1

WORLD

HEALTH

ORGANIZATION

COMMITTEE

DIPONEGORO MODEL

UNITED NATIONS

2014

TOPIC A

THE GLOBAL CONCERN OF

MENTAL HEALTH : PARADIGM,

PREVALENCE AND ACCESS TO

TREATMENT

INTRODUCTION

The World Health Organization

(WHO) recognizes that good mental

health is essential not only for individual

well-being, but also socioeconomic

development within the surrounding

community.Mental health, defined by

the WHO, is “more than the mere lack of

mental disorders;” it is “astate of well-

being in which every individual realizes

his or her own potential,... and is able

tomake a contribution to her or his

community.” It is an “integral part of an

individual’s capacityto lead a fulfilling

life”, and includes the ability to maintain

relationships, to study, to work, topursue

one’s interests, to make autonomous

decisions about one’s own life.

While according to the Merriam-

Webster Medical Dictionary, a mental

disorder is “a mental or bodilycondition

marked primarily by sufficient

disorganization of personality, mind, and

emotions toseriously impair the normal

psychological functioning of the

individual.” This can consist of avariety

of conditions, including but not limited

to depression, schizophrenia, bipolar

disorder,anxiety disorders, eating

disorders, and addictive disorders.

The Importance of Mental Health

While mental health may be thought to

be secondary to physical health, it is, in

fact, a widespread cause of morbidity

and mortality. Some disorders,

especially those that lead to suicide, can

be deadly in and of themselves. Others,

which can cause sufferers to engage in

2

high-risk activities or to be unable to

care for themselves, can lead to the

development of chronic, physical

ailments, such as heart disease and

cancer. Those suffering from depression,

for instance, comprise a

disproportionately high percentage of

those also suffering from hypertension,

epilepsy, diabetes, and HIV/AIDS. That

is not to say that the high physical cost

of mental illness is the only cost; in fact,

the costs of mental illness frequently

extend from the individual suffering to

society as a whole.

Untreated mental illness is also

often linked with substance abuse, the

consequences of which are well

recognized, and with high- risk

behaviors, such as unprotected sex,

which contributes to the transfer of

sexually transmitted infections. The

burden poor mental health places on

families is also severe individuals

afflicted with mental illness are subject

to stigmatization and disconnection from

society, and without a heightened

awareness and sensitivity to these

disorders, members of these individuals'

families suffer as well. Further, in areas

where mental health care is not always

available, families of those who are

disabled by mental illness become

caregivers, placing a significant financial

and personal burden on them. Suicide,

which is frequently a consequence of

many untreated mental illnesses, adds to

that burden by placing emotional strain

and distress on loved ones.

In industrializing countries, many

of which are already tasked with

combating problems of poverty, relative

political and institutional instability, and

higher rates of unemployment, the

burden of mental illness can be

especially difficult to bear. Without

access to specialized care and without

“safety nets” in place to assist those who

become disabled by mental illness, the

problems arising from the illness can be

aggravated.

3

STIGMA OF MENTAL ILLNESS

Mental health stigma can be

divided into social and perceived, or self

stigma. The first ischaracterized by

prejudicial attitudes towards individuals

with mental health problems as a result

of the psychiatric label placed on those

individuals. The second is the result of

the mental health sufferers’ internalizing

the aforementioned discrimination. This

perceived stigma cansignificantly lead to

feelings of shame, and lead to poorer

treatment outcomes. A studyconducted

in the UK found that the most commonly

held belief was that people with

mentalhealth problems were dangerous;

that some mental health problems such

as eating disordersand substance abuse

were self-inflicted; and that those with

mental health problems weredifficult to

talk to.

Stigma against those suffering

from mental health problems

encapsulates both prejudicialattitudes

and discriminating behaviour towards

individuals. This leads to exclusion, poor

socialsupport, a lower quality of life, and

low self-esteemand when these people

lack access to services and treatment,

consequences only worsen and can lead

to unemployment, substance use,

homelessness, and even suicide. These

factors alone represent

significantreasons for eradicating mental

health stigma, and to ensure that social

inclusion and recoverycan be efficiently

achieved.

GLOBAL IMPORTANCE OF THE

ISSUE

The WHO emphasized in a

report from earlier this year that the

effects of mental health issuesare not

4

insignificant on a national level. For

example, mental and neurological

substance usedisorders account for

almost 50% the global leading causes of

years lived with disability, as wellas

10% of the global burden of disease. The

World Economic Forum further

estimates that thecumulative global

impact of mental disorders in terms of

economic output will amount to

$16trillion USD over the next 20 years.

It happens due to mentally disorder

result in individual lower productivity,

missed work, and reduced productivity

at work. Reduced earnings and

decreased employment potential put

mentally ill individuals at an increased

risk of poverty.

In addition, mentally illness also

contribute to other public health issues.

Depression for instance, it could

increases the developing a chronic

physical illness, particularly

cardiovascular (heart) disease or stroke.

More than that, in 2001, at least five to

ten million people across the world used

intravenous drugs, that result 5 to 10%

new HIV infections. Furthermore,

maternal depression may put infants at

increased risk of low birth weight,

childhood health problems, and

“incomplete immunization”, all of which

are risk factors for childhood mortality.

This emphasizes that mental health is by

no means a simple issue of public health,

but also important for economic

development and societal welfare.

