- Email: [email protected]
Tuberculosis control: hard questions
Correspondence
Tuberculosis control: hard questions
For WHO TB strategy see http:// www.who.int/tb/post2015_ TBstrategy.pdf?ua=1
1744
Although in their Comment in The Lancet Mishal Khan and Richard Coker (Aug 23, p 646)1 raise real and well known challenges in the global tuberculosis response, they fail to propose any solutions and downplay efforts and achievements by many stakeholders to address these complex issues. We have some questions: How much can the statement that countries are ”incentivised to obscure programmatic challenges” be generalised? Are the definite tuberculosis burden declines in countries such as China and Cambodia, reported from prevalence surveys,2,3 somehow unconnected to the expansion of tuberculosis control efforts over the past few years?4 What should replace performancebased funding to prevent the so-called perverse incentive by international donors? Financing needs to somehow be linked to performance measured through targets and indicators. How could accountability be otherwise demonstrated? Can there really be any trade-offs between the ”urgency to treat” versus ”long-term health systems strengthening goals” as is proposed? We need both, as outlined in the WHO post-2015 Global Strategy endorsed by the World Health Assembly. Would it be ethical to delay introduction of new tools until health systems are working to perfection? How would this affect urgently needed development of new diagnostics, drugs, and vaccines, or operational research to guide their introduction? Is there a counter-proposal to the essential, WHO-recommended health systems to deliver treatment to patients with multidrug-resistant tuberculosis?5 Can we ethically watch patients with multidrug-resistant tuberculosis die while waiting for improved health systems? Is duty of care different for tuberculosis than for cancer or HIV? Would anyone
privileged enough to live in an affluent country decline treatment if they contracted multidrug-resistant tuberculosis? Should we not learn from HIV control how creativity and mass action can overcome formidable programmatic barriers associated with complicated, costly interventions? The latest WHO Global Tuberculosis Report 4 (and special supplement) stresses that prevention and proper first-line treatment are the first step in the control of multidrug-resistant tuberculosis. Is the growing evidence showing that scale-up of multidrug-resistant tuberculosis services and improved treatment are achievable under programmatic condition—even in high-burden countries—not convincing enough to let us proceed with both prevention and treatment?4,6 We believe that the public health crisis of drug-resistant tuberculosis needs urgent, concerted actions, although we may not yet have all the answers. All authors are staff members of WHO. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of WHO. We declare no competing interests.
*Karin Weyer, Dennis Falzon, Fraser Wares, Ernesto Jaramillo, Mario Raviglione [email protected] WHO Global Tuberculosis Programme, 1211 Geneva 27, Switzerland © 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. 1
2
3
4
5
Khan MS, Coker RJ. How to hinder tuberculosis control: five easy steps. Lancet 2014; 384: 646–48. WHO. Global tuberculosis control: WHO report 2011 (WHO/HTM/TB/2011.16). Geneva, World Health Organization. 2011. Tan Eang M, Kosuke O, Norio Y, et al. Cross-sectional studies of tuberculosis prevalence in Cambodia between 2002 and 2011. Bull World Health Organ. 2014; 92: 573–81. WHO. Global tuberculosis report 2015 (WHO/ HTM/TB/2014.08). Geneva, World Health Organization. 2014. WHO. Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 2015. WHO progress report 2011. (WHO/HTM/TB/2011.3). Geneva, World Health Organization. 2011.
6
Falzon D, Jaramillo E, Wares F, Zignol M, Floyd K, Raviglione MC. Universal access to care for multidrug-resistant tuberculosis: an analysis of surveillance data. Lancet Infect Dis 2013; 1: 690–97.
