Speaking in her car from an undisclosed location somewhere in war-torn Ukraine, Yana Teerleva, head of TB in the country’s Ministry of Health, lamented the destruction that she is witnessing every day in hospitals and clinics – including the shelling of three huge dispensaries where the country had stockpiled sufficient TB medications for the remainder of 2022. 

This month, Teerleva had been planning to implement an innovative new TB treatment regimen to further step up the national response to its drug resistant TB burden – which TB control officials in Geneva had praised as a model. 

“Instead we are dealing with the Russian invasion and discussing military hardware”, Teerleva said in a media briefing Tuesday, just ahead of World Tuberculosis Day, 24 March.

Global TB experts are bemoaning the destruction of Ukraine’s innovative TB programme, which had made significant progress in addressing the country’s high burden of multi-drug resistant TB (MDR-TB) over the past 15 years. 

Meanwhile, with global TB funding well below needs, prospects of meeting the UN Sustainable Development Goal target for ending the TB epidemic by 2030 look increasingly dim, Lucica Ditui, executive director of the Geneva-based STOP TB Partnership, told Health Policy Watch in an interview.

“This gives us very little chance of meeting the UN 2030 targets,” she said.

Model programme now in ashes – literally

Almost one-third of Ukraine’s TB cases are drug-resistant, and last year the country diagnosed and treated 24,000 people with TB, including almost 5,000 people with MDR-TB.

But the Ukrainian government had been “extremely committed” to addressing TB over the past two to three years, paying for new drugs and diagnostics and building strong relationships with civil society organisations, Ditiu told Health Policy Watch.

“The country did a lot to improve their health system. It is devastating to see these bombs destroying everything. These are losses that will take decades to regain.” 

Over the past 15 years, Ukraine had significantly reduced its TB cases from over 127 cases per 100 000 people in 2005 to just 42.2 cases per 100 000 people in 2020.

Just before the war, says Ditiui, “The country was paying for their own TB drugs as well as diagnostics – and they had secured enough to treat and diagnose everyone in need in Ukraine.

“They were very keen to implement new tools like rapid molecular diagnosis, as well as new drugs.  They had cohorts of people enrolled in studies for new TB treatments. Collaboration between public health officials, civil society and communities also was very good.”

The gains in TB treatment were part of a broader health sector reform that had been underway, Ditiu added, saying: “What I am really upset about is that the country did a lot to improve their health system, their hospitals, to do health sector reform. To see these bombs destroying everything. These are losses that will take decades to regain.”

“Ukraine was always at the forefront of the fight against tuberculosis,” Teleeva told the Stop TB briefing Tuesday. “We wanted Ukraine and the entire world to be free from the TB and for that, we have done everything possible.”

However, she said that according to health ministry information, “more than 135 hospitals in Ukraine have been shelled by the Russian aggressors”, including “three huge regional anti-tuberculosis dispensaries” and the country’s health infrastructure “is not working”.  WHO has confirmed some 60 attacks on hospitals and other health facilities. 

Appeal to combat stigma – among the war’s knock-on effects

Both Ditiu and Teeleva stressed the need to focus now on countering the knock-on effects of the war – including how to treat internally displaced people, how to ensure people fleeing can continue their medications, and how to combat stigma that refugees elsewhere may encounter.

 “We worked to overcome the stigma discrimination of these people living with TB”, Teleeva said, of the pre-war period. 

She appealed to neighbouring countries that have a much lower burden of TB disease not to stigmatise Ukrainian refugees. 

“TB is very sensitive, and if we broadcast information about its uncontrolled spread, we will stigmatize people who are already stigmatized, for people who are already in a very difficult situation,” said Terleeva. 

Ditiu acknowledged that it’s very likely the war will lead to a higher level of TB cases -particularly inside Ukraine itself. “We’ll see an increase in TB, in drug-resistant TB and in mortality,”  she predicted, “because people will be staying close together in shelters, in crowded places, with bad food and stress.”

However, she said good tracking and surveillance by countries that receive refugees can help counter any spillover effect, beyond the borders.

‘Stupid war’

Decrying the “stupid war”, Romania’s Health Minister, Professor Alexandru Rafila, told the briefing that his country was doing everything it could to assist the refugees that had fled across the 600km border with his country, including identifying and ensuring treatment for TB patients.

As a country with a relatively high burden of TB itself, Romania has “a network of TB hospitals and TB ambulatory care centres where we can perform rapid diagnosis and treat Ukrainian patients if they are resistant or need to initiate treatment”, added Rafila.

The Global Fund has also provided Romania with additional Gene Xpert rapid testing machines and TB medication to assist Ukranian patients, the health minister added.  

However, while Romania and Moldova had “some capacity” to deal with TB, Ditiu warned that Poland is in a different category – precisely because its own burden is quite low.

“Poland is not a country with a lot of TB – so I’m not sure how well the network will be able to deal with it – even though the doctors certainly have a lot of knowledge”.

In addition, prices of TB medication in both Romania and Poland are up to ten times higher than in Ukraine, as both countries are part of the European Union and pay EU prices for drugs that Ukraine was able to procure through the Global Fund, Ditiu added. 

“We are having a conversation with the Global Fund to see how we can lower the cost,” she added. 

TB civil society trying to locate patients

Olya Klymenk, head of TB People Ukraine, a network of over 70 organisations, said that her organisation was doing its best to locate displaced patients who have fled their homes or their communities, and offer them humanitarian aid, including food.

“We are trying to take care of the patients who are out of the hospital right now because we understand that, without social support, they will not have a good life,” said Klymenk.

Teleeva stressed that in the emergency the primary need is to, “focus on ensuring patients know where to go and have a desire to continue treatment.

“They have to be assured there is a reason to live, that they will go back to Ukraine, and they have to be healthy to help us rebuild. They need this optimism, to have this desire to live and continue living.”

‘Pathetic’ investment in TB

Meanwhile, Ditiu lamented that “investments in TB are pathetically low” – perhaps because 90% of the disease burden is in lower-income countries.

“In 2020, we had $1.9 billion [in] domestic investments, which is very very, very little,” she said, referring to national governments’ own contributions to beating TB. In addition, “The Global Fund, which is a big donor for TB, gave around $800 million, which is completely insufficient.” 

Stop TB estimates that $19.6 billion per year will be needed over the next eight years for TB prevention and care, and $4 billion per year will be required for research and development (R&D) of the new diagnostics, medicines and vaccines needed to end TB. 

This represents about four times what is currently available for the TB response (in 2020, $5.3 billion was available for care and prevention and $0.9 billion for R&D).

The year 2022 is critical for the global fight to end TB as the world faces a fast-running countdown to reaching the 2018 United Nations High-Level Meeting (UNHLM) TB targets, which the international community agreed to meet by the end of December. All projections show that the world is not on course to meet the UNHLM treatment targets set for 2022.

“We simply cannot continue to stand on the sidelines and watch while people around the world fall ill and die from a preventable and treatable disease,” said Ditiu.

“We also cannot continue to accept what we accepted for years—every year having less than 40% of the funding need for the TB response. Now we are facing a disastrous funding shortfall, bigger than what we had expected. We not only need to step up efforts to meet targets set at the 2018 United Nations High Level Meeting on TB,” she said, referring to the UN pledge to accelerate progress toward the 2030 targets, “but the TB response must also recover from the devastating impacts of the COVID-19 pandemic.”

Image Credits: The Global Fund / Evgeny Maloletka.