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Tuberculosis: the return of the white plague?

The last few weeks have seen an explosion of reports
concerning the status of the worldwide fight against tuberculosis, largely
precipitated by World TB Day last month on March 24. Tuberculosis was once
considered a disease of the past, an illness, like diphtheria, thought to have
faded away with the Victorian era as a serious cause for concern. Indeed, for
many people today any mention of TB might still be more likely to evoke
thoughts about the death of Helen Burns due to “consumption” in Jane Eyre,
than to incite any sense of panic. And while many people from more developed
countries might not have ever known anyone personally to have been infected
with TB (I know I haven’t), the reality is that TB has resurged as one of the
most pervasive and deadly diseases in the world. What was once historically
referred to as the “white plague” is today thought to cause one death every 15 seconds (1).
It is estimated that approximately one third of the world’s population is
currently infected with TB, with higher incidence rates found primarily in
African and Asian countries, and 1 in 10 of these latent infections resulting
in death (2). The rate at which TB spreads is equally alarming: the most recent
data estimates that a new person is infected with TB every second of every
day (3).

So what is the status of the fight against TB? From what
I can glean from recent reports, there is both good news and bad news.

The Good News:

Researchers at Sydney's Centenary Institute recently announced that they have made great strides towards developing the first new drug for TB treatment since the 1960’s (shockingly the current first-line drug regimen for treating TB is 40 years old with a minimum treatment time of 6-9 months. The timing for such a development couldn’t have been better as there has been a resurgence of TB since the 1980’s due in large part to the emergence of drug-resistant strands of TB. According to reports by the World Health Organization, the presence of drug-resistant strands of TB has been detected in every country it has surveyed. Worryingly today there is not only multi-drug-resistant tuberculosis (MDR-TB), but also extensively-drug-resistant tuberculosis (XDR-TB) (4). The drugs required to treat both MDR-TB and XDR-TB are extraordinarily expensive to treat compared to standard TB treatment. Recently, the New York Times reported (5),

Even standard tuberculosis takes six months to cure with a four antibiotic cocktail. But the drugs cost only $20 and are relatively easy to take. Drug-resistant forms can take two years and require dangerously toxic drugs that cost $5,000 or more per person…

The Bad News:

In light of the extraordinary cost involved in treating MDR-TB and XDR-TB, it is easy to see why it is crucial for governments and corporations to invest in drug innovation leading to more cost-effective medicines that have the potential for universal accessibility. Some might be prima facie dubious of this claim: why should the governments of wealthier countries, like the U.S. and U.K., invest millions in developing better drugs in order to treat a disease which do not even afflict high proportion of its own population? One might argue that a government ought to continue to channel it’s funding towards the treatment of those diseases that are the most significant threat to the lives of its own citizens. For example heart disease and cancer continue to be the leading causes of death in both the U.S. and U.K., so wouldn’t these governments be doing a disservice to their own citizens were they to prioritize the development of drugs for treating TB when these additional funds could go towards developing new treatments for heart disease and cancer?

However the reasoning that underlies this sort of argument is not only morally and legally questionable, it also lacks foresight. It is morally questionable because it assumes that governments are morally obliged to prioritize the medical needs, and in this case lives, of its own citizens over the medicals needs and lives of people in other countries. (I’m not arguing that this position is necessarily morally reprehensible, I’m only pointing out that it can be called into question, and would certainly need separate, and quite substantial, moral justification. Such a principle is in tension, for instance, with the principles that on many accounts ground universal human rights, global justice, and distributive justice.)

The argument is legally questionable given that the human right to medical care is established in international law by a number of international treaties, covenants, and agreements. For example the governments of any of the 192 countries that are currently member states of the United Nations are legally obliged to recognize, and more importantly, legally obliged to protect the human right to medical care as established in the 1966 International Covenant on Social, Economic and Cultural Rights which expands upon Article 25 of the 1948 Universal Declaration of Human Rights:

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care… Everyone is entitled to a social and international order in which the rights and freedoms set forth in this Declaration can be fully realized.”

