 Good afternoon and welcome. I'm Sally Besby, the executive editor of the Washington Post, and we're very glad to have all of you here today for this conversation about efforts to end the global scourge of tuberculosis. Specifically today, we're going to focus very much on efforts to ramp up the development of safe and effective new vaccines and how that might help in the fight against tuberculosis. We're going to start with some comments, some brief opening remarks from the Minister of Health of India, Minister Mansook Mandaviya. Sir, if you would get us going, thank you. Excellencies, astemed guests and friends, tuberculosis has caused 1.6 million deaths globally in 2021, making it the worst leading cause of death from infectious disease before COVID-19 surpassed it. Under the visionary leadership of our honorable prime minister, India has been at the forefront of fight tuberculosis globally. Our commitment is iterated by the fact that we have advanced the SDG goals related to TB by five years, that is by 2025. TB affects millions of lives, and its management is specifically close to my heart. Being the chair of the Stop TB Partnership Board, I also have additional responsibility towards TB management efforts globally. As per the global TB report, the estimated TB case and deaths have increased since the last two years, primarily due to the impact of COVID-19 and consequence increase in missing cases. Most high burden countries are trying their best to recover from this challenge, and India's efforts could be an example for wider emulation across the world. We have taken several initiatives to intensify case-fighting and shore medicine supply, including tele-consultation service to every TB patient. India recently launched a very unique campaign of community engagement, Pradhan Mantri TB Mukta Bharat Abhyan, that is Prime Minister TB-free mission, which aims to provide TB patients with increased nutritional, diagnostic, and vocational support delivered through the community. This initiative has already seen over 50,000 Niksha Mitra community volunteers and donors adopting over 1.3 million TB patients, just as vaccines were a game changer in the battle against COVID-19. The global plan calls for approving a new TB vaccine by 2025 and making it widely available to adults and adolescents in TB-affected countries. India is fully prepared and in an advanced stage for taking this forward. Friends, it is important to ensure that we collaborate globally and ensure that innovations in surveillance, supported by technology tools, novel diagnostic, and drugs become accessible to every country in its fight against tuberculosis. Full implementation of the global plan developed by the Stop TB Partnership requires $250 billion over the next eight years, the equivalent of just $4 per person per year worldwide. And full implementation of the global plan would deliver an economic return of $40 for every dollar invested. The world at large needs to ensure that sufficient funds are made available for the initiatives. Since if we do not invest to end TB, now we end up paying a much higher price later. I am confident that the approach, envisaged, and present strategies to address tuberculosis will lead required success and a global level concertiam efforts can ensure TB-free world. Thank you. Thank you very much. Thank you so much, Minister. We appreciate that. Joining me also today on the panel, we have a very esteemed group of scientists and world leaders, Dr. Tedros Gabriosis, the Director General of the World Health Organization. Thank you for joining us, sir. The Honorable Gloria Arroyo, the Deputy Speaker of the Philippines and former President of the Philippines. Jeremy Farah, the Director of the Welcome Trust and soon to become the Chief Scientist at the World Health Organization. And Peter Sands, the Executive Director of the Global Fund to fight AIDS, tuberculosis, malaria. We've done so much, obviously, in this area. I'd like to open just by asking each of you to provide brief introductory remarks about today's topic. Perhaps, Speaker Arroyo, we could begin with you. All right. Well, let me speak from the point of view of being the only politician in this group. And I was a president who had to deal with tuberculosis. When I first became president in 2001, we were number seven in tuberculosis in the world. And I got a public health expert, Manolet Nairit, as my Secretary of Health. In fact, later he joined WHO, handling human resources. And he remembers the Director General as Minister of Health in your time. And he said, you are the darling of the world health community because of your devotion to training health personnel. Anyway, to go back to my Secretary of Health, we put together a national tuberculosis program that featured the Direct Observed Treatment Short Course or DOTS, and a strong public-private sector partnership. So tuberculosis prevalence went down during my time. By 2007, there was a 31% reduction in bacterially positive TB, and 27 in smear positive TB compared to 10 years before that. And another thing we did was, we had mandatory testing of children. So we improved our rating somewhat. From number seven, we improved somewhat to number nine. But I'm so sorry to learn that sometime 10 years later, we were number four, which was worse than the situation I started with. So I am very happy to be in this panel because of the fact that we are ranked number four. And I asked my Secretary of Health why. He said that after our term, he saw that, he was in WHO then, he saw that there was