Nigeria still searching for right formula

661Bulletin of the World Health Organization | September 2008, 86 (9) News Groundbreaking approach to disaster relief The humanitarian response to Cyclone Nargis, which struck Myanmar on 2 and 3 May, heralds a fundamentally new approach to relief coordination. As a result, a unique survey showed what really happened to the survivors. Sarah Cumberland reports. W HO (M ya nm ar ) WHO staff demonstrate water sanitation techniques to the voluntary and community health workers following Cyclone Nargis. The provision of safe drinking water is a high priority immediately following natural disasters. Dr Rudi Coninx had just finished train- ing on coordinating emergency relief efforts when he was summoned by WHO Director-General Dr Margaret Chan to join her at a teleconference. A devastating cyclone had just struck Myanmar. More than two million people were believed to be affected across the Ayeyarwady delta and Yangon regions. “I was the only one from WHO headquarters in Geneva who could go because I happened to have a current visa,” says Coninx, who was despatched to Myanmar the following day to coordinate health relief in the stricken region. “Technical and administrative units in the south-east Asia office of WHO worked almost round the clock, drawing experience from the tsunami,” says Dr Poonam Khetrapal Singh, deputy regional director for WHO Regional Office for South–East Asia (SEARO). Meanwhile, staff from the World Health Organization (WHO) Country Office in Myanmar were already put- ting a new system into action with other United Nations (UN) agencies and nongovernmental organizations (NGOs) that were present. First, WHO convened the agencies provid- ing health relief – known as the “health cluster” – to assess the situation and decide which health interventions were needed to prevent death and disease. The “cluster” approach – the idea that a group of relevant UN agencies and others coordinate specific areas in an emergency response – is the result of recent UN reforms. “The tsunami of 2004 made clear the need for a coordinated approach that is predict- able, accountable to donors and doesn’t duplicate the efforts of different orga- nizations,” says Coninx. WHO co-chaired the Myanmar health cluster with United Kingdom- based charity Merlin. “This relationship was extremely beneficial as it allowed for the sharing of staff, technical and strategic expertise and the administra- tive burden,” says Yves-Kim Creac’h, head of Merlin’s Emergency Response Team. I was the only one from WHO headquarters in Geneva who could go because I happened to have a current visa. Dr Rudi Coninx Unlike previous humanitarian re- sponses by multiple agencies, the cluster approach meant that all UN agencies and partners, such as Save the Children and World Vision, worked together to share information and resources with agreed common goals. “When I visited Aceh after the tsunami, there were about 300 NGOs but coordination was an issue,” says Poonam Singh. “A lot of supplies were delivered that weren’t needed and there was a huge logistics overlap. This time there was a platform to bring everyone together as a combined effort.” Coninx adds: “In Myanmar, when an aeroplane landed with medical supplies, we could make it known among the [members of the health] cluster what was available and allocate resources to underserved areas.” As the extent of the disaster and the health needs of the people in the stricken region became clear, the collaborative effort gathered momentum. Each week more organizations joined the cluster voluntarily, until more than 40 partners were meeting twice a week to pursue a single plan of action. When responding to disasters, it is vital to have reliable information on the health needs of the survivors. “The first thing that needs to be done to provide relief is to find out what is really happening,” says Coninx. As with many disasters, an early warn- ing system for epidemics was needed in Myanmar. This involved a daily News 662 Bulletin of the World Health Organization | September 2008, 86 (9) exchange of information between these agencies to compare reports of outbreaks and verify those reports. For example, they confirmed that there was no cholera epidemic, but that the number of cases was only slightly higher than it was before the disaster. Poonam Singh who visited Myan- mar after the cyclone says that, despite negative media reports, the govern- ment was actually doing quite a lot to meet the health needs of the people. “Because of WHO’s long relationship with the Ministry of Health, we were looked upon a little differently by the government. Right from the beginning, the WHO representative to Myanmar [Professor Adik Wibowo] met every morning with the health ministry and we managed to get around the visa restrictions by recruiting