Tuberculosis (TB) is a social disease that weaves through and enervates civilization. It is a cause of war, an outcome of natural disasters, a counterpoise to prosperity; though barely a talking point in the metropoles of the west, it is a feature of our global culture, one that destroys the hopes and aspirations of millions of people in the Majority World. The incidence of TB in prosperous countries is low. Over 95% of deaths are in poor countries. Eight countries account for two thirds of the total, with India leading the count, followed by China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa. The percentage of the families in these nations that face catastrophic costs is 47%. This means that nearly half the families who face this disease can no longer shelter, feed, or educate their families. Black people get TB twice as much as white people in any given country. History of TB Tuberculosis may be the oldest disease known to humankind. It has many names: phthisis, yaksma, scrofulous, the king’s evil, consumption, and “the captain of all the men of death”. Some say one out of every seven persons who ever lived died from tuberculosis. Homer wrote in 800 BC that tuberculosis “steals the soul from the body” and causes men and women to “lie in sickness” and over a long time, “waste away”. Shakespeare described its victims as “swoln and ulcerous, pitiful to the eye”. TB afflicts many people who do not vote such as refugees, prisoners, and the destitute. Humankind has fought it with wild guesses, superstitions, and warmed-over science. Still, 1.5 million people slowly suffocate and die from it every year. And every day, 1000 of them are children. Research and innovation Most multinational pharmaceutical companies will not invest in a cure. Almost all the jurisdictions that have tuberculosis do not have medical insurance. And COVID-19 has made it worse. The World Health Organization’s (WHO) 2021 TB report states, “In many countries, human, financial and other resources have been reallocated to the COVID-19 response...” Dr. Tedros Adhanom Ghebreyesus, the WHO Director-General, said this “confirms our fears that the disruption of essential health services due to the pandemic could start to unravel years of progress against tuberculosis.” What must be true to eradicate tuberculosis? First, Global values need to align: Can we see every human life as having the same high, inherent value? The late Dr. Paul Farmer, the Harvard Medical School professor, an innovator in TB treatment and cofounder of the University of Global Health Equity (UGHE) in northern Rwanda, gave us the starting point, “The essence of global health equity is the idea that something so precious as health might be viewed as a right.” Second, global institutions must be representative across culture, nation, race, religion, and gender. Mia Amor Mottley, the Prime Minister of Barbados, in the 2022 UN General Assembly, called for the reform of the G20 and G7 groups. She argued that Barbados cannot accept these “informal committees of governance” when they have no representation of African- descent and exclude 1.5 billion people in the world. Third, “Advanced Market Commitments” must be a new kind of global public-private partnership. The current market dynamics are not sufficient to meet the risk reward profile of the firms who can do this work, let alone the needs of the majority world during a pandemic. Therefore, a public-private partnership with a guaranteed market, a small country co-pay, explicit science and manufacturing standards, and clear incentives for nations and for the private sector - may be part of the answer. These ideas have been put forward by Dr. Rachel Glennerster, and Nobel laureate, Dr. Michael Kremer. Early outcomes have been good with faster than normal rollout and are now focused more on capacity commitments. These economists and others have reckoned that the faster one can roll out medicines during a pandemic, the faster we can lower the approximately US$500 billion monthly losses in the rest of the world, and nearly US$ 900 billion monthly losses in the United States. They add that we need to create stockpiles, standby capacity, and intermediate goods to prevent hoarding by the few nations who can manufacture the drug and whose citizens can pay for it. Glennerster and Kremer do not equivocate, “Moral suasion is unlikely to be helpful.” And fourth, indigenous innovation or decentralized and autonomous strategic actions at the national level are vital. This is a function of local leadership that is visionary. The recent accomplishments in the biotechnology sector in Rwanda strains credulity. The African Development Bank has announced that it will put its African Pharmaceutical Technology Foundation in Rwanda. Rwanda competed against the largest nations on the continent and will host the new African Medicine Agency. The University of Global Healthcare Equity, UGHE, the new medical school in rural Rwanda, is a leader in “social equity”, and now attracts students from around the world, and as far away as Australia. BioNTech is set to inaugurate its manufacturing processes for infectious diseases at the end of year. Akagera Medicines, majority-owned by the people of Rwanda through the Rwanda Social Security Board (RSSB), has created vaccines for Lassa, TB and HIV; and has a TB therapeutic that will enter human trials in South Africa in the first quarter of 2024. TB and society Tuberculosis destroys productive capacity in a society. It derails the delivery of resources, stymies investment capital, caps innovation, and erodes human initiative. The more poverty, the more tuberculosis. The more tuberculosis, the more poverty. Poverty is not just the lack of shelter, nutrition, education, and healthcare for one’s family; it’s the loss of aspirations and hope. As a country gets poorer, certain progressive human values deteriorate. They include self-determination, tolerance for people with different views, civic mindedness, and optimism about the future. This means the poorer that the nation becomes, the more fractious its society may become. (This is especially salient when one considers that many of the nations that have the highest incidences of tuberculosis and poverty also possess nuclear weapons and live in unfriendly neighborhoods.) Weak societies create the conditions for unaccountable leadership like populism and fascism. And that kind of leadership is less likely to see every human life as having the same high, inherent value, or that something “so precious as health might be viewed as a right” of all men, women, and children. Michael Fairbanks and Dr. Daryl Drummond, PhD, are founders of Akagera Medicines in Kigali, Boston and San Francisco.
