Ezekiel “Zeke” Emanuel, MD, PhD, Special Advisor for Health Policy at the Office of Management and Budget, is currently on a two-week trip in Africa looking at various health programs. On Thursday, he visited St. Peter’s Specialized TB Hospital in Addis Ababa, Ethiopia, and afterward talked with John Donnelly about his impressions of the hospital, which treats 145 patients with multi-drug resistant tuberculosis (MDR-TB), and how the trip influenced his thinking about future strategies in fighting TB.
This is the first of two parts of the interview with Emanuel. On Friday, Science Speaks will run Emanuel’s impressions of an HIV prevention program along heavily traveled road corridors that pass along Djibouti, Ethiopia, Sudan and Kenya.
Q: What impressions did you come away with from your visit to the TB hospital?
A: It’s an amazing site and they clearly are very concerned about the patients. It’s a big investment in terms of renovating the buildings, and the whole high quality about the place. You see they are committed to excellence. Mainly we focused on the MDR-TB ward. We discussed extensively the challenges in trying to make the diagnosis of TB, and MDR-TB, and Ethiopia’s large population, with 85 percent of it rural.
What you have a sense is of an amazing number of dedicated people, 22 doctors in all, and 45 beds for MDR-TB, and 200 beds for others with TB. And yet the demand, or need for services, way outstrips capacity, and that is the big challenge. That is one thing.
We had a long discussion about how do you prioritize who comes in. It’s a big issue. We have a limited supply. We had a disagreement about that.
Q: What was your disagreement?
A: They focus on first-come, first-serve. They focus on the sickest first, on people with HIV-TB co-morbidity, and other co-morbidities. But one of my more controversial papers, the one that Sarah Palin attacked, is all about the principles you want to use when you have scarce resources, and here we absolutely have scarce resources to treat TB in Ethiopia. We are highly critical of first-come, first-serve. We advocated the “Complete Life” view – but, wait, that is not about the purpose of this visit. It was an aspect of it. They wanted to see the paper. They weren’t wedded to their view, they weren’t ethicists, and they wanted to learn more about my views.
Of the other two major issues we discussed, first was just the expense here. Just the drugs for MDR-TB are $3,000 per patient. We’re not talking about the hospital bed, the lab test, just the TB drugs! We’ve had a lot of attention put toward ARV (antiretroviral drugs) cost, but we haven’t had nearly enough attention to TB drug cost. We also talked about the medicine list for most of these patients, which have just enormous number of side effects, causing depression and psychosis, among other things. They are tough to take, tough to stay on. That poses its own challenge, even if they are free. We saw young patients there who had depression, one had a psychotic break. We are also facing patients who are co-infected with HIV, and they may not be in stable condition, and you pile problem upon problem upon them, and the challenge is enormous.
I don’t think the solution is more St. Peter’s Hospitals. I do thing we will have to have other creative answers.
Another major issue is we need to have better diagnostic tools for TB, better microscopy. They have fluorescent microscopy to allow for more accurate diagnosis. But it’s not only about getting the diagnosis. You have to think about getting a sputum sample from a health center in a rural area to a laboratory, and this can be an enormous task. The WHO estimates that 300,000 people in Ethiopia have TB and 6,000 people have MDR-TB. You are staggered by the scale of the problem here.
Q: You said that more St. Peter’s Hospitals are not the answer. What is the answer?
A: I wish I were more of an expert in this area. I do know I have to ask a lot of questions. But either fiscally or structurally, building hospitals for (6,000) beds for MDR-TB patients in Ethiopia is not the answer.
Q: What about the innovative models of caring for MDR-TB patients in the Philippines or in Nepal, for example, where the national TB programs do not put people with MDR-TB in hospitals but instead monitor them daily and allow them to return to their homes in the community? They travel every day to the clinic to receive their medicine and then return home.
A: Again, I’m not an expert. But every day here, transport is a big challenge. This is not Nepal or the Philippines. We have a four-wheel drive vehicle, and we went off-road for an hour to get to a health post, and we didn’t see a bicycle or a car the entire time. We saw one bus. There’s no way to get people in to take these medicines. And in the health post, they don’t have refrigeration for the drugs. You have got to tailor your solution to each particular country.
Q: You described the great unmet financial need to fight TB in Ethiopia. Has this trip changed your thinking about the U.S. government’s contribution to increase its funding for TB, which is very low compared to AIDS or malaria?
A: But the funding for TB is higher than, say, neglected tropical diseases, where the numbers of people affected are even higher than those affected by TB. Global health is both a great place to work because there are many things we can do very cheaply, and because we can make a huge difference with those interventions. If you look at what the Senegalese or the Malawians, or the Zambians have been able to do with malaria in very short order shows we can make huge progress on these things. The hard numbers are a 90 percent decline in malaria by using more bed nets, residual spraying, and early treatment. That is an area we are making huge, huge progress.
Q: But what do you say to the argument that by not treating MDR-TB now, the cost will only multiply in the future?
A: I don’t disagree. As I said, TB is not an area I fully understand. But I learned something today. I see this is as a big challenge, and I have to ask a lot of hard questions now about how we do this. I can tell you unequivocally that building St. Peter’s Hospitals all over the world is not sustainable. You got 22 doctors there carrying for 145 total MDR-TB patients. You are going to need another model.
Upcoming Friday: Emanuel’s views on an HIV prevention program in rural Ethiopia.