locals, includ- ing retired WHO staff.” Having just established its first health emergency fund through the contribution of US$ 1 million by its 11 Member States, SEARO was able to release US$ 350 000 to buy essential supplies such as health kits, mosquito nets and chlorination tablets. However, a larger relief operation was still being hampered because the government would not provide visas for additional relief workers and was imposing strict control over access to information on the incidence of diseases and suspected outbreaks. Dr Nihal Singh, from the WHO office in Myanmar, said that this was perhaps because the Ministry of Health was not clear on the “concept” UN P ho to /E va n Sc hn ei de r United Nations Secretary-General Ban Ki-moon (in white jacket) speaks with survivors of Cyclone Nargis at a camp of internally displaced persons in the township of Bebaye, Myanmar. of the health cluster and did not feel comfortable working directly with the UN agencies and NGOs. We’ve never had an emergency situation where we’ve gathered such good data. Dr Richard Garfield Then, Dr Surin Pitsuwan, Secretary-General of the Association of Southeast Asian Nations (ASEAN), stepped in. After negotiating with government officials, the turning point came on 21 May – three weeks after the cyclone struck – when the government agreed to accept inter- national assistance and to collaborate with ASEAN and the UN in a unified approach. “We had to be careful not to politicize the situation,” said Dr Anish Kumar Roy, special representative of the ASEAN Secretary-General. Senior officials from the country’s Ministry of Health began to partici- pate in health cluster meetings, sharing data and providing assistance, and the government allowed open access to the entire stricken area to do a survey to assess health needs. The unique political situation and the lack of existing data meant that donors demanded even more informa- tion and accountability than usual, resulting in what has been considered the most comprehensive survey ever conducted after a disaster. In just one month, a surveillance team of 225 people, including 50 volunteers, travelled across the affected area to interview about 3000 house- holds and conduct 1000 specialized interviews with village leaders, house- wives, farmers and health workers. The survey used a grid to select a sample of almost 300 villages from a total of 6000 so that it was a truly representa- tive assessment. Due to flooding many villages were cut off and had to be reached by helicopter or boat. “We’ve never had an emergency situation where we’ve gathered such good data,” says Dr Richard Garfield, UN P ho to /E va n Sc hn ei de r A United Nations High Commissioner for Refugees (UNHCR) aid worker distributes blankets to the survivors displaced by Cyclone Nargis in Yangon, Myanmar. News 663Bulletin of the World Health Organization | September 2008, 86 (9) Fact file: Cyclone Nargis Dead: 84 537 Missing: 53 836 Medical supplies dispatched by WHO and health cluster partners: more than 500 metric tonnes, including: • 33 000 insecticide-treated bed nets • 500 dengue fever disease kits to detect and confirm cases • 30 000 surgical masks and gloves Funds supplied immediately: • US$ 350 000 from SEARO’s new emergency health fund • US$ 50 000 from WHO headquarters Total needed to rebuild health facilities (75% of which were damaged or destroyed): US$ 2 billion from WHO’s Health and Nutrition Tracking Service, who managed the surveillance team. “We had one guy who came in off the street as a volun- teer and he turned out to be one of our best people. You really see what some people are capable of in an emergency.” Garfield says that surveys held after previous disasters have mainly mea- sured aid provided. How many people received goods? How many villages were visited? For the first time, Garfield says, this survey asked questions to compare conditions before and after the cyclone. What kind of sanitation was in use? How far did people have to travel to seek health care? What kind of health problems did they have? Some results were surprising, with most common health problems being diarrhoea and the common cold rather than the trauma and injuries that had been predicted. “We were expecting dramatic injuries but there were far fewer deep wounds caused by the cyclone than the Asian tsunami, where waves had a much greater force. A further surprising result was that the greatest health need was psychological support,” says Garfield. The survey revealed that twice as many women as men died during the cyclone, many falling into the flood waters since they were unable to clutch on to the trees for as long as the men. Other women died trying to save their children. The data are being used to closely monitor recovery and reconstruction in Myanmar and will assist future relief efforts. “We don’t usually