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REACHING MISSING TB PATIENTS AMONG DRUGS USERS THROUGH A HUMAN RIGHTS BASED APPROACH TO HEALTHCARE
Rosa is no stranger to tuberculosis (TB). She has witnessed the devastating suffering by people affected by TB in the course of her 19-year career as a Sub-County, TB and Leprosy Coordinator and her personal life.
Her first encounter with TB was as a child. She remembers how people distanced themselves from an aunt who suffered from TB. Young Rosa was scared whenever her aunt visited. Her second encounter was when she went to Medical Training College in Nakuru while being screened for TB. They had to take the Mantoux test to check if they had antibodies against the TB bacteria. She underwent a re-vaccination as the results showed she had no antibodies against the TB bacteria. This was despite being vaccinated as a child. The BCG Scar took so long to heal, giving her yet another unpleasant experience with TB.
Her third encounter with TB was at her first job posting. Immediately she finished her internship, a colleague who used to work in the male TB isolation ward was diagnosed with TB. “By the time it was discovered he had TB, he was surviving on half a lung… It was a sorry state because he had to be admitted in the same ward he worked in. Because he went into depression, he never managed to get better and he died, despite being HIV negative,” Rosa recalled.
Rosa’s fourth encounter was the toughest. A member of her family had a cough and it was not responding to antibiotics. One of the consultants could not understand why there was no improvement. “A test revealed it was TB… TB had come to my home! It was the worst thing that could have happened to me… There is no book I did not read about TB as a healthcare worker to understand and support the treatment regime,” she narrated.
Little did she know that her experiences were preparing her for a bigger mission. One of the TB coordinators invited her for a sensitization forum and she emerged the best trainee. It was then that one of the three TB coordinators decided to handover TB coordination to Rosa when he retired. “From that time, as I started meeting real people who have TB and seeing them get well, seeing a difference in their lives, I became passionate and I did whatever it took, without violating my values, to make sure our TB patients got well. I have seen a lot of people and children recover from TB, in the 19 years I have worked in the TB programme,” she said.
She has seen the negative impact of stigma and discrimination against persons living with TB in the course of her work. “It was terrible. I remember having female patients who were chased out of the marital home. One of them had her breastfeeding baby taken away from her and chased away from Lamu back to her people in Mombasa. She landed at my desk in tears, had congested breath. In another case, neighbours did not want to hang their clothes on the same cloth line as people with TB,” Rosa recollected. She believes with the availability of more information, people are getting to know facts about TB and stigma is on the decline.
Various challenges hamper the TB response across the globe. The World Drug Report (2019) estimates that as of 2017, an estimate 271 million people worldwide used drugs at least once in the previous year (range: 201 million-341 million). Of these, 11.3 million people injected drugs (range: 8.9 million–15.0 million). The criminalization of drug use, along with associated law-enforcement practices, increases vulnerability and negatively impacts access to services, and is among the factors driving the epidemics of HIV, viral hepatitis C (HCV), and tuberculosis (TB) among people who use drugs. In many parts of the world, people who inject drugs are denied access to essential health services and support, including the provision of sterile equipment, antiretroviral therapy (ART), opioid substitution therapy (OST), and the opioid overdose antidote naloxone. As a result, they are often forced to share and reuse equipment such as needles and syringes, placing themselves and their sexual and injecting partners at significant risk of HIV infection and other harms, including overdose and death.
In sub-Saharan Africa, Global Fund-funded programs in Benin, Côte D’Ivoire, Kenya, Mozambique, Nigeria, Senegal, South Africa, and Togo have identified an increase in drug use and injecting practices. People who inject drugs are susceptible to Mycobacterium tuberculosis in several ways. A 2017 study on people who inject drugs in California showed that the prevalence of M. tuberculosis infection was 23.6%, with 0.8% co-infection with HIV and 81.7% co-infection with HCV. Drug use weakens the immune system, making people who use drugs more susceptible to TB infection.
In Kenya, one of the biggest challenges facing the TB programme in Kenya is the identification of missing TB patients. This informed their decision to conduct screening services among different populations.
