as robust a toolkit of interventions such as diagnostics, therapeutics, or vaccines that are 21st century-style, not the old ones that once seemed to fit the bill. What I was calling for is that the biomedical research community, with help from funders, and help from people who show leadership in that arena, is to look upon TB research in a more transformative way. That’s opposed to an incremental way.
Yes, it’s true we do need an additional drug here or an additional vaccine here. But we also need to understand some of the complexities that we never even bothered to look at with TB. Because historically, in the best of all worlds, we had curative drugs, and a diagnostic—antiquated as it was. Under the best circumstances, you could cure the disease. We never really catapulted TB research into the arena for highly sophisticated questions that we can ask and answer right now. So, despite the fact that we have a long way to go in implementing the tools we already have, if you really want to get a sustained control of TB, you will have to get the kind of diagnostics that you’d expect in the 21st century. You need a whole new way of looking at treatment. It’s not just a matter of adding another drug to the regimen, or subtracting one here. You have to look at the comprehensive package of the regimens we use. Then we have to understand host-pathogen interaction if we’re really going to get a vaccine that’s highly effective, safe, and could have a major impact. All of those things will come from a robust research agenda that’s sustained, and that involves young people with new ideas, who see a career in research as an opportunity to not only make a contribution to global health, but also will be exciting for them as a career.
X: You also mentioned there has been a big leap ahead in resources put toward this disease since you’ve been around at NIH. How big?
AF: When I started in 1984, the fiscal year TB resources from NIAID was $665,000. Now, NIAID supports over $130 million a year of TB research. Granted, that is over a 25-year period. But if you look at the relative increase of TB research over the last few years, comparing it to the overall flat NIH budget, it is clear that we have preferentially, with a high priority, put our limited resources on TB.
I have to underscore the resources are limited. Even though the NIH budget is a robust budget, it’s $30 billion, and we just got an additional $10.4 billion stimulus package, the budget for NIH over the last several years has barely, and in fact, hasn’t kept up with inflation. So despite the flattening of the NIH budget over the last five years, following its doubling at the end of the 20th and early part of the 21st century, despite that, we have still preferentially grown tuberculosis research.
X: So imagine I’m a young investigator. Tell me why I should get into this? What’s intellectually exciting?
AF: When I talk to young people, and the people who work in my own laboratory, the two things that drive them are this. Number one, what is the public health issue involved? Is it an important problem? You don’t need to be a genius to figure out that when one-third of the world’s population is infected—and it’s responsible for 1.7 million deaths, and 9 million new infections each year—that this is a really big public health issue. So it has relevance.
The other thing is, what is the scientific opportunity? Let’s focus on that. The point I was making in my talk is we have not even begun to explore the extraordinary scientific opportunities. The TB research agenda has been this neglected arena of endeavor. If you look at what we have, it’s almost embarrassing. Diagnostics that are decades, decades, decades old. A vaccine that doesn’t work for adult pulmonary TB. Treatment regimens that have not been rejuvenated for the last several decades. We don’t even understand the fundamentals of host-pathogen interaction. These are questions that should have been asked, but weren’t, because we were so successful in the developed world, of addressing TB.
I use the AIDS comparison. We poured a lot of resources into it, and got a lot of good young people involved in it. We now, really, have an extraordinary handle on the pathogenesis, the pathophysiology, the targets for drug development. Those are the things we need to do with TB. We’ve got to get young investigators to realize there are enormous and exciting opportunities, not only for their own careers, but because they are dealing with a disease of extraordinary relevance.
X: Do you run into a certain amount of scientific snobbery?
