Treatment Action Campaign

Key papers on TB

• Prevention, Early Diagnosis, Treatment and Cure of Tuberculosis: A Guide and Recommendations for TAC, Government and Civil Society - TAC position paper Presented by Lesley Odendal at South African TB Conference, 3 July 2008
• Isoniazid Preventive Therapy in the context of HIV: An intervention that can save lives - TAC Position Paper on IPT
• Human Rights and TB: Time to demand Action - Presentation by Mark Heywood, Executive Director, AIDS Law Project, South African TB Conference, 3 July 2008

Op-Ed Piece: How a preventable disease gets its licence to kill

By Paula Akugizibwe, ARASA (Published in Business Day, 1 July 2008)

IN OUR deranged global system of relative rights, where one's money determines the value of one's life, it is not terribly surprising that very little research has been done on improving the management of tuberculosis (TB) — a leading cause of mortality in many poor countries — in the past 50 years. Equally unacceptable, but more surprising, is that even as global research machinery finally begins plodding towards serious action on this public health disaster, many national TB programmes continue to underperform without being held accountable.

Don't be fooled by the rhetoric — in recent years, every health authority with a voice has declared TB an "emergency", a "crisis", a "threat", a "catastrophe". There is talk of urgent action, of bold action, of immediate interventions. There is a constant and justified buzz of urgency in TB rhetoric, deflected by a constant and unjustifiable drone of lethargy in TB action. When an "emergency" becomes the status quo, it indicates a state of chronic failure.

How does a preventable, curable disease become the leading cause of all natural deaths in SA, and the leading cause of all AIDS-related mortalities on our continent?

Well, first we take drug-sensitive TB, a perfectly curable form of tuberculosis, and mismanage it for decades in health structures with poor infection control, weak diagnostic capacity, insufficient education on TB, inadequate resources and minimal political commitment.

We observe substandard cure rates and increasing mortality figures. Over time, our poorly functioning TB programmes are manufacturing drug-resistant TB strains — the result of inadequate or incomplete TB treatment — but we don't worry about this too much until multidrug-resistant (MDR) TB explodes in our faces.

Unfortunately, the programmes that are now forced to deal with this new demon are still plagued by the lack of education and capacity that manufactured MDR TB in the first place. Inadequate diagnostic capacity, for example, ensures that many cases go undetected and that, even in the cases where detection does happen, it takes place after a lengthy waiting period during which infection is spread further. Appropriate treatment is not always available. Support that is available for strengthening drug-resistant TB management is ignored by the countries that need it the most.

So, more people die. Many deaths go unrecorded. It becomes kind of chronic tragedy — one that features in millions of death certificates but few headlines.

Until, suddenly, TB is back in the spotlight — a more powerful and lethal strain is on the scene. The same failures in the TB programs that manufactured MDR TB have now produced its progeny: extensively drug-resistant (XDR) TB, which responds to very few TB drugs and kills with alarming efficiency. We're not quite sure how to lock down this killer, so we lock up the patients that have fallen prey to it, trap them in the system that generated XDR TB to begin with. We invest our energies in confining the victim to the scene of the crime, while the instigators of the crime continue to run rife. The great outrage is that these are the very same instigators that we have faced from the start, against which we have not made any significant progress, despite many promises of "urgent" action. As the global TB crisis grows worse, the chronic failure of TB programs to respond to this crisis becomes more and more obscene. Diagnostic systems are a disaster. Infection control is a disaster. Resource allocation is a disaster. Management of drug-resistant TB is a disaster.

That is how a curable, preventable disease becomes a leading cause of death — because our chronically failing systems give it licence to kill, because we cannot seem to summon enough momentum to shake the underperformance that got us to this point. The disaster that is TB today was not by any means inevitable — it has been systematically generated for decades. And it continues to be generated and aggravated as the sluggishness that characterised the global response to TB in the past persists, most markedly at country level, where the same old mistakes are perpetuated with the same stupefying apathy.

When will we learn from these mistakes, and correct them? When will the emergency be over? Where is the bold and urgent action? Where are the resources? How much longer will our leaders drag their feet on delivering on the lofty commitments that they have been making for years?

These are the tough questions that we need to ask every government in the region, starting at the South African National TB Conference in Durban this week. This is not about pointing fingers; it is about accepting responsibility and effecting leadership. It is about honest evaluation of the response to TB and honest commitments to improving it. Nobody needs to die of a preventable, curable disease. And yet they die in increasing numbers. So we have failed, and failed dismally. It is time to put out the dirty laundry, wash it and move forward.