Dr Lucica Ditiu is the Executive Director of Stop TB Partnership— one of the most influential advocacy voices on global health and tuberculosis that provides support for a TB response to achieve a world without TB.
A specialist in lung diseases from Romania, Dr Ditiu started her international career with the WHO in January 2000 as a medical officer for TB in Albania, Kosovo and FYR Macedonia within the disaster and preparedness unit. She has worked for the past 18 years with WHO and the UN system at every level: national, sub-regional, regional and global.
At the helm of the Stop TB Partnership for the past eight years, Dr Ditiu has been relentless in pushing for the inclusion of everyone affected by TB.
In an interaction with S Harachand, she speaks about the international body’s ambitious goal to make the world free of the curable infectious disease and how the programme has been impacted by various challenges, including the COVID-19 pandemic.
A recent report by Stop TB Alliance says that 12 months of COVID-19 eliminated 12 years of progress in the global fight against tuberculosis. What are your strategies to mitigate the pandemic effect?
The COVID-19 pandemic is a big setback for the global efforts to eliminate TB. We need to see what can be done to mitigate the impact.
I think there are three or four important things countries need to do to offset all these losses. The first is to have data and information to know how much they lost in terms of people getting diagnosed and treated for TB. However, not every country has had a similar impact. Countries from Asia, which have a very high number of people with TB, are seeing a huge number of losses. Then we have, for example, countries in Africa, where the pandemic of COVID-19 has resulted in less of a pushback. In a few countries in the African region, we actually don’t observe a drop in the number of people with TB that are diagnosed and treated. So, to understand the impact, first we need to know how many people were diagnosed and treated in 2020 and in the first quarter of 2021 vis-a-vis 2019. The second thing is that we need to be aware that COVID-19 heavily impacts health systems, health workers and in fact, the life of every single person. We also need to be mindful of the fact that lockdowns are continuing in most of the countries in the world. TB is neglected, because healthcare workers are very tired or directed away from TB to COVID-19. Hospital beds and dispensaries are also diverted from TB to COVID-19. Stakeholders like ministers of health and officers in charge of fighting the pandemic must make sure that they are not completely destroying the entire healthcare services system by pushing everything back to COVID-19. They must try to ensure that TB services remain untouched or suffer little impact.
Next, we need to be cognisant of the fact that TB and COVID-19 are two air-borne infectious diseases. The symptoms, as well as the way in which we do infection control, contact tracing, diagnosis for TB, are almost the same for COVID-19, except for the medicines used in treating them. I mean that the diagnosis for COVID-19 is done using the equipment that can as well diagnose TB. As a matter of fact, a lot of these machines that were doing TB diagnosis were borrowed or moved to do COVID-19 detection. Our call is now that countries do bi-directional testing, which means that once you try to do diagnosis for COVID-19, you can as well do diagnosis for TB, you just need to have the cartridges specific for TB. So, one big thing, to get back to where we were, is to do bi-directional testing.
Secondly, find more people with TB. Why do people not go for TB diagnosis? There are many barriers. Distance is one issue. They have to travel. Poverty is another, which is encountered on a lot of occasions. They don’t have enough money to go. There are a lot of vulnerabilities that people have. They are shy, they are stigmatised, they are scared and worried to go because of either their vulnerabilities or because of the way they are treated. The closer we can bring diagnosis of TB to the people, the better it will be.
So, in addition to doing bi-directional testing, ensure that there is a possibility to do diagnosis for TB at the lowest level of health care unit in the field, the ones that are in the community at the grassroots.
The third part is really working with the organisations, networks of survivors, communities, community health workers and primary health care providers and at the smallest administrative unit levels for them to be in touch with the people and hold hands with them till they get diagnosed and treated. This way, we can ensure that it’s easier for these people to get their diagnosis done and to know what their status is.
As with COVID-19, the longer you stay at home and remain sick, the more you infect the ones around you. Even though TB is less contagious than COVID-19, since people stay in their households and spend a lot of time these days, there is a chance of a lot of transmission for TB..
Multi-drug resistant TB remains a big challenge, but access to novel diagnostic modalities and therapies to tackle it is still limited in certain regions where the burden of the infection is quite high. How does it impact the global efforts to end TB in targeted timelines?
MDR TB is a very tricky type of tuberculosis because it is more difficult to diagnose and even more difficult to treat. It requires a longer duration and complicated treatment with very bad side effects. We observe a drop in people with drug-resistant TB being diagnosed and treated at a rate of around 30-35% globally. We have a target to put around 1.5 million people with MDR TB on treatment by the end of 2022. As we see it right now, it will not be possible to reach that. We will be actually falling far short on this target because 2020 saw a big drop. We were not in a good place at all for MDR TB even before, in comparison with normal TB. This is the target that I think we will fall short of. For me, it is not about the target, but it is about the fact that behind each of these numbers that are not being achieved are people. These are not numbers but people who are suffering in their lives with problems. People with MDR TB will also be infecting the ones around them and entering into a very difficult cycle of treating and diagnosing this form of TB. So, we observe these numbers, and find that MDR TB figures are probably much bigger in terms of missing people in the Asian region, with Europe coming after that and then the African region.