PREVALENCE

The World Health Organization

(WHO) has reported numerous cases of

depression, post-traumatic stress

disorder (PTSD) and anxiety due to the

outbreak of war, violence and

industrialized nations. According to

WHO, “four of the six leadingcauses of

years lived with disability,” are due to

mental illnesses, the most common one

being depression, which hasreached

epidemic levels in many

countries.Depression, which is one of

the mostcommon mental health

conditions, affects 350 million people

worldwide. The number of

suicidesinduced by depression is

projected to increase to 1.5 million

annually by 2020. The condition

ofdepression can be a precursor or

5

consequence of physical disease or a

result of various interactiveeffects such

as genetic predisposition and societal

upbringing. Those with depression have

a 40%increased risk of mortality. These

risk factors have been attributed to the

condition range frompost-partum

depression, unemployment, and poor

physical health to natural disasters and

militaryservice. In fact, in areas where

there have been recent or ongoing

disasters, wars, or refugee crises,the

prevalence of mental health conditions

of all sorts are raised by 5%.TheWHO

also recognizes the damage that occurs

when mental illnesses are not properly

addressed;for instance, there may be

increased violence, a lower quality of

life for affected individuals,

andwidespread prejudice.

In case of refugee for instance,

which in January 1999, it was estimated

that there were some 50 million refugees

and displaced personsworldwide. To

ease discussion the term "refugee" as

used herein includes asylum seekers,

refugees,internally displaced and

repatriated persons, and other non-

displaced populations affected by war

andorganized violence. Of the 50 million

refugees only 23 million are protected

and assisted by the Office ofthe United

Nations High Commissioner for

Refugees. The current lack of

international consensus over

legaldefinitions deprives the remainder

27 million people of the same support.

The overwhelming majority ofrefugees

are from and in low-income countries;

women and children represent more than

50 per cent ofthe total. Heavier toll is

imposed on the most vulnerable: the

children including the

unaccompaniedminors, the orphans, the

child soldiers, those detained, the

children heads of household; the women

andgirls survivors of torture and sexual

violence and the widows; the disabled,

the mentally ill and retarded;also the

elderly who are alone.

Some 5 million constitute a

group presenting chronic mental

disorders (prior to the war) and of

seriouslytraumatized, who would require

specialized mental health care had it

been available. Another 5 millionpeople

suffer from psychosocial malfunctioning

affecting their own lives and their

6

community. Theremainder majority are

faced with distress and suffering.

PAST UN ACTIONS

Although mental health is not

specifically addressed in theUnited

Nation’s Millennium Development

Goals, adversities associated with mental

health standdirectly in the way of the

achievement of the goals. The United

Nations has specifically recognizedthis

issue by identifying mental health

illnesses as a key part in achieving

developmental goals acrossthe globe.

The UN has further delegated the

responsibility of this issue to WHO,

which isappropriate due to the

committee’s founding mission. In 1948,

WHO was founded with the duty

todirect and coordinate the health

authority within the United Nations.

WHO continues to set theagenda on

health research, to create international

standards, as well as to provide technical

supportto states. Overall, the goal of the

committee includes “the attainment by

all people of the highest possible level of

health.

Mental health has become a topic

of recent interest for the World Health

Organization for a number of reasons.

As of October 2012, WHO estimated

that 350 million people suffer from

depression, and the number is rising,

imposing an ever-greater burden on the

world's health resources. Additionally,

concern over the omission of mental

health as a Millennium Development

Goal caused concern for public health

experts. These, and other factors, have

driven mental health to the forefront of

WHO's agenda.

A specific WHO program that

has addressed mental conditions is the

Mental Health Gap Action Program, or

mhGAP. The program launched in early

2011, to train health professionals to be

able to deal with mental health issues

more competentlywith proper support

and resources for patients.A driving

statistic for the mission of this program

has been that as many as 75% of the

population insome low-income countries

does not have access to the treatment

they need. Through mhGAP,WHO

hopes to increase the availability of

treatment to low and middle countries to

7

be utilized innon-specialized health care

settings. In 2010, WHO implemented the

mhGAP Intervention Guide(mhGAP-

IG.) This guide is primarily geared

towards regions where resources for

mental health are inequitably distributed

and hard to find, such as the Eastern

Mediterranean. The availability of

mhGAP-IG has allowed countries, such

as Jordan, to successfully train its

doctors to provide care at community

centers and other medical centers for

mental health illnesses.90 The mhGAP-

IG is an essential tool to achieve one of

the goals of the Comprehensive Mental

Health Action Plan 2013- 2020,

providing comprehensive mental health

care and services in communities.

As of late, the WHO has been

working to raise awareness about the

prevalence of depression. Depression is

listed as a “priority” in WHO's Mental

Health Gap Action Programme

(mhGAP), and through the Programme,

WHO is working to equip non-

specialists in the medical field to work

with patients on this common and often

debilitating condition. Depression was

also the subject of WHO's 2012 World

Mental Health Day. Still, this disorder is

widespread, and as it may be fatal –

leading to suicide – it has garnered much

of WHO's attention in recent years.

Suicide prevention has also

become a priority on WHO's agenda.

WHO has been working to combat

suicide by encouraging those already

concerned to speak on the issue, by

promoting initiatives that address the

underlying risk factors for suicide, and

by keeping decision-makers and

professionals engaged with the issue.

Awareness has been a key tool in

addressing the issue; however,

increasing suicide rates over the past

several decades would indicate that more

work is needed in this area.

BLOC ANALYSIS

Within WHO member

states,three main factions can be

recognized: higher, middle, and lower

income countries, as defined by

theWorld Bank. There are huge

discrepancies in the needs and resources

possessed by each of thesegroups, as

well as in the strategies and action plans

8

that each group will want to see

implemented.

Lower Income Countries

Lower income countries have an

average GNI per capita of USD 571, and

GDPs of USD 475.8billion. Regions

such as Sub-Saharan Africa, East Asia,

and parts of the Caribbean all fall into

thiscategory. In these regions, there are

little to no resources available for

treating mental healthillnesses, and

awareness for the recognition and proper

prevention of these conditions is

drastically low. These member states

suffer an inequitable amount from the

globalshortage of medical professionals

able to address problems brought on by

mental illnesses and totreat patients. In

the countries within this bloc, it takes

just an estimated USD 2 per person per

yearto fund the proper mental health care

that they need.

