This op-ed is re-posted from the UN Inter Press on September 28.
In the early months of 1993, there was frenetic activity within the Geneva headquartered WHO’s Communicable Diseases program, to get Tuberculosis designated as a Global Emergency.
While countries like India had instituted TB Control programs as early as 1962, and Tanzania in the late 1970’s had shown field level evidence of programmatic innovations like directly observed treatment would reduce TB related mortality, the global reality was things were not going too well as far as reducing incidence and mortality for this age-old disease.
Frighteningly, for the western world at least, the disease had made a dramatic comeback, showing up in a drug resistant avatar in New York between 1991-92.
Fast forward 25 years — it is 2018: Tagged the world largest TB burden country, India’s Prime Minister Narendra Modi has committed to India eliminating TB by 2025; and at last, TB had a special UN High Level Meeting on September 27th.
The intervening 25 years since the declaration of the “Global TB Emergency” has seen robust growth of national TB control programs. The WHO expanded the list of 22 high burden countries of the late 1990s to include many more countries and three different categories of burden.
India’s Prime Minister Narendra Modi at the Delhi End TB Summit, March 13, 2018
India, Indonesia, and Nigeria remain hosts to a large proportion of the global TB burden and represent the best opportunities for making the largest impact to it. Though Brazil, South Africa, and China also have sizeable TB burdens, they have remarkably responsive TB control programs in place already.
The toolkit to combat TB has changed somewhat too. There is a growing awareness that old diagnostic tools will not help. Newer technologies, available but still not entirely affordable by lower income countries at scale, need to be deployed extensively.
Advances in information technologies are also reshaping the use of old tools like chest X Rays, digitizing and transmitting them to cloud based servers where they are analyzed and reported back in minutes, without waiting on radiologists.
There is growing understanding that in the battle against bacilli, there will be the need to prevent the emergence of resistance, and where already present, manage with appropriate drug regimens. This is expensive, but no longer optional, and will require the same collective bargaining power that institutions like the Global Fund to Fight AIDS, TB and Malaria brought to the fore to bring down anti-malarial drug prices in the mid 2000’s.
While the bio-medical toolkit to combat TB will change, and it will – with enough urgent support and resources directed towards research and development, the greatest change needs to be in focusing political capital to the elimination of this age-old disease.
Tuberculosis in the community, like the mycobacterium bacilli inside the human lung, is to be found where there is little chance of it being discovered and dislodged easily. In real terms, communities and individuals who are on the margins of society, geographically or socially, are most likely to be where the disease continues to find its long-term incubatory refuge.
Without adequate political capital to reach, diagnose and treat those at the social and geographical margins, even the best new toolkit and operational innovation to fight TB will fail. Which is why Prime Minister Modi’s public statement on March 13th this year at the Delhi EndTB Summit is both welcome, and necessary to be replicated at sub-national and local levels, and in every other country where TB currently takes a toll.
When a disease elimination program is politically led, resources are eventually found. The Global Polio Elimination Initiative over the past 20 years showed us that. Tuberculosis has that moment in 2018.
The technical and TB program community, ably marshalled by the Stop TB Partnership, needs to provide the required assurances to those whose careers are electorally determined, that TB is a winning proposition, both from a public health perspective and from the good that it does to restoring individual productivity.
It is estimated that a dollar invested on TB control in today’s terms returns over $43 in cumulative productivity gains. It is the technical and program implementers community, from the WHO at global, regional and national levels, national health programs, partners like the World Bank and the Global Fund, and the myriad civil society organizations and voluntary groups who need to provide robust encouragement to, and backstop, the commitments political leaders make to their communities.
Mycobacterium Tuberculosis bacilli are notoriously insidious growers, taking their own time to make dramatic, debilitating appearances. One hopes that the growth features of the bacilli is a metaphor for the global movement against TB –long in the making, but truly dramatic in the way things change to eliminate the epidemic.
Bobby John is a New Delhi based physician and global health advocate and heads up ACTION partner Aequitas, which is based in India.