Considering the WHO Global Tuberculosis Report 2021 in light of COVID-19
In October of this year, the World Health Organisation (WHO) reported that deaths from tuberculosis (TB) have risen for the first time in a decade, a major blow to their End TB Strategy. Simultaneously, global spending on TB declined by 8.7%, falling far below targets. The report attributed the rise in deaths to the impact of COVID-19 on global healthcare capacity and access. This comes as no surprise—you would be hard-pressed to find a single area of healthcare that has not been negatively affected by the pandemic. However, I find that there is something particularly hard to swallow about the increase in TB deaths attributable to COVID-19.
In comparing the response to these two diseases, I do not intend to downplay the devastation that COVID-19 has wreaked upon our world. As of 1 November 2021, the WHO reports that approximately 5 million people have died of the virus since the start of the pandemic, and the effects of COVID-19 go far beyond the death toll, from economic devastation, to mass burnout of healthcare workers, to major disruption to education. The constant headlines, though tiresome, are certainly well-deserved. My question concerns why TB does not receive comparable media coverage—or more importantly, funding.
TB, one of the oldest infectious diseases to affect humanity, has been termed the “forgotten pandemic”. Prior to the COVID-19 pandemic, it was consistently the top single-agent cause of infectious disease death in the world, and it continues to kill approximately 1.5 million people per year. Along with this death toll come the other, less quantifiable effects many of us are much more familiar with now—missed school, financial ruin, and bereaved families. It is difficult to conceptualise the impact of this toll over the span of decades. And yet, because the brunt of the disease burden is borne by countries with lower incomes, TB rarely makes global headlines. TB is a disease of poverty, endemic in areas where many people do not have access to well-ventilated housing or where malnutrition is common. In endemic regions, TB perpetuates inequalities both within and between countries by acting as a constant financial drain on individuals and healthcare systems, stagnating economic development. Cases in most high-income countries are rare and tend to affect marginalised people such as those who are homeless. The dominant attitude towards TB is complacency. The world has decided that this death toll is not newsworthy.
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“In endemic regions, TB perpetuates inequalities both within and between countries by acting as a constant financial drain on individuals and healthcare systems, stagnating economic development.”
Consider the global vaccine response to COVID-19. Mobilisation to develop a vaccine for COVID-19 was swift, a remarkable and unprecedented success. Thanks to financial investment, researchers were able to develop multiple highly effective vaccines in mere months. The most recent data suggests that the Pfizer and Moderna vaccines are 88% and 93% effective at preventing hospitalisation respectively, both very impressive figures. For TB, by contrast, we have one vaccine, the 100-year-old Bacillus Calmette–Guérin (BCG) vaccine. This vaccine works well for preventing disseminated TB in children, but for pulmonary TB, the main contributor to TB deaths, it varies in efficacy from 0 to 80%. For unknown reasons, vaccine efficacy depends on latitude, decreasing closer to the equator—a cruel and peculiar parallel to the geographic gradient of global disease burden.
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We need a better vaccine for TB. In the long-term, this will save the most lives, and even moderate improvements in vaccine efficacy would be cost-effective. Through the hard work of those committed to the cause, there are currently 14 vaccine candidates in the pipeline. However, the funding needed to accelerate vaccine development and improve our understanding of TB is simply not there, despite the fact that investing in TB has high financial as well as population health returns. The unfortunate reality is that research for deadly diseases often does not receive sufficient support until those with the most financial and social capital are affected, as we have seen in the past with the HIV pandemic.
“The unfortunate reality is that research for deadly diseases often does not receive sufficient support until those with the most financial and social capital are affected.”
Most of us in non-endemic regions are lucky enough to not have to think about TB in our daily lives. However, COVID-19 has illustrated that in an increasingly globalised world, infectious disease is everyone’s problem. Although we are far from ending the COVID-19 pandemic, the rapid development of vaccines has shown us what we can accomplish when urgency demands investment. How much longer will the world wait for an effective TB vaccine? We are capable of better. Those affected by TB deserve better.
The WHO Global Tuberculosis Report 2021 can be found here: https://www.who.int/publications/i/item/9789240037021