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Losing the Fight Against Tuberculosis

by Patrick Adams

Originally published by New York Times on January 5, 2015

On a recent morning at Persahabatan Hospital in East Jakarta, patients, some from remote villages accessible only by boat, gathered in a waiting room. Nearby, lab technicians used new diagnostic technology to test sputum samples for multidrug-resistant tuberculosis, in an effort to tackle a growing caseload of the deadly disease.

Indonesia’s recently sworn-in president, Joko Widodo, takes the reins of a rising economic power poised to play a larger role on the world stage. But he also confronts a set of entrenched public health problems fueled by the poverty in which millions of Indonesians still live. None is more urgent than the spread of drug-resistant tuberculosis across this sprawling archipelago.

Thanks to support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, the international financing mechanism established in 2002 to help poor countries address these diseases, Indonesia has been able to provide the costly drugs for drug-resistant tuberculosis to patients free of charge. It has also supplied laboratories like the one at Persahabatan with the Xpert MTB/RIF device, which allows health workers to diagnose suspected cases of drug-resistant disease in under two hours (conventional methods take as long as eight weeks).

These are encouraging steps, but as Indonesia is learning, the tools of clinical medicine can do only so much. “This is a social disease,” Dr. Erlina Burhan, the head of pulmonology medicine at Persahabatan, told me, referring to multidrug-resistant tuberculosis. “We have 7,000 new MDR cases a year, and many of those are defaulting on their treatment.”

It’s easy to understand why. For one thing, there’s the financial strain; the drugs may be free, but as a recent multinational study found, the cost to patients — for everything from transportation and hospital stays to months of missed work — can amount to a year’s earnings. And then there is the treatment itself: a grueling, two-year regimen of toxic drugs involving months of daily injections and possible severe side effects. And so stigmatized is tuberculosis in Indonesia that when volunteers go house to house looking for cases, families often try to hide sick relatives.

“Most of our patients don’t know how the disease is transmitted,” Dr. Burhan said, “so they return home and spread their drug-resistant strain to others.” The World Health Organization estimates that every untreated MDR patient will infect, on average, between 10 and 15 people per year — and some of those may be their children, in whom tuberculosis is more difficult to diagnose and treat.

In October, the W.H.O. reported that improved data collection had revealed an epidemic significantly larger than previously estimated: In 2013, nine million people developed active tuberculosis, and of those, nearly half a million were infected with multidrug-resistant strains. Indonesia, home to the world’s fifth-highest number of tuberculosis cases, is expected to publish its own prevalence survey soon; experts believe those figures will only add to the global burden.

The White House should view these trends with alarm. After all, drug-resistant tuberculosis is a threat to people everywhere, including in the United States. An outbreak in New York City that started in the late ’80s and involved drug-resistant strains cost at least $1 billion to quell. Given that caring for a single case of extremely drug-resistant tuberculosis can run more than half a million dollars, a similar outbreak today could impose crippling burdens on health departments at the front lines of the nation’s defense. And the United States almost certainly underestimates its vulnerability.

Despite congressional calls to increase tuberculosis funding for the current year, President Obama proposed a 19 percent cut to the global tuberculosis budget of the United States Agency for International Development, which would put tuberculosis funding below $200 million for the first time in five years. The spending bill recently passed by Congress rejected those cuts and maintained level funding, at $236 million. That is still far below the $400 million per year public health advocates say is needed to combat the world’s leading curable killer.

In 2013, President Obama pledged that America would contribute up to $5 billion to the Global Fund over the next three years. But by opposing increases to bilateral tuberculosis funding, the president jeopardizes this generous investment. While Global Fund grants support the purchase of drugs and diagnostics, like the $30,000 Xpert device, the agency doesn’t have the in-country staff to ensure the tools’ effective implementation. It’s here that U.S.A.I.D. plays a vital role, by training technicians, strengthening supply chains and educating doctors and nurses about novel therapies.

Without that help, our aid dollars don’t go nearly as far as they could. Between 2010 and 2012, for example, Indonesia, though a major recipient of Global Fund support, used only half of the funds allocated for tuberculosis control activities because it lacked the capacity to use that aid.

Perhaps the most tragic consequence of underfunding tuberculosis control, though, is that it undermines the fight against H.I.V. and AIDS. After billions of dollars and decades of research, antiretroviral drugs have transformed what was a death sentence into a manageable chronic disease. In spite of this monumental public health achievement, the leading killer of people living with H.I.V. today, accounting for one-quarter of AIDS deaths worldwide, is tuberculosis, a disease so neglected that the current first-line treatment is more than 50 years old.

Americans can no longer afford to be indifferent to the rise of drug-resistant tuberculosis. As Indonesia illustrates, technology alone can’t solve the problem. At least in the short term, poor countries need the specialized expertise only America can provide. When the president’s budget requests for the next fiscal year are released, they should reflect the reality that if drug-resistant tuberculosis is allowed to flourish in faraway slums, it will most certainly return to haunt us — and at potentially great cost.

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