The global failure of tuberculosis (TB) programs has reared its head again, and the recent strain of totally drug resistant TB (TDR-TB) has assuredly caught the attention of every TB official around the globe. Instantaneously the murmurs of ‘what are the global implications,’ and ‘what do we do’ have arisen like gossip in a grade school playground. It has stricken fear into the hearts of men, and threatens to terrorize global public health systems. Soon, it would seem, we will be poised for a biological massacre of poverty-stricken populations.
But this has been happening for decades.
In our deranged world of relative importance, where headlines and catchy names transcend basic public health necessities, it is not terribly surprising that we forget about uncomplicated, drug-susceptible TB. This acronym-less killer is responsible for more deaths on the African continent than any other natural disease, yet is allowed to run rampant throughout poor and forgotten communities. The result of this negligence is hundreds of thousands of deaths each year, but they are hidden in shantytowns and remote villages of the world’s poorest countries. Communities that we continue to turn our backs on.
It’s not that we can’t cure TB, it’s that we can’t cure TB for poor people.
“We live in a fabricated world where Band-Aid remedies allow the poverty-stricken patients to be out of sight and out of mind. Then when it arises, we carry out our half-hearted attempts to manage drug resistance in TB with baffling stupidity.”
Total resistance to TB has been present for decades, but instead of pathological resistance the culprits are apathetic governments, broken promises, paltry support for R&D, and non-functioning infrastructures that elude accountability. We have seen the resistant-TB hysteria before: first with the emergence of multi-drug resistant TB (MDR-TB), and again with extensively drug resistant TB (XDR-TB). Yet somehow, despite knowing the exact cause in resistance etiology, we manage to continue underfunding essential programs. We dilute accountability. We cut off international aid. We mirror the same ineptitudes that created these drug resistant demons. Inadequate diagnostic capability allows the unrestricted spread of disease, lack of capacity forces clinics to struggle with patient load and drug security, critical support is ignored, and political indifference allows all of this to continue with no accountability.
TDR-TD reinforces my claim that tuberculosis management should be deemed the largest violation of human rights the global health community has ever seen. We live in a fabricated world where Band-Aid remedies allow the poverty-stricken patients to be out of sight and out of mind. Then when it arises, we carry out our half-hearted attempts to manage drug resistance in TB with baffling stupidity. Quarantine policies plagued by limited bed space means that the vast majority of patients remain in the community highly infectious. Forcing patients to trek to centralized clinics creates an insurmountable logistical and financial barrier and localizes the specialized clinicians that should be in the community. Diagnostic systems remain a disaster. Quality of treatment remains a disaster. Drug supply security remains a disaster. Resource allocation remains a disaster. Management of TB remains a tragedy.
This is not to undermine the fact that novel efforts to address existing TDR-, XDR-, and MDR-TB cases are paramount to containing these epidemics – this importance cannot be overstated. Nor can the importance of research and support for new vaccines and better drugs, which need desperate funding and scale up. But today, on the ground, the only solution lies in basic public health. Left gutted, unfunded, and understaffed, TB infrastructures that remain substandard continue to allow countless deaths while hemorrhaging cases of drug resistance into the surviving population. Trial after trial, human rights based, patient-centered approaches to TB care have been shown to have tremendously positive results. Yet these successful programs, such as MSF’s work in Khayelitsha, South Africa, remain inundated with excuses from decision-makers as to why they cannot be replicated.
Given our wealth of technology, it is embarrassing that a curable, treatable disease has become the largest threat to public health systems in our lifetime. We allow our rhetoric and policies to fail with no repentance, remaining in a pitiful cycle with no signs of change. We fail to recognize that TB has transcended merely a medical disease and is one of poverty that must be addressed appropriately, including full incorporation of human rights. And every few years when a new resistant strain ‘surprises’ us, we pretend that we summon enough momentum for change, but in reality, we make the same mistakes with mind-blowing irrationality.
