World TB Day 2020 - and it's a very different one...

Today (march 24th) is World TB day and it feels very different this year.

It's because of COVID -19, of course – which is another potentially lethal infectious disease which mainly infects the lungs, but that’s pretty much where the similarities end. TB is a (myco)bacterium, for instance, while COVID is a (corona)virus. When it does so TB takes its victims slowly over years while COVID does so fast. The interaction between TB and humanity, meanwhile goes way back millennia into prehistory, while our human species’ interaction with COVID-19 is less than four months old. And while TB has continued to suffer from not getting anywhere near the appropriate attention and resource to drive down the nearly two million avoidable deaths it causes each year, almost incalculable sums are already being spent on trying to contain this new viral infection.

Not for a second are we suggesting that doing this is wrong. Rightly, COVID is now being called the biggest threat to humanity from an infection since the 1918 ‘flu, so there’s no question that everything must be done to control it. We are just wondering what this is going to do to TB programmes everywhere and also to the subsequent profile of the disease for global authorities.

We don’t know the sort of total budget that has already been awarded globally to fighting COVID, nor do we have any idea what the total amount of precious human resource that is being thrown against it might be. We suspect that it already amount to hundreds of billions of dollars, and will involve hundreds of thousands of health workers. We cannot help, though, but quietly compare these sorts of numbers with what gets annually allocated to TB control.

COVID-19 in the Global South

What’s been interesting (and paradoxically also very concerning) is the apparent lack of cases of COVID-19 in the Global South. To us this seems improbable. The truth is that many developing countries have constant interactions with China, so the likelihood that it hasn’t taken root in many of these countries is frankly unlikely.

Of course, there may be a simple explanation for this – lack of tests and lack of laboratories to conduct them in. Exactly the same is the case with MDR-TB, incidentally, with lack of surveillance and diagnostic resource still being deficient in most TB endemic countries a full 27 years after TB was declared a global emergency back in 1993.

It’s hardly radical to suggest that diagnostic resource is the key to fighting both of these diseases – you can’t really expect to control something if you don’t know its extent. But while this deficiency in relation to COVID is being rapidly addressed in most industrialised countries (having been very well addressed almost immediately in some countries in East Asia) it’s unlikely to be seen in countries in the Sub-Sahara for some very critical time.

This is a matter of major concern. Please be in no doubt that COVID will almost certainly kill far more extensively in these countries than in Europe or North America. There’s been a myth put about that those with African ethnicity might have some inherent genetic resistance to this infection. We don’t for a second expect it to be proved to be true, not least because we’ve already heard from Uganda (when they were officially not reporting a single case) that they were seeing a lot of people with flu-like symptoms.

So why will there be more deaths in these countries (given, for instance, that the average age of the population is younger so might be considered to be of lower risk)? It’s for the same reason that they have such terrible TB epidemics – because their populations are intrinsically immune compromised because of under-nourishment, poor living and working conditions and (more recently) because of the effects of climate change.

Can anything be done about this?

This is a big question, and it’s one that we’re almost unwilling to ask because of the probable answer (which is ‘probably not so much’ particularly in the critical short-term). Perhaps China will manage to help if they are able to maintain their current reductions in infections and deaths from COVID. Cuba may well do the same (we saw that they flew a plane load of their doctors into Italy yesterday, for instance).

But we suspect that the effect of COVID-19 generally in the developing world will be immense and go largely unnoticed. Moreover, a vaccine (when one is hopefully developed some time very soon) will be distributed (like global treasures) unequally – in truth how do you distribute a vaccine ‘fairly’ anyway? And if drugs are developed, the same will apply.

But since this is World TB Day, we feel it’s important to ask – what will happen to these countries TB programmes while all this is going on?

National TB programmes.

There is no debate anywhere that TB programmes (and indeed TB research) are already massively under-resourced, both financially and in terms of human resource. “Funding for the provision of TB prevention, diagnostic and treatment services has doubled since 2006 but still falls far short of what is needed” was what was reported by the WHO last year, amounting to US$6.8 billion in the last reported year. (Compare this with the sorts of numbers being thrown around in industrialised countries for fighting COVID-19[i]). These deficiencies were similarly well identified at the High Level Meeting on TB which was convened at the UN in November 2018, with all members states signing up to sets of targets for 2022 to help address them.

(These deficiencies, incidentally, sound miniscule when compared with the sums being thrown at COVID in the last few weeks).

So what is likely to happen in these countries as the reality of COVID emerges properly from the shadows. It seems more than probable that health ministries will rob Peter, as they say, to pay Paul – will pull human and financial resources from their slow-burning persistent national TB programmes, and use them fighting the immediacy of COVID-19.

Wouldn’t you do the same when faced with such an immediate problem? It’s certainly what politicians are doing all over the industrialised world – borrowing heavily from anywhere to fight the new disease.

Here’s an article that specifically discusses this in relation to TB programmes in both China and South Korea as they have brought their COVID epidemics under control.[ii]

World TB Day Message from TDR

Today we were sent an email circular from TDR, the Special Programme for Research and Training in Tropical Diseases, including the flowing specifically from it’s Director, John Reeder:

“As the world comes together to tackle the COVID-19 pandemic, it is important to ensure that essential health services and operations are continued to protect the lives of people with TB and other diseases or health conditions.” Dr Tedros Adhanom Ghebreyesus, WHO Director-General, made a similar statement which amplifies this:

“COVID-19 is highlighting just how vulnerable people with lung diseases and weakened immune systems can be.”

The heart of the matter.

Let’s assume that we roughly see the end of COVID-19 before the end of this current year. In what state with the fight against TB and MDR-TB be at that point? Resources (both human and financial) will have been decimated); any progress towards meeting the ambitious UN-set targets will have gone into reverse; and, of the 1.7 billion members of our human family who are estimated to already be infected with sub-clinical latent TB, many will have died. But of the survivors (and hopefully this will be the vast majority) will it be less or more likely that their latent infections will reactivate into active potentially lethal disease?

Sadly, we don’t think you need to be an epidemiologist or an expert in TB to know the likely answer to this.

So March 24th 2020 is unfortunately a landmark World TB Day for all the wrong reasons. Many reading this may find it too challenging to consider all that this implies for the world’s poorest.

As the world recovers from this pandemic, we will all face massive challenges. What is blindingly obvious, though, is that after this pandemic the world must change, and we will have to finally recognise our interdependence in the course of making these changes or go down like the dinosaurs.

[i] For instance, last week New Zeland with just 29 confired cases committed US$12.4 billion to fioghting its COVID epidemic. It may well prove to be money well spent, but should still beg lots of questions down the ine about the funding for tuberculosis control. [ii] https://www.forbes.com/sites/madhukarpai/2020/03/17/covid-19-and-tuberculosis-we-need-a-damage-control-plan/#226d8c22295c