Tuberculosis control is crucial to achieve the MDGs

When world leaders signed the UN Millennium Declaration in 2000, they were united around one common agenda—to eradicate poverty. The leaders agreed to meet eight Millennium Development Goals (MDGs) by 2015; goals that are not only about extreme poverty, but also about education, maternal health, child mortality, public health, environmental sustainability, and biodiversity. The MDGs emphasise the need for an integrated partnership approach, and MDG 6 aims to combat major pandemics and to set the target for reversing the global incidence of tuberculosis by 2015.¹

There have been improvements in tuberculosis control over the past 15 years. Between 1995 and 2008, 43 million tuberculosis patients were treated and 36 million cured through national Directly Observed Treatment Short-course programmes, therefore saving an extra 7 million lives.² The incidence of global tuberculosis peaked in 2004; however, subsequent decline has been very slow and the absolute numbers have not decreased. Tuberculosis, or the white plague, remains a worldwide scourge, which devastates lives especially in sub-Saharan Africa. Globally, there were 9·4 million new cases of tuberculosis in 2008, 1·7 million deaths (more than half among women), and half a million deaths among people with HIV. The elimination of global tuberculosis by 2050, as envisaged by the Stop TB Partnership,³ is far off target.

Because tuberculosis control is integral to achieving the MDGs, increased and sustained efforts are required. Every year, up to a quarter of the 2 million HIV-related deaths are due to tuberculosis,⁴ therefore improved efforts in joint tuberculosis and HIV control are crucial. Importantly, tuberculosis control also contributes to declines in mortality among children (aged under 5 years) and among women of childbearing age⁵ (for women, approximately 2 million lives were saved between 1995 and 2008), thereby helping progress towards MDG 4—to reduce mortality by two-thirds in children aged under 5 years from its 1990 level—and MDG 5—to reduce maternal mortality by three-quarters by improving maternal health. Gains in tuberculosis control have been achieved through a partnership approach as envisaged in MDG 8, with the Stop TB Partnership having an important part. Despite successes in tuberculosis control, in the availability of inexpensive curative treatment, and in the visible contributions to MDGs 4, 5, 6, and 8, major challenges remain.

Tuberculosis is still rooted in poverty and inequity (including gender inequalities). In low-income and middle-income countries, tuberculosis predominates in the poor who remain economically and socially excluded, and in women who bear the brunt of the HIV burden in sub-Saharan Africa. Beyond ill health, tuberculosis fuels poverty. Catastrophic expenditures for tuberculosis sink those affected by the disease and their families further into poverty. Therefore, efforts to prevent the spread of tuberculosis extend far beyond health benefits for the individual patient and beyond the health MDGs. Success in tuberculosis control will help to achieve the MDGs, and in turn, achievements in MDGs will help to avoid unnecessary disease-related deaths. Herein lies the challenge: although focused tuberculosis control efforts are essential to contain the spread of disease and save millions of lives, this control is unlikely to be achieved with a predominantly biomedical approach and a singular focus on MDG 6. A new paradigm is needed.

Beyond the core efforts of national programmes described in WHO's Stop TB Strategy, bold health policies are necessary to increase access to care and prevention, starting with universal health coverage.⁶ Better governance, transparency, accountability, fighting corruption, and increased political commitment will ensure efficient use of funds for MDGs and will reduce the waste of scarce resources. Equally crucial is a sharp focus on intensively addressing the social and economic determinants of tuberculosis that are common to many other ill-health conditions—tackling poverty, poor housing, malnutrition and undernutrition, poor education, gender inequalities, and curtailing the escalating numbers of HIV-associated tuberculosis, smoking, diabetes, and alcohol abuse⁷—through partnerships, which include all central individuals from public and private sectors and civil society working through health and community systems.⁸ Such a holistic approach requires a combination of interventions, which simultaneously address all health MDGs, especially MDG 1—to eradicate extreme poverty and hunger.

Partnership approaches and socio-developmental emphases involving ministries of health, finance, social affairs, labour, and education are paramount for sustained success. While governments should recognise the challenge, act responsibly, and allocate domestic resources, international financial institutions, such as the Global Fund, should sustain additional financial resources when necessary. UN and international agencies, starting with WHO but including UNAIDS, UNICEF, the World Bank, and others, must recognise that tuberculosis control is a key global-health priority deserving much more attention than it has received so far. Without visible commitment, the ultimate goal of eliminating tuberculosis and achieving the inextricably linked Millennium Developmental Goals will continue to elude us.