When Romanian TV journalist Paula Rusu went to the doctor with a persistent cough, no one thought to test her for tuberculosis (TB) because of her social standing. The doctors treated her for asthma instead, which worsened her TB. Eventually, she lost a lung and was off work for six months.
“Romania has a large number of people with TB, but due to stigma no one talks about this,” she says. “That’s why I need to speak out.”
Rusu is a supporter of the Stop TB Partnership’s Global Plan to End TB 2016-2020. The plan is designed to focus the world’s attention on TB, and ensure sufficient resources are devoted to it so countries can reach the targets of the World Health Organization’s (WHO) End TB strategy.
The global plan is based on the WHOs End TB strategy and is centered on five targets. They are, first, to reach at least 90% of all people with TB, and second, to successfully treat those people. The final target is to reach 90% of the key populations – people who are at increased risk of TB, such as those with HIV, health workers, miners, children, homeless people and, overall, all people with limited access to TB services.
However, according to Suvanand Sahu, deputy executive director of the Stop TB Partnership: “We are far behind where we should be to meet those targets. “Over 10 million people get TB each year, but only 60% are on treatment,” he says. That gap of 4 million people not officially being treated is referred to as the “missing millions”.
The main factor hindering progress is lack of funding. Rapid progress will only occur when there are increased financial resources to help identify new ways of tackling TB, which can then be scaled up and implemented.
“Somehow in all activities that address TB, there is a perception it can be treated with something cheap,” says Viorel Soltan, head of the country and communities support team at the Stop TB Partnership. But just two new drugs have been developed in five decades and TB is still often diagnosed using a microscope. “What we think is, you can’t end TB without money. You can’t end it without new methods of diagnosis, new approaches, if you don’t put new technologies on the ground. Of course, these need additional resources.”
The diagnostic tool GenExpert, for instance, is being used in some countries and offers a far speedier and more accurate method of diagnosis than traditional methods. It also shows whether the individual being tested has drug-resistant TB. But it is expensive and needs a stable source of electricity. As a result, it cannot be used as a point of care in many communities where it would be of benefit.
David Lewinsohn is chair of the working group on new TB vaccines for the Stop TB Partnership. He points out that researchers are actively looking at potential new drugs and drug regimens (which could bring down the length of treatment from years to months), and that promising new work is being done on vaccines in South Africa and the US.
“Part of the need is to develop a cohort of researchers who can see the needs and tackle those problems,” he says. “We want to have colleagues in India, Russia and China who can work on this.”
Rates of TB vary considerably across the world, not simply in terms of how many people have it, but whether they have drug-resistant forms of the disease; whether they have particular vulnerabilities to TB (for instance in mining communities); and whether the country’s health systems are structured, staffed, funded and equipped to cope with the challenge. As a result, funding and other needs are very different across countries, communities and settings.
Eliud Wandwalo is senior disease coordinator, TB at the Global Fund to Fight Aids, TB and Malaria. The Global Fund provides around $700m a year in funding – representing 70% of all external funding for TB – and its work is therefore key to ending TB. It is working closely with the Stop TB Partnership and the WHO to find and treat people with TB who are currently being missed by countries’ health systems. While the fund generally gives money to the poorest countries, it also provides funds to some high-burden, middle-income countries such as India.
“Over the next three years, we have a strategic initiative that will focus on 13 countries, where there are 75% of all missing cases [of people with TB]. We want to achieve concrete results, finding and treating an additional 1.5 million people with TB, and we have extra money – $115m for this ” he says.
The Global Fund is also investing a further $65m in multi-country programmes – for instance, on cross-border issues, for mining communities and to improve laboratory services.
Nevertheless, the Stop TB Partnership estimates that if the current overall level of investment for tackling TB continues at the same rate, the WHO’s 2020 targets will be missed, with millions of lives lost as a result.
September’s United Nations High Level Meeting (UNHLM) on TB will see the Stop TB partnership, partners and stakeholders ask that the current level of funding globally be doubled to $13bn annually. They are also calling for increased funding for TB research and development – up to $2.1bn a year.
There is a lot of hope that the UNHLM will see a genuine shift in the level of political and financial commitment to tackle TB.
“This is a unique opportunity for TB,” says Wandwalo. “I have been in [the TB] space for over 20 years and I have never seen this kind of momentum in the community.”
According to Sahu, investing in TB is one of the most cost-effective investments in moving towards meeting the sustainable development goals. He hopes that the UNHLM will generate discussion about funding for TB, encourage heads of state to use it to inform their budgets, motivate external donors to give more, and put forward methods of innovative funding to be considered.
“There is a cost that the world is paying for TB from different sources – including out-of-pocket expenses [from people with TB] and unfortunately also by lives of people who die from the disease. Our effort should be to shift these costs to government and donor budgets,” he says.
“Modelling and costing work has shown that the return on investment for TB is excellent – amounting to $27 for every $1 invested. It is more expensive not to invest on TB than it is to invest.”
