The UNHLM Political Declaration and Country Targets – targets, aims or obfuscation?

As everyone agrees, the UN HLM was without question ‘historic’ - not least because it has finally brought the global community of TB activists and civil society together and has allowed everyone to find a collective voice. Finding this voice (and each other) may even prove to have been the Meeting’s most significant achievement (brought about by immense dedication and hard work by key individuals who are all to be congratulated) because beyond this there are some reasons for concern.

It certainly also brought Civil Society’s so-called ‘key asks’ into real focus, however - specifically in paragraph 24 of the Political Declaration[i] that demands that 40 million TB cases be found and treated by 2022, along with 1.5 million MDR cases and 3.5 million children. But it looks like something got left out of this paragraph – the crucial words ‘and cured’.

The National Targets

These demands have now been broken down by StopTB into a list of national targets and were published a week ago – something of real practical value since (as many have been pointing out) setting ambitious goals is one thing, seeing them acted upon is another, but find ways of making those responsible for implementing and achieving them accountable is something else again. A set of individual national targets surely must make such a process infinitely more possible in the aftermath of this Meeting, however – far more so than after previous World Health Assemblies where similarly aspirational aims have been set but have been abjectly and shamefully ignored afterwards.

So far so good, but it seems that there is a fundamental problem in this three-pronged demand (for TB, MDR-TB and Children) – and it’s not just in relation to these demands’ implicit achievability, which a careful review of its numbers and a corresponding analysis of the number in the last WHO Report serves to identify. It relates to its very wording.

‘Successful’ Treatment

This issue is a fundamental one. All three StopTB Target documents are entitled ‘Diagnosis and Treatment Targets’. At first it looked to us like the most important word of all had been somehow erroneously left out of the title – the word ‘SUCCESSFULLY’. Because we believed that this paragraph had been under-written by the principle that 40 million TB patients should be found and successfully treated by 2022. Surely successful outcome is the ultimate key to everything ambitious, aspirational or call it whatever you will?

So we took a look at the wording of the key paragraph in the signed Political Declaration (Para 24) that supposedly reflected Civil Society’s original ‘Key Ask #1’ and began to wonder if we’d been mistaken in our belief. So here is the final wording:

“Commit to providing diagnosis and treatment with the aim of successfully treating 40 million people with tuberculosis from 2018 to 2022, , including 3.5 million children, and 1.5 million people with drug-resistant tuberculosis”.

The wording is subtle – and arguably it’s even ambivalent in that there’s no mention of successful outcomes in it. Had we been naïve (even mistaken) in believing that successful treatment had been implicit in this ‘key ask’? That had been the whole idea, hadn’t it? Not just to find and diagnose 40 million TB cases in five years, but to actually successfully treat them as well?

So we dug back a few months and this was the target language that had been sought by Civil Society:

“Commit to diagnose, treat and cure 40 million people ill with tuberculosis from 2018-2022, including 3.5 million children and 1.5 million people with drug-resistant tuberculosis”[ii]

The demand for successful treatment back then was explicit and unambivalent, and we find it astonishing that this appears to have been given away in ambivalent language, not least because of what it implies for MDR-TB (which we will come to later).

So here’s our attempt at defining the difference between an ‘aim’ (as in Paragraph 24) and a ‘target’ (which is what StopTB are attempting to set for each nation):

- an aim is something you hope to achieve by doing something;

- while a target is the exact result that is intended to be achieved by doing something.

It’s a subtle, but very potent, difference, with an ‘aim’ arguably having a lower threshold in terms of accountability (and we all know how critical accountability is.

Actually, for ‘all TB’ we do have a de facto target for cures (at least if we are prepared to accept that an ‘aim’ is the same as a ‘target’ which plainly StopTB believe to be the case). This is because the goal for the proportion of treatments to have successful outcomes as defined by the WHO is defined in the End TB Strategy to be 90% by 2020. This means that we can easily convert all of the targets in Stop TB’s new document to targets for SUCCESSFUL treatment with a few strokes of a calculator – essentially globally the member nations have committed to ‘diagnose, treat and cure 36 million people with tuberculosis from 2018 to 2022’.

But at the same time let’s be clear as to what this means: it means that we have apparently given away 4 million lives in negotiation.