have the information that permits us to answer questions such as: What difference did we make? How well did people recover? With this survey, we will be able to know when people get back to normal.” Work is already under way to de- velop this survey as a model for future relief efforts and to prepare a bank of potential questions for different kinds of disasters. Dr Eric Laroche, assistant director-general for the Health Action in Crises cluster at WHO, wants the Organization to strengthen its opera- tional role in relief efforts by taking the lead on the ground, as it did in Myanmar. “Some people say that WHO shouldn’t be focusing on operational work,” he says. “But that would be de- nying our historical role. WHO will be remembered for eradicating smallpox and for our anti-tobacco campaign, both of which assumed very much operational roles.” ■ Nigeria still searching for right formula Despite several attempts at reform over the past 30 years, Nigeria still lacks a clear and coordinated approach to primary health care. Michael Reid reports. In 1990, Michael Asuzu held high hopes for the development in Nigeria of a primary health care (PHC) system based on community participation, using well-trained, well-equipped and motivated community health profes- sionals. Writing in the March 1990 issue of World health magazine, Asuzu, at the time a lecturer and consultant in the Department of Preventive and Social Medicine at the University College Hospital in Ibadan, enthused about a “bottom-up” grassroots PHC project in the hamlet of Elesu, 32 kilometres north of Ibadan. Members of Asuzu’s university department had helped vil- lagers develop a programme to control outbreaks of waterborne guinea-worm disease and adopt other PHC measures. “We expect to be able to replicate this programme in any local commu- nity ready to take charge of its needs for PHC as the Elesu community has,” he said. “This case history shows that, when community health development work- ers are available and willing to go out and assist communities, it is possible for them to come forward to request and be helped to provide community- owned and self-reliant PHC pro- grammes for themselves.” Fast forward 18 years and Asuzu, now professor of Public Health and Community Medicine at the University of Ibadan, is less ebullient when discuss- ing PHC in his country. Addressing the Nigerian Academy of Science Seminar in Abuja in May this year, Asuzu said: “Nigeria has never succeeded in establishing community medical and health services for very many reasons … some limited levels [have] been practised in Nigeria, even during the colonial days, but never fully.” In June, Asuzu told the Nigerian Medical Students Association that Nigeria had in the mid-1980s joined the international push for PHC after the 1978 Alma-Ata Declaration of ‘health for all’. “Some progress seemed to have been made with the health services between then and the mid-1990s,” he said. “However, the health indices have been deteriorating since then [judging] by every health system evaluation [car- ried out] in the country. Unfortunately, Nigeria has never learnt or developed any system of authentic and full-scale community health care before Alma-Ata or after it. This explains why we have not made any success of the system.” The world health report 2000 ranked Nigeria 187 out of 191 coun- tries for health service performance, a News 664 Bulletin of the World Health Organization | September 2008, 86 (9) W HO /D A be gu nd e WHO health economist Dele Abegunde (second from right) visits members of a Village Health Committee in the Delta State of Nigeria in 1996. situation that has not changed much since then, according to Asuzu, who cites several statistics to highlight the inadequacies in Nigeria’s PHC system. Annual budget allocations to health have been persistently below 5% except for the years 1998–1999 and 2002–2003 when they were at or just above this level. Infant mortality rates have been deteriorating from 85 per 1000 live births in 1982, 87 in 1990, 93 in 1991 to 100 in 2003, according to the Nigeria Demographic and Health Survey, 2003. And in 2007, the Federal Ministry of Health reported 110 deaths per 1000 live births. Maternal mortality ratios are esti- mated at 1100 per 100 000 live births in WHO's World health statistics 2008. Asuzu identifies five attempts at reform over the past 70 years: 1940s. The Nigerian Colonial • Development Plan had a limited framework for a unitary health service. 1950s. Regional governments ran • independent and sometimes paral- lel health systems to the federal government. 1960s. The Second National • Development Plan in the post- independence era did not articulate a system with clear responsibilities for each level of government. 