TDR-TB calls for novel strategies to stem this and other resistant strains, but should highlight how basic public health infrastructure could prevent resistance in the future. As exogenous primary infection of drug resistant TB rises, the world cannot afford to bicker in political offices. Lets put it bluntly: it will take more money, action, support, and far less rhetoric. But with appropriately directed, patient-centered methods, it can indeed be overcome. So lets get to work.
Bravo Jonathan – you’ve hit the nail absolutely on the head; tuberculosis management should be deemed the largest violation of human rights the global health community has ever seen. Accepting this and moving forward from it, we must all accept responsibility for the situation at hand and step up (as you are) to make change happen. WE must be the change. Who really cares what the most appropriate name for TDR-TB is? It seems to me we should be much more concerned with what to DO about it – for example, establishing an effective and GLOBAL public health infrastructure for properly treating all people with TB. This will require a scale of money, action, and support that will only come when enough people care about TB. How can we work together to accomplish this? As you’ve pointed out, this latest development seem to have garnered some attention. Let’s make the most of it. We should learn not only from our mistakes but also from the success of others – for example, programs for HIV prevention and treatment. Cheers
india a third world country there are mdr tb xdrtb and xxdrtb and now tdr totally drug resistant tb a misery of dots in india.
I was a former TB patient. The disease is the easiest to deal with but it’s the society’s attitude against TB victims that has been excruciatingly unbearable.
Thank you very much Jonathan.
Well I guess it depends on how you define human rights. Would TB treatment not have higher success rates if infectious patients were detained, by force if necessary, until their treatment was complete?
Human rights are defined by the United Nation’s Universal Declaration of Human Rights, and more specifically to TB and human rights can be found in these documents here, here, and here. There is little ambiguity in defining these.
Personal rights should be restricted in cases where the individual puts the population at significant risk – but it must make logical sense. In the U.S. or Canada for instance, forced isolation makes more than perfect sense. But legal frameworks assuming this is the answer in situations overwhelmed with TB are – at their core – a fundamental violation of these rights. South Africa, for example, has a centralized MDR-TB policy and its legislature allows for forced quarantine. Their rates of TB and drug resistant TB have only increased. They have a WHO estimated 13,000 cases and only 3,364 beds to treat patients.
In the context of the South African constitutional Bill of Rights, Section 36 provides an established framework for determining the legitimacy of restricting any individual’s rights, especially in the discussion of disease. This framework is heavily based on, “human dignity, equality and freedom,” and incorporates the nature of the right itself, the limitation proposed, its importance, and the connection between the limitation and the purpose. Section 36(1)(e) requires that the law address a “less restrictive means to achieve the purpose” if it is illogical to restrict this right. Accompanying that, Section 27 ensures the rights of healthcare, food, water, and social security. It further elaborates that, “The state must take reasonable legislative and other measures, within its available resources, to achieve the progressive realization of each of these rights.” This provides an excellent base of justification in regards to South Africa developing legal frameworks fundamentally centered on a human rights approach to TB.
Unfortunately South Africa isn’t close to the poverty levels that other high-burden TB countries have. They at least have some infrastructure. If they are unable to establish an appropriate response, then little hope is left for the poorer countries on the list. For poor people, forced quarantine doesn’t make sense – but again, pilots showing that treating these populations with a patient-centered approach has been shown to work. TB treatment is a lengthy, difficult regimen and will take significant time, money, and energy to over come – it will not happen overnight. But we are ignoring that our current trajectory is not near as effective as it should be.
That is a comprehensive answer and leaves me much more informed. Thank you.
In the US, that right (and practice) already exists. Counties sometimes force people to remain in sanitoriums until they are cured, if they don’t adhere to treatment until they are cured. This is very costly to the counties, and could be the one reason that more attention could be given to TB worldwide. Many immigrants who come here (such as refugees) get treatment for their TB. If we don’t find a way to successfully treat it, the cost of only 1 case could bankrupt a county. So the same reasons that Johnathan says are preventing us from really implementing what will work to provide a cure could be the drive to do just that — financial.
I think the link attacched have some relation with the maters of this blog:
http://www.trust.org/alertnet/news/industrialists-sentenced-to-jail-in-italy-asbestos-trial