Daily Times

Tuberculosis (TB) has been claiming human lives throughout history, starting with records of human deaths dating back to over 9,000 years ago. As its killing spree peaked in most of the Western world, it assumed titles such as the “Captain of Death” or “The White Plague.” After the eighteenth century, it began to decline in Europe and North America, yet it continued its ravages in poorer countries and came to be seen as a disease of poverty. A major breakthrough came on March 24, 1882, with the identification of Mycobacterium Tuberculosis as TB’s causative agent by Heinrich Hermann Robert Koch. He would go on to do the same for cholera and anthrax and is regarded as the main founder of modern bacteriology. He secured the 1905 Nobel Prizes for Physiology and Medicine and was knighted. However, it was his discovery of Mycobacterium Tuberculosis 140 years ago that we recollect around March 24 every year as World TB Day. Then came BCG vaccination around a century ago followed by tuberculosis drugs starting with the discovery of streptomycin in 1944 and isoniazid in 1952.

The theme of World TB Day this year is the bluntest in my 25 years’ association with the control of the disease– “Invest to End TB – Save Lives.” In simple words, it is telling all national governments and their development partners to enhance their level of spending if they are really serious about eliminating TB and not merely paying lip service. Come COVID-19, hail or sunshine, we need to ensure equitable financing and access to TB prevention and care consistent with the Sustainable Development Goal of achieving Universal Health Coverage.

Every day, over 4,100 people die from TB and nearly 30,000 people fall ill globally – despite
it being preventable and treatable.

Every day, over 4,100 people die from TB and nearly 30,000 people fall ill with TB disease globally – despite it being preventable and treatable. In Pakistan, which has the fifth highest burden of TB, 600,000 new people get the disease while 35 people die daily due to the disease.

Tuberculosis is the leading killer of infectious diseases and among the ten priority areas of the Government of Pakistan’s Health Sector. Around a quarter of the world’s population is infected with Mycobacterium tuberculosis without symptoms, commonly known as latent TB infection (LTBI), and thus more at risk of developing TB disease, it is generally assumed that this includes 30-40% of our population of 280 million. Certain deprivations of poverty such as overcrowding, lack of basic education in rural females, poor ventilation, malnutrition, smoking and diabetes constitute the more important risk factors for the disease. However, TB has historically claimed the lives of monarchs and thousands of eminent men and women over the years. In Pakistan’s national life, its main victim was our Founder Governor-General Mohammed Ali Jinnah, who had to be flown to a hill station and was administered a few vials of Streptomycin – it was too little too late! Thus, the new dominion of Pakistan could benefit from his statesmanship for only 11 months with another two months devoted entirely to his treatment and care.

Coming nearly four years after the United Nations General Assembly declaration of September 2018, World TB Day also highlights the need to urgently accelerate the TB response by intensifying TB awareness among health care providers, diagnosing and treating latent TB and TB infection through quality measures, highlight personal experiences of TB survivors or those undergoing treatment themselves or through celebrities to the end stigma attached to this ancient disease.

As pointed out on January 18, 2022, by President Arif Elahi around 360,000 cases are identified and over 90 per cent of them are cured by the national and provincial TB control programs, over the course of six months. We have free diagnosis and treatment facilities available in thousands of public health facilities across the country, even for those resistant to first-line TB drugs, who are even being provided basic psychosocial support, food support and travel costs in addition to their treatment regimens. Now people neither need to go to hill stations nor should there be any stigma attached to the disease. The President has been taking a keen interest in health issues ever since assuming his high office and was presiding over the second TB Summit – both held during his tenure.

Despite a high level of political commitment available in Pakistan, the main concern is the slow pace at which Tuberculosis incidence is decreasing. It is in fact growing slightly in Pakistan, keeping in view the population growth rate. This makes it imperative to harness over 200,000 missing cases who are not being identified or notified by the public sector and who are either being treated by the private health sector or quacks. Unless these cases are tracked and notified there is no way of bringing about a 90 per cent reduction in the number of deaths due to tuberculosis, or an 80 per cent reduction in tuberculosis incidence by 2030, despite the use of new diagnostic and therapeutic tools, and applying principles of equity and human rights with equitable financing. We must not allow the unprecedented level of political commitment leveraged after the United Nation’s extraordinary meeting to be dampened due to COVID-19. We must instead capitalize on the newly created opportunities and materialize our goals through funding, concrete action, and accountability at all levels, despite the huge drain on health resources due to COVID-19, which thankfully is on the wane at present.

Several high-tuberculosis burden countries like Pakistan are also depending heavily on the Global Fund grants for TB control and elimination and which play an important role in several low-income and middle-income countries. However, there is a need for indigenous national budgets to increase significantly in Pakistan to ensure government ownership and accountability. In the context of the country’s devolved set-up, a lot will depend on the investment of the provincial governments, with the Federal Government looking after the residual mandates left at the Ministry of National Health Services, Regulation and Coordination including inter-provincial coordination, the establishment of program modalities, setting on national targets and goals, operational research and disbursement of grant logistics. This year is a critical year for all of us as what we do now will be reflected and reviewed by the international community, while will meet by the end of December 2022. The ongoing efforts to contain the COVID-19 pandemic accompanied by critical funding gaps are also likely to cause disruptions leading to an adverse impact on TB control activities.

Certain positive developments in the fight against TB include the formation of a proactive End-TB Parliamentary Caucus in Pakistan comprising of members from all political parties headed by the highly dynamic Parliamentary Secretary for Health Dr Nausheen Hamid and its alignment with the Prime Minister’s Task Force on SDGs, detection of private-sector patients through private pharmacies and their inclusion in the database, piloting of a multi-sectoral accountability framework for TB control at the district level, focus on community involvement, gender mainstreaming and human rights to make the interventions more patient-centred and user-friendly and a genuine desire to improve things augur well for the future of TB control and elimination.

However, it is highly probable that the enormity of the task may have been grossly under-estimated and the pace of effort currently underway may not be able to make a significant dent in the state of affairs, keeping in view the weaknesses of our otherwise impressive network of health facilities. All the stakeholders need to be mindful of the barriers involved in this immense task, particularly at the provincial and district levels.

What is really required is casting the net more broadly to harness all the missing TB cases and follow their treatment process until they are fully cured, particularly in the private sector. The facilities for drug-resistant TB patients need to be enhanced with greater psychosocial support and attention paid to their mental health needs. The provincial governments need to redouble their efforts consistent with the national guidelines. Communities and civil society need to provide monitoring to the program to make it accountable with a greater consortium of partners having a shared vision of the way towards the coveted goal of TB elimination by the year 2030. It is a goal we cannot afford to miss!

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