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§ John Barrett (Edinburgh. West) (LD)For many people in this country, tuberculosis is something from the past. Many young people do not know what it is. It is something that people used to suffer from in this country. Many older people often remember when it was a problem and are glad that it is now only a bad memory. However, while we might not be seeing too much sign of TB at first hand in this country, what is happening elsewhere in the world, and also here in the UK, deserves much greater attention. I am glad to have initiated this debate, and I am delighted to see that the Secretary of State is present to respond to it. I know that he shares my concerns.
During the early 20th century, TB was the leading cause of death from infectious disease in the UK. The same was true in much of Europe and the USA. As social conditions improved, it became increasingly rare. Although it is commonly associated with poverty and overcrowding, it can affect anyone. The world has witnessed an increase in the problem, and over the past 10 years we have seen it return in the UK. There were over 7,000 cases in 2002, and in some parts of London cases have risen by 80 per cent. It is hard to believe that one area of London has a TB rate that is higher than China's.
As I walked into the building this morning, I met my hon. Friend the Member for Mid-Dorset and North Poole (Mrs. Brooke). She told me of her own experience of suffering from TB, and of her horror when she discovered that her children would not be able to get the BCG vaccination because of a shortage in her area a few years ago. Although that does not provide 100 per cent. protection, it is still seen by many as the best way of minimising risk in the UK. She said that few people thought that the issue of the global control of TB related to the UK, but when friends and family have suffered or are suffering it brings it home that we are part of that global community. Members on both sides of the House have gone public about having suffered from TB in the past.
The British Medical Association has pointed out that although a high incidence of TB is linked to areas with high numbers of immigrants, it is the poverty and overcrowding suffered by many of them after their arrival rather than their physical health that causes the problem. Surprisingly, the health of many of them worsens after they enter the UK. The problem of TB is back, and it is right here on our doorstep. Another issue that we will have to deal with is that some doctors also think that TB is a problem of the past, and misdiagnosis is easy. One famous case in the USA was when Eleanor Roosevelt fell ill and went to Massachusetts general hospital where she died, undiagnosed, of TB. What we are seeing in the UK is a tiny tip of a very large iceberg. Worldwide, that iceberg sinks the equivalent of three or four Titanics every single day.
What is TB? Anyone who is breathing can get tuberculosis. All it takes for bacteria to be released into the air is for someone with TB to sneeze, cough or even just talk. Those bacteria can hang around for up to six hours and anyone can breathe in that air, allowing the 93WH rod-shaped bacteria to travel down into the lung. The body reacts and white blood cells surround the bacteria.
When the bacteria are contained inside microscopic lesions, the individual has inactive—or latent—TB and cannot give it to anyone else. It is estimated that 2 billion people—a third of the world's population—are latently infected. HIV multiplies by a hundredfold the likelihood that a person with latent TB will develop the active disease. If I have time. I will talk about the increased problems of HIV and TB.
If the immune system is compromised—if the sufferer is HIV-positive or is weaker in some other way—more bacteria are produced and thousands of bacteria can spread throughout the lungs. That is active TB. Everyone around the infected person can then be infected, and it can spread to other parts of the body such as the spine.
Without any treatment, TB will take its time to kill a patient. The victim will lose weight. find it impossible to breathe, suffer night sweats, cough up lots of blood and in the end will either suffocate or drown in their own blood. That is a gruesome end. Left untreated, 50 per cent. of TB patients will die within five years. The most tragic aspect of the matter is that so many are suffering when it is so easy to cure. There are tried and tested methods, and the drugs cost only about $11 per patient.
I have touched on the situation in the UK; I should like to place on record the scale of the problem worldwide before I go on to consider what can be done about it. Every year, TB kills about 2 million people in the developing world. Some 7 to 8 million people become sick with TB every year. Some 3 million TB cases occur in south-east Asia. More than 250,000 TB cases per year occur in eastern Europe, and 8 million people develop active TB every year. Each of those active cases can affect between 10 and 15 people just by breathing.
Almost everyone could have and should have been cured. The best way to prevent TB is to treat and cure those who already have it. TB kills 5.000 people a day, equivalent to 15 jumbo jets crashing. More people die every day of TB than died on 11 September in the attack on the World Trade Centre.
As I said earlier, the problem can be cured and the approach known as the DOTS strategy was found to be the best way forward. That is the directly observed treatment short course, and on a recent trip to India, the hon. Member for Leicester, East (Keith Vaz) and I saw first hand how the strategy was put into place and how effective it was; I will touch on that later.
The World Health Organisation has reported that more than 10 million people have been successfully treated since 1994. DOTS works by making patients take their medication under supervision and by coordinating Government health workers' and patients' fight against the disease. Five elements make up the DOTS strategy. One is political commitment, which means not only obtaining funding from Government and local authorities, but involving key decision makers nationally and locally. Everyone has a stake in the project and everyone benefits from its success.
