Where Has All the Money Gone for Fighting Tuberculosis?

In spite of all these efforts, this fully curable disease has become a global pandemic. There are 8 million new cases in the world each year and 1.8 million deaths.
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Minna lies curled up on the floor, covered with vomit and excreta. She is pitifully thin, her eyes glazed and lifeless. She is unable to walk. There are no windows in the room, only the stench of death and decay.

Minna has XDR TB, a horrifying form of TB, which relentlessly devours the body. Treatment lasts a lifetime, and there is no certainty of recovery. Her family members avoid her for fear of catching the disease. They don't care if she dies. "It's her bad Karma," they say with a shrug. "It's the result of her evil deeds in her past life."

Tuberculosis has been around since times immemorial. Evidence of TB has been found in the spines of Egyptian mummies, which makes the disease 5,000 years old. Hippocrates named it "consumption"; in those days there was no treatment, and patients were doomed to die. As time passed, things improved. In 1882, Robert Koch presented his path-breaking discovery of Mycobacterium Tuberculosis, the bacteria that cause the disease. TB drugs were discovered from 1940 onwards.

In 1993 the WHO declared TB "a global health emergency." Eradication of TB became a priority and one of the MDGs. Now governments, non-profits, technical and international agencies are all focussed onto TB eradication, and billions of dollars have been poured into TB control programs across the world.

In spite of all these efforts, this fully curable disease has become a global pandemic. There are 8 million new cases in the world each year and 1.8 million deaths. Unfortunately one fourth occur in India alone, which has the dubious distinction of being the TB capital of the world.

As a disease, TB is terrifying. According to the WHO, it is the biggest infectious-disease killer, taking more lives than AIDS, cholera and other pandemics combined. But we have made matters worse. We have created Drug Resistant TB by our failure to ensure the complete six months of treatment. Incomplete and irregular treatment has led to successively worsening of disease forms, each more deadly than the last. We talk of MDR, XDR, XXDR and TDR-TB without realizing the enormity of the problem. We have developed the jargon, but not the solutions.

The chilling truth is this; apathy, arrogance, corruption and nepotism are all responsible for Drug Resistant TB, a disease inexorable as death.

TB has comeback with a vengeance, and that too in countries from where it had been eradicated. Let us see the writing on the wall. 84 countries have reported XDR TB. The EU spent $700 million on TB in one year alone. By 2015, there will be 1.3 million drug resistant cases, needing $16 billion to treat. 10 million children will be orphaned. In the next decade, the loss to the world's economy, due to TB in 22 high burden countries, will be $3.4 trillion. The brunt of the burden will be borne by low and middle countries. With 12 cases of TDR TB reported in Mumbai, India will soon become the TB factory of the world, and its biggest exporter.

Huge amounts of funds have been poured into a bottomless pit. Global fund gave $3.8 billion to TB in 2012 alone. India revived $10 million from the Global Fund for increasing awareness. This funding should have led to better outcomes, i.e. improved case detection and decreased deaths. Unfortunately, this has not been so. Processes are documented, but not the results nor impact. India has invested billions in the RNTCP -- the Revised National TB Control Program. The World Bank gave $100 million twice and now another $17 million is coming to India. No doubt one needs to improve infrastructure, but if the benefit does not trickle down to the poorest of the poor, then what is the use of it all? It's a sad story.

Where has all the money gone? We have to clean up our act. Make everything accountable. Ensure transparency. Emphasise that reporting MUST include measured impact. Promote NGOs that provide the last mile, use funds wisely, and believe in outcomes.

Pioneers such as Dr Carl Taylor, founding Chair of Johns Hopkins Department of International Health, stated, "There is no universal solution, but there is a universal process to find appropriate local solutions." Operation ASHA is instrumental in extending the Government's TB Control Program to reach marginalised communities who are susceptible to contracting diseases like TB. Delivering such services in hard-to-reach areas, such as in urban slums, rural villages and tribal areas, creates TB awareness and increases diagnosis, treatment and prevention of MDR-TB. The model effectively and appropriately bridges the gaps to deliver last-mile services in accordance with the needs and demands of a community, thus reaching the unreached. In TB, where drug resistance is becoming rife, Operation ASHA's model is being acknowledged for its transparency, impact, and cost-effectiveness. In eight years, their model is operating in India, Cambodia, Uganda and currently in talks with Afghanistan, Philippines and countries throughout Africa.

This is the path we have to take. If we do not, TB will continue its merciless march towards destruction, and millions of Minnas will continue to suffer and die.

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