We should add something here immediately: this subtle slight of hand doesn't in any way reflect negatively on the effort put in by hundreds of TB activists who did their damndest to see a more just and better world come out of the HLM for TB patients. It's a truly terrible reflection on the cruel callous nature of the forces they were up against. [extra text added to blog on 30.10.18 following comment by Action.org]

But what about MDR-TB for which we have no targets in the End TB Strategy at all? (We’ll discuss this further below because it’s such a big problem).

At this point we should add that we’ve only reviewed two of these documents (TB & MDR-TB): we confess that we haven’t looked at the Children’s targets at all. We simply haven’t had the time – but invite others to do this in the light of what we observe below.

The Targets for ‘All’ TB – are they really that ambitious?

We need to take a quick look at the ‘All TB’ targets first.[iii] Broadly speaking, the self-evident overall intention of this para. 24 is to bridge the gap between notified patients and current incidence estimates – that truly awful gap of almost 40% that so incredibly persists a quarter of a century into an official global emergency[iv], and which was revealed to be widening at the same time as those Millennium goals were being reported as being largely met.

Let’s not pussy-foot: the likelihood is that this gap will (at least retrospectively) widen further once the long-promised Indian prevalence survey finally gets reported on (and according to the last Global Report it sounds like it still hasn’t even been properly started let alone completed - this in the same year that it was originally stated that it would finished). Is this Indian elephant-in-the-room so big that no-one notices it, or are we collectively still too timid to wonder aloud what’s happening in case it upsets some key politicians’ sensitivities? (Surely after New York this can’t be the case?). But it’s a little disconcerting that (according to its Target) India is only being required to up its game of finding and treating patients by 472,000 a year when (without the possible complications enshrined in its dreaded Prevalence Survey) it’s currently missing nearly double that number. (See the image immediately below which is published by Action.org, identifying by country where the missing millions are – which lists India as missing over 953,000 cases[v]).

But that’s just India – there are 215 other countries to consider in these targets.

Well, most of TB endemic countries kick in at a hike-factor of less than two – including the high incident ones with low case detection rates (CDR). Even Nigeria (which is still estimated to be missing three out of every four of its TB patients) is only being asked to find and treat an average of 236,000 new patients a year (an extra 131,000 patients each year on existing numbers), this at the same time as it’s missing 315,000 according to Action.org (see the graphic above). Surely this doesn’t make sense?

No-one should underestimate the demand that even these inadequate and unambitious demands are going to put on every NTP which is cash- and human-resource constrained, but wasn’t it fully accepted that we have no choice but to be ambitious in our demands now? We know, for instance, that we are currently treating 6.4 million cases a year (missing 3.6 million of the estimated 10 million new cases). With a current success rate of 81%, that makes for 5.2 million TB cases treated successfully (or only just over 50% of the estimated annual burden). This gives us a clear idea how much we have to make up. Extrapolate those 6.4 million notifications across five years (2018-2022) and we end up with 32 million (or 8 million short of the 40 million demanded by paragraph 24). This only requires an extra 1.6 million a year when we know we need to double that. That 40 million target is simply not enough unless they are successfully treated – and so it’s certainly not ambitious!

But it’s not reflected in epidemiological realities either.

Take the global picture with 10 million new cases a year. Multiply that by five, and it’s fifty million, not forty! That’s not a 90% CDR (which is what’s required by the End TB Strategy that all these same countries signed up to in 2015). It’s 80%.

Or take Zimbabwe with a 2017 cohort of 26,401 and a case detection rate of 71% (19 points short of the 90% target): surely it will be required to increase its rates of diagnosis and treatment? Well, not according to the StopTB document. Next year it will be required to report 25,300, and in 2022 the demand is for only 19,400 with an annual average over the five years of 22,380 (making for a DROP of 15%!).

Something not dissimilar exists for South Africa, the so-called head of snake of TB in Africa, this one with a drop of 10%!!

Or try Ghana with a current cohort 14,550 with a lowly CDR of 32% - oddly not mentioned in the Action.org graphic above (a CDR which is almost 60 points short of the 90% target so their targets should surely be tripling). Their peak requirement will occur in 2021 (23,500) with an annual average over the five years of 19,780 (a hike of just 36%).