Case detection is carried out by sputum smear microscopy, SSM. The hon. Member for Leicester, East and I can now both identify active TB under a 94WH microscope. We feel suitably qualified as participants in the course. We have been able to identify the small, red. active TB viruses. What follows detection is the standard drug regime, which has now been proved successful. The drugs have been identified, and if patients take them regularly and are observed taking them, they can take the full course lasting six months.
That can mean chasing up people who have started the course. If a person does not turn up, somebody is sent out to track down the patient and make sure that they take their prescribed drugs. If they do not take them, or if they feel better halfway through the course, other problems can develop. Most patients are expected to come in on a Monday, Wednesday and Friday to take their course. The drugs come in small bubble packs. It is vital that there should be no missed doses.
It costs only $11 for a six-month dose, but if people break off their course they can develop drug-resistant TB, which can cost much more to treat. There also has to be a regular supply of drugs, the lack of which was a problem in the past. Before the DOTS strategy was implemented, people were given the prescription for a certain amount of the drugs. However, when they were halfway through their course, they would go back to the chemist and find that there were no drugs available to complete the course.
The DOTS scheme identifies sufficient drugs for one patient, which are placed in a cardboard box with the patient's name on it, so that when the patient goes to the clinic, the box can be opened; they then know that when they start the course there are enough drugs to complete it. They are then more inclined to finish a complete course because they know that it is unlikely to fall apart halfway through.
TB quickly becomes resistant to drugs if treatment is inadequate; for example, if the drugs are interrupted or run out. It is then almost certain that patients will develop multi-drug-resistant TB. Treatment for MDR TB costs more than 100 times as much as the initial treatment, and the drugs have to be taken for four times longer. If I have time, I hope to say something about MDR TB, which is a growing problem in eastern Europe, particularly in some of the EU accession states.
The fifth and final aspect of the DOTS programme is the recording and reporting system that must be put in place. Health workers and observers who watch their patients take their drugs develop a system that stops people slipping through the net. It is relatively easy to quantify the success of DOTS, unlike the fight against many diseases. It is easy to provide the statistics that say how successful the fight against TB has been. The DOTS strategy is a huge success, and the Department for International Development must be congratulated on playing its part.
Along with the hon. Member for Leicester, East, I was at a recent meeting with the Secretary of State and the Minister regarding the funding of the DFID India programme and the possible ending of a very successful project in Andhra Pradesh. Hopefully the Secretary of State will be able to say something today about plans for the future of the funding of the programme in India, especially as there is one project that has given hope to so many and could be replicated elsewhere. It would be sad to see that project come to an end, especially when there is money that has been allocated but is as yet 95WH unspent. It might be that if slightly more time were given in which to spend the money, it could last for longer. As I said, DFID must be congratulated on committing more than £20 million between 2000 and 2005. The concern in Andhra Pradesh is that the excellent programme that they have should be built on and that it should not come to an end.
The situation in India is generally stark. It has the world's highest number of TB cases, involving more than 4.5 million people. Foreign aid and debt relief also have a major part to play in the fight against TB; the disease is intimately linked to poverty. Again, credit where it is due, the Government are moving in the right direction on the issue.
The recording of the success of the DOTS strategy is relatively easy, because the statistics are recorded in each hospital or medical centre. The WHO targets for 2005 are 70 per cent. case detection and for 85 per cent. of those cases to be cured. There is a long way to go; only 32 per cent. of TB patients worldwide are being treated by the DOTS programme, or at least that was the case in 2001. In some countries coverage is rising fast. For example, in Brazil it has increased from a low base of 7 per cent. to 32 per cent. in only four years.
It is easier to list the countries where TB is not an issue than those in which it is. Nowhere can ignore the problem. North America, Europe, Australia and Japan constitute most of the world that has a low incidence of TB, but the USA and Italy have had problems and outbreaks, as we have had in the United Kingdom. The increased number of people who travel by plane means that TB crops up everywhere. We all have a vested interest in its global control. For those who ask why we are so interested in what is happening elsewhere, we answer that as well as reducing the suffering abroad we can prevent it at home.
A quick run through some of the countries where infectious cases are being treated using DOTS is contained in the report card that was produced by the WHO. It covers countries such as Vietnam, South Africa, the Philippines, Congo, Kenya, Uganda, Mozambique, India, Bangladesh, China, Ethiopia, Pakistan, Nigeria, Brazil, Russia and many others. Twenty-two of the world's poorest countries account for 80 per cent. of its TB cases. DFID's work is rightly poverty-focused, and few diseases are more poverty-focused than TB.
