An end to TB18/05/17Health
Dr Lucica Ditiu, the executive director of the Stop TB Partnership, reflects on the complex factors which have made TB the world’s leading infectious disease killer.
Every day close to 5,000 people across the globe die of a disease which is preventable, treatable and even curable. Tuberculosis (TB) killed 1.8 million people in 2015 – a tiny fraction of the estimated two billion people infected with TB worldwide. The result is that TB is today the world’s leading infectious disease killer.
PEN asked Dr Lucica Ditiu, the executive director of the UN-based international organisation the Stop TB Partnership, what lies behind this epidemic. She attributes it to three main factors: first is a lack of understanding of TB at all levels, which has led many to mistakenly believe it is a ‘disease of the past’; second is the nature of tuberculosis itself – an airborne infectious disease which is passed from person to person by air, it has an “amplifying effect”, as every one person who is not diagnosed and enrolled in treatment each year infects roughly 15 people; and third is the large number of people with TB living undetected and untreated. The World Health Organization (WHO) estimates that 200 million of the two billion people living with TB will get sick at some point in their lifetime. In 2015, 10.4 million people were newly affected – over 40% (4.4 million) of them were missed by the health systems.
The poverty problem
Why are so many people being missed? The answer, according to Ditiu, is simple – it’s the outcome of years of negligence. “TB is a very medicalised disease. The conversations about it have been mainly between doctors, nurses and technicians – with very little involvement of the people affected by TB, communities, or the private sector – and have focused on the dry aspects of developing guidelines and so on, instead of focusing on the people with TB, who exactly they are, what their needs, problems and other medical conditions are, and who, if anyone, is representing them. Because we haven’t brought those affected people into the conversation (in part also because we haven’t had the funding for proper engagement), we’ve never had an opportunity to build the civil society networks that you see in HIV – the kind of support systems where affected people can share their pain and experiences and go through treatment together.
“Combined with that is the fact that the majority of TB cases are found among people who – for whatever reason, be it gender, poverty, stigma, etc. – are unable to easily access health services and live in low-income countries that are least visible on the world stage – the countries that ‘don’t matter’ globally.”
TB is both a consequence and driver of poverty, Ditiu explains. It mainly affects people in their most productive years, taking them out of employment and depriving families of their major earners. Urban slums and overcrowded, poorly ventilated living and working environments are a breeding ground for undetected TB. Particularly at risk are homeless and poor people, migrants, refugees, prisoners, children, women and the LGBTQ+ community – those people for whom access to quality TB care and services is limited for a multitude of reasons, including costs, geography, legal status or stigma. Drug, tobacco and alcohol users, the malnourished, and people living with diabetes or silicosis face an increased risk of getting TB, as do people who are HIV positive – in fact, tuberculosis is now responsible for roughly one-third of HIV deaths.
In early 2015, the Stop TB Partnership moved its secretariat from the offices of the WHO to the more general projects and aid-focused United Nations Office for Project Services (UNOPS) in recognition of the fact that TB is not simply a medical issue but a multisectoral one, and as such demands a multifaceted response – from the ministries of not just health but education, agriculture, housing and the interior, etc. Ditiu would therefore like to see wider consideration of TB built into socioeconomic policies, into initiatives to tackle housing crises and poor sanitation, under- and malnutrition, pollution and discrimination.
The Sustainable Development Goals set the ambitious aim of eradicating ‘extreme poverty for all people everywhere’ by 2030. Can we end poverty without first ending TB? Not according to Ditiu: “We won’t end poverty, we won’t end HIV, and we won’t achieve universal health coverage until we reach every single person living with TB,” she says.
To do that, new tools – diagnostics, drugs and vaccines – will be vital. Current TB treatment is long (for MDR TB cases up to two years), time-consuming and very inconvenient (MDR TB still requires daily injections and as many as 14,000 pills), and comes with horrible and painful side effects (ranging from hearing loss, nausea and skin rashes to jaundice). As a result, many people drop out of treatment without completing the full course of antibiotics, making them vulnerable to increasing drug resistance – a challenge which is exacerbated by the fact that no new TB drugs have entered the standard treatment regimen in almost 50 years. There is thus an urgent need for greater research funding. Figures from health policy analysis firm Policy Cures Research show that investments in TB ($567m (~€520m)), malaria ($565m) and HIV/AIDS ($1,012m) made up the lion’s share of global funding for R&D on neglected diseases in 2015 ($3,041m), the latest year for which figures are available, but overall spending reached its lowest level since 2007.