1970s. The ambitious Third • National Development Plan had the Basic Health Services Scheme as its focus, but again failed to share responsibilities between the governments for resource gen- eration, manpower development, health professional deployment and service delivery. 1980s. Following the Declaration • of Alma-Ata, there were serious attempts at health system reform, based on the principles of PHC resulting in the National Health Policy in 1988. However, the policy failed to create a unified system of care or address finance and staffing for competent local leadership. What are the reasons for Nigeria’s failure to develop a successful PHC model? Asuzu says some are rooted in the country’s colonial past, while others stem from a lack of political will and poor policy-making that failed to divide responsibilities effectively between federal, state and local government and resulted in PHC services lacking staff and funds. Others say it was also mistaken to treat PHC as “the first level of care” since it was conceived as universal access to all types of care. “As a result, the potential of hospitals, for example, was not well leveraged,” says Nosa Orobaton, a Nigerian doctor who worked to implement primary health care in the 1980s. Future implementation of primary health care in Nigeria will have to address the considerably more decentralized political system, a much more dominant private sector, increasing demand for a reliable health information system and expanded roles for non-health sectors. Nosa Orobaton Another mistake was to focus on the health sector at the expense of other sectors, such as work, housing, agricul- ture and transport. “Future implemen- tation of primary health care in Nigeria will have to address the considerably more decentralized political system, a much more dominant private sector, increasing demand for a reliable health information system and expanded roles for non-health sectors,” says Orobaton, now a manager with the WHO-hosted partnership, Health Metrics Network. Dele Abegunde, a Nigerian health economist working with WHO’s Department of Chronic Diseases and Health Promotion, also refers to the misguided attempts to develop PHC in Nigeria. “Health care instituted by the colonialists was organized primarily to meet the needs of the colonialists. After independence, the new government naturally adopted the colonialist health system primarily responding to the needs of the post-colonial elites.” “But there was no understanding of health care the way we understand it now. What the early policy-makers understood as health was hospitals somewhere – grand, big elephants – 50- to 100-bed hospitals. But the beds were empty because services were not designed to respond adequately to the needs of the people. The impact of that in the 1960s was that life expectancy did not improve and diseases were prevalent because secondary-care hos- pitals really didn’t do much to prevent diseases. They cared for the people once they had them,” Abegunde says. Early developments in PHC post-Alma Ata were encouraging, said Abegunde, a medical student during that period, between 1979 and 1984. “For the first time, rural communities News 665Bulletin of the World Health Organization | September 2008, 86 (9) began to see that, well, we may not have 50-bed hospitals but we have a clinic where we can go to if we have a headache or a cough or a snakebite. Health needs of the larger rural popula- tion were gradually being met, and after a while people began to see the results, particularly in immunization programmes, diarrhoea in children, malaria treatment and acute respiratory infections.” There was no understanding of health care the way we understand it now. Dele Abegunde But early advances often lost momentum, Abegunde said, because communities were not encouraged to take control of PHC schemes them- selves. “Initially, they did not put a lot of emphasis on community participa- tion and ownership,” he said, adding that later on many doctors and nurses left the rural areas for better paid jobs in the cities. Abegunde says policy-makers and administrators should note the success of the PHC scheme in Elesu. After initial reluctance to adopt the monofila- ment water filtration system to control guinea-worm promoted by Asuzu’s team, the villagers embraced it once they had seen how it worked. “The success in Elesu came from people’s own experience, being able to see it and say, ‘wow this works, we did it!’ In future, primary health care plan- ners should adopt this recipe as it has the potency to provide ownership and sustainability.” Asuzu, too, remains optimistic that reforms of the health system and legislation governing that can deliver a sustainable PHC system. ■ The Bulletin at 60: from scientific organ to public health journal The journal’s shift of focus from science to public health has been a 60-year journey, with twists and turns along the way, writes Brigit Ramsingh in this second instalment of a three-part series on the history of the Bulletin. The Bulletin of the World Health Organization is recognized as one of the world’s pre-eminent public health journals, having maintained its role as the organization’s “principal scientific organ”. This dual focus has not sprung up overnight but has been the result of an evolutionary process over its 60-year history. Several changes to both its content and format and, crucially, the publication of several landmark articles have helped forge the journal’s unique identity. When it was launched in 1948, as a deliberate continuation of the earlier Bulletin of the League of Nations Health Organization, the Bulletin was expected to have an important influ- ence on medical opinion in the widest sense, and especially on the opinions of those responsible for formulating and guiding medical theory and practice: that is, medical scientists and teachers, and public health administrators. The first few issues of the Bulletin were distributed free to national health and research institutes, medical schools and faculty libraries, often in exchange for medical journals. Subscriptions were soon offered; in June 1948, there were almost 600 paid subscribers, though few were private individuals. The work of WHO’s Expert Advisory Committees – external international experts invited to advise WHO on specific subjects – was the main “inspiration” for much of the Bulletin’s early content. The journal’s main function at that time was also to publish studies relevant to the Expert Committees’ work and to cover subjects for which there were experts within the WHO secretariat. The Executive Board believed the Bulletin should publish articles on the following six categories: laboratory studies on topics such as • biological standardization and com- municable diseases, one of the main objectives being to encourage the use of uniform methods to obtain comparable results; internationally significant studies of • results achieved by specific disease control methods; studies of the geographical distribu-• tion of diseases; reports of surveys, especially those • involving studies of relevant world literature and visits to countries; reports of original findings made • in the course of field programmes; and review articles based primarily on • surveys of literature summarizing the present state of knowledge in different fields W HO /D H en rio ud Dr Michael Asuzu talking to the Village Health Committee (VHC) in the hamlet of Elesu, Nigeria, in the 1980s. The VHC and its village health workers (VHWs) became crucial in administering primary health care, including the prevention of guinea worm disease. News 666 Bulletin of the World Health Organization | September 2008, 86 (9) By October 1958, the Bulletin was mainly publishing articles on com- municable diseases, especially malaria and tuberculosis. By this time, entire issues of the Bulletin dedicated to a specific topic had started to appear, ranging from plague control (1953) and environmental sanitation (1954) to occupational health (1955) and the serology of syphilis (1956). In 1963, the Bulletin started to publish supplements to the regular volumes, covering topics of interest to the public health community – often with a more public health than scien- tific focus. One of the first was devoted to meningitis in Africa. This balance between science and its application for public health purposes would continue to characterize the journal for decades to come. By the end of the 1950s, the Bulle- tin had established a clear international character. A report delivered to the 25th session of the WHO Executive Board in 1959 noted that 67% of articles published since the journal’s inception qualified as “international or unrelated to a geographical area”. The Bulletin’s format was also evolv- ing along with the content. In 1950, a bibliographical section (containing references relevant to the international sanitary conventions) was included and the Executive Board authorized the publication of a single edition con- taining articles in French or English, with summaries in both these working languages. In 1959, the format and the cover were redesigned, with a larger page size and smaller print with a double-column layout, facilitating the inclusion of more tables, graphs, maps and other illustrative material. Intro- ductions, describing the specific topic being dealt with in a particular issue, were added. By the start of 1960, 21 volumes of the Bulletin, comprising 20 000 pages, had been published. Within its first decade, the Bulletin had carved an identity as a reliable source of medical and scientific infor- mation, but with little public health content. Barbara Campanini, a former staff member of the Bulletin, said: “It is interesting that the present Bulletin’s orientation is towards