With global health threats, investing in health systems pays off

Updated April 10th, as published in the Duluth News Tribune

In 2014, there were 9,421 new cases of Tuberculosis reported in the United States.  Major diseases considered, this was a relatively low number, meaning that of the worrisome events 2016 may bring to your life, a positive TB diagnosis likely is not one of them.  Through a global lens, however, things get a little more common: One in every three people worldwide is infected with the tuberculosis bacteria.  March 24th was World TB Day.  Why should we care? 

The low incidence of a given disease is poor precedent to gauge American concern.  When Ebola ravaged West Africa in 2014, Americans infected by the virus remained in single digits.  Even so, the media’s frenzied response that followed was far from calm.  The U.S. eventually pledged $6 billion in aid to address the Ebola epidemic.  Two-thirds of thatcould have been estimated as preventable spending had robust health systems been in place. 

It makes sense to invest early in global health systems to prevent outbreaks of Ebola, tuberculosis, and other infectious disease.  Thankfully, portions of aid already have been earmarked for health workers and public health infrastructure. 

Tuberculosis is now the world’s leading infectious killer (1.5 million deaths in 2014), recently surpassing the number of deaths to HIV/AIDS.  In 2014, over 9 million people contracted Tuberculosis, according to the World Health Organization.

Unfortunately for humans, especially those that live on the margins of accessible health care, tuberculosis is a stubborn, hardy bug.  Once infected, the bacteria walls itself inside the body through various defense mechanisms, causing treatment challenges that require diligent medication schedules and long-term follow-up.  These traits have spawned resistance to medicines—labelled as "MDR-TB," or multpile drug resistant and "XDR-TB," or extensively drug-resistant—which leaves health professionals with few antibiotic regimens to combat resistant forms of the disease.  And without the treatment, outcomes are deadly.

An estimated 480,000 cases of MDR-TB occurred in 2014, but a paltry 123,000 were reported.  When fewer than half of new infections are being addressed, that’s recipe for disaster, and, worse, preventable human suffering.

So often health is considered as here or there rather than as its true nature: a global web of patients, governments, and civic societies.  Bacteria like tuberculosis travel along neglected health systems and medical structures that have the potential to affect communities well beyond where its patients, doctors, and nurses interact.  Whether in rural Minnesota or Haiti’s Central Plateau, health always will remain distantly and intimately connected.

Last year the White House released the "National Action Plan for Combatting Multidrug-Resistant Tuberculosis,” which aims to put 560,000 people on treatment in 10 high impact countries.  Full funding at $400 million to support USAID (U.S. Agency for International Development) tuberculosis programs in the upcoming fiscal year to galvanize that action plan, build robust health systems and respond to tuberculosis.

While World TB Day has come and gone, we can still celebrate by recognizing the interconnectedness of our health and by seriously addressing the risk tuberculosis poses. This stance requires action as opposed to reactions after future outbreaks arise. 

Between quilts and conversations: The commitment to an AIDS-free generation

Somewhere beneath a sea of quilts lay the carefully tended fall grass of the National Mall in Washington DC.  A mosaic of fabric and sequins stretched toward the horizon as the Washington Monument towered over thousands of embroidered names, sentiments from “We love you Dwight,” to a simple blue guitar accompanied by “Freddie Mercury.”

For some, the quilts were timelines of lives closed too quickly.  For others, they were a supportive blanket, in more ways than one, a silent sanctuary for those lost.  Many had photos; many stitched together clothing.  All expressed love.  In the wake of a virus, this was its legacy.

Today marks World AIDS Day.  A reminder and reflection for people living with HIV; people who’ve lost loved ones to AIDS-related diseases; and those who battle daily to see their first AIDS-free generation.  The crossroads of human rights, public health, and even art forms—quilts that are now shared each year around the country—find their respective roles in HIV’s history.

Photo credit: NIH, https://history.nih.gov/NIHInOwnWords/

Photo credit: NIH, https://history.nih.gov/NIHInOwnWords/

Since 1988, each December 1 we catch a glimpse into the past decades of HIV.  It’s a history that holds biting failures—Senator Jesse Helms’ evidence uninformed health policies of the 80s and 90s—as well as triumphs—AIDS activists’ achievement of dramatic price drops for expensive antiretrovirals, the drugs that changed HIV from “death sentence” to “manageable disease.”

While history discloses vital lessons, it remains indelible.  The future of HIV, however, is yet to be determined.

The problem faced today is not a failure of remembrance. Nor is it an absent effort to create open environments to discuss HIV status (though, stigma maintains ugly company.) The issue today is a lack of renewed commitment to the future of HIV and investment in an AIDS-free generation.

Presently, about 2 million new HIV infections occur each year with 50,000 annual cases in the U.S. Yet of people living with HIV around the world, less than half receive appropriate antiretroviral therapy. As funding sources have plateaued, and in some cases declined, an appropriate response to HIV is handcuffed.

Southern Indiana learned firsthand what sparse support looks like when it navigated an HIV outbreak earlier this year.  Rural America tends to be a stigma stronghold, and when coupled with poverty and health professional shortages the stage is set for an outbreak. The South Carolina Rural Health Research Center found in a 2013 study that only 5 percent of American rural counties had a medical professional supported by the Ryan White Program, the largest federal program that supports people living with HIV.  For urban counties, that figure was over 30 percent.

Since 2010, the President's Emergency Plan for AIDS Relief, or PEPFAR, has seen cuts of 300 million dollars.  This beacon of George W. Bush’s health policies to address the global HIV epidemic, one that saves millions of lives each year, has dimmed compared to the guiding light it once was.  To be serious about ending AIDS, correcting the failures of past policies, and investing in future health systems, those cuts must be reversed.

A few years ago, I rode a bicycle from San Francisco to Boston in the Ride Against AIDS.  As I traveled across the country, I joined a great number of conversations about the current state of HIV.  Many of those discussions were heartfelt considerations of how HIV affected our lives, families, and communities, but many began with, “I didn’t know HIV was still a problem.”

Alone, drugs were never going to stop HIV.  The virus runs just as easily through bloodstreams as it does fault lines in public health policies. To end an epidemic, you need a cocktail of drugs and a toolbox of non-pharmacological treatments, the most important of which being the conversations and compassion found between people.

Earlier this month when news broke that Charlie Sheen was living with HIV, many fingers reflexively pointed condemnation in his direction for his lack of transparency.  While one could say it’s encouraging the public sees importance in being open about HIV status, a better question would be: What about our environment still prevents people from talking about HIV?

An AIDS-free generation begins with a renewed commitment to proven programs like PEPFAR. It’s achieved with driving the virus back into productive public conversation, a place that ends epidemics.