Considering the WHO Global Tuberculosis Report 2021 in light of COVID-19
The new pandemic sheds light on an old foe. Page summarises the World Health Organisation's 2021 Global Tuberculosis Report and discusses disparities in vaccine advancement and equity.
In October of this year, the World Health Organisation (WHO) reported that deaths from tuberculosis (TB) have risen for the first time in a decade, a major blow to their End TB Strategy. Simultaneously, global spending on TB declined by 8.7%, falling far below targets. The report attributed the rise in deaths to the impact of COVID-19 on global healthcare capacity and access. This comes as no surprise—you would be hard-pressed to find a single area of healthcare that has not been negatively affected by the pandemic. However, I find that there is something particularly hard to swallow about the increase in TB deaths attributable to COVID-19.
In comparing the response to these two diseases, I do not intend to downplay the devastation that COVID-19 has wreaked upon our world. As of 1 November 2021, the WHO reports that approximately 5 million people have died of the virus since the start of the pandemic, and the effects of COVID-19 go far beyond the death toll, from economic devastation, to mass burnout of healthcare workers, to major disruption to education. The constant headlines, though tiresome, are certainly well-deserved. My question concerns why TB does not receive comparable media coverage—or more importantly, funding.
TB, one of the oldest infectious diseases to affect humanity, has been termed the “forgotten pandemic”. Prior to the COVID-19 pandemic, it was consistently the top single-agent cause of infectious disease death in the world, and it continues to kill approximately 1.5 million people per year. Along with this death toll come the other, less quantifiable effects many of us are much more familiar with now—missed school, financial ruin, and bereaved families. It is difficult to conceptualise the impact of this toll over the span of decades. And yet, because the brunt of the disease burden is borne by countries with lower incomes, TB rarely makes global headlines. TB is a disease of poverty, endemic in areas where many people do not have access to well-ventilated housing or where malnutrition is common. In endemic regions, TB perpetuates inequalities both within and between countries by acting as a constant financial drain on individuals and healthcare systems, stagnating economic development. Cases in most high-income countries are rare and tend to affect marginalised people such as those who are homeless. The dominant attitude towards TB is complacency. The world has decided that this death toll is not newsworthy.
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“In endemic regions, TB perpetuates inequalities both within and between countries by acting as a constant financial drain on individuals and healthcare systems, stagnating economic development.”
Consider the global vaccine response to COVID-19. Mobilisation to develop a vaccine for COVID-19 was swift, a remarkable and unprecedented success. Thanks to financial investment, researchers were able to develop multiple highly effective vaccines in mere months. The most recent data suggests that the Pfizer and Moderna vaccines are 88% and 93% effective at preventing hospitalisation respectively, both very impressive figures. For TB, by contrast, we have one vaccine, the 100-year-old Bacillus Calmette–Guérin (BCG) vaccine. This vaccine works well for preventing disseminated TB in children, but for pulmonary TB, the main contributor to TB deaths, it varies in efficacy from 0 to 80%. For unknown reasons, vaccine efficacy depends on latitude, decreasing closer to the equator—a cruel and peculiar parallel to the geographic gradient of global disease burden.
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We need a better vaccine for TB. In the long-term, this will save the most lives, and even moderate improvements in vaccine efficacy would be cost-effective. Through the hard work of those committed to the cause, there are currently 14 vaccine candidates in the pipeline. However, the funding needed to accelerate vaccine development and improve our understanding of TB is simply not there, despite the fact that investing in TB has high financial as well as population health returns. The unfortunate reality is that research for deadly diseases often does not receive sufficient support until those with the most financial and social capital are affected, as we have seen in the past with the HIV pandemic.
“The unfortunate reality is that research for deadly diseases often does not receive sufficient support until those with the most financial and social capital are affected.”
Most of us in non-endemic regions are lucky enough to not have to think about TB in our daily lives. However, COVID-19 has illustrated that in an increasingly globalised world, infectious disease is everyone’s problem. Although we are far from ending the COVID-19 pandemic, the rapid development of vaccines has shown us what we can accomplish when urgency demands investment. How much longer will the world wait for an effective TB vaccine? We are capable of better. Those affected by TB deserve better.
The WHO Global Tuberculosis Report 2021 can be found here: https://www.who.int/publications/i/item/9789240037021
The new red scare: how rhetoric shapes the US healthcare system
Page argues that the rhetoric surrounding universal health care often plays into fears and misconceptions about a lingering socialist threat in the US, preventing the implementation of a more equitable and effective healthcare system.
“The current system is both economically inefficient and inequitable, and there is no reason that universal healthcare could not be implemented for a reasonable price tag.”
It is old news at this point that the United States (US) is one of the richest countries on the planet, but consistently ranks low across multiple metrics of healthcare quality in comparison to other countries with a similar gross domestic product (GDP). While there are many factors that contribute to the difficulties of delivering healthcare consistently across the US (not least its sheer size), the fact remains that among its higher performing peer countries, the US is the only country that does not have some system of universal healthcare.
