Where did you grow up?
I grew up in Brazil, in Rio de Janeiro mainly. When I was young my family moved around all over the country. I must have moved 29 times in my life! I graduated as a physician in Rio. I was a medical doctor for 29 years, specialising in public health and epidemiology.
How did you come to work in global health?
I treated patients just for two years in the Amazon region. After a postgrad in Rio, I moved to epidemiology and public health. I like big challenges and I like thinking about how to run health programmes. It’s my personal preference, rather than treating patients. Medicine is a nice profession because you can feel useful to an individual, a community, a city or a country. I prefer work with programmes where you can make a difference for many people at the same time.
When did you become interested in tuberculosis?
I started out working with HIV /AIDS as programme manager for Rio, and led the epidemiology unit for the national level AIDS programme in Brazil. Then in 2007 I became head of the TB unit. So the connection was HIV co-infection.
Brazil has a concentrated HIV epidemic – you find the virus in in men who have sex with men, sex workers and those who use injectable drugs. This makes it easier to target the programmes, but HIV always comes with stigma. Sex and drugs are not always easy topics for people to talk about. For TB it’s a different type of stigma. It’s much more about transmissible diseases – people avoiding TB patients for fear of infection.
What were the main challenges for TB programmes in Brazil?
Administrative fragmentation was really bad in Brazil. People didn’t talk to each other – that was a big challenge. I believe it was my main legacy in the TB programme in Brazil was that I could work with everybody. I created a steering committee with people from all sectors: academics, civil society, patients, nurse and medical societies.
Probably the main problem for TB in Brazil is lack of information – not only the population, but also health professionals. Some 50% of the population doesn’t know that TB still exists – they see it as a disease of the past. Among health professionals, 50 % don’t know the symptoms or how to treat it. And then there’s the stigma – doctors often tell patients that they have some other disease, such as pneumonia, to protect them from stigma.
Tuberculosis has been around for thousands of years. Why is it still with us?
One main challenge is that it’s an airborne transmissible disease: just by breathing you can catch the bacterium and develop the sickness.
The other main issue is that it’s disease related to poverty, so it is neglected by industry, wider society, and health systems. TB changed a lot in the 90s after AIDS came along; now TB became an opportunistic disease. So AIDS contributed in that sense to fighting TB – though the numbers of cases increased, it was no longer neglected.
TB is also a problem for vulnerable populations. Brazil has the worst TB figures for prisons, where people are stacked like animals in terrible conditions. Homeless people, indigenous people and those living with HIV are also vulnerable.
What is UNITAID doing to alleviate the burden of tuberculosis around the world?
UNITAID’s role is to promote access to diagnostics and treatment for those suffering from TB and other diseases.
The test for TB stayed the same from the 19th century right up to 2012. Now we have new diagnostic tools, and the first new TB drugs since WW2 have just come out. But it’s still not enough. You may have the best treatment and diagnostics, but if you do not promote access to the people in need you will not eliminate TB.
The theme for World TB Day this year is “Unite to end TB”. Do you think tuberculosis can be eradicated?
It’s important to say that we are not talking about complete eradication. No country eradicates TB – even the richest. We are talking about eliminating the disease as a public health issue. That means fewer than 10 cases per 100,000 people. This is already a reality in 30 countries. My country has 33 cases per 100,000. So it’s well on the way. Many countries could achieve this before 2035 and they will.
But for the whole world to achieve the target, we need new tools. We need a vaccine. We need shorter treatments and diagnostics that are easy to use.
What remains to be done?
Defeating tuberculosis is not only a matter of diagnostics and treatment but also of alleviating poverty.
At the World Health Assembly in 2014 we fought for three pillars: Diagnostics and Treatment, but also Social protection and Research. We need to advance in all three pillars, and I believe we will.
TB patients should not be charged for treatment – they are already penalized by the social conditions that gave them the disease. So it’s unfair to make them pay for medicines or diagnostics. This is clearly expressed in the new End TB strategy. It’s a pool of actions we need at the same time.
I am optimistic about ending TB. My career has been a very rich experience. I have had the opportunity to run programmes at municipal, state, and national level in Brazil, and now – at UNITAID – I get to think globally.
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