At the same time, delegates

representing these countries might

consider promoting the betterallocation

of funding and resources for prevention

and treatment of mental health

concerns.Considering the lack of

personnel and resources devoted to

mental health, this type of health care

isparticularly negligent in many of these

areas. In the Democratic Republic of the

Congo, for example,most of the primary

health care doctors and nurses have not

received training, read manuals, or

beenproperly trained on procedures for

mental health illnesses within the past

five years.Similarly, inThailand,

although manuals and reading materials

have been available, most primary health

caredoctors have not received official

training for approaching mental health

patients in the last five years.

Lower income countries have

many other obstacles that they are facing

that span,from politicalinstability to

widespread poverty to climate concerns.

Due to these unfortunate

circumstances,mental illness is often

considered to be a lower priority. When

compared to pressing issues such

asmalaria and hunger, mental illnesses is

present as an “invisible disease.”

Nevertheless, these issuesshould be of

focus for states within this bloc.

9

Middle Income Countries

Middle-income countries can be

divided into lower middle- and upper

middle-income brackets formore

appropriate consideration of policy

approaches to the topic. The lower-

middle incomecountries have an average

GNI per capita of USD 1,772 and a GDP

of USD 4.793 trillion. Theseregions can

include parts of Latin America, Eastern

Africa, Eastern Europe, Central Asia,

and somePacific Islands. These countries

often appear more similar to developing

countries in terms of healthcare.

Included in this category is Sudan,

where people have free access to most of

the necessarypsychiatric medications,

but only under emergency situations.

Although the region has mentalhealth

facilities, there is a great deal of room

for improvement in components of

health care. Thisincludes improving the

quality of facilities and instruments, and

addressing the large shortages ofmedical

personnel. As noted by a study

conducted by WHO, the medical staff in

Sudan has notreceived any human rights

training, though a necessary aspect to

mental health care, seeing as

mentalhealth patients have historically

been subjected to inadequate and unjust

treatment. While manymiddle-income

countries have basic facilities and

resources to address mental health, states

shouldfocus on their improvement.

Upper middle-income countries

have an average GNI per capita of USD

6,563 and a GDP of USD18.25 trillion.

Much of North Africa, the Caribbean,

South America, East Asia, and

EasternEurope are considered to be a

part of this bloc. As the name suggests,

these regions place in themiddle of

international rankings when it comes to

the need for funding and division of

resources. However, in the case of

mental health, these regions hold

relatively similar views and practices

tothose of lower income countries. In

these regions, it only costs between

about USD 3 and USD 4per person per

year to fund mental health care. Many

countries in this bloc are beginning to

betteraddress the mental health concerns

of their populations. India, for example,

is set to pass its MentalHealthcare Bill

2012 to serve the estimated seventy

million people that suffer from mental

10

health disorders. The new bill is

considered groundbreaking as it grants

those with mental health illnessesthe

right to decide their own care and

treatments. At its core, the bill gives the

people of India theright to their own

mental health care. Countries within this

bloc should consider avenues for

growthin their approaches to mental

health care prevention and treatment, as

well as analyze their currentallocation

practices to better benefit patients with

mental illness.

Higher Income Countries

In stark contrast to the previous

blocs, higher income countries have a

GNI per capita of USD41,224 and a

GDP of USD 43.89 trillion. These

countries already enjoy a plethora of

resourcesavailable for use, thus their

focus should be on delivering resources

to citizens, developing strategiesto

combat health care costs, and

overcoming stigmas. One prominent

country in this bloc is theUnited States.

US agenda included recognizing signs of

mental illness in young people,

improving veterans’ access tomental

health services, and addressing insurance

coverage for mental health care and

substanceabuse. In the US, one in four

people suffer from a mental illness at

some point in their lives,making the

topic relevant to a significant portion of

the American population and therefore

vital forthe country to address. The

United Kingdom also took recent action

by amending its mentalhealth laws with

the Mental Health Act of 2007. One

change included the expansion of

thedefinition of what constitutes a

mental health professional, therefore

widening the number ofprofessionals

who can care for patients.The U.K. also

amended the meaning of “mental

disorder”to “any disorder or disability of

the mind,” while discarding the narrower

categories that had existedpreviously.

Higher income countries possess a wide

scope of influence across the world

andshould therefore consider how they

can best use that power to carefully

induce changes in the

mental health care industry.

11

QUESTION A RESOLUTION MUST

ANSWER

1. How can WHO provide mental health

care to all different background of

society (including but not limited to

civilian, refugee, people in developing

nations, etc)

2. Who is to go hand in hand with WHO

to alleviate the existing mental illness

problem? And to be spesific, how can

WHO ensure it is going to work out?

3. What type of programme should

WHO establish in order to not only raise

awareness,

but also motivate citizens on Member

States to take action? (When considering

this

issue, remember that the WHO is acting

as a international body and not as an

nation state.)

4. Does mhGAP programme sufficiently

address the mental health issues in all

nations? Otherwise, what kind of further

action does WHO need to take in order

to create and maintain the accessibility

of treatment?

5. What more can WHO do to engage

government and NGOs in the promotion

of mental health?

6. What preventive actions do WHO

need to do in reducing the prevalence of

mental illness?

7. What are the major opportunities that

exist today that the WHO can use to

improve the livelihood of mentally ill

people?

Bibliography

Bloom DE et al. The global economic

burden of noncommunicable diseases.

2011

Burden of Disease, 2007, accessed 2

May 2014,

http://www.vichealth.vic.gov.au/~/media

/ProgramsandProjects/Publications/

Attachments/Research%20Summ

%20BOD_FINAL_Web.ashx

“Comprehensive Mental Health Action

Plan 2013–2020,” WHO, Accessed 1

May 2013,

http://www.who.int/mental_health/

action_plan_2013/en/.