public health as the idea of an international journal of public health published by WHO was discussed in the first few years.” As early as 1953, editors and sen- ior managers discussed whether it was necessary to establish a public health quarterly, in addition to the scientific organ of WHO, the Bulletin. One senior manager Dr Chu pro- posed including discussion articles on public health issues in the Bulletin. But the editor of the Bulletin at the time, Dr Norman Howard-Jones, rejected proposals to establish a separate public health journal or to include discussion on the subject in the Bulletin. “A quarterly journal of public health would not fully serve its purpose if it were not as much a journal for discussion as for the description of cur- rent health administration structures,” Howard-Jones continued, “the Bulletin is very largely a journal for the report- ing of scientifically verifiable results, and these two different types of mate- rial would not mix well.” Over the years the Bulletin has published many landmark papers. For example, in 1956, it issued a paper entitled: La lutte contre le paludisme en Afrique tropicale by Médicin-Colonel PM Bernard, which identified prob- lems with the WHO global malarial eradication campaign. By highlighting such problems, the article demon- strated how the Bulletin could serve as a forum of discussion that included views that were not necessarily those of the Organization on matters of public health importance. In 1966, another landmark paper on tuberculosis treatment was pub- lished, based on a series of studies at the Tuberculosis Chemotherapy Centre in Madras, India. Authored by Kamat et al., this study was seminal in bringing about the shift from sanatorium care of tuberculosis to a more ambulatory form of treatment in that country. In 1975, an overview study by Foege, Miller and Henderson reported that smallpox had been eradicated in west and central Africa, thanks to the surveillance-containment strategy they had tested in Nigeria in 1966. This paper provided the first convincing evidence that surveillance-containment was essential to eradicating smallpox across the world. It had a catalytic effect on eradication activities and led to the 1980 declaration at the World Health Assembly that smallpox had finally been eradicated globally. By 1978, the Bulletin had intro- duced features such as the Update (Le Point), where external experts were invited to provide concise surveys of biomedical science and public health topics. These updates appeared along- side the ‘WHO scientific activities’ section and other regular items such as news and memoranda from WHO meetings. By 1989, the Bulletin had added the ‘Scientific Journal of the WHO’ to its title, echoing once again the aims of the Interim Commission that originally established the journal in the 1940s. In 1999, however, the subtitle would change once more as the Bulletin underwent yet another major transfor- mation. The third and final instalment of the history of the Bulletin will detail the major changes to the journal insti- gated under former Director-General Gro Harlem Bruntland. The first instalment in this series was published in January 2008. Avail- able at: http://www.who.int/bulletin/ volumes/86/history/en/index.html ■ W HO /J M oh r Dr N Howard-Jones, Director of the division of editorial and reference services, WHO. News 667Bulletin of the World Health Organization | September 2008, 86 (9) Tuberculosis: in it for the long haul Professor Brigitte Gicquel is head of the Mycobacterial Genetics unit at the Pasteur Institute in Paris, France. After completing her undergraduate and doctoral studies at the University of Paris VII, she joined the Pasteur Institute in 1973 and has spent much of her scientific career concentrating on the genetics of Mycobacterium tuberculosis. Gicquel coordinated both the European Commission's efforts to find a vaccine more efficient than bacille Calmette-Guérin (BCG) for tuberculosis and its TB Ethics project. She was editor-in-chief of the scientific journal Tuberculosis. In 2004 she was made a Chevalier of the Légion d’Honneur, France's highest order, and on World Tuberculosis Day in 2008 she was awarded the Georges, Jacques et Elias Canetti Prize for her research. Co ur te sy o f B rig itt e Gi cq ue l Prof. Brigitte Gicquel Tuberculosis is a disease that has come full circle. In the 1950s, as our cover poster shows, a treatment revolution prematurely downgraded its public health importance. The Bulletin spoke to Brigitte Gicquel about why there has since been a global resurgence and increased drug resistance and what the future holds for the control of the disease. Q: The Pasteur Institute is 120 years old this year. How much does its history inspire and affect what you do today? A: Many important historical findings are relevant to my work. Louis