Tuesday, March 27, 2007

By BOBBY JOHN and TIM FRANCE

Special to The Japan Times

GENEVA-- A much larger tuberculosis drug-resistance problem exists than researchers previously thought. New global data on TB, published this month by the World Health Organization (WHO), highlight serious weaknesses in many national TB programs, increasing the potential for widespread TB drug resistance.

How did we reach this precarious state?

Ask a WHO expert that question and he'll assert that increasing levels of TB drug resistance "reflects a failure to implement the WHO Stop TB Strategy." The strategy hopefully maps out the steps that national TB control programs need to take. By all accounts then, our national TB programs are failing us.

The bacterium that causes TB, Mycobacterium tuberculosis, is naturally sensitive to the antibiotic drugs used to treat the disease. The accepted truth about how TB drug resistance starts is that it is mostly "acquired" in individual patients, because of inadequate treatment with TB drugs, now at least 40 years old.

Poor patient drug adherence, or the use of too few drugs leads -- the story goes -- to various forms of drug-resistant TB. Multidrug-resistant TB (MDR-TB) is a specific type that does not respond to the two most powerful anti-TB drugs. Latest estimates are that MDR-TB makes up about 4 percent of all new and previously treated TB globally. Apparently, our antiquated TB drugs are failing us too.

Drug-resistant TB is already geographically widespread, including in places where TB control programs have been in place for many years. But incredibly little is known about just how much TB drug resistance there is outside capital cities, for example, and even in some entire countries where drug resistance may be common because of historically poor TB control.

No progress can be made if the TB clinics are there but the patients are not. Today's standard test for TB relies on a technique (sputum microscopy) invented over a hundred years ago. It provides no information about drug resistance. Apparently TB diagnosis is also failing us.

Too many weak points to deal with? A further litany of vital TB program components has also been ignored for years in favor of a single jewel in the TB strategy's crown: directly observed treatment short course, or DOTS. In many places, a consistent lack of focus and investment has led to:

Chronically weak TB diagnostic and laboratory services

Infrequent and incomplete TB drug-resistance surveillance

Inadequate management of individual drug-resistant TB cases

Paltry TB infection control measures, including in health-care settings.

Predictably, many TB-endemic countries have indeed failed to meet the exacting standards of the WHO Stop TB Strategy. Given the circumstances in many countries where TB is rife, what is surprising is that they should be asked to pursue such a pipe dream.

DOTS was supposed to stem TB drug resistance. Because of sloppy and unimaginative implementation, it is evidently failing us. As the full extent of TB drug resistance comes to light, prioritizing TB drug delivery above all other areas of TB diagnosis and care looks increasingly as if WHO has been building a house without a foundation. We cannot now claim to be surprised when a decade of overlooking the systemic challenges faced by high TB countries threatens to bring the entire house tumbling down.

Promoting policy frameworks is no replacement for working together to achieve what needs to be done to address TB. The Global Plan to Stop TB, (2006-2015), launched by the Stop TB Partnership just over a year ago, is a road map for such a coordinated action.

WHO urgently needs to look beyond its Stop TB Strategy to help promote and coordinate the comprehensive range of actions set out in the Plan -- and to recognize the track record of more than 500 global partners who put their name behind it.

When she took office just a few months ago, the new WHO director general, Dr Margaret Chan, identified the organization's many partnerships as one of her immediate priorities. "Either the partnerships have to change, or we have to change, or both of us have to change to be more relevant," she said. "What is important to me is, are we getting the results that matter?"

In the case of controlling TB drug resistance, the answer is an unequivocal no.

Bobby John, M.D., is executive director of the Center for Sustainable Health and Development, India, and president of Global Health Advocates ( www.ghadvocates.org). Tim France, Ph.D., is technical and policy adviser to Health and Development Networks and chairman of Stop TB Partnership ( www.stoptb.org) Media and Events Task Force.

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