Responding to the Drug-Resistant TB Crisis

Note: A version of this article originally appeared under the headline Advancing a TB Security Agenda in Global Health and Diplomacy. Today, the United Nations General Assembly is convening a High-Level Meeting on Antimicrobial Resistance. The meeting has drawn worldwide attention to the global crisis of drug resistance. We must now turn that attention into action.

by José Luis Castro

At approximately 9pm on a Saturday night in July 2011, Kalpana Gaikwad returned to her home in Mumbai. In the kitchen she discovered her husband, Dnyanoba, age 45, hanging by a clothesline — Dnyanoba had suffered from tuberculosis for two years before taking his own life.

Meanwhile, a day’s drive away, fourteen-year-old Zehra Begum’s health was deteriorating. For more than a year Zehra had been actively seeking treatment for multidrug-resistant TB — but her symptoms had not yet improved. Dejected, two days after Dnyanoba hanged himself, Zehra set herself on fire in her home in Hyderabad. With burns covering half of her body, she died in hospital care the next day.

These are not isolated incidents.

Last October, Dilip Kadam, also seeking treatment for multidrug-resistant TB, slit his throat with a shaving blade while admitted at Mumbai’s Sewri Tuberculosis Hospital. So resolute was Dilip that when hospital staff took a blade away from him the first time he attempted suicide, he made sure to keep a second one in reserve. According to the Mumbai Mirror (headline: “Another TB patient ends life…”) Dilip’s was the third suicide among TB patients in the hospital just this year. The hospital has also seen two attempted suicides plus a violent attack against hospital staff.

Such tragic acts of desperation should make us pause and consider the true human and societal implications of escalating TB drug resistance. Caused by a bacterial infection, TB spreads through the air, typically when someone sick coughs or sneezes. In 2014, an estimated 1.5 million people died from TB, making it the world’s most deadly infectious disease.

The World Health Organization (WHO) classifies multidrug-resistant TB, or MDR-TB, as any strain of the disease proven to be resistant to at least isoniazid and rifampicin — two of the four standard first-line medicines used to treat drug-susceptible TB. WHO estimates that 480,000 people developed MDR-TB in 2014 (the last year for which they have data). Of these, only 123,000 were diagnosed, and 111,000 began treatment. The rest were left, inevitably, to become sicker, to transmit drug-resistant infections to people in their communities, and then to die.

Credit: NY Times

Meanwhile, the intensity of TB drug resistance is increasing. In 2005, in the rural South African town of Tugela Ferry (population: 2,093), hospital patients started succumbing to a resistant form of tuberculosis that later became known as extensively drug-resistant TB, or XDR-TB. To be considered XDR-TB, a TB strain must be multi-drug resistant plus show resistance to at least two classes of second line medicines used to treat exclusively MDR-TB strains, including one fluoroquinolone and one injectable medicine. Of the 53 people who developed the disease, 52 died. Since then, 91 other countries have reported cases of XDR-TB.

What’s more, in 2011, a research team in South Africa conducted drug sensitivity testing on samples isolated from 18 XDR-TB patients. Of the 18 patients, 13 were resistant to all eight drugs available in South Africa at the time, leaving them contagious and with no treatment options. Since then South Africa has confirmed additional cases of TB disease resistant to all available medicines. And South Africa isn’t alone. In 2012, Mumbai physicians reported having a dozen patients in hospital who showed resistance to a dozen different medicines — the entire battery of antibiotics available in the country.

With exorbitant costs and the sheer complexity involved in treating drug-resistant TB, countries are struggling to contain its spread and safeguard the public’s health — and some officials have gone to extremes over the last decade. South Africa has held patients in hospitals surrounded by armed guards, leading local news media to report on incidents using terms normally reserved for violent criminals: “dangerous” patients “escape” to be “hunted” by police wearing masks. In 2007, an MDR-TB patient was shot at a Johannesburg TB facility in the midst of a violent protest over hospital conditions. Many States in the U.S. have held XDR-TB patients in actual jails.

XDR-TB patient receiving treatment. Photo credit: James Nachtwey

It’s become almost a cliche by this time to point out that the world is interconnected; that global trade, travel and communications have brought the sum total of humanity closer together than ever before in history. In our globalized world, a local outbreak can travel around the planet in a matter of hours or days, putting public health at risk and potentially causing political and economic destabilization.

