Common health for a Commonwealth?..
..or a collective tuberculosis emergency?
When the political media of the English speaking world use the word “commonwealth” they most often refer to the “Commonwealth of Nations” – a hodge-podge of countries which are largely left-over from the de-colonisation of the British Empire but which have since become a force of advocacy for human rights, for gender equality, for the welfare of smaller countries and for a fairer deal for the poor. First referred to as the “British Commonwealth” (and it is often still referred to that way by many native British) it hasn’t had that title for over half a century. Collectively it comprises an unlikely voluntary association of 53 independent sovereign states across the world which in turn comprises a mix of just under a third of humanity.
Map of the world showing Commonwealth of Nations countries in blue
(Zimbabwe, which was recently expelled, is the country in orange)
The London Declaration of 1949 (which originally established the organisation) specified that all its member states were not just “free” but that they were also quasi-constitutionally “equal”. Even more wonderfully (with the curious exception of Australia) these 53 countries elected to consider themselves as technically not being “foreign” to each other in mutual recognition of their shared heritage and culture. They are more generally seen today, however, as a family of countries which convenes biennially for heads-of-government pow-wows (when they sometimes squabble with each other but generally end up friends), and whose athletes gather every four years for the so-called ‘friendly games’ – a lower key and less commercial version of the Olympics.
These 53 nations may be equal partners but their 2.3 billion citizens are far from equal with each other. Whilst three of its member countries are up there among the IMF’s top ten world economies, when taken as a whole this one-third of mankind collectively only musters about a sixth of the world’s gross product when measured in purchasing power parity (PPP) and just under a seventh when measured nominally in GDP. Many Commonwealth countries are unusually rich in mineral resources (one reason why they found themselves part of the British Empire in the first place) but the vast majority of the people who live in this Commonwealth of Nations are unusually poor.
Some of them are lucky enough to be born with some of the highest life expectancies on earth, and some are born with the lowest. What’s rarely recognised, however, is how many of these countries also have a significantly heavy burden of tuberculosis. In fact, as can be seen in the table below this huge human collective includes more than half of humanity’s estimated new cases of tuberculosis each year.
Commonwealth = a 'common good'
In light of this burden of disease the word “commonwealth” turns out to be ironic – though the reason may not be immediately obvious. It’s because the English word ‘wealth’ is derived from the old English word ‘weal’ – a word which never originally referred to the accumulation of money but instead referred to ‘goodness’ or ‘well-being’. In the fields of philosophy, of ethics and (most importantly of all in this instance) in the field of political science ‘commonwealth’ generally refers to a ‘common good’ or a ‘common well-being’. The word ‘commonwealth’ in this sense actually dates from the 15th century – and it suggested something mutual that could be shared and be beneficial for all (or at least for most).
We can go back further though – to the Bible - for what may be the earliest reference to this idea in the Western literature, and quote from the Epistle of Barnabas: “Do not live entirely isolated, having retreated into yourselves, as if you were already justified,” Barnabas entreated whoever he figured would be reading his letter, “but gather instead to seek together the common good.” This idea is quite in line with the general ideas behind today’s Commonwealth of Nations but, given the new age of globalised inequality which we now live in, it surely deserves fresh consideration.
Of course such a concept of ‘common good’ changes over time – it’s unlikely that the idea of a common good as conceptualised by the recipients of Barnabas’s letter two thousand years ago would be the same for a reader of these same words today, but there are certain things that remain as constants in the human condition nevertheless – relating to the important business of staying alive. So in the face of an impending plague of drug-resistant disease which largely threatens the most vulnerable, the idea of any sort of commonwealth-within-the-Commonwealth might just be coming of age.
The Estimated extent of tuberculosis in the Commonwealth
With this in mind we should take a look down the list of the member states of this modern Commonwealth of Nations – particularly at their relative populations [column 2], at their respective incidence rates of tuberculosis [column 4] - i.e. the estimated new cases of disease each year per 100,000 population - and at their total numbers of estimated cases which occur each year [column 5]. At first glance it will be seen that they vary enormously, but on further review they tell us a story that is really rather worrying and we'll draw some conclusions about this immediately below the lists of numbers.
