Opinion article by Profs Christo Heunis, Gladys Kigozi-Male, Michelle Engelbrecht, Centre for Health Systems Research & Development, University of The Free State, and Prof Martie van der Walt, South African Medical Research Council.
On 24 March each year World Tuberculosis (TB) Day is commemorated to raise public awareness about the devastating health and socio-economic effects of the disease and to intensify efforts to end the global TB epidemic. The date marks the day in 1882 when Dr Robert Koch announced his discovery of the bacterium that causes TB, thus making its diagnosis and cure possible. Koch emphasised the importance of TB, stating that “if the number of victims which a disease claims is the measure of its significance, then all diseases, particularly the most dreaded infectious diseases, such as bubonic plague, Asiatic cholera, etc., must rank far behind [TB].” TB is perhaps most famously portrayed in Thomas Mann’s Nobel prize-winning The Magic Mountain: “It was a cough, apparently – a man’s cough, but a cough unlike any [he] had ever heard; indeed, compared to it, all other coughs with which he was familiar had been splendid, healthy expressions of life – a cough devoid of any zest for life or love, which didn’t come in spasms, but sounded as if someone were stirring feebly in a terrible mush of decomposing organic material.”
In 1994, the World Health Organisation (WHO) declared TB, “alone among health concerns”, a global health emergency. In 1999, WHO questioned the persistence of TB despite a century of microscopic detection methods, and nearly half a century of effective anti-TB drugs, highlighting the paradox of increasing deaths. Adopted in 2014, the WHO’s 90-90-90 End TB Strategy aimed to reach, by 2020, at least 90% of all people with TB and commence of them on appropriate therapy, i.e. first-line, second-line and preventive therapy, as required. The strategy underscored the imperative for affordable, effective, and rapid-point-of-care diagnostics, as well as vaccines offering pre- and post-exposure protection, alongside safer and shorter treatment regimens across all forms of TB.
BRICS countries grapple with significant TB burdens
The BRICS nations – the Federative Republic of Brazil, the Russian Federation, the Republic of India, the People's Republic of China, and the Republic of South Africa – collectively account for nearly half of the global population, around 25% of the world’s gross national income, about 50% of the world’s poor, and approximately 40% of the global burden of disease. Specifically, the BRICS countries account for almost half of global TB cases, and the world’s largest number of multidrug-resistant TB cases.
Regarding health cooperation among BRICS, the pursuit of universal health coverage stands out as a paramount objective aligning with the primary healthcare agendas of each member state, including the imperative to address the complex challenges posed by increasing burdens of both communicable and noncommunicable diseases. It is a sobering observation that all the BRICS countries continue to grapple with significant TB burdens, far surpassing those of other nations within their respective WHO regions in terms of TB incidence. However, each country faces unique weaknesses and constraints in tackling the TB crisis. So, for example, Brazil and Russia are challenged to address TB among vulnerable groups such as drug users and prisoners, while India contends with a high number of missed TB cases, China confronts the pressing need to enhance access to treatment for multidrug-resistant TB, and South Africa bears a staggering burden of TB-HIV co-infection.
In November 2017, the establishment of a BRICS TB Research Network was announced during a meeting of health ministers in Moscow. This network aims to spearhead robust research into new tools, diagnostics, vaccines, and drugs, thereby informing and accelerating the utilisation of existing and emerging interventions in TB control toward eventual elimination. In December 2023, the BRICS TB Research Network Innovation Summit was convened in Durban. Health scientists from the BRICS bloc reasserted their commitment to collaborative TB research. Stressing the urgent need for joint action, delegates highlighted the importance of innovation in addressing TB’s significant impact within their countries and unanimously endorsed the targets and commitments outlined in the 2023 United Nations High-Level Meeting on TB, particularly regarding the strengthening of research capacity and collaboration through dedicated TB research platforms and networks. The summit also raised concerns about the dearth of new diagnostics, medicines, and vaccines essential for combating TB, advocating for collaboration among member states to facilitate technology transfer, information sharing, and knowledge exchange. Additionally, experts emphasised the importance of transnational cooperation in financing and conducting research necessary to transition the BRICS countries from consumers to suppliers of innovative TB tools, thereby ensuring affordability and accessibility. The establishment of the BRICS TB Research Network provides a platform for joint research initiatives aimed at developing new tools, diagnostics, vaccines, and drugs for TB prevention and treatment. This collaborative approach enhances the capacity of member states to conduct robust research and to effectively translate findings into policy and practice. The broad success story, so far, is that these nations have come together to contemplate the global health agenda and present a new agenda – one that is different from the traditional Western health agenda and will address TB in the context of the BRICS and non-Western countries’ predominantly public healthcare systems. Moreover, the BRICS countries have an indispensable responsibility in elevating the “social determinants of health” as a lens through which to scrutinise and address the health challenges facing the developing world, not least of which is to achieve Sustainable Development Goal 3, aspiring to ensure health and wellbeing for all, including a bold commitment to end the epidemics of AIDS, tuberculosis, malaria, and other communicable diseases by 2030.
BRICS TB Research Network a beacon of inspiration
With adequate funding and political support, the BRICS TB Research Network promises to become a beacon of inspiration. In addressing the current dependence on external funding sources like the US government and the Bill and Melinda Gates Foundation, the network could bolster research infrastructure, support scholarships, and foster drug discovery and clinical trial capabilities within member states. Whereas much-needed TB vaccine clinical trials are under way and in different phases across each of the five BRICS countries, it could be argued that they should not have acted in isolation, but rather should all have been simultaneously involved in transnational vaccine development efforts.
Given the scale and influence of BRICS nations, advancements in TB research can yield significant global impacts on TB control efforts. These countries have a collective responsibility to help avoid a scenario of uncontrollable antimicrobial resistance which will be truly catastrophic to global TB control efforts. Overall, TB research within the BRICS countries plays a pivotal role in enhancing understanding and developing effective strategies for TB prevention and control, both domestically and internationally. Identification and development of innovative and cost-effective solutions and best practices will likely also be applicable to transforming health and TB control in the rest of the world.
The BRICS countries have the potential to be important leaders in a variety of social policies such as health. Each of these countries has set a national pledge to the right to health and is working on health system reforms to achieve universal health coverage. However, according to WHO data from 2022, South Africa exhibits the highest TB incidence, particularly among HIV-positive individuals, and faces significant challenges in TB treatment success rates compared to the other BRICS countries. Despite substantial investments in its national TB programme, South Africa must particularly improve coordination between its HIV and TB programmes to effectively combat TB, aligning with the overarching goal of ending TB accentuated by the World TB Day’s theme, “Yes! We can end TB”. BRICS collaboration in terms of TB research holds great promise to achieve this end.