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Support for universal healthcare among the American public has risen in recent years. Despite this, the idea of actually implementing it remains highly controversial, ostensibly due to the concern that it would be exorbitantly expensive. However, in reality, the US spends vastly more on healthcare per person than its peer countries with universal healthcare systems. In 2019, the US spent an eye-watering 17.7% of its GDP on healthcare, with nearly half of that coming from federal, state, and local governments. By contrast, Japan spent 10.9% of its total GDP on healthcare in the same year, and Germany 11.2% in 2017. In 2019, 10.2% of the United Kingdom’s (UK) total GDP went to healthcare, 79% of which was government funding. In other words, the US government is spending nearly the same percentage of its funds on healthcare as the UK government, but US citizens are more than doubling the country’s expenditure through insurance payments and out of pocket costs. The current system is both economically inefficient and inequitable, and there is no reason that universal healthcare could not be implemented for a reasonable price tag.
Here, I am not interested in discussing in detail the breakdown of US healthcare spending. Rather, I ask you to consider why the fallacy that universal healthcare would be unfeasibly expensive has persisted, when universal coverage has been achieved many times in other countries at much lower per capita costs than those in the US currently incur.
Healthcare is a highly political issue in the US, and much of the rhetoric surrounding universal healthcare seems to be left over from the Cold War. During the lead-up to the 2020 presidential election, universal healthcare (under the title “Medicare for All”) was, for the first time, floated as a legitimate policy position by multiple candidates. During this time, Fox News talk show host Tucker Carlson said, “Medicare for All is actual socialism, ‘for real’ socialism … Why do you think we don’t have it already? Because we can’t afford it.” He then proceeded to paint a vivid image for his three million some viewers of then presidential candidate, Senator Elizabeth Warren, having “complete and unquestioned control of America” under Medicare for All. “She is the most powerful person in the world—you can almost hear her repeating the phrase to herself,” he lamented.
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It may be unclear to the viewer what Mr Carlson’s definition of “socialism” is, but whatever it is, it’s bad. One imagines Senator Warren lording over the American populace with an iron fist as they are forced to give up their dental coverage to pad her coffers in the era of “socialised medicine”. This Red Scare-esque use of language is nothing new—The Affordable Care Act (ACA), colloquially known as Obamacare, was subject to similar rhetorical treatment by conservative political commentator Bill O’Reilly in 2014, and by Fox News: “Obamacare is much more than providing medical assets to the poor—it's about capitalism versus socialism.” Further examples abound; the ACA has been variously referred to as “the crown jewel of socialism” and a “centralised health dictatorship”. Former presidential candidate and MD Ben Carson once proclaimed, also on Fox News, that Vladimir Lenin had called socialised medicine “the keystone of the arch of the Socialist State”. This quote has not actually been linked to Lenin, and was likely fabricated during the 1940s when the American Medical Association launched a propaganda campaign against one of the first universal healthcare bills. This rhetoric, especially in spoken language, is successful because it plays off American distrust of big government, values of self-sufficiency, and belief in free-market capitalism; it is designed to induce a response of fear.
But let’s look at the facts—compared to peer countries, the US has low life expectancy; high infant and maternal mortality; high rates of teen pregnancy and sexually transmitted infections; high disability prevalence; and high rates of diabetes, heart disease, chronic lung disease, and obesity. A recent analysis also found that in addition to health outcomes, the US ranked last among 11 other high-income countries in terms of access to care, administrative efficiency, and equity.
“The first step to developing a system that works for everyone is to end fearmongering and combat misinformation.”
The issue, clearly, is multifaceted, and there are no easy answers. Some of the issues with the system overlap with larger inequalities within the country; for instance, the US has much wider disparities in access to care by income than its peer countries, and black mothers have higher rates of maternal mortality regardless of socioeconomic status or education. However, costs are high across the board compared to peer countries. In a recent analysis, 22% of US patients recorded serious problems paying medical bills, over twice as high as the next highest country, France. 34% of US patients reported their insurance denying or underpaying for care, again double the next highest country’s rate. It is worth noting here that increasing insurance coverage only does so much when insurance fails to cover costs. In 2017, over half of those experiencing catastrophic healthcare costs in the US were insured. Even for those who can afford coverage, medical bills can be devastating when a sudden illness or injury occurs.
The misconceptions surrounding universal healthcare in the US must be addressed. Many Americans worry that universal healthcare would increase their wait times or restrict their choice of provider. In reality, other countries with universal coverage have achieved comparable or even lower wait times, and even in the UK’s single payer system you are perfectly at liberty to choose which practice you attend. In fact, in some countries with universal coverage, such as Germany, many citizens opt for private insurance. Others are concerned that adopting a universal system would increase administrative costs; however, the US already devotes a larger proportion of its health spending to admin than its peer countries with universal healthcare.
I am certainly not equipped to offer an easy solution here. The American healthcare system is a vast and complex entity, and what works well in any other given country may not be the best solution in the US. However, I can say that no one should be left with the double burden of a dead loved one and a six figure hospital bill, or die from rationing insulin after aging out of their parents’ insurance plan. The first step to developing a system that works for everyone is to end fearmongering and combat misinformation. No, universal healthcare will not send us hurtling back through time and space to the USSR. But it just might save a few bucks—and a few lives.