March 26, 2005

March 26, 2005
An Old Disease Needs New Cures
Published in The New York Times

By Martha Bedelu - Op-Ed Contributor

Khayelitsha, South Africa — THE World Health Organization released its global tuberculosis figures on Thursday, World Tuberculosis Day, and much was made of the news that incidence rates are declining or stable in five of the six regions of the world. Yet the global incidence rate is still rising, and every day, tuberculosis kills 5,000 people, nearly all of them in underdeveloped countries. We are still losing the battle against the disease, and it is time to admit that prescribing more of the same just won't work.

A big part of the problem is the increasing number of patients with the deadly combination of TB and H.I.V., which renders both diagnosis and treatment more difficult. From my native Ethiopia to Cambodia, tuberculosis is the No. 1 killer of people with H.I.V. and AIDS. In Khayelitsha, the poor township where I work, one in every four adults is infected with H.I.V. Tuberculosis incidence rates here are 1,122 per 100,000 people per year, nearly 10 times the global rate. Often, the only diagnostic tool I have is the sputum test, a procedure invented in 1882. In ideal conditions and in the absence of H.I.V. infection, the sputum test detects 75 percent of pulmonary tuberculosis infections. But for children, people with extra-pulmonary tuberculosis, and the majority of H.I.V. patients with TB, the test is virtually useless.

Like the sputum test, the only available medicines to treat the disease are from another era. They were invented three to five decades ago, and require patients to take four to six pills every day for up to eight months. In many countries, patients have to go to separate clinics run by national tuberculosis programs several times a week to receive their medicines, and then wait for a counselor to watch them swallow their pills. This direct observation is intended to prevent the development of multidrug-resistant strains of tuberculosis, an especially grave concern since no new drugs are yet available to counter it. If the patients are also being treated for H.I.V. they must go through all of this in addition to their daily regimen of antiretroviral therapy. These burdens cause many patients to abandon treatment.

I refuse to believe that we cannot find better methods of diagnosis and treatment. We urgently need an easy-to-use blood, urine or sweat test that quickly detects active tuberculosis.

We have to make a regimen that is simpler for patients, creating innovative ways of improving treatment adherence and reducing the need for direct observation, as we have done here with antiretroviral therapy for the treatment of H.I.V. It should also be standard practice to integrate tuberculosis and H.I.V. care so patients receive their medicines for both diseases in one place, as they can at our clinic in Khayelitsha.

In the longer term, we need newer, more potent medicines that shorten the duration of treatment. Patients with multidrug-resistant tuberculosis, for example, have to endure up to two years of hospitalized treatment with expensive drugs whose severe side effects can include acute psychosis. Research and development of new drugs over the last 35 years has been nearly nonexistent.

To this end, the World Health Organization and governments need to create a research and development program based on public health needs as an alternative to the pharmaceutical companies, which are motivated by profit. When the commercial interests of pharmaceutical companies threaten to hamper the development of potential TB treatments, governments should step in by finding ways to make promising tuberculosis compounds available to groups willing to develop them into medicines.

Promises will not be enough to tackle this resurgent scourge. In an age of unparalleled medical advances, we must refuse to accept that millions of people will be left to perish at the hands of this antique disease.

Martha Bedelu, a physician, works with Doctors Without Borders.