some slippage in the implementation of the natural of the tuberculosis program. And part of the slippage was a slippage in the strong public-private sector partnership that we used to have together. And meaning later on after our time, the burden of treatment medicines was more with the public sector and the role of the private sector became less. And that was, so when I say that we were number four, that was 2019, and that's even before COVID. So you can imagine the problems we had when COVID came and the resources went to COVID rather than to the detection and treatment of tuberculosis. So what can I say now about that as a politician? Let me say that, well, he gave, my former Secretary of Health gave me a, the results of the 2016 National TV Prevalence Survey where the shortcomings were pointed out. Now you're all technical here, so I'm not gonna talk about the shortcomings. But let me just say that, like a coin, dots has two phases to it. One is the political will to implement. And the other one are the technical matters, you know, microscopy and the direct observed treatment and monitoring systems, et cetera, et cetera. But your role is to talk about the technical aspect, but my role is to talk about the political aspect. And I would say that there are three political factors that are crucial as far as the political aspect of facing tuberculosis today and trying to eradicate it. First is something I learned from my own experience in executive governance. Policies and programs are good and you gentlemen for sure have good policies and programs. But in the end, the decisive option will be implementation and executive management. And that's what we would have to provide as a country that is dealing with tuberculosis. The second is political vision. You know, before I came here, I was discussing with our president, Bongbong Marcos, about this session. And we talked about many other things. And when the health authorities of the Philippines were speaking out, they said that we have to go back to pre-COVID levels in healthcare. But our new president said, no, pre-COVID is not good enough. There has to be transformation. And that is what I think gives me optimism because there is political vision. And finally, third is political will. Because we're all concerned about COVID, how to get now the political will to realize that we may have to shift somewhat from a COVID-centric mindset to deal with other important and essential health issues, including tuberculosis. So I'm glad that there is this session because we are focusing again on other things, other issues rather than COVID. But our experience in COVID taught us some things in our country that we can apply to fighting tuberculosis. One is that vaccines are a game changer. The session papers were talking about vaccines being developed, already developed, and being developed. And we thought it was a game changer in the case of COVID. It can be a game changer in the case of tuberculosis. And the other thing that COVID taught us in our country was that when you had strong public-private sector partnership for instance in the testing and in the vaccines, they can work. So we can do that too for tuberculosis, not only for COVID. So COVID was a bad experience, but in a way it also taught that other things that we can apply to other issues like tuberculosis. And now as you say, I was president then, many years ago. Now I'm a humble congresswoman, but I'm very inspired that since we are giving attention again to tuberculosis, I certainly would like to be able to experiment or to model testing and vaccines in my own country. And I would like to be able to do that in my own constituency with the help of WHO and the NGOs that are fighting tuberculosis. Thank you so much, ma'am. Vaccines are a game changer. Jeremy, tell us your thoughts about tuberculosis at this moment in time. Yeah, thanks very much to those two opening remarks. Vaccines are a game changer, but they're never going to be enough on their own. Some vaccines change all things. But actually the truth, one of the lessons of the last three years is you can have vaccines, but you do need other systems, health systems, you need diagnostics, you need trust in your systems, you need health systems that can deliver that, and of course you need treatment. So one caveat to this vaccine discussion would, yeah, there's a focus on vaccines, and we're very focused on vaccines, but put vaccines into a broader system, rather than thinking it's going to be the only thing. We were last really, I was here at sort of Snowy Davos in I think January 2020. Look how the world has changed since then. Of course we've had COVID in the pandemic. We have war in Europe. We have war in Ethiopia. The disruption, the debt crisis that's going to come, inflation, et cetera. That does have to be, and this is I think one of the crucial elements of coming to Davos, is to also inject some realistic hope of where you can make a difference. And I would say that for the first time in my career, which as a clinician, 20 years living in Vietnam, being a young doctor in London at the start of the HIV epidemic, this is the first time in my career when I felt that within this decade, we could make a real change to tuberculosis. And that's because of advancing in science that's been supported and invested in by a number of different places over many years, by the progress we've made in science over the last three years through COVID. And because I think with the coming of a greater appreciation of the importance of diagnostic