But even if one remains unmoved by these moral and legal challenges, or maintains that she can adequately respond to them, this still does not justify the claim that in those countries where TB rates are low, that the development of better drugs to treat TB ought not to be a top priority. Here we see why the main fault of this argument is that it lacks foresight: just because the rates of TB in wealthier Western countries are low at the moment does not mean that they will remain low! Moreover, it is naïve of us to fail to consider the fact that the borders of nation-states will not deflect the spread of the mycobacteria that cause TB. If the medicines used to treat TB are not improved and made universally accessible, it poses a serious threat not only to people in those countries where TB is presently an epidemic, but also endangers the lives of citizens in more developed countries like the U.S. and U.K. As the MDR-TB and XDR-TB strands continue to spread, TB runs the risk of becoming a serious global pandemic—on par with what many governments and global organizations feared SARS and Swine Flu might have become— perhaps even much worse. Even in wealthy Western countries TB rates continue to rise. In the UK, for example TB rates have consistently risen every year since the late 1980’s, and a press release last month by the Health Protection Agency indicated that 2008-2009 saw the largest year-to-year increase in the incidence of TB in UK in the last five years at 5.5% (2004-2005 saw a 10.1% increase) (6). Therefore even if one wants to reasonably maintain that a government only has a moral and/or legal obligation to protect the medical needs of its own citizens, governments still ought to make the fight against TB a top priority as the citizens of every country are at risk. It would be gravely mistaken to conceive of TB as a disease that is exclusively a threat to those in the developing world. The imminence of the global community’s need to develop more efficient and more efficacious drugs for treating TB cannot be understated.

Unfortunately current global patent laws do not encourage medical innovation to fight drugs like TB. In 1994, the WTO adopted the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement caused the most of the important regulations governing the development and sale of medicines to shift from a national level to a global level. In its present form, the TRIPS Agreement imposes such strong patent protections on new pharmaceuticals that it prohibits generic drug manufacturers from lowering the prices of new medicines below a certain threshold (even when they are willing to do so!) which keeps many new medicines from being in an accessible price range for millions in less developed countries. This is not beneficial for the citizens of developing countries, nor for many firms in the pharmaceutical industry. Perhaps unsurprisingly it is often more profitable for firms to invest in developing and manufacturing of other drugs used primarily in the Western world to treat conditions like heartburn, depression and high cholesterol.

Our current systems of innovation are not fully achieving the needs of patients or even of investors in the pharmaceutical industry. They encourage drug firms to spend too much on developing minor modifications of exists drugs and on competitive marketing and patent litigation instead of focusing their efforts on the innovations that would have the largest global health impact. This is not what patients need, it is not what the research scientists want, and it does not seem to be creating the returns that investors demand (7).

A recent amendment to the TRIPS Agreement suggests that the WTO has no intention of changing its ways anytime soon. (See “Amendment to WTO TRIPS Agreement Makes Access to Affordable Medicines Even More Bleak” ) Pair this with the proposed funding cuts to TB research on the Obama administration’s blueprint for the 2011 budget, and things seem bleaker still (8).

Strategies for fighting TB

It is vital that governments provide incentives for the development of new drugs that combat TB before it is too late. As the saying goes: “Building a firehouse won’t do much good when there’s already a fire.” It seems to me a wise broad strategy for combating TB ought to at least be trifold. First we need to make a concerted effort to ensure that the first-line of defense treatment of ordinary TB (that is, the cheaper medicine that costs $20 per person) is readily available and administered properly, primarily through the provision of funding and education. Doing this will at least work to minimize the number of cases of ordinary TB that evolve into multi-drug resistant and extensively-drug resistant forms of TB.Second, and I think more importantly, we ought to supplement the TRIPS Agreement so that pharmaceutical companies have not only the legal ability, but also the incentive to develop better drugs to treat TB. One proposal for accomplishing precisely this task, the Health Impact Fund (HIF), has been carefully developed and powerfully advocated for by Prof. Thomas Pogge of Yale University and Prof. Aidan Hollis of the University of Calgary. The HIF is a 130-page-long plan that provides guidelines for supplementing the TRIPS Agreement with a program that provides monetary incentives for the development of certain drugs according to their perceived global impact. The general idea is that when a firm develops a new drug with the potential for large global impact it would be offered the choice of either: 1) proceeding in the ordinary way and exercising their usual patent rights under the regulations of current global patent law or 2) be given the option of instead registering their drug with the HIF for substantial monetary rewards and additionally still be entitled to profits from the sale of their drug at lower prices. In their own words, “The HIF is specifically designed to reward pharmaceutical innovators directly on the basis of health impact, while requiring low prices to enable access. In addition, the HIF will create incentive for manufacturers to engage in facilitating the appropriate distribution of their products in poor as well as in wealthy countries, since improved use will increase the rewards they earn.”

