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Tuberculosis: The World’s Unknown Killer



Written by: Aiai Calmer ‘26

Editor: Andrew Ni ‘26


What comes to mind when you think of the world’s most deadly infectious diseases? COVID-19 would likely rank first for many people, but what about the second most deadly infectious disease?


Tuberculosis (TB) is ranked second on the World Health Organization’s (WHO) list of most deadly infectious diseases globally with a shocking total of 1.3 million deaths in 2022 [1]. It is caused by the bacterium Mycobacterium tuberculosis which generally attacks the lungs, and leads to excessive coughing, coughing up of blood (hemoptysis), fatigue, and weight loss. Even though TB has been outranked by COVID-19 since its emergence in 2020, TB was the reigning cause of death amongst infectious diseases for several decades before 2020 and has been a leading cause of death in the world for centuries. In 2019, TB ranked first, causing almost double the number of deaths than HIV/AIDS, which was the second leading cause of death [2]. If you’re anything like me, you might be shocked at these statistics. Tuberculosis seems like a faraway plague from a time too long ago for it to possibly be so fatal now.


In actuality, TB is currently ignored because of its recent prevalence in countries with high percentages of low-income citizens. In 2021, WHO reported that the top four countries making up nearly 50% of total global TB cases were India, Indonesia, China, and the Philippines [1]. That year, three of these countries (India, Indonesia, and the Philippines) had per capita incomes of less than 13,000 PPP, paling in comparison to the world per capita income of 18,724 PPP [3]. There is a clear international disparity in rates of tuberculosis between countries whose citizens can afford to be sick and those whose citizens cannot.


As you might expect, there are modern pharmaceutical treatments for tuberculosis. Streptomycin, the first-ever drug for TB, was introduced in 1943 by scientists Selman Waksman, Elizabeth Bugie, and Albert Schatz. By 1951, isoniazid was introduced as an inexpensive, first-line drug treatment. You would think that with the advent of affordable treatments, TB would be virtually non-existent now. In fact, the problem is not the first-line drugs discovered nearly a century ago, but that tuberculosis has since mutated into drug-resistant forms, now known as multi-drug resistant (MDR) TB. Even Streptomycin, one of the more cost-effective second-line drugs, is now rendered ineffective for many forms of MDR TB. The other second-line or third-line drugs necessary to treat tuberculosis are too expensive for the communities that need the medication most.


Although several first-line drugs (isoniazid, rifamycin) are readily available at relatively low costs for the US and can be provided in developing countries through free TB treatment programs like Partners in Health in Haiti, MDR TB is “practically incurable by standard first-line treatment” [5]. In 2022, WHO estimated that the total number of people infected with MDR TB was 410,000 [6]. The cost of second- or third-line drugs which would be necessary to even have a chance at treating MDR TB is astronomical, far too expensive for the majority population of developing countries. Paul Farmer, MD, wrote the book Infections and Inequalities (1999) to relay his experiences treating HIV and TB patients in Haiti and Peru. His stories serve as good examples of the experience of a TB patient in a developing country as there are fewer studies published about these regions. In concerns of financing, for example, the cost of a third-line regimen for a Peruvian woman named Blanca in 1996 was nearly $200 per month, far more than her family’s monthly income [7]. In addition to finances, the social situation makes it difficult for the entire duration of treatment (a recommended 24 months) to be carried out: if, like Blanca, a patient has a family, who will work and who will take care of the children? Should the mother be expected to abandon her children to seek expensive treatment that may or may not cure her?


When the cost of drug treatment is so high and there are not enough regional financial resources to have more effective methods like directly observed therapy or isolation in negative-pressure airflow rooms, what can we do?


It turns out that the answer might just be decreasing the cost of drug treatments, which is totally doable unless you’re a capitalist pharmaceutical company like Johnson & Johnson.


Johnson & Johnson have held a patent on SIRTURO® (bedaquiline) since 2012. Bedaquiline, the first approved anti-TB drug since 1998, is different from other second-line TB medications that could be used to treat MDR TB. Mainly, its mechanism reduces “susceptibility to developing cross-resistance with other antitubercular drugs”: in other words, it decreases the risk of newly developing MDR TB or transfering to MDR TB after prior treatment of TB [8]. Johnson and Johnson were set to renew their patent on this potentially life-saving treatment in July of 2023.


The negative implications of patents are profound, particularly in the pharmaceutical industry. Patents make it impossible for generic substitutes of medications to be made and distributed, forcing patients to pay whatever cost the company holding the patent demands. If a patient cannot afford these patented treatments, there’s simply no other way to get them.


In March of 2023, India rejected Johnson & Johnson’s renewal of their bedaquiline patent, setting a new precedent for how a nation protects its citizens’ right to health. As a result of this confrontation, Johnson & Johnson came publicly under fire: how can a company whose credo is to “maintain reasonable prices” on the treatments it finds simultaneously drive up prices around the globe, creating an impossible situation for developing countries [9]? Some experts have predicted that further cost reductions enabled by the removal of the patent could “potentially reduce treatment expenses by up to 80%, lowering the cost per patient from $46 to $8 per month” [10].


As we reflect on the ongoing battle against tuberculosis, it becomes clear that the fight is not only against the pathogens themselves but against the structures and systems that inhibit access to crucial treatments. The public and governments must work together to keep pharmaceutical companies accountable, ensuring that they are a part of the solution. The battle against TB is a stark reminder of our shared duty to advocate for policies that ensure scientific progress benefits all of humanity, not just a privileged few.




References

  1. Global Tuberculosis Report [Internet]. World Health Organization; 2022. Available from: https://iris.who.int/bitstream/handle/10665/363752/9789240061729-eng.pdf

  2. Number of deaths caused by selected communicable diseases annually worldwide as of 2019 (in 1,000) [Internet]. World Health Organization; 2020 Dec. Available from: https://www.statista.com/statistics/282715/deaths-from-communicable-diseases-worldwide/

  3. World Bank. GNI per capita, PPP (current international $) [Internet]. 2021. Available from: https://data.worldbank.org/indicator/NY.GNP.PCAP.PP.CD

  4. endTB. Haiti [Internet]. Available from: https://endtb.org/haiti

  5. Seung K, Keshavjee S, Rich M. Multidrug-Resistant Tuberculosis and Extensively Drug-Resistant Tuberculosis. 2015 Sep; Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4561400/

  6. Global Tuberculosis Report [Internet]. World Health Organization; 2023. Available from: https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2023.

  7. Farmer P. Infections and Inequalities: The Modern Plagues. University of California Press; 2001.

  8. Yadav S. India Declines Patent Extension Application of Bedaquiline: A Remarkable Step Towards Tuberculosis Elimination. Cureus [Internet]. 2023 Nov 2; Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10692960/pdf/cureus-0015-00000048146.pdf

  9. Johnson & Johnson. Our Credo [Internet]. Available from: https://www.jnj.com/our-credo#:~:text=We%20 believe%20our%20first%20 responsibility,costs%20and%20 maintain%20 reasonable%20prices

  10. Petersen E, Hui D, Nachega J, Ntoumi F, Goletti D. End of the Bedaquiline patent – a crucial development for moving forward affordable drugs, diagnostics, and vaccines for infectious diseases in low- and middle-income countries. International Journal of Infectious Diseases. 2023 Jun 1;131:180–2.

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