Democratic Inequality Between the Rich and Poor can Influence TB Dynamics

The message that struck us all around the World Tuberculosis Day 2018 was on Twitter by Shirin Aliabadi, who tweeted that Dr. Richard Horton (Editor in chief of The Lancet) said, politics is, in many ways, the ultimate determinant of our health. Bad decisions made by politicians determine our well-being in so many ways. Elected parliamentarians, especially in democracies, must be held to account, as to why a tiny minority of rich people get richer and enjoy the highest quality of life, whereas the majority of the populations are forced to live in inhumane conditions that put them at increased risks of not just TB, but several other infectious diseases, non-communicable diseases; as well as put them at high risk of facing exploitation, abuse and violence at different levels.

Booker Prize winner and noted writer-activist Arundhati Roy had rightly said that "There's really no such thing as the 'voiceless.' There are only the deliberately silenced, or the preferably unheard." Despite political decisions majorly determining our health and well-being, it is indeed shocking that health and social security has slipped so far out of the political radar.

TB gets on political radar but is it high up?

Even if late, TB is definitely moving up the ladder as a priority for not only national TB programmes (NTPs), but also beyond NTPs within Ministries of Health, and at times, further beyond for other ministries and stakeholders. When we talk of pushing TB up on the political agenda, one of the most historic meetings was the first-ever "WHO Global Ministerial Conference: Ending TB in Sustainable Development Era" held in Moscow, Russia, in November 2017.

Russian President Vladimir Putin endorsed the #endTB agenda in this meeting of over 75 ministers of health as well as of other non-health disciplines (especially from high-burden TB countries), and other stakeholders and affected communities.

These ministers endorsed the Moscow Declaration and acknowledged that TB (including its drug-resistant forms) causes more deaths than any other infectious disease worldwide, and is a serious threat to global health security. Earlier, over 190 governments had promised to Sustainable Development Goals (SDGs) in UN General Assembly 2015, which includes goals to achieve Universal Health Coverage (UHC) as well as to end TB by 2030. Last month in Delhi, the Indian Prime Minister gave another thrust to the promise of ending TB by 2025 in India.

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One of the keys leads in organizing the WHO Global Ministerial Conference was Dr. Mario Raviglione (then head of the WHO Global TB Programme). Dr Raviglione is now the Director, Global Health Centre, University of Milan, and was the key expert for World TB Day 2018 Webinar, who reiterated the political (and public health) significance of TB getting on the agenda of G20 meeting in Germany (2017), G7 meeting in Italy (2017), Asia Pacific Economic Cooperation (APEC) meeting in Viet Nam (2017), among others.

But does this indicate that TB is high up enough on political agenda? Or for that matter, is health security high up on political agenda? For instance, will Prime Minister of India's commitment to end TB by 2025 give a thrust to TB agenda in political decision making? Probably early next year India goes to general elections and let us hope that public health takes center-stage in politics.

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Progress made to stop TB but not enough to #endTB

Dr. Mario Raviglione who spearheaded the global fight against TB for several years said that efforts to prevent TB have been successful but not enough to end the epidemic. Soft political and financial commitments have posed major challenges.

Dr. Mario Raviglione said that 53 million lives were saved from TB, and TB deaths fell by 22% during 2000-2016. This is a commendable achievement where the world, especially the high burden TB countries, built up a strong fight to stop TB as per the Millennium Development Goals (MDGs) targets. But progress is clearly way off track to end TB by 2030. As per the latest WHO Global Tuberculosis Report, 1.7 million TB deaths occurred in a year, 5000 TB deaths every day! Out of these, were 400,000 people living with HIV (PLHIV) who died due to TB in the same year.

MDR-TB is now at crisis level, with only 1 in 5 being able to access existing care services. Half a million women and 250,000 children died of TB in 2016. With the call to end TB reaching its zenith, we have to ensure that TB rates decline faster enough so that we can keep the promise to end TB, and also make better progress on other SDGs.

