in September because that’s when many of these Heads of State will be in New York for the September session of the General Assembly and are therefore far more likely to attend the HLM, but only if the appropriate pressure can be put on them to do so. In other words, this timing provides a huge opportunity to see TB prioritised not just among high burden nations (many of which have poor records of focusing appropriate resources on TB control) but also among the donor nations on which the poorer nations depend.
Right now, though, things seem to be on a knife edge. It’s becoming ever more clear that most of the main delegations are demonstrating an unwillingness to really commit to numbers when it comes to supporting this fight – whether globally (there’s a massive hole in the two critical budgets for TB – both for treatment and for research and development, both of which are absolutely vital), or nationally (there’s been a key demand from the grassroots that all countries commit 0.1% of their GDP to fighting this disease). But it’s also looking worryingly like heads of state aren’t generally even that keen on showing their faces on the day either.
So why might this be?
The usual outcome from a UN HLM is a political declaration. Its text is pre-drafted by the states concerned (which is what’s happening at the moment – through representatives of national governments in UN Missions in New York, who are themselves coordinated by the countries concerned before the meeting). The final text of a declaration, however, is often agreed at the meeting itself with a few last-minute negotiations taking place on the side-lines.
So what does such a political declaration actually mean? It is generally considered a set of guidelines or principles that countries agree to commit to and (most importantly of all) then deliver on (we include these key words very deliberately in bold because commitment and delivery in TB in the last 25 years has been desperately deficient given the scale of the deathtoll). These same countries (the same 193 of them) regularly grandstand in Geneva at various World Health Assemblies, setting aspirations and targets for TB and then doing far too little to follow them up because they’ve allowed TB to remain so low on their political agendas (mainly because the disease so disproportionately affects the poor and powerless). There has so far been no accountability attached to their aspirations and this is why it’s going to be so important to see as many Heads of State at that meeting as possible. This HLM is intended to conclude with a statement which is meaningful to those who live in the headlights of this pandemic and which will include clear frameworks of accountability.
So perhaps this is also exactly why the Heads of State are all hanging back from even making a commitment to be there!
The draft declaration which is already crafted is clear (at least in its principles): all countries agree that “tuberculosis, an airborne infection, is a threat to us all, as it is the leading infectious disease killer, the leading killer of people living with HIV, and drug-resistant tuberculosis is the most common and deadly form of antimicrobial resistance in the world and [is] a global health security threat”. Such a statement, of course, can be trotted out with ease. The devil has been in the detail of developing any sort of serious commitment so that something can be done about driving down the disease (in the next twelve years which is what the Sustainable Development Goals demand – and twelve years is a VERY short time with a slow-burning disease like TB). The existing draft even accepts that TB “can be eliminated”, however. So, why is there such hesitation in committing real numbers to their declaration?
It's noteworthy that in the existing draft version all countries also “recognize the lack of sufficient and sustainable financing for the TB response … including diagnosis, treatment, care and prevention [and]… the development and evaluation of better diagnostics, drugs, treatment regimens and vaccines as well as other innovative care and prevention approaches including against the social and economic determinants of the disease” (i.e. in literally every aspect of a response to it). So we all at least appear to agree that more money is needed!
The problem is that no missions are currently championing the need to actually finance any targets (an absence of which has to be a very serious omission). Worse still, evidence from the drafts suggest that the EU and U.S. are even resisting including any concrete commitments on new funding at all. Despite it being universally recognised that funding for TB R&D needs to at least double (and some reckon that it needs to treble), both the EU and the U.S. have been specifically pushing to strike out any reference at all in the declaration to “a doubling of annual investments” in the section on sustainable financing for research. This is truly baffling if any serious commitment is expected from them.
Worse still, these same two regions are also visibly pushing to eliminate any language that would urge countries to work to separate the cost of R&D from the price of any new drugs — a principle known as ‘delinkage’. Experts believe such delinkage is absolutely vital if any new treatment is to be affordable where it’s needed. What this essentially means is that these two wealthy regions are apparently backing the interests of their pharmaceutical multinationals at the expense of the millions who are otherwise inevitably destined to die from this disease in the coming two decades (forty-odd million lining up if the current rates persist).
There are even signs that the U.S. is also trying to strike out any references to support from either UNITAID or the Global Fund from the document, both organisations having been vital in what’s been achieved to date in the fight against tuberculosis. This, perhaps, is most worrying of all because of what it may imply for the wider world in the face of any global problem in the future.
The TB Coalition, meanwhile, reckons that there are five main areas which require urgent attention at the UN HLM, each of which should be assessed and adapted to any individual national context for any Declaration to be effective:
1. To successfully treat at least 10 million people for TB a year by 2022 (that’s pretty much double what is being achieved currently).
2. To close the TB funding gap and ensure sufficient and sustainable domestic and donor financing (meaning doubling the money).
3. To renew global support for TB innovation, including supporting mechanisms to fast track the development and uptake of new drugs, diagnostics, vaccines and interventions for TB.
4. To ensure all countries adopt and implement World Health Organisation standards and guidelines and adopt people-centred models of care.
5. To commit to a robust, independent accountability mechanism at the Head of State level to monitor progress towards ending TB.
This is hardly rocket science by any standards, and there’s nothing unreasonable in there if you know anything about TB, but the key missions are really still wriggling around on this issue of accountability.
Two guys called Moe, a gal named Mae
(and one called Vladimir)...
