While the World Watches Ebola, Tuberculosis Stays Under the Radar

An airborne bacterium that usually targets the lungs, TB is a treatable and preventable illness, yet it is still prevalent in parts of the world. The worldwide rate of infection has been falling slowly over the past decade, but it remains a global health problem. In 2012, 8.6 million people were infected and 1.3 million died. TB killed more than 3,500 people on average per day in 2012. To put that into perspective, fewer than 2,000 people have died since the start of the current Ebola epidemic in West Africa.

The worldwide economic impact of TB is estimated to be as high as $12 billion annually, a figure that includes loss of potential income and decreased productivity. Gradual progress is being made in the fight against TB, but treatment of multidrug-resistant TB is still a challenge.

The Cost of Treatment and Containment

In 2012, 3.6 percent of all new infections of TB were defined as multidrug-resistant, which is when at least two of the four most commonly used drugs are ineffective. Drug resistance develops when the bacteria are able to adapt to the current treatments. In the case of TB, incomplete or improper administration of antibiotic treatments is the primary cause of the increased prevalence of drug-resistant strains.

Treating drug-resistant TB is a long and arduous process. Standard treatments for non-drug-resistant TB require 6-9 months, whereas multidrug-resistant cases can take more than two years to treat. The expenses are greater — between 15 and 200 times more, depending on the country or region — and the potential side effects of the drugs required for treatment are much harsher and can include seizures, hearing and vision impairment, depression and psychosis.

In regions where drug availability is low and monitoring to ensure adequate and complete treatment is difficult, there is a higher risk for drug resistance to develop. To make matters worse, treatment of drug-resistant TB is often impractical in poorer countries and regions, where treatment costs can exceed per capita income.

International aid is vital for controlling the spread of TB of both the drug-resistant and non-drug-resistant varieties, especially in developing areas such as India and sub-Saharan Africa. But to truly beat the disease, the governments of affected countries will also need to find the political will to invest economic resources and manpower into improved health care and monitoring. Many of the 22 countries that are classified as high-burden nations (those with the highest infection rates) are located in developing parts of Asia and sub-Saharan Africa. Together, these 22 countries account for 80 percent of the world's total TB infections.

To control the spread of drug-resistant strains, new treatments will probably be necessary. This is where pharmaceutical companies' research and development will be crucial. The recently announced collaboration between pharmaceutical company Novartis and nongovernmental organization TB Alliance could help advance a new family of drugs that shows potential to treat drug-resistant strains of TB. However, there are no guarantees that promising targets (compounds currently being tested) will prove effective after further testing. Drug development is by its nature a gradual process, and it could be several years before drug targets become viable treatment options.

In the meantime, control will remain a significant issue for regions that are disproportionately affected by multidrug-resistant TB. China, India and Russia account for more than half of the total multidrug-resistant TB cases, but prevalence of drug-resistant cases is especially high in the former Soviet Union. The collapse of the Soviet Union in the early 1990s resulted in a degradation of the health care system in the region, enabling drug resistance to develop more rapidly in an area where TB was already prevalent. The global average rate of drug resistance is less than 4 percent for new cases and about 20 percent for recurrent cases. But in many of the former Soviet states, more than 20 percent of new cases and more than 50 percent of recurrent cases exhibit drug resistance.

The High-Risk Country: Russia

The rate of multidrug-resistant TB infection is extremely high in parts of Russia, with roughly 23 percent of new TB cases showing multidrug resistance. Some regions have higher rates: Yamalo-Nenets Autonomous Area in the north has the highest rate of multidrug-resistant TB infections, with nearly 42 percent of new cases showing resistance. In addition, 74 percent of recurrent TB cases in Ulyanovsk province are multidrug-resistant.

However, because Moscow is focused on other matters, including the struggle for influence in Eastern Europe and domestic economic problems, allotting the necessary funds to treat and control the disease is problematic. The estimated per patient cost of treating multidrug-resistant TB in Russia exceeds $10,000. Persistently high rates of TB and drug-resistant TB infection could be an additional economic hindrance for parts of Russia's population, especially in poorer areas.

TB primarily affects individuals in working-age populations. Russia also has a high rate of HIV infections — a population subset that is highly susceptible to TB infections. Taken together, the impact of TB and HIV on the working-age population will hasten the demographic decline Russia will face in the coming decade. In addition, Russia limits access of outside nongovernmental organizations and medical groups because it is wary of Western influence in the country. The result is that the Kremlin has struggled to gain ground on all sorts of endemics in the country, including TB. Instead, it is ignoring the issue to an extent. Stratfor expects this approach to continue for now.

The Outlook for the Rest of the Region

Central Asia is also looking forward to a line of obstacles over the next several years that will complicate efforts to control the rate of infection. Stratfor expects to see leadership turnovers in Uzbekistan and Kazakhstan in the not-too-distant future. Coupled with existing border tensions and unequal resource distribution, the potential for unrest in Central Asia is high. There will be little initiative or capital to focus on health care issues. In addition, an uncertain security situation or closer ties with Russia could restrict the ability of international aid to contribute to controlling the disease.

Unrest in the region will also likely aggravate the problem of poor treatment monitoring, which results in incomplete treatments, in turn breeding drug resistance. The economic impact of a continued TB epidemic includes productivity loss, and the World Bank estimates that this deficit plus other indirect costs from all TB cases will be between 0.5 and 0.8 percent of gross domestic product for Central Asian countries.

Eastern Europe is in limbo, pulled between Russia and Europe. Countries with higher potential for outside investment, such as the Baltic states, which have high incidence rates of multidrug-resistant TB, could see future economic growth. With this growth would come additional funds for treating endemic diseases such as TB, although some international aid would probably still be needed. Also needed is the political will to make social changes, such as improving the health care system by, for example, facilitating better access to proper care, necessary advanced equipment and better monitoring and testing to track the disease's spread. As economic growth brings better quality of life, Eastern European countries could gain better control over the spread of drug-resistant TB. Estonia and Latvia are already beginning to see reduced rates of drug-resistant cases after a concerted effort to address the problem.

Countries such as Ukraine, Belarus and Moldova will probably have a harder time maintaining control of the problem of drug-resistant strains within their borders in the near term. The upheaval in Ukraine could lead to cutbacks in funding for social programs, including health care. Belarus' options are also somewhat limited by the country's close ties with Russia — ties that could impede Belarus' access to future investments from the West. Moldova will remain an important territory for Russia and Europe, but as a small country sensitive to external economic shocks, it may not have the political will to invest in the health care sector.

Finally, in the middle of these scenarios is Azerbaijan. The potential for economic growth exists, but it is closely tied to the price of natural resources. Azerbaijan also understands that outside powers can take advantage of social dissatisfaction, however, so one of its critical measures is to divert oil revenue for social development. As in other countries, the needs of the poor surpass available money, so the maintenance of internal security is crucial. The focus on social investment has the potential to benefit the health care sector, aiding in the future control of drug-resistant TB.

The outlook for reducing the number of standard TB cases in the world is positive. With some of the United Nation's Millennium Development Goals within reach by 2015, the medical field is making progress in the war against TB, but the bacteria is also adapting. Multidrug-resistant TB is poorly controlled, and the former Soviet Union is one of the regions most severely hit.

The economic burden of treating the disease is high, especially for developing nations, and until new treatment methods are found, effectively administering the treatment will itself be a hurdle. We will likely see greater international effort to contain the spread of drug-resistant strains, but social, political and economic factors in some regions may limit the success of the effort.