PAKISTAN is a cauldron of infectious diseases, including a wide range of hepatitis, HIV/AIDS, malaria, dengue, chikungunya, diarrhoea and dysentery, as well as older diseases like rabies and various zoonotic illnesses, all of which could be prevented with effective local governance. No disease inflicts more suffering and death than tuberculosis (TB). We rank fifth globally, trailing only India, China, Indonesia and the Philippines, primarily due to poverty, overcrowding and malnutrition.
At the daily TB clinic in Indus Hospital, Karachi, the number of patients diagnosed with TB has tripled over the past 12 years. Patients of all ages arrive with severe complications of TB, including meningitis, perforated intestines, adrenal crisis and shock. One in four patients in a routine medical outpatient clinic has TB affecting the lungs and glands of the neck, breast, skin, bones, joints, kidneys, ovaries and uterus.
At the purpose-built TB clinic, over 100 new patients and those seeking follow-up care visit daily. Apparently healthy individuals in the outpatient waiting area were randomly screened for symptoms such as fever, persistent cough or weight loss. Ten per cent of those with minimal symptoms were diagnosed with TB, including one with drug-resistant TB. Among those randomly tested, three girls from a government school were found to have TB, and we are now conducting contact screening for all students and teachers. Many of our patients with TB who work in factories, restaurants, banks or schools, or are children studying in schools or madressahs, breathe the same air for hours in unventilated spaces. One infected person coughing up TB bacteria will transmit it to many. More alarmingly, several healthcare workers have contracted TB. Individuals with few or mixed symptoms who remain undiagnosed and hence untreated spread the disease in communities.
On World TB Day in March 2024, the health ministry announced grim statistics: newly notified cases increased from 11,050 in 2002 to 608,000 in 2024, with 1,500 being resistant to conventional drugs. This escalation corroborates our experience.
Are we prepared for the challenge?
As Pakistan’s population explodes, living space diminishes, forcing large families to crowd into poorly ventilated spaces. Nutritious meals are out of reach for most. TB does not spare children — the frail bodies of infants and adolescents are wracked by it. Rising diabetes, malnutrition and HIV/AIDS weaken immunity, rendering them more vulnerable to TB; abject poverty and paucity of funds present enormous challenges to TB control.
The National TB Programme, supported by the Global Fund, provides free treatment services through 1,500 facilities across Pakistan via provincial TB programmes, guaranteeing access to trained personnel, diagnostics and treatment. GF is primarily funded by USAID, while contributions from other countries and private donors are relatively small. Eighty-two per cent of the NTP’s budget is funded by GF, with the remainder expected to come from Pakistan. GF procures anti-TB drugs and diagnostics from countries that comply with good manufacturing practices and meet global standards. India is the world’s third largest pharmaceutical producer, primarily supplying drugs for sensitive TB. Drugs for resistant TB are prohibitively expensive, as diagnostic machines and cartridges are made in Japan or Europe. Despite considerable global investment, the results from Pakistan fall short of expectations. We are far from achieving global milestones in mitigating deaths and incidence.
Dr G.N. Kazi, aglobal health and public policy specialist and the editor-in-chief of Public Health Action, voices concerns about America’s ab-rupt decision to halt foreign aid, which has delivered a seismic shock to programmes combating TB, AIDS and malaria. Dr Shifa Habib, a public health scholar at Johns Hopkins University, also expresses worry ab-out the impending depletion of resources for GFATM (Global Fund for AIDS, TB and Malaria).
Given the dire situation of TB in Pakistan, we must prepare for the inevitable: the support for diagnostics, drugs and manpower will soon face severe disruption. Our reliance on donor funds must be lessened and domestic financing increased. At least three pharmaceuticals in Pakistan that marketed TB drugs in previous years wound up because of dwindling returns due to GF support. Today, there is no local provider. It would be prudent for the government to explore options for the local manufacture of first-line drugs. Diagnostics and costly second-line medicines could be procured through grant resources.
Without access to diagnostics and medicines, TB will affect tens of thousands more with drug-resistant bacteria, which will become untreatable. If these challenges are not addressed soon, it could be too late to control this highly transmissible and dangerous disease that will impact both rich and poor.
By Naseem Salahuddin. The writer is an infectious disease specialist. (Dawn)