Stop TB Alliance has ‘women at the centre’ as one of its predominant themes. In what ways do the focus on women and gender equality serve to improve TB response and treatment outcomes?
It is a hot topic and very close to me for many reasons. When we look at the numbers, TB affects men more in their active age. It has a huge impact on the households and the economies in the world and the economies of the individuals, because it affects working men. However, what is far more important is that women suffer more than men and have more difficulties in accessing health care. Women are much more impacted by TB and the stigma associated with it, and suffer rights abuse. For women, there are barriers that are related to not only the above topics like poverty and stigma, but also societal barriers to access services and treatments. Earlier, even in my own country, if you had TB, it wasn’t possible to even get married. People had a lot of preconceptions about the disease, and we know of couples that are getting separated because of this. So, that is why I am very happy and supportive of women who are raising their voices for their rights and to support the TB response. We have a group where women affected by TB, suffering from TB, providers of care for TB, donors and so on, stand shoulder to shoulder. So, what women can do is really push for the need to make the TB response inclusive and accessible for everyone. I think because of the power that women have, it’s possible to do that. We see that in some of the countries, the TB response includes gender-sensitive policies and practices that are becoming a norm. We are not yet there, but you know in TB, we did not even have this conversation about gender and how it can be important. When you speak about gender as well transgender groups, we don’t speak about women only, we speak about all the aspects related to gender so that the TB response is constructed around all these aspects. So what women can do is raise their voice, not accept the status quo, and be engaged and we will be supportive of any TB women and grassroots organisations, and patients and the survivors’ groups however they are called, because there is a need for them to be part of the design of the TB response group in various countries.
HIV and TB often co-exist. It has become impractical to fight one without defeating the other. How should we overcome this challenge?
There are two important questions here. One is related to data that I mentioned before as well. So, first of all, we need to know how big the burden of TB/HIV co-infection is. I am saying that, because if you look at the global level, the TB/HIV co-infection represents around 10% of the TB burden. But for people living with HIV, TB is a huge killer, meaning 1 in 4 people with HIV unfortunately pass away because of TB. It is very important to know this at the country level because it is a much bigger issue in African countries than in Asian countries. Also, we need to be mindful there is an incredible association between TB and malnutrition. 20% of TB cases are due to malnutrition and I expect that this figure could be actually higher. Going back to TB/HIV, it is very important that people living with HIV are being tested for TB infection and disease and are getting either TB-preventive treatment or treatment for TB if that is the case.
The treatment can be very long, can have side effects and can make people very tempted to abandon. We need to ensure that people living with HIV getting TB are being taken care of and supported by community care and other networks of peers.
The last point that I would make is that it is a big stigma to have TB. It is an even bigger stigma to have HIV. Very often, people living with HIV have problems with their rights. Communities and civil societies and the network of survivors at the community level and at the grassroot level should be supported.
India, which has the highest burden of TB in the world, has set ambitious goals to end the malady well ahead of WHO targets. But the country is still faced with several hurdles on the way, such as poor reporting of the disease etc. As a global body that envisions a world without this curable disease, how does Stop TB Alliance look at this?
India has the highest burden of TB, has the highest ambition to end TB and has the most impressive package of interventions put in place to end TB. Is this perfect? Absolutely not. Is this enough? Absolutely not. Is this fairly and rightly implemented? Absolutely not. But it is the first country that actually put in place a very robust plan thinking of what it will mean to end TB. Very, very few countries have this plan in place with very concrete deliverables to completely end the disease.
So, without having that conversation, it is not possible to even seek all the funding that is needed. In addition to this, only India, as far as I can tell, has built a platform that has live data on TB. It is open access. Any of us can go online and find the data on TB cases that were diagnosed and treated in India by state, by district, by gender, by age group as of yesterday. It is spectacular. There is nowhere in the world this is available. What we have right now is yearly data in most of the countries. So, we have a long way to go from that perspective in other parts of the world vs India. India also has a package of providing a small — but still something — nutrition support. As I said, is it enough? No. Is India the only country in the world that does that? Yes, at the scale that India does. There are projects in a lot of countries to provide this kind of support, but these projects are covering small numbers. Still, as we know, India has a challenge. There are usually a lot of bureaucratic delays for a decision taken in the capital to reach the ground. It takes a lot of time and very often leaves space for interpretations and people having a lot of questions and deciding at variance with what was already proposed. For example, we know very well the commitment of India to ensure that people don’t take any more injectable treatment for drug-resistant TB because injectables are difficult to provide, besides having horrible side effects. However, we keep hearing that injectables are still used for the treatment of drug-resistant TB in many places. Surely, these are deviances from the national policy and its application at the state level. These kinds of aspects are everywhere, but India actually is trying to fight TB very strongly. In addition to putting in place this plan, I forgot to mention that India also significantly increased the funding to fight TB. So, for these reasons, we can support and push the government of India to not drop this fight against TB. As we know, right now there are some difficult situations with COVID-19. But I have trust in India that it will continue to keep the pressure. I think India will be on a good path to end TB by 2025.