testing, the surveillance systems that WHO, Global Fund, national governments put in place to allow you to know more people have TB and the ability then to make the science work for us on vaccines. But don't wait for vaccines. I don't know when we're going to have a vaccine. Don't wait for vaccines to do the things that we already know work and double down on those, as we heard from the Honourable Minister from India. Vaccines will be a game changer, but only when they're integrated into everything else. Okay, excellent. Peter, your thoughts before we dive into questions. I can start by saying collectively, I think we should be a little embarrassed or ashamed about where we are with TB. This is a disease that's been around for a very long time, that we've proven that we can eliminate as a public health threat in virtually all the richest countries in the world. And yet we allow millions of people to be sick and die continuing. And the... I mean, we're in a funny position in that. We are 77%. So we are by far the largest provider of external financing for programs against TB. But we spend less than a billion dollars. I mean, it's a shockingly small amount of money when you think about the tens and hundreds of billions of dollars that have been spent in fighting COVID-19. And in 2022, the number of people in the world who will have died of COVID-19 and the number of people who will have died of TB won't be massively different. It's just that the people who've died of COVID-19 are on average a lot richer than the people who died of TB. Now, the positive thing is that we are seeing political will to really tackle that. Not everywhere, but certainly India has shown extraordinary determination and leadership. And we know that it can be done. I mean, the progress that's been made in India is a very good example and we've seen other countries make that progress. And we also know, as Jeremy said, is that we have a new generation of tools, the prospect of a vaccine. We have better diagnostics. We have already got better treatments for drug-resistant TB that will enable us to do the dark job more efficiently. But my worry is that just having better tools is not gonna be enough if we don't have the political will and the political determination to see it through. And frankly, the care about the people who aren't in front of you, because TB is the disease of the poor, the marginalized, the people who aren't on the TV screen. And unless governments and communities and those of us who work in the multilateral sector are determined to reach out to those people, we're not gonna achieve the objective whatever the tools are that we have. So my sort of starting point in this is we know we can beat this disease. We've done it in other places. If we really set up to do it, it's a no-brainer from an economic point of view. It's also a no-brainer from a pandemic preparedness point of view, because the things you need to put in place, the diagnostic infrastructure, the community systems and outreach, the treatment protocols, the ability to actually support adherence to treatment are the kind of infrastructure and capacities that you want to deal with any new respiratory infection. And in fact, one of the problems we had in the COVID was that a lot of the TB infrastructure got repurposed for COVID. But that just kind of proves the point. And so one of the most practical, sort of economically effective and human life-saving effective ways of making the world more prepared for future pandemics would actually be to turbocharge the fight against TB. Mm-hmm. Dr. Tedros? Tell us what you think at this moment in time, coming out of the pandemic, thinking about tuberculosis. What are the thoughts that you have? Thank you. I think they have covered many things. Maybe to add a bit, I will follow from what he said. This is the disease of the poor, as Peter said. And it's not the problem of the high-income countries. There is one pattern that we see again and again. For instance, if you take just in 2014 Ebola, once it crossed the border to high-income country, the whole world started to get crazy. Just one case. And then fast forward 2018, we were in DRC with Jeremy. And without even crossing anywhere, the whole world was really worried. And doing everything to support, to stop it there, to contain it. And then COVID, the same reaction. So when do we stop this behavior? It's only when the rich countries affected that then becomes a serious issue. Why? Unless we stop that, I don't think the TB, with the behavior we have, I agree that we can make progress. We can defeat TB, but I think that mindset has to change. If it's the problem of few countries elsewhere, it has to be a global problem. It's a matter of time, but sooner or later, of course those countries who think that will not come to them as a problem may come. Even imagine the extreme disease resistance, TB. It's already coming. So I think the world should, one, helping humanity wherever it is, is very important because we are one family. But second, if we are really affected by self-interest, then we have what they call enlightened self-interest. So we should do it for our own sake because sooner or later it may come. So globally, of course that mindset important, but at the national level, I'm really glad, as minister said, the commitment of Prime Minister Modi is very, very clear. And I had a chance also to meet with your president and in Manila a few months ago. And I was so impressed by the understanding of TB you have and your commitment. And as a speaker, you are