Despite Health Minister Aaron Motsoaledi publicly calling on the top leaders of China, India, Brazil and Russia (BRICS) to prove their commitment to tackling TB by simply showing up at the first UN high-level meeting on TB, not one of them is representing their nation. This is according to a reliable source who confirmed this information with Health-e News on Tuesday.

This prompted Medicins sans Frontieres’ Sharonann Lynch to quip: “You can’t fight TB if you don’t show up.”

At the South African TB conference in June Motsoaledi said all of these leaders should “attend without failure because 50% of all drug-sensitive TB as well as 60% of multi-drug resistant TB cases in the world are found in BRICS countries”.

Motsoaledi, who is head of the international Stop TB Partnership, says he was “given an assurance by BRICS ministers of health that they will do everything in their power to have their heads of state attend”.

Clearly this was not enough. Only 32 leaders from the 193 UN member states have confirmed that they will attend Tuesday’s meeting, where countries will ratify a political declaration that has been heralded as one of the most significant moves in the fight against TB to date.

In July, President Cyril Ramaphosa and the Rwandan President Paul Kagame were the first heads of states to confirm their participation in the meeting. Ramaphosa will also be delivering a speech at the summit in the pre-lunch session.

“For us, this is very significant because it shows that we are committed to dealing with the TB epidemic at the highest political level,” said Department of Health Deputy Director-General Dr Yogan Pillay.

TB is the biggest killer of South Africans, yet it is a curable infectious disease.

South Africa has played an integral role at all stages of the high level meeting’s negotiations, and Motsoaledi first called for the summit to be held in 2016 at another high-level meeting on health.

“I think, for the world, South Africa has played an important role in the negotiations around the meeting, and showed remarkable leadership that should be applauded,” said MSF’s Candice Sehoma.

The TB summit, and the political declaration that will be ratified by countries there, has the potential “to turn the tide” against TB and it could be “a turning point in the fight against this terrible disease”, according to Dr Paula Fujiwara, the scientific director for the International Union Against TB and Lung Disease.

“We know that [these meetings] can be circuit breakers and you need look no further than the 2001 HLM on HIV which forever transformed that epidemic,” she said.

The HIV HLM galvanised the political will and resources used to tackle Aids at a global level and a similar outcome is hoped for TB.

Following intense pressure by the United States, the first draft of the political declaration excluded references to public health safeguards that can be used to access affordable anti-TB medicines for poorer countries.

But on 24 July 2018, South Africa disrupted negotiations, calling for the declaration to include language around the World Trade Organisation’s Agreement on Trade-related Aspects of Intellectual Property (TRIPS). TRIPS allow countries to use mechanisms to circumvent patent rights in to make essential medicines affordable, particularly in public health emergencies.

“The lack of this language can only be interpreted as a move to protect the interests of drug companies at the expense of universal access and saving lives,” said Fujiwara.

Thanks to South Africa’s intervention, the final draft of the declaration now explicitly mentions TRIPS.

“By taking a stance against a superpower like the US, South Africa showed how serious they are in the fight against TB, and that we don’t care about profits, we care about human beings,” said Sehoma.

South Africa has also been a global leader in ensuring widespread access to the only new anti-TB drug developed in five decades: bedaquiline.

South Africa was the first in the world to officially include the drug in first-line treatment for drug-resistant TB, replacing some of the older existing medicines with significant side-effects including deafness. In August, following South Africa’s move, the World Health Organisation updated its TB treatment guidelines to include bedaquiline.

Two thirds of all patients receiving bedaquiline are in South Africa, and because the drug is new and protected by intellectual property laws, the TRIPS language featuring in the declaration is particularly important.

The declaration has many tasks for countries, including committing to increasing global and domestic funding for research and development, finding the missing patients, ensuring broad access to affordable new drugs and ensuring that TB cases are properly monitored and reported.

The World Health Organisation released its annual Global TB Report last week, which painted a grave picture of the status of the epidemic and highlighted the $1.3-billion shortfall in funding for research and development.

Although patients from BRICS countries account for about half the global TB burden, their countries only contribute about 5% of the world’s spend on TB research, according to SECTION27’s Marcus Low.

Of the $726-million invested in TB research in 2016 only South Africa and India featured in the list of the top 10 contributing countries, according to Low. India was in sixth place (contributing $ 14,765,283) and South Africa in 10th (investing $ 6,465,746).

The US advocacy organisation Treatment Action Group published a report on TB funding in 2017 which showed that South Africa spent more on TB than any other country as a percentage of gross domestic product and is also first in the world when investment in TB research is measured against the total spent on all research and development in a given country.

The WHO’s report noted that TB funding needed to be scaled up dramatically across the globe if there is hope of beating the disease.

Last year, 1.6 million people died of TB in 2017 despite the disease being preventable and curable.

Fujiwara congratulated “the extraordinary leadership that South Africa has shown” and for Ramaphosa’s attendance which, she said, “is highly significant”.

“As of 2016, TB has now surpassed HIV as the biggest infectious disease killer in the world… So the stakes [of this HLM] are really very high.”

Meanwhile, Low said Indian and China accounted for one-third of the world’s cases.

“TB is an absolute crisis in both those countries. Those leaders’ absence sends a very bad signal.” DM