Crisp AH et al. Stigmatisation of people

with mental illnesses. 2001

“How We Classify Countries,” The

World Bank, accessed 1 May 2014,

12

http://data.worldbank.org/about/countryc

lassifications.

Link BG et al. On Stigma and its Public

Health Implications. 1989

“Lower Middle Income,” The World

Bank, accessed 2 May 2014,

http://data.worldbank.org/income-

level/LMC.

“Low Income,” The World Bank,

accessed 2 May 2014,

http://data.worldbank.org/income-

level/LIC.

“Mental Disorder,” Merriam-Webster,

accessed 29 April 2014,

http://www.merriamwebster.

com/medical/mental+disorder?

show=0&t=1374640636.

“Mental Health Act 2007,” 2007,

accessed 2 May 2014,

http://www.legislation.gov.uk/ukpga/200

7/12/contents

“Mental Health Atlas 2011: Democratic

Republic of the Congo,” World Health

Organization, 2011, accessed 2 May

2014,

http://www.who.int/mental_health/evide

nce/atlas/profiles/cod_mh_profile.pdf.

“Mental Health Atlas 2011: Thailand,”

World Health Organization, 2011,

accessed 2May

2014

,http://www.who.int/mental_health/evide

nce/atlas/profiles/tha_mh_profile.pdf

“Mental Health Online Course”,

accessed 1 May 2014,

http://www.uniteforsight.org/mental-

health/module1

“Mental Health,” WHO, accessed 2 July

2014,

http://www.who.int/topics/mental_health

/en/.

“Mental Illness,” Mayo Clinic Staff, 15

September 2012, accessed 29 April

2014,

http://www.mayoclinic.com/health/

mental-illness/DS01104.

“Obama Calls for National Debate on

Mental Health,” US News & World

Report, 3 June 2013, accessed 2 May

2014, http://health.usnews.com/health-

news/news/articles/2013/06/03/obama-

calls-for-national-debate-on-

mentalhealth.

Vos T et al. Years lived with disability .

2012

World Health Organization. Depression.

2013

13

WHO, Draft Comprehensive Mental

Health Action Plan for 2013-2020. 2013

World Health Organization. Investing in

Mental Health. 2013

World Health Organization. Promoting

mental health. 2005

WHO-AIMS Report on Mental Health

System in Sudan, Khartoum, Sudan:

World Health Organization, 2009,

accessed 2

May 2014.

http://www.who.int/mental_health/who_

aims_report_sudan.pdf.

“WHO Mental Health Gap Action

Programme (mhGAP),” WHO, 2013,

accessed 29 April

2014,http://www.who.int/mental_health/

mhgap/en/.

Saraceno, Barriers to improvement of

mental health services in low-income

and middle-income countries, 2007.

“Upper Middle Income,” The World

Bank, accessed 2 May 2014,

http://data.worldbank.org/income-

level/UMC.

14

TOPIC B :

EXAMINING TUBERCULOSIS : ACCESS TO TREATMENT AND

THE ADVANCEMENT OF TECHNOLOGY

Background Information

Tuberculosis (TB) has claimed its

victims throughout much of known human

history. People who are infected with

Mycobacterium tuberculosis can easily

transmit the disease by releasing to air

droplets from the throats or lungs when they

—pulmonary TB patients—cough, sneeze or

spit, making this airborne disease highly

infectious. TB is common in parts of the

world where poverty strikes. The majority of

TB cases are concentrated in Sub-Saharan

Africa and South Asia countries where

AIDS are epidemic and patients have only

minimum access to diagnosis and treatment.

People with compromised immune system

are also most at risk for falling ill or dying

from TB

Tuberculosis (TB) is specifically

known to share close interaction with human

immunodeficiency virus (HIV). It has

become the leading cause of death among

people with HIV, while HIV infection is the

most potent risk factor for latent TB

infection to convert to active TB. People

living with HIV—representing over 10% of

annual TB cases—are up to 37 times more

susceptible to TB than people who are TB-

negative, making it the second greatest killer

after HIV/AIDS by accounting for

approximately one-fifth of all HIV/AIDS

death cases.

Up until now, tuberculosis kills nearly

two million people worldwide annually

at a rate of 5000 each day. About one-

third of the world’s populations are

infected with latent TB—that is, they

have strong possibilities to develop the

disease later. In 2012, nearly 8.6 million

people got infected with TB and 1.3

million of them died of it. In the same

year, it is estimated that 530.000

children fell ill with TB and 74.000 who

were HIV-negative died of it.

Tuberculosis is also particularly

devastating because of how easy it is to

transmit; “it is estimated that each

infectious patient infects 25-50 percent of

his household contacts.”3 The high

likelihood of transmitting the disease is

compounded by the ever-present

harbingers of poor health: poverty,

malnutrition, overcrowding, lack of proper

15

air circulation, and unsanitary living

conditions.

The World Health Organization

(WHO) declared this disease a global

emergency as long ago as 1993. In

adherence to the Millennium Development

Goals (MDGs), the global community has

done a great job in reducing TB prevalence

in many countries through use of DOTS and

the Stop TB Strategy. The TB death rate

dropped 45% between 1990 and 2012. A

cumulative total of 22 million lives were

saved within the same period. However,

there has been a recent global resurgence of

TB in some countries. Several factors such

as HIV-infection, immigration, and

overcrowding contribute to this resurgence.

Within the period of no longer than a year,

where do we actually stand now?

Currently, the countries in Eastern Europe

and Central Asia are amongst the global

hotspots for MDRTB and these countries

“are putting EU[European Union] states at

risk of a deadly outbreak.”Sub-Saharan

African countries continue to constitute an

area of grave concern for public health

officials and Afghanistan is also a growing

TB trouble spot. Multidrug-resistant

tuberculosis (MDRTB) is especially

insidious because of the increased

difficulty in treating the infected as well as

the resistance and resignation,

respectively, of many politicians,

pharmaceutical companies, and public

health professionals to introducing

second-line drugs and to higher mortality

rates.

