Dr Paula I Fujiwara knows all too well what happens when funds for tuberculosis programmes are slashed and systems for TB control atrophy. As New York City’s Deputy Health Commissioner in the 1990s, she led the response to the worst outbreak of multidrug-resistant TB the city has ever seen. “I can still vividly remember the sense of hesitance people had – the fear that riding the subway or waiting in line at the post office might result in a brutal infection and the two years of painful treatment that went along with it,” she recalls.
That’s why, in the lead up to World TB Day, Dr Fujiwara went to Washington, DC as The Union’s Scientific Director to brief US Senate offices on the potential consequences of President Obama’s decision to slash 2017 funding for TB by 19 per cent, or roughly US$ 45 million.
“Right now, what we’re seeing with US federal funding cuts for TB is really the precursor to another resurgence of TB – not just in a major cities like New York, but in places all across the US,” she says.
“I want to help Congress understand what’s at stake here: another New York-sized outbreak could cost hundreds of millions of dollars simply to contain – and that doesn’t take into account the economic and human tolls. We simply cannot afford to let another New York happen.”
Dr Fujiwara was a young physician working in the highly regarded San Francisco TB Clinic when she landed a position with the US Centers for Disease Control and Prevention (CDC) based in New York City’s Department of Public Health. There she joined colleagues Dr Thomas Frieden, now Director of the CDC, and José Luis Castro, now Executive Director of The Union, in the fight to stop the New York MDR-TB outbreak.
With some 800 active MDR-TB cases on treatment and with the vast majority of patients lost to follow-up, the situation required the overhaul of the City’s entire TB programme. But eventually they succeeded in cutting the City’s TB incidence by half and MDR-TB by 80 per cent, and the programme they built became a model for TB control.
“The outbreak in the 1990s likely occurred because of grant-restructuring in the 1980s,” says Dr Fujiwara. “At that time, the US federal government changed the way it doled out grants: they created block grants, which didn’t explicitly tell states how to divide money. So bureaucrats would say, ‘TB isn’t a problem in my jurisdiction anymore, so let’s move this TB money over here.’ This is how changes in funding priorities can lead to unexpected negative outcomes."
"MDR-TB is a human-made problem," she asserts, "and failures in funding, leading to failures in systems, are central to its evolution."
In 2001, the CDC seconded Dr Fujiwara to The Union. There she worked on TB with countries such as Uganda and started the Integrated HIV Care for TB Patients Living with HIV (IHC) Programme, one of the first to successfully model integrated care for the burgeoning number of patients co-infected with TB and HIV. She became the Director of The Union’s first HIV Department and then the consolidated the TB and HIV Departments before being appointed Scientific Director for the whole organisation in 2013.
She sees her new role as one of facilitating the work of The Union staff and consultants based in offices around the world. “My role is to shine a light on them and to make sure that they are resourced in a way that they can do their work to the best of their abilities. I try to clear the path of obstructions so they can do their work,” she says.
MDR-TB continues to be a major focus for both Dr Fujiwara and The Union. “The Union is leading on MDR-TB through its critical research on reducing the length of treatment regimens. However, ultimately, what we need to do is not just develop new medications; we need a better vaccine.”
As head of the writing committee for the Stop TB Partnership’s Fourth Global Plan to End TB 2016-2020: The Paradigm Shift, Dr Fujiwara is deeply aware of both the goals and the challenges ahead. These range from tackling TB-specific issues, such as the unmeasured impact of zoonotic TB, to recognising that ending TB is linked to a world where healthy populations live in stable, thriving communities, economies and governments.
“When you’re on-the-ground, you see the massively devastating effect TB has on the community. More of us involved in policymaking have the responsibility of seeing and talking to the people in-country who are affected by our actions—for, at the end of the day, we’re all linked by the air we breathe.”
“I came to Washington this week to put TB in its proper place,” she says. “I’m an advocate for the cause and my goal now is to make sure that all the great people I work with have all of the support they need to end this terrible disease.”
Read more: Leadership needed to end TB epidemic, Fujiwara's op-ed in the Huffington Post on World TB Day