While there is good news, it is worrying that in some countries the problem is worsening. I mentioned the problem of drug-resistant TB and the possible threat to the EU. Drug-resistant TB presents one of the most difficult challenges, but with funding from the Bill and Melinda Gates Foundation, along with the Harvard medical school and the WHO, the fightback has started.
In the largest ever study of drug-resistant TB, the WHO examined 63 countries and more than 60,000 patients worldwide. MDR TB rates were 10 times the average in Latvia, Lithuania and Estonia, which are all countries from which we expect increased migration to the UK from 1 May. The only way to deal with the issue is through investment in global TB prevention.
There are positive indicators. There is an increased flow of funding through the global fund to fight AIDS, tuberculosis and malaria, a flow of anti-TB drugs 96WH through the global drug facility and a decreased TB incidence rate in the American, Mediterranean and south-east Asia regions. I urge the Department for International Development to play its part in helping to develop new vaccines, which are needed now but will more desperately be required in years to come. The problem is well documented, and the solution is tried and tested. I look forward to hearing from the Secretary of State about the part that his Department can play in the war against tuberculosis.
§ The Secretary of State for International Development (Hilary Benn)I begin by thanking the hon. Member for Edinburgh, West (John Barrett) for initiating this important and timely debate. I know, from the discussions that he referred to during his speech, that he has a personal interest in this matter, as does my hon. Friend the Member for. Leicester, East (Keith Vaz). Both of them recently visited India and saw an excellent programme that my Department is helping to support. I should like to take this opportunity to congratulate them on their newly found microscopic skills, which show how the talents of Members of this House spread far and wide.
I shall begin with the programme that we discussed when we met recently. As the hon. Member for Edinburgh, West will remember, my hon. Friend the Under-Secretary of State for International Development and I undertook to reflect on the points that were made. We have not yet made a decision about what will happen when the current project comes to an end, and we need to talk to the Indian Government about that. We have promised that we will respond to the hon. Gentleman and to my hon. Friend the Member for Leicester, East, and we shall do so. I am grateful for the comments about the quality of that programme, which is an example of the contribution that DFID is making to tackle the problem of TB around the world.
As we have heard, 2 million people a year die of TB. It disproportionately attacks poor people: it is a disease of poverty that is made worse by poverty. Some 92 per cent. of cases and deaths occur in developing countries, and infection transmits more readily in the conditions of poverty, where people face overcrowding, inadequate ventilation and not having enough food to eat. Once they are infected, poor people are more vulnerable to economic effects, because if they cannot work, they cannot get an income. They therefore have less to spend on food, treatment and supporting their families. It is a vicious cycle that affects all parts of their lives.
I learned more about the problem of TB and the challenges of trying to treat it from the first visit that I paid to Africa as a DFID Minister in November 2001, when I was Under-Secretary of State. I got off the plane in Lilongwe and went straight to what is known locally as the Bottom hospital to visit its TB treatment centre. In the course of that morning, and during a visit to the slums of Lilongwe, I learned exactly what can be done to treat TB. I also learned about the problems that people with the disease face.
The treatment centre had recently moved to the DOTS—directly observed treatment short course—system. As I recall, the TB ward had six or seven beds. The doctor said that if I had come three months before, 97WH I would have seen 30 people in the room—seven in the beds and the rest sleeping on corners or the floor. However, the centre had moved to the DOTS programme, which means that patients can be treated at home.
I also learned that people wanting to go to the hospital for testing had to give up a day's pay and find the bus fare to get them there. Despite their low incomes, they had to repeat the whole process to return for the results of the sputum sample and the microscopy that had been undertaken, and they then had to find a friend or family member who was prepared to observe the treatment.
For those able to do all that, the system works, and the hon. Member for Edinburgh, West was right about the benefits of that approach. However, when I went to the slum area, I found that, for many people who could not afford to make the journey to the Bottom hospital, the alternative was a private provider who had set up in that part of Lilongwe. For those who could not afford the cost of seeing the private provider, the alternative was to go to the local kiosk and buy a cough sweet. At the bottom of the chain of "treatment" was the act of buying something simple to deal with the symptoms without treating the TB itself.
That crash-course lesson in the economics of health care choice—or, to be more accurate, in the lack of such choice—for people living in poverty in Lilongwe in Malawi opened my eyes to the scale of the problem and to the practical difficulties that poor people can face in accessing treatment.
§ John BarrettWhen I visited that hospital, I was struck by the optimism there, but I was also aware that the health service workers themselves suffered from TB and HIV. Could the Secretary of State say anything about the impact that we have on these countries when we recruit their staff?
§ Hilary BennThe hon. Gentleman will be aware of the code of practice that the Department of Health has drawn up, which makes it clear that the NHS will not recruit directly from poor countries and further reduce the capacity of their health service staff. Malawi is probably the most pressing example because of TB, but particularly because of HIV/AIDS. It lacks the capacity in many areas to carry on with the job of providing services and running the Government because so many nurses, doctors, police officers, members of the armed forces, teachers and civil servants are dying of AIDS. We need to address that major capacity problem in Malawi.