16

TB and Poverty

Tuberculosis (TB) is known to

disproportionately affect the most

economically disadvantaged strata of

society. The burden of TB follows a strong

socioeconomic gradient both between and

within countries, and also within the poorest

communities of countries with high TB

incidence. For instance, TB will most likely

strike those who are afflicted with poverty.

Sub-Saharan Africa regions such as

Namibia, Botswana, Djibouti, Zambia and

South-East Asia countries especially

Cambodia and Timor Leste are parts of the

world where TB infection has become

highly prevalent, along with HIV infection.

Some studies have shown a strong

association between TB and poverty, they

have also demonstrated that poor and

vulnerable groups are at increased risk of

TB infection.

Poverty usually comes together with

poor nutrition, inadequate sanitation,

smoking, alcoholism, diabetes, exposure to

indoor air pollution, dense population, HIV,

and minimum access to health care.

Duplicatesall TB risks and increases the

likelihood of bacteria transmission. It is also

well-known that TB can contribute

toincreasing poverty by reducing patients’

physical strength and ability to work. Patient

costs can be particularly burdensome for

TB-affected households in the developing

world. These costs include direct costs of

medical and non-medical expenditures and

indirect costs of time utilizing health care or

lost wages. TB patients and households in

Sub-Saharan African often incurred high

costs when utilizing TB treatment and care,

both within and outside Directly Observed

Therapy Short-course (DOTS) programs.

For many households, TB treatment and

care-related costs were considered to be

catastrophic because the patient costs

incurred commonly amounted to 10% or

more of per capita incomes. Under DOTS

programs, all high burden TB countries

provide free first line anti-TB medication,

but many patients purchase anti-TB drugs in

private pharmacies (some without

prescriptions), which can be costly.

In high TB burden countries, 60%

of overall health expenditure is in the private

sector, and a large proportion of these

expenditures are paid out-of-pocket by

patients. More than 50% of TB patients have

been reported to experience financial

difficulties due to TB. TB patient costs have

been shown to result in reduced food

consumption, taking children out of school,

diversion of resources from other types of

healthcare, and borrowing or selling assets.

In general, the World Health Organization

(WHO) estimates that 100 million people

every year fall into poverty from paying for

health services.

Poverty is both a cause and

consequence of

tuberculosis.Programmatically, the poor

needs to be focused on, not merely for

diagnosis and treatment, but with attempts to

address the related social determinants such

as housing, livelihoods, nutrition, food

security, and risk behavior. This will require

the health sectors to move beyond their

regular realms of action.

Through the Network of Action

for TB and Poverty Secretariat, the

WHO Stop TB Department and Stop TB

Partnership have provided a guideline

for nations around the world—especially

countries with high TB burden—to

tackle the practical issues of poverty so

that controlling TB can be as efficient as

possible.

The costs of treating tuberculosis

are significant, especially for developing

countries. The British Broadcasting

Corporation (BBC) reports that “treating

patients with drug resistant TB is beyond

the pocket of many developing countries.

The cost of treatment can rise from $2000

per patient with non-resistant TB to

$250,000 for multi-drug resistant TB.”8

And as the strains of drug- resistant

tuberculosis mutate further, health

professionals are now encountering

tuberculosis patients who have TB that is

resistant to almost all of the first and

second-line drugs now available to treat

the disease. Farmer also notes “the

strikingly nonrandom occurrence of

MDRTB” when pointing out that the

overwhelming majority of cases have been

“registered among the inner-city poor,

with significant outbreaks confined to

prisons, homeless shelters, and public

hospitals.”9 These groups are also amongst

the least likely to be able to resist the

ravages of the disease, are more likely to

be HIV+, and have the least access to

high-quality affordable health care needed

to combat MDRTB.

TB in Women and Children

Tuberculosis (TB) in women and

children is undoubtedly one major issue.

Any child living in a setting where there are

people

suffering

from

infectious

TB can

become ill

with TB,

even if

they are vaccinated. Children with weak

immune systems, such as children who are

very young, HIV-positive, and severely

malnourished have the most likelihood of

getting infected with TB. Moreover, infants

and young children have higher risk of

developing disseminated disease associated

with high-mortality, such as milliary TB or

TB meningitis. The problem is that TB in

children is often missed or overlooked due

to difficulty in diagnosis and non-specific

symptoms. There is still lack of effective

diagnostics that can detect TB in children

and proper child-friendly dose of drugs

combination. Current TB vaccine protects

children against the most severe forms of

TB such as meningitis and disseminated TB

disease, but does not actually prevent them

from contact or transmission. Attention to

TB in children is still rarely included in

budgets and strategic plans of ministries of

health.

In 2012, 410.000 women died from

TB and, again, South-East Asia and the

African regions accounted for 68% of all TB

cases in women. In the same year, more than

half of the estimated TB cases in women

went undetected, compared with less than

40% in the total population.

Tuberculosis has given major

impacts on maternal health. TB among

mothers is associated with a six-fold risk in

perinatal death and a two-fold risk in giving

birth to premature child and low birth-

weight. Facility-based studies conducted in

high TB burden areas have shown that TB

accounted for 15-34% of indirect cause

obstetric mortality. Genital TB is something

very challenging to diagnose and treat, and it

has been identified as an important cause of

infertility in several low-income areas.

Needless to say that newborn child of

women with TB is a serious risk factor for

them to develop the disease later.

Global and national communities

need to make full commitment to assure

gender-equitable access to diagnosis,

treatment care and support. Integrating TB

screening and expanding investigation into

reproductive health service, including

antenatal and postnatal care is of great

importance. New drugs research and

development for women with specific needs

—pregnant and lactating—should also be

taken into consideration.

