International TB Day 21: The clock really IS ticking
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It is eminently preventable and curable! Yet, Tuberculosis (TB) keeps rearing its ugly head claiming over 1.4 million lives in 2020 as if it is showing two fingers to human hubris and complacency.
Today, March 24, as the world marks World TB Day 2021, we should be asking our governments and ourselves why are we still plagued by one of the world’s deadliest infectious killers some 129 years since Dr Robert Kock first identified the bacterium that causes TB in 1882, which opened the way towards diagnosing and curing the disease?
The major historical landmark TB therapy include streptomycin and para-aminosalicylic acid in 1944; the “triple therapy” cure comprising the above two plus isoniazid in 1952; the recognition in the 1970s that isoniazid and rifampicin reduces treatment from 18 to 9 months; and the observation in the 1980s that adding pyrazinamide to the latter two antibiotics resulted in cures in only six months.
South Africa, unfortunately, is well entrenched in the Top 30 High Burden TB countries, which account for 85% of new TB cases. The latest WHO data shows that, globally, the number of new and relapse TB cases per year decreased from 4,393,980 in 2016 to 3,829,228 in 2020. In South Africa, the figure similarly decreased from 237,045 in 2016 to 124,426 cases in 2020.
Lest these figures are beguiling, they are skewed by the impact of Covid-19.
Beleaguered governments wantonly raided the revenues and resources allocated to other pandemic pathogens, which in South Africa include HIV, TB and malaria, to boost Covid rescue packages as if it was a zero-sum Game of Pathogens.
The true extent of mortality costs of this misplaced strategy of diverting resources away from the battle against HIV, TB and malaria, including reassignment of health staff and equipment, as opposed to the opportunity costs gained from the Covid response will become clear later this year as more data gets reported and analysed.
WHO provisional data for 2020 presents a sobering and disturbing reality for which policymakers and other direct stakeholders including errant patients and vaccine deniers have to be held accountable for. WHO fears that over half-a-million more people may have died from TB in 2020, because they were unable to obtain a diagnosis, setting the world back a decade, to the level of TB mortality in 2010! This is directly the result of the impact of reductions in TB detection and care on TB mortality in 2020.
Data from 84 reporting countries also indicate that an estimated 1.4m fewer people received care for TB in 2020 than in 2019 – a 21% decrease from 2019. In 2020, they reported 4.9 million cases, compared with 6.3 million for 2019. In the group of 10 high-burden countries with the largest reported shortfalls including South Africa, compared with 2019, the overall shortfall was 28%.
Monthly notifications for 2020 in the top countries with the largest shortfalls compared with 2019 were Indonesia 42%, South Africa 41%, Philippines 37% and India 25%. This suggests a gross under-reporting of TB incidence and deaths in these countries.
“The effects of Covid-19,” emphasises Dr Tedros Adhanom Ghebreyesus, WHO Director-General, “go far beyond the death and disease caused by the virus. The disruption to essential services for people with TB is one example of the ways the pandemic is disproportionately affecting some of the world’s poorest people, who were already at higher risk for TB. These sobering data point to the need for countries to make universal health coverage a key priority as they respond to and recover from the pandemic.”
The data gap is nothing new. Before Covid-19 struck, the gap between the estimated number of people developing TB each year and the annual number of people reported as diagnosed with TB was about 3m. The Covid pandemic greatly exacerbated the situation. WHO’s new guideline for 2021 calls for a more systematic use of screening approaches. In high burden countries, surely it would make sense to have simultaneous screening for Covid-19, HIV and TB. Imagine the economies of scale.
TB claims nearly 4 000 lives a day and close to 28 000 people fall ill with it. Over 10m people fell ill with TB in 2019, of which 1.5m died of the disease. Some 465 000 contracted a drug-resistant (DR) strain of TB. The emergence of new DR strains and high prevalence of HIV in South Africa further undermines TB strategies.
Global bodies especially WHO have been exemplary in leading from the front. But how does one reconcile the gap between strategy and the reality on the ground?
That TB is largely a disease of the poor is not in doubt. But then viruses do not discriminate on the basis of race, creed or class. WHO Global Health Estimates/World Bank gross national income classification puts TB as the 8th leading cause of death in low-income countries, and the 7th in lower-middle-income countries. TB is bereft from the Top 10 leading cause of death in the remaining two groups – upper-middle and high-income countries.
“For centuries, people with TB have been among the most marginalized and vulnerable,” says Dr Tereza Kasaeva, Director of WHO’s Global TB Programme. “Covid-19 has intensified the disparities in both within and between countries. We must renew efforts to work together to ensure that TB programmes are strong enough to deliver during any future emergency.”
The themed for World TB Day 2021, ‘The Clock is Ticking’ – seems alarming. Blaming a coronavirus is convenient. The real challenge is to learn the lessons. WHO says that $13bn ( about R193.8 billion) is required every year to support efforts to end TB.
With Covid-19, Ebola, HIV, Malaria and a host of others competing for resources, the last thing the world needs, is a ‘Pathogen Beauty Parade!’
* Parker is a writer and economist based in London.
** The views expressed here are not necessarily those if IOL.