WHO reinvigorates role to fight ‘big three’ diseases
Dr Jack C. Chow, 44, obtained his medical degree from the University of California in 1987 and trained at Stanford University Hospital. He has since held a number of senior public health posts in the US Government and worked as a management consultant with McKinsey & Company. Prior to joining WHO, Dr Chow was the Special Representative of the US Secretary of State for Global HIV/AIDS and became the first US diplomat of ambassador rank to be appointed to a public health mission. He led US diplomatic efforts to help establish the Global Fund To Fight AIDS, Tuberculosis, and Malaria in 2002 and in combating global infectious diseases, including SARS (severe acute respiratory syndrome).
Q: What are the major challenges facing the ‘3 by 5’ campaign, to get ARVs to three million people in developing countries by the end of 2005?
A: The treatment numbers went from about 300 000 to 700 000 in a year. We are very encouraged by this progress but much more needs to be done. The stories of several countries show that when a confluence of factors come together this goal can be attained. For instance, in Uganda political leadership, investment of the country’s own resources and investment by external donors working with societal partners helped to deliver health care and HIV/AIDS care and de-stigmatize the illness. The top-line story is that when you make treatment available and abundant at low cost people are much more willing to seek testing, counselling and treatment for HIV/AIDS. When access to treatment is scarce and the price is high people are discouraged. We are seeing that in Uganda. We are encouraged also by what we see in Zambia. Botswana is one country that has already attained the 50% goal to deliver treatment, and there are several countries in South and Latin America that have made ARVs universally available. The challenge is making treatment more available in big countries, such as South Africa, India and Nigeria because of their size and the number of people with the virus.
Q: Even if WHO and its partners achieve the ‘3 by 5’ goal, how sustainable is this treatment and what happens after December 2005?
A: ‘3 by 5’ has a time-limited goal, but the mission is much longer term. Building health systems, training and educating the health workforce, and promoting community action are among the key things that need to happen.
Q: How do you persuade donors to make that long-term commitment?
A: It’s been made very clear that the present therapy is lifelong. That implies a logic of having ample supplies of medicine and a long-term financial commitment by the global community, as well as having a sufficient numbers of doctors nurses, community workers and counsellors who can confer clinical judgement, manage care, and treat other primary and secondary illnesses. WHO and others are striving to say that with the benefit of ARVs people can live longer and be productive members of the workforce. AIDS care has economic value and is socially indispensable.
Q: How is the global community helping governments to fill the huge shortage of health workers needed to scale up ARV treatment in sub-Saharan Africa?
A: That’s the emerging story. In public health as well as in development human resources are the critical pillar. We need to make a robust investment not only in the health workforce but in getting communities involved in health care. WHO is rolling out a number of products and projects to help train and educate the health workforce. One is the IMAI, the Integrated Management of Adult and Adolescent Illness package, which is a module which can be rolled out at country and community level to train health workers in HIV/AIDS care. It’s the challenge of promoting what I call ‘skill’ and ‘will’: ‘skill’ is the tasks that can be done through education and learning by doing, but even more important is ‘will’. How do you motivate people to provide health services or to educate patients amid very difficult circumstances? We are thinking about economic incentives as well as morale boosting actions through role models and group discussions so that people feel connected to a greater cause and that they are contributing to their neighbourhoods and countries.
Q: Can this approach to health-care delivery be applied to other diseases?
A: The story is emerging, and we absolutely hope the lessons of ‘3 by 5’ will be studied and applied to treating other infectious diseases or other primary health-care needs.
Q: Why are generic medicines important to your work with the ‘big three’ diseases?
A: We value both generic and research-based medicines because HIV is a very powerful mutator and we need fresh, innovative generations of ARVs that can stay ahead of drug resistance, have fewer side-effects and could eventually contribute towards a curative treatment. At the same time, HIV is penalizing the poor disproportionately and generics are valuable because they are effective and low cost. I don’t see it as an ‘either’ ‘or’, it’s about promoting a strong armamentarium to offer people with HIV in developing and developed countries.
Q: Was the switch in WHO’s drug recommendation to ACTs last year a setback for the malaria cause?
A: WHO has articulated the value of ACTs and worked assiduously with countries to change their policies in favour of these drugs, which are highly curative when applied properly. The old line of medicines, chloroquine etc., have encountered parasite resistance. They were inexpensive but didn’t work so any expense on them is too high. We are heartened that at least 20 countries in Africa have adopted ACTs as part of their first-line regimen and we are working with the private sector, and countries such as China to grow more of the plant that provides the raw ingredient for ACTs. ■