One of my TB heroes—a man who has dedicated his life to stopping the disease—tells a story about how he first got involved with a killer everyone else seemed to have forgotten.

In 1990, he was a doctor at Muhimbili Hospital in Dar es Salaam, Tanzania. It was the first time he saw how TB and HIV conspired to kill more patients than over-stretched and under-funded health systems had any hope of treating. The hospital had only 3,000 beds for nearly 6,000 patients, so patients with HIV and patients with TB ended up doubled up in the same beds. Looking back, it is easy to see a recipe for disaster: patients with infectious TB in close quarters with highly immune-compromised neighbors. But the TB diagnostic was lousy, and by the time he and other doctors knew a patient had TB, that patient had almost certainly infected dozens of others.

With stories like these, why doesn’t TB have us all marching through the streets? Nearly two million people each year are dying of a disease that developed countries such as the U.S. “defeated” half a century ago. Twenty years after Muhimbili, the most commonly used diagnostic is still lousy and misses up to one-half of all TB cases. The drugs are old, have unpleasant side effects and take a minimum of six months to treat a patient. If patients don’t complete treatment—whatever the reason—they may develop and spread a more deadly form of drug resistant TB. There are doctors and nurses in the field doing their heroic best to stop the TB epidemic. But without more resources and new and better tools TB will continue to spread.

TB needs strong champions to push back against the neglect that led to a resurgent epidemic. If the history of the HIV/AIDS epidemic has taught us anything, it’s that effective advocacy and communications can shape the international response to a disease. At the grassroots level, TB patients, doctors and community activists need to demand better access to, and tools for, treatment and prevention. At the national and international level, advocates have to make the case for increased funding for healthcare and investments in research that will lead to improved tools and methods.

Fortunately, much progress is being made. Passionate, engaging and effective TB patient advocates and grassroots organizations have emerged, either independently or with support from international TB or HIV organizations. Many of these activists are joining forces with colleagues focused on other disease. At the November 2009 Multilateral Initiative Against Malaria Conference in Nairobi, Kenya, I witnessed a sizable and impressive demonstration convened with the help of several TB groups that called on President Obama and other leaders to meet their commitments to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

At the international level, funding for TB prevention and control has increased significantly, particularly through the Global Fund, UNITAID, and the US government. This is largely due to the efforts of TB advocacy organizations and increased attention to the dangers of TB/HIV and drug resistance. At the same time, many high TB burden countries, particularly those with emerging economies like South Africa, China and India, are now taking increased steps to stop TB—and there is hope that these gains could translate into assistance for countries like Tanzania.

There is still an enormous amount of work to do, and resources available for TB are still a fraction of what is needed. But sustained voices will lead to sustained commitment. By telling stories like that of Muhimbili and using those experiences to push for change, we can draw renewed attention to an ancient killer.

Brad Tytel is a Director at Global Health Strategies, an international consulting company that uses advocacy and communications to help ensure development and worldwide delivery of health technologies and information – including for TB.

Photo captions: Activists in Nairobi, Kenya, call on donor governments to stop TB, AIDS and Malaria – November 2009. Credit: Global Helath Strategies

An X-ray of a patient diagnosed with advanced bilateral pulmonary tuberculosis. Credit: US Centers for Disease Control (CDC)

The Who Cares? Campaign blog is exploring tuberculosis (TB) for the month of March.

Tuberculosis (TB) is an airborne, bacterial disease that has been around for centuries. In fact, scientists now estimate the disease may have existed 3 million years ago! We now have the tools to diagnose and treat this deadly disease, but almost 2 million people continue to die each year. This is unacceptable.

Those who are infected with and die of TB predominantly live in the poorest communities of the world. A disease of poverty, TB generally affects the most marginalized communities who are also affected by malnutrition, HIV/AIDS, and malaria. They lack adequate access to clean water and basic healthcare.

