Dr Ghulam Nabi Kazi
Tuberculosis remains a dreaded disease even today although its causative organism Mycobacterium Tuberculosis was identified By Robert Koch in 1882. It has almost always been present in the human population, as evidenced by pathological signs found in bony fragments of Egyptian mummies from 2400 BC. The major brunt of the disease is faced by low to middle-income countries mainly in Asia, Africa and South America. Resistance to first-line drugs and HIV/AIDS is fuelling the pandemic of Tuberculosis. which continues unabated. According to the World Health Organization, 10.6 million people acquired active TB, while 1.6 million died due to it in 2021 globally.
Tuberculosis has caused enormous havoc in Pakistan’s national life and affected 611,000 people in 2021–fifth highest burden in the world-out of which service coverage was provided to only 55 per cent of them. The scenario is indicative of the adverse effects of climate change, torrential rains, flooding and COVID-19, which have jointly hampered TB work for nearly three consecutive years since March 2020. Currently, TB incidence is estimated at 264/100,000 in a population exceeding 231 million, while an estimated 50,100 persons died due to TB in Pakistan in 2021. The position of the 16,000 drug-resistant (DR) TB cases is more disturbing with a case notification rate of around 15 per cent, mainly owing to the low number of Programmatic Management of Drug-Resistant TB (PMDT) sites across the country.
There is yet hope that we can fulfil our targets of lowering TB incidence by 90 per cent in the next seven years (2030) and by 95 per cent in 12 years (2035); eliminating the disease as a public health problem in Pakistan in line with our national aspirations and international commitments. This optimism stems mostly from the rapid advances in technology for diagnosis, and availability of faster-acting medicines along with the enduring hope of an effective vaccine raising expectations of a breakthrough in the control and elimination of the disease. However, what is clear is that all this cannot be achieved with the current pace of effort and it cannot be business as usual.
In September 2018, Pakistan’s Foreign Minister pledged at the United Nations to do everything possible to curb the TB pandemic. Nearly five years later, and with the next high-level meeting due in September this year, there is not much good news to report. Meanwhile, macroeconomic issues threaten to slash nondevelopment funding, including that for healthcare and more specifically for TB.
TB stems from the deprivations of poverty and is more of a social problem than a clinical one. We have been treating TB sufferers with free diagnostics and medicines, not taking into account their other needs such as transport, days of work lost and travelling overnight for accessing DR-TB services to distant areas in addition to nutritional support, which contributes to substantial out-of-pocket expenditure, warranting urgent remedial action.
Recent actions for TB control in Pakistan include the formation of an End-TB Parliamentary Caucus, identifying private sector patients through private pharmacies while initiating community involvement through a rights-based approach. The President of Pakistan has presided over two TB Summits, the last in January 2022, while the First Lady has presided over a TB community rights and gender seminar in December 2022 as part of efforts to de-stigmatize the disease and raise awareness that the condition is eminently curable. These top-down approaches need to be complemented with community-led accountability mechanisms and inter-sectoral collaboration. The Constitution of Pakistan 1973 unequivocally stresses the Right to Life for which good health is an essential imperative and the Right to Education for all children. Simply by acting on this supreme charter and overarching legal umbrella, which completes 50 years next month, we can provide legal cover to TB patients by removing all barriers to TB care. The paucity of domestic funding is another sore issue with over 80 per cent of the TB care costs coming from donors, particularly The Global Fund, while some claim the figure is 92 per cent.
More importantly, we need a change in mindset. The association of tuberculosis with mental health symptoms, such as anxiety, psychosis and depression, has been repeatedly documented in Pakistan’s context affecting over 70 per cent of patients on TB medication, particularly in drug-resistant persons. When we add to it the plight of millions of persons displaced from their homes due to the massive floods and already in need of psychosocial support, the scenario becomes all the more critical. Then certain anti-TB drugs are implicated with mental side effects, while possible interactions with psychotic drugs could lead to a further deterioration of mental health.
This nexus of TB care and mental health issues is unfortunate for patients in Pakistan, subjecting them to double jeopardy in accessing care as both conditions are highly stigmatized, particularly for women.
The World Health Organization has been calling for patient-centred care and it is therefore imperative to make TB care processes user-friendly while adopting a holistic approach substituting a clinical one and according to due importance to preventive aspects such as treatment of latent TB patients who do not manifest any symptoms and enabling adequate attention to vulnerable and at-risk populations like women, children, IDP, refugees and prisoners.
We also need to build partnerships across different sectors and social safety nets like health insurance and use innovative approaches for destigmatizing the disease, bridging system-wide barriers, amending policy guidelines and building synergies in the existing TB care system to make it more patient-friendly through the proper utilization of TB survivors, celebrities and civil society representatives, complemented with the use of digital technologies and innovative tools to improve TB treatment outcomes. To do anything less is not an option – and yes, we can do it!