At the time Rosa participated in the Regional Forum on the law, HIV, TB and human rights for law enforcement officers and healthcare workers in Kenya in 2018, she had never thought of drug users in connection with TB within the context of their plight, their criminalisation and how the criminalisation of drug use affects their access to TB services. “All along whenever I heard of drug use it’s always concerning HIV. I had never connected how stigma, discrimination and violence as a result of punitive laws also affect access to TB services. Also, we came to realize the health-seeking behaviour of persons who use drugs is hampered by their lifestyles and addiction. My eyes have also been opened to the fact that taking care of the vulnerable is goes a long way in the control of the spread of TB, and it must be through the rights-based approach,” said Rosa.
After the regional training forum, Rosa went back to work inspired and built the capacities of her colleagues and empowered the County TB and Lung Department on how drug users are a population left behind when it came to TB screening. Persons who use drugs often confuse TB symptoms with withdrawal symptoms and once they take in the drugs, the sedative effects numb away the symptoms. By the time a drug user is taken for treatment, it is usually too late and the TB bacterium already widely spread in the body.
With support from the County Government of Mombasa, Rosa scaled up TB screening in drug dens. “We coordinated with KELIN and other partners such as Reach Out Centre Trust and Muslim Education and Welfare Association (MEWA) and worked with their outreach workers in collecting sputum samples. The samples were then taken to Shimo La Tewa Prison, one of the facilities with GeneXpert machines for screening. We were able to get quite a number who had TB and they were started on treatment,” she explained.
“The synergy between law enforcement officers and health care workers will lead to a reduction in infection rate, increase uptake and access to health services, while at the same time uphold human rights and prevention of health-related violations,” Rosa asserted.
She also worked on a research paper on drug-resistant TB, treatment, adherence and the treatment outcomes for people who use drugs for Mombasa County. It showed that their performance was low due to people who use drugs who had developed drug-resistant TB and were unable to finish their medication. They developed the resistance for failure to complete the treatment regimen two to four times and then eventually the same TB became drug-resistant. Rosa presented the findings through a poster paper during the 2017 Kenya International Scientific Lung Health Conference held at the Weston Hotel, in Nairobi. “If we had a seamless linkage with law enforcers and healthcare providers in a rights-based approach, I am seeing a probable increase in picking the number of missing cases of TB among key populations and have better outcomes in the programmes. Once we have dealt with the disease burden, then we can focus more on improving the livelihoods of people and the economic development progress of communities will be easier to achieve,” she concludes.
Indeed, concerted efforts are required to #EndTB, one of the world’s highly infectious diseases, that kills 4,000 people every day. KELIN commends Rosa for taking the mantle to spearhead the rights-based approach to TB response, the County TB and Lung Department for supporting this initiative and the County Government of Mombasa for their support in scaling up the screening in the drug dens.
Since 2016, KELIN with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria and the UNDP Regional Service Centre for Africa (as the Principal Recipient) has been implementing the Africa Regional Grant on HIV: Removing Legal Barriers. The Grant is aimed at addressing human rights violations by vulnerable communities in Africa and facilitating access to lifesaving healthcare. The goal has been to assess, monitor and strengthen the legal and policy environment to reduce the impact of HIV and TB on key populations in 10 countries: Botswana, Cote D’Ivoire, Kenya, Malawi, Nigeria, Senegal, Seychelles, Tanzania, Uganda and Zambia at the country level. At the regional level, the project provides intensive capacity strengthening opportunities for key stakeholders, like Rosa, who will escalate the gained knowledge to impact the HIV and TB response in their countries.