Pogge and Hollis make clear that the HIF is “not a charity for the developing world.” The affluent will benefit alongside the poor, who will be able to purchase high-impact medicines for lower prices than they would have otherwise. “The difference will be most obvious to individuals who lack complete drug insurance.” But even for those that have drug insurance, “the lower prices of HIF-registered drugs will result in lower insurance premiums and national health system expenditures.” It is true that initially the drugs that will have the greatest overall impact will be ones that treat communicable diseases primarily found in the developing world, but as Pogge and Hollis rightly point out, “so long as these diseases are poorly controlled there, they pose a substantial danger to humankind. It is in everyone’s interest that the diseases of the poor not be treated with half-measures that lead to drug resistance and new virulent strains…”

The third prong of this strategy concerns raising awareness of the seriousness of the global health risks posed by TB. When one considers the disproportionate amount of media coverage that the Swine Flu “pandemic” received last year given the mortality rate of the disease relative to the amount of media coverage of TB given the mortality rate, one is surely forced to characterize either the former as over-hyped or the latter as severely underreported. (Dr. Hans Rosling, a Swedish doctor and statistician, has made efforts to warn the public about disproportionate media hype surrounding certain public health issues. Dr. Rosling pointed out last year that inside of 13 days there were 31 deaths due to Swine Flu, and 253,442 news stories covering Swine Flu, whereas in the same time period there were 63,066 deaths due to TB, and only 6,501 news stories on TB, which makes for a news/death ratio of 8,176 and 0.1 respectively.) All severe health threats deserve attention from the government, the media and the general public, to be sure, but it is irresponsible, if not dangerous, for public health officials and the media to underrepresent the magnitude of the ongoing international struggle to combat TB, especially when public opinion and media coverage plays such a substantial role in determining which issues politicians choose to prioritize and consequently where health funding is directed.

1 “The White Plague”
2 “Scientists in Hot Pursuit of First New Drug for Global Killer in 50 Years”
3 Ibid.
4 V. Roy “On World Tuberculosis Day, Time to Step Up the Fight”,, March 24, 2010.
5 D. McNeil Jr. “Tuberculosis: Drug-Resistant Strains Still Spreading at Deadly Rates, W.H.O. Report
Says”, New York Times, March 22, 2010.
6 “Cases of tuberculosis continue to increase” 16 March 2010,
7 Pogge and Hollis, “The Health Impact Fund”, a report for Incentives in Global Health (2008).
8 (See: )

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1 Comment on this post

  1. You raise a very important question, one that needs more serious and thorough treatment than what it has had up to now. The question is whether and to what extent do ordinary ideas about morals or ethics exist for states. Is there an international culture from which norms can be taken to determine what the right thing to do is for states? Or can one say that a state must proceed according to the norms applicable to persons interacting in the market place in that state, with respect to foreign countries? I have an awful time thinking about the mortal or ethical obligations of states with respect to other states, because interactions among states is different in kind, I think, from that among persons in the same culture. You can say what you want about the mortality of a state’s intervention in an ugly situation in another country, but it is nonsense without considering what that intervention costs the state in terms of its ability to further the interests of that states as protector of its own people.

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