We worry for Angolans in particular, though. In spite of a CDR of 54% and a sorry treatment success rate of just 27% (which we can’t help but wonder might be a simple typo given that they simultaneously report a success rate of 72% for MDR-TB) they’re being asked to improve their act by just 26% across the five years. Angola treated just under 58,000 patients in 2017, by the way, meaning that only 15,626 were treated successfully if that success rate is correct and maintained (just 15% of incident cases). We also note that Angola also has the lowest proportion of TB patients with known HIV status in the African region, something which can’t help either and must reflect a severely constrained health infrastructure that must be at breaking point if not already past it.

But this isn’t just an African issue. Indonesia has a very poor rate of known HIV status among its notified TB patients too, and also has a poor CDR (at 52%), but despite this its demand is only an average annual hike of 54% on existing notified cases.

The list could go on. But at least we can anticipate that these ‘targets’ take us in a better direction and surely they must be expected to be fully achievable (certainly Civil Society will accept nothing less). But it’s when we start to look at MDR that things become very troubling indeed.

The Targets for 2022 for MDR-TB

So what about these MDR targets?[vi]

Well, we had to dig around not just in the Stop TB Target List but also in the WHO Report comparing the StopTB chart with the WHO numbers[vii]. So here’s what we figured out.

1. The national cohort numbers targeted for reporting in the next Report (i.e in 2019 from this year’s numbers) are largely much the same as those reported in 2018 for 2017. In other words, there’s not much difference being immediately looked for unless it’s in treatment successes (which have no targets set). We’ve not found one exception to this despite the fact that several countries more than doubled their cohort sizes between 2015 and 2017 so are moving fact in the right direction (Afghanistan, Angola, Central African Republic, DPRK, Guinea, Niger, Nigeria, PNG, Sierra Leone, Somalia, Thailand, Venezuela and Zambia to name a few). This alone adds up to a curiously UNAMBITIOUS lead out to a set of targets that is due to begin to be reported on next year.

2. But after this innocuous start things begin to look very hairy indeed for a lot of countries. Let’s start by looking at Angola again (sorry Angolans, but we hope you will understand that we’re concerned for you and we hope that you will share our concern). The numbers of MDR cases reported to be started on treatment in 2017 was 534 (taken from www.who.int/tb/data); the target for 2018, meanwhile, is 542. As discussed above, superficially this looks like a terribly unambitious hike of just six cases in twelve months. But this first year is nothing – because then the fun really begins, since in 2022 the world’s ‘demand’ for Angola is that 3,900 MDR cases are started on treatment. That amounts to a hike-factor of over seven (on top of the parallel hike on their DS-TB programme). Sheesh! Does anyone believe that they can achieve this (or that, if they get anywhere near it that their 72% success rate for treating MDR-TB will still exist?) Who wants to be Minister of Health in Angola and be accountable!

3. It may sound like we’re cherry picking, but please be assured that we’re not. There are at least thirty countries in this list that are being expected to hike their MDR numbers by at least what is expected of Angola in one or more years before 2022. Most are in Africa (Nigeria, for instance, by a factor of 13), but not all: Afghanistan is expected to hike its MDR notification performance by a factor of 14; China by 11; Indonesia by 7; Yemen by 23; Syria by 32. The DPRK are expected to hike their treatment rate by a factor of three by 2022 (but to do so at the same time as all drug and diagnostic support has been cut for them by the Global Fund!). Most of them, however, are African low-income countries with poor health infrastructures and some are not obvious candidates at all. According to our calculator, for instance, Madagascar is expected to shake its MDR booty to a hike-factor tune of 24; and Gabon by 29. Moreover, South Sudan (who haven’t reported starting a single MDR case on treatment in either of the last two years) are expected to treat 638 a year by 2022. The worst we could find, incidentally, is little Timor Leste which may not be estimated to numerically have much TB or MDR-TB but which is being expected to up its act by a hike-factor of 69 on what it achieved in 2017. At least its actual numbers aren’t anywhere near as immense and terrifying as those of China or Indonesia, but was anyone considering these sorts of hikes when they drew up this target list? (Of course they must have…).

