Health solutions for the poor

Abstract

The International Union Against Tuberculosis and Lung Disease (The Union) is the oldest international non-governmental organisation involved in the fight against tuberculosis. In 2008, the Institute of The Union was challenged to think boldly about the future and to develop a diverse work portfolio covering a wide spectrum of lung health and other disease-related problems. The vision adopted by The Union at that time was ‘Health solutions for the poor’. More recently, there has been lengthy debate about the need for the Union to concentrate just on its core mandate of tuberculosis and lung health and for the Union's vision to reflect this narrower spectrum of activity as ‘Lung health solutions for the poor’. In this viewpoint article we outline our reasons for believing that this narrower vision is incompatible with The Union's mission statement, and we argue that making such a change would be a mistake.

The International Union Against Tuberculosis and Lung Disease (The Union) is the oldest international non-governmental organisation involved in the fight against tuberculosis.¹ In the last 10–15 years, the portfolio of The Union has expanded, and it has become a major player not only in the global and national fight against tuberculosis, but also in the field of lung health, focusing particularly on childhood pneumonia, asthma and the complex issue of tobacco control, the prevention and treatment of HIV/AIDS and the increasingly important domain of operational research. In 2008, The Union's Board of Directors challenged the Institute to think boldly about the future and to develop a diverse work portfolio covering a wide spectrum of lung health and other disease-related problems.² The Union's mission statement developed at that time read as follows: ‘The Union brings innovation, expertise, solutions and support to address health challenges in low and middle-income populations’. The vision adopted was ‘Health solutions for the poor’.

More recently, there has been a lengthy and fractious debate about the need for the Union to refocus and concentrate just on its core mandate of tuberculosis and lung health, and for the Union's vision to reflect this narrower spectrum of activity as ‘Lung health solutions for the poor’. We believe that limiting the vision is incompatible with The Union's mission statement, and that such a change is a mistake. We outline our reasoning below.

First, tuberculosis (TB) is a communicable disease that affects not only the lungs but many other extra-pulmonary sites such as the peritoneum (TB ascites), the meninges and brain (TB meningitis) and the bones (spinal TB). In managing patients who are sick as a result of the wide spectrum of tuberculosis, a focus on lung health alone is inappropriate. This philosophy can similarly be applied to both tobacco control and HIV/AIDS. Cigarette smoking kills people through respiratory, neoplastic, vascular and other diseases, especially ischaemic heart disease and stroke.^3,4 The Union, with support from Bloomberg Philanthropies and working in conjunction with an extensive partnership, aims to reduce global adult smoking prevalence by addressing price, image, exposure, cessation and monitoring, and in so doing aims to prevent 100 million deaths from tobacco.⁵ This is not just a lung health solution but a general health solution to reduce premature deaths due to a wide variety of smoking-related diseases. Finally, HIV is a virus that is transmitted predominantly by sexual intercourse and which targets the immune system, causing opportunistic infections, non-communicable and metabolic disease and malignant diseases that affect multiple sites in the body. The prevention and treatment of HIV/AIDS call for general health solutions.

Second, the framework for tuberculosis control, originally branded as DOTS by the World Health Organization (WHO), was based on the pioneering work of the late Dr Karel Styblo, former Director of Scientific Activities at The Union. We have argued and shown that the DOTS paradigm, particularly the monitoring and evaluation component using cohorts of patients, can be successfully applied to the delivery of antiretroviral therapy (ART) for patients with HIV/AIDS and to the management of patients with non-communicable diseases such as diabetes mellitus and hypertension.^6–9 In Malawi, for example, by 30 September 2013, a total of 641 158 patients had ever been initiated on ART in both the public and private sectors and had known treatment outcomes: of these registered patients, 459 261 were alive and on therapy and can be stratified by ART regimen (Union quarterly report, Q4, 2013). Obtaining, aggregating, analysing and interpreting this kind of data every three months at a facility and national level is a task that goes beyond the use of paper-based registers and treatment cards, and one of the appropriate health solutions to this challenge is the development and scale up of a robust, easy-to-use, touchscreen electronic medical record system.¹⁰ This has been developed, with support from The Union and other partners, and by 30 September 2013 it was being used for 280 000 patients in 29 government clinics in the country. A vision of ‘Health solutions for the poor’ provides an overarching direction under which such innovations can be tested and scaled up to serve the interests of poor patients and poor countries, which would be difficult to justify under a narrower direction focused just on lung health.

Third, The Union is engaged with Médecins sans Frontières and the WHO Special Programme for Research in Tropical Diseases in operational research capacity development in many low- and middle-income countries.¹¹ Although the focus of operational research is tuberculosis and HIV/AIDS, largely because of the excellent routine data monitoring systems that underpin the control of these diseases, projects are increasingly being undertaken in other infectious and tropical diseases, smoking, non-communicable diseases and areas such as maternal and child health, nutrition and health worker education. Important principles are being learnt and developed as these research capacity development courses evolve, and it seems entirely amiss not to apply these to other public health areas outside of tuberculosis and lung health that cause concern in resource-poor countries.

Finally, there is the old adage ‘less is more’. A vision statement describes the aspirations of an organisation and where it wants to go. The simpler this statement is, the easier it will be for people to understand and implement it well. The vision ‘Health solutions for the poor’ is simpler and easier to get over to people and understand than a lengthier message. It also more strategic to have an over-riding vision that is broad and which therefore allows activities and innovations to be undertaken across a wide spectrum of diseases and portfolios rather than have to work within a narrow vision, with the subsequent need to continually justify why The Union is doing work in areas outside of tuberculosis and lung health. The last 10–20 years have shown the inter-connectedness of many global health issues, and as an institute with the mission to improve public health for poor people, we would be abrogating our responsibilities if we did not embrace and engage in the larger picture. We are interested in what others think about this viewpoint.