Tuberculosis control: hard questions

Although in their Comment in The Lancet Mishal Khan and Richard Coker (Aug 23, p 646) raise real and well known challenges in the global tuberculosis response, they fail to propose any solutions and downplay efforts and achievements by many stakeholders to address these complex issues. We have some questions: How much can the statement that countries are ”incentivised to obscure programmatic challenges” be generalised? Are the definite tuberculosis burden declines in countries such as China and Cambodia, reported from prevalence surveys, somehow unconnected to the expansion of tuberculosis control eff orts over the past few years? What should replace performancebased funding to prevent the so-called perverse incentive by international donors? Financing needs to somehow be linked to performance measured through targets and indicators. How could accountability be otherwise demonstrated? Can there really be any trade-off s between the ”urgency to treat” versus ”long-term health systems strengthening goals” as is proposed? We need both, as outlined in the WHO post-2015 Global Strategy endorsed by the World Health Assembly. Would it be ethical to delay introduction of new tools until health systems are working to perfection? How would this affect urgently needed development of new diagnostics, drugs, and vaccines, or operational research to guide their introduction? Is there a counter-proposal to the essential, WHO-recommended health systems to deliver treatment to patients with multidrug-resistant tuberculosis? Can we ethically watch patients with multidrug-resistant tuberculosis die while waiting for improved health systems? Is duty of care different for tuberculosis than for cancer or HIV? Would anyone privileged enough to live in an affl uent country decline treatment if they contracted multidrug-resistant tuberculosis? Should we not learn from HIV control how creativity and mass action can overcome formidable programmatic barriers associated with complicated, costly interventions? The latest WHO Global Tuberculosis Report (and special supplement) stresses that prevention and proper fi rst-line treatment are the fi rst step in the control of multidrug-resistant tuberculosis. Is the growing evidence showing that scale-up of multidrug-resistant tuberculosis services and improved treatment are achievable under programmatic condition—even in high-burden countries—not convincing enough to let us proceed with both prevention and treatment? We believe that the public health crisis of drug-resistant tuberculosis needs urgent, concerted actions, although we may not yet have all the answers.