Ending tuberculosis is an exercise in futility

For a millennia-old disease that is preventable and curable, tuberculosis (TB) continues to rear its pernicious head and prevails as one of the world’s top infectious killers, claiming 1.3 million lives in 2022 (including 167,000 people with HIV).

This despite global efforts to combat the spread of the resilient mycobacterium that causes the disease, and affects over 10.6 million people annually, including 5.8 million men, 3.5 million women and 1.3 million children.

As the world marked World Tuberculosis Day on Sunday the perennial stocktaking of the progress towards eradicating the disease shows that any competition in bragging rights over resilience, staying power and ending TB is an exercise in futility.

While global efforts to combat TB have saved an estimated 75 million lives since the year 2000, according to the World Health Organization (WHO), the reality remains that the scale-up of access to TB preventive treatment has been slow, and the global number of people living with HIV and household contacts of people with TB who were provided with TB preventive treatment increased to 3.8 million in 2022. In addition, multi -drug-resistant TB (MDR-TB) remains a public health crisis and security threat, with only about 2 in 5 people with MDR TB accessing treatment in 2022.

Strategies to combat health threats such as the WHO End TB Strategy target of zero new incidence by 2030 and the global targets are only as good as the funding pledges honoured. Also essential are the political will and leadership of each country ‒ especially that unenviable group of High Burden Countries (HBCs) which includes South Africa ‒ the compliance culture and monitoring of affected patient cohorts infected (failure of which only increases the propensity to drug-resistance), and above all, continuing the momentum of evidence-led research in vaccine and programme development, community education and awareness of TB transmission, as well as easy access to drugs.

WHO estimates that $13 billion (about 247.7bn) is needed annually for TB prevention, diagnosis, treatment and care to achieve the global target agreed at the Head of States UN High Level Meeting on TB and achieving the Ending the TB Epidemic by 2030 target of the UN Sustainable Development Goal (SDG 3.3.2).

“The next five years,” says Dr Tereza Kasaeva, Director of WHO’s Global Tuberculosis Programme, “will be critical for ensuring that the political momentum we have now is translated into concrete actions towards reaching global TB targets.” What Dr Kaseava is alluding to is how to inculcate a meaningful sustainability incorporating all the various metrics to advance the battle against this deadly disease.

Judging by the uphill struggle to adopt sustainability structures in the climate action discourse, for instance, marked by its manifold ambiguities, anomalies, contradictions, insanities (such as the $7 trillion in subsidies to the fossil fuel industry in 2023) and factionalism, is there any room for optimism and hope that tackling TB could be an exception to the above rule?

After all, the theme of World TB Day 2024 ‒ “Yes! We can end TB!” ‒ we are told, “conveys a message of hope that getting back-on-track to turn the tide against the TB epidemic is possible through leadership, increased investments and faster uptake of new WHO recommendations.”

As such, the immediate task ahead is turning these commitments into tangible actions. In this respect, the modelling study developed by WHO in co-operation with Brazil, Georgia, Kenya and South Africa and released on World TB Day, which puts an investment case for expanding TB screening and preventive treatment, and its impact to be achieved, assumes much greater importance given the socio-economic impact in especially high-burden TB countries.

The modelling shows that modest investments could lead to significant health and economic benefits in all four countries, with a return on investment up to $39 gained for every dollar invested.

TB screening plus preventive treatment can substantially reduce TB incidence and mortality.

“The investment case,” maintains Dr Tedros Adhanom Ghebreyesus, WHO Director-General, “outlines the health and economic rationale for investing in evidence-based, WHO-recommended interventions on TB screening and prevention that can contribute to advancing universal health coverage (UHC). These crucial public health investments are essential for addressing the needs of vulnerable populations and achieving the End TB targets.

Today, we have the knowledge, tools and political commitment that can end this millennia-old disease that remains one of the world’s top infectious killers.”

For a high-burden country like South Africa (and we all know a family member or neighbour or colleague who has been stricken by this disease over the years) the implications are particularly important. According to WHO, some 80% of spending on TB services in 2022 was from domestic sources. In low-and-middle-income-countries (LMICs), international donor funding remains crucial.

For R&D, according to the Treatment Action Group, only $1bn was available in 2022 of the $22 billion required per year to accelerate the development of new tools. A South African economy with subdued GDP growth and budget deficits over the next three years and burgeoning debt and debt servicing is shackled by meagre increases in health budgets estimated to rise from R267.3bn in 2023/24 to R271.9bn in 2024/25. TB budgets are competing with other pandemics such as Covid-19, HIV/Aids and malaria. The introduction of Universal Health Insurance (UHI) could undermine a TB strategy.

To achieve UHC and UHI, substantial increases in investment in health care are critical.

WHO data suggests that Pretoria’s domestic funding on TB services has declined from a peak of $561 million in 2013, to $172m in 2021 to $138m in 2022. Similarly, international funding for TB intervention in South Africa has remained flat at $68m in 2021 and $65m in 2022. South Africa is one of 10 HBCs which falls into all three lists of the disease incidence TB, HIV-associated TB and MDR/rifampicin-resistant TB used by WHO in its 2021/25 assessment.

South Africa has a TB incidence of 513 persons with TB for every 100 000 people.

To its credit, Pretoria has achieved a reduction of TB incidence in 2022 of 50%. South African data on TB also needs urgent updating, but this requires additional R&D resources. Its last National TB Prevalence Survey covers 2017/19, albeit an inventory study is currently under way. The impact of modelling based on investing now on TB screening and preventative treatment is emphatic for the four countries.

In South Africa this translates into 1.4 million fewer people developing TB and 276 000 lives saved by 2050.

To achieve this, the Treasury will have to find additional annual investment per capita of $1.11bn, resulting in a total healthcare cost of scaling up TB screening plus preventative treatment of $1.77bn (about R33.7bn) from 2024 to 2050. The social return yield on investment, is $39.1 for every dollar spent now on TB screening plus TPT by 2050. The carrot is that more gains could be made by further scaling up proposed interventions by repeating them in the high-risk population beyond a third year.

Finance Minister Enoch Godongwana indeed has his work cut out!

Parker is a writer and economist based in London

Cape Times