TB: Tackling an orphan disease

Tuberculosis (TB) is (1) the leading cause of death in South Africa and (2) a public health crisis. Most of the TB deaths are preventable and the public health crisis should be managed by decreasing transmission of TB. Political will, commitment and visible leadership are therefore urgently needed to manage this health crisis that is out of control.

While TB rates are decreasing worldwide, including in Africa, the World Health Organisation’s Global Tuberculosis Report 2013 notes that the estimated TB incidence in South Africa – already unacceptably high for many years – has continued to increase. TB incidence in South Africa is now estimated to be more than 1,000 cases per 100,000 people while in countries like USA, Japan, Australia and many countries in Europe it is less than 10 per 100, 000. In addition, South Africa is one of three countries (together with India and Ukraine) with the largest increases in multidrug-resistant tuberculosis (MDR-TB) between 2011 and 2012.

The causes of the recent increases in TB in South Africa are complex, and addressing these problems requires a clear framework of action in which research findings inform the actions of the South African government.

The first of the actions we need to take is to identify and treat the cases that have been missed. According to the World Health Organisation Global Tuberculosis Report 2013 “about 75% of the estimated 2.9 million missed [TB] cases – [i.e.] people who were either not diagnosed or diagnosed but not reported to National Tuberculosis Programmes (NTPs) – were in 12 countries”, of which South Africa is one.

The percentage of cases on treatment in South Africa has been estimated to be [as low as] 22%. This is because many people who have TB symptoms do not access healthcare services, and many of those who do access the healthcare system with symptoms of TB are not tested. It is estimated that in South Africa, a quarter of people who are diagnosed with TB are never started on treatment. The gap in treatment coverage for detected cases of MDR-TB is also continuing to widen. The inability of health services to provide adequate follow-up and treatment is both cost inefficient and a poor use of health service resources. It may also be regarded as an ethical and professional failure.

The second action we need to take is to increase the amount of funding for TB services. While it is encouraging that new diagnostic tools are available, these are expensive. Careful evaluation of new approaches is needed within the context of South Africa-specific operational research. A commitment from the government to fund such research should be given, as well as a commitment to using the findings from such operational research to bring about changes in policy, management, and practice.

Finally, gaps in the provision of basic healthcare must be addressed as a matter of urgency, and raising awareness of current weaknesses is important. Politicians should be encouraged to raise awareness of TB as a health crisis by talking publicly about TB and challenges in the health services more often. Lastly, there is an urgent need for proper governance and management in the health services, including the need for skills training and personnel deployment.

Overcoming our current challenges is important because it is the constitutional duty of the South African government to ensure that its expenditure on healthcare is cost-effective, that structures are in place to monitor and govern health service delivery, and that healthcare workers have the appropriate clinical and managerial skills. As Sections 27 and 28 of the Constitution specify, it is the duty of the state to ensure that “everyone has the right to access to health care services” and that “every child has the right to basic health care services…” and “to be protected from maltreatment…”

A failure to diagnose and treat TB in adults leads to ongoing transmission and places children at greater risk of contracting TB. This may be interpreted as a further potential failure on the part of the state to meet its constitutional obligations. At the same time, it is the responsibility of all healthcare workers, as public servants, to ensure that the constitutional rights of children are respected. This can be done by ensuring that all children and adults with TB are diagnosed and treated. The importance of upholding the rights of children is a particularly strong and positive incentive for the state to succeed in combating the current TB epidemic. As the WHO data indicates, urgent action is needed. •