No One Should Die Of Tuberculosis In The 21st Century

"How unromantic it is to die of tuberculosis in the twenty-first century?"
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"How unromantic it is to die of tuberculosis in the twenty-first century." These were the words of a Russian man in his twenties, written just before he died from drug-resistant tuberculosis (TB). Unromantic indeed: 130 years after it was first discovered and almost 60 years after the first antibiotics became available, one third of the world's population is infected with TB. Every four seconds someone becomes sick, every day 4,500 people die from this largely treatable disease because they do not have access to proper diagnosis, medicines and care. We do not even know how many children die from TB because until very recently pediatric TB has been largely ignored by the global community. TB continues to be the leading killer of people with HIV.

It gets worse: A growing proportion of those infected with TB, like our Russian man, have drug-resistant forms which require longer courses of treatment with more toxic second-line drugs. Many patients die without any treatment, but not before transmitting the disease to others in their communities. These strains are now found everywhere. Some of them have become resistant to all known treatments.

But drug-resistant TB is not new. An outbreak in New York City in the late 1980s was successfully contained by building appropriate diagnostic capacity, using second-line drugs and by supporting care to patients over the grueling two-year long treatment. Resistant TB strains were also found in poor countries, but the global response was limited by international health policies that said that in poor countries it was "too expensive" to treat these forms of TB. This was a mistaken approach to an airborne disease.

There was a moment of hope at the turn of the century. A group of non-governmental organizations and global health advocates -- most notably Drs. Paul Farmer and Jim Yong Kim and our team at Partners In Health as well as colleagues from Médecins Sans Frontières and the U.S. Centers for Disease Control -- proved that drug-resistant TB could be treated in poor countries. The Green Light Committee (GLC), a mechanism to help countries access quality-assured second-line drugs at affordable prices, was created. This partnership negotiated massive price reductions (from more than $30,000 per patient per year to less than $3,000). In 2003, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) voted to require the use of this mechanism for countries receiving its funding. This was done to make sure programs were using good quality medications, but led to unexpected bottlenecks and effectively created a monopoly.

So why are patients still dying and the problem of drug-resistance getting worse? While the GLC helped small pilot treatment projects begin in more than 75 countries, in its first decade of existence it only provided medicines and assistance for 25,000 patients out of an estimated 5 million new drug-resistant TB patients. In that same period, an estimated 1.5 million patients died of drug-resistant TB, and over 3.4 million people received substandard care or no care, and continued to transmit the disease.

The irony is that, all the while, there has been no problem with the global supply of second-line drugs. In fact, they can be purchased in pharmacies in many countries. There is, however, a shortage of quality-assured second-line drugs through our current global mechanism. Prices have remained very high, even as the prices of HIV drugs have plummeted. Some programs face a lag time as long as two years between the ordering and the receipt medicines (read examples here). Everywhere that I have visited in recent years -- more than 10 countries -- I have seen the same thing: drug supplies delayed; patients buying drugs of unknown quality in their local market; patients struggling and dying, but not before infecting many others. It is no surprise, then, that rates of drug-resistant TB are on the rise.

But today is World TB Day, so perhaps it is a good time to offer new ideas to fight this deadly scourge. One first step is for the GFATM to open the supply of quality-assured second-line TB drugs, and further work to ensure that the lowest prices are being paid as it does for malaria and HIV medicines. This would lead to more patients being treated and would also show an organizational commitment to seeing real outcomes in the battle against all forms of TB.

Another step would be for the United States government to play a strong leadership role in ensuring that treatment of drug-resistant TB is a prominent part of its global health agenda. At a time of budget cuts this may seem unrealistic, but given that this is an airborne disease that is rapidly becoming impossible to treat, this is of critical national importance. It also would follow on our nation's achievements in extending treatment for HIV and malaria globally.

If these two steps are taken, I see reason for hope. And I know that many individuals share my concerns, if not the suggested solutions. What was once a hushed conversation in hallways is now out in the open. Several global experts recently led a virtual expert panel on, where I and others from Russia, Ukraine, Armenia, Uganda, and other high-endemic countries shared views on this matter. The conversation on that panel was like direct democracy for practitioners on the frontlines. Now let's rise to the occasion, like we did to respond to HIV/AIDS. Let's follow with new policies so that no one dies of TB, a preventable and treatable disease. Indeed, "if there could be an Arab spring after decades of dictatorship and oppression," as a colleague from a large European NGO recently told me, "then surely there is hope for transforming our approach to TB." President Obama just nominated Dr. Kim to head the World Bank, so maybe this is a sign that we are ready to transform our approach to global health and TB. This may well be our harbinger of spring.

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