New Tools Needed to Fight Ancient Disease

If you ask people to think about ancient Egypt, they will probably immediately point to the Great Sphinx of Giza and the pyramids that to this day still represent one of the greatest human architectural triumphs. But there was a disease that affected people in ancient Egypt times that is still a massive killer across the world today.

From Anton Chekhov, to Eleanor Roosevelt, to Nelson Mandela; for centuries tuberculosis has attacked people of all races, socio-economic backgrounds and genders. By the nineteenth century, tuberculosis had killed one in seven people that had ever lived on Earth and many believed it was hereditary, related to witchcraft or a punishment from God.

It was only later in the century that following tests on guinea pigs, the now legendary Robert Koch announced to the Berlin Physiological Society that he had identified an infectious disease: Mycobacterium tuberculosis.

Today, 135 years later, the world marks the anniversary of Koch’s momentous findings on what is now known as World TB Day. Although Koch’s discovery is recognised, rightly, as one of the most critical breakthroughs in TB history, the world still has a long way to go before we can begin to think about consigning it to the history books. As was done with another ancient disease, smallpox.

According to the World Health Organization, in 2015, an estimated 10.4 million people fell ill due to TB and 1.8 million died due to the disease. TB is the biggest infectious killer. Those with HIV are particularly at risk from TB as their suppressed immune system means they are more susceptible to developing infection.

Ever growing resistance to TB treatment is making the disease even more difficult to treat. Multi drug-resistant (MDR) and extensively drug-resistant (XDR) TB can be particularly difficult to treat. Of the 480,000 cases of drug resistant TB, only a quarter of them are actually detected because diagnostics are either outdated or inaccessible. The treatment can be expensive and long, which puts pressure on already overburdened health systems and is part of the reason why the mortality rate is so high. For some types of drug resistant TB, we still have no effective treatment.

Last year the United Nations General Assembly High-Level Meeting on Antimicrobial Resistance stated that “resistance to antibiotics, which are not like other medicines, including medicines for the treatment of tuberculosis, is the greatest and most urgent global risk, requiring increased attention and coherence at the international, national and regional levels.”

Unless we are able to develop new more effective diagnostics and medicines, the situation will only get worse. One of the reasons for a lack of innovation and progress in tackling TB is the lack of market incentivisation to develop new tools. I have a track record of embracing innovation and as the next Director-General of the WHO; I would work with governments, civil society, pharmaceutical companies, and academia to create the enabling environment needed to ensure the development of new health technologies to tackle TB.

There are signs of hope. The world now has a rapid diagnostic test, which has been recommended by WHO to improve identification of MDR -TB patients. On the treatment side, a new drug, delamanid, is one of the first new TB medicines to be developed in the last 50 years and has had impressive results that have cut treatment times significantly.

In 2016, WHO approved the use of a much shorter treatment for drug resistant patients who do not have strains that are resistant to second-line TB medicine. Also, last year saw progress in our ability to treat children with TB. For the first time in history we now have formulations appropriate for children.

For any new health technologies we must learn lessons from history. At the turn of the Millennium, the dramatic scale-up of antiretrovirals in sub-Saharan Africa, saved millions of HIV patients’ lives. It’s critical to find ways to ensure that those that need the drugs can access them, while also ensuring sufficient rewards for innovation and investment for those that invest in research and development.

Furthermore, this isn’t just about medical innovation. It’s critical to put the systems and infrastructure in place that reduces drug-resistance in the first place. This means training health workers, and ensuring they have the right tools and skills so that they can effectively diagnose, prevent and treat people with TB and drug-resistant forms of the disease. We also need to overcome health systems barriers, ensuring Universal Health Coverage for TB treatment and reducing poverty and addressing the social determinants of health, which leave an indelible mark on human health in terms of TB susceptibility.

I have seen and treated TB in most conceivable forms as I trained and worked as a physician, in a country with one of the highest TB burdens in the world. As a physician, I have treated drug resistant forms of the disease and understand what a test of endurance it is both for patients, as well as physicians.

With my health systems policy background, I can appreciate the critical importance of functioning health systems to achieve both TB as well as other chronic disease goals. With my background in non-communicable diseases, I am well positioned to exploit these synergies. Also, through my civil society experience, I can appreciate and tap the potential of civil society, which can play a major role — from providing treatment, to educating the public about TB, to holding other stakeholders accountable for the investment, development and accessibility of new TB health technologies.

Tuberculosis has been around since the time Ancient Egypt saw the rise of the pyramids, but this is no time for complacency and all stakeholders must work together to stop TB. Encouragingly, the world seems to be waking up to the challenges. The UN Secretary-General recognised the urgency by announcing a high-level meeting at the United Nations General Assembly in 2018. To get ready for the critical moment, Russia will be hosting the WHO Global Ministerial Conference on the fight against TB, in November this year. Both meeting are critical milestones to ensure that the world acts quickly to prevent a TB global contagion.

