The pandemic that just keeps on killing (and it’s not the coronavirus…)

Today (March 24th, 2022) marks the day in 1882 when Dr Robert Koch announced that he'd discovered the bacterium that causes TB. It was a milestone event that opened the way towards diagnosing and curing this disease.

If only this had actually happened as he’d hoped it would.

What’s happening with TB today?

TB has been tragically but correctly described as ‘the everlasting pandemic in plain sight’, and the WHO's press release for this World TB Day states that still “every day, over 4,100 people die from TB and nearly 30,000 people fall ill – despite it being both preventable and treatable.” In other words, despite TB being curable in most cases, roughly one-in-seven people who develop symptoms still die from this ancient disease despite it being diagnosable for nearly one-and-a half centuries and curable for three-quarters of a century.

So how can this possibly be the case given the might of modern medicine?

TB and COVID-19

Compare this with COVID-19 disease and these numbers begin to look deeply disturbing in respect of the risk from infection. It means that TB’s case fatality ratio is at least ten times higher than the newer pandemic pretender (the coronavirus) which comparatively-speaking had such vast sums of money thrown at it.

Here’s one example of this realting to vaccine expenditure. In the annual forecast for global drug spending made last April, the IQVIA Institute for Human Data Science projected that a total sum of US$157 billion will be spent just on purchasing coronavirus vaccines through to 2025. This only allowed for purchase and not administration, and it also allowed for two uncertainties: firstly a general price drop down to US$9 a dose (which hasn’t yet been glimpsed at yet at all); and secondly a dose rate of between 1.3 and 1.8 doses per person per year (which is modest based on current record). In other words, it may well prove to be a conservative estimate).

In contrast, currently a global total of only around US$5 billion is being spent annually on TB - on diagnostics, on treatments and on prevention services (i.e. the whole works including BCG vaccinations). This is not just less than half of the proportionately diminutive annual budget that was actually unanimously committed to for better control TB at the UN in 2018, but (if projected forwards to 2025 to compare it with the IQVIA conservative projection for money spent on COVID vaccines) is in total actually probably around a sixth of what is being projected to be spent just on COVID vaccinations.

Some deeper perspectives

The 17th century poet John Bunyan called TB ‘the Captain of these men of death’ and apart from a decade at the turn of the 21st century during which HIV was reckoned to be humankind’s most lethal infectious foe, Bunyan’s descriptor consistently stood for over 400 years right up until April 2020.

This was the month that COVID-19 disease (that's provoked in so many cases following infection with the SARS-CoV-2 coronavirus) stole TB’s unholy crown and has apparently continuously held it since, with around 6 million people reported to have lost their lives so far to the coronavirus over the last two years.

But there are now very strong indications that this situation will revert if it hasn't done so already, that TB will reclaim its crown. Only a month ago the 7-day global average of daily COVID deaths was nearly 11,000. In the last four weeks, however, it’s dropped to less than 5,000. This is still higher than the WHO’s TB daily estimate of 4,100 TB deaths, but in the week following this year’s World TB Day it looks almost certain that TB will once again officially be reckoned to be the most lethal disease affecting humanity.

What makes this assessment worse is that it’s been consistently reported since 2020 that TB deaths have been back back on the rise (and those 4,100 daily deaths quoted above relate to 2020 not 2022).

The fact is that in the most recent Global TB Report, the annual deaths from TB for 2020 (the most recent year wirth available data) were already reckoned to have increased for the first time in a decade, but this same Report contained an additional caveat, warning that ‘TB mortality is projected to be much higher [in 2021] than in 2020’.

In other words, in the next Report reflecting numbers for 2021 (due in October 2022) TB mortality isn’t just predicted to be higher, but is actually predicted to be ‘much higher’, and it will be even higher still on this year’s World TB Day, quite probably nearer 5,000 deaths a day - already higher than deaths from COVID-19.

Has TB really stolen back its unholy crown?

So, given so little is reported on the matter, is it really reasonable to suggest on this World TB Day 2022, that TB, this ‘everlasting pandemic in plain sight’, is once again the most lethal infectious pathogen affecting humankind, killing more human beings than COVID-19 and so deserves much more appropriate attention because of this? All the available statistical evidence suggests so.

Such an idea is really significant for those responsible for TB control, not just because things change slowly with TB, but also because there’s actually been such a shamefully small decline in death rates anyway over the last thirty years (i.e. since 1993 when TB was officially declared a Global Emergency). Back then there wasn’t really any idea at all how many were dying of TB – annual estimates were ranging wildly between 2 and 3 million deaths a year. They have been most recently estimated to be 1.5 million for 2020, but are almost certainly more today.

At best, we think we can reasonably suggest that overall the death rate from TB may have been reduced by 50% during what amounts to a thirty year period of serial neglect and under-funding (not least because deaths didn’t even begin to drop for the first two decades). This World TB Day the WHO sounds more upbeat, about this than they might do currently proclaiming that since 2000 ‘an estimated 66 million lives have been saved due to global efforts to combat TB’. It's a big number, but we are sadly unable to recognise this estimate as being that coherent with other estimates and, what’s more, we’d suggest that it’s not as impressive as it sounds anyway if simultaneously compared to the corresponding death toll. Their total (66 million lives saved) over the period concerned (22 years) suggests that around 3 million lives have been being saved each year since 2000. Since 1.5 million lives are still being lost annually (probably more now), this in turn suggests that a total of 4.5 million lives would have been being lost without these ‘global efforts’ occurring. And yet the WHO has never estimated anywhere near 4.5 million deaths per year from TB (hence the incoherency) and, any way we look at it, those global efforts have been terribly inadequate anyway given that TB is curable in most cases and treatment is really cheap. (Saving the life of a TB case is REALLY cheap!).

Conclusions for World TB Day 2022

Have they overestimated the number of lives being saved, or have they been serially underestimating the annual deaths? It hardly matters. What matters is that this incoherence is one more reflection of the essential neglect that those most vulnerable to TB (i.e. the poor) have consistently suffered from for the past thirty years.

And what matters more is that this abysmal global record is consigned to history starting this World TB Day 2022. At the UN back in 2018 world leaders unanimously pledged to end TB by 2030. We need to stress this one important word – they did so UNANIMOUSLY And they committed to fulfilling funding to do so. They have totally, shamefully and collectively failed to honour their unanimous commitment, which is surely worth identifying today.

The WHO, meanwhile, states that “World TB Day is an opportunity to focus on the people affected by this disease and to call for accelerated action to end TB suffering and deaths, especially in the midst of the ongoing COVID-19 crisis”.

They are so right about this.

So let us focus on this: the total annual budget reluctantly awarded it by world leaders at the UN in 2018 (US$13 billion a year) remains miniscule compared with the eye-watering amounts of cash lavished on the coronavirus pandemic since January 2020. What’s so disconcerting is that even this comparatively tiny TB budget wasn’t being even nearly met at the end of 2020 (they only managed to cough up half of it...). This was even before we’d heard of the coronavirus or called it out as a pandemic.

The WHO’s theme for World TB Day 2022 is also ‘Invest to End TB. Save Lives.’

Damn right we need to invest and save lives. And there are millions of them waiting for our response.