Multidrug-resistant Tuberculosis (MDR-

TB) and Extensively Drug-resistant

Tuberculosis (XDR-TB)

Both multidrug-resistant

tuberculosis (MDR-TB) and extensively

drug-resistant tuberculosis (XDR-TB) are

the emerging threats to the success of anti-

TB programs.The World Health

Organization (WHO) has recognized M/XD-

TB as a major impediment in eradicating

tuberculosis. In April 2009, WHO has

adopted resolution WHA62.15 on

prevention and control of M/XDR-TB.

Important progress has been made ever

since, however, severe bottlenecks are

limiting the response to M/XDR-TB

epidemic. Only 10% among notified TB

cases in high TB countries and 11% globally

were enrolled on treatment. Some countries

are making progress by implementing policy

changes that rationalize the use of hospitals,

such as South Africa, or treating patients

through community-based models of care,

such as the Phillipines.

However, nowadays, diagnostic

capacity remains limited while the success

of MDR-TB treatments depends on how

quickly a case of TB is identified as drug

resistant and whether an effective drug

therapy is available. The second-line drugs

used in cases of MDR-TB are often less

effective and more likely to cause side

effect.

Furthermore, the price of quality-

assured second-line drugs has not fallen and

shortages of drugs still occur. Tests to

determine the resistance of a particular strain

to various drugs usually take several weeks

to complete. During the delay, the patient

may be treated with a drug regimen that is

ineffective.

The emergence of drug resistance in

TB patients is mostly a result of deficient

TB control programs. Factors related to the

development of drug resistance comprise the

following: inadequate or inefficient

administration of effective treatment,

inadequate or irregular drug supply, non-

adherence of patients to the prescribed

regimens, availability of anti-TB drugs

without prescription, illiteracy, low

socioeconomic status of patients, laboratory

delays in identification and susceptibility-

testing of M. tuberculosis isolates, quality

control measures and ignorance of health

care workers in the treatment and control of

TB.Essentially, MDR-TB occurs in the areas

where TB control programs are weak.

Programmatic Management of

Drug-resistance (PMDT) TB is one of the

tools of the TB Care II Project—a five-year

cooperative agreement financed by the

United States Agency for International

Development (USAID)—that has made a

quite significant impact in controlling

M/XDR-TB cases. However, PMDT is a

complex intervention in public health. It

needs careful planning, intensive technical

assistance and mentoring during

implementation, as well as regular

monitoring. If eradicating tuberculosis is to

be done, countries need to mobilize

resources, build capacity and coordinate

operations within the health care system.

The Global Fund (GFATM) and UNITAID

are some of the main sources of funding for

PMDT in several countries, however

domestic funding is also central to the

implementation of the program.

Getting from DOTS to DOTS+: WHO responds to changing conditions

Treating tuberculosis effectively

requires concerted action at the local,

national, and global levels. The World

Health Organization (WHO) occupies a

central position in the global pantheon of

public health professionals and political

decision makers. WHO’s primary

mechanism for combating the effects and

spread of TB has long been its directly

observed therapy, short-course program

known as DOTS. DOTS was established in

1993 as WHO and the world community

began to face the enormous toll that

untreated TB can exact. DOTS relies upon

health care workers and providers

observing the prescribed short-course

regimen of high protein diets and first-line

drugs of isoniazid and rifampicin to treat

and cure patients with TB. If DOTS is

administered correctly and the treatment

regimen lasts for a minimum of 6 months,

non-drug- resistant TB patients have a

very likelihood of being cured. Farmer and

others conclude that “the DOTS approach

is one of the most cost-effective

interventions in all of global public health,

but we now know that in many regions of

the world it will not be enough to control

the epidemic.”10 As the extent of the

MDRTB crisis became more widely

appreciated, WHO, in conjunction with

national governments, NGOs, and related

international organizations such as the

International Union Against Tuberculosis

and Lung Disease, began negotiating with

pharmaceutical manufacturers to provide

the more expensive second-line drugs at

much lower prices and to expand the

length of the treatment regimen for

patients with MDRTB.

Access to diagnosis and treatments

Access to diagnosis and treatments

is one of the major difficulties faced by

almost all sectors in curing people from TB.

Many factors do contribute to this.

Stigmatization is one of them.

Stigma and discrimination have an

enormous impact on sufferers, that impact is

felt at home, in the workplace and

institutions and in the community. The

principal effects in developing countries are

social isolation of patients, both outside the

family, where the person may be avoided by

former friends and acquaintances and inside

the family where the patient may be forced

to eat and sleep separately.  Being either a

patient or an ex-patient is likely to affect

employment and employment prospects.

Unmarried women often find it difficult to

get married, due to discrimination by

prospective husbands and in-laws, while

married women may find they are divorced

because they have TB or if a history of TB is

subsequently revealed. Stigma and

consequent discrimination have a double

impact on TB control. First, concerns about

being identified as a person with TB make it

more difficult for people with a cough of

long duration who suspect they may have

TB to seek care, because of the public nature

of the TB diagnostic process. By delaying

seeking care, these people may develop

more serious symptoms. Second, concerns

about stigma and discrimination for TB

make it more difficult for patients to

continue with care, because their fears of

being identified as being, or having been

infected with TB hinder their access to

services on a daily basis. A survey

conducted in Nepal shows that the main

causes were fear of contracting the disease

(58%), association with poverty (40%) and

lack of knowledge (34%).

 Poverty is undoubtedly an issue. It

is highly associated with the occurrence of

TB, not only as a cause for the disease but

also an impediment in curing the disease.

