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Why interdependence is key to end TB

Indian government has committed to end TB by 2025 - a welcome commitment indeed - but warrants urgent  actions to muscle up the required pace to keep this promise. Writes Bobby Ramakant

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When major weak-spots go beyond the purview of health ministry, inter-sectoral programming becomes critical to progress towards ending tuberculosis (TB) by 2030, globally. Indian government has committed to end TB by 2025 - a welcome political commitment indeed - but warrants urgent and unprecedented actions to muscle up the required pace to keep this promise.
 
As our governments met at the 70th World Health Assembly (#WHA70) to decide the agenda for the World Health Organization (WHO) and elected its new Director General, Now we do hope they also prioritise inter-sectoral programming beyond ministries of health so that TB declines at the required rate to end TB as envisaged. Current TB decline rates are a fraction of the required rate for TB decline in order to end TB by 2030.
 
Interdependence is key 
 
The wise words of Mahatma Gandhi, "Interdependence is and ought to be as much the ideal of human as self-sufficiency" provide a good compass when we think of ending TB. Scientific evidence shows that major risk factors for transmission of TB infection as well as those that jeopardize treatment are often beyond the purview of health ministries. If we are to end TB, we ought to ensure that there is no further spread of TB, as well as, every person with TB gets prompt access to accurate diagnosis and gets cured by effective treatment and support.
 
We slip backwards in fight against TB with each new infection transmission, and, every time we fail to accurately and timely diagnose, treat and cure TB. The journey to the #endTB finish line, consists of small but significant victories when we prevent TB transmission, accurately and timely diagnose each case of TB, treat the person promptly with effective treatment regimen and ensure treatment completion and cure.
 
Political Will is firming up 
 
Governments of 194 countries globally have demonstrated their commitment to integrated development by adopting the UN Sustainable Development Goals (SDGs) in 2015. This is 'no brainer' that to succeed on any one of the seventeen SDGs, we also have to succeed on the remaining ones too. Healthy independence also warrants healthy interdependence to achieve shared visions and progress collectively towards common goals.
 
Even before SDGs got adopted, at the World Health Assembly 2014, the Ministers of Health of over 190 governments had approved the WHO End TB Strategy.
 
In addition to these global commitments to end TB, domestic political will is also firming up. India bears the highest burden of TB globally. Indian government’s National Health Policy 2017 promises to eliminate TB by 2025.
 
At 2017 World Health Day, the Himachal Pradesh state government announced to end TB by 2021-2022 at TB Free India Summit held in Dharamshala, Himachal Pradesh, India. TB Free India Summit organized by the Ministry of Health and Family Welfare of Government of India.

Policymakers were of the view that if every Indian state moves towards ending TB before national commitment to end TB by 2025, then only India will be able to keep its promises. Likewise if every country moves towards ending TB before 2030, then only the world will be able to eliminate TB by 2030.
 
Jose Luis Castro, Executive Director of the International Union Against TB and Lung Disease (The Union) agreed, “To end TB in the world we must first end TB in India.”
 
Union Health Minister JP Nadda said at the TB Free India Summit that the fight against TB under the Revised National TB Control Programme (RNTCP) has come a long way in India and helped save lives. “We cannot turn a blind eye on the fact that despite successes of RNTCP there are so many people suffering and dying of TB even today. We have a long way to go but with an aggressive strategy we will end TB by 2025.”
 
JP Nadda shared that the National Health Policy (NHP 2017) released by India recently, aims to increase domestic health funding to 2.5 percent of GDP (from 1.2 percent currently). He called for the need of a very active and robust system for dispersing drugs like Bedaquiline.
 

United to #endTB!
 
Risk of TB transmission as well as TB treatment outcomes both are dependent upon health systems as well as social determinants that directly influences public health. For example, malnutrition, poverty, migration, urbanization, sanitation and hygiene, gender disparities, economic and other inequalities in the society that marginalize communities, and a host of other development indices can impede TB programme outcomes.
 
Failure to avert every new transmission of TB infection and failing to diagnose, treat and cure every case of TB without any delay, push us backwards in our #endTB mission. We need to partner with everyone that can help prevent transmission of TB infection and help ensure early TB diagnosis, treatment and cure with 'no one left behind' becoming the reality on the ground.
 
“In the fight against TB, we need to focus more on social determinants” said Dalbir Singh, President of Global Coalition Against TB (GCAT) and a TB survivor who has been making countrywide efforts to engage parliamentarians and other sectors in the fight against TB. “Unless we address malnutrition, urban development, sanitation and hygiene, among other social determinants, we will fail to end TB” rightly warned Singh.
 
There are important government-run programmes on specific social determinants coordinated by a range of different government ministries and departments, as well as wide range of other development actors. Meaningful engagement of all actors, who can play a role in progressing towards ending TB, is undoubtedly a compelling public health priority.
 
Prevention cannot take a backseat
 
Dr Jamie Tonsing, South East Asia Regional Director of the International Union Against TB and Lung Disease (The Union) emphasized upon the risk factors that elevate the TB risk, such as diabetes, tobacco use, HIV, malnutrition, among others. She called for scaling up collaborative programming to address these risk factors to improve TB programme outcomes.
 
Another expert at the TB Free India Summit, Dr Masae Kawamura, Senior Director of Scientific and Medical Affairs, Qiagen, and senior member of Vital Strategies, pointed out "Without prevention we cannot accelerate the TB decline”. Addressing latent TB has to be a part of comprehensive strategy to eliminate TB.

Ensuring standard infection control in healthcare facilities as well as communities and homes cannot be ignored if we are committed to end TB.
 
Could vaccine be a silver bullet ?
 
We have had a TB vaccine since almost one hundred years now: BCG (Bacille Calmette Guerin) which was first medically used in 1921. It is still being used for children in high burden nations. Even though BCG is the most widely used vaccine in the world, it has not successfully eliminated TB due to its very limited (but important) efficacy. There is no doubt that research and development for new vaccines would have the biggest impact on the epidemic, and remains the cornerstone for reaching global elimination within the coming decades. "Can we have better vaccines to prevent TB? Boosting research for more effective vaccines is an important priority" said Dr Srikanth P Tripathy, Director of National Institute for Research in Tuberculosis (NIRT), Indian Council of Medical Research (ICMR).
 
Experts pointed out that till research and development pipeline gives a new effective TB vaccine, India needs to realize that the country currently has a good range of evidence-based methods to prevent, diagnose and treat TB, do infection control and provide care and support. 

Additional funding 
 
Christopher Ben, Director (External Relations), Global Fund to fight AIDS, TB and Malaria (The Global Fund) said that "Finance and innovation are key and often interconnected as they may lead to each other." The Global Fund has funded over USD 2 billion in previous years for fighting AIDS, TB and malaria in India. He announced a new additional funding of USD 280 million for TB over the next three years.
 
Let's hope the 70th World Health Assembly and the new Director General of the WHO will prioritise integrated responses to boost up health security globally. 

( Author is Health Editor at Citizen News Service. Views expressed are personal)  

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