4. There are a couple of other curious anomalies in there as well. South Africa, for instance, the head of the snake of MDR-TB in Africa, is only being asked to raise its game by 18%. But according to the StopTB document, ZA’s target for the next few years (averaging 10,800 per year) exceeds the current estimated incidence of pulmonary MDR-TB (of 7,700). We should note, however, that this estimate is only among notified cases so at best this can be only 70% of what’s out there. But are they winning their war against MDR-TB anyway? If they are we’ve not heard anyone shouting about it.

5. Of course, this was never going to be any sort of perfect science and we fully recognise that creating some form of framework of accountability is very important, but these issues surely raise big questions, which it seems we may still all be too polite to ask. (Are we TB activists still so polite? Surely we can’t afford to be after New York?). The bottom line is that it looks likely to make controlling MDR-TB a very fragile business indeed.

6. We also need to acknowledge that reporting treatment outcomes (which was the goal of Civil Society’s Key Ask in the first place) is going to get very tricky with MDR-TB now. They always have been, but with variable approved treatment regimens of differing lengths as well, ones that can vary in length between 9 months (for the shorter Bangladesh regimen) and 24 months for the old regimen, it’s going to be turning peoples’ hair grey in Geneva. Meeting these targets is going to be tough – but so is reporting on them!

Our Big Question

So here’s the big obvious question that these targets/aims (call them whatever you like) raise for us:

DO WE REALLY THINK THAT MOST OF THESE COUNTRIES ARE GOING TO GET ANYWHERE NEAR WHAT IS BEING ASKED OF THEM WITHOUT MASSIVE HELP?

Our Answer

Our answer is quite simple: of course they won’t, and everyone must already know this! They already have significant TB epidemics, which strongly suggests that they all also have health infrastructure problems. And if they have health infrastructure problems, they also are obviously missing too many TB patients (quite possibly more than currently estimated if they have no recent prevalence survey), and when treating any TB cases they are probably doing so sub-optimally. The focus of that original ‘Key ask #1’ (though not of Para. 24) was to find all those missing TB patients and successfully treat them. Under those conditions that was always going to be a challenge to meet these new targets – but it seems to be one that’s been made too easy for DS-TB and too hard for MDR-TB (or too unambitious and too ambitious respectively).

Under these sorts of conditions, it’s easy to see which targets are likely to be most focused on – the easier ones (i.e. DS-TB).

But what’s more (and we can’t help but want to say this as quietly as possible for fear of upsetting our rickety applecart), if these countries do have a problem managing their DS-TB programme then they probably already (as a natural consequence) inevitably have a more significant MDR-TB problem than estimated as a consequence of this - whether or not anyone is seriously attempting to either measure or estimate it. In other words, the WHO’s baseline estimates are quite probably already a bit shy of reality in most low-income countries, and the Targets listed by StopTB are quite possibly already lower than what’s needed! So in the grand scheme of things, these huge demands are quite probably all not that unreasonable – it’s just that it’s extremely difficult to see how they may be achieved.

A More Useful Answer

Of course, just simply saying these targets won’t be met (which must be obvious) - isn’t a good enough answer at all at this point of time. What’s also obvious is that these countries need help, particularly to address their MDR-TB. And if we are seriously agreed on this, then surely, we need collectively to figure out how this can be best afforded them - particularly given that we know that funding for TB is already short and struggling, and that proportionately more of it may even be directed towards much needed research in wealthier countries as a direct result of the HLM and Paragraph 47.

Well here’s our idea – okay, it’s an optimistic one, but then so are these blessed targets!

0.01% of GDP

Let’s just recall that idea of each member state spending “up to or beyond 0.1% of its annual Gross Domestic Expenditure on Research and Development (GERD) on TB research”. This was another of those Key Asks which seems to have been emasculated to another nebulous ‘aim’ – this time to committing “to mobilize sufficient and sustainable financing, with the aim of increasing overall global investments to 2 billion dollars”[viii] – with the idea that this could and should be usefully directed by every UN member country towards TB research.

Well, why the hell not have another go at this percentage idea as these targets begin to unravel, and see whether proper support can finally and properly be unlocked for a Global Health Crisis? How about asking for a hundredth of a percent, not of annual GERD this time, but of annual GDP from all member countries who signed up to this Declaration (i.e. 0.01%) and then see it directed towards countries which plainly can’t manage to meet the targets that have been set for them? And while doing so, maybe we can then simultaneously “recognize the constrained health system capacity of low-income countries” (as included in that same paragraph 24 in the Political Declaration that was signed up to as well) and make our global response a little more coherent?

