The forgotten deadly pandemic

The writer is a senior public health specialist and editor-in-chief of Public Health Action, a journal of the International Union Against TB and Lung Disease.

Tuberculosis (TB) has been claiming human lives throughout history, starting with records of human deaths dating back to over 9,000 years ago. As its killing spree peaked in most of the Western world, it assumed titles such as the ‘Captain of Death’ or ‘The White Plague’.

After the 18th century, it began to decline in Europe and North America, yet it continued its ravages in poorer countries and came to be seen as a disease of poverty. A major breakthrough came on March 24, 1882 with the identification – by Heinrich Hermann Robert Koch – of Mycobacterium Tuberculosis as TB’s causative agent. Koch would go on to do the same for cholera and anthrax, and is regarded as the main founder of modern bacteriology. He secured the 1905 Nobel Prizes for Physiology and Medicine and was knighted. However, it was his discovery of Mycobacterium Tuberculosis 140 years ago that we recollect on March 24 every year as World TB Day. Then came the BCG vaccination around a century ago, followed by tuberculosis drugs starting with the discovery of streptomycin in 1944 and isoniazid in 1952.

The theme of World TB Day this year was the bluntest in my 25 years’ association with the control of the disease – ‘Invest to End TB - Save Lives’. In simple words, it urged all national governments and their development partners to enhance their level of spending if they are really serious in eliminating TB and not merely pay lip service. We need to ensure equitable financing and access to TB prevention and care consistent with the Sustainable Development Goal towards achieving universal health coverage.

Every day, over 4,100 people die from TB and nearly 30,000 people fall ill with the disease globally – despite it being preventable and treatable. In Pakistan, which has the fifth highest burden of TB, 600,000 new people get the disease while 35 people die daily due to the disease

Tuberculosis is the leading killer among infectious diseases and among the ten priority areas of the government of Pakistan’s health sector. Around a quarter of the world’s population is infected with Mycobacterium tuberculosis without symptoms, commonly known as latent TB infection (LTBI), and thus more at risk of developing TB disease; it is generally assumed that this includes 30-40 percent of our population of 280 million.

Certain deprivations of poverty such as overcrowding, lack of basic education in rural females, poor ventilation, malnutrition, smoking and diabetes constitute the more important risk factors of the disease. However, TB has historically claimed the lives of monarchs and thousands of eminent men and women also over the years.

Coming nearly four years after the UN General Assembly declaration of September 2018, World TB Day also highlights the need to urgently accelerate the TB response by intensifying TB awareness among healthcare providers, diagnosing and treating latent TB and TB infection through quality measures, highlight personal experiences of TB survivors or those undergoing treatment themselves or through celebrities to the end stigma attached to this ancient disease.

As pointed out on January 18, 2022 by President Arif Alvi, around 360,000 cases are identified and over 90 percent of them are cured by the national and provincial TB control programmes, over the course of six months. We have free diagnosis and treatment facilities available in thousands of public health facilities across the country, even for those resistant to first line TB drugs; patients are even being provided basic psychosocial support, food support and travel costs in addition to their treatment regimens. Now people neither need to go to hill stations nor should there be any stigma attached to the disease.

Despite a high level of political commitment available in Pakistan, the main concern is the slow pace at which tuberculosis incidence is decreasing. It is in fact growing slightly in Pakistan, keeping in view the population growth rate. This makes it imperative to harness the over 200,000 missing cases that are not being identified or notified by the public sector and who are either being treated by the private health sector or quacks. Unless these cases are tracked and notified, there is no way of bringing about a 90 percent reduction in the number of deaths due to tuberculosis, or an 80 percent reduction in tuberculosis incidence till 2030, despite the use of new diagnostic and therapeutic tools, and applying principles of equity and human rights with equitable financing.

We must not allow the unprecedented level of political commitment leveraged after the UN’s extraordinary meeting to be dampened due to Covid-19. We must instead capitalize on the newly created opportunities and materialize our goals through funding, concrete action, and accountability at all levels, despite the huge drain on health resources due to Covid-19, which thankfully is on the wane at present.

Several high-tuberculosis burden countries like Pakistan are also depending heavily on the Global Fund grants for TB control and elimination, which play an important role in several low-income and middle-income countries. However, there is a need for indigenous national budgets to increase significantly in Pakistan to ensure government ownership and accountability. In the context of the country’s devolved setup, a lot will depend on the investment of the provincial governments, with the federal government looking after the residual mandates left at the Ministry of National Health Services, Regulation and Coordination including inter-provincial coordination, establishment of programme modalities, setting on national targets and goals, operational research and disbursement of grant logistics.

This year is a critical year for all of us as; what we do now will be reflected and reviewed by the international community, while will meet by the end of December 2022. The ongoing efforts to contain the Covid-19 pandemic, accompanied by critical funding gaps, are also likely to cause disruptions leading to an adverse impact on TB-control activities.

Certain positive developments in the fight against TB include the formation of a proactive End-TB Parliamentary Caucus in Pakistan comprising members from all political parties and headed by the highly dynamic parliamentary secretary for health, Dr Nausheen Hamid, and its alignment with the Prime Minister’s Task Force on SDGs, detection of private-sector patients through private pharmacies and their inclusion in the database, piloting of a multi-sectoral accountability framework for TB control at district level, focus on community involvement, gender mainstreaming and human rights to make the interventions more patient-centered and user-friendly and a genuine desire to improve things augur well for the future of TB control and elimination.

However, it is highly probable that the enormity of the task may have been grossly under-estimated and the pace of effort currently underway may not be able to make a significant dent in the state of affairs, keeping in view the weaknesses of our otherwise impressive network of health facilities. All the stakeholders need to be mindful of the barriers involved in this immense task, particularly at the provincial and district levels.

What is really required is casting the net more broadly to harness all the missing TB cases and following their treatment process until they are fully cured, particularly in the private sector. The facilities for drug-resistant TB patients need to be enhanced with greater psychosocial support and attention paid to their mental health needs. The provincial governments need to redouble their efforts consistent with the national guidelines. Communities and the civil society need to provide monitoring to the programme to make it accountable with a greater consortium of partners having a shared vision of the way towards the coveted goal of TB elimination by the year 2030. This is a goal we cannot afford to miss.