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From The Lancet, Volume 376, Issue 9749, Pages 1283 – 1284, 16 October 2010

Salmaan Keshavjee,a,b,c Francoise Girard,d Mark Harrington,e Paul E Farmera,b,c

Tuberculosis—a curable infectious disease—continues to cause illness in more than 9 million people annually. In the past 20 years, the global response to tuberculosis has had moments of vigour. Millions have received treatment for drug-susceptible tuberculosis, treatment of drug-resistant tuberculosis has been integrated into official tuberculosis-control policies worldwide, and there have been major breakthroughs in rapid molecular diagnostics. Nevertheless, almost 2 million people die annually from tuberculosis—most in the prime of their lives—half a million of whom have HIV co-infection, and more than 150 000 have multidrug-resistant tuberculosis or extensively drug-resistant tuberculosis.1

The Stop TB Partnership—a network of international organisations, countries, tuberculosis technical agencies, and donors—was convened in 2001 with the goal of eliminating tuberculosis as a public-health problem. Its mission is: to ensure that every patient with tuberculosis has access to effective diagnosis, treatment, and cure; to stop tuberculosis transmission; to reduce inequities in the social and economic burden of tuberculosis; and to develop and implement new preventive, diagnostic, and therapeutic tools and strategies to stop tuberculosis.2 Although the Partnership has had important successes since its formation, it has not adequately addressed scale-up of treatment for multidrug-resistant tuberculosis or for tuberculosis-HIV co-infection.3, 4 The Stop TB Partnership will soon have a new Executive Secretary. As we look to the second decade of this alliance and, more importantly, to the future of tuberculosis control, a new leader will have to address three important challenges.

First, tuberculosis control and elimination need to be more closely aligned with the general economic development of afflicted communities. The natural history of tuberculosis clearly shows that to achieve tuberculosis elimination there needs to be some degree of poverty alleviation.5—7 This requirement means that the Partnership will need to work closely with organisations whose efforts address poverty, and hence the social antecedents to tuberculosis. It also means that innovative thinking should be encouraged about how approaches to poverty reduction—such as conditional cash transfers in Brazil—can be used to reduce tuberculosis risk and to help patients complete treatment.8 These approaches must occur in parallel with efforts to tackle social exclusion, discrimination, and detention (situations that are often ameliorated by community-based approaches to care), and to ensure universal access to treatment for patients with tuberculosis in all of its forms.

Second, treatment of tuberculosis must be much better integrated with the treatment of comorbidities such as HIV, diabetes, viral hepatitis, alcohol and substance abuse, and with the reduction of cigarette smoking. This integration means moving beyond the silo that tuberculosis occupies as a vertical programme in ministries of health and globally.9 Such an effort will need leadership and building of new partnerships with those working on other diseases.

Third, and closely linked with point two, is the need to set goals that will inspire new partners to push for tuberculosis elimination. The world is on the path to meet the Millennium Development Goals (MDGs) for tuberculosis.10 In view of the large number of people who still die from the disease, especially in Europe, Africa, and Asia, now is the time for the Partnership to state more ambitious goals for the tuberculosis community. These goals should be linked to the MDGs for maternal and child health in a way that will both advance common aims and build important synergies.

To face these challenges, WHO’s Director-General and the Stop TB Partnership Coordinating Board should focus on certain qualities when recruiting the new Executive Secretary. The ideal person will have a strong track record in working with multiple international partners and across multiple sectors, public and private; this includes working closely with the Global Fund to Fight AIDS, Tuberculosis and Malaria, which currently provides two-thirds of all international funding for tuberculosis. In addition to a commitment to human rights, the new recruit should have the intellect, ability, and stature to form novel partnerships that can fully engage in a more aggressive development-oriented tuberculosis-elimination strategy. While possessing high levels of public-health and public-policy experience, the Executive Secretary must also be capable of making powerful arguments to funders for the benefits of a broader, more uncompromising agenda in response to a long-standing epidemic. Here is an opportunity to reinvigorate the struggle against tuberculosis by recruiting new talent and energy from outside the traditional world of global tuberculosis control. Recruiting such a person will show serious commitment to a bold new vision. This opportunity should not be missed.

We declare that we have no conflicts of interest.


1 WHO. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response. (accessed Oct 7, 2010).

2 Stop TB Partnership. Basic framework for the partnership to stop TB. (accessed Oct 1, 2010).

3 Wells CD, Cegielski JP, Nelson LJ, et al. HIV infection and multidrug-resistant tuberculosis: the perfect storm. J Infect Dis 2007; 196 (suppl 1): S86-S107. CrossRef | PubMed

4 Keshavjee S, Seung K. Stemming the tide of multidrug-resistant tuberculosis: major barriers to addressing the growing epidemic. (accessed Oct 7, 2010).

5 Szreter S. Rethinking McKeown: the relationship between public health and social change. Am J Public Health 2002; 92: 722-725. CrossRef | PubMed

6 Keshavjee S, Gelmanova IY, Pasechnikov AD, et al. Treating multidrug-resistant tuberculosis in Tomsk, Russia: developing programs that address the linkage between poverty and disease. Ann N Y Acad Sci 2008; 1136: 1-11. CrossRef | PubMed

7 Keshavjee S, Farmer PE. Time to put boots on the ground: making universal access to MDR-TB treatment a reality. Int J Tuberc Lung Dis 2010; 14: 1222-1225. PubMed

8 Lindert K, Linder A, Hobbs J, de la Brière B. The nuts and bolts of Brazil’s Bolsa Família Program: implementing conditional cash transfers in a decentralized context. (accessed Oct 1, 2010).

9 Broekmans J, Caines K, Paluzzi JE. Investing in strategies to reverse the global incidence of TB. (accessed Oct 1, 2010).

10 UN. The Millennium Development Goals Report, accessed Oct. 1 2010. (Note that the original link to this report is no longer available. However, there’s an archive of their reports available here: )

a Program in Infectious Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA

b Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA

c Partners In Health, Boston, MA, USA

d Open Society Foundations, New York, NY, USA

e Treatment Action Group, New York, NY, USA

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