Is this indicative of a lack of will to end TB? “We have encountered many challenges over the years, and the TB community has traditionally been very conservative and cautious when it comes to pushing the envelope, but there is a lot of goodwill and recent indications suggest that the world is beginning to take notice,” says Ditiu, who is optimistic that progress over the last few months will inspire something of a step change in the way policy makers talk about and approach the disease.
“One of the advantages of the Stop TB Partnership is that we can work at global and regional level to make TB part of the big conversations,” she explains, “and so far I am very happy with what we have delivered in that respect, because alongside our partners we have managed to secure the kind of high-level political visibility and initial commitments that we just hadn’t been seeing before.”
This progress began in December 2014, when the Stop TB Partnership supported high-level stakeholders from BRICS (Brazil, Russia, India, China and South Africa) to commit to joint action to improve access to first line tuberculosis medicines and to co-operate on scientific research and innovation on diagnostics and treatment – in line with the TB 90-90-90 targets first proposed two months earlier by the minister of health of South Africa and the chair of the Stop TB Partnership’s Co-ordinating Board, Aaron Motsoaledi, whose “amazing leadership” Ditiu credits for pioneering and inspiring “some of the world’s most innovative approaches to tuberculosis”.
A great number of things have happened since then: in 2015, the first lady of Nigeria, Aisha Muhammadu Buhari, was announced as a Stop TB Partnership ambassador, and has joined the country’s health minister in calling for accelerated case funding. In February of this year, the minister of health for Indonesia launched the Ministerial Decree on Tuberculosis, which among other things sets out guidelines for TB control and speeding up the implementation of TB programmes. Also in February, the government of India announced its plan to eradicate TB by 2025. Ditiu points to initial high-level commitments in the Americas in Peru, and in Europe and central Asia in Kazakhstan, Belarus, Moldova and Georgia – all of which will be discussed at the WHO Global Ministerial Conference in Russia in November 2017, a precursor to the UN General Assembly high-level meeting on TB, which is to take place in 2018.
“Five years ago, we would have been amazed to hear a minister of health talking about TB. Now we have four amazing ministers of health on our board. The challenge now for me and Stop TB is to engage and ensure the support of ministers of finance and heads of governments and, more importantly, we need to look at what’s actually happening on the ground – what the impact of all this talk and meetings is for the countries and communities and people who are affected by TB.
“So for me, the next step is to hold people accountable for what they say, irrespective of where and who they are, and to do that we need to put systems in place to allow infected people to report back to us and tell us how they’re being affected and what they need.”
The WHO’s End TB Strategy lays out a clear pathway and targets for tuberculosis prevention, care and control after 2015. Included is a 95% reduction in TB deaths and a 90% reduction in incidence rate by 2035 compared with 2015. Is this ambitious enough? Not according to Ditiu. Instead, she hopes that the upcoming UN General Assembly will deliver concrete numerical targets for TB detection and treatment.
“Governments can make all the commitments they want, but they mean nothing if we can’t deliver tangible improvements for those on the ground, at risk of infection or already living with TB. They mean nothing if we can’t find those missing cases of TB. So I would like to see the UN high-level meeting move towards a target of, let’s say, ten million people diagnosed and enrolled in treatment by 2020 – because then it’s counted in actual people and not as a percentage of an unknown whole; it’s a concrete figure.”
Towards a vaccine
Meeting any such TB targets will require action not just on diagnosis and treatment but also, crucially, on prevention. The BCG (Bacillus Calmette-Guérin) vaccine was introduced in 1921 and remains the only TB vaccine in existence today. But while it is effective against severe forms of childhood TB, it is unreliable against pulmonary TB, the most infectious form of the disease, has very limited efficacy in adults, and can be life-threatening if given to infants with HIV.
