The WHO's 2014 Global TB Report - and three questions...
The WHO published its annual Global TB Report for 2014 last month...
We’ve been studying these reports for several consecutive years now, drawing some disturbing conclusions and forming questions based on the data that they include. Three of our questions are listed below and we’d welcome comments, corrections or answers to them – but first we want to identify one single fact which we believe to be undeniable:
While the Reports purport to pull together a contemporary representative picture of the pandemic, at their very best they amount to no more than a best-guess as to the real situation given the continuing dearth of disease surveillance, most particularly for drug-resistant tuberculosis.
This latest Report certainly doesn’t attempt to hide this (“There is uncertainty in all estimates," it states, "whether published by WHO or other sources”) but no-one – and we feel obliged to repeat this – no-one - should be drawing conclusions about the true state of the disease in countries where it is rife from the numbers quoted in the Report. More importantly, perhaps, nor should anyone be using them to develop future supposedly evidence-based strategies.
The fact that they are all ‘best guesses’ means, of course, that they may be too high or too low, but we have an ever stronger suspicion that some of the most important ones are way too low.
Astonishingly the Report suggests the following: “A new analysis of trends 2008-2013 shows that, at the global level, the proportion of new cases with MDR-TB remains unchanged.” This must be a matter of immense relief to the WHO because MDR disease is so much harder to treat than drug-susceptible disease as well as being so much more costly. But we do not believe that this can possibly be the case... which leads us to the the first of our three questions.
1. Can anyone logically explain how a part of the pandemic (the MDR-TB part) which is broadly speaking just as infectious as the major body of drug-susceptible disease but which is successfully treated in only around 1 in 10 cases (48% of a highly optimistic Case Detection Rate of 20%) can possibly not be proportionately increasing in relation to the main body of drug-susceptible disease that is being successfully treated in over 1 in every 2 cases (86% of a CDR of 64%)?
We are convinced that the fundamentals of epidemiology as well as the laws of logic mean that this cannot possibly be the reality – in fact the proportion of MDR disease has to have been increasing year on year and this increase is probably proportionately speeding up.
The WHO also states that there’s a current gap of US$2 billion in the funding needed to defeat this disease. The current ‘split’ in their budget dictates that around 66% of the total TB budget is being expended on drug-susceptible TB (DS-TB), and 20% on MDR-TB. But it’s also identified that treating a case of MDR-TB costs over 90 times as much as treating one that’s DS-TB. In other words if there were 90 times as many DS-TB cases as MDR-TB cases, the budgetary split would need to be about 50/50 (which it’s not – it’s 66/20). But the estimated split of MDR cases is not one in 90, it’s around five in 90 (and that’s if we accept that the proportion of DR disease really isn’t changing as is being claimed).
So here’s our second question:
2. Can anyone explain how there can only be a two billion dollar annual shortfall in funding when the figures for treating MDR-TB are proprtionately so very much higher?
What emerges in these reports looks like an institutional inclination to underestimate the numbers as well as the costs and therefore an implicit resistance to acknowledging the true consequences of the drug-resistant pandemic.
There’s actually good evidence of this in the WHO’s own ‘media notes’ which were released for journalists who are too busy to pick apart the pages and pages of numbers as we have.[i]
Here’s one of the things they said about MDR-TB last year:
“… at least 39,000 patients, diagnosed with this form of TB, were not treated last year ...”.
This seems an innocent enough statement, but can “at least 39,000” really be a proper summary? In fact the WHO’s own estimate suggests that there were 480,000 new MDR cases out there last year (along with at least another 200,000 existing cases already with the disease). They also recorded 97,000 MDR cases being started on treatment – which is at least an increase on previous years. But in this case we’re looking at “at least 383,000” untreated infectious MDR cases out there, not 39,000 as the media release so disingenuously implies. What’s of particular concern, though, is that whilst this media release suggests treatment shortfalls that are so plainly adrift by a factor of ten, it’s not actually wrong! This is because the Report itself reported that 136,000 MDR cases were globally diagnosed last year within national TB programmes. So with 97,000 of them started on treatment then this innocent statement that 39,000 diagnosed with this form of TB weren’t treated can be justifiably claimed to be correct. Technically correct it may be, but it goes nowhere near acknowledging the true scale of the problem nor does it cast appropriate light on what might be really happening out there.
