By Victoria Irwin
At the United Nations General Assembly in September, while the world’s attention was on the brinksmanship of the United States and North Korea, UCSF Institute for Global Health Sciences’ Eric Goosby was behind the scenes, meeting with the secretary-general and the ministers of health from several member countries, harnessing support for the global fight against tuberculosis.
A professor of clinical medicine and the director of Global Health Delivery and Diplomacy in the UCSF Institute for Global Health Sciences (IGHS), Goosby is also the UN Special Envoy on Tuberculosis, bringing to the job a combination of expertise in infectious diseases and experience running large public health response programs in the U.S. and internationally. He also brings a sense of urgency and passion and a history of success.
Goosby received his MD degree from UCSF and began treating AIDS patients at San Francisco General Hospital in the early 1980s, just as the disease was emerging. That experience led to several government jobs, overseeing the public health response to the epidemic.
In 2009, he was tapped by President Barak Obama as the U.S. Global AIDS Coordinator – an ambassadorial position – heading up the President’s Emergency Plan for AIDS Relief (PEPFAR), which supports HIV testing and counseling and provides antiretroviral treatment in under-resourced countries. According to Goosby, “it’s the largest motor of resources supporting treatment and diagnosis” of a single disease. Established by President George W. Bush in 2003, PEPFAR expanded under Goosby’s watch, with the number of people served jumping from about 1.7 million to 7.2 (it’s now 11.8 million). He also expanded the pediatric program, which, through identification of HIV-infected women, education and counseling, has seen the number of new mother-to-infant infections drop from 200,000 per year to about 40,000.
As Goosby prepared to leave the Obama administration and return to UCSF in 2013, then UN Secretary-General Ban Ki-Moon, with whom he had worked closely on PEPFAR, approached him with a plea: Help eradicate tuberculosis. There’s significant overlap between HIV and TB (TB is the biggest killer of people living with HIV), Ban reasoned, and Goosby would be able to apply the successes achieved in the fight against AIDS to an even bigger killer. Besides, he would be working with many of the same countries and leaders he had engaged with through PEPFAR.
Goosby assumed the position of Special Envoy in January 2015. Later that year, when the UN adopted its Sustainable Development Goals for 2030, the body included a call for elimination of TB, a killer that claims more lives than HIV and malaria combined.
It’s a daunting objective that will take a massive investment of resources. According to the World Health Organization, 1.8 million people died of tuberculosis in 2015, while 10.4 million new cases were reported. Asia and Africa bear the heaviest burden, with 87 percent of cases, with just six countries accounting for 60 percent of all TB infections. Even more challenging, WHO estimates that 40 percent of cases go unreported and untreated.
“It’s ironic that of the three major infectious diseases – AIDS, malaria and TB – the one that has a cure is the one left behind,” Goosby says. “Drug-sensitive TB is curable almost 90 percent of the time.”
From his base at IGHS, Goosby travels the world meeting with presidents and prime ministers, health ministers and finance ministers, raising awareness and marshaling resources. He also insists on meeting patients and their families, as well as front-line health workers. But he’s discovered he has the most impact when talking to legislators, especially those on appropriations committees since “they write the checks,” he says. “In targeting them, you see lightbulbs go off. You’re talking to politicians who have a good idea about HIV in their country, but have no idea how TB impacts mortality and morbidity. I have been humbled by how entrenched in their belief they are that they have contained TB in their countries.”
Once political leaders find the will, Goosby helps them secure resources to fight the disease. “We look at the resources each country has identified and see if there are different tactics that can be used,” he says. “Sometimes it’s a matter of moving the deck chairs.”
He sees promise in India, which has one of the highest rates of TB, as an example. “They’ve owned up to the fact that their response has been less than optimal,” he says. “They’re aggressively targeting the disease and have developed an ambitious national strategic plan. After working at cross-purposes for years, they’re now engaging private-sector doctors in the fight.”
When he’s not meeting with political leaders, Goosby is convening international meetings, bringing together scientists, researchers, health economists, funders, government officials and other experts in the prevention and treatment of TB. He chairs the Lancet Commission on Tuberculosis, which met at UCSF in July, and will attend the First Global Ministerial conference on TB hosted by the Russian government in November. Ministers of health and finance from 40 countries will be present and Vladimir Putin is expected to attend. (“Russia wants to adopt a donor posture on the global health stage,” Goosby notes.)
Goosby hopes these meetings will provide a roadmap for policy change. During next September’s General Assembly, the UN will hold a high-level meeting focused on TB, only the fourth time the body has hosted a meeting about a single disease.
Reaching the UN’s Sustainable Development Goal to eliminate TB will take more than getting countries – both donor nations and those burdened by TB – on board. It will take significant advances in prevention, diagnosis and treatment. One of the reasons the disease has continued to thrive, Goosby says, is that “ the breakthroughs in immunology of the last 30 years have not been applied to TB.”
Today most people are diagnosed with a microscope, the TB vaccine is nearly 100 years old and the standard drug regimen is nearly 40 years old. In this environment, it’s not surprising that drug- resistance has become a significant problem. Most countries lack the capacity to check for drug resistance quickly and the traditional method of culturing the bacteria can leave patients on the wrong treatment for up to six weeks.
Goosby has hope a few advances including a sputum test, first developed for diagnosing AIDS, which takes only two hours will help. There are also new drugs — bedaquiline and delaminid – that show promise, with a cure rate of 80 to 90 percent in drug-resistant forms of TB.
Despite these advances, Goosby remains indignant. “This is BS that you have a disease that you can cure 90 percent of the time and can’t deal with it,” he says. “It’s pathetic, a failure of our systems. We need to regroup and come back stronger. That’s what I hope this effort generates.”