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.
From:
Julie
To:
Dad
Subject: Happy Father’s Day!
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.
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.
2.
Government commitment to sustained TB control
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 noncommunicable 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 cooccurrence
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 countries
Change in Fatality per 100,000
Population 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 & Middle
Income
Countries
High Income
Countries
9%
Source: WHO Database
The disproportionate occurrence in
developing countries is a challenge
Fatalities per 10,000 Crashes
1000
1500
2000
2500
3000
3500
Viet Nam
3,181
1000
1500
2000
2500
3000
3500
2500
3000
3500
Kenya
1,786
1000
U.S.
66
1500
2000
250
0
Japan
UK
Canada
Italy
Germany
Spain
USA
France
Czech Republic
Bulgaria
Greece
Portugal
Hungary
Poland
Indonesia
Romania
Malaysia
Thailand
Vietnam
Turkey
Byelarus
Russia
Pakistan
Zimbabwe
South Africa
India
Venezuela
Kazakhstan
Algeria
Sri Lanka
China
Peru
Columbia
Zambia
Bangladesh
Ecuador
Kenya
Nigeria
Uruguay
El Salvador
Tanzania
Chile
Uganda
Argentina
Brazil
Malawi
Ethiopia
Motor Vehicles Are More Lethal
Vehicles in Developing Countries
Fatality rate (deaths/10,000 motor vehicles)
200
150
100
50
Jacobs, G., Aeron-Thomas, A., & Astrop, A. (2000). Estimating Global Road Fatalities (TRL report 445). London: Transport Research Laboratory.
er capita ($)
rate (deaths/10,000 mv)
(Fatality rate (deaths/10,000 mv))
(GNP per capita ($))
Ethiopia
Malawi
Tanzania
Nigeria
Vietnam
Uganda
Kenya
Bangladesh
India
Zambia
Pakistan
El Salvador
Zimbabwe
Sri Lanka
China
Indonesia
Bulgaria
Kazakhstan
Romania
Algeria
Ecuador
Byelarus
Columbia
Peru
Russia
Thailand
Turkey
South Africa
Venezuela
Poland
Hungary
Malaysia
Brazil
Chile
zech Republic
Uruguay
Argentina
Portugal
Greece
Spain
Canada
Italy
UK
France
Germany
USA
Japan
The Lethality Seems to
Increase with Lower GDP
• Cars are up to 200 times more lethal in the poorest countries
60000
250
50000
200
40000
150
30000
100
20000
10000
50
0
0
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 predicted
2050
“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 Health
Organization
The FIA
Foundation
UNICEF
The Task Force
Secretariat
The World Bank
UNDP
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
Strategy
• Clear value proposition for the
whole as well as each member
• Specific, agreed-upon objectives
• Focused scope
• Complementary participants
• Credible convener
Structure
•Organizational structure
appropriate for the mission
•Participative, but decisive governance
•Dedicated, core team
•Clear roles and responsibilities
•Funding sources
Social Capital
• Shared, inspiring challenge
• Open, constructive communication
• Culture of risk-taking and learning
• Conflict resolution capacity
• Camaraderie, regular contact
• Trust
Management
•Accountable leadership
•Effective resource management
•Detailed launch and operating plan
•Performance tracking
•Meeting management
“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
coalitions
Ability to see the details and the
big picture—at the same time
Tenacity
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