The columns are as follows:
1.Country 2.Population 3.Health Ranking[ii] 4.TB incidence[iii] 5.Cases[v]
High Burden Country/ High Incidence country[i]
Antigua & Barbuda 86,295 86 4 4
Australia 23,795,300 32 6 1,428
Bahamas 368,390 94 14 52
Bangladesh 6/22 HBCs 158,088,000 88 225 355,725
Barbados 285,000 46 2 6
Belize 358,899 88 40 144
Botswana 8/22 HICs 2,024,904 169 548 11,097
Brunei 393,372 40 66 260
Cameroon 21,143,237 164 182 38,475
Canada 35,702,707 30 5 1,785
Cyprus 858,000 24 4 6,864
Dominica 71,293 35 13 9
Fiji 859,178 96 23 198
Ghana 27,043,093 135 92 24,800
Grenada 103,328 85 4 4
Guyana 46,900 128 112 835
India 1,269,090,000 112 190 2,411,271
Jamaica 2,717,991 53 7 189
Kenya 15/22 HBCs 46,749,000 140 314 146,795
Kiribati 106,461 142 409 434
Lesotho 6/22HICs 2,120,000 183 634 13,441
Malawi 16,310,431 185 245 39,960
Malaysia 30,538,100 49 83 25,348
Maldives 341,256 147 39 133
Malta 425,384 5 12 51
Mauritius 1,261,208 84 22 277
Mzmbque 14/22HBCs; 9/22HICs 25,727,911 184 539 138,673
Namibia 3/22 HICs 2,113,077 168 693 14,643
Nauru 10,084 98 49 5
New Zealand 4,572,100 41 8 360
Nigeria 10/22HBCs 183,523,000 187 338[vi] 620,230
Pakistan 5/22HBCs 189,388,000 122 231 437,370
Papua New Guinea 7,398,500 148 303 22,415
Rwanda 10,966,891 172 115 12,610
St Kitts &Nevis 55,000 100 7 4
St Lucia 185,000 68 8 15
St Vincent & the Grenadines 109,000 75 24 26
Samoa 187,820 119 12 23
Seychelles 89,949 56 31 28
Sierra Leone 5/22 HICs 6,319,000 191 645 40,758
Singapore 5,469,700 6 36 1,968
Solomon Islands 81,344 80 115 668
S. Africa 3/22HBCs 2/22HICs 54,002,000 175 971 524,340
Sri Lanka 20,675,000 76 66 13,645
Swaziland 1/22HICs 1,119,375 177 1257 14,065
Tanzania 18/22HBCs 47,421,786 156 164 77,770
Tonga 103,252 116 18 18
Trinidad and Tobago 1,328,019 64 22 292
Tuvalu 11,323 136 247 28
Uganda 20/22HBCs 34,856,813 149 226 78,775
United Kingdom 64,511,000 18 13 8,386
Vanuatu 64,652 127 72 190
Zambia 12/22HICs 15,473,905 182 481 74,425
Totals 267,278,528 n/a 227 5,161,315
There’s an awful lot of data to absorb in this table, so here are a few of the significant low spots:
1. Twelve of the 53 countries (i.e. 23% of the total) have national TB emergencies as defined by the WHO (at over 250/100,000 incident cases per year) - see column 4. In fact Commonwealth countries comprise nearly half of all 26 countries with current estimated TB emergencies.
2. Fourteen of the 53 are either in the WHO’s list of 22 High Burden Countries (HBCs) or in an alternative list of the countries with the highest incident rates of disease (the highest 22 HICs) or both (see column 1). That makes up more than a third of the collated two lists which amounts to 38 countries. Meanwhile seven of the ten countries which have the highest incidence rates of TB of all are Commonwealth ones.
3. The overall average Commonwealth incident rate of 227/100,000 (see bottom of column 4) means that the entire Commonwealth is only 23 cases per 100,000 population per year short of being a 53-country collective emergency. This is an astonishing conclusion, particularly given that the global incidence rate of TB (at 126/100,000) is estimated to be nearly a half lower than this Commonwealth average [vii].
4. Six of the ten countries of the world (as ranked by the WHO) as having the most deficient health systems in the world are in the Commonwealth. (see column 3) Meanwhile at the other end of the scale only two of the top ten countries are Commonwealth ones – Malta and Singapore. Furthermore a significant 16 of the 48 countries which comprise the worst quartile of these countries (as ranked by health provision) are Commonwealth members as in the list above (ranking 148th or more in Column ii). These rankings are highlighted in bold, and it will be readily noted that there are uncomfortable correlations between such deficiencies and high rates of tuberculosis.
5. And at least 19 of these 53 Commonwealth countries (i.e. 36%) can be reasonably considered to have recognisable risks of MDR-TB emergencies - either by being in the lowest quartile of health provision as estimated by the WHO or by having existing recognised estimated TB epidemics at emergency proportions (see columns 3 & 4).
