TB on the Rise: Big Pharma Delighted

Although TB is often mentioned along with HIV, it doesn't get nearly as much attention, certainly not as much attention as it deserves. And it gets a fraction of the funding. It happens to be in the news now because World TB Day was just last week. Unlike HIV, TB is easier to catch but also easier to prevent. It's also curable. But like HIV, TB spreads rapidly in populations which face serious and long term economic challenges, have poor and inaccessible health systems, low educational standards and an inadequate infrastructure.

Like HIV, TB will not be eradicated until the determinants of health are tackled. Like HIV, you can spend as much as you like on the disease but as long as people live in terrible living conditions without even basic water supply and sanitation, suffer from poor health and nutrition and face many other stresses that allow any diseases going to spread rapidly, neither will be eradicated. The huge amounts of money spent on HIV over the last three decades has done little to reduce its spread and the far smaller amounts spent on TB have been equally unsuccessful.

Kenya ranks 13th in the 22 high burden TB countries and fifth in Africa, although it is notable that they are only rank 9th for HIV. There were 132,000 new cases last year. It is estimated that there were 2000 multiple drug resistant cases but only 4.1% of these were diagnosed. And only 48% of new TB patients were coinfected with HIV. New cases of TB are declining but the number requiring retreatment, those who either weren't treated successfully or who didn't finish their treatment, is increasing.

I think it is important to note that just over half of the new TB cases were not people who also have HIV. TB is an epidemic in its own right. While high HIV prevalence will increase the spread, TB is spreading independently of HIV too. And why wouldn't it? Most people in Kenya live in the sort of conditions where all diseases spread rapidly. Just as HIV has been treated as if it is exceptional and as if it is possible to eradicate a disease without also dealing with the determinants of health, TB is being treated as if people's living conditions don't matter. But they do matter, very much.

Jeffrey Sachs points out that if Africa had better health systems, HIV would have been identified a decade earlier. This is quite true, the symptoms that were later recognised as those of Aids were not recognised as being out of the ordinary. They were consistent with very poor health, poverty and malnutrition. It was only when people in more developed countries started to be infected that HIV and Aids were identified. By then, it was too late to avert a massive epidemic. Then, as now, the conditions in which people lived were appalling. 

Nigeria has an even more serious TB epidemic, third in the world, with 100,000 new cases last year, although they only rank 21st in the world for HIV (despite being estimated to have the second highest number of people living with HIV, after South Africa). Rwanda and Malawi have the highest rates of TB in the world but Rwanda, at number 14 and Malawi, at number 8, certainly don't have the highest rates of HIV. The point I'm trying to make is that in developing countries, conditions are poor and declining but also, are not being remedied by the pouring of funds into programmes that merely treat sick people (ok, a small amount goes into prevention, but not much).

Aside from neglecting the determinants of health in general, programmes for TB and HIV are mainly targeted at people who are already sick. Most of the money goes to treating people who are already infected. Preventing both HIV and TB has a lot in common, indeed, preventing all diseases has a lot in common. People need good living conditions, water and sanitation, education, health, employment, economic well being, good nutrition, food security and many other things. Instead, most of the aid money going into these diseases is spent on drugs and other technologies.

PRWeb has a cringe-making release about a report on TB theraputics (which costs $3450, in case you are interested. This release enthuses about the "excellent commercial opportunity for existing as well as new companies in this marketplace." The "marketplace" is certainly growing, because if the only solution to TB is to wait until people become infected and then treat them with drugs, resistance is only a matter of sitting back and waiting. People in developing countries with TB are given the drugs and sent home to continue spreading it in their inadequte housing and with their poor nutrition and lack of education and water and sanitation.

These pharmaceutical companies have been humming and hawing because public funding hasn't been forthcoming but now that it looks like that will be made available, they can start raking in the cash. Remember, that's public funding, because the profits certainly won't be public.

All the conditions for the rapid spread of TB are in place and many of them are the same conditions for the spread of HIV. Little has been done to alleviate these conditions and in countries like Kenya, they have been steadily disimproving for several decades. It may be popular to blame the HIV epidemic, for TB and just about everything else that's happened since the 1980s, but this excuse won't wash. Winding down public services and public spending started before HIV was even identified. TB was around before HIV was identified. The opportunity to eradicate TB is still there, but throwing a lot of drugs and money at it will continue to fail.

Developing countries need to be enabled to develop. Diseases are not just inconvenient pathogens that can be eradicated with some extremely expensive drugs. They require an appropriate environment and suitably weakened hosts. Current and past approaches to TB and HIV ignore the existence of appropriate environments and weakened hosts aplenty. That's why HIV and TB are spreading, despite the billions spent on them.

Deciding Who Gets to Eat and Who Gets to Starve

A curious feature of some of the big famines in history is that the countries experiencing the famine were not necessarily short of food. Likely as not, the majority of people were very poor and did not have the money to buy food, but food was being produced and exported.

Many millions of people in a number of developing countries currently face food shortages, malnutrition and probably famine at a time when the world is producing record crops. The Food and Agriculture Organisation (FAO) estimates that 2008 saw the highest recorded cereal crop production figure ever. It is predicted that 2009 will see the second highest figure.

Wikipedia is a great source of information but their bald statement that "[f]amine is caused by a human overpopulation relative to the available food supply" is in need of qualification. It is estimated that as many as 10 million Kenyans face serious food shortages, but this is not clearly because the country is overpopulated. There are several other significant pressures on food production and access to food.

For example, many people are extremely poor, have always been poor and have little prospect of ever becoming less poor. Food prices have been driven up over the past few years by market speculation and by the use of productive land for growing biofuels. So poorer people, who could barely afford enough food before these trends began, are now facing starvation.

Other pressures include droughts, often followed by serious floods, which result in poor harvests and destroy large tracts of arable land. There was also widespread unrest in Kenya in 2008 and people abandoned their land. A number of these internally displaced persons (IDP; the Kenyan government is not keen on releasing figures for just how many are still displaced) now have little means to feed themselves and no chance of returning to where they came from. And the majority of people have only a tenuous hold on land, renting it from unscrupulous landlords, who can treat tenants as they wish and sell their land at the drop of a hat.

In addition to growing biofuels in Kenya, there are other trends that result in less land being used for affordable food. Land is bought up by natural resource prospectors, such as those in search of oil around Isiolo and those in search of gold in the Mara. This land will not be used to benefit any Kenyans and certainly won't be used to grow food. And much of Kenya's land is used for non food crops or for food products intended for export, such as coffee, tea, flowers, fruit and vegetables. Controversially, a lot of land comprises national parklands, preserved for use by those who can afford to visit it. Most can't.

Despite all these pressures, there is a lot of food being produced in Kenya for export and a lot of arable land available for food production. The reasons people face food shortages and poor nutrition are the same as they have always been: widespread poverty and increasing levels of impoverishment along with rising food prices that mean the poorest will lose out.

When things get really bad and people are dying of starvation, maybe other countries will start shipping in relief food, but this will not improve food security in Kenya. Food security refers to access to food, as well as its production. As with other countries that experienced famines throughout history, resilience will continue to be low, there will be widespread disease, many people will have abandoned rural areas and moved to cities; there will be no remaining seed to grow the next season's crops, no fertilizer, no chance of resisting whatever new pressures arise.

The more I read about famine, the more it seems like a process whereby the rich systematically deny food to the poor in order to increase their profits. But that couldn't be correct, could it?