Accountability of each actor in multisectoral partnership

Since TB was threatening to reverse gains made in other health 'silos,' partnerships had to be eventually forged between TB programmes and those on HIV, diabetes, tobacco control, to name a few. These partnerships are at different levels, but all are gearing towards not only improving TB programme outcomes but also of those addressing other specific health issues.

But delays in forging partnerships despite the compelling and scientific evidence is not acceptable. Who is accountable for avoidable disease burden, as well as for averting preventable untimely deaths? As per the latest WHO Global TB Report, 400,000 TB deaths occurred in PLHIV.

With scientific evidence, policies and programmes being in place to prevent, diagnose, treat TB in PLHIV, each of these 400,000 TB deaths could have been averted, and both TB and HIV programmes would have fared better, only if we could translate scientific evidence into public health benefits with utmost diligence and urgency.

Unless we determine and monitor accountability of different actors who need to do their part to end TB, multisectoral partnerships can seldom become very efficient. But the good news is that in the Moscow meet, governments and other partners agreed to progress on multisectoral accountability framework, so that the world gets on track to end TB by 2030 as per SDG targets.

The deadly mismatch

On the one hand, political leaders commit to ending TB by 2030, but on another hand, they also promote questionable development policies that exacerbate inequalities in society - one manifestation of which is increased the risk for diseases like TB.

Wardarina, Co-Chair of Asia Pacific Regional Civil Society Engagement Mechanism (AP-RCEM), who has been a part of Asia Pacific Forum on Women, Law and Development (APWLD) for past several years, rightly pointed out such contradictions: "We have to look into SDGs critically, focussing on the existing contradictions, and not just on their progress and implementation. For us the contradictions are that along with the SDGs, we also have a lot of unjust trade and investment agreements, massive land and resource grabbing, patriarchy, and fundamentalism, militarism and conflict, retaliatory governance. All these need to be addressed if we aim to achieve the sustainable development goals."

If we truly want a world where no human being is forced to suffer inhuman treatment and end TB and other preventable/ avoidable causes of human suffering, then it is critically important to ensure that the gap between 'haves' and have-nots' is reduced as much as possible.

But it is the political decisions that make us chase a 'development model' which not only further widens this chasm between the rich and the poor, but also puts the poorest of the poor at highest risk of undergoing even more severe forms of suffering, including elevating TB risk. A report released by Oxfam, around the time of recent World Economic Forum, showed that in 2017, 1% of the world's richest owned 82% of the global wealth. This report also showed that in India, 1% of its population owned 58% of the nation's wealth in 2016, and in 2017 this inequality worsened with 1% owning 73% of the wealth.

How can we expect to have social equity if only a minuscule percentage of our population enjoys the highest quality of healthcare, education, lifestyles, while the vast majority of the people are forced to live with the appallingly poor quality of healthcare, education, and are deprived of even the most basic amenities? Renowned Indian socialist leader Dr. Ram Manohar Lohia had advocated a ratio of not more than 1:10 between the lowest and highest incomes. An unbridled income gap brews inequality, exploitation, imbalance, injustice, and unrest in society.

Dr. Mario Raviglione also said in the webinar that migrants, refugees, prisoners, and ethnic minorities face a higher risk for TB, and also face discrimination and barriers to accessing care. "To prevent latent TB converting into active TB disease we need food security and compulsorily have to address malnutrition" rightly said Dr. Raviglione, pointing out another area where NTPs need to partner effectively with government programmes to end hunger (one of the SDGs is to end hunger by 2030). It is apparent that addressing all forms of inequality and injustices will also have a positive ripple effect on TB programmes' performance too.

There is hope

Over 950 doctors and 150 junior doctors (who are pursuing post-graduation studies or seeking advanced super speciality training) in Quebec province of Canada recently declined to accept a salary hike, saying that they cannot, in “good conscience”, accept an increase in their salary when nurses and other healthcare staff and patients are facing hardships due to cuts in health budget. These doctors believe that only stronger public health systems can deliver health security to all.

