TB: The forgotten global health threat

As Congressional Committees debate the future of critical global health programs, they must not forget an all too neglected global health threat – tuberculosis (TB). 

TB is the second largest killer behind HIV/AIDS, taking the lives of 4,000 people a day. TB is also the most common cause of death among people living with HIV in sub-Saharan Africa.  More than 1,000 people infected with HIV die every day from TB.  Tuberculosis and HIV/AIDS constitute a deadly combination that speeds the progression of illness and death.  As the former U.S. Global AIDS Coordinator and the current UN Special Envoy on TB, I can attest to the fact that HIV/AIDS and TB are true partners in crime.

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Of the estimated 9 million annual deaths from all infectious causes, 1.5 million are caused by tuberculosis. That translates into one out of six deaths of all infectious diseases. 

Moreover, we are detecting only half of the estimated people suffering from HIV- associated tuberculosis and an alarming 45 percent of the estimated people with multi-drug resistant TB (MDR-TB).  

And, there are numerous systemic challenges in the fight against tuberculosis.

The lack of universal health coverage aggravates the economic burden on the poor. This is compounded by associated income loss and non-medical costs.  Regulatory mechanisms essential to ensuring effective infection control, rational use of tuberculosis diagnostics and drugs, mandatory disease notification, functioning vital registration systems, and protection of the legal rights of people with tuberculosis are non-existent or remain weak. Weak health systems prevent establishing linkages required across social sectors to address poverty, under-nutrition and other risk factors that adversely influence people’s vulnerability to tuberculosis and the health outcomes of people with tuberculosis.

While this news is sobering, we are seeing some progress.  The 2015 Millennium Development Goal of halting and reversing TB incidence has been achieved globally.  The TB mortality rate fell by an estimated 45 percent between 1990 and 2013. Sixty one million people were cured and 37 million were saved. 

We must not give up on this progress.  TB interventions are cost effective and save lives.  There is a return of $30 to $43 dollars for every dollar spent on TB interventions. 

Revolutionary new technology and improved ways of delivering services are needed to end the TB epidemic. This will require intensifying basic and implementation research with innovation. This will be possible only through increased investments and effective engagements of both the public and private sectors.

In my role as Special Envoy, I will be raising awareness about TB focusing on three central points:  Test, Treat and Tackle Resistance.  First, it goes without saying that we can’t treat if we don’t first test.  And we can’t test if we don’t get people into clinics.  Moreover, we need to increase investments in improving and innovating tools for prevention, testing, treatment and tackling resistance.    Current TB tools are not up to modern standards and can’t adequately respond to the changing nature of the disease.

Second, TB is treatable and curable, but the process isn’t easy.  I know that first-hand from when I was diagnosed with TB.  Even when you have patients on a regimen, getting them to stick to it is a challenge.  And treatment will not work if patients don’t stay on the drugs.  In fact, TB will spread. Moreover, most TB drugs were developed more than 40 years ago.  The TB vaccine, which is more than 85 years old, is unreliable against adult pulmonary TB.

The third principle, but probably the most pressing priority, is tackling drug resistance.  About 480,000 people developed MDR-TB in 2013.  Seventy percent of these people were not treated. The costs of treating drug resistant TB vary widely – with many drugs being out of reach.  Yet, drug-resistant TB is a threat to everyone, everywhere.  And the global community must respond.

Dr. Tom Frieden, head of the Centers for Disease Control and Prevention, and two of his colleagues wrote earlier this year in the Journal of the American Medical Association (JAMA) that, “Forgetting is the key challenge in tuberculosis control.”  He couldn’t be more right.  We can’t let TB be the forgotten disease. Just as we can’t let patients forget their treatment because they are feeling better.  With TB, forgetting is a deadly option. 

Goosby is a professor of Medicine; the UN Secretary-General’s Special Envoy on Tuberculosis; and ambassador-at-large and U.S. Global AIDS Coordinator, 2009 to 2013. 

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