Please be in no doubt: without the inclusion of clear financial targets for both TB response and research (ones which will articulate the overall funding need, and also highlight the responsibility of each country to deliver its fair share of the global funding need whether it be donor or high-burden), and without any provisions for an accountability framework that includes an independent accountability body, this HLM will end up being no more than the same old same old. And it now looks like the only way these will be achieved is through grass roots pressure on heads of state, not just to make them recognise this by acting through their delegations but by them actually turning up on the day and signing their names to it.
President Putin was first out of the blocks last November at the Moscow TB summit publicly calling for an end to TB (Russia has an immense problem with drug-resistant TB), but despite this he hasn’t yet committed to be there.
Second out of the blocks was Prime Minster Shirendra Modhi of India (our first ‘guy called Moe’). India has a truly huge TB epidemic and another immense problem with MDR- and XDR-TB, none of which has yet even been properly surveyed and assessed let alone brought under any sort of control. Despite this, Modhi has recently also hoisted his flag up the mast declaring that TB will be defeated in India by 2025 – in just seven years, a full five years before any other country has reckoned it possible, and still with no accurate assessment of the true scale of its epidemic! Please forgive our cynicism, but as much as we might welcome such a bold statement we can’t help but register our disbelief at this statement. Some experts recently suggested that the true scale of India’s TB epidemic may truly be three times what it is officially estimated to be. Notwithstanding all of this, however, please note the fact that Prime Minister Modhi also hasn’t yet committed to showing up at the HLM in September.[i] Surely, he must do given what he’s said on the subject?
The Health Minister of South Africa, Aaron Motsoaledi (our second ‘Moe’), will certainly be there – though he’s not head of state only the minister of health. He’s also the Chair of the StopTB Partnership, however, so has a high and active profile in the TB community. South Africa certainly hasn’t been averse to making radical leadership decisions on TB (it was the first country to commit to using the new generation diagnostic GeneXpert, and has also recently committed to being the first country to use a three-drug protocol for DR-TB that doesn’t use any injectable drugs that are so hard to endure, that have no scientific evidence base for their use and which cause deafness in half of those who are given them). These are positive progressive and decisive steps which should inspire others to follow, but there’s another side to TB control in South Africa that is much less positive to report and which has also been happening under Motsoaledi’s watch: the rainbow nation’s case detection rate for TB is still one of the lowest in the world (only 54% of estimated TB case are being found) and rates of childhood TB in the country are rampant. So is President Ramaphosa going to commit to coming to New York in September and sit alongside his health minister to ramp up the cause?[ii] Not yet he hasn’t.
Similarly, last month we saw the first debate on TB in the UK House of Commons in 65 years. Prime Minister May wasn’t in attendance unfortunately (she has a lot on her plate at the moment), the debate having been called by a tiny group of pro-active parliamentarians who have been working tirelessly (and with some success) towards drawing together a worldwide Global Caucus of parliamentarians who are willing to commit to ramping up the fight against this disease. Those who spoke in this debate certainly did so informatively, each one calling for more investment for TB programmes, championing the 0.1% targets to close the R&D funding gap, and each one also calling on Prime Minister May to be there in September (representing the UK being not just as being a major donor nation but also making increasing contributions to the field of TB research).[iii] So will she?
I guess that if we can encourage her to do so, maybe she will!
There are intrinsic tensions at play with including accountabilities, it seems.
Donor nations tend to view accountability as if it’s simply something that high-burden countries must sign-up to deliver (not them), not just in relation to meeting treatment targets but also regarding mobilising their own domestic resource. In contrast, high burden countries take the opposite view, wanting accountability for donors to do their part (which is absotuley vital), and they are understandably particularly sensitive about this given the shifting sense of global responsibility manifesting under the Trump administration. This applies to financing for R&D as well as treatment, of course. But if one major player on either side blinks and makes any concessions in this respect, then it’s likely that others will follow and historic progress will be made. The challenge is getting the first blink out of them, rather than more and more entrenchment. It’s a tense affair with leadership being critical, and by leadership we inevitably mean our heads of states.
Meanwhile, unfortunately heads of state appear to be resisting the idea of attending because, if real commitments do get made, they will have been seen to have personally signed up to them. TB activists and stakeholders (the key people in this business), meanwhile, see attendance of heads of states attendance as being vital to any meaningful outcome from the HLM. Dr Lucica Ditiu, executive director of StopTB, is customarily explicit on the matter: "The right audience that we have to have [at the HLM] is the heads of governments!" she rails. Dean Lewis, a TB activist from India, goes a step further still, warning that if they're not there on the day then it'll be "a pretty useless meeting". That’s a very depressing prospect given that there’s a real risk they won’t show, but he has every right to share his concern having been hit by TB not once but twice (with devastating effects that sum up many of the social complexities of this awful disease). The first time he got TB his family was thankfully able to afford private treatment. By he went down with it the second time, however, “I was poor and homeless. I had lost my job, was living in the slums of Bandra, and could not afford private treatment. Since I had no permanent address to register for treatment, I was unable to access government treatment too.”
Mr Lewis will surely have already written to Mr Modhi, his head of state, asking him to attend. We’ll be doing the same with our own head of state, Prime Minister May.
So can you do the same with yours? Because doing so really could help save millions of lives. If you want any help in doing so, please just get in touch.
Thanks so much for reading.
[i] http://gctacommunity.org/?p=6486&v=79cba1185463
[ii] https://www.health24.com/Medical/Tuberculosis/News/ramaphosa-called-upon-to-attend-global-tb-meeting-20180615
[iii] https://hansard.parliament.uk/Commons/2018-06-07/debates/9BF50C2B-C9AF-47C5-9000-F306378A3821/
