“The Union is a pathfinder. What’s important about our projects is not their size, but how they show the way forward.”
“The Union is a pathfinder. What’s important about our projects is not their size, but how they show the way forward,” says Dr Chen-Yuan Chiang, a tuberculosis expert and Director of the Department of Lung Health and Non-Communicable Diseases. Over the past decade, he has played a central role in several such path-finding initiatives -- from the groundbreaking FIDELIS project, to the World Bank-funded Comprehensive Approach to Lung Health, ADF asthma pilot projects, Global Asthma Network, and the current campaign to improve the treatment for multidrug-resistant TB.
A chest physician from Taiwan with a master’s in public health and a Dr Philos, Chiang joined The Union in 2003 as a technical monitor for FIDELIS -- the Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB. At that time – as it is now -- TB case-finding was a major challenge, especially among those with limited access to health care and in remote and under-served areas. FIDELIS tackled this problem by funding 54 locally designed and focused case-finding projects in 18 countries—a successful approach that served as a model for the Stop TB Partnership’s subsequent TB REACH project.
When FIDELIS wound down in 2007, Chiang was invited by then Executive Director Nils Billo to head a new Department of Lung Health and Non-Communicable Diseases. Although TB had been his main focus, he welcomed the new assignment, and started to assess the link between TB and smoking, the impact of indoor air pollution on lung health, and to work on a project called Comprehensive Approach to Lung Health.
“The idea was to apply the DOTS principles for the management of patients with chronic airflow limitations”, says Chiang. Pilot projects in Benin, China, El Salvador and Sudan generated valuable lessons on implementing standard case management for asthma and reducing the cost of medicines as a barrier to asthma treatment in resource limited settings. At a time when smoking cessation was not considered a priority in tobacco control, The Union pilots demonstrated that TB clinics could effectively provide brief advice that helped TB patients quit smoking which greatly benefited their treatment. When indoor air pollution was estimated to account for a substantial proportion of global TB burden, Chiang and his colleagues questioned the estimates and conducted studies to show that scientific evidence supporting the link between indoor air pollution and TB has not yet been convincingly established.
While Chiang hopes to revise The Union’s asthma guide – he has been predominantly focused on prevention and management of multidrug-resistant TB (MDR-TB). A highly regarded expert, he travels the world training clinicians, advising national tuberculosis programmes and advocating for change.
“The problem with MDR-TB today”, says Chiang, “is similar to the one faced by TB in the 1970s. When you have a low treatment success rate, you keep patients alive without curing them, so you’re promoting transmission of TB.” With the regimen currently approved by the World Health Organization (WHO) only achieving about a 50% treatment success rate, Chiang and other colleagues from The Union have worked hard to gain the WHO’s consent to broadly test a nine-month regimen that demonstrated >85% treatment success in Bangladesh.
“Our role is to help colleagues understand what’s practical and feasible, and we’re good at pointing out when something is off track,” says Chiang. In this case, their feelings were strong enough to be summed up in a 2013 article: “A poor drug-resistant TB programme is worse than no programme: time for a change”.
Now at last the change is happening – and picking up speed.
The Union and its partners are testing shortened regimens through both the STREAM clinical trial and observational studies in nine francophone African countries.
And others have also joined the campaign. The Royal Netherlands TB Foundation (KNCV), Médecins Sans Frontières and Partners in Health are testing shortened regimens in different countries, and the accumulating evidence from STREAM and observational studies will ultimately demonstrate whether shortened regimens is a better choice of treatment for the estimated 450,000 MDR-TB patients that arise worldwide annually.
“We kept making the case, and now the landscape has changed,” says Chiang. “That’s The Union’s impact. We advocate -- with evidence -- until people see that a different approach might bring much better outcomes for the patients we all serve.”
Read more:
Chiang C-Y, Van Deun A, Enarson DA. A poor drug-resistant tuberculosis programme is worse than no programme: time for a change. Int J Tuberc Lung Dis 2013;17:714-718. http://www.ingentaconnect.com/content/iuatld/ijtld/2013/00000017/00000006/art00004
Photos by Jan Schmidt-Whitley