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Written Testimony By Dr. Elena McEwan
Of Catholic Relief Services
Before The Committee on Foreign Affairs
Subcommittee on Africa and Global Health
U.S. House of Representatives
Donald M. Payne (D-NJ), Chairman
March 21, 2007

Good afternoon. Chairman Payne, Ranking Member Smith, and Members of the Subcommittee, thank you for inviting me to testify today before the Subcommittee on "The Global Threat of Drug Resistant TB: A Call to Action for World TB Day." My name is Dr. Elena McEwan, and I am the Program Quality Support Department Senior Technical Advisor in Health for Catholic Relief Services. My medical degree thesis was: Quality of Tuberculosis Programs in Three Municipalities in Nicaragua. From 1987 to 1991, I was the director of TB programs in three municipalities of Nicaragua and my main responsibilities included quality assurance to three TB programs and training Ministry of Health (MoH )staff and Community Health Workers (CHWs) in TB and related topics. From 1991 to 1995, I was employed as a pediatric specialist providing secondary care to children with TB referred from primary hospitals and health centers. Since 2006, I have served as a Senior Technical Advisor in Health and the technical backstop for the United States Agency for International Development USAID funded Tuberculosis Project in the Philippines. I am the co-chair of the Child Survival Collaborating and Resources Group (CORE)`s Tuberculosis Working Group which shares best practices and lessons learned with the larger Private Voluntary Organization (PVO) community and provide updates and training to the field staff and MoH partners. The group also held a Lessons Learned Exchange Workshop in February and is in the process of reviewing abstracts from the field related to TB experience and innovations. I represent CORE on the writing committee that is preparing guidelines of component five of the STOP TB strategy, and I am in the process of providing feedback on the last draft to be published this year.

Let me express, my thanks for you and your staff's efforts to facilitate my testimony through the U.S. Department of State and the American Embassy in Nicaragua. Let me also note Catholic Relief Services' (CRS) deep appreciation of this Committee's efforts both historically and continuing through each new Congress to be advocates for those greatest in need. Chairman Payne, Ranking Member Smith, in particular, you have served as champions to the cause of humanitarian work and social justice and welfare throughout the world, and we are grateful.

Catholic Relief Services was founded in 1943 and is the overseas relief and development agency of the U. S. Catholic Conference of Bishops and the American Catholic community. In FY2006, CRS engaged in program operations in 99 countries through programs in emergency and disaster relief, child survival, HIV/AIDS and other health programs including TB programs, agriculture, education, microfinance, conflict resolution, and social justice programs. The benefits that millions are receiving from these programs are at risk because of conditions like (Extremely Drug Resistance) XDR TB that compromise the effectiveness of inexpensive first line TB drugs and endanger the lives of patients and their caregivers as well as program staff. Our program staff are very concerned for their health and that of their family thus making staff retention in TB programs challenging.

Increasingly more of our programming requires TB components and corresponding resources often leaving managers to juggle needs and priorities. The relatively recent rise in XDR is prompting us to review our HIV/AIDS guidelines as a model for developing similar guidelines for TB.

CRS as the lead agency of AIDSRelief funded under the President's Emergency Plan for AIDs Relief (PEPFAR) is concerned that untreated or poorly managed TB treatment will result in increased morbidity and mortality from Multi-Drug Resistant (MDR) and XDR TB. In countries like South Africa, this is especially unsettling for HIV patients when available life saving Antiretroviral Therapy (ARTs) should be prolonging their lives. Increasingly prevalent MDR and XDR TB put the entire community at risk. The alarming rise in MDR and XDR is in part due to 1) lack of health staff knowledge; 2) equipment and supplies not consistently available; 3) patient's and community's lack of knowledge and awareness; and, 4) lack of adequate collaboration around TB with key stakeholders.

Over the past 60 years CRS, has worked in improving primary health care services and child survival and safe motherhood programs. Lessons learned from these successful projects are enabling us to address TB/HIV-related issues and uniquely position us to work with communities, health providers, religious leaders and research institutions as well as government. These lessons include:

1. Brokering partnerships between faith-based and government health services for more effective and sustainable programming:

An essential element in the fight against TB is mobilizing both faith-based structures, including health services and parish volunteers, and community workers to educate and promote testing and treatment. One example is our four-year USAID funded TB project in Maguindanao Province on the southern Philippine island of Mindanao for 495,000 individuals that builds on a previous Child Survival program in the same area. Maguindanao is one of five Muslim-majority provinces comprising the Autonomous Region of Muslim Mindanao (ARMM).

