Were any of the world leaders at the UN in New York yesterday really thinking seriously about MDR-TB

In Part 1 we asked whether the implications of the target for MDR-TB set by the Political Declaration at the UN and signed up to by world leaders yesterday have really been properly considered. In this piece, we suggest what’s really needed to see this target met (because despite it being such an immense challenge, it really still could be met).

Yesterday’s Political Declaration on TB is (according the WHO) a tool “endorsed by Heads of State that will strengthen action and investments for the end TB response, saving millions of lives”.[i] In the WHO’s most recent Global Report, the organisation adds that, “urgent action is required to improve the coverage and quality of diagnosis, treatment and care for people with drug-resistant TB.”

So please be in no doubt that we are all on the same side here!

One of the most urgent challenges of all is how to scale up funding. In 2018, investments in TB prevention and care in low- and middle-income countries fell a sorry US$ 3.5 billion short of what’s needed and without an increase in this funding this annual gap is anticipated to widen to US$ 5.4 billion by 2020 and to at least US$ 6.1 billion in 2022 (the same year when those 1.5 million MDR-TB cases are intended to have been successfully treated). In other words an addition of at least an extra US$ 1.3 billion per year is required RIGHT NOW, just as five times more MDR-TB cases need to be successfully treated RIGHT NOW if anyone in New York is taking this seriously.

Much TB control is funded by the countries themselves (almost all of it in the case of middle-income countries, which is where it is officially suggested that most MDR-TB exists). But we are seriously worried that this belief about where MDR-TB exists (because that’s all that it is) may be partly mistaken.

Just take a look at the following map of the world (taken straight from the Global Report). It shows where the highest and lowest proportions of testing of new TB cases are currently being done for drug-resistance.

It’s rather clear that very little is done in low-income countries (less than 10%) while in many high income countries (and in some poorer ones which are taking their MDR problems very seriously and have appropriate support) it’s over 70%.

So we think it’s reasonable to suggest that there may be a gaping and very dangerous knowledge gap in terms of the true state of drug-resistance in most low-income countries – and of course it’s these same countries that particularly depend on donor aid. In 2018, for instance, international donor funding is accounting for 57% of funding in low-income countries (this is US$ 0.9 billion in 2018, which is a slight decrease from 2017, a trend which really isn’t good news right now).

So is anyone really confident just how much MDR-TB there may really be in these low-income countries, given that all of the diagnostics and reporting is happening in middle- and higher income ones? The reason we ask this is because it is these same countries that already can’t afford to treat their drug-susceptible TB burden themselves (proof of which is in that 57% donor budget) so it seems incredible that anyone rational might expect them to fund treatment of drug-resistant TB given that it is so much more expensive and requires so much more infrastructure.

In other words, they’re going to need significant extra financial help to do this!

Here’s another map to further illustrate our concerns (again direct from last week’s Report). This one shows where the highest incidence of TB is believed to exist.

If you check back, you’ll see that the darker shades (where most TB exists) almost all fall where the lighter shades fell in the previous map (where fewest patients are being tested for drug-resistance). So we can at least be confident of the fact that low-income countries carry high burdens of tuberculosis at the same time that they aren't testing for drug-resistance.

But here’s another map that (just maybe) clinches our concerns. This one is a map of the highest mortalities from TB (with the map only including deaths of those who are not also co-infected with HIV – in other words, these shadings don’t reflect the impact of HIV co-infection which might otherwise cloud things in some countries even further).

Pretty much the same darker shadings as the second map above, right?

Overall it’s fairly obvious that there’s high mortality where there’s higher incidence of disease, and that much of this Is happening on low-income countries. Of course those living in these countries also may have constitutionally compromised immune systems (contributing to higher mortalities) and their care may also be handicapped by poorly resourced health systems – but isn’t it strange nevertheless that these higher death tolls are occurring where there’s supposed to be precious little MDR-TB (given that first line treatment of drug-susceptible TB has generally high success rates)? Is it possible, in other words, that many of these mortalities in these countries, are actually down to undiagnosed MDR-TB that simply fails to respond to available drugs?

So is it stupid or unreasonable of us to ask whether there’s any connection (particularly given that nearly all of these are low-income countries that depend on donor aid that is not already short, but is also dropping, and will be underestimated anyway if there’s more MDR-TB in these countries than anyone cares to contemplate).

As of yesterday, the call is out for all countries (rich or poor) to invest 0.1% of their GDP in TB control. Perhaps this, as a target for 2020, will be the easiest to measure and monitor of all – and might even be the most important. Perhaps this one alone might help unlock the problem – because without more funding, not just for research for vaccines and new drugs in Europe and the U.S., but also for meaningful support for already overstrained health services, nothing is going to change. Much of the lower-hanging fruit of drug-susceptible TB will surely be picked (and in the shorter term this will surely be greeted with great joy) but the far more insidious higher-hanging fruit of DR-TB will be festering away, out of reach and largely out of site.

Zero point one percent of GDP... (and also finding out how much MDR-TB really is out there). Together they really could make a difference.

[i] http://www.who.int/tb/features_archive/UNGA_HLM_ending_TB/en/