Authors’ reply We thank Karin Weyer and colleagues for their interest in our Comment.1 We would like to address the following two conceptual disagreements. First, in reference to the role of academic discourse, we happily accept the criticism that our Comment does not propose simple solutions to all issues raised. The purpose of our Comment, in keeping with the role of academic discourse, was to stimulate debate about questions that do not yet have clear answers. Although we do not downplay the efforts of any stakeholder, we question the need to promote simple solutions that WHO seems to expect to work in all settings. For example, we do not suggest that performance-based funding be replaced. We highlight issues that can arise when programme managers are responsible for providing data that might affect their job security. Weyer and colleagues imply that we suggest that the reported decrease in tuberculosis notifications from China is “unconnected to the expansion of tuberculosis control efforts”. We simply highlight that correlation does not necessarily mean causation. We acknowledge that attribution is challenging, but causal pathways are important to elicit.2 Instead of proposing simple solutions or methods, we are arguing for a more profound understanding of how disease-specific programmes sit within health systems and, more widely, acknowledging contextual complexity.3 Second, in attempting to address the ethically and politically challenging notion of how resources are best allocated, Weyer and colleagues question whether it is ethical to “watch patients with multidrug-resistant www.thelancet.com Vol 384 November 15, 2014
Tuberculosis control: hard questions
For WHO TB strategy see http:// www.who.int/tb/post2015_ TBstrategy.pdf?ua=1
1744
Although in their Comment in The Lancet Mishal Khan and Richard Coker (Aug 23, p 646)1 raise real and well known challenges in the global tuberculosis response, they fail to propose any solutions and downplay efforts and achievements by many stakeholders to address these complex issues. We have some questions: How much can the statement that countries are ”incentivised to obscure programmatic challenges” be generalised? Are the definite tuberculosis burden declines in countries such as China and Cambodia, reported from prevalence surveys,2,3 somehow unconnected to the expansion of tuberculosis control efforts over the past few years?4 What should replace performancebased funding to prevent the so-called perverse incentive by international donors? Financing needs to somehow be linked to performance measured through targets and indicators. How could accountability be otherwise demonstrated? Can there really be any trade-offs between the ”urgency to treat” versus ”long-term health systems strengthening goals” as is proposed? We need both, as outlined in the WHO post-2015 Global Strategy endorsed by the World Health Assembly. Would it be ethical to delay introduction of new tools until health systems are working to perfection? How would this affect urgently needed development of new diagnostics, drugs, and vaccines, or operational research to guide their introduction? Is there a counter-proposal to the essential, WHO-recommended health systems to deliver treatment to patients with multidrug-resistant tuberculosis?5 Can we ethically watch patients with multidrug-resistant tuberculosis die while waiting for improved health systems? Is duty of care different for tuberculosis than for cancer or HIV? Would anyone
privileged enough to live in an affluent country decline treatment if they contracted multidrug-resistant tuberculosis? Should we not learn from HIV control how creativity and mass action can overcome formidable programmatic barriers associated with complicated, costly interventions? The latest WHO Global Tuberculosis Report 4 (and special supplement) stresses that prevention and proper first-line treatment are the first step in the control of multidrug-resistant tuberculosis. Is the growing evidence showing that scale-up of multidrug-resistant tuberculosis services and improved treatment are achievable under programmatic condition—even in high-burden countries—not convincing enough to let us proceed with both prevention and treatment?4,6 We believe that the public health crisis of drug-resistant tuberculosis needs urgent, concerted actions, although we may not yet have all the answers. All authors are staff members of WHO. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of WHO. We declare no competing interests.
*Karin Weyer, Dennis Falzon, Fraser Wares, Ernesto Jaramillo, Mario Raviglione [email protected] WHO Global Tuberculosis Programme, 1211 Geneva 27, Switzerland © 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. 1
2
3
4
5
Khan MS, Coker RJ. How to hinder tuberculosis control: five easy steps. Lancet 2014; 384: 646–48. WHO. Global tuberculosis control: WHO report 2011 (WHO/HTM/TB/2011.16). Geneva, World Health Organization. 2011. Tan Eang M, Kosuke O, Norio Y, et al. Cross-sectional studies of tuberculosis prevalence in Cambodia between 2002 and 2011. Bull World Health Organ. 2014; 92: 573–81. WHO. Global tuberculosis report 2015 (WHO/ HTM/TB/2014.08). Geneva, World Health Organization. 2014. WHO. Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 2015. WHO progress report 2011. (WHO/HTM/TB/2011.3). Geneva, World Health Organization. 2011.
6
Falzon D, Jaramillo E, Wares F, Zignol M, Floyd K, Raviglione MC. Universal access to care for multidrug-resistant tuberculosis: an analysis of surveillance data. Lancet Infect Dis 2013; 1: 690–97.
Authors’ reply We thank Karin Weyer and colleagues for their interest in our Comment.1 We would like to address the following two conceptual disagreements. First, in reference to the role of academic discourse, we happily accept the criticism that our Comment does not propose simple solutions to all issues raised. The purpose of our Comment, in keeping with the role of academic discourse, was to stimulate debate about questions that do not yet have clear answers. Although we do not downplay the efforts of any stakeholder, we question the need to promote simple solutions that WHO seems to expect to work in all settings. For example, we do not suggest that performance-based funding be replaced. We highlight issues that can arise when programme managers are responsible for providing data that might affect their job security. Weyer and colleagues imply that we suggest that the reported decrease in tuberculosis notifications from China is “unconnected to the expansion of tuberculosis control efforts”. We simply highlight that correlation does not necessarily mean causation. We acknowledge that attribution is challenging, but causal pathways are important to elicit.2 Instead of proposing simple solutions or methods, we are arguing for a more profound understanding of how disease-specific programmes sit within health systems and, more widely, acknowledging contextual complexity.3 Second, in attempting to address the ethically and politically challenging notion of how resources are best allocated, Weyer and colleagues question whether it is ethical to “watch patients with multidrug-resistant www.thelancet.com Vol 384 November 15, 2014