In a few days’ time the WHO will publish its annual Global Tuberculosis Report. You may find some reference made to it in the media. If you do, then what you'll read about it will most probably reflect a press release crafted by the WHO, the organisation which has the unenviable responsibility of trying bring this disease under control. What you read will also probably depend on where you live because, despite tuberculosis being a truly immense humanitarian problem, astonishingly little gets properly discussed about it in the media of those countries where the disease has now been dramatically reduced. Unfortunately, however, the same extraordinary reductions were simply never achieved in those countries (or at least in their poorer quarters where those who are most vulnerable to this disease live) which is why today we have such a serious collective public health challenge on our hands.
And we really are worried about what this imminent Report may contain - not just because of what it might say, but also what it may NOT say. So this is the first of a short series of blogs to promote awareness of this important publication – comprising a couple of discussion pieces before its publication, followed byn one on the day of the publication itself, and probably one a day or two afterwards once we’ve had a chance to take a proper look at it. In truth we hope that much of what we have to say in these earlier blogs will be proved wrong or even grossly unfair – and you’ll understand why if you read on.
This Report comes at a critical moment – it will appear at the end of the ‘Millennium Development Goal’ period (which has run up to 2015) – at the moment when a set of new targets are being set in stone for the next 15 years in the hope of achieving what hasn’t yet been achieved – which is a significant reduction in the incessant death and destitution brought about by this terrible disease. If this Report tells the truth about this devastation then we believe that any strategy developed from it will stand a chance of success, but if it chooses not to (and we do recognise that many of the reasons for not doing so may seem to the authors of the Report to be politically good ones) then we’re not at all sure that it will do much at all. In fact we fear not just that this emergency will continue, but that this treatable disease is now going to get more and more difficult to both cure and control.
Here’s something that we believe that this Report is going to say: that TB has this year taken back its old title of being humanity’s most lethal infectious killer disease. For some years now it’s been believed that HIV/AIDS had stolen this particular crown away from it – but if you recognise that a majority of those who live with an HIV infection in Africa actually die of TB even this interpretation has always been challengeable.
The Report is also probably going to say that TB still activates in around 9 million new victims a year, and kills about 1.5 million of them. In fact we believe that it kills many more than this – probably as many as 2.5 million. We also have a hunch that one or more recently completed national prevalence surveys are going to force the WHO to suggest that the rates of TB (incidence, prevalence and mortality) are all a bit higher than previously estimated – but ten we even know of an eminent London expert who thinks that even this will be a gross underestimation.
How can this carnage possibly have been allowed to have happened when the disease is said to be treatable and is almost eradicated in so many developed countries? Or when the world appears to be able to tool up so readily to control and outbreak of SARS or swine ‘flu?
Back in the 19th century it was being reckoned that as many as one in seven deaths in Europe were down to tuberculosis. Such terrible death rates began to reduce in the 20th century, to the extent that when the first TB drugs arrived the 1940s they really could make a difference and it was quickly realised that the ancient killer disease really could be driven into submission. What happened next (with enormous effort it should be said) was an incredible public health initiative which saw rates of TB infections plummet in both North America and Western Europe and “man’s oldest bacteriological foe” driven nearly to extinction.
But in the rest of the world, unfortunately this wasn’t quite the case.
When the United Nations was formed in 1945, one of the first things that it proposed was the setting up of a global health organization. The result was the WHO whose constitution came into force on 7 April 1948 – a day which we now celebrate each year as World Health Day. The Organisation was initially directed to attack three specific diseases: venereal disease, malaria and tuberculosis – so right from the outset it was directed to keep TB securely in its sights.
Unfortunately, the first forty-plus years didn’t see the same sort of progress made in what were then referred to as the second and third worlds as had been seen in Europe and America. In fact rather the opposite, and this was partly because almost all of those many experts in lung disease who’s learnt plenty about TB now switched their focus on to treating lung cancer. TB was left to fester away in the slums and the barrios, killing at will - but that was until HIV arrived to stir things up and the Organisation at last woke up to the implications of its own neglect.
So in 1993, a full 45 years after it was first formed with a founding intention of driving TB into submission, the WHO found itself unprecedentedly officially declaring TB to be a Global Emergency. And 22 years later, that same Emergency still exists though with an added twist.
Sure the rates of the disease have now begun to reduce (though it took twelve years of struggle to see this begin to happen). It’s now reducing at a little less than 2% a year which means that at this rate the disease could finally give itself up to biomedicine some time in the middle of the 22nd century. So energies are now being directed towards accelerating this decline. But since this Global Emergency was first declared something else has developed which makes things a lot more complicated than they were in 1993: a proportion of the disease has been becoming increasingly drug-resistant, and is threatening to become untreatable just as these belated efforts have finally begun to take effect.
Drug-resistance isn’t simple. Clinically speaking with TB it comes in two basic forms – either multi-drug resistant (MDR-TB) or extensively drug-resistant (XDR-TB). With the former the disease is resistant to the two strongest anti-TB drugs, it’s difficult to treat successfully and it takes a lot of money to do so. With the latter it’s resistant even to some (or even all of the weaker drugs as well, and it’s REALLY difficult to treat successfully, and is REALLY expensive. Each type of TB requires vastly different resources, entirely different clinical strategies and different infrastructural resources as well. In other words, we have three pandemics where before we had one.
Effectively we can look back and see that we’ve had two phases of TB control. The first (1948-1993) when this treatable disease was allowed to fester and flourish in poorer countries while it was practically eradicated in the richer ones; and the second (1993-today) when it’s been allowed to morph into three distinct diseases, two of which are only treatable depending if local resource can afford to do so. And this epidemiological disaster hasn't just happed onits own - it's been allowed to happen because drug-resistance develops through treatment mismanagement. It's a man-made disease in other words. What’s most astounding of all, though, is that this has been allowed to happen during 22 years of an official Global Emergency..
Is this all a gross oversimplification? Well some might argue that it is. But it’s at this particular point in this debatable history (when everything is undebatably on a knife edge) that this Report is going to be published.
Should we be interested in what it's gon to say? We think so, which is why we’re publishing this series of blogs.
The next blog in the series intends to discuss some of the responsibilities and what they imply.