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Fighting TB “ is the responsibility of every citizen”: Marcos Espinal

PHOTO: Sarah Hiddleston

Dr. Marcos Espinal: “India is scaling up, but the government needs to solve the key issues of upgrading labs, training human resources and having good procurement systems.”

What has changed is the visibility of TB [tuberculosis] in the international community. It has never been controlled properly. Only in some industrialised countries. Five years ago we launched the Stop TB partnership to change the mentality that TB was a medical problem. TB is not a medical problem. TB is a social, political and human rights problem. It’s a disgrace that TB has not been controlled for decades. We still have 9 million new cases and 1.6 million deaths every year.

Multi Drug Resistance is one of the threats to TB control, to DOTS [directly observed treatment, short course), so is TB-HIV. But TB is an independent pandemic. Ninety per cent of TB cases can be cured easily. Only 3-4 per cent of global cases are estimated to have drug resistant TB — about 400,000 cases each year. Those cases cannot be treated like normal TB. Current drugs are not very effective for MDR TB and for XDR [extreme drug resistant] TB there is nothing, basically. So the only way to prevent MDR XDR TB is by implementing the Stop TB strategy, mainly DOTS.

The other mistake of the international community was that five to six years ago we were not advocating for new tools, engaging the private sector, pharma. Now, we have new drugs, vaccines and diagnostics in the pipeline.

Seven years ago the mentality was that TB is only the responsibility of the government. No. TB is the responsibility of every citizen. Stop TB has 500 partners, a global plan that costs $56 billion dollars [for 10 years]. We hope by the end of the decade we will have new tools. But TB is a slow incidence decline disease. It’s not going to go away immediately…

There is a gap in the global fund. This plan should be funded by endemic countries for their own backyard and by donor countries. Endemic countries could do more. Donor countries could do more. For new tools the Bill and Melinda Gates Foundation is very committed but we need others to step up.

TB and HIV are married in sub-Saharan Africa and in South-East Asia it is growing. There is no doubt that TB is the number one cause of mortality among people living with HIV/AIDS. There are actions that can be done now. AIDS programmes can work with TB programmes to reduce the burden of TB among people living with HIV and vice versa. Access to antiretrovirals should be scaled up. It is a disgrace that for so long antiretrovirals were available and now we are seeing them slowly rolled out in Africa.

The HIV epidemic is growing in India. So this is the time to do the prevention, to start scaling up testing for HIV among TB patients, to be more open about the fact that the two diseases are working together secretly and slowly.

Asia is more complex because of the population growth. Africa has the highest per capita rates of TB but the highest absolute numbers are in Asia. Sixty-four per cent of the TB cases come from Asia. There is a potentially explosive problem in Asia if TB-HIV and drug resistant TB are not addressed.

India is one of the top three high burden countries and population growth is huge. The TB programme is one of the best. But more than the national TB programme, it’s a problem of society. It’s a problem of making sure everyone in India is aware of TB. And I don’t think we are there yet.

If you look at India many of the TB cases go to the private sector. They [the government] are trying to roll out engagement of private providers, it’s not easy because it’s such a huge country. While the authorities are doing their best, which I recognise, it’s more than that. The concept is engaging society at all levels. At the end of the day that will help the government.

I understand that the government is working with the green light committee. But that’s the challenge — to scale up. The Indian government has expressed their commitment but I agree with you that they are a little bit behind. If they don’t act quickly they might see an explosive situation.

It’s a catch 22 question because if you ask “What do we do to sustain high quality DOTS or tackle MDR?” then obviously you should sustain high quality DOTS in a middle income country that has limited resources because of the vast population. You have to shut down the generator of the problem. If you don’t do that you will always have MDR no matter how much you cure MDR cases.

TB can be cured by participation of the community, faith-based organisations, sport clubs, the private sector. We need to make sure we educate people and convince the community to participate. Health systems are weak, infrastructure is not available widely, there are areas in India and Africa where people have to walk a long way to get to the health services. Convincing the community leaders the tribes, the society, community is the most important.

Explosive!

In some countries they are putting people behind bars. It’s up to every country. The responsibility of the government is to provide good public health services to the people. They will have to put things in context and decide if they want to enforce treatment or not. It’s a very difficult situation. The best solution is to talk to the patients, to educate them, to convince them that they can be cured and have a productive life after TB.

The number one tool to prevent disaster is high quality DOTS. India is not doing bad within the limitations. It has a huge problem of TB, but there is political will. There are constraints — the absorption capacity, the health system, human resources. Not everyone can manage MDR TB.

There is also the bottleneck of improving and enhancing the capacity of laboratories. We have to improve time for diagnosis but also build the capacity, the human resources. Laboratories are not very widely available. This is what improving the health system is about. India is scaling up, but the government needs to solve the key issues of upgrading labs, training human resources and having good procurement systems.

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Fighting TB “ is the responsibility of every citizen”: Marcos Espinal

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