If you ask people to think about ancient Egypt, they will probably immediately point to the Great Sphinx of Giza and the pyramids that to this day still represent one of the greatest human architectural triumphs. But there was a disease that affected people in ancient Egypt times that is still a massive killer across the world today.

From Anton Chekhov, to Eleanor Roosevelt, to Nelson Mandela; for centuries tuberculosis has attacked people of all races, socio-economic backgrounds and genders. By the nineteenth century, tuberculosis had killed one in seven people that had ever lived on Earth and many believed it was hereditary, related to witchcraft or a punishment from God.

It was only later in the century that following tests on guinea pigs, the now legendary Robert Koch announced to the Berlin Physiological Society that he had identified an infectious disease: Mycobacterium tuberculosis.

Today, 135 years later, the world marks the anniversary of Koch’s momentous findings on what is now known as World TB Day. Although Koch’s discovery is recognised, rightly, as one of the most critical breakthroughs in TB history, the world still has a long way to go before we can begin to think about consigning it to the history books. As was done with another ancient disease, smallpox.

According to the World Health Organization, in 2015, an estimated 10.4 million people fell ill due to TB and 1.8 million died due to the disease. TB is the biggest infectious killer. Those with HIV are particularly at risk from TB as their suppressed immune system means they are more susceptible to developing infection.

Ever growing resistance to TB treatment is making the disease even more difficult to treat. Multi drug-resistant (MDR) and extensively drug-resistant (XDR) TB can be particularly difficult to treat. Of the 480,000 cases of drug resistant TB, only a quarter of them are actually detected because diagnostics are either outdated or inaccessible. The treatment can be expensive and long, which puts pressure on already overburdened health systems and is part of the reason why the mortality rate is so high. For some types of drug resistant TB, we still have no effective treatment.

Last year the United Nations General Assembly High-Level Meeting on Antimicrobial Resistance stated that “resistance to antibiotics, which are not like other medicines, including medicines for the treatment of tuberculosis, is the greatest and most urgent global risk, requiring increased attention and coherence at the international, national and regional levels.”

Unless we are able to develop new more effective diagnostics and medicines, the situation will only get worse. One of the reasons for a lack of innovation and progress in tackling TB is the lack of market incentivisation to develop new tools. I have a track record of embracing innovation and as the next Director-General of the WHO; I would work with governments, civil society, pharmaceutical companies, and academia to create the enabling environment needed to ensure the development of new health technologies to tackle TB.

There are signs of hope. The world now has a rapid diagnostic test, which has been recommended by WHO to improve identification of MDR -TB patients. On the treatment side, a new drug, delamanid, is one of the first new TB medicines to be developed in the last 50 years and has had impressive results that have cut treatment times significantly.

In 2016, WHO approved the use of a much shorter treatment for drug resistant patients who do not have strains that are resistant to second-line TB medicine. Also, last year saw progress in our ability to treat children with TB. For the first time in history we now have formulations appropriate for children.

For any new health technologies we must learn lessons from history. At the turn of the Millennium, the dramatic scale-up of antiretrovirals in sub-Saharan Africa, saved millions of HIV patients’ lives. It’s critical to find ways to ensure that those that need the drugs can access them, while also ensuring sufficient rewards for innovation and investment for those that invest in research and development.

Furthermore, this isn’t just about medical innovation. It’s critical to put the systems and infrastructure in place that reduces drug-resistance in the first place. This means training health workers, and ensuring they have the right tools and skills so that they can effectively diagnose, prevent and treat people with TB and drug-resistant forms of the disease. We also need to overcome health systems barriers, ensuring Universal Health Coverage for TB treatment and reducing poverty and addressing the social determinants of health, which leave an indelible mark on human health in terms of TB susceptibility.

I have seen and treated TB in most conceivable forms as I trained and worked as a physician, in a country with one of the highest TB burdens in the world. As a physician, I have treated drug resistant forms of the disease and understand what a test of endurance it is both for patients, as well as physicians.

With my health systems policy background, I can appreciate the critical importance of functioning health systems to achieve both TB as well as other chronic disease goals. With my background in non-communicable diseases, I am well positioned to exploit these synergies. Also, through my civil society experience, I can appreciate and tap the potential of civil society, which can play a major role — from providing treatment, to educating the public about TB, to holding other stakeholders accountable for the investment, development and accessibility of new TB health technologies.

Tuberculosis has been around since the time Ancient Egypt saw the rise of the pyramids, but this is no time for complacency and all stakeholders must work together to stop TB. Encouragingly, the world seems to be waking up to the challenges. The UN Secretary-General recognised the urgency by announcing a high-level meeting at the United Nations General Assembly in 2018. To get ready for the critical moment, Russia will be hosting the WHO Global Ministerial Conference on the fight against TB, in November this year. Both meeting are critical milestones to ensure that the world acts quickly to prevent a TB global contagion.

Dr. Sania Nishtar is nominee for the Director-General of the World Health Organization