As part of this project, CRS in partnership with the Integrated Provincial Health Office (IPHO) in Maguindanao is institutionalizing the five components of the Directly Observed Treatment Short Course (DOTS) strategy: 1) sustained political commitment; 2) case detection for quality-assured sputum smear microscopy; 3) TB treatment with standard short-course chemotherapy regimes, including DOTS; 4) uninterrupted supply of quality-assured anti TB drugs; and 5) recording and reporting systems.

2. Leveraging private funding to support TB services to call attention to urgent and critical needs when public services are limited or unavailable:

Since 1997 Catholic Relief Services has donated funds to the Eugene Bell Foundation for tuberculosis treatment for approximately 4,200 Korean patients. The funds have been used for: 1.) capacity building to health staff; 2.) regular re-supply packages for Jongju City TB Care Center in the North Pyongan Province and Anju City TB Care Center in the South Pyongan Province TB; 3.) and an initial "partner package" for Pyongsong City TB Care Center in the South Pyongan Province. The partner package is supplying tuberculosis hospitals, tuberculosis care centers (for chronic and MDR patients) and some local hospital tuberculosis departments with the necessary medicines, microscopic diagnostic kits, X-ray kits, agricultural support kits, vitamins, bedding, pajamas, basic medical equipment, and other necessities on regular basis.

In addition, CRS, the Vatican, and the Korean Catholic Church joined together in supplying a mobile X-ray vehicle for the South Pyongan Province Tuberculosis Hospital. CRS has also provided the needed re-supply packages to keep these mobile X-ray services operational: that is used for general medicine as well as TB-related work. Since beginning in 1997, partner organizations and supporters of Eugene Bell have provided approximately 205,000 Directly Observed Treatment System (DOTS), and tuberculosis medication kits. On the average, the cure rate for Category I patients (first-time tuberculosis patients with mild cases) have a cure-rate of 85-95% with completion of a six-month Direct Observe Treatment (DOT) course. Category II patients (those who suffer relapses or have serious infections) have a cure rate of 70-80% with completion of an eight-month DOTS program. As yet there is no Category IV (multi-drug resistant tuberculosis patients) program in North Korea. These cases are almost always fatal and the number of MDR cases is rising. Eugene Bell and CRS are trying to promote interest in and find support for an MDR TB program.

3. Mobilize local volunteers to support programs and build community capacity and awareness:

Home-based care is the foundation of all CRS programs. Home care services are crucial in communities where most people cannot afford even the most basic medication and have little access to formal health care. Community volunteers, who are often poor themselves, are the heart of home care programs and are at the forefront of our battle against the HIV/AIDS pandemic. The home-based care workers represent an additional resource for screening and early identification of TB among People Living with HIV (PLWHIV). TB treatment is provided by TB clinics that make treatment decisions and dispense the drugs in a vertical program.

All AIDSRelief projects have a TB component which provides palliative care for those with TB. The MoH provides the drugs and treats TB first as an opportunistic infection and then treats the HIV. In addition, CRS provides lab facilities, pay staff, and provides psychosocial support and services. Co-infection is very high in South Saharan Africa. For example in Angola the prevalence of TB among HIV+ persons is 40% and the prevalence of HIV among TB patients is about 60%.

ART programming has borrowed heavily from the TB DOTS approach to promote treatment compliance using volunteers. In many places where we work there is already a trained cadre of volunteers and community health workers that can be mobilized around TB as well as HIV and basic primary health care.

The country programs where CRS is implementing AIDSRelief program that include HIV/AIDS and TB components are: South Africa, Tanzania, Zambia, Kenya, Uganda, Rwanda, Nigeria, Haiti, and Guyana. These programs include tens of thousands of trained volunteers.

