Tuberculosis at the United Nations: a missed chance

Lancet Infectious Diseases
Nov 2018 Volume 18 Number 11 p1161-1288  e339-e367

Tuberculosis at the United Nations: a missed chance
The Lancet Infectious Diseases
On Sept 26, the UN General Assembly hosted the first high-level meeting on tuberculosis under the key theme “United to end tuberculosis: an urgent global response to a global epidemic” in New York (NY, USA). The purpose of the meeting was to provide a platform for high-level leaders to reaffirm their commitment to accelerate efforts towards the Sustainable Development Goal of ending the tuberculosis epidemic by 2030, but the outcome was unsatisfactory.

The meeting was preceded by the publication of the WHO 2018 Global Tuberculosis Report on Sept 18. The report showed that despite progress in reducing mortality and incidence, tuberculosis remains a leading cause of death worldwide. In 2017, 1·7 million people died of tuberculosis (300,000 of whom were coinfected with HIV) and there were around 10·4 million new cases. These data show that we are not on track to meet the End TB strategy targets set by WHO in 2014: a 95% reduction in tuberculosis deaths and 90% decrease in new cases between 2015 and 2035.

The WHO 2018 Global Tuberculosis Report indicated that current funding for tackling tuberculosis is insufficient: of the estimated US$10·4 billion needed by countries to fund tuberculosis interventions in 2018, only $6.9 billion were available. Thus, it was expected that the UN high-level meeting would address the gap in the funding by stimulating a stronger commitment from funders and governments to invest more resources to control tuberculosis.

The main objective of the UN high-level meeting was the endorsement of a declaration that should have been agreed in terms of wording by all partys in advance. However, a dispute between the USA and other member countries over language related to intellectual property, an area in which agreement had existed internationally for many years, and with implications for the affordability of drugs, complicated the drawing up of the declaration. South African Health Minister Aaron Motsoaledi bravely took the lead in standing up against the world’s largest donor and drove negotations towards a compromise that maintained the status quo on intellectual property rights, but hard feelings that the USA had tried to side with the pharmaceutical industry instead of giving the priority to saving lives persisted during the meeting.

Looking closely at the final endorsed version of the political declaration on tuberculosis, however, shows that only two quantifiable short-term objectives are mentioned: commitment to provide diagnosis and treatment with the aim of successfully treating 40 million people with tuberculosis from 2018 to 2022, including 3·5 million children; and provision of preventive treatment for 30 million people by 2022. How these targets will be met, where the money and infrastructural strengthening will come from, and what individual countries will need to do to achieve those goals was not clearly defined.

People working in tuberculosis control expressed disappointment at the outcome of a unique opportunity to put tuberculosis at centre stage. One of the main issues raised was low attendance and absence of political leaders from Europe and North America. Since most funding for tuberculosis comes from these regions, the disinterest of leaders of high-income countries in the meeting gave the impression that tuberculosis was seen as a problem of others.

Another crucial point was the absence of clear targets to define improvements in tuberculosis control at the country and regional levels. The declaration fails to give any indication of what measures will be considered and what milestones a country should meet to ensure its contribution to the achievement of the Sustainable Development Goal of ending the tuberculosis epidemic by 2030.

The vague political wording of the declaration also underlies another important problem: who will be accountable for the progress or worsening in the control of tuberculosis? Despite a pledge to raise the funding for tuberculosis, from where will the money come and who will manage it? And for a disease such as tuberculosis, which is strongly associated with poverty and inequalities, should there have been more focus on the role of universal health care?

The UN high-level meeting was seen as a unique chance to gain a strong political support to strengthen measures to control tuberculosis in the coming years and define targets and responsibilities. The reality is that—despite some nice words on paper—a valuable opportunity to galvanise tuberculosis control has been missed.