PHM-Exch> [PHM NEWS] TB morbidity reflects poverty and exclusion

[Claudio Schuftan]

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From: <dlegge at phmovement.org>
Date: Fri, Jan 19, 2024 at 2:01 PM

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TB morbidity reflects poverty and exclusionTB control depends on
confronting these drivers

WHO’s Executive Board meeting this week in Geneva will consider a report on
tuberculosis (EB154/10
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=70b318eccc&e=5f3cea0f3e>)
which shows that on every indicator the current levels of achievement are
far behind what it takes to achieve the agreed global targets. Incidence
and mortality continue to be high, treatment coverage stagnates, and
preventive treatment rises too slowly. A considerable proportion of
symptomatic cases are missed.

The objective of 100% financial protection is still far off with over half
the patients experiencing catastrophic health expenditure. Over 80% of
people with drug resistant TB experience catastrophic health expenditure.
The use of rapid diagnostic tests that were projected as becoming the first
line of diagnostics for 100% of cases, has a coverage of only about 47%.
Only two out of five drug resistant TB patients are enrolled in treatment.
In terms of funding, the present budget available for TB in LMICs would
have to quadruple to meet the target of $22 billion funding, and as of now
over 80% of this funding is coming from domestic financing.
Universal access to comprehensive primary health care

Critical to controlling TB is the need to strengthen and universalize
access to primary health care so that fewer cases of infectious
tuberculosis are missed and so as to ensure follow up and medication
compliance. As many as 50 percent of those with symptomatic lung
tuberculosis are not seeking appropriate care. Whereas active case finding
will help, this needs to be done as part of routine work where health
workers are in close solidarity and support of all families through regular
visits, rather than a reliance on sporadic campaigns. Technology improves
care for those who have entered the care cascade but does not touch the
problem of the many who have not entered it.

Malnutrition, overcrowding, unsafe working conditions

The second major requirement for TB control is effective action on social
determinants taken to scale. This depends on governments pursuing a
development path that would reduce inequities and proactively reach out to
the poorest and most marginalized.

Nutrition is critical. Recent studies have demonstrated that nutrition
supplements lead to better patient outcomes and prevent the development of
disease in contacts (Bhargava et al, 2023a
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=6e267f12c7&e=5f3cea0f3e>
and Bhargava et al 2023b
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=93371c0033&e=5f3cea0f3e>
).

Governments must choose programmes and development pathways that eliminate
hunger and malnutrition in the entire population. Both pandemics and wars
aggravate the food crisis and create nutrition insecurity. Climate changes
worsens with respect to food production, procurement and distribution.
Mitigation and adaptation strategies must address these crises.

Other social determinants include housing (overcrowded shelters), poor
working conditions with low wages, and occupational lung disease. While
introduction of new technologies is welcome, the notion that TB can be
eliminated without addressing social determinants is fantasy.

Conflicted innovation system

The report advises that “Overall, the development of novel tuberculosis
vaccines, diagnostics and medicines and critical research projects is
advancing slowly mainly due to inadequate funding.” Tuberculosis research
and development investment of US$1 billion in 2021-2 is far below the
United Nations global target of US$ 5 billion per year by 2027.”  Global
treatment targets are based on assumptions regarding a new range of
technologies, in particular, a vaccine. Though work is underway, progress
is too slow.

The promised shift from sputum microscopy to rapid molecular testing as the
first line of TB diagnostics and for wider access to genomic testing for
multi-drug resistance, would require considerable health systems
strengthening and increased financial support.

The failure to go to scale with new technologies reflects supply chain
barriers and intellectual property rights restrictions. These barriers are
manifest as stockouts of anti-TB  drugs including for drug resistant
tuberculosis. Many of the drugs meant for MDR & XDR TB are under patent and
are unaffordable for governments as well as civil society organisations
working in tuberculosis care.

The report advises, “Wider availability of these (new) regimens requires
improving supply and access to the drugs central to them, including through
approaches that harmonize the interplay between trade, intellectual
property and health.” Too many countries have failed to implement and
utilise the flexibilities available under TRIPS, partly because of big
power bullying but also misinformation by industry. A TRIPS waiver with the
expansion of local production would be very useful. WHO must intervene more
boldly to reform current trade and IPR barriers.

However, without comprehensive primary health care and action on the social
determinants, the introduction of a new and costlier technologies will take
up a larger share of public health budgets, giving the suppliers higher
profits, but with only slow progress towards TB control.



The full PHM commentary on this item (here
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=b8522b5eac&e=5f3cea0f3e>)
provides more detail and references. See also Tracker links to previous
discussions of TB
<https://phmovement.us20.list-manage.com/track/click?u=559d715f58f654accf3de987e&id=c427f19f7f&e=5f3cea0f3e>
.

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on the full agenda of EB154 (or read the flipbook version
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