4. Collaborating with research organizations and global partners

The Catholic Church's long-standing commitment to health care throughout the world is noted for its program quality, excellence in care and extensive networks. One way of assuring quality and continual staff training and use of best practices is through collaborating with research organizations and global partners such as World Health Organization (WHO). An example of this collaboration is in our AIDSRelief project in South Africa. All 19 Antiretroviral (ARV) sites screen all patients and refer them to appropriate TB clinics. Because of the link between TB and HIV, the International Research and Programs Branch, Division of TB Elimination at Centers for Disease Control and Prevention (CDC), in conjunction with CRS, and the Global AIDS Program (GAP) South Africa have partnered to evaluate TB screening, referral, and treatment services in two ARV sites: Orange Farm ARV and the Winterveldt ARV that in 2005 provided ARV therapy to 140 patients and provided home-based care to an additional 450 patients with HIV/AIDS. The findings will be used to design improved and earlier TB screening and Isoniazid Preventive Therapy (IPT) uptake at ARV sites. In addition the evaluation will help improve the effectiveness of training home-based care workers to screen for TB. The findings will be shared among the stakeholders in HIV and TB control in South Africa, including the CDC Global AIDS Program and other relevant program partners. This series of activities which leads to earlier diagnosis and treatment is designed to reduce risk of resistance to drugs.

5. Integrated programs:

Single interventions often do not address the full range of complex needs of TB patients. Thus, many of our programs are integrated into larger development activities such as the Food for Peace (FFP) TITLE II. CRS/Ethiopia provides limited assistance for TB through our partners including indirect support through the provision of Title II food to Missionaries of Charity.

CRS' TB program in Angola is part of a larger HIV/AIDS program that is being implemented by our partner, Caritas Benguela. The project goal is to contribute to the prevention of HIV incidence through participatory AIDS education, mass media, and capacity building in Benguela province over one year. In order to improve knowledge in HIV/AIDS, the project has implemented different participatory education and mass media activities in Benguela province over one year, such as posters, pamphlets and billboards, oral presentations, and development of World AIDS Day campaigns. They have also trained and carried out outreach activities with target groups, such as religious leaders of Faith-based organizations (FBOs). They have also provided basic HIV/AIDS and management training to our partners in Benguela. The TB component of the project also provides training to nurses in the Benguela Province

As a physician who has been working in TB for many years, it is my professional opinion that in order for agencies like CRS, our local health care providing networks, our local church partners and other US PVOs and FBOs to contribute significantly to the reduction of the burden of TB, the following actions must be taken into consideration.

1. Increase resources for sustainable local health services: To date most of the global public efforts to address TB are aimed at national government institutions often overlooking the FBO and private health care providers that deliver 30 to 50% of health services in lesser developed countries. CRS and our partner networks excel at reaching the most vulnerable through community managed services. Future funding needs to not only strengthen quality of government programs but also support linkages and resources to include FBO and private health care providers. These additional resources are needed for expansion of standardized trainings and supervision of volunteers and community health workers to increase community awareness and extend TB services, as well as equipment and quality control. This would extend DOTS from Secondary and Tertiary units to the primary health care settings in communities in which PVOs and FBOs are present. PVOs and FBOs are uniquely positioned to expand TB services to areas underserved if resources were available

2. Support for sharing lessons learned and best practices: Learning and documenting lessons and best practices is a key part of quality assurance and scale up of successful cost-effective interventions. Often projects do not have sufficient funds for doing this type of documentation. To do this effectively we recommend that a percentage of the budget for each TB program be required for learning and documentation. Lessons learned from CRS' Child Survival and HIV work show that well-documented practices can be replicated and further refined across countries and regions.

3. Long-term integrated programs rather than short term: Infections and global health conditions like TB and HIV do not often lend themselves to four or five year annually renewable funding cycles nor to silo funding of specific interventions. Lessons learned in PEPFAR Title II and Child Survival funding require consistent and predictable funding over multiple years. At household level, families need more than drugs and treatment. Because TB is a disease of poverty, support for food security, livelihoods and basic services are needed as well. Therefore we recommend that all new TB programs integrate livelihood security and food security within long-term predictable funding cycles.

Again Chairman Payne and Ranking Member Smith thank you for the opportunity to testify before the Subcommittee today. I look forward to answering any questions you may have.