Such anomalies don’t just constitute academic or epidemiological semantics. They amount to issues of major concern particularly when some of the reported national figures are equally misleading.
Nationally estimated numbers of MDR cases
China (which of late has been one of the good news stories of TB control as far as the WHO Reports have been concerned) was reckoned to have 45,000 new MDR-TB cases in 2012. Yet according to a “National Survey of Drug Resistant Tuberculosis in China” published in the New England Journal of Medicine in 2012 they were already reckoning on 110,000 new MDR cases each year back in 2007.
So here’s our third question that we think deserves an answer:
3. Given that so few Chinese MDR cases are being treated with second line drugs (only just over 2,000 new MDR cases were started on treatment in China in 2013) can anyone explain how these rates can have possibly dropped so dramatically in the last five years?
South Africa, meanwhile, a country which is well known to be a hotspot for lethal XDR-TB and which is recognised by its local experts to have a TB epidemic that is out of control, is improbably estimated to have a percentage of drug-resistant disease within its epidemic which is less than half the global average. As unlikely as this is (and it’s not just unlikely, it’s impossible), such lower percentages for South Africa have been published not just this year, but in previous years as well, so it seems that few within the system are inclined to question the official estimated numbers even when they're absurd.
Absurd? Well that’s what it looks like to us, and here’s why. The gross estimate of new drug-resistant cases last year in South Africa was 6,800 – according to “expert opinion” that is. Meanwhile the actual notified number of drug-resistant cases in the country last year was just over 26,000 (or about three times the expert estimate). It seems reasonable to wonder exactly what the WHO's experts have been working on in the last twelve months. It looks unlikely that they were focusing much of their attentions on South Africa - which is alarming given that it’s known to be the furnace for TB in the African region, which is in turn the worst in the world.
If you are finding yourself scratching your head in disbelief at these anomalies, then rest assured, so are we (and we’ve found plenty more of them within the Report). They simply don’t make sense, do they?
Given that this disease is taking at least 1.5 million lives each year (and we believe that this is far more probably 2.5 million – amounting to nearly 7,000 every day), and given that by far the most challenging part of the pandemic (the drug-resistant component) is almost certainly growing year on year, then heads should surely be being scratched in all relevant quarters. But we’re uncertain as to whether many want to do more than keep their unscratched heads down below the parapet for now and hope for the best. Here, for instance, is a statement made by Ray Chambers, who works for the UN as their Special Envoy for Financing the Health Development Goals. He made it on 4th November as a direct response to the release of the WHO Report. He said that :
“Only one-quarter of the nearly 400,000 people living with the drug-resistant strain of TB received proper treatment [in 2013]...”[ii]
So this key individual (he’s at the very heart of efforts to finance the global campaign against the pandemic) first of all seems to believe that there are only “nearly 400,000” prevalent cases of MDR-disease (i.e. those ‘living with the disease’) when, even according to the WHO, it’s about 650,000 prevalent cases and is far more likely to be a lot more. But he’s also disingenuously promoting the idea that around one in four MDR cases are receiving proper treatment – when we’d go so far as to speculate that it’s far more likely to be one in 40.
It’s long past the time when proper efforts should have been made to confront the anticipatable scale of the threat from DR-TB, and it’s also well past the time when precautionary principles should have been adopted rather than these current hopeful (and possibly hopeless) ones. Dr Lucica Ditiu, the Executive Secretary of the Stop TB Partnership, is explicit on this:
“We aim to defeat TB – but to defeat it, we need to acknowledge it and understand it.”
The truth is that if we don’t properly acknowledge and understand the possible scale of this disease, particularly in respect of its drug-resistant aspect, we will inevitably face what has been described by some as a “medical apocalypse” in many vulnerable countries.
And ‘apocalypse’ is an interesting word to have been used in this context because it is derived from the Greek ἀποκάλυψις (apocálypsis) meaning an 'un-covering'. Translated literally from the Greek, it amounts to literally constituting a disclosure of knowledge, or a lifting of a veil – which is something which the WHO Reports show little evidence yet of wanting to do.
For the other four analytical discussions of the 2014 Report: