A CALL TO ACTION: IT’S TIME TO END DRUG-RESISTANT TUBERCULOSIS

© The Economist Intelligence Unit Limited 20191

Drug-resistant tuberculosis (DR-TB) is a growing public health threat. Over the past two centuries, tuberculosis (TB) has claimed the lives of over 2 billion people. Today, it remains the world’s deadliest infectious disease, killing many more people than HIV and malaria. Its grim history is now taking a darker turn as strains of the disease that can withstand current treatments take hold. DR-TB affected 558,000 people in 2017, causing 230,000 deaths.

l In the past, drug resistance was most common in patients who previously suffered from TB, due to their past use of TB medicines. Now, first-time TB patients are increasingly showing drug resistance, as DR-TB is being spread from person to person. Drug resistance is forecasted to increase in high TB-burden nations including the Philippines, South Africa and Russia.

l In 2007, the first reports emerged of totally drug-resistant TB, resistant to all first and second-line drugs, with further clusters of cases reported in Iran, India and South Africa. Unless these highly resistant forms are stopped, an untreatable epidemic could emerge.

The world is seriously unprepared. Antimicrobial resistance (AMR) should be a top public health priority; a major AMR review forecasted a potential ten-fold increase in deaths to 10 million annually by 2050, and DR-TB accounts for a third of AMR-linked fatalities. Too little is being done to tackle this scourge.

l Only an estimated one in three people with DR-TB are diagnosed, and one in four treated. Among the treated, only 55% are cured. To make matters worse, TB is airborne, and one untreated person can infect 10-15 others in a year through close contact.

l The resources available for tackling TB fall far short of what countries need. For example, international donor funding for TB is less than that for HIV and malaria, despite having a similar impact in years of healthy life lost. Low and middle-income countries, which account for 97% of reported TB cases, spent US$3.5 billion less than needed on TB overall in 2018. The shortfall for DR-TB specifically is estimated to be US$500 million.

l TB also faces a research and development (R&D) funding gap of nearly US$1.3 billion. While TB accounts for almost 2% of all of the healthy years of life lost to any condition globally, it receives only 0.25% of the estimated annual spend on medical research.

DR-TB costs billions of dollars from loss of life and worker absenteeism, and could reduce foreign direct investment and tourism. Estimates and forecasts now show the enormous cost of inaction. Unchecked, DR-TB could cost the global economy US$17 trillion by 2050. These impacts will play out across multiple direct and indirect channels:

l Loss of life. DR-TB is most prevalent in those aged 25 to 34, robbing families and the economy of their most economically productive members. Economist Intelligence Unit analysis shows that deaths attributed to DR-TB in 2017 cost the global economy at least US$17.8 billion in future GDP (in purchasing power parity, or PPP, terms; see Figure 1). India alone accounts for 41% of losses from early mortality, at US$7.3 billion in PPP terms.

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A CALL TO ACTION: IT’S TIME TO END DRUG-RESISTANT TUBERCULOSIS

© The Economist Intelligence Unit Limited 20192

l Work absence. Time off work necessitated by DR-TB treatment (hospitalisation and clinic visits) resulted in global GDP loss of at least $3 billion in PPP terms in 2018, according to Economist Intelligence Unit analysis. Hospitalisation can mean months of absence from work, and even outpatient treatment can incur costs, such as transport to and from facilities. Following treatment, some people’s ability to work can continue to be undermined by permanent side effects of treatment or long term complications such as persistent lung disease. The overall cost of care for a person with DR-TB, which requires longer and more toxic treatment regimens, is almost six times higher than that for a person with drug-susceptible TB (DS-TB).

l Drug resistant infectious disease could threaten tourism, investment, and utilisation of public infrastructure. DR-TB causes wider economic impacts beyond households and labour markets. As an airborne disease, concern about transmission could lead to reluctance to use public transport and public venues, impacting the local economy. Crucial sectors like tourism could also be adversely affected, as occurred with Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) in recent years. Eliminating infectious disease, conversely, can drive positive growth; one study showed that eradicating malaria, dengue, yellow fever and Ebola could result in 10 million more tourists visiting disease-affected countries, adding US$12 billion in tourism revenue for these often under-resourced economies.

DR-TB undermines the Sustainable Development Goals. Policy-makers intent on achieving the SDGs cannot ignore the income and inequality implications of DR-TB, since catastrophic medical spending, defined as costs amounting to 20% or more of household income, is a key driver of chronic poverty.

l A patient survey in Kenya showed a doubling of people below the poverty line following TB contraction. Children in 9% of TB-affected households faced education disruption and up to half of households faced food insecurity. Nearly a third of families were forced to use coping strategies like loans, sale of assets, or use of savings. Drug resistance amplified these impacts; 63% of people with DR-TB lost their jobs, compared with 39% of those with DS-TB. 86% of households affected by DR-TB incurred

A CALL TO ACTION: IT’S TIME TO END DRUG-RESISTANT TUBERCULOSIS

© The Economist Intelligence Unit Limited 20193

South AfricaSouth Africa has won plaudits for its progressive and proactive TB response, mobilising domestic resources and scaling up the use of new tools. In 2017, all individuals with confirmed TB were reported to have been tested for susceptibility to one of the main first-line TB drugs, and 73% of those with DR-TB were treated, the second-highest rate for high-burden countries after Kazakhstan.

Pakistan

In Karachi, the most populous city in Pakistan, the Zero TB Initiative has utilised a proactive, comprehensive approach to find and treat people with TB. This multifaceted programme has included using mobile X-ray vans to screen nearly one million people for TB. The initiative has also involved training of high-school age girls to assist with finding individuals with TB in the community, thereby also raising awareness and cultivating advocates in the younger generation. There are early signs that the programme is having an impact on TB rates.

India

As part of the government’s increasing focus on TB, it has introduced measures to reduce catastrophic costs. This includes a 500-rupee monthly transfer to TB patients for nutritional support (an important part of treatment). Companies and state bodies are also stepping up. The state-run public transport and electricity supplier in Mumbai provides paid leave of up to one year for employees suffering from TB. The Transport Corporation of India Foundation has scaled up a sexually transmitted infection screening programme for truck drivers to now include TB screening and education.

Micronesia

In 2007, Chuuk State in Micronesia saw the identification of the state’s first DR-TB cases. Thanks to political commitment and support from national and international partners, it implemented a programme to trace people that might be affected, and diagnose and treat all cases. A year on, TB mortality had fallen from 11% to 1% overall. By 2017, there were just four cases of DR-TB across Micronesia, with treatment success of 100%.

catastrophic costs, compared with 26% of households affected by DS-TB. These statistics highlight the importance of social support mechanisms as part of DR-TB care provision.

l Just as poorer citizens are worst affected, so too are poorer countries. Economist Intelligence Unit estimates of future GDP losses, as a proportion of economic size, finds Sub-Saharan African countries could be hardest-hit. Zimbabwe’s future losses from early mortality from DR-TB are the greatest in relative terms, representing 0.21% of its 2017 GDP (US$84 million in PPP terms), while six other African countries also feature in the top 10 list. If the status quo in TB care continues, over 20 million households in India and over 1 million households in South Africa are predicted to experience catastrophic costs between 2016 and 2035.

DR-TB is a winnable fight—if leaders act now. Although DR-TB is largely preventable and curable, almost a quarter of a million people die each year from this disease. The benefits of eliminating DR-TB, and TB as a whole, are immense; estimates suggest a return of US$85 for every dollar invested in TB elimination as a whole, and a return on investment for DR-TB of up to US$23 for every dollar. To take advantage of recent innovations in DR-TB care and act before it is too late, leaders and policy makers should pursue a multi-pronged approach:

l Rapidly mount a comprehensive response. Countries cannot afford to wait before acting; tardy responses create future vulnerabilities. Russia and New York City, for instance, both experienced a growing burden of DR-TB in the early 1990s but while New York City mobilised resources and brought the outbreak under control, Russia did not. Today, despite some promising local successes, Russia has the third-highest numbers of cases of DR-TB, with 56,000 cases estimated in 2017. Many countries are not doing enough to lay the foundations of an effective response. In 2017, only 22 of the 40 countries with the highest TB burdens had official DR-TB data covering more than one year.