As we discussed in Select Committee yesterday afternoon, the fundamental problem for health service workers is the push factor that leads people to leave developing countries and take their professional knowledge and skills to earn a better living elsewhere, in much better conditions. Those issues have to be addressed in the long term, if we are going to make a difference. That is why the considerable investment of resources that DFID has put in to support better health services—£1.5 billion since 1997—is the best long-term contribution that we can make to help developing country Governments tackle the problem that the hon. Member for Edinburgh, West has rightly identified.
98WH The World Health Organisation estimates that, between 2002 and 2020, approximately 1 billion people will be newly infected with TB. It says that more than 150 million people will get sick, and that 36 million will die of the disease if we cannot make better progress in tackling the epidemic. In 1993, the organisation declared TB a global emergency. It is an emergency that affects a small number of countries in particular: 22 countries account for 80 per cent. of the global TB burden.
It is a problem that is getting worse. One of the reasons is HIV/AIDS. The hon. Member for Edinburgh, West talked about the interrelationship between HIV/ AIDS and the growth of TB. The other reason—the second point to which he referred—is the growth of multi-drug-resistant TB. That arises either because patients do not complete their treatment programmes or because the drugs themselves are not of a sufficient standard. It is a particular problem in the former Soviet Union, especially among the prisoner population, where infection rates for multi-drug-resistant TB are extremely high.
One challenge that we will have to face together is the cost of treating TB, as it is so expensive. The hon. Gentleman may be interested to know that in the early 1990s the United States spent $1 billion on treating an outbreak of multi-drug-resistant TB in New York. That is a lot of money in the context of the scale of the epidemic that we are talking about. It is important that we should respond.
A certain amount of progress has been made towards the targets for 2005 set by the World Health Assembly for global TB control efforts—to detect 70 per cent. of TB cases and to treat successfully 85 per cent. of detected cases—but much remains to be done if we are to achieve those common goals.
In 2002, an estimated 37 per cent. of new smear-positive cases were notified under the DOTS programme, an increase from 27 per cent. in 2001 and halfway towards the 2005 target. In other words, progress is being made, especially in some high-burden countries such as India, which the hon. Member for Edinburgh, West recently visited. However, even with those encouraging recent trends, we expect the case detection rate to be only 50 per cent. by 2005. In other words, the target will be missed. That is another reason why we must intensify our efforts to deal with the problem.
The Stop TB partnership aims to do precisely that by encouraging social and political action to stop the spread of TB around the world. The independent external evaluation of the partnership that was undertaken in 2003 found that there had been real achievements, including sustaining a broad network of partners that commands support. Under the elements of the DOTS programme, the hon. Member for Edinburgh, West spoke about the importance of political leadership, and he is right. Whether we are talking about TB, HIV/AIDS or the other problems that developing countries face, political leadership above all else is required to find the means and the will to tackle the problem. The partnership also achieved heightened political commitment and support for the global plan to stop TB, and has done work to highlight developments in new diagnostics, drugs and vaccines. It is important that we build on that.
99WH We have seen the development of global partnerships and have put a great deal of effort into supporting them. I have talked about Stop TB, and the Global Fund to Fight AIDS, Tuberculosis and Malaria has also been established. So far, DFID has committed itself to contributing $280 million to the fund up to 2008. About 17 per cent. of the resources disbursed from the fund so far have been in response to proposals to fight TB. We have put in £2 million to support the work of the Stop TB partnership, and to help its co-ordination efforts. That is alongside the other funding that we have put in, but more will undoubtedly be required—a big challenge for the international community. One reason why we are strongly encouraging other donor partners to consider the international finance facility—the proposal made by my right hon. Friend the Chancellor of the Exchequer to give us the potential as a world to double development aid over the next few years—is that this is one issue that requires additional financing to enable real progress to be made.
The action that needs to be taken in order to make a real difference in tackling the scourge of TB is now reasonably clear, but we need to get on and make it happen. We need to increase funding levels and strengthen public health services, because if a village or community does not have such a service, the DOTS programme cannot be administered and drugs cannot be provided to tackle multi-drug-resistant TB. More staff resources are needed: although money is a constraint, the sheer lack of staff is also an issue. Inadequate health facilities are real obstacles to progress, and we need to fund and investigate further new technologies and treatments.
We know, from our experience in London, of the problems of TB control, and we need a concerted international effort, working across borders, if we are to make progress. DFID will remain committed to that goal, but it is above all the responsibility of the international community collectively to ensure that we will the means, the resources and the political commitment to make progress in tackling this terrible disease.
§ Sitting suspended until Two o'clock.