So which countries have the least currently demanded of them by these Targets? The richer ones, of course: those with least TB and best managed TB programmes (and the most GDP), so surely the ones who can do most to help.

Actually, we have to admit that it’s not quite that simple. It turns out that, of the sixteen countries with highest GDPs globally, one of them has the most TB, while another has the most MDR-TB; in fact, with India, Russia, China and Indonesia making up a quarter of this top sixteen it turns out that the richest sixteen countries in terms of GDP have over half of all the world’s TB cases, MDR-TB cases and XDR-TB cases (all in countries with plenty of resource to deal with them). Things aren’t quite as simple as we’d prefer them to be!

Notwithstanding this, here’s a rather big number to chew on for a minute. It’s the World Bank’s estimated total global GDP for 2017 which amounted to 80.69 trillion US dollars.[ix] (So 0.01% of this amounts to 8 billion US smackeroonies each year which is surely enough to help everyone sort this MDR mess out).

Now you can see where we’re going with this, here’s a little fag-packet calculation.

Low-income countries contribute a little over half a trillion to this total GDP (so, using the 0.01% measure, they need to contribute 50 million to the 8 billion dollar pot); lower-middle-income meanwhile contribute 6-and-a-half trillion to the GDP total (so need to contribute 650 million to our pot); upper-middle-income meanwhile contribute just over 22 trillion (so need to chip in 2.2 billion); and high income ones contribute 51-and-a-half trillion total (so need to give 5.1 billion dollars).

Not just this, we think that many of them could do even more. Some of them could contribute useful expertise and technology to some of those countries that have least of either, and they could even voluntarily pair up to do this – bigger countries with bigger countries (the US, for instance, with Nigeria), smaller ones with smaller.

This isn’t a new or original idea by the way. Over twenty-five years ago Dr Annik Rouillon suggested the idea of richer countries ‘adopting’ poorer TB endemic ones with a view to helping them reduce their TB burden. The idea smacks a little of post-colonial paternalism but could surely be managed or framed in ways that avoid this since the idea plainly still has legs. It was originally raised when the problem wasn’t anywhere near so complicated by DR-TB. So while it may have been rejected first time out, there’s no reason not to reconsider it now in terms of MDR-TB.

The Global Caucus

Okay maybe we’re part-joking (but then maybe we’re not) – because MDR-TB is a very, very serious problem indeed with millions of vulnerable lives on the line. StopTB did something else important in their run up to the HLM, by the way – they called on political leadership in the battle against TB. Well, surely this is exactly what’s needed now – some politicians with genuine vision and human spirit to step out of line, knock heads against heads to break the resource deadlocks, and say “Yes we can!”.

And something else that’s changed since Dr Rouillon first mooted her idea is that today we have a Global Caucus of Parliamentarians. We’ll certainly be writing to our national representatives sharing our thoughts on this with them in the coming weeks - because if real help isn’t provided to these countries we have little doubt that MDR-TB will be cutting itself loose at the same time as those TB unambitious targets or aims (take your pick) for DS-TB are being reported as being met in the coming five years.

[i] http://www.stoptb.org/webadmin/cms/docs/Political-Declaraion-on-the-Fight-against-Tuberculosis.pdf

[ii] Email sent by Action.org 19th June 2018.

[iii] www.stoptb.org/assets/documents/global/advocacy/unhlm/1.%20UNHLM%20on%20TB%20-%20TB%20Country%20Targets.pdf

[iv] http://www.who.int/tb/publications/global_report/tb18_ExecSum_web_4Oct18.pdf?ua=1

[v] www.action.org/uploads/documents/Missing_Millions_TB_v6.pdf

[vi] http://www.stoptb.org/assets/documents/global/advocacy/unhlm/2.%20UNHLM%20DR-TB%20Country%20Targets.pdf

[vii] www.who.int/tb/data

[viii] See paragraph 47 in the HLM Declaration.

[ix] http://databank.worldbank.org/data/download/GDP.pdf