in charge of the oversight. You decide on the money, still you have a lot of leverage to make this happen. That's why I can see the political commitment also in you, which is very important. So I think with the political commitment, which she said also the vision, I think we can make progress. But there should be both national, the most important is actually at the country level. And of course at the global also with a changed mindset, TB can be challenged now. We have to be honest, all that it takes, it's doing it as madam said, the implementation, which is not done with real commitment, but we have really what it takes. And we have shown it with COVID. Of course in equity again, there was a problem, accelerated development. It was really historic. So for TB, which we know very well, TB well known, I think it's possible to make significant progress. Thank you. So Jeremy, let me ask a follow up question. Why is TB so deadly? Talk a little bit about why vaccines would not be enough. What is, obviously with the connection with poverty, what is it that the course of treatment is long and complex. And so not able to be followed through in areas that are lower income. What are the challenges in implementation beyond, obviously a vaccine would be an amazing breakthrough, but in treatment and in terms of the connection with poverty, what are the challenges to actually addressing? A lot of them have already been talked about. I mean, the link into poverty and I hate to say it, but continued stigma remains a huge issue. People in the system and people not in the system. The treatment schedules, as Peter says, have improved dramatically over the last few years, but they're still, you know, imagine taking the amount of drugs you have to take to treat multi-drug resistant for the next whatever period of time. If you ever tried doing that or treated a patient who said it's not easy, you are like COVID, like you can pass it on before you may know you've got a TB diagnosis, particularly if your access to healthcare is limited, as it is often for people living in poverty. And then I would say, which is why it's so good to have both India and the Philippines here and Tedros's leadership, without political will, you can't do very much, particularly on intractable problems like this. But I do want to just instill a little bit of optimism and hope because I think one of the most important aspects of de-risking something and crowding in people is to not take your nihilism too far to the point of putting people off. I think we also have to offer some hope. And as I said, I've worked in tuberculosis for 30 years or something, this is the first time where I feel truly that if we bought those things together that we already know about, and we were to add some others, a vaccine or strong political leadership, then within this decade, we will not eradicate TB, but we will reduce it as a public health burden in many, many parts of the world. But if I've got one second more, I want to pick up Peter's comment. TB is a pandemic, COVID is not the only pandemic going on. TB is a pandemic. And I've argued very strongly against us setting up new vertical systems to deal with future pandemics. I would much rather we built the surveillance systems into horizontal ways of working so that if you went in with your cough, whether it would be tuberculosis or whether it be COVID or whether it be influenza or any of the other respiratory infections, that could be picked up in a horizontal system that's integrated into health systems in a strong way, and then that will be dealt with in the appropriate way. So I would plead that we build this into strong horizontal systems for pandemic preparedness and surveillance and prevention rather than setting up a whole new set of silos. And that is government's doing that. They change their systems. I don't have a WHO hat on, so I can't do anything. But WHO, Global Fund, everybody involved in this space, but critically governments, critically government. So Peter, you're on the front lines of funding in this area and the thinking around funding. And the words creating that political will have been spoken by almost everyone. And so how do you actually do that? How do you convince rich nations to care about something that's affecting more low-income nations? There was a reason that rich nations found that political will around COVID-19 because it was scaring them, and this perhaps doesn't scare them as immediately or viscerally. So how do you create that political will? I don't think there's a single strategy, but the most important political will, as has been stressed before, is the political leadership in a country like the Philippines and a country like India and Bangladesh and Indonesia in all the places where TB is. Because without that domestic political leadership, you're not going to win. It's not going to be done from outside. In terms of political will in the rich countries in the world where it is no longer a public health threat, but where the money is going to come from for interventions like the Global Fund, well, A, showing them the numbers and saying, actually you've got a pandemic going on here, which you're resourcing at a tiny, tiny fraction. What's the moral argument here? Are those people dying not worth the money in the same way? A second is to use, and you refer to it a bit, Teras, the fear strategy. The reality is that the nasty forms of TB, MDR TB or XDI, extensively drug resistant TB, have fatality rates that make COVID look very mild indeed. I mean, the fatality