Pasteur’s original discovery that diseases and mi- crobes don’t just appear spontaneously allowed the whole field of infectious diseases to develop. Since then, we have seen the development of molecular biology, work on gene expression and studies on the enzymatic properties of proteins. When I began working at the Pasteur Institute in 1973, the two worlds of infectious disease and mo- lecular biology were quite separate. In 1986, I decided to bring the work I’d been doing on DNA–protein interac- tions to research a disease that wasn’t very well studied – tuberculosis. We started a small group in the unit that was headed by Julian Davies and, in 1994, that became the Mycobacterial Genetics Unit. Q: How is scientific progress linked to public health goals? What does your own research concentrate on today? A: You can look at that from several different viewpoints, depending on the science in question. The development of new drugs against tuberculosis, particularly ones that could shorten the current 6-month treatment regimen, could allow us to be more ambitious with our treatment targets – possibly even aiming to treat 100% of patients. Tied into that, advances in tuber- culosis diagnosis over the past 20 years not only help us to diagnose cases more quickly but can also give us drug susceptibility tests. These allow health workers to target specific antibiotics against particular strains of tuberculosis which are resistant to different drugs. Our own laboratory is working on molecular probes that can identify the particular tuberculosis bacillus causing an infection. That lets you work out how contagious a patient is and which drugs might be useful for treatment. The probes are increasingly being used in countries that were until recently only using microscopy to diagnose tuberculosis. We’re also working in collaboration with Carlos Martin’s team in Zaragoza, Spain, to develop a new vaccine to replace BCG (which was also devel- oped at the Pasteur Institute). The new vaccine is safer than BCG and tests in animals have also shown it to be more effective. Lastly, molecular epidemiology has allowed us to identify the genetic markers that separate different strains of tuberculosis. With that, we can track specific outbreaks of tuberculosis – particularly drug-resistant forms – and actively track down infected individuals and offer them free, supervised treat- ment. That approach has already been used in New York and other major cities. Q: The Pasteur Institute is one of the world’s foremost medical institutions. Can you tell us about your centres across developing countries, and are they all francophone? A: Institutes belonging to the Pasteur Institute’s international network focus on the public health problems of their own countries. To do that, it’s very important for their laboratories to be in constant contact with scientists in industrialized countries. The scientists can, in turn, exchange information with front-line health-care workers and find out about the real problems in the field and how the tools are be- ing used. It used to be a French-speaking network because of the link with former French colonies. Now there are Pasteur Institutes in countries, such as Cambo- dia, China, the Republic of Korea and Uruguay, which communicate with each other in several languages, not just French. Q: In France there has been a lot of discussion over the dominance of English as the language of science. Should more scientific writing and studies be in the French language? A: In science, English happens to be the primary language. If we try to promote French, to the detriment of English, you may prevent people having access to the latest information and findings. The most important thing is to com- municate, regardless of the language. Q: An estimated two million people die of tuberculosis every year, particularly people with HIV/AIDS. Given that, why is it difficult to attract interest in research in an area such as tuberculosis, even though it causes a large burden of disease across the world? A: First of all, Mycobacterium tuberculo- sis is difficult to work with. The bacillus grows very slowly. If you’re a geneticist News 668 Bulletin of the World Health Organization | September 2008, 86 (9) working with the mycobacterium, it can take up to two years to complete an experiment. That’s compared to just three weeks for a disease such as cholera. So when it comes to publish- ing, you have to submit studies in small pieces, which isn’t very attractive to prestigious journals – so the research isn’t attractive for ambitious young scientists. The costs are also higher; not just because of the time taken, but the containment environments need to be quite stringent to prevent any accidental outbreaks of the disease. Because there’s less financial return, industry makes less of an investment in the