Marginalized groups are often the most

affected. The barriers to effectively address

the issues of TB of the poor are several and

severe in many countries. On the side of

treatment, access is of paramount

difficulty.Poverty can complicate people,

particularly women, to prioritize their health

over other resources demand: the threat of

lost income and the costs of travel can stop

them from seeking proper help even where

treatment is free. Very poor and vulnerable

people may have to make harsh choice—

knowing putting their health at risk so that

their children do not go to bed hungry, for

example. The cost of doctors’ fees, drugs,

and transports to get to the health centre can

be devastating for them to reach and pay for

treatment. It could mean that they will have

to sell property, take their children out of

school, and start begging on the street.

Moreover, due to lack of education, most

people who live in poverty simply do not

know about TB or recognize their symptoms

as TB.

Finding the poor and providing the

treatment poses both cultural and logistical

concerns. This requires persuasion, and

awareness creation. Because it is still

difficult to mainstream into the TB

programs actions. This is because

determinants often lie outside the parameters

of the health sector, and the health sector has

traditionally been reticent about dealing with

factors beyond health: housing,

overcrowding, social habits, sanitation and

personal hygiene. So far there has been low

emphasis on the above aspects in the

ongoing TB programs in most countries.

Despitefully, poor health systems

also play important role in complicating TB

treatment. Even when people are able to

overcome the main barriers, the variety of

the quality of health system throughout the

world gives varying consequences to people

when accessing TB diagnostics and

treatments. Insufficient numbers of health

care professionals, limited funding

resources, inequality in services provision,

poor infrastructures, and the lack of

diagnostics have contributed much to the

severity of TB cases.

Access to diagnostics and treatments

for M/XDR-TB is also of great importance.

The prospects for global tuberculosis control

in the near future will be determined by the

effectiveness of the response of countries to

their burden of MDR-TB. Belarus, Brazil,

Kazakhstan, and Peru are the several

countries that has been detecting and

enrolling their citizens on treatments up to

50% of their estimated cases of MDR-TB.

These countries can achieve universal access

to MDR-tuberculosis care by 2015 should

they sustain the current pace of progress.

Other countries like Azerbaijan,

Afghanistan, North Korea, and Mozambique

have slower progress in detection and

enrollment on treatments.

The Global Fund and the Global Stop

TB Plan

One key avenue for preventing the

spread of TB and MDRTB and to also

treat cases that are found is the Global

Fund to Fight AIDS, Tuberculosis, and

Malaria (GFATM). The Global Fund

was established in 2002 as a result of

recommendations made by WHO’s

Commission on Macroeconomics and

Health (CMH) and is one of the

cornerstone programs within the UN

System to combat the spread of TB and

MDRTB, along with the World Health

Organization’s directly observed

therapy, short-course (DOTS) and the

expanded DOTS-plus program

introduced within the past few years. At

the time, the Commission on

Macroeconomics and Health (CMH)

estimated that $400 million would be

needed annually for at least 10 years to

combat TB and MDRTB effectively but

lately the total amount needed has been

raised to $700 million annually. Private

foundations such as the Bill and Melinda

Gates Foundation have given gifts of

hundreds of millions of dollars to the

Global Fund as well as the Global Stop

TB Plan over the past 6 years but it

remains abundantly clear that the

national governments of the world’s

wealthiest countries need to contribute

significantly greater resources if TB and

MDRTB are to be effectively resisted.

As critical as support from Western

governments is, corporate donors have

been especially slow in contributing to

the Global Fund to date. At the end of

January 2006, only $5 million out of a

total of $4.7 billion had been contributed

by corporate donors but the launch of the

“Product Red” campaign has

significantly bolstered corporate

contributions of the Global Fund;

according to the latest figures from the

Global Fund, Product Red contributions

have totaled over $183 million USD.11

Western governments and decision

makers can point to relatively low rates

of TB and MDRTB in their own

societies today but they must remain

cognizant of the fact that TB and

MDRTB are highly infectious airborne

diseases that spread easily and that their

own populations remain at risk because

of the prevalence of TB and MDRTB in

neighboring corners of the globe.

Ultimately, though, even with all of the

challenges currently confronting the

international community as a result of

TB, MDRTB, and even XDRTB, which

will be discussed below, WHO estimates

in its 2013 data on TB that 22 million

lives have been saved through DOTS

and Global Stop TB. (Fact Sheet No.

104)

Recent Outbreaks, including XDRTB

As tuberculosis continues to mutate and

evolve, the medical community must

seek to keep pace with new

developments. In early 2006, WHO and

the US Centers for Disease Control

(CDC) named the most frightening TB

mutation thus far: extensively drug-

resistant tuberculosis (XDRTB). This

new strain, XDRTB, is not only resistant

to the two primary front-line drugs,

isoniazid and rifampicin, it is also

resistant to at least three to six of the

eight second-line drugs. On October 9

and 10, 2006, the WHO Global Task

Force on XDRTB met in Geneva,

Switzerland to develop guidelines for

countries facing outbreaks of XDRTB.

Combating XDRTB will require

countries to provide greater access to

second-line TB drugs as well as to

increase the prescription of anti-

retroviral medication to HIV+ patients,

many of whom are very likely to

contract either MDRTB or XDRTB.

XDRTB is still considered relatively rare

but WHO estimates, based upon TB

population samples, that up to 20% of all

MDRTB patients can develop XDRTB,

although WHO cautions that the overall

percentage is likely to be lower than

20% of MDRTB cases developing into

XDRTB; in 2008, the percentage of all

TB cases that were diagnosed as

XDRTB was estimated at approximately

7%.12 In September 2006, the

government of South Africa issued an

urgent appeal to WHO for immediate

assistance in confronting an outbreak of

XDRTB in that country. With the

dangerously high incidence of HIV/

AIDS in Africa, especially southern

Africa, combating MDRTB and XDRTB

must be considered an urgent public

health priority throughout the region.