“We can make a difference without the vaccine. With the tools we have now, I am very confident that we can reach 90% of people sick with TB,” says Ditiu. “But we will never ever be able to end the disease until we have a safe, affordable and effective vaccine.”
Again, this comes down to a greater commitment and sense of urgency among pharmaceutical companies and public funding bodies.
“If we can find a vaccine that will stop infected people from becoming sick and will stop people from becoming infected, that would be amazing,” Ditiu adds. “By 2025 would be the ideal, but I am very worried because investment into vaccine development has declined in the last three years when it has really needed to increase. The more the investment is delayed, the longer we will have to wait on a vaccine, and the less time we will have to roll it out and see an effect.”
In the meantime, July will see heads of state and government meet in Hamburg, Germany, for this year’s G20 Summit, and Ditiu is hopeful that political interest in antimicrobial resistance (AMR) will force tuberculosis up the agenda. Drug-resistant TB is airborne and accounts for roughly one-third of all AMR deaths and has a higher incidence rate than any other form of antimicrobial resistance. More than half of all TB cases in 2015 were in the G20, including 55% of all multidrug-resistant cases – it seems obvious, then, that G20 leaders should take a particular interest in and responsibility for ending the TB epidemic, and Ditiu would consider it a “huge win” if each individual leader commits to concrete action to end TB in their own countries as soon as possible.
As for Moscow, she is hopeful that the global ministerial conference will contribute to a certain extent to the discussions at next year’s high-level meeting. “It would be great to see some strong statements and accountability from key stakeholders about the scale-up of TB treatment, drug-resistant TB, and TB/HIV co-infection, as well as research,” Ditiu said. “I also hope that we can have a very good discussion in Moscow about how to bring into our work the people who are directly affected by TB, civil society and advocates, and how they can lead our work.”
The Stop TB Partnership
This push to include more of civil society in the fight against TB is a particular focus of the Stop TB Partnership, which is working alongside many partners, including UNAIDS, the Global Fund, the United Nations Development Programme (UNDP) and the WHO to develop a human rights-based approach to ending TB that better serves those living with the disease. Within this, the Stop TB Partnership is calling on countries to prohibit discrimination against people with TB; remove the legal, financial, physical and cultural bottlenecks that limit access to tuberculosis services; and better include people with TB in health policy decision making processes. The organisation is also supporting civil society actors and networks in many ways, including in the form of the Challenge Facility for Civil Society (CFCS) – a funding mechanism which invests specifically in community and patient-centred initiatives.
Providing concrete support is central to what the Stop TB Partnership does. Through initiatives like the Global Drug Facility (GDF) – which works to increase access to affordable, high-quality TB treatments and diagnostics – and TB REACH – a funding tool for innovative approaches and technologies for TB treatment and diagnosis – the partnership is making a tangible difference in the communities that need it most. GDF provided more than 24 million treatment courses to 133 countries in 2014, while TB REACH is supporting a wide range of tailored initiatives to ensure screening samples, medicines and lab results get to where they’re needed in whatever way they can – whether by horse or by drone.
“We are very proud of what we do, and we like to be risk takers and innovators in the Secretariat of Stop TB Partnership,” says Ditiu. “We keep missing at least four million TB cases – if we want to diagnose and treat them, we need to change the way we think, the way we act, the way we take risks. We need to be smarter and more innovative and ahead of the curve.”
That’s why the Stop TB Partnership named its 2016-2020 Global Plan to End TB ‘The Paradigm Shift’ – to reflect the new kind of thinking that will be necessary if TB is truly to be a disease of the past. Do recent events mark the beginning of such a shift?
“If you had asked me a few months ago, I would have said no, but now I am slightly more optimistic,” replies Ditiu. “If we have this new mindset, if we work together, bring in the civil society, get the private and public sectors on-board, and have the investment, then we’ll see. We are more challenged when things are difficult, so we should just go ahead and never give up.”
Dr Lucica Ditiu
Stop TB Partnership
This article will feature in issue one of Pan European Networks: Health, due for publication in May.