first place. Q: Mycobacterium tuberculosis is becom- ing resistant to more and more drugs, cheap diagnosis leaves much to be desired, and the BCG vaccine has varying efficacy and is 80 years old. Why has it taken so long for control measures to be updated, and where do we go from here? A: After the Second World War, antibiotics had just been developed and people thought they could solve any problem and kill any microbe. For many bacteria, it was true. But after we had the antibiotics revolution, we had the revolution in microbial resistance to antibiotics. In recent years, scientists have come up with new research look- ing at the genetics of M. tuberculosis, but we’ve lost 20 years of research time because of the [over] confidence we had in antibiotics. Increased drug resistance has meant that scientists and public health officials cannot act indepen- dently. We are hampered by the political and socioeconomic situation. Many people in need of improved tuberculosis control are in countries that lack political stability, resources and infrastructure. When the political system and infrastructure collapsed in the former Soviet Union, for instance, a new political system appeared but there was no new health system. That led to patchy drug distribution and patients not having the supplies to finish their treatment, which again led to drug resistance. Q: WHO declared tuberculosis a global emergency 15 years ago in 1993. Has progress been made since then in terms of tuberculosis control or are things getting worse? A: The situation has been improving since 2003. After an initial increase in cases, we’ve now reached stabilization and even a small decline. It’s not good, but it could be worse. There have been major break- throughs and more money is appear- ing, but a lot of it is going into specific tuberculosis research. Many scientific advances come from outside the field. For instance, the discovery of restriction enzymes, which cut DNA into small pieces, was made by Werner Arber and colleagues who were looking at the im- mune systems of bacteria but the work ended up having a big biotech impact. We need more basic research to acquire knowledge on the TB bacillus and its interactions with its host – if we only put the money into research specifical- ly for precise goals like new antibiotics, vaccines or diagnostics, much of it will just be wasted. ■ Recent news from WHO • WHO joined the World Alliance for Breastfeeding action to celebrate World Breastfeeding Week, 1–7 August. Breastfeeding ranks among the most effective interventions for improving child survival and health, but less than 4 in 10 infants under the age of 6 months are exclusively breastfed. WHO has developed, together with the United Nations Children’s Fund (UNICEF), a range of infant and young child- feeding counselling courses and job aids for use by health-care workers and lay counsellors. • Severe flooding in Moldova, Romania and Ukraine since 23 July has caused the loss of 42 lives and the evacuation of 40 000 people, as of 1 August. WHO has been supporting the local ministries of health with investigations and technical assistance. As well as the immediate drowning-related deaths, the main health concerns include contamination of water by toxic chemicals and disruption of health infrastructures and supplies of water and food. • An extra US$ 50m to help prevent mother-to-child transmission of HIV was announced at the global conference on HIV and AIDS in Mexico City by WHO, UNICEF and UNITAID on 31 July. The money will be targeted to the Central African Republic, China, Haiti, Lesotho, Myanmar, Nigeria, Swaziland, Uganda and Zimbabwe. • Also in Mexico, new guidelines were announced on 4 August to help stop the spread of TB among HIV positive drug users, focusing on the use of antiretrovirals and isoniazid, which slow the development of AIDS and reduce the risk of TB, respectively. The guidelines are available at: http://whqlibdoc.who.int/publications/2008/9789241596930_eng.pdf • WHO has welcomed the announcement of the Bill and Melinda Gates Foundation and Bloomberg Philanthropies to put US$ 375 million into the global fight against tobacco use. This contribution will help countries with limited resources to reduce tobacco use through such measures as “quit smoking” programmes. • A new report on the progress of improving access to drinking water and sanitation has been published by WHO and UNICEF’s Joint Monitoring Programme for Water Supply and Sanitation. According to the report, 2.5 billion people suffer from a lack of access to adequate sanitation and nearly 1.2 billion practise open defecation, the riskiest sanitary practice of all. The report is available at: http://www.who.int/entity/water_sanitation_health/monitoring/jmp2008.pdf For more about these and other WHO news items please see: http://www.who.int/mediacentre