Lessons from Two Global Plagues:

TB and Global Road Traffic Injuries

California Childhood Injury Conference

September 22, 2003

This Talk is Dedicated to Dr. Fernando Llanos

• Fernando Llanos is a physician, Director del Instituto Nacional de Salud Pública

• He is a passionate, enthusiastic, and brilliant colleague on our MDR-TB project

• He fell 16 feet when a ladder collapsed out from under him

• He blamed himself and may not receive disability payments “because he was stupid”

Injury prevention suffers from:

– Lack of understanding– Lack of a magic pill--complex

interventions required– Lack of political will– AS a result there is a great

disparity between the importance of injury and the attention it gets

The Task Force for Child Survival and Development

provides Optimism

• Lessons about keeping children safe in our own communities can be learned by looking at two modern plagues

• Work at the Task Force provides a valuable perspective

• Founded in 1984 by Bill Foege• Formed a coalition to close the childhood

immunization gap—and save the lives of 3000 children who were dying every day

The Task Force for Child Survival and Development Today

• Our mission is fostering collaboration with partners globally to transform the practice of public health.

• Our legacy is building coalitions, forging consensus and leveraging scarce resources to address complex global health issues.

• Our key staff are recognized world leaders in global public health, many have come from CDC and WHO.

• We currently have a variety of programs in infectious diseases, informatics, injury control and child development - all drawing on our technical expertise and collaborative skills.

Lessons about keeping children safe in our own communities can

be learned by looking at two modern plagues

• Our work at the Task Force covers multiple areas of global health including TB and global road safety, among others.

• The diversity of this work provides the opportunity to learn lessons from one area and apply those to another.– TB Through the Eyes of Paul Farmer and Liberation

Theology– Road Traffic Injuries (The perfect plague: Human Road

Kill)

• The importance of collaboration to build momentum and leverage scarce resources

Lessons from the Fight Against MDR-TB

• The Task Force has been working on a coalition funded by the Gates Foundation to address multidrug-resistant TB in resource poor settings.

• Coalition members include Partners in Health, Socios en Salud, CDC, WHO and MINSA.

Hola Querido, Papa! Today's the big day to celebrate you.

For a lot of people here, Father's Day is sad, though. Their father died when they were young or left them or they just never knew him.  I'm going to the cemetery today with a few families to keep them company while they celebrate their fathers, and it's amazing to me that they keep celebrating and thanking their fathers, showing their love and respect, even when their fathers were never there. It makes me feel lucky not only that I still have a father, but that I have a father who has been there for me.

From: Julie

To: Dad

Subject: Happy Father’s Day!

TB had become a Neglected Disease

• One-third of the World’s Population is infected with TB but since it is not prevalent in the developed world, it was ignored.

• Progress was made when WHO created a simple and direct approach to attacking it.

DOTS Became Packageable

Elements of DOTS (Directly Observed Therapy, Short Course) 1. Government commitment to sustained TB control

2. Sputum-smear microscopy to detect the infectious cases among people with a cough of three weeks' duration or more

3. Standardized short-course anti-TB treatment with direct observation of treatment for at least the initial two months

4. Regular, uninterrupted supply of anti-TB drugs and diagnostics

5. Monitoring and accountability system for program supervision and evaluation of treatment outcome for all patients diagnosed

Strategic Campaign for TB

• Based on the Burden of Disease and further economic analysis (Commission on Macroeconomics and Health) WHO made a strategic decision to focus on AIDS, TB, and Malaria rather than all infectious and non-communicable diseases

• Focus on specific diseases led to “massive effort” on AIDS, TB, and Malaria as priorities for WHO and led to support for the Global Fund

Partners in Health

• Founded by Dr. Paul Farmer and Dr. Jim Kim in 1990

• Mission: give preferential option to poor of Cange (Haiti) and Carabayllo (Peru)

Paul Farmer• MD and PhD

in anthropology, Harvard• A modern day “Albert

Schweitzer” who focuses on the problems of infectious diseases and poverty—TB and AIDS.

• Guided by “liberation theology”– Preferential options for the

poor– Solidarity with the poor

Liberation Theology:Preferential Options

for the Poor

• Do the most good by helping those least well off

• Diseases also have a preferential option for the poor

• TB kills 1.5 million a year; overwhelming majority are poor

• Toll of AIDS in Africa is paid largely by the poor

Liberation Theology:Solidarity with the Poor

• Best serve when we understand the situation

• Gain an understanding by living in the situation

• Paul Farmer shares with those he serves

Then came multiple-drug resistant TB (MDR-TB)

• Since the treatment for TB requires six months of therapy, patients in poor settings were not reliable in taking their medication prior to DOTS.

• Drug resistant strains emerged.

• In resource poor settings, this was a death sentence before PARTNERS.