Delegates to WHO need to bear in mind,

however, that XDRTB may be found in

other regions of the world, too; in March

2013, Australia’s Health Ministry

confirmed the country’s first XDRTB

death. i (Please see the corresponding

endnote for this reference)

The Advancement of Technology

Early TB diagnosis is crucial to

reducing transmission and mortality. Smear

microscopy and mycobacterial culture are

currently the most widely used diagnostic

tests. Microscopy, though relatively fast, is

not accurate—missing over half of cases. On

the other hand, culture is accurate but slow

—taking about 2-8 weeks to definitive

result. Basically, the key barriers to the

detection of TB are the difficulties of

diagnosing latent TB infection and active

TB; the lack of accessible, rapid, and

validated testable biomarkers; long delays in

seeking treatments; lack of an accurate POC

test and the unavailability of facilities that

can test for drug-resistant tuberculosis.

The case of childhood tuberculosis

represents an event in the community

suggesting recent transmission from an

infectious adult. The diagnosis of

tuberculosis in children is traditionally based

on chest radiography, tuberculin skin

testing, and mycobacterial staining/culture

although these investigations may not

always be positive in children with

tuberculosis. Newer diagnostic methods,

such as PCR and immune-based methods,

are increasingly being used although they

are not widely available and have a limited

role in routine clinical practice. Diagnostic

approaches have been developed for use in

resource-limited areas, however, these

diagnostic methods have not been

standardized and only few have been

validated. Despite, compliance is a major

determinant of the success of drug

treatment. Treatment of latent infection and

chemoprophylaxis of young household

contacts is also recommended for

tuberculosis prevention, although this may

not always be carried out, particularly in

high incidence areas.

Another

key question in

tuberculosis

control is why

some strains

of Mycobacterium tuberculosis are

preferentially associated with resistance to

multiple drugs. M. tuberculosis develops

drug resistance exclusively through

chromosomal mutations. Whole-genome

sequencing technology has identified

unexpected genetic diversity among clinical

M. tuberculosis populations. It raises the

possibility that environmental factors might

act as key mutagens during M. tuberculosis

infection. A study shows that M.

tuberculosis mutation rate from different

lineages predict substantial differences in

the emergence of drug-resistant tuberculosis.

Research and development focusing in new

drugs, either broad-spectrum or narrow-

range antibiotics, should immediately take

place.

Xpert MTB/RIF assay is one major

achievement in diagnosing TB infection.

This new test method is thought to be

revolutionizing TB control. This method is

accurate with sensitivity at 95% and

specificity at 98%—detecting almost all TB

cases. However, recently, shortage arose.

Cepheid experienced difficulties in keeping

up with cartridge orders that were placed by

countries. The lack of Xpert MTB/RIF

cartridges is another ongoing drug and

diagnostic stock-outs. An inconsistent

supply of Xpert MTB/RIF cartridges means

that there will be fewer people to be

accurately diagnosed and treated in a timely

manner.

Questions a Resolution Must Answer

(QARMAS)

1. How to ensure the poor having

better access to diagnostics and

treatments?

2. How can governments, public health

agencies, regional offices of WHO,

and health providers work together

more effectively to prevent and

combat pandemics that spread when

people travel between countries?

How might governments,

philanthropic organizations, and

corporations increase their

contributions to voluntary funds,

including the Global Fund to

Combat Tuberculosis, especially in

light of contemporary global

economic and financial problems?

What can be done to address the

social issues affected by this

epidemic, such as stigma and

discrimination?

3. What steps can the WHO take to

improve its effectiveness at

preventing and combating

pandemics?

4. What can be done to integrate and

expand TB screening and

investigation in order to specifically

meet children and women’s need?

5. What more can the World Health

Organization (WHO) do to answer

the urgent needs for new testing and

curing technology, in specific

concerns for MDR-TB?

6. What can WHO do to strive for

funding in mitigating TB?

Biblography

World Health Organization. (2006). The Global Plan to Stop TB 2006-2015/Stop TB Partnership. Retrieved 6 May 2014 from: http://www.stoptb.org/assets/documents/global/plan/TB_GlobalPlanToStopTB2011-2015.pdf

World Health Organization. (2014). Fact Sheet No 104. Retrieved 6 May 2014 from: http://www.who.int/mediacentre/factsheets/fs104/en/

World Health Organization. (2011). WHO Progress Report 2011: Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 2015. Retrieved 6 May 2014 from: http://whqlibdoc.who.int/publications/2011/9789241501330_eng.pdf

United States Agency for International Development. (2013). Community Programmatic Management of Drug Resistant Tuberculosis Planning Tool. Retrieved 6 May 2014 from:

http://tbcare2.org/sites/tbcare2.org/files/CommProgManDrugResTBPlanTool_v7%20%282%29.pdf

World Health Organization. (2006). The Stop TB Strategy: Building on and enhancing DOTS to meet the TB-related Millenium Development Goals. Retrieved 6 May 2014 from: http://whqlibdoc.who.int/hq/2006/WHO_HTM_STB_2006.368_eng.pdf?ua=1

Falzon D, Jaramillo E, Wares F, Zignol M, Floyd K, Raviglione MC. (2013). “Universal access to care for multidrug-resistant tuberculosis: an analysis of surveillance data”. The Lancet Infectious Diseases 13(8):690-7. Retrieved 6 May 2014 from: http://www.ncbi.nlm.nih.gov/pubmed/23743044

Eric J. Rubin, M.D., Ph.D. (2014). “Troubled with Tuberculosis Prevention”. The New England Journal of Medicine. Retrieved 6 May 2014 from: http://www.nejm.org/doi/pdf/10.1056/NEJMe1312301

Alimuddin Zumla, M.D., Ph.D., Mario Raviglione, M.D., Richard Hafner, M.D., and C. Fordham von Reyn, M.D. (2013). “Current Concepts: Tuberculosis”. The New England Journal of Medicine. Retrieved 6 May 2014 from: http://www.nejm.org/doi/pdf/10.1056/NEJMra1200894