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The results of decades of inaction on TB are that doctors are stuck with an antiquated treatment regimen that is both challenging to administer and monitor
Mandeep Dhaliwal is Director of HIV, Health & Development Group, United Nations Development Programme.
Six thousand years since tuberculosis first appeared and 137 years after Dr Robert Koch identified the bacteria responsible, world leaders are now facing a new challenge that could lead to a major health crisis if urgent action isn’t taken.
The problem is that, despite being an ancient disease, tuberculosis (TB) is increasingly defiant to treatment. Multidrug-resistant TB affects half a million people each year and now accounts for one in three deaths caused by antimicrobial resistance, a phenomenon whereby germs like bacteria and fungi develop the ability to defeat the medicines designed to kill them. In reality, given that only a quarter of drug resistant TB cases are diagnosed, this figure is likely much higher. This growing crisis threatens to undo what limited progress there has been in quashing TB, especially in middle-income countries.
A UK Government-led review into antimicrobial resistance, which included TB, warned that unless there is serious action to address drug resistance there will be 10 million deaths a year by 2050 and cost the global economy up to 100 trillion dollars by 2050.
The results of decades of inaction on TB are that doctors are stuck with an antiquated treatment regimen that is both challenging to administer and monitor. The mainstream treatment course is still a lengthy six months. Patients often start to feel better long before treatment is complete and can neglect to take their full course. This drives drug resistance, as it gives the bacteria a chance to mutate and develop immunity to medications. Over the past 40 years, there have only been two new treatments for drug resistant TB.
The sad reality is that while TB is the world’s deadliest infectious disease, it is far from the most lucrative. The vast majority of its victims are poor and live in developing countries, so there are few commercial incentives for the biomedical private sector to develop new diagnostics, medicines and vaccines.
Yet, there are green shoots of hope. Last year, world leaders came together in New York to commit to a new plan to tackle TB, with drug resistance a prominent part of the strategy. The UN declaration, as well as previous agreements on access to medicines and antimicrobial resistance, noted that it is possible to both change the trajectory of TB and tackle a significant cause of antimicrobial resistance.
Developing new antibiotics may not be lucrative enough to encourage the biomedical private sector industry to invest. Therefore, alterative mechanisms like ‘delinkage’ have been put forward by a range of actors, from treatment activists to governments in the outcome document from the UN High-Level Meeting on Antimicrobial Resistance. This could mean introducing new incentives to purchase a set volume of the new products when they hit the market, ensuring a return on investment.
Furthermore, an estimated 40 percent of health technology research and development comes from the public and non-profit sectors, so aligning priorities amongst these key actors would help avoid duplication and ensure that funding is focused on addressing global health needs.
Some countries have taken a lead in tackling the dual challenge of both innovation and access. For example, the Government of Japan supports the Global Health Innovative Technology Fund (GHIT) and the UNDP-led Access and Delivery Partnership – two initiatives that both fund the development of new medicines, vaccines and diagnostics while also strengthening developing country health systems to ensure that new innovations reach those that need them most.
Finally, achieving all of the above will still leave us short of the ambition of eradication, unless new drugs are discovered and made affordable, so they can reach poorer populations and countries. Programmes like GHIT’s can help to address a market failure but ultimately governments must strengthen their health systems to ensure new drugs are properly distributed and used, as they take full ownership of managing this disease.
Tuberculous has spread and contributed to antimicrobial resistance – which threatens us all – because the global response has not matched the gravity of the epidemic. Today as the world acknowledges the anniversary of Robert Koch’s invention, in what is now known as World TB Day, the world has started to take steps to tackle TB and the threat of drug resistance. However, there is still significant work to do if we are going to consign an ancient disease to the history books. Against this old enemy, creating new pathways for innovation and access will be key to success.