For this reason, global public health has been moving more squarely into the security and foreign policy realms, with drug resistance a major point of action on the agenda.

In its 2007 World Health Report, WHO defined global health security as “the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries.”

These events need be mitigated on two levels: the individual or household, and the international. Individual health security concerns access to primary health care and to resources and facilities that can prevent and treat disease. At the international level, the focus is on mitigating cross-border health threats caused by infectious disease epidemics and other acute health events such as bioterrorism.

In 2005, two years before WHO’s seminal report, the United Nations published the International Health Regulations to guide international efforts to improve global health security. Since then, various observers have argued that the global health security agenda has predominantly focused on protecting people living in developed countries from contagion that arise within and have the potential to spread beyond the borders of developing countries. (See, for example, McInnes and Lee’s 2006 essay “Health, Security and Foreign Policy” published in Review of International Studies and Sara Davies’s 2008 International Affairs article “Securitizing Infectious Disease.”) Indeed, one could see this garrison mentality reflected in the public statements made by some elected officials in response to the Ebola epidemic that ravaged Guinea, Liberia and Sierra Leone, which called for severe commercial travel restrictions — moves that public health experts and first responders have been nearly unanimous in calling out as counterproductive.

In contrast, a robust global health security agenda, properly implemented, would use public health measures to prevent outbreaks from occurring and becoming a security threat where they originate. To this end, in February 2013, 29 countries, in partnership with WHO, the Food and Agriculture Organization of the United Nations, the World Organization of Animal Health, and the European Union, launched the Global Health Security Agenda (GHSA).

With the launch of this initiative, underpinned by the legally binding International Health Regulations, we now have an opportunity to advance a TB security agenda which prioritizes building the public health systems that can prevent the emergence and spread of drug resistant TB. This agenda needs to go beyond the GHSA and the Regulations in three areas.

First, countries need to act quickly to implement new treatment options for patients diagnosed with MDR-TB.

Last May, the World Health Organization endorsed a new treatment regimen that reduces the length of MDR-TB treatment from two years to nine months, and has far better success rates. Governments now need to incorporate the new treatment option within clinical guidelines as a first step toward reaching patients.

Second, a TB security agenda needs to deliver better psychosocial support to individuals and families undergoing treatment for MDR- and XDR-TB.

TB suicides, attacks against health workers, and the prison-like conditions resorted to in some healthcare settings are all indications of an underlying breakdown in the relationship between health systems and the people whose health security they’re meant to protect.

Third, we need to more aggressively counter the illicit activities and poor quality control in manufacturing processes that have allowed falsified and substandard TB medicines to enter international supply chains.

This is an area in which the malaria control community has been proactive. A 2013 study in the International Journal of Tuberculosis and Lung Disease, which my organization publishes, found that 9 percent of first-line TB medicines procured from private pharmacies across 17 countries were either of substandard quality or falsified. In sub-Saharan Africa, the rate was 17 percent. Whether falsified or substandard, medicines having little or no active ingredient will drive the emergence of drug resistance, while illicit activities directly weaken national and international security.

After undergoing treatment for extensively drug-resistant TB, Edgar is healthy and back to running his grocery store in Quito, Ecuador. Photo credit: Javier Galeano

When New York City faced an epidemic of multidrug-resistant TB in the late 1980s, media reports at the time described public panic. Today we face more extreme forms of resistance, and the Ebola crisis recently stoked public fear — not only of the Ebola virus itself, but of the prospect of lethal outbreaks of any kind — and bred distrust in the institutions tasked with keeping us all safe from dangerous microbes. But strong public health systems will always provide the best lines of defense against pathogenic threats. As the United Nations General Assembly convenes the first High Level Meeting on Antimicrobial Resistance — and as we approach the 10-year anniversaries of the publication of the International Health Regulations and the first recorded outbreak of XDRTB — we have a key opportunity to promote a global health security agenda that protects individuals and society from the emergence and spread of increasingly drug-resistant TB.

José Luis Castro is Executive Director of The Union.

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