Recent data from the Global Burden of Disease (GBD) project confirms that tuberculosis (TB) remains among the most stubborn and dangerous of the world’s public health problems. Global TB deaths have declined at an annual rate of 3.7% since 2000, but there were at least 7.5m new cases and 1.4m deaths from TB in the world in 2013, and the GBD report challenges World Health Organisation (WHO) projections about the trajectory of the global TB epidemic. Recent research from the University of Sheffield concluded that childhood TB in 22 high-burden countries is more common than current estimates, casting further doubt on prevalence data.
There were at least 450,000 cases of multidrug-resistant tuberculosis (MDR-TB) in the world last year. Just as MDR-TB threatens to reverse global progress in TB control, funding for TB research actually fell in 2013 compared to 2012. Truly transformative tools are many years, probably decades, away. Meanwhile, the WHO’s targets for reducing TB include milestones of a 75 percent reduction in deaths and a 50 percent reduction in incidence between 2015 and 2025. Some experts argue that these targets are not aggressive enough to stop policymakers from treating TB like public health “background noise”. Even if they are galvanised into action, the targets are only attainable if the right policy decisions are made and the right tools and systems implemented.
Some new tools are on the horizon. Drugs currently being tested could shorten treatment duration by as much as one-third and preventive regimens could stop millions of cases of TB from ever developing in the first place. Excellent new diagnostic technologies have been introduced like Xpert MTB/RIF, which is capable of diagnosing TB and detecting drug-resistance within hours. This could be a significant step forward, but to date it has not translated into large reductions in TB deaths in places where it is being used. Indeed, early lessons from the use of Xpert show that putting a sophisticated and expensive diagnostic tool into poorly functioning, underfunded and under-supported TB control programmes will not change the trajectory of the TB epidemic.
So what will work now? TB really should be controllable. The vast majority of cases are still caused by bacteria that can be (relatively) easily cured with drugs that are widely available and inexpensive. TB control begins with a strong national commitment to basics of public health: accurate reporting and surveillance of cases; establishing systems for prompt diagnosis and initiation of treatment; improving infection control programmes in hospitals; maintaining an adequate and affordable drug supply; establishing standards for proper care in the public and private sectors and holding physicians and public health officials accountable to those standards; and using proven methods of treatment in a community-based setting, through directly observed therapy rather than self-administered or prolonged inpatient care.
Targets can focus minds, but like new tools they can’t deliver significant progress if a country's public health system is poorly organised or administered, or suffers from a lack of political and financial support. That’s why getting back to basics is the best strategy for moving forward.
Dr Schluger was interviewed in Ancient enemy, modern imperative: A time for greater action against tuberculosis, an Economist Intelligence Unit report supported by Janssen. To read the full report, click here.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the views of The Economist Intelligence Unit Limited (EIU) or any other member of The Economist Group. The Economist Group (including the EIU) cannot accept any responsibility or liability for reliance by any person on this article or any of the information, opinions or conclusions set out in the article.
