On September 26, the United Nations General Assembly addressed, for the first time, the global health epidemic of tuberculosis (TB). In a meeting overshadowed by global anxiety surrounding denuclearization, international trade wars, and the looming threats of climate instability, the prominent inclusion of tuberculosis in the 2018 agenda represents an unprecedented global commitment to fight against a disease that infects 10 million people and kills 1.7 million each year. The timing of the inclusion is not accidental.
In 2015, TB surpassed HIV-AIDS as the world’s deadliest infectious disease, largely due to advances in HIV treatment adherence. However, this shift alone was not enough to prompt response to a disease that has long faced minimal commitment from the global community. The sudden emergence of multiple drug-resistant (MDR) and extremely drug-resistant (XDR) tuberculosis, strains of the disease that are highly transmissible and expensive to treat—or, in the case of XDR TB, largely incurable—poses a serious threat to security-concerned member nations. The fact that countries such as the US and the UK have been largely apathetic toward TB’s global plight for so long and are only willing to respond now that they are threatened is not an isolated incident. Rather, it’s an indicator of a systemic failure in the way Western states approach global health. An examination of the evolution of TB and anti-TB efforts over the last century reveals a global health system more concerned with containing diseases within poor nations than with addressing their causes. The explosion in the number of cases of MDR and XDR TB is due to the politicization and lack of widespread interest in the disease, as well as a lack of global funding to address it. Developed countries must move away from national health securitization and toward a holistic view of global disease if there is to be hope of ending TB, MDR and XDR TB, and other impending health epidemics.
For wealthy populations in areas with established infrastructure, TB, once called consumption, is a disease of the past. Although TB lies dormant in a quarter of the world’s population, since the 20th century it has presented little risk to developed nations. In 1943, Selman Waksman and Albert Schatz created the antibiotic streptomycin, which effectively eliminated TB in the US. In 2017, the risk of contracting what was once the single highest cause of death in the US was just 0.003 percent. In the 21st century, a cocktail of antibiotics and a rigorous six-month treatment regimen render the disease curable in almost all cases. Because of this, an instance of tuberculosis in the US—or any industrialized nation—is little cause for concern.
In other places, however, the disease remains infectious and deadly. In developing countries, the risk of contracting TB is high. India, for example, had a 0.2 percent incidence rate. Moreover, severely underfunded treatment programs and the difficulty of administering strict drug regimens for long periods of time render the disease essentially impossible to cure in countries without adequate disease management infrastructure.
Intervention solutions are further complicated by the fact that MDR and XDR TB can be caused by poor management of the more treatable strain. MDR and XDR TB are not natural mutations, but rather occur when a patient contracts TB and begins an antibiotic regimen that does not successfully suppress the infection, giving the bacteria the ideal environment in which to develop antibiotic resistance. It is clear that the structural failures driving both drug-resistant and standard TB emergence involve patient misdiagnosis, lack of education on treatment regimens, and economic limitations that prevent an effective, full-course treatment. And these are just issues facing patients who receive medical attention: In 2015, of the 10.4 million estimated cases of tuberculosis, only 6.1 million were reported, leaving the rest undiagnosed and untreated.
The dual nature of tuberculosis as a disease that is both largely curable and incredibly infectious places it squarely in the blind spot of a security-obsessed global health system. Although the global health system is a diverse conglomerate of government programs, international structures, and NGOs, it is largely funded through various countries’ budgets. In fact, 67 percent of the funding for the fight against TB comes from the United States alone. Such a homogenous funding block leaves anti-TB efforts with little leeway, with differing US political sentiments causing global variation in the quality of care. Since the US has perceived TB to be a disease with no real threat, other countries have not provided sufficient funding to address it. Compare the US response to HIV-AIDS with its response to tuberculosis. Both diseases take comparable tolls on human life, yet, in 2013 the US put 8 times more money towards the fight against HIV-AIDS internationally than that against TB. This is not to say that the fight against AIDS is overfunded—simply that the anti-TB effort is clearly underfunded. US engagement in global health is less contingent on the humanitarian impact of a disease and more on the threat the disease may pose to the already strained US health care system.
It is this chronic underfunding of tuberculosis that is almost directly responsible for the MDR and XDR TB epidemics we face today. International efforts to overcome the disease have repeatedly faced funding discrepancies inconsistent with the global commitment to end the TB epidemic by the year 2030, as ratified in the 2016 UN Sustainable Development Goals. The 2018 World Health Organization report on tuberculosis estimated that, to meet the UN goal, the international community would need to provide $10.4 billion in aid to middle- and low-income countries in 2018. The shortfall this year was close to $3.5 billion. This 34 percent underfunding of anti-TB efforts limits further research on the disease, leads to infrequent and imprecise diagnosis, and decreases the number of patients that can be supplied with the necessary antibiotics.
The September 26 UN meeting on tuberculosis was largely focused on closing this gap. Much of that discussion, however, surrounded using limited third-party investment to stimulate and support programs in low- and middle-income countries where incidence rates are high. Financing strategies like these, if implemented with targeted spending models and clear accountability, have the potential to create an outsized impact for each dollar spent. In India, for example, the commitment of Prime Minister Modi to end TB nationally by 2025 has been supported by the United States Agency for International Development, which pledged at the UN meeting to contribute up to $30 million to support the development of national programs. But if wealthy nations do not lead the charge in closing the TB funding gap, low-income countries will not be able to bear the full brunt of the cost; no amount of strategic refinancing will change that fact. If shuffling money around becomes the norm, global funding will stagnate. High-level meetings like the one held on September 26 hold little significance if the nations involved do not make concrete and specific pledges to end the TB epidemic. As the conversation continues, this financial reality needs to be underscored.
It is difficult to overstate the threat MDR and XDR TB pose to the global community. As of now, TB is a tangible security risk in our state-centric understanding of the term. If the global community continues to allow TB to go untreated, the line between countries where TB is a threat and those where it is not will cease to exist. Emerging, more dangerous strains of TB are forcing wealthy nations to contend with the possibility of an incurable, highly transmissible infectious disease. As a result, the gears of the global health system have begun to turn, a far too delayed response to a devastating health epidemic that could have been solved far earlier for far less money and with a far lower toll on human life. While the securitization of global health has proven to be effective in handling immediate, large-scale threats such as biological weapons, it has been unsuccessful in funding global disease prevention. Any system of global health security that can only respond reflexively to immediate health risks either has a fundamental misunderstanding of disease or a very narrow definition of risk.
Disease is constantly evolving, and patterns of drug resistance are inevitable. The cases of MDR and XDR TB do not exist in a vacuum: They are simply the most notable case study in the dangers of leaving global disease untreated. Security-centric and humanitarian frameworks of disease prevention are not mutually exclusive. On the contrary, developing sustainable global health security is contingent on engaging with the active and evolving epidemics of a global population. If world leaders are truly committed to ending TB by 2030, they must move beyond sentiment and sensationalization in their response to global health, and firmly and finally close the funding gap needed to effectively treat the world’s deadliest infectious disease.
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