When public health systems are reeling under resource crunch, how can raise the salaries of doctors to be justified? If nurses and other healthcare staff are forced to work in stressful and challenging conditions, and lifesaving healthcare services slip beyond the reach of people, then how will the tall promises of health security and universal health coverage be delivered? These doctors have appealed that instead of raising their salaries, the government should rather utilize these resources in strengthening the public health system, so that nurses and other healthcare staff can work in better and secure conditions, and healthcare services are within reach of all those in need, especially the most deprived or terminally ill.

Oxfam tweet is online here

Public health systems are getting weakened, not strengthened with aggressive privatization and other chronic issues that ail the system. Oxfam tweeted on 3rd April 2018 "Sorry state of India's #Healthcare. Nearly 2000 Primary Health Centres (PHC) in India do not have a single doctor. Meanwhile, 61% operate with just one doctor. Guidelines suggest two doctors minimum per PHC." If we are to deliver on SDGs, ensuring health security for the 'last person in the queue' is of utmost urgency. And delivering healthcare and other social security and welfare benefits to the most marginalized cannot be privatized, so do we believe.

Canadian doctors have indeed shown a silver lining for those who believe in strong public health systems. Other doctors and people from all sectors should emulate them, be inspired by their conscience and agree to share resources equitably with all.

Low domestic funding to #endTB is bad politics and economics.

Evidence shows that 22 countries with the world’s highest numbers of TB cases (India shares biggest TB disease burden globally) could earn significantly more than they spend on TB diagnosis and treatment if they fully fund and effectively implement the WHO strategy to end TB. So not funding TB control is a bad economic decision and bad politics, right?

Dr. Mario Raviglione said in the webinar that the global fight against TB faces a financial crunch of US$ 2.3 billion. TB research funds are short of US$ 1.2 billion! Unless governments step up to fully fund the fight to end TB and deliver on other SDGs, promises will remain mere words, and fail to translate into action.

Another bad politics and a bad economic decision is not to implement tobacco control effectively. A critical report provides the vital evidence that the tobacco industry and the deadly impact of its products cost the world’s economies more than US$ 1 trillion annually in healthcare expenditures and lost productivity. Tobacco kills more than 7 million people every year worldwide. More than 6 million of those deaths are the result of direct tobacco use while around 890 000 are the result of non-smokers being exposed to second-hand smoke. Who should be held to account for not protecting people from tobacco (including secondhand smoke) despite over 180 governments ratifying the global tobacco treaty (formally called the WHO Framework Convention on Tobacco Control - FCTC)? It is not a coincidence that around 80% of the world's 1.1 billion smokers live in low- and middle-income countries, and major tobacco companies and industries are headquartered in the richer nations. No prizes for guessing that it is the low- and middle-income countries that are reeling under the severest impact of non-communicable diseases (such as heart disease and stroke, cancers, diabetes, chronic respiratory diseases, etc.)!

Corporate interference in development policy?

Is it not bad politics to make funding decisions that do not serve the best of interests of the majority of our population? Who is influencing these political decisions that make the rich, richer, and deprive communities from accessing basic services? While corporate interference in development policy-making needs to be further investigated, but there are no prizes for guessing who is financially benefitting due to such policy decisions that only serve the interest of the rich!

To end TB, we need to deliver on all SDGs

One of the most important statements made by Dr. Mario Raviglione in the World TB Day 2018 Webinar was that "approach to ending TB cannot be different or other than the approach for comprehensive development." Only by ensuring that sustainable development becomes a reality for everyone, where "no one is left behind" we can progress towards ending TB, as well as achieving all the other SDG targets and goals.

World Health Day: Health security, SDGs, and politics?

Let us hope that on 2018 World Health Day, and before the governments meet for World Health Assembly 2018 next month in July, health security and all SDGs begin to take center-stage in politics in every country. Amen!



Source-Shobha Shukla and Bobby Ramakant, CNS (Citizen News Service)