l Learn from other infectious diseases. The international community can take lessons from the history of infectious diseases of the past which have been tamed or eliminated. HIV/AIDS struggled to attract political commitment during its early years, but over time, a vocal grassroots advocacy movement achieved lasting change. The eradication of smallpox was achieved in 1979 through political commitment and concerted efforts from both high and low-burden countries.

l Not underestimate the need for political will, or doubt that progress can be made. Evidence across multiple contexts shows that governments can make meaningful change even in resource-limited settings, if political will is strong and comprehensive strategies are put in place. There are signs of growing political momentum, with the prime minister of India (the country facing by far the highest DR-TB burden) publicly committing to eradicate TB in the country by 2025, and global commitments arising from the first ever UN High Level Meeting on TB in 2018.

A CALL TO ACTION: IT’S TIME TO END DRUG-RESISTANT TUBERCULOSIS

© The Economist Intelligence Unit Limited 20194

About this reportThis document is a summary of an editorially independent research programme carried out by the Economist Intelligence Unit that explored the burden, economic impact, and health security implications of DR-TB. The full final report, inclusive of a full description of our findings, analyses, methodology (illustrated below), reference list, and acknowledgements is available online from the Economist Intelligence Unit website (www.eiu.com/drug-resistant-TB).

ConclusionThe case for addressing DR-TB is clear, and progress on different fronts made in recent years, from diagnostic technology to service innovation, signals a greater chance of success than ever before. To help to chart a course for the elimination of DR-TB, the Economist Intelligence Unit has arrived at five key conclusions:

To eliminate DR-TB the world must act now. Although DR-TB is largely preventable and curable, almost one person dies from the condition every two minutes. Growing global momentum and advances in DR-TB care mean now is the time to accelerate efforts to end this disease. This can be done via a rapid scale-up of commitment and resources led by governments in high-burden countries and the international donor community.

The cost of inaction is high. Evidence and analysis in the Economist Intelligence Unit’s report show the massive economic cost of inaction, including loss of productive life, cost of care and treatment, reduced productivity at work, and potential wider impacts, such as deterring tourism. In short, DR-TB, especially as it grows more resistant, threatens global health security and holds back economic growth.

Addressing DR-TB aligns with other important health, economic and societal priorities. Working towards ending DR-TB can leave a positive legacy of strengthened health systems where healthcare provision has historically been the weakest. For example, key to the fight will be providing access to comprehensive health services and social support for vulnerable communities, representing a move towards universal healthcare. Eliminating DR-TB can also create fiscal space for broader health priorities.

National leaders, in partnership with other stakeholders, must be held accountable for progress to end DR-TB. The growing threat of DR-TB can be directly traced to a legacy of complacency and lack of political will. Although there are signs that this is changing, national and international accountability frameworks and the voice of the wider public are needed to ensure that governments and other stakeholders take effective, concerted action.

Stronger public advocacy is required. Public advocacy and citizen pressure has already had a major positive impact on diseases like HIV; the same effort will now be critical to ensuring that governments and policymakers remain committed to the fight against DR-TB and tuberculosis as a whole. The voice of the TB community is critical for engaging a wider group of stakeholders to drive change.

Millions of lives can be saved over the coming years, and the very real threat of DR-TB can be ended by a combination of increased commitment, investment and coordination at the local, national and global levels. This disease can be ended, and we all have a role to play.

Phase 1: Review of literature, data analysis, and expert interviews to gather existing knowledge.

Phase 2: Global advisory board of key stakeholders to stimulate dialogue and capture new ideas.

Phase 3: A final report that captures the case for tackling DR-TB and charts a path forward for elimination.

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