In a rare demonstration of solidarity, Members of the National and Provincial Assemblies, both from the treasury and opposition benches met to delineate the way forward to accelerate efforts to End TB amidst the ongoing COVID-19 pandemic, and reiterated their desire to work beyond their capacity and selflessly towards the cause. More than 20 MNAs and MPAs, the National Coordinator CMU, representatives of National / Provincial TB Control Programs along with senior TB experts and activists attended the third meeting of Pakistan’s Parliamentary Caucus to #EndTB both in person and virtually, under the leadership of Dr. Nausheen Hamid Federal Parliamentary Health Secretary/Chairperson of the End-TB Parliamentary Caucus. The Parliamentary Secretary for Climate Change also attended the meeting, which was jointly organized by Stop TB Partnership,Pakistan and Dopasi Foundation through the support of the Stop TB Partnership. The participants were apprised about the follow-up actions taken on the decisions agreed upon in the previous meeting, including tabling a Bill in Parliament for declaring TB a notifiable disease with mandatory notification of TB drug sales, a presentation to the Standing Committee on Health in the National Assembly and similar actions at provincial level. The distinguished parliamentarians reaffirmed their absolute and unflinching support for the cause and pledged to support the caucus at all levels through raising awareness, talk shows and interaction with people in their constituencies, adding voice to that of the CMU and the National TB Control Program by scheduling a meeting with His Excellency the Prime Minister urging him to direct sustained and equitable financing for TB Control in Pakistan to lessen external dependence, while establishing contacts with the SAPM Health Dr Faisal Sultan, SAPM Poverty Alleviation and Social Support Dr Sania Nishtar and the Federal Minister for Human Rights Dr Shirin Mazari, and ensuring their participation and organizing of the Second Presidential Summit on TB by end-2021 to follow-up on the 2019 Summit and review the progress made so far in eliminating this deadly menace that claims 44,000 lives annually, in addition to damaging the social fabric of the country by perpetuating poverty.
World Tuberculosis Day, observed on 24 March each year, is designed to build public awareness about the global epidemic of tuberculosis (TB) and efforts to eliminate the disease.
Menteri Kesehatan Budi G. Sadikin menyampaikan pentingnya komitmen setiap negara untuk mencapai eliminasi TBC di tahun 2030, termasuk Indonesia. Eliminasi tuberculosis (TBC) dapat dilakukan dengan menemukan dan mengobati pasien.
Hal itu disampaikan pada Side Event Majelis Umum Perserikatan Bangsa-Bangsa (PBB) tentang ‘Progress and multisectoral action towards achieving global targets to end TB’, yang diadakan di sela-sela sesi Majelis Umum PBB ke-77 di New York, Amerika Serikat, pada Selasa (20/9).
Unitaid launched a US$ 60 million project in 2015 to increase access to better, shorter treatments for MDR-TB. The four-year endTB project to expand new drug markets for TB is being implemented by Partners in Health, Médecins Sans Frontières, and Interactive Research & Development.
Lesotho has one of the highest TB incidence and HIV prevalence rates in the world. This translates to 17,000 new TB cases annually out of which less than half (45%) are notified. Among TB patients, 72% are co-infected with HIV. Lesotho’s mountainous terrain makes it difficult to treat patients in rural villages.
Image: Graeme Williams/Unitaid
Tuberculosis is the leading cause of death among people living with HIV, causing almost one third of all HIV-related deaths. Together we can #EndTB and #EndHIV. (Photo: Warren Zelman)
A TB patient at Alert Hospital in Addis Ababa, Ethiopia. Alert Hospital provides free treatment for multi-drug resistant tuberculosis (MDR-TB) patients, funded by the Ethiopian government and international donors. Patients stay at the hospital for up to four months to start their treatment.
Photo credit: Michael Tewelde/UNITAID
Lesotho’s multidrug-resistant TB (MDR-TB) rates are higher than other African countries (excluding South Africa). The main reason for high MDR-TB rates in Lesotho is the high transmission in neighbouring South African mines where thousands of men from Lesotho work to earn their living.
Image: Graeme Williams/Unitaid
#Tuberculosis usually attacks the #lungs but other parts like #kidneys or #brain can also fall prey to it. It is important for us to be aware and stay united to #endTB. #worldtuberculosisday
Diego* (center), an endTB participant, receives advice from PIH community health worker Verónica Quispe and PIH nursing technician Yecela Rodríguez at the Punchauca Health Center in Carabayllo, Peru. *Name has been changed.
Photo: William Castro Rodríguez/Socios En Salud
Two young men in traditional blankets riding horses, the traditional mode of transport in Lesotho’s mountainous terrain.
Image: Graeme Williams/Unitaid
Nurse Feleku Tsegaye takes blood from a patient who has been at the clinic for two months. ‘I’m here so that my children don’t become infected too,’ he says.
Photo credit: Michael Tewelde/Unitaid
Tsebo Nuebe, the lab technician, conducts a test to detect MDR-TB with the GeneXpert machine, a new rapid TB test.
Image: Graeme Williams/Unitaid
The Ministry of Health has outsourced MDR-TB management to Partners in Health (PIH), a US-based health care non-profit organization. PIH has seven primary health care clinics across the country and manages Botshabelo MDR-TB Hospital, the only one in the country.
