TB or not TB

Bikram Rai

Neglect by Nepal's rulers of the poor, the disenfranchised and marginalised has been a given throughout our history. Royal or revolutionary, democrats or demagogues, upliftment of the underserved has always been a mere slogan. This chronic inattention has determined who gets to live, and who dies. 

Till about a decade ago, Nepal’s main problem was with infectious diseases like diarrohea, pneumonia, typhoid, and insect-borne ailments. The first line of defence against communicable diseases is communication: and the government’s campaign for public health awareness through a network of female health volunteers yielded dramatic results. 

Even though the emphasis has now shifted to non-communicable diseases, there is still one infectious disease that has fallen below the radar: tuberculosis. It is obvious why, TB afflicts the poorest in the remotest parts of the country. 

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This is true not just in Nepal but worldwide. Despite advances in medicine, TB is still the biggest infectious killer – 35 million people died of it in the past 18 years. If nothing is done, another 30 million will die of TB from now till 2030. 

Tuberculosis is caused by a bacterium transmitted through coughing, and if left untreated, affects the lungs and leads to a slow and painful death. The fact that it is still killing millions every year despite the availability of antibiotics is an indictment of the global and national inequity in health care. 

Most Nepalis are carriers of the bacillus that causes TB, but the disease is kept in check by our immune system. Chandra Shumsher had TB, and many of Nepal’s kings died of it. The bacteria proliferates when a person becomes weaker due to malnutrition, age, or other diseases like HIV. Last year, 45,000 new cases were detected in Nepal, and nearly 7,000 of them died. 

Although Nepal is a role model in the community-based DOTS process that requires medical supervision of the administration of antibiotic treatment to patients, researchers say a more active case detection method is now required. This calls for an increase in Nepal’s annual TB control budget of $18million of which about half is met through donor contribution.

Last week in New York, the United Nations held its first ever high-level meeting on TB during which leaders adopted a historic UN Political Declaration on TB timed for World TB Day on 26 September. This largest ever gathering of world leaders hoped to do for TB what had earlier been achieved with such meetings for diseases like HIV and Ebola.

The declaration had a checklist that included reaching 40 million people by 2022 with diagnosis and treatment, and another 80 million with preventive therapy. It also committed to double the current $13billion to fund the World Health Orgnaisation (WHO) End-TB Strategy and the Stop TB Partnership’s Global Plan to End TB. 

WHO developed the End-TB by 2035 strategy in 2014 but it was clear more investment and political commitment was needed. Globally and within countries, it is the poor who suffer, which means the disease is not a priority for pharmaceutical companies, the private health care industry and most governments. Tuberculosis and poverty go hand-in-hand: TB fuels poverty, and poverty in turn fuels TB. 

In addition to the challenge of surveillance, detection and early treatment, there is now a new threat: the tuberculosis bacterium is getting resistant to prevalent antibiotics, and untreatable superbugs are spreading. Multi-drug resistant (MDR) tuberculosis is difficult and expensive to treat, and the drugs have severe side effects. 

ew drugs, diagnostics and vaccines are urgently required but investment in TB research falls far short of what is needed. BCG vaccines are no longer considered effective enough, and diagnosis of multi-drug resistance is too expensive for poorer countries like Nepal. The ‘Alaska Model’ of treating all carriers preventively with antibiotics would be too expensive and too difficult here.
Nepal’s location is an added problem: the two countries with the heaviest TB disease burden are India and China. Both have increasing numbers of MDR TB, and eradicating TB within Nepal will not be the end of the story.

There are new interventions on the horizon like the GeneXpert molecular diagnostic kits, but there are only 50 of them in Nepal and each cartridge costs the government Rs1,800. The Britain Nepal Medical Trust is using drones for delivery of specimens and drugs in a pilot project in Piuthan to overcome the accessibility barrier. (Story: page 14-15).Since a national eradication program is too complicated, Nepal’s strategy should be to adopt best practices from elsewhere like establishing TB-free zones district-by-district. One thing is clear: business as usual will mean this medieval disease will be around for much longer.

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10 years ago this week

The front page of Nepali Times ten years ago (#419) 26 September – 2 October, 2018 covered the visit by Prime Minister Pushpa Kamal Dahal to New York for the UN General Assembly, and attendance at a reception by US President George W Bush. The editorial cited Dahal’s promise to generate 10,000MW of power in 10 years. It has been 10 years, and we still generate less than 1,000MW. Excerpt from the editorial:

‘The Maoist-led government wants to “think big” and increase present generating capacity from 600MW to 10,000MW in 10 years. This will cost Rs 1.4 trillion. There’s no harm in dreaming, but even if we manage to generate that amount of electricity by 2018, our domestic demand will have risen to 3,000MW and India’s generation capacity will be 300,000MW. Our exports will make up only 2% of India’s electricity needs in 10 years, so they can do quite well without our power. We need it much more here. Nepal needs to generate more electricity to meet rising domestic demand and then sell the surplus to balance our Rs150 billion annual trade deficit with India. The most prudent course of action for us is to fast-track hydroenergy projects by turning Nepal into an investment-friendly destination. For this, the new government must get serious and streamline licensing, respect the sanctity of contracts, and temper militant labour. If that isn’t done, forget about 10,000MW in 10 years.'