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Tuberculosis: Silent killer

Tuberculosis, as a Lancet editorial once put it, it is an “unsexy” disease.

No one dies of it in a matter of days. It’s not highly contagious. it does not come with rashes, hemorrhage, or other dramatic symptoms. And it has been around for so long.

And yet, in terms of sheer impact, tuberculosis (TB) should rank as the public health crisis of our time. In India alone, TB kills over 400,000 people every year. In relative terms, the numbers are no less disconcerting in Indonesia and the Philippines – 107,000 and 26,000 annual deaths, respectively. Various other Asian countries are considered as having high TB burden – including Bangladesh, China, Myanmar, Thailand, and Vietnam.

Moreover, while TB has been documented since ancient times, the disease is changing with the emergence – and continued evolution – of multi-drug resistant and extremely-drug resistant strains (MDR-TB and XDR-TB).

Normally, the standard treatment for TB takes six months (an already-difficult regimen) but these strains require even longer courses using expensive, often inaccessible, medicines. Further adding to the complexity of controlling TB is the rise of HIV and diabetes, both of which render bodies particularly vulnerable to the mycobacterial infection. HIV infection rates may be decreasing globally, but the opposite is happening in countries like the Philippines. The incidence of diabetes, meanwhile, is rising throughout the region.

Public health ministries in Asia are acutely aware of the threat posed by TB – which slowly but surely destroys body tissues (usually in the lungs), leading to organ failure that can, in turn, lead to death. At a UN General Assembly high-level meeting last September, various health ministers reaffirmed their commitment to come up with an “urgent global response to a global epidemic”. Philippine Secretary of Health Francisco Duque declared that we cannot continue doing “business as usual”.

In the same speech, Duque called for the adoption of new technologies to identity TB cases  – as well as greater integration of health systems to facilitate patient monitoring and surveillance.

Various factors, however, have undermined the implementation of existing efforts and the pursuit of new approaches. Directly observed treatment, short-course (TB-DOTS) – the cornerstone of TB treatment – has not worked in many settings owing to the inaccessibility of the centers where patients are supposed to get their daily medicines, the lack of human resources and sadly, even the shortages of anti-TB medications. Many people fail to complete the six-month regimen, causing relapses and antimicrobial resistance. MDR-TB patients, for their part, are even more hard-pressed to get medicines and adequate care.

Given that the major difficulty in stopping TB is the long course of treatment, some are proposing that we rethink (or refine) TB-DOTS itself, that is, consider other approaches (e.g. training and empowering community health workers to administer the drugs). Another approach is to pursue the development of novel drugs that can shorten the months of therapy – or vaccines to prevent the disease altogether. For many countries, dealing with TB necessarily means dealing with the rise of HIV.

 

There are also scholars and activists who point out that poor living conditions – e.g. overcrowding, lack of ventilation, inadequate or low-quality food – play a big role in determining who gets to acquire TB. Rightfully, they argue that it can only stop TB if we deal with its social determinants. While acknowledging that “practical ideas for action are scarce”, these voices nonetheless underscore the need to provide social and economic support to urban poor communities in the region, amid the continuing rapid pace of urban migration and rising inequity.

Ultimately, however, all of these proposed actions will have to rely on political leadership commensurate to the magnitude of the problem. Over the past decades, we have seen heads of state responding quickly and forcefully to public health threats, perceived or real – as in the height of the SARS outbreak in 2003, particularly when there is huge public interest (and media attention) in them. We need this same level of political support that will provide enough resources – financial and human – to detect, treat, and prevent TB; strengthen local health systems, mobilise new technologies and address TB’s social determinants.

Indeed, TB is nothing less than a public health emergency – and our leaders must treat it as such. We need to stop a disease that is silently but surely claiming the lives of so many people.

The writer is a physician, medical anthropologist, and op-ed columnist at the Philippine Daily Inquirer.