WHO’s approach to MDR-TB had been “Just let

them die”

Partners in Health did not accept that inequity

• PIH pioneered treatment of MDR-TB in Carabayllo, a resource-poor setting in Peru

– Trained community health promoters, who confirmed the infected took medication daily

– Negotiated drastic cuts in cost of second-line drugs for MDRTB

– Dropped cost of treatment down to $800 to $1200 per case

– 80% plus success rate

HIV/AIDS has Increased Urgency and Importance of

MDR-TB • Increased incidence of active disease• More people dying from TB now than ever

before—50 years after development of effective treatment

• “Ebola with wings”—The Time Bomb• WHO now links TB programs with

HIV/AIDS programs because of co-occurrence

Lessons for Injury Control from MDR-TB

• Deal with a specific disease, not all infectious diseases, in order to address an under attended problem

• Local areas of work can make a global difference• Focus on the patients, faces, families and community• Realize it is a complex intervention in resource poor

settings—not an impossible intervention• Understand the dynamics and economic aspects• Be tenacious

III. The Perfect Plague: Human Road Kill

• Road Traffic Injuries take about 1.2 million lives per year and seriously injure over 20 million people each year

• Rates are accelerating rapidly in developing countriesChange in Fatality per 100,000Population 1980-1995

The Global Burden of Disease shows RTI at number 9 for

1998…1 - Respiratory Infections

2 – HIV/AIDS

3 – Perinatal Conditions

5 – Unipolar Depression

6 – Ischaemic Heart Disease

4 – Diarrhoeal Diseases

7 – Cerebrovascular Disease

8 – Malaria

9 – Road Traffic Injuries

10 – Obstructive Pulmonary Disease

…but expected to climb to number 3 by 2020

1 – Ischaemic Heart Disease

2 – Unipolar Major Depression

3 – Road Traffic Injuries

4 – Cerebrovascular Disease

5 – Obstructive Pulmonary Disease

6 – Respiratory Infections

7 – Tuberculosis

8 – War

9 – Diarrhoeal Diseases

10 – HIV/AIDS

“Out of sight, out of mind”

    Falling rates in US make the problem invisible—same thing happened to TB in US

Road traffic injuries are a also problem of poverty: the poor and

most vulnerable are being hit hardest

Proportion of Global Injuries

91% Low & MiddleIncomeCountries

High IncomeCountries

9%

Source: WHO Database

The disproportionate occurrence in developing countries is a challenge

Fatalities per 10,000 Crashes

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3,181

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The Lethality Seems to Increase with Lower GDP

• Cars are up to 200 times more lethal in the poorest countries

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Motor Vehicle Manufacturing Is an Accelerant Like AIDS

for TB

• We can predict the rates of increase in RTIs

• We can control the rates of death in RTIs

• Because we can predict this and control this plague, this makes it the Perfect Plague

The number of vehicles is expected to increase dramatically, thus

increasing the likely number of deaths

• India as an example– 23% increase in number of vehicles between

1990-1993– Predict a 60-fold increase by 2050

1990 3.7 million vehicles

1993 4.5 million vehicles

over 267 million vehicles predicted2050

“Just Be Careful”

• Just like MDR-TB, there are difficulties getting injury control implemented– not high on the agenda– fatalism abounds (there is nothing we can do)– disproportionately affects the poor – it is a complex intervention in a resource poor

setting– injuries are seen as accidents, people blame the

victim, they say “just be careful”

A man entered the hospital to have his heart

fixed• He was still working, playing tennis, and an excellent

candidate for surgery.• 36 hours after a catheter had been inserted through his

leg and into his heart, he developed internal hemorrhaging in his leg.

• The nurses did not respond to his extreme pain and the new intern failed to recognize his problem, allowed the hemorrhage to continue, and as a result, he went into shock.

• The shock led to a massive heart attack that caused his heart to rupture beyond repair during surgery.

We must do more than tell doctors and nurses to be

more caring and more careful

• The new intern and unresponsive nurses certainly contributed to his death.

• We could say they need to be more caring, more informed, and quicker to respond.

• But, we also need to realize that medical errors will still be made.

• How do we provide protection for those times when human errors will be made? We change the system to build in back-up protection.

Likewise in Road Safety, The System Must Protect Us from the Errors that Will Inevitably

Happen• The historical view was that road users were responsible

for the crashes and injuries that occurred and that through training, supervision, and punishment they could be made to prevent these crashes and injuries.

• However, just as in the example of the doctors, it takes much more than focusing on the driver to protect us on the roads.

• We realize now that the operator of a motor vehicle is just one part of the system with specific limitations on his or her performance brought about by the effects of inexperience, fatigue, alcohol, and predictable error rates.

Forming a Collaboration to Prevent Road Deaths

• The Task Force’s heritage is forming coalitions to address complex public health problems.

• To address RTIs, the Bone and Joint Decade approached us to create a similar coalition.