Image: Graeme Williams/Unitaid
Limpho Taka, a 47-year old patient with HIV and MDR-TB, receives medication from his treatment supporter, Maliensoane Khafo, at the Bobete health clinic in Thaba-Tseka district.
Image: Graeme Williams/Unitaid
The introduction of bedaquiline and delamanid has been very successful as they are less toxic than many other MDR-TB drugs.
Image: Graeme Williams/Unitaid
Lesotho’s Health Minister, Dr Molotsi Monyamane, confirms that TB, HIV/AIDS and maternal and child health are the top health priorities in Lesotho. Universal health coverage is also a priority, but its geography and limited human and financial resources pose a significant challenge.
Image: Graeme Williams/Unitaid
PIH’s temporary accommodation houses MDR-TB patients who do not qualify for hospital accommodation, and have problems staying at home due to distance or lack of care. Recovering MDR-TB patient Marethabile Tjeketsi (right) with her treatment supporter (left).
Image: Graeme Williams/Unitaid
Limpho, who is married with one daughter and two grand-children, lives in Mpokochela village in the Drakenberg mountains of Lesotho. It takes him three hours on his horse to reach the Bobete clinic. He was diagnosed with MDR-TB, started but failed the standard MDR-TB treatment regimen because of its side effects. He was bedridden for one year, which caused severe bed sores and oedema.
Today he is feeling much better thanks to the new MDR-TB drugs he is taking as part of the endTB project.
Image: Graeme Williams/Unitaid
PIH manages Lesotho’s service delivery for MDR-TB, which features well-trained staff, quality-assured laboratory and medicines, availability of ancillary drugs to manage side-effects and a strong system of treatment supporters (community health workers) responsible for individual patient care. There is also social support to patients (including housing) and each month the patients receive a basic food-package sufficient to cover the needs for a family.
Image: Graeme Williams/UNITAID
Lesotho is one of 15 countries included in the Unitaid-funded endTB observational study and one of six countries planning to also implement the endTB clinical trial.
Image: Graeme Williams/Unitaid
Highly resistant TB strains are no longer a death sentence in Lesotho as new medicines improve cure rates. It is estimated that the MDR-TB mortality rate has decreased by 50% since the introduction of the new drugs.
Image: Graeme Williams/UNITAID
A great opportunity to listen to the leaders who are driving change in the field of TB. We go live @UnionConference on 21st Oct, 2021 at 1.15 PM IST. Register at: theunion.org/registration
Menteri Kesehatan Budi G. Sadikin menyampaikan pentingnya komitmen setiap negara untuk mencapai eliminasi TBC di tahun 2030, termasuk Indonesia. Eliminasi tuberculosis (TBC) dapat dilakukan dengan menemukan dan mengobati pasien.
Hal itu disampaikan pada Side Event Majelis Umum Perserikatan Bangsa-Bangsa (PBB) tentang ‘Progress and multisectoral action towards achieving global targets to end TB’, yang diadakan di sela-sela sesi Majelis Umum PBB ke-77 di New York, Amerika Serikat, pada Selasa (20/9).
Menteri Kesehatan Budi G. Sadikin menyampaikan pentingnya komitmen setiap negara untuk mencapai eliminasi TBC di tahun 2030, termasuk Indonesia. Eliminasi tuberculosis (TBC) dapat dilakukan dengan menemukan dan mengobati pasien.
Hal itu disampaikan pada Side Event Majelis Umum Perserikatan Bangsa-Bangsa (PBB) tentang ‘Progress and multisectoral action towards achieving global targets to end TB’, yang diadakan di sela-sela sesi Majelis Umum PBB ke-77 di New York, Amerika Serikat, pada Selasa (20/9).
Ms. Veena Reddy @USAIDIndiaMD talks about the importance of locally led initiatives for the most vulnerable populations in meeting the national TB elimination goal of 2025 and consequently, helping solve a global problem.
Let us the occasion of World Tuberculosis Day by helping people recover from this disease and embrace a healthy life. let us drive away tuberculosis. #worldtuberculosisday
Lack of access to basic health services, food insecurity and inadequate living conditions fuels TB transmission.
A vicious relationship exists between poverty and TB, the impoverished are at greater risk of TB.
