Can we stop COVID-19 from becoming the next tuberculosis?

The medical and scientific community must rally around equitable access to medical countermeasures

The ongoing inequitable access to tests, treatments and vaccines for COVID-19 risks relegating it to a disease of poverty like tuberculosis. The hoarding of essential tools by wealthy countries will inevitably extend the pandemic, leading to more devastation in high- and low-income countries alike. By acting now, the world can prevent this outcome for COVID-19 while also making conditions better to tackle TB.

The medical and scientific community should mobilize around COVID-19 in a manner similar to their recent coordination on climate change. An editorial published in more than 200 medical and health journals in September 2021 sounded a far-reaching alarm about the impact climate change will have on global public health; the action was followed by a similar letter in February 2022 to the U.K.’s Prime Minister. The current trajectory of the COVID-19 crisis, which is headed for TB-like status in large parts of the world, and its more rapid timeline than climate change, call for at least as much urgency —the medical countermeasures our community creates will continue to have limited impact if they aren’t disseminated globally.

In less than a year, pharmaceutical companies were able to develop vaccines to address the COVID-19 pandemic, followed shortly thereafter by novel therapeutics.

Antigen rapid diagnostic tests, necessary for detection of the pathogen and to stem the spread of disease, were developed within eight months of the initial outbreak.

However, these tools, along with other protective equipment, have been monopolized by high-income countries, leaving low- and middle-income countries (LMICs) that are unable to afford them without the essential supplies they need to contain the pandemic.

The situation could soon see COVID-19 become the next tuberculosis. TB represents a significant public health threat, having infected an estimated 10 million people, and resulting in the death of 1.5 million people in 2020 alone, according to data from WHO. The vast majority of these infections occurred in LMICs. Despite the fact that TB is the 13th leading cause of death overall and the second leading infectious killer after COVID-19, it is not considered to be an important health issue in high-income countries. The burden of TB is predominantly shouldered by the world’s poorest people.

This is because, for thousands of years, TB has resisted eradication by circulating in impoverished areas with poor living conditions — causing missed latent infections and co-infections in the immunocompromised, including those living with HIV, and generally thriving where economic growth and healthcare improvements are not. A combination of these factors along with crucial diagnostic gaps mean that ‘missing millions’ are evading TB diagnosis and available treatments.

COVID-19 has devastated the global fight against TB, eliminating 12 years of progress in just 12 months. What’s more, the inequity of the response to the current pandemic means that COVID-19 is in danger of becoming a disease of poverty, similar to TB.

Not only will withholding COVID-19 testing, vaccination and treatment support from LMICs result in unnecessary deaths, it will also increase the risk of imported cases leading to additional outbreaks in high-income countries, and the emergence of new variants that could prolong the pandemic.

The roots of disparity send up new shoots

How did we get here? Although COVID-19 has caused substantial harm in high-income countries, much of this has been self-inflicted. Politicians looked to place blame, rather than acknowledging the potential impact of the disease on the health of their populace and economy.

Misinformation resulting from rapidly changing and divergent guidance on safety precautions eroded public trust in the benefits of public health measures, testing and vaccines.

Many countries were caught flatfooted with shortages of rudimentary protective equipment for healthcare workers, resulting from poor pandemic preparedness planning. As such, even countries with universal health coverage and robust primary care systems did not escape the heavy toll of COVID-19.

However, the procurement of high volumes of the diagnostic tests needed to contain the disease, and vaccine supplies sufficient to roll out COVID-19 vaccination programs to large proportions of their populations, have put wealthy countries at a significant advantage over LMICs in the long-term fight against the pandemic.

With these tools, and an increasing number of people with immunity to COVID-19, the rate of life-threatening infections in high-income countries is likely to stabilize, easing COVID-19 into an endemic disease that is as much a part of life as the seasonal flu.

Until now, COVID-19 had marked a shift from the usual trend of infectious diseases, causing more deaths in high-income countries than in LMICs. However, uneven endemicity is liable to change this, and research shows COVID-19 already hits LMICs where they can least afford it, in places with sharp declines in living standards and food insecurity. Indeed, the pandemic has wreaked havoc on livelihoods and economies, only serving to compound the challenges to pandemic management that these countries are already experiencing.

A human approach for a global benefit

As high-income countries mobilize resources to achieve the transition to endemicity, it will require ongoing surveillance to prevent outbreaks and track the duration of immunity and level of protection against emerging variants. That will need to be coupled with continued development and implementation of modified vaccines and therapeutics to keep up with the evolving virus, and recurring booster programs.

However, LMICs lack the disease management infrastructure and, most importantly, the funds to procure and implement the tools needed to prevent infections and deaths. As LMICs clamored for supplies, national policies in wealthy countries dictated their deprivation.

In low-income countries, only 11.4% of the population has received a primary COVID-19 vaccine series, compared with 78.5% in high-income countries. Rich nations have given more booster doses in three months than poor countries have given primary doses, a situation that has been termed “vaccine apartheid” by South African NGOs.

Vaccination efforts in LMICs are further hindered by logistical challenges including lack of adequate refrigeration facilities as well as the genomic sequencing capabilities needed to effectively track the emergence of new variants.

Given the current situation, one can envisage a scenario in which COVID-19 becomes a disease that primarily affects LMICs, much like TB. There are clear parallels between TB and COVID-19 in LMICs — continuous local transmission, infection and the emergence of new strains — and in both cases this is overwhelmingly due to uneven access and implementation of tests, treatments and vaccines needed to control the spread of disease.

In an interconnected world where pathogens do not adhere to national boundaries, it behooves wealthy countries to ensure that LMICs have access to these tools. Instead of exacerbating the plight of LMICs, high-income countries have both a responsibility and a vested interest in supporting them with pandemic management.

A global response to COVID-19 is not only the humane approach, it is the only way to stem the spread of the virus and prevent it from continuing to take a toll across the world.

And yet this responsibility and opportunity to act does not fall solely in the domain of world leaders; recent global campaigns by professional groups and healthcare practitioners demonstrate that industry can influence policy innovation. The COVID-19 pandemic response must not stop until its devastation has ceased — everywhere. This means ensuring that preparedness infrastructure in supply chain and manufacturing capacity, for example, does not lapse.

Through supporting global populations with equitable access to pandemic-fighting tools, we can contain COVID-19 once and for all, preventing it from following the path of TB while also improving the conditions in which TB eradication becomes possible.

The most efficient path to achieving equitable global access may be a matter of debate, but it is the responsibility of all of us to make clear to policy makers the urgency of the need to act.

The United Nations General Assembly should take immediate action to call attention to the lack of equitable access and encourage the wealthy member states to address it. Likewise, the G20 needs to provide greater funding in light of the risk that Covid-19 will develop new strains and have an adverse effect on their economies.

Mark Kessel is chairman of FIND, the global alliance for diagnostics. He previously served as a director of the Global Alliance for TB Drug Development.