May 24th 2009

Last week we were sent an extraordinary recent WHO publication on Drug Resistant TB entitled "Airborne - a Journey into the Challenges and Solutions to stopping MDR and XDR-TB". The paper powerfully discusses treatment implementation in such diverse locations as the Philippines,Tajikistan and Lesotho. Importantly, it focuses on the urgent necessity of ramping up the mobilisation of both diagnostic and pharmaceutical resources to comprehensively fight TB globally. Within its pages there are some jaw-droppingly shocking observations from some important experts in the field, and we wish to quote them here. (We are fully aware that these individuals might well find some of our own ideas challenging and problematic from their biomedical perspectives, but we include their comments because they so powerfully highlight just how serious this problem is, and particularly how it is developing in Africa. We hope, therefore, that they might forgive us if their remarks are used in this particular arena since ultimately we share a common cause.)

Doctor Peter M Small is the Senior Program Officer for TB at the Bill and Melinda Gates Foundation. He writes: " We are combating a disease that kills someone every 20 seconds, with a 125-year-old diagnostic test that fails to diagnose half the number of cases, with an 85-year-old vaccine that does not protect adults and with 40-year-old drug regimens that you have to take for six months."

Elsewhere he says: "We are pitifully behind. To be honest, even our understanding of the epidemiology is severely limited. We don't actually know where the worst conditions are. Nor do we know whether in most places the situation is getting better or worse."

Doctor Hindi Satti is a Director of Partners in Health in Lesotho, possibly the best resourced country in Sub-Saharan Africa in the fight against TB: " We're finding higher rates of side effects among patients than anywhere else in the world - and we think it's due to co-infection."

Doctor Jim Yong Kim was a founder of Partners in Health, is a Professor of Medicine and Social Medicine at Harvard Medical School, is former Director of the WHO HIV/AIDS Department and is an expert on TB and a hero in the global war against AIDS. He writes chillingly: "It's not just one or two drugs. We need four or five immediately. People aren't sounding the alarm loud enough. Every time we look the problem is worse than we thought. Now it is coming together with HIV in sub-Saharan Africa, and it could be the most frightening thing we are ever going to see."

Doctor Margaret Chan is the Director General of the World Health Organisation. She sums it up: " XDR-TB could take the world back to the era that predates antibiotics, with nothing in hand to guarantee treatment success."

For the last month we have been being scared by the media (and most probably by the pharmaceutical industry as well) by the spectre of a pandemic of swine flu. A far worse pandemic is very clearly already on the loose and has been for years - for some curious reason the media have found it so far relatively uninteresting, and the pharmas have found it too unprofitable to focus their energies and resouces upon. This is just too bad for those who are accused of over-hyping the problem to attract aid, it would seem. And even worse for those directly affected by this dual pandemic.

This week has seen "World TB Day" (March 24th, an anniversary of the day the TB bacillus was identified) come and go. Once again, it attracted little in the way of media attention.

A couple of reports emerged, however. The World Health Organisation revealed that rates of co-infection of TB with AIDS, particularly in Africa, have been "significantly" underestimated. A letter was also publlshed in the London Times, signed by twelve expertes on TB and infectious disease in the UK. It identified that the major agencies involved in the fight against TB are still facing "serious shortfalls" in funding. They called for world leaders attending the forthcoming G20 meeting to "fulfil urgently the promises they have made to avoid potential devastating effects"..

Stories of successful local campaigns in desperate circumstances do exist (google: Khayelitsha South Africa, TB, and MSF for instance) but they happen only with the help of dedication and resource. In Uganda, in contrast, the national referral hospital in Mulago is reported as currently suffering from a stock-out of anti-TB drugs. What this adds up to is that there have been no drugs suitable for treating kids with TB since December, and out-of-date drugs are currently being used for adults. If this is the case in a central hospital, we wonder what must be the state of medicine in more remote areas.

We received a response this week from a member of the WHO to some tentative contacts we'd made some months ago. In the context of the Uganda report, it makes for difficult reading: "It is difficult to envisage field testing moxa with and without first and second line medication - surely given the wealth of experience of using drugs for treatment of TB this cannot be ethically acceptable."

We have to ask - where is this "wealth" in Mulago, Uganda today? We know that what we are proposing is challenging - but surely it must be worth investigating in the clinical realty that exists.