rates on XDR are sort of 40, 50%. And even if you get XDR TB in the richest countries in the world, you are still far more likely to die than if you got COVID. Because it's a very, very difficult thing to treat. Now, so far, we've been relatively fortunate that the transmissibility of these forms of TB is nothing like as high as it is for COVID. But as we've learned with COVID, you can't count on these things being the same forever. If we got a more transmissible version of XDR TB, your job, Teras, would get extremely difficult because it's a very, very nasty disease. And we're kind of playing with fire a bit. With drug resistant TB, about a third of the people who get diagnosed and treated and most of the others die. And so we're allowing this thing that is an extremely nasty disease to be happening in the world. And we're just not really grappling with it. And that would be my message to the rich countries that if you're worried about health security, you've got to be looking at this one. You've really got to be looking at this one. And then there's another, because we're at Davos and the private sector. There's a very simple argument for anybody who employs a lot of people in those parts of the world where TB is highly prevalent, which is that you are losing a lot of employee time every year. I can guarantee you, and there are companies like Anglo-American who've done the work and know exactly how much they were losing because you lose people for six, nine months. And that's if they get better. And it's a very cost effective intervention to do workplace TB programs, where you screen people and you provide them to support in the workplace around treatment. And it just works as an economic equation, if nothing else. So I think there's some very powerful arguments. I'd also point to one, Japan, the leading killer in Japan in the 1950s, 40s and 50s was TB. And Japan launched a national TB elimination program which was extraordinarily successful and became the basis for the entire universal health coverage system of Japan. And so, that wasn't that long ago. So there is a really positive story to be told here. We can get rid of TB everywhere with the existing tools and we've got better tools coming. And you can use it to make a platform that both protects from future threats and delivers health services on a UHC type basis. Dr. Tedros, on the vaccine issue specifically, obviously some of the breakthroughs that happened around COVID-19 were really these partnerships of government and private sector and just the accelerant of the development, basically. And would you tell us just a little bit at this stage where the state of TB vaccines are and what would really be needed to create that acceleration of the process beyond political will? I mean, what are the holdbacks? Is it they're not getting pushed forward? The science is lacking. What is needed the most to make progress on the vaccines? So we have now 16 candidates under development. Many of these vaccines, by the way, were there the candidates before even COVID. And the difference between COVID and the 16 candidates is the whole world focused on really finding a solution for COVID. So accelerated the development of the COVID vaccines while TB that started decades ago, some of them are lagging behind. We have the BCG, which is 100 years old, 100 years. That's it. So what's now needed is the renewed commitment, real one, I will remember, really action with a sense of urgency, believing that we can do it. It can be done. If it was done for COVID, there is no reason that it cannot be done for this. And we have a lot of information on the 16 candidates already. And we say for COVID, accelerate. So we can accelerate this one too. And countries, high burden countries can take the lead, by the way. Thank you so much for your candor. I mean, the solution comes from being candid. Some countries, by the way, when even they have high burden, they don't want to say it. And I was very glad to say, okay, it became back even the current situation in your country is back to the level that you received it as president. I think that leadership, candid leadership commitment is very, very important, meaning the government side. And of course, to accelerate, not only government, you will need the health agencies. I think some of us are here, academia, the private sector, the civil society, all of us together like we did for COVID. If we can use the lessons that we have learned there to accelerate, it's doable. And now there is a proposal to establish some call it a accelerator council or can be given any other name, but that can help in accelerating the vaccine development. And we have Philippines and India here, and especially we're fortunate since they are the G20 president at the current. I think your leadership, as you have said, as you have shown now, and I know president, Prime Minister Modi's commitment, if we can use the opportunity of India, G20 president, I think we can make good progress even this year. But we need to install this team, have everybody that can contribute, come to the tent and give its best to accelerate and make progress. But the involvement of all these players will be very, very important. Speaker Arroyo, during the pandemic of COVID-19, it was very obvious to the world the economic impact of a pandemic, right? And I'm curious, we've talked here about obviously the health impacts of TB not being eradicated. We've talked about the social impacts of that. Can you talk a little bit for a country like the Philippines, the economic