TB: What the numbers tell us about political will

By Marcus Low

Last month the annual Union World Conference on Lung Health was held in Liverpool, United Kingdom. As always at this conferences, much was said about how the world needs to step up the fight against tuberculosis (TB) – about how we need new agendas and paradigm shifts.

Unfortunately, new data released at the conference and in the preceding weeks paint a very bleak picture of the global TB response. The severity of the crisis is unquestionable. Per the World Health Organisation’s Global Tuberculosis Report 2016, 1.8 million people died of TB in 2015, there were 10.4 million new TB infections in the same year and over half a million (580 000) of those cases were drug resistant forms of TB.

How is the world responding to this crisis? Well, according to Treatment Action Groups (TAG) annual report into TB R&D, not good. Their report reveals that the already low investment in TB research has declined even further in 2015. The entire global investment in that year was $621 million. This is less than a third of the $2 billion that the WHO estimates is needed per year. That the entire world together can’t even come up with this comparatively small amount (given the size of national budgets) is mind-boggling.

As Mike Frick of TAG recently pointed out in Spotlight, the situation is even bleaker when looking at high burden countries. The BRICS (Brazil, Russia, India, China, South Africa) have roughly half of the world’s TB cases and TB deaths, but only contribute 4.3% of public funding for TB research. South African universities received more TB research funding from the US National Institutes of Health (NIH) and the Bill & Melinda Gates Foundation than from the South African Medical Research Council or other domestic agencies. With a Trump presidency in the United States, it is unclear whether even these NIH funds will be there in future. (For those who are interested, there is a petition calling for BRICS to triple investment in TB R&D.)

The inescapable conclusion is that, even though TB is killing their citizens, BRICS nations do not see TB research as a priority. This is fundamentally a political problem. Most people who die of TB are poor and not politically well-enough organised to advocate for a better TB response. And, unfortunately, with a lack of grassroots political pressure most politicians remain indifferent to TB – the one notable exception being South Africa’s Minister of Health Dr Aaron Motsoaledi.

India has more TB cases and TB deaths than any other country. It is the epicentre of the TB epidemic much like South Africa is the epicentre of the HIV epidemic. Yet, while the Indian government has made several encouraging announcements regarding its TB response, almost two years after making these announcements they have failed to implement many of the things they have promised. These include absolute no-brainers like daily fixed-dose combination TB treatment for people with HIV and the provision of appropriately dosed pediatric FDC treatment for children. When activists interrupted Jagdish Prasad, Director General of Health Services of the Government of India, he responded by telling media that the activists are “unstable” and “mentally unwell”.

But one wonders why it was left mostly to activists to call out India’s broken TB promises. For all the talk of paradigm shifts and new agendas, most of the TB establishment seems more committed to politeness and quiet diplomacy than to doing what it takes to bring about a paradigm shift.

This inertia may in part be explained by the fact that many in the TB establishment are from and live in countries where there is very little TB. Incidentally, as pointed out in a recent civil society letter, of the 10 Union World Conferences on Lung Health from 2007 to 2016, six were held in Europe (none of which were in Eastern Europe), two in Africa (both in Cape Town), one in North America and one in Asia. Mostly, the conferences are where the TB is not.

There is nevertheless some limited reasons for hope. Firstly, there are a number of good researchers and healthcare professionals dedicating themselves to TB research under often very difficult conditions. As with the very encouraging early results from a trial of a new XDR TB treatment, these efforts are already resulting in life-saving advances. We must urgently do more to support these researchers and to encourage more medical researchers to work in TB a big part of that will be finding more money for TB research.

Secondly, and getting back to TB’s bigger picture political problem, there appears to be a growing awareness among at least a small group of committed people that we need to politicise TB outside of these annual conferences. Two things stand out in this regard: the push for a UN High Level Meeting (HLM) on TB and the growth of the Global TB Caucus of parliamentarians. In both the HLM and in the work of the TB Caucus, it will be difficult to find the correct balance between staying politically correct and saying what needs to be said – for example in relation to India. As was the case with HIV, we will need bureaucrats, diplomats and researchers to step out of their comfort zones and to become activists.

As always, most governments and government officials will attempt to underplay the TB crisis in their countries and the short-comings in their own responses. We should not stand for such short-sightedness. The numbers make it clear that TB is an urgent crisis in the lives of millions. We should allow it to become a political crisis as well. Only then will we see the paradigm shift people keep talking about.