The Task Force brought together key parties to form

the Global Road Safety Steering Committee

The World Bank

The World Health Organization

The FIAFoundation

UNICEF

UNDP

The Task Force Secretariat

The Bone and Joint Decade

Plans to raise awareness through UN meetings and

World Health Day 2004 include:

• Holding an interactive high level technical meeting to brief ambassadors and key personnel on road traffic safety (scheduled for May 29, 2003)

• Obtaining official support and plan for a plenary session of the UN General Assembly in April 2004 (General Committee has recently approved the resolution)

• Supporting World Health Day (April 7, 2004) and use the UN meeting to help launch the World Report on Road Traffic Injury Prevention

• Coordinating activities in different regional media centers around the world to advance the cause in Europe (targeting France), North America, Africa and possibly Asia  

• Helping develop a road safety agenda and programs within the UN and UN agencies

We believe we can work for global equity in road

safety• Get ahead of the curve: accelerate progress to

improve outcomes and increase safety• Build support for programs at UN Agencies

(WHO, World Bank, UNICEF, UNDP)• Start and strengthen developing country programs• Develop and share knowledge about how to

improve road traffic safety• Raise awareness and capacity to address this

impending epidemic

Key Lessons for Childhood Injury Prevention

• Focus on a particular injury rather than injury as a whole or infectious diseases in general—we are focusing on RTI because it has global distribution and the highest burden

• Take a systems approach: moving beyond blame, beyond education as the sole answer. – Children are not in a position to look out for their own

safety. We have got to build a system that protects them against the errors that will inevitably happen.

Key Lessons for Childhood Injury Prevention

• Intersectoral approach—include law enforcement, EMS, public health, rehabilitation, transportation and vehicle design, urban planning, and education

• Economic and socio-economic analysis—emergence of new concepts—macroeconomics and safety

• Injury has a preferential option for the poor—many types of injury differentially affect the poor and those least able to protect themselves

• Convene the right players—this is important to leverage scarce resources, people working in isolation are less effective; utilize the partners’ unique strengths (BJD, Oman, WHO, ASIRT)

The Ability to Build and Maintain Coalitions

• A coalition is like a marriage….we think it is pure bliss and that the bliss will last forever

• As most married people have found, it’s easy to get into it, but very hard to make it work

Maximizing a coalition’s success requires diligence in key areas

Structure•Organizational structure appropriate for the mission

•Participative, but decisive governance•Dedicated, core team

•Clear roles and responsibilities•Funding sources

Structure•Organizational structure appropriate for the mission

•Participative, but decisive governance•Dedicated, core team

•Clear roles and responsibilities•Funding sources

Management•Accountable leadership

•Effective resource management•Detailed launch and operating plan

•Performance tracking•Meeting management

Management•Accountable leadership

•Effective resource management•Detailed launch and operating plan

•Performance tracking•Meeting management

Strategy• Clear value proposition for the

whole as well as each member• Specific, agreed-upon objectives

• Focused scope• Complementary participants

• Credible convener

Strategy• Clear value proposition for the

whole as well as each member• Specific, agreed-upon objectives

• Focused scope• Complementary participants

• Credible convener

Social Capital• Shared, inspiring challenge

• Open, constructive communication• Culture of risk-taking and learning

• Conflict resolution capacity• Camaraderie, regular contact

• Trust

Social Capital• Shared, inspiring challenge

• Open, constructive communication• Culture of risk-taking and learning

• Conflict resolution capacity• Camaraderie, regular contact

• Trust

“In theory, there is no difference between theory and practice; in practice, there is.”

– Yogi Berra, on receiving an honorary degree from Montclair University, NJ, USA

Dr. Bill Foege, founder of The Task Force, influenced

our thinking

• Foege’s Secret Ingredients for Success in Public Health: – Ability to form and sustain

coalitionsAbility to see the details and the big picture—at the same timeTenacity

Tenacity• You have it—in this field you don’t survive

without it.

• Still, it is hard to maintain interest and commitment and passion while pushing the rock uphill, without budgets and politicians to support you.

• I hope that looking at this larger picture—at the same time that you look at your specific issues—will prove helpful

Epilogue – what a small group can do

• Paul Farmer spoke about the treatment he was providing to AIDS and MDRTB patients in Cange at the AIDS conference last year in Barcelona he received a standing ovation from the 10,000 people in the audience

• Tracy Kidder’s book about Paul—Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World--received rave reviews in last week’s NYT book review

                                                                                                                                        

Jim Kim and JW Lee

• JW Lee, as director of TB for WHO, was one of our partners on the MDR-TB program in Peru

• Jim Kim helped to elect JW as the new Director General of WHO in Geneva—

• Jim is now in Geneva at WHO—helping to transform WHO from an organization that sets norms to one that delivers programs, with a preferential option for the poor. They are setting their sights on AIDS and completing the eradication of Polio. In his brief inaugural speech, JW mentioned Road Traffic Injuries twice

Ahead of General Assembly, Annan urges

commitment to road safety

• 9 September – In a report issued ahead of the upcoming session of the United Nations General Assembly, Secretary-General Kofi Annan recommends that the UN's chief legislative body call on Member States to stimulate a new level of commitment in tackling the problem of road traffic injuries, projected to rank third among causes of death and disability by 2020.

• "Improving road safety requires strong political will on the part of Governments," Mr. Annan says, recommending that countries be encouraged to develop and implement a national strategy on road traffic injury prevention and appropriate action plans.

They said it would take 5 years…

• At the start of this project, we were told that it would take no less than five years to put road safety on the UN agenda; by bringing together the right players and fostering a successful collaborative effort, we have reached our initial road safety goal in less than one year.

“Justice will come when those who are not injured are as indignant as those who are.”

- Thucydides