Drug-Resistance - the Invisible Threat
This last percentage opens up a particularly uncomfortable projection for the Commonwealth in respect of the two clinically distinct types of TB (whether MDR or XDR) that are drug-resistant, not least because currently only four of the 53 have recognised DR epidemics (as defined by inclusions in the WHO’s list of 27 High Burden MDR-TB Countries).
Initially this might seem encouraging, particularly because both MDR- and XDR-TB are so challenging to diagnose and to treat. Unfortunately, however, this turns out to be only cause for further concern. This isn't just because TB’s realities dictate that wherever health provision is poor tuberculosis is probably being generally mismanaged because local resources are too stretched to cope - it’s because of the wider implications of this reality. It means that the numbers may well be underestimated in these countries (as has been recently been dramatically proved to be the case in Nigeria) and that any in-country capacity to diagnose MDR-TB (let alone estimate it with any accuracy) remains largely a fantasy despite there being a desperate need.
As such the fact that there is estimated to be so little MDR-TB is actually really worrying. No-one should pretend that the epidemiology of TB is straightforward, but it’s a given that in any country where the four first line drugs are consistently mismanaged for a period of fifteen years or more the probability will be that MDR-TB already exists as a significant proportion of an epidemic whatever current estimates might suggest.[viii] The bottom line is that no-one really has a clue how much MDR-TB there is in almost all of these countries (and this even includes South Africa where drug-resistant TB is already recognised to be out of control).
There are two examples that substantiate such suspicions and both are worth highlighting.
One is India where rates of MDR-TB were being serially under-estimated for years (and probably still are) but where a very serious DR epidemic has recently emerged, not just of MDR-TB but also of XDR-TB.[ix
The other is in southern Africa, in the member countries of the so-called Southern Africa Development Community (SADC). Nine of the 15 of these SADC countries are also members of the Commonwealth but of these only one (South Africa) is currently recognised to have an MDR-TB epidemic. South Africa’s in-country diagnostics are among the best in the world for diagnosing MDR-TB but the WHO’s last Global Report for TB proved that its experts’ estimates were actually well short of the numbers of cases that were actually being revealed, and the country’s epidemic is well recognised now as being out of control.
Meanwhile there is a strong probability (given that South Africa is both the economic and epidemiological furnace for the whole Development Community, and that five of the nine Commonwealth SADC countries border it) that all five of these countries already have MDR-TB epidemics of real significance (as surely will others within the SADC). In fact this probability is as good as a certainty given the high rates of temporary worker migration into South Africa particularly to provide labour for its mining industry where TB is a recognised occupational disease and whose miners are known to have probably the worst rates of TB in the world. The South African mines are often referred to as the ‘head of the snake’ of the region’s TB epidemic, but Botswana, Namibia, Ghana, Malawi, Mozambique, Sierra Leone, Zambia and Tanzania (all Commonwealth countries) also all have economies which are dominated by mining activity and all of them have high rates of tuberculosis, some of them very high indeed. Mining is of course also a significant activity in the economy of India.
It should also be noted that three Commonwealth countries (Australia, Canada and South Africa) are among the most preeminent and influential in the world of mining. The UK is also prominent partly because of its capital markets which are a source of finance for many mining projects around the world but also because most of the large international mining companies outside the U.S. are currently headquartered in London. Three of the largest mining companies in the world happen to be also of Commonwealth origin (Rio Tinto, BHP Billiton and Anglo American).
The StopTB Partnership is convinced that addressing the mining factor is a critical part of their strategy for the next ten years. They are also convinced that Civil Society now has a critical role to play in turning the tide of this ancient disease. In fact on the Commonwealth’s own website we can find the following cogent and helpful statement on this very topic that should be encouraging:
“The Commonwealth continues to provide a space for civil society organisation from across the globe to come together, influence governments and each other, and ultimately provide the people of the Commonwealth with the opportunity to have their voices heard and unite around common goals that aim to fashion a better world.”[x]
Conclusions - Civil Society, Human Rights and the Heads of Government Conference in Malta
So where exactly does that word ‘commonwealth’ (in that sense of the common weal) stand in the world of tuberculosis in the 21st century? How exactly is community well-being being shared within the Commonwealth? Is anyone within this family of Nations yet making an appropriate noise about what is almost certainly coming down the track in terms of drug-resistant TB?
A team of economists commissioned by the UK Government certainly made some noise last year by suggesting that 75 million will have died from MDR-TB by 2050 unless something is done, and that most of these deaths will have occurred in South Asia and Africa. (They didn’t add that most of these deaths will also be occurring in predominantly Commonwealth countries, but they could have.)
