Recently I was fortunate enough to travel far and wide across China (after an equally exciting trip to Russia) to understand the growing epidemic of multi-drug resistant tuberculosis (MDR-TB). China suffers from the world’s second largest TB epidemic, after India, with approximately 1.4 million new TB patients, and 140,000 TB-related deaths each year.
Tuberculosis is a disease of poverty. Over 80% of cases occur in Africa and Asia, amidst poorly developed health systems and rampant poverty. China has slowly adopted methods for treating TB over the last 20 years, and the majority of the country is covered by the internationally recognized standard for treatment—DOTS (Directly Observed Treatment Short course).
But despite adoption and uptake of DOTS across China since the 1990s, drug-resistant TB is on the rise. Resistance to TB drugs can occur when drugs are misused or mismanaged, when patients do not complete their full course of treatment, when healthcare providers do not manage treatment correctly, or when drugs are not regularly available, or of high quality.
In China today, there are an estimated 120,000 cases of MDR-TB every year, and only approximately 6,000 patients are enrolled in treatment. The proportion of new MDR cases every year is on the rise, and has now reached approximately 8.3% of all TB cases. Treating patients for MDR-TB is hugely expensive, mostly due to the cost of second-line drugs, and is also very time consuming—a 24-month course of treatment can cost a patient between RMB 40,000-60,000, or about $6,000-$9,000 per person.
These jarring statistics really began to hit home when our team took a trip to Qinghai Province, in western China. We visited an impressive young doctor there, Mr. Ma, who is working—with very limited resources—to raise awareness of MDR-TB locally, to encourage people to get tested if they have symptoms, and to ultimately treat a small number of patients. The majority of TB cases are among farmers and herdsmen, and among the elderly in rural and highly isolated areas. Treatment rates are very low, mostly because patients cannot reach clinics, or do not have the needed supervision in their own communities to manage treatment.
Very limited human resources, low capacity to diagnose, and likely poor quality of drugs are the most significant challenges facing Qinghai. We were shocked to learn that only 12 patients were being treated for MDR-TB in Qinghai province. In a province of over 5.2 million, it’s truly a stunning statistic.
In a situation so bleak, where do you find hope? Efforts to make a real dent in MDR-TB are in the nascent stages, as many healthcare professionals and public officials lack a deep understanding of the disease. However, the Ministry of Health in China is beginning to come to terms with this epidemic, and is developing a National Action plan to achieve universal treatment and diagnosis of all MDR patients. They are working in close collaboration with the Global Fund, Gates Foundation, the Red Cross, and pharmaceutical companies like Eli Lilly and Johnson & Johnson.
While the landscape of activity is sparse, the ambition and hopes among many doing this work are high. The Ministry of Health aims to cover the entire country with diagnosis and treatment for MDR-TB by 2020. Historically, the Global Fund was the largest external source of support for addressing TB in China, working in 16/34 Chinese provinces. The Gates Foundation has partnered with the Chinese government, spending $33 million over five years to pilot new diagnostics and develop new approaches for ensuring high-quality first-line drugs. We witnessed a real hunger among local doctors and healthcare workers to learn more from the international community and other experts on best practices for MDR-TB treatment and prevention. In these people’s hands, China’s hopes for tackling MDR-TB are all the more encouraging. This is certainly an area to watch in the coming years.