Daily Times

World Tuberculosis (TB) Day is here again to commemorate the 140th anniversary of the discovery of Mycobacterium Tuberculosis as TB’s causative agent by Heinrich Hermann Robert Koch. Having been associated with the program in Pakistan since 1998 or 1999 when we seriously initiated an inter-provincial dialogue on the need for a proper mechanism to adopt the World Health Organization’s DOTS strategy, this may be an excellent time to recount the successes and challenges that TB control programs have encountered in nearly a quarter-century. But let us take a broader view of things.

Neither Robert Koch nor those who invented the appropriate drugs and/or diagnostics replicable on national scales would be happy had they been alive to see the disease still prospering today in developing countries. The reasons for these are multifarious – some are fragile states with weak health systems, others have existential threats, some have not prioritized TB as a major health threat, but they all have one thing in common; they are not spending enough to control or eliminate the disease. As a result, multi-drug resistant strains of TB are appearing in the richest nations with the strongest health systems. But let me add that the emergence of COVID-19 has revealed that no health system in the world is really strong, particularly in terms of communicable disease control. The proverbial “Captain of Death,” as TB was once called, continues to wreak its havoc globally. In 2020, around 10 million, including 3.3. million women and 1.1 million children, fell ill with TB while 1.5 million died from it, many more than the new pandemic.

Tuberculosis Control in Pakistan–Bridging the Rights’ GaIn Pakistan, we seem to have relied too much for too long solely on a medical solution to the social problem of TB.

Returning to Pakistan, it is fifth on the list of high-burden TB countries after India, China, Indonesia and the Philippines, with 600,000 new people getting the disease and 44,000 dying annually from it. The national and provincial programs took off in a big way from 2000 onwards and on March 24, 2001, TB was declared a national emergency. However, that sense of urgency seems to have diluted since 2020 when the COVID-19 pandemic brought about a significant lowering in case notifications as well as the expenditure on controlling TB.

TB control is based on the principle of treating and curing the existing pool of persons suffering from the disease to prevent them from infecting others. Thus, we have to identify as many TB patients as possible and cure them mostly with a six-month treatment regimen. Moving towards elimination by the year 2030, Pakistan will also need to provide preventive treatment to a sizable proportion (30-40 per cent) of its population, estimated to have latent TB without symptoms, to prevent them from developing active TB. While there are more than 5,200 public sector health centres providing free TB diagnostic care for 2 decades, we are yet missing 200,000 cases annually due to which the disease incidence is not lowering, despite significant investment from the and donors, particularly the Global Fund, USAID, WHO and the Stop TB Partnership.

This year’s World TB Day comes around 8 months before the United Nations will review the progress of countries in controlling TB following the powerful 2018 declaration and has the theme: “Invest to End TB. Save Lives.” The message is clear. We have to look beyond COVID-19 and spend more money to control the more deadly pandemic of TB that has haunted us since pre-historic times.

In Pakistan, it seems we have relied too much for too long solely on a medical solution to the social problem of TB, which requires a human rights-based TB response, supported, of course, by good clinical practices. We must bring about a paradigm shift to focus more on the people affected by TB and not just their medical problems. TB is a disease of poverty that is known to perpetuate poverty further. Just the way, the constitution of the WHO calls for attaining the highest standards of health for the entire world population, it is imperative to adopt a rights-based approach that is more gender-sensitive and leverages existing national laws including the right to health, non-discrimination, privacy & confidentiality, information and liberty. This will, in turn, transform the TB response to be more equitable and people-centred making it necessary to target those most at-risk for TB whether due to their social status, peripheral locations or occupational hazards.

More importantly, we have to eliminate the discrimination, which stems from the stigma attached to TB, which is known to be widespread and impinging on employment, education, housing, and even family relations. As pointed out by the President of Pakistan Dr Arif Alvi at the TB summit on the 18th January 2022, it is this very stigma and discrimination that leads to delayed diagnosis and treatment initiation. The President and First Lady are personally leading the fight against Tuberculosis and Breast Cancer, respectively by reducing the stigma attached to both conditions.

It is also widely known that while fewer women contract TB, they disproportionately bear the brunt of it in terms of personal relationships and diminished social status. Our health facilities may also be failing to provide the right to privacy & confidentiality in avoiding disclosures of personal health information. Although laws in Pakistan safeguard this right, our socio-cultural fabric tends to violate it. Then the right to liberty does not permit us to confine people with TB but rather treat them in domiciliary settings with the necessary precautions. Marginalized groups including the homeless, nomads, refugees, IDPs, migrants, minorities and people with mental health issues often require special attention for their specific needs.

In case Pakistan’s provincial TB programs can incorporate this missing link in their care protocols, we can accelerate the elimination of this disease much more rapidly and hopefully by the targeted date of 2030. It will entail a lot of empathy, adherence to laws, enhanced efforts for better diagnostics and treatment choices, with sharing of human suffering and pain, yet it is a goal we simply have to achieve!

The writer is a senior public health specialist and Editor in Chief (Public Health Action).