This is a guest blog jointly submitted by Jerald C. Sadoff, MD, the President & Chief Executive Officer of the Aeras Global TB Vaccine Foundation and Mel Spigelman, MD, the President & Chief Executive Officer of the Global Alliance for TB Drug Development.
In recent weeks, U.S.-based global health advocates have been scrutinizing and providing public comments on the recently released draft strategy of the President’s Global Health Initiative (GHI), which rightly expands the US government’s global health policy to address several key areas that were neglected in recent years. However, although tuberculosis kills almost two million people each year, the GHI – more accurately, what’s not in the GHI – suggests that TB is just not a priority for the Administration.
This is puzzling, since TB kills almost 2 million people each year and is the world’s second-leading infectious killer. There is more tuberculosis today than ever before in history, but it is truly a forgotten disease. That’s evident by the low level of funding requested by the GHI– only a $5 million increase for FY11– and the dramatic scaling back of treatment targets for TB patients. Better prevention and treatments are urgently needed, yet will remain far out of reach if the current GHI proposal is not changed.
TB is a disease of poverty, affecting the most vulnerable and marginalized people around the world. It rarely captures headlines or garners celebrity attention. Still, it’s difficult to reconcile the low levels of US government funding dedicated to TB with the significantly higher levels for other diseases that take similar numbers of lives. We don’t question the need to fund those devastating diseases, but we do question the neglect and imbalance in the approach to TB. This disparity is certainly not evidence-based, since TB claims a staggering number of lives.
The meager funding for tuberculosis vis-à-vis other serious health threats is all the more baffling when you consider the alarming rise in multiple drug-resistant (MDR) and extensively drug-resistant (XDR) TB, which recognizes no borders and threatens the United States. Failure to invest in drugs and vaccines to better control TB will have severe ramifications for our public health system and for US taxpayers. For example, the 1989-1991 outbreak of MDR-TB in New York cost more than $1 billion to contain. The expense of treating newly emergent, extensively resistant strains is even greater –a single case of XDR-TB in the US can cost taxpayers almost $600,000, according to the CDC. Better TB prevention and treatment will benefit people at home and abroad.
The devastation caused by tuberculosis was recognized in 2008 when the US government passed the Lantos-Hyde PEPFAR reauthorization to increase funding and prioritize TB research and control. (To read more about Lantos-Hyde, click here.) Over five years, it aimed to treat 4.5 million drug-sensitive patients and 90,000 drug-resistant patients and authorized $4 billion for TB control. It also set out a long-term strategy of investing in research and development to create new and improved tools, including vaccines and drugs, to prevent and treat the growing TB problem.
By contrast, the proposed GHI treatment targets and funding levels represent a step backwards. The GHI proposes to treat 2.6 million patients afflicted with drug-sensitive TB and 52,700 patients suffering from drug-resistant tuberculosis around the world – 40% fewer than called for in Lantos-Hyde. The GHI also does not explicitly address R&D, which is crucial to any long-term sustainable response to TB. In particular, this draft strategy omits the significant role played by USAID in funding the development of new technologies to combat tuberculosis – efforts that urgently require greater investment.
New tools are desperately needed. Current TB treatments were developed over 40 years ago and require patients to undergo a lengthy and complex regimen – which is even longer and more difficult to comply with in the case of drug-resistant tuberculosis – and which cannot be administered with certain HIV medications. The existing vaccine – which has limited effectiveness and is not recommended for HIV-positive infants – was invented almost 90 years ago. The most commonly available diagnostic method in developing countries, sputum smear microscopy, was developed over 120 years ago. The GHI should highlight the fact that TB will not be controlled or ultimately eliminated without the development of new tools, such as new drug regimens, new TB vaccines, and improved diagnostics.
By failing to invest adequately in TB, the GHI also undermines its ability to make progress in all priority areas or leverage the cross-cutting global health impact of a comprehensive TB elimination strategy. Consider the following:
• HIV/AIDS – TB is the leading killer of people living with HIV in developing countries. In 2008, the United Nations identified the integration of TB and HIV control programs as a global health priority. Failing to address TB undermines existing US investments in AIDS treatment; each year, thousands of people whose lives have been preserved by antiretroviral treatment die from undiagnosed and/or untreated TB.
• Reproductive, maternal, newborn, and child health – TB kills more women each year than all causes of maternal mortality combined and claims the lives of more than 100,000 children every year. In India alone, 300,000 children are orphaned each year because their mothers have died of TB.
• Health systems and health workforce – Combining the more than 9 million cases yearly with the lengthy and complex TB treatment (including drug-resistant TB) places substantial burdens on healthcare systems.
Commitments to funding levels and treatment targets in the GHI must be, at a minimum, restored to the levels contained in the Lantos-Hyde Act, and the development of new tools to address the epidemic must be an expressly defined part of the strategy. The lives of current and future tuberculosis sufferers are worth saving.