Read More: www.khpt.org/
Menteri Kesehatan Budi G. Sadikin menyampaikan pentingnya komitmen setiap negara untuk mencapai eliminasi TBC di tahun 2030, termasuk Indonesia. Eliminasi tuberculosis (TBC) dapat dilakukan dengan menemukan dan mengobati pasien.
Hal itu disampaikan pada Side Event Majelis Umum Perserikatan Bangsa-Bangsa (PBB) tentang ‘Progress and multisectoral action towards achieving global targets to end TB’, yang diadakan di sela-sela sesi Majelis Umum PBB ke-77 di New York, Amerika Serikat, pada Selasa (20/9).
About one-third of the world’s population is infected with tuberculosis (TB) bacteria. Only a small proportion of those infected will become sick with TB. People with weakened immune systems have a much greater risk of falling ill from TB. A person living with HIV is about 26 to 31 times more likely to develop active TB.
One of the targets of the Sustainable Development Goals for 2030 is to end the global TB epidemic. The WHO "End TB Strategy", approved by the World Health Assembly in 2014, calls for a 90% reduction in TB deaths and an 80% reduction in the TB incidence rate by 2030, compared with 2016. Let's Unite to #EndTB #HealthforAll
Menteri Kesehatan Budi G. Sadikin menyampaikan pentingnya komitmen setiap negara untuk mencapai eliminasi TBC di tahun 2030, termasuk Indonesia. Eliminasi tuberculosis (TBC) dapat dilakukan dengan menemukan dan mengobati pasien.
Hal itu disampaikan pada Side Event Majelis Umum Perserikatan Bangsa-Bangsa (PBB) tentang ‘Progress and multisectoral action towards achieving global targets to end TB’, yang diadakan di sela-sela sesi Majelis Umum PBB ke-77 di New York, Amerika Serikat, pada Selasa (20/9).
Menteri Kesehatan Budi G. Sadikin menyampaikan pentingnya komitmen setiap negara untuk mencapai eliminasi TBC di tahun 2030, termasuk Indonesia. Eliminasi tuberculosis (TBC) dapat dilakukan dengan menemukan dan mengobati pasien.
Hal itu disampaikan pada Side Event Majelis Umum Perserikatan Bangsa-Bangsa (PBB) tentang ‘Progress and multisectoral action towards achieving global targets to end TB’, yang diadakan di sela-sela sesi Majelis Umum PBB ke-77 di New York, Amerika Serikat, pada Selasa (20/9).
Meet Rosa Muthoka, the Sub-County TB and Leprosy Coordinator from Mombasa County. She is one of the participants of the 2018 Regional Forum on the law, HIV, TB and human rights for law enforcement officers and health care workers in Kenya.
The training was an eye-opener for Rosa. She empowered her department on how people who use drugs are a population left behind when it comes to TB screening. Their symptoms are confused for withdrawal symptoms, delaying detection and treatment.
Rosa has scaled up TB screening in drug dens. This is with support from the County Government of Mombasa and outreach workers working with KELIN, Reach Out Centre Trust and Muslim Education and Welfare Association (MEWA) in collecting sputum samples for testing at Shimo La Tewa Prison, one of the facilities with GeneXpert machines for screening.
The synergy between law enforcement officers and health care workers will lead to the reduction of infection rate, increase uptake and access to health services, while at the same time uphold human rights and prevention of health-related violations,” asserts Rosa Muthoka.
Indeed, concerted efforts are required to #EndTB, one of the world’s highly infectious diseases, that kills 4,000 people every day. KELIN commends Rosa for taking the mantle to spearhead rights-based approach to TB response and the county government of Mombasa for their commitment to invest in structures and facilities to address TB.
Menteri Kesehatan Budi G. Sadikin menyampaikan pentingnya komitmen setiap negara untuk mencapai eliminasi TBC di tahun 2030, termasuk Indonesia. Eliminasi tuberculosis (TBC) dapat dilakukan dengan menemukan dan mengobati pasien.
Hal itu disampaikan pada Side Event Majelis Umum Perserikatan Bangsa-Bangsa (PBB) tentang ‘Progress and multisectoral action towards achieving global targets to end TB’, yang diadakan di sela-sela sesi Majelis Umum PBB ke-77 di New York, Amerika Serikat, pada Selasa (20/9).
