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Article submitted 14 March 2021. Final version accepted 16 March 2021.
Earlier last month, while working as an infectious disease doctor in a busy hospital in San Francisco, I watched an old man die. He was breathless and terribly thin. His words muffled by a medical mask, the only thing he repeatedly said was, he wanted to go home. The hospital was busy because of a surge in COVID-19 cases, but he was not dying from COVID-19 but from TB. Despite being curable and preventable, data from around the world, including here in the United States, suggest that TB cases may be on the rise. Nearly a third of people with TB are missed each year by health systems around the globe. Before the start of the COVID pandemic, TB was responsible for more deaths than any other infection. In addition to the 29% of all people with TB, 56% of children with TB and a shocking 62% of people with multidrug-resistant TB were missed or not treated.
A few years ago, there was hope that the tide against TB was turning. After years of global neglect, the UN High-Level Meeting (UNHLM) in September 2018 had made ending TB a priority, and global leaders committed to unprecedented steps, including ambitious country-specific case-finding and prevention targets, and a revitalized research agenda. In Congress, 106 members of the House and 43 members of the Senate signed bipartisan letters that provided strong backing to US engagement at the UNHLM and accelerated progress against TB.
Unfortunately, we did not capitalize on that momentum. A lack of political will from the previous US administration, inadequate US funding and poor coordination between United States Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC) and US President's Emergency Plan For AIDS Relief (PEPFAR) all stymied US efforts. And then COVID-19 happened, decimating TB control efforts in many parts of the world. In a USAID survey of priority countries in 2020, 57% reported a reduction in the number of beds available for in-patient treatment of drug-resistant TB, and 83% of countries reported that TB healthcare workers, at all levels, had been re-assigned to the COVID-19 response. Perhaps most worrisome, TB notifications (detection and treatment initiation) have fallen significantly in 12 countries, meaning that many people with TB are going untreated and are potentially transmitting the infection. Even in San Francisco, we have seen a drop in new cases of TB since the start of the COVID-19 pandemic. We worry this means TB may be spreading untracked through our communities.
As the newly-elected Biden-Harris administration advance their global health agenda, there is a unique opportunity to press ‘reset’ on the US response to TB. Failure to do so could have catastrophic clinical and economic implications. We estimate that reducing deaths from TB by 90% by 2030 will save the global economy $13 trillion – and save 23 million lives between now and 2050. By contrast, maintaining our current efforts could lead to 31 million deaths over the next three decades, at a cost of $17.5 trillion.
Both home and abroad, the Biden-Harris administration must respond quickly to invest in TB control efforts. Increased global investment in TB by the United States would pay huge dividends in global public health. It would also pay dividends at home. According to a CDC study published in 2020, effective global TB control would avert 40,000 new TB deaths in the US between now and 2035. In comparison with the sums invested in the response to COVID-19, a relatively modest investment – $1billion over and above existing funding – could have a transformative impact on TB efforts. This could also contribute towards broader pandemic preparedness and health system strengthening.
More than just funding, leadership from the Biden-Harris administration is needed to ensure that global TB efforts are coordinated across US agencies. Moreover, these efforts should be aligned with global work on COVID-19 to ensure that US efforts are coordinated with all other global partners. Investing in TB and COVID-19 does not need to be an either/or scenario. With sound science, effective collaboration, smart investments and efficient synergies, COVID-19 efforts can enhance the global TB response, not undermine it. However, the US should not revert to pre-COVID-19 ways of investing in TB globally, instead TB policy needs to be coordinated at the highest level. US leadership in global health, desperately lacking for the past four years is urgently needed to bring improved coordination, ensuring a more strategic approach to TB programs and optimal alignment of investments in global TB across all US government agencies.