The image above (which was published fifteen years ago in the BMJ in 1999) gave us a picture of the known public health challenge that existed then within the Commonwealth from TB and HIV. The brown column of TB in the middle has, in the last fifteen years, unfortunately moved further upwards (cresting now at over 50%), and may even today have converged on the green column of HIV.
But where can we yet find the columns for MDR- or XDR-TB – which is where today’s real threat lies? Until a new multi-drug regimen is approved and rolled out at scale the clinical reality is that we have three clinically distinct pandemics on our hands, not one.
Surely it’s time for conferences to be convened to discuss this threat of DR-TB within this family of nations, to share good practice, to garner the strength of Civil Society, and (perhaps in honour of the spirit of St Barnabas) to look to “seek together the common good”. At the very least the topic should be being tabled for discussion at this November’s Commonwealth Heads of Government Conference in Malta. (Given that Malta holds pride of place in the WHO’s list as having the best health care provision in the entire Commonwealth of Nations, it actually seems a rather good place to start such discussions.)
Back in 2003 in Nigeria this Commonwealth of Nations committed itself “to democracy, good governance, human rights, gender equality, and a more equitable sharing of the benefits of globalisation”. Does this include addressing the human rights issues associated with a predictable and predicted risk for a billion or more of the Commonwealth’s most vulnerable people from untreatable disease in the coming decades? Or indeed of the human rights issue of access to universal health care? And should it include committing to a common weal?
Surely it should do.
[i] It should be noted that the category of High Burden Country (HBC) is one developed by the WHO, though it remains a dubious one. Where these are identified as ‘5/22HBCs’ etc. they refer to their ranking within these so-called 22 HBC’s in terms of their numerical (but not proportional) burden of disease. Since some of the 22 HBCs have much lower incidence, prevalence and mortality rates than do other countries with much higher proportional burdens of disease which don’t appear on this list at all, an alternative list of High Incidence Countries (HICs) offers us a much better measure of proportional burden. Again, where they are enumerated they refer to their rankings in a list of the highest 22 HICs. If this list alone is used, then Commonwealth countries actually include 32% of these 22 highest HIC’s and 7 out of the 10 highest ones. For much more information on this please see the Chapter ‘Incidence Rates and the Obscuring of Severities’ in ‘Blowing in the Wind – Drug-Resistant TB and the Poor’, published by the Moxafrica Charity)
[ii] These are taken from the WHO’s World Health Report of 2000. Those in the lowest quartile are shown in bold. It should be noted that this list is viewed sceptically by some experts but there are unquestionably terrifying instances of health worker shortages across this community of nations. Taking two examples: Sierra Leone (before Ebola) had 2 health workers per 10,000 population; meanwhile in rural areas of Papua New Guinea (where there have been alarming incident rates of TB reported, as high as 1,290 per 100,000) there are less than 7 health workers per 10,000. (23/10,000 is the threshold below which is assessed as a “catastrophic deficiency”).
[iii] These rates (with the exception of Nigeria) are taken from the WHO’s most recently published three-year average of incidence rates (from 2008,2009,2010). The rates which are reported annually to the WHO tend to fluctuate, so a three-year average was seen to be a way of developing a better overall picture. TB rates globally since 2010 have marginally dropped, but some (for South Africa for instance) have continued to rise, and many may be significantly underestimated anyway. (see note vi below).
[iv] Figures which appear in bold in this column represent countries with an accepted national TB emergency (of over 250/100,000 new cases each year).
[v] These numbers are simply computed from the population numbers and the incident rates.
[vi] Unlike all of the other estimated numbers which reflect the average across three years 2008-2010, this number was recalculated by the WHO in 2014 from a national prevalence survey for Nigeria which showed rates that were startlingly higher than were being estimated. The country’s estimated incidence rate (as in the 2008-2010 average) would otherwise have been a far lower 136/100,000. At a stroke this correction (which is based on better data than almost all of the rest of the above estimates) adds over 370,000 incident cases to the total pot. If this sort of anomaly is even remotely typical of other Commonwealth African nations generally then many of the figures quoted above have to be considered to be probable under-estimates of some significance.
[vii] As per the WHO’s 2014 Global Report on Tuberculosis.
[viii] Unfortunately it has to be suggested that the WHO’s tendency to officially talk down the numbers of MDR cases, particularly its institutional reluctance to recognise or look for evidence that they are on the rise at all, may well be because confronting this issue more openly means also confronting the possibility that their DOTS strategy has essentially failed in the longer-term.
[ix] There is a strong possibility that the officially estimated number of MDR-TB cases for India (64,000 in the last Report) is still an under-estimation.