Although tuberculosis (TB) has plagued mankind for over 20,000 years and was declared a global emergency by the World Health Organization (WHO) in the early 1990s, political attention and funding for TB has remained low. This looks set to change for the first time.
On 17 November 2017, 75 national ministers agreed to take urgent action to end TB by 2030. This landmark commitment, known as the Moscow Declaration, was made at the WHO Global Ministerial Conference on Ending Tuberculosis which was attended by leaders such as Russian President Vladimir Putin, the UN Deputy Secretary General, and the WHO Director-General. Further commitments from heads of state will be called for in September 2018 at the first UN General Assembly High-Level Meeting on TB. The resulting increases in investment and political pressure to end TB urgently is of course critical to progress. But to push ahead in the right direction requires critical analysis of strategies that have and have not worked in decades of TB control. And to push ahead at the right pace, which may not be the fastest pace possible, requires a deep understanding of the health systems that are expected to scale up TB control activities.
My encounter with a middle-aged paramedic in charge of “patient monitoring and data management” in Myanmar illustrates some of these complexities well. Sitting in a room surrounded by stacks of paper records with a hand-drawn keyboard on his desk, Tun Aung* explained that he was practising for when a computer arrives, which he had been hoping for years was imminent. This would allow him to computerise patient data and track whether patients in Yangon, Myanmar, are completing their drug resistant TB medication over the lengthy two-year course of treatment.
This situation not only demonstrates the lack of human resource capacity and infrastructure facing health facilities in countries like Myanmar but it also serves to highlight a conundrum of global health funding. With funding comes targets such as giving more people the medication they need. However, with TB in particular, where drug treatments are lengthy, it’s one thing to start patients on treatment but another to ensure they continue. Unless health systems and staff have the capacity to monitor this effectively, there is a real risk of non-completion and more drug resistance.
While ambitious goals to end TB help to galvanise support, this will not be the first time that TB control targets have been set, and lessons can be learnt from history. In the 1990s, global targets were set for the minimum proportion of cases that must be detected (70%) and successfully treated (85%) to result in an estimated 10% decline in new TB cases every year. With much investment from international and national funders, and efforts from stakeholders in low resource, high-TB burden countries, most countries have now met these targets.
But the decline in TB cases since 2000 has been minimal at only 1.5% per year, nowhere close to the anticipated impact of meeting the global targets. Western China, which has exceeded all TB related targets, failed to see a reduction in TB incidence. A recent investigation – the largest study of its kind analysing data from almost 80,000 TB patients diagnosed between 2006 and 2013 – shed light on a potential reason for this.
Simply put, the 70% target for detecting new TB cases did not represent how long it was taking TB patients to be diagnosed, only how many were being diagnosed. More than a third of TB patients were only diagnosed after more than 90 days of symptoms (most commonly a persistent cough), providing a lengthy period over which the infection could be transmitted. In light of these findings, it is perhaps less surprising that the number of new TB cases occurring in this region of China did not decrease as expected based on the high case detection rates.
“In the rush to meet targets for getting as many patients on treatment as quickly as possible, we forgot that drugs alone do not successfully cure patients – skilled and motivated doctors, nurses with tools to monitor patients’ progress do.”
In the study involving Tun Aung in neighbouring Myanmar, our findings have implications for increases in drug resistance, the global nemesis. In 2012 the world learnt about the explosive drug resistant TB problem in Myanmar, with an estimated 9,000 new cases being generated every year. Attracting most attention and outrage was the fact that, due to resource limitations, more than 90% of the drug resistant TB patients were not being treated. During a visit to Yangon’s overburdened health facilities in this period, the pressure on international funding bodies from growing patient waiting lists and stories of avoidable deaths while patients suffered untreated was palpable. The hand-drawn keyboard was just one example.
Soon after I returned, funding for drugs to treat Myanmar’s drug resistant TB patients was made available, and the government TB control was given aggressive targets to treat 100% of patients by 2015. This would require a huge increase in the number of patients treated each year, which would amount to several thousand. Unfortunately, funding for laptops and training for staff struggling to run Myanmar’s public health services did not receive as much attention.
In the rush to meet targets for getting as many patients on treatment as quickly as possible, we forgot that drugs alone do not successfully cure patients – skilled and motivated doctors, nurses with tools to monitor patients’ progress do.
The unprecedented political attention to TB is no doubt a huge victory resulting from years of advocacy efforts, but could the resulting urgency to act end up creating a worse drug resistance problem? The UN meeting on TB in September 2018 will bring together stakeholders from around the world to commit resources in order to accelerate towards a shared goal. However, acceleration will only lead to progress if we are moving in the right direction. For that we need to base our investment decisions of evidence of what has and has not worked.
*Name has been changed for confidentiality.
Featured image credit: Pulmonary Tuberculosis Collection by Puwadol Jaturawutthichai via Shutterstock.