Overcoming our socialisation for scarcity in TB - Dr Madhukar Pai

Dr Madhukar Pai, Professor & Canada Research Chair McGill University, Montreal, gave this thought-provoking speech during the opening ceremony of The Union World Conference on Lung Health 2022.

All of us are aware that the Covid pandemic has had a devastating impact on tuberculosis (TB) care, and we are unlikely to meet the TB targets. Given how slow our progress was even before the pandemic, and how much we have fallen behind, honestly, I’ve been struggling to find hope and optimism.

I believe Dr Paul Farmer, who sadly died earlier this year, has some key lessons for all of us working in TB. His work and legacy could give us some hope and guidance.

Paul taught us that global health, as a field, is ‘socialised for scarcity on behalf of others’

• We accept a low bar for the poor vs ourselves and are comfortable with dual standards
• Due to chronic under-investment, we are forced to pit one condition vs another
• We push ‘control over care’ approach; TB, even today, struggles to centre on people with TB; instead we centre on TB controllers and technical experts

I am sure Paul would agree that TB is a textbook case of what he called ‘socialisation for scarcity’. All of us suffer from this. Even today, we are socialised for scarcity when we assume TB budgets are fixed, and therefore we cannot implement all effective interventions; we are socialised for scarcity when we continue to use century-old tools like smears and BCG; when we assume that molecular TB tests or shorter drug regimens are too expensive to use for all; when we say that drug-resistant TB (DR-TB) is not ‘cost effective’ to treat.

Everyone in TB must intentionally work hard to overcome this type of conditioning that has gone on for decades. Socialisation for scarcity is like a splinter in our minds that we cannot get rid off.

But, Paul Farmer showed us that with struggle and effort, it is possible to ‘bend the arc’. His team managed to improve access to antiretroviral therapy (ARVs), and to DR-TB treatments, even in clinical deserts. He found a way to get the staff, space, stuff, systems and support even in the most resource-limited settings.  He showed us that it is always possible to put the patient’s care and needs above public health goals. He demonstrated to us that we can work in solidarity with people and communities who are most impacted by TB and diseases of poverty.

Most importantly, Paul’s life is a clear illustration that we can overcome what he called the ‘failures of imagination’. I hope we can all be bold enough to imagine a world where people with TB receive humane and quality care wherever they are, have access to all the best tools we have today, and a world where TB gets the budget we really need to implement all key interventions across the continuum of care. I hope we can imagine a world where we have new, effective vaccines, better tests and much shorter treatments for TB. Covid has shown us that nothing is impossible, if we set our minds on it, and make the necessary investments.

To realise this dream, all of us working in TB, like Paul Farmer must also become advocates for social justice, and we must take the lead from the most impacted people and communities. With struggle, I am sure we can bend the arc to end the TB epidemic. Thank you for this opportunity.