Focus on Arts and Ecology

The fact that more than 10 million people fall ill with tuberculosis annually, and that 5000 die of it every day, including about 1000 because of HIV-associated infection, speaks to the gravity of the global problem of tuberculosis. Tuberculosis has many other dubious distinctions that merit attention: it is one of the oldest diseases known to mankind and yet one of the top ten global causes of death today, the top infectious cause of death worldwide, the top killer of people with HIV infection, and a top cause of death due to antimicrobial-resistant infections.¹ Bearing this in mind, investing in the fight against tuberculosis is a “no brainer” development target, according to The Economist and the Copenhagen Consensus, given the benefits gained per dollar spent.² Countries have committed, as part of the WHO's End TB Strategy and the Sustainable Development Goals (SDGs), to ending the tuberculosis epidemic by 2030.^{3, 4} The Stop TB Partnership's Global Plan to End TB, 2016–2020, laid out the estimated financing needs for the first 5 years in implementing the End TB Strategy.⁵ Yet in 2016, WHO reported that the world was failing to accelerate actions to meet the first milestones towards these targets.

At the end of 2016, there finally seemed to be a swell of political recognition of the problem, in view of the dire facts and growing vocal demand from people affected by tuberculosis. First, WHO and the Russian Federation decided to hold the very first WHO Global Ministerial Conference on Ending TB (Nov 16–17, 2017) to stimulate action and commitments. Second, the UN General Assembly announced the first ever high-level meeting on the fight against tuberculosis in 2018.⁶ Third, in July, 2017, the G20 leaders recognised that acting on priority pathogens, including tuberculosis, is a crucial part of global efforts to combat antimicrobial resistance. Fourth, at the meeting of the Brazil, Russia, India, China, and South Africa (BRICS) leaders in September, 2017, these countries committed to combat tuberculosis together, including advancing tuberculosis research. There is a strong foundation on which this work is building: between 2000 and 2016, tuberculosis treatment alone saved 53 million lives, including those of people with HIV.

However, there are profound weaknesses that inhibit acceleration of these movements. Weak health systems are still far from providing universal coverage without financial hardship for high-quality services, including use of new tools for tuberculosis care and, more urgently, for multidrug-resistant tuberculosis, leaving more than a third of all tuberculosis cases unreported. There is a dearth of innovative approaches that enable reaching the high-risk groups and susceptible populations. There is also a paucity of new and better tools for tuberculosis care and prevention: point-of-care diagnostics, new drugs, shorter and better treatment regimens, and safe and effective tuberculosis vaccines. Finally, there is no truly multisectoral tuberculosis response, which is essential to address the drivers and determinants of the epidemic.

The latest global burden of disease assessment measuring progress on health-related SDGs concludes that tuberculosis is one of the health challenges for which dramatic acceleration of progress is most needed.⁷ Such urgent acceleration of efforts and investments is possible considering recent changes in global political economy: half of the countries with high tuberculosis incidence that were classified as low-income in 2000 are now in the middle-income category, and more countries are expected to join by 2020.⁸ The five BRICS countries bear about 45% of the world's burden of tuberculosis and more than 60% of the multidrug-resistant tuberculosis burden.⁹ BRICS and other middle-income countries with growing economies could ensure that domestic resources are mobilised and sustained to finance their responses to tuberculosis. Ending the global tuberculosis epidemic also requires parallel and substantial progress on health-related and other SDGs. Within the health-related SDG3 targets, universal health coverage and controlling the epidemics of HIV, diabetes, alcohol-use disorders, and tobacco smoking need to be addressed. The drivers and determinants of the tuberculosis epidemic and the direct risk factors for tuberculosis will, however, need action on other, non-health-related SDGs. These include addressing poverty and social protection (SDG1), hunger (SDG2), indoor air pollution (SDG7), working and living conditions (SDG8), inequalities (SDG10), and urban slums (SDG11). The triple feat of reaching more people who need care today, broadening actions to prevent tuberculosis, and investing in research to deliver innovations means that leaders from within and beyond government need to act in a coordinated fashion.

There are at least four clear expectations from the health ministers and all partners gathering at the ministerial conference in Moscow. First, speed up universal coverage of care and prevention for tuberculosis, HIV-associated tuberculosis, and multidrug-resistant tuberculosis in the context of the global agendas of antimicrobial resistance, health security, and SDGs, while ensuring that equity, ethics, and human rights are recognised as urgent concerns and are protected and promoted. Second, enable sufficient and sustained financing for the full response from strengthened domestic and external sources. Third, urgently increase coordinated investments in research and innovations. Finally, and most importantly, to drive real action built on written commitments, a multisectoral accountability framework needs to be prepared and adhered to. This framework needs to encompass all dimensions of the tuberculosis response and enable not just measuring progress towards ending tuberculosis, but also timely reviewing of results through government and civil society accountability mechanisms at national and global levels, as well as taking corrective actions.

WHO Member States, the Stop TB Partnership, civil society, and other stakeholders are working to make the most of the historic UN General Assembly high-level meeting on tuberculosis in 2018. The WHO Ministerial Conference in November, 2017, should provide ministers of health and their heads of state with essential building blocks towards achieving revolutionary commitments in 2018, and beyond.