Summary

In April 1998, a special meeting of physicians working on TB is convened at the American Academy of Arts and Sciences, a meeting to present the early results from the MDR treatment project in Peru. They want to show that they have had a more than 85% cure rate for MDR-TB patients. Howard Hiatt moderates the meeting and declares it an astonishing result that the world must hear about.

One of the world's ranking TB experts who attends is Arata Kochi, the head of WHO's TB program. He actually comes to quell the bad publicity Farmer had been stirring up, because he had been laboring for years to sell DOTS to the world. However, he has also come to the conclusion that WHO needs to come up with a solution for drug-resistant TB: one of his staff has coined the phrase DOTS-plus for this new initiative. He knows that they have to respond to clinicians like Paul Farmer who are screaming at them for help. It's time to start a dialogue. As for Farmer and Jim, they love the phrase and are encouraged by Kochi's attitude: if you can't beat them, join them, and then control them!

Kochi has made a dramatic concession, but the discussion is just beginning for other doctors there. One of the first to express his concern is Alex Goldfarb, a microbiologist from Russia who states first off that Russia is a TB nightmare. He is most concerned about the prison inmates who are being treated with a single drug. His nightmare is money. There is not much Farmer can say to alleviate Goldfarb's money worries, but he does indicate they have overcome these problems for a small number of patients and that it's possible to do it on a bigger scale. Goldfarb also has a bigger conundrum: He has only six million dollars from the Russian government, and he can spend a large portion of it on the 10% of patients who have MDR-TB or go to another region and make it available for 5000 who have regular TB. How do you use limited resources? It is a very serious question. He is also angry that men like Kochi are trying to control TB globally, and so have a different set of priorities. He doesn't have time to do a pilot project like Kochi would recommend. Hiatt responds that Kochi is thinking about controlling TB not in a few months, but in decades to come. That is an admirable goal. Of course, Goldfarb has made an argument that they will all have to respond to sooner or later.

Jim speaks to the group the next day, explaining that they had taken resources from PIH in Haiti, feeding 4000 children, in order to try to assure that they would attract the very men and women from the around the world who are sitting in the room at that very moment. They want to expand resources to a problem that afflicts the populations they serve. When one of the members comments that they must find the political will, Jim responds that politics is outside of their focus, because places like Zaire, where the country's president had stolen more than 30% of the loans from the World Bank, need outside help. He opines that shrinking resources are only ever a reality when it has to do with poor people. They need endorsements from academics with clout and the total support of the TB community. He concludes by quoting Margaret Mead who said, Never underestimate the ability of a small group of committed individuals to change the world. Jim then responds to that quote by saying, Indeed, they are only ones who ever have.

Notes

The meeting with physicians from around the world is an important step in drawing attention the TB problem everywhere, but especially to patients who have MRD-TB. The argument of course is an old one: where do you use the resources?