Menteri Kesehatan Budi G. Sadikin menyampaikan pentingnya komitmen setiap negara untuk mencapai eliminasi TBC di tahun 2030, termasuk Indonesia. Eliminasi tuberculosis (TBC) dapat dilakukan dengan menemukan dan mengobati pasien.
Hal itu disampaikan pada Side Event Majelis Umum Perserikatan Bangsa-Bangsa (PBB) tentang ‘Progress and multisectoral action towards achieving global targets to end TB’, yang diadakan di sela-sela sesi Majelis Umum PBB ke-77 di New York, Amerika Serikat, pada Selasa (20/9).
Menteri Kesehatan Budi G. Sadikin menyampaikan pentingnya komitmen setiap negara untuk mencapai eliminasi TBC di tahun 2030, termasuk Indonesia. Eliminasi tuberculosis (TBC) dapat dilakukan dengan menemukan dan mengobati pasien.
Hal itu disampaikan pada Side Event Majelis Umum Perserikatan Bangsa-Bangsa (PBB) tentang ‘Progress and multisectoral action towards achieving global targets to end TB’, yang diadakan di sela-sela sesi Majelis Umum PBB ke-77 di New York, Amerika Serikat, pada Selasa (20/9).
About one-third of the world’s population is infected with tuberculosis (TB) bacteria. Only a small proportion of those infected will become sick with TB. People with weakened immune systems have a much greater risk of falling ill from TB. A person living with HIV is about 26 to 31 times more likely to develop active TB.
One of the targets of the Sustainable Development Goals for 2030 is to end the global TB epidemic. The WHO "End TB Strategy", approved by the World Health Assembly in 2014, calls for a 90% reduction in TB deaths and an 80% reduction in the TB incidence rate by 2030, compared with 2016. Let's Unite to #EndTB #HealthforAll
About one-third of the world’s population is infected with tuberculosis (TB) bacteria. Only a small proportion of those infected will become sick with TB. People with weakened immune systems have a much greater risk of falling ill from TB. A person living with HIV is about 26 to 31 times more likely to develop active TB.
One of the targets of the Sustainable Development Goals for 2030 is to end the global TB epidemic. The WHO "End TB Strategy", approved by the World Health Assembly in 2014, calls for a 90% reduction in TB deaths and an 80% reduction in the TB incidence rate by 2030, compared with 2016. Let's Unite to #EndTB #HealthforAll
Alcohol use has long been linked to a risk for tuberculosis, with the prevalence of alcohol use disorders ranging from 10% to 50% in patients with tuberculosis. Also, studies have shown that populations with a high prevalence of alcohol use disorders have an increased risk for tuberculosis. However, these studies did not control for potential confounding factors.
Mechanisms explaining the link between alcohol intake and the risk for tuberculosis may include specific social mixing patterns among people with alcohol use disorders, leading to a higher risk for infection, or impaired immunity leading to a higher risk for clinical illness resulting from tuberculosis infection. The latter may be caused by direct toxicity of alcohol on the immune system or by other alcohol-related comorbidities.
Tuberculosis is a potentially serious infectious disease that mainly affects the #lungs. The date marks the day in 1882 when Dr. Robert Koch announced that he had discovered the bacterium that causes TB, which opened the way towards diagnosing and curing this disease.
Ms. Karen Klimowski discusses approaches to community screening at the exhibition gallery of communication materials and behaviour change solutions.
Tuberculosis is one of the most infectious diseases in the world, but TB is Preventable and Curable. Now it's time to unite like never before to #EndTB!
#WorldTBDay #WorldTuberculosisDay #Tuberculosis #Lungs #PrathimaHospitals
The Graama Panchayath Arogya Amrutha Abhiyaana was launched in #Koppal today in the presence of Shri Halappa Achar Shri Karadi Sanganna, Shri Suralkar Vikas Kishor, DC Koppal & Koppal Zilla Panchayat Smt. Fouzia Taranum
The diagnosis of TB can lead to isolation, anxiety, and loneliness which can lead to mental distress. This is only worsened by stigma which is a massive part of the disease’s social consequences. We must build support systems for those most vulnerable to TB in an attempt to realise the vision of ’TB-Mukht Bharat’.
Read Dr Kirit Solanki’s Dr Kirit P Solanki piece on the learnings of the The Union World Conference on Lung Health here: