The Greek physician Hippocrates was highly gifted and prophetic in some respects. In the 90 years of life allotted to him from 460-370 BC, he emerged as the Father of Medicine. Despite vast additions to knowledge and tools in the medical sciences over centuries, many of his ethical principles and standards are conformed to this day. He advised physicians to always be well-kempt, honest, calm, understanding, and serious, while as regards diseases, he ordained upon all caregivers to “make a habit of two things-to help, or at least to do no harm”. Nearly 25 centuries later, physicians daily contend with how not to harm persons entrusted to their care, by weighing the benefit and harm in each action they take.
Tuberculosis (TB) is a disease, which preceded Hippocrates, and has been traced back to humans 9,000 years ago, while its causative organism Mycobacterium tuberculosis appears to have been in nature since 15,000 years. Sadly, even in 2022, 10.6 million people fell ill with TB while 1.3 million died from it. In Pakistan, over 600,000 get TB every year while an estimated 47,500 die annually directly or indirectly due to the disease.
While we are all anxious to eliminate TB, let us first examine how in doing so, we at least do not harm’ persons with Tuberculosis and our communities in our national context. Firstly, we have to reduce our disease burden by identifying and curing all the existing persons with TB. If 600,000 persons are developing active disease, detecting even 400,000 or a little more will not help. We have to try and harness all the ‘missing’ persons, put them on the appropriate regimen and follow them till they are effectively cured to contain drug resistance. With a cure rate of 94%, Pakistan is doing very well, only if it can address the early loss to follow-up of patients registered, particularly in tertiary care hospitals.
Governments need to streamline their financial and human resources to attain universal health coverage and TB elimination.
This is where the need for health equity comes in. Remember although it can affect anyone, TB is essentially a disease of poverty, and more a social than a medical problem. It is fueled by deprivations of poverty like lack of universal primary healthcare or educational facilities; illiteracy in rural females, gender inequities, unemployment, unsafe transportation, occupational hazards, social exclusion of vulnerable groups and overcrowded environments in ever-growing urban and rural slums, with suboptimal provisions for social protection.
Unless we are equitable in our approach and do not address these social determinants of health, we can never eliminate TB. For this we need overarching fairness and social justice, accountability and transparency while meeting the needs of local communities. If people who are marginalized, more vulnerable than others or live in remote locations and cannot access health facilities, it naturally becomes incumbent upon us to go to them and ensure that they get the same treatment as anyone else in Pakistan.
The entire process requires excellent leadership and ownership from the federal, provincial and district governments down to the lowest administrative tiers to make an adequate impact and enhance our potential for delivering results. Mutual trust and a shared vision of what is required among all stakeholders are also of the essence to this effort.
Governments need to streamline their financial and human resources to attain universal health coverage and TB elimination while realizing the immense significance and diverse ramifications of such efforts. These include addressing high out-of-pocket expenses to patients resulting in catastrophic costs, which push vulnerable population segments below the poverty line. Encouraging the use of innovative diagnostics and facilitating correct treatment regimens suited to specific patients and integration of TB care with mental health is highly warranted, through the provision of adequate psychosocial protection wherever needed. Governments also need to acknowledge investments towards a healthy population as a legitimate pathway towards economic growth. Indeed this was the rationale of the United Nations in conducting two High-Level Meetings in 2018 and 2023 to impress upon the highest tier of policymakers what was required of them and they have already pledged their willingness to do so.
It is also important to dispel myths enduring for centuries to destigmatise TB, more importantly, persons suffering from it, particularly females fearing social exclusion for which the active collaboration and involvement of the communities is required, and which can be catalysed by notables, educated religious leaders, celebrities, and TB survivors. What is of utmost importance is to make our interventions highly focused, patient-centred, user-friendly, community-oriented and less resource-intensive; the provision of free diagnostics and treatment is not enough. We need to incorporate costs incurred on improved nutrition, travel to the designated facilities and loss of work income due to TB into our budgetary provisions.
TB preventive treatment to eligible groups is fast emerging as a high priority given the fact that Pakistan is significantly lagging in this area. Together with reports of an emerging new TB vaccine for both adults and children, these measures promise great dividends. Care providers have already been trained on TB preventive treatment, while the Pakistan Chest Society is complementing governmental efforts in this regard.
Above all and ‘to do no harm’, TB elimination requires concerted efforts from several social sectors other than health, social security nets like BISP, Zakat and Baitul Maal, professional bodies of chest physicians, private medical practitioners and family physicians, in addition to civil society and communities. With the targeted dates of 2030 and 2035 set towards TB ceasing to be a public health problem and 2050 for absolute elimination, it cannot be business as usual anymore, making it imperative for all of us to walk the extra mile. As the Secretary for National Health Services said a few days ago, we may need to run but we will End TB!
The writer is a senior public health and policy specialist and can be reached at gnkaziumkc@gmail.com