impact, the, you know, just the stress on the system and does it suppress economic growth in your country? Is it a problem in that way? Well, certainly, Peter was talking about the lost manpower because the system that we nationalized was the dots, it's a six-month treatment. But for six months, if he gets well, then the person can't work. So the more people, the more prevalent is tuberculosis, the more prevalent is the loss of jobs and employment because they have to be home during the treatment. They can't be going to office or to the factory or to the farm during the treatment. Very big loss. We're almost out of time, but I wanted to, before we end, just essentially kind of go around to the public health officials on this panel and talk just a little bit about, you know, what is the one thing that you think is most needed to accelerate vaccine development? I mean, if we're trying to take takeaways from this panel and we know this is very complex disease, as we talked about with a multitude of factors, they need to go the right way. But on the vaccine issue, what is the thing, we'll just kind of go around here, that is most, you're gonna start, most needed to accelerate the development of vaccines? Hope. TB has been the most nihilistic of the three diseases in my career, at least. We've had catalytic moments in malaria, with bed nets and with Artemis and combination therapies. In HIV, when I started a career, there were no antiretroviral drugs. There are now. TB has not had that catalytic moment. And I think hope is the biggest way of de-risking things. People will crowd in if they can see some success. Believe that it can be beaten. It can be done. Okay, Peter? Well, there's been a lot of discussion in the global health community in G20 about the 100 days mission, right? About being able, when we have a new pathogen, to be able to produce a vaccine within 100 days. Why wait for theoretical new pathogen? Why not apply all the things we're thinking about to accelerate that process to this pathogen that is killing so many people now? Why don't we take a TB vaccine as a test case of how rapidly we could actually bring something to the people who need it and be really ambitious about it? All right. Director General Tedros? I ask India to champion this. Yeah. As G20, make it a big issue at the G20. All these things we're asking whether 100 days mission is on, I think can happen. Okay, all right, okay. So I am going to thank all of our panelists for this session and for giving us your ideas on what is needed in the future. We are actually going to, and also want to thank the audience for being here, both in the room and live stream for listening to this and thinking about this issue. We're going to actually end with some remarks by Dr. Shyam Bhishan, the head of health and healthcare for the World Economic Forum, who's going to give us some closing remarks on his thoughts on tuberculosis. Thank you. Thanks, Ali. You thank everyone, so I want to thank you. What a great job moderating this session and I want to thank the esteemed speakers here. It's been a really eye-opening discussion. In this day and age, as Peter was saying, 10 million people in 2021 got sick of TB. More than a million people, close to one and a half million people died. That's a shame on all of us. That doesn't need to happen. So that's clearly an area where we need to work and we need to work harder. We need to come up with, you know, obviously, you know, a vaccine will be great, but we don't need to wait for that. There are some tools available. We want to make sure that, you know, the 16 vaccines that Dr. Ted Rose mentioned, that are in pipeline, they have funding available. They have financing available to get developed, to go through the clinical trials, get registered, which costs millions of dollars, several hundred million dollars. So we want to make sure that that happens and we have a way to bring public and private sector together. And that's why we are here at WEF in Davos to make sure that our partners, WEF partners, public partners come together with private partners and form this coalition to fund this development. Along with that, obviously, we are working on health system strengthening, health system sustainability and resilience so that when the vaccine is there, there is a way to deliver those. The other two areas that I would like to mention here are one is vaccine manufacturing. We want to make sure that there is a regionalized vaccine manufacturing. There is manufacturing in other parts of the world, not just in the US and Europe and India and China, but also in Africa and other parts of the world, that if a vaccine comes through, I know it will, when it comes through, we are able to manufacture it in different parts of the world. That's one part. The other one is we are working very closely with Africa CDC on pathogen surveillance. Jeremy knows that, he's part of that discussion, where we come up with a system where we have a federated data system, we have a good pathogen genomic surveillance so that if a new pathogen appears, you are able to identify it and come up with the medical countermeasures quickly. So without taking too much of your time, I know we are out of it. I just wanted to thank all of you for being here and participating in this. We look forward to working with both, with the government, with India, with Philippines, with NGOs, with Peter's organization, as well as WHO and private sector to help develop these vaccines we are talking about. Thank you, thanks everyone. Thank you very much.