Sub-Saharan Africa, therefore, faces a particularly high burden of TB with the largest number of TB-related deaths. Tanzania is hard hit, with TB responsible for taking more than 32,000 lives per year. In fact, TB has made a deadly resurgence in Tanzania and elsewhere in sub-Saharan Africa over the past two decades in large part to the spread of HIV/AIDS. The HIV/AIDS pandemic presents a multitude of challenges in tackling TB:

• People who are HIV-positive are more susceptible to TB infection due to their weakened immune systems. This fuels the spread of TB.
• TB is more difficult to diagnose among people who are co-infected with HIV. People who are co-infected often suffer longer before accessing treatment and may also spread TB to their loved ones unknowingly.
• TB is harder to treat among people with HIV. The antibiotic drug regimen to combat TB must be carefully coordinated with other medications, such as antiretrovirals.

Dr. Fred Lwilla, senior program officer for Tanzania’s National TB and Leprosy Program, noted that the number of reported tuberculosis cases is increasing in Tanzania in part because of high HIV prevalence, weak health infrastructure and poverty, according to a recent Tanzanian publication. He cited lack of public awareness and insufficient integration between TB and HIV/AIDS programs as additional obstacles.

The extreme shortage of doctors, nurses, laboratory technicians and other critical healthcare workers in Tanzania makes diagnosis and treatment of TB even more challenging. Treatment, for example, requires a minimum six-month course of antibiotics. Community health workers have proven instrumental in providing daily observed treatment (DOT), but patients often require periodic follow-up with a doctor, especially if they face complications due to HIV/AIDS.

Emily Bell is Head of Advocacy and Communications at the Touch Foundation. She was formerly a Program Officer at the Open Society Institute, where she oversaw a TB monitoring project that focused on several countries, including Tanzania.

The Who Cares? Campaign Blog is exploring HIV/AIDS for the month of December.

The first day of December marks World AIDS Day – a time to remember the 25 million people who have died of AIDS and the estimated 33 million who are living with the HIV virus that causes this disease. It is also a time to redouble our collective efforts to fight this global pandemic.

Sixty-seven percent of all people living with HIV are in sub-Saharan Africa. In Tanzania, approximately 6.2 percent of the population, or 1.4 million people, are living with HIV. Considerable progress is being made in Tanzania (e.g., reported drops in HIV incidence among Tanzanian women). But, far too many women, men, and children in Tanzania continue to become infected, remain undiagnosed, or continue to lack access to treatment. HIV/AIDS has also caused a deadly resurgence in tuberculosis and it is critical that the two diseases be tackled in tandem.

The Tanzanian government recognizes that a holistic approach to fighting HIV/AIDS is required to make real progress. This includes behavior and communication strategies to prevent infection and spread of HIV, more community health workers, improved education in schools, reliable drug and food supplies, addressing socio-cultural factors such as women’s rights, and a comprehensive medical approach that addresses  malnutrition, malaria, TB and other complicating factors among HIV-positive individuals.

A radical increase in the number of trained medical professionals – including medical doctors, nurses, assistant medical officers (AMOs), laboratory technicians, among others – is also crucial to the fight against HIV/AIDS.

The US President’s Emergency Program to Fight AIDS (PEPAR) is demonstrating awareness about the urgent need to build the health worker pipeline and has set a target to train 140,000 new health workers over the next five years in the countries hardest hit by the epidemic. Congress included this milestone when lawmakers reauthorized the program last year. At a recent meeting of the Consortium of Universities for Global Health, the US Global AIDS Coordinator, Dr. Eric Goosby, spoke about the need to partner with medical schools to increase their numbers, training capacity and the clinical capability of medical students from Africa and other developing countries (see Science Speaks blog).

The Touch Foundation is supporting Weill Bugando’s university to train more health workers, many of whom are already engaged in responding to the disease on a daily basis at Bugando’s teaching hospital (the second largest in the country). Nearly one quarter of Bugando’s patients test positive for HIV. The Touch Foundation and Abbott Fund’s support to refurbish the laboratory there will enable more timely and effective diagnosis – and therefore treatment – of HIV.

Emily Bell is Head of Advocacy and Communications at the Touch Foundation.