“Oh my God, it’s terrible,” said the physician and humanitarian Paul Farmer, who has written extensively on community-based healthcare models as a way to quell the spread of drug-resistant tuberculosis and other diseases. “It’s awful. It’s been 40 years since we’ve had new drugs. It’s so sad.”
Farmer calls the lack of community-based care the “Achilles heel” of the health care system in the U.S., which incentivizes frequent and costly hospitalizations for patients with TB and other chronic diseases who have few other options for care. “They get bounced in and out of hospitals or halfway houses, where if they had a community health worker checking in on them every day, you always see decreased use of emergency rooms.”
The idea behind community-based care is to set up a system where nurses and other workers visit people who need care each day, encouraging them to take medicine, taking vital signs if necessary, and so on. Eligible patients for such visits might be people who have HIV, TB, mental illness, or diabetes, he says. For tuberculosis specifically, Farmer says, community-based care would help people stay on course with their antibiotics; a crucial component of keeping drug-resistant TB at bay. “Without community-based care, I don’t see how it can work,” he said. “There’s not a lot of evidence that anything else works. It costs a lot more to give bad care in a facility than to give good care with community health workers.”
At the same time, Farmer, Gray, Fauci, and other public health leaders emphasize the need for an infusion of research funding for development of new and better medicine to treat tuberculosis. The Bill and Melinda Gates Foundation has donated tens of millions of dollars in grant money to pursue a tuberculosis vaccine, but public funding for such research is scant. TB is now a “standout poor performer” compared with research focused on “most bacterial infections, parasitic infections, and viral infections,” Farmer told me. Meanwhile, existing drugs may become obsolete due to antibiotic resistant strains of the disease. “You’re facing the valley of death because there’s nothing on the horizon.”
Given the link between HIV and TB—a huge proportion of HIV deaths are linked to TB, as people living with HIV are up to 30 times more likely to develop active tuberculosis than people without HIV—scientists often point out how much better HIV researchers have been at securing funding for fighting that disease.
“All the things that we have with HIV are in stark contrast to what we have with TB,” Fauci told me. “With tuberculosis, we don’t have a good way to monitor the disease, we don’t have good biomarkers, we don’t have good ways to figure out the efficacy of treatment.”
In other words, there’s urgent need not just for newer drugs with less burdensome treatment regiments; but also a need for a faster way to diagnose TB, and drug-resistant TB in particular. But it may be impossible to secure financing for such efforts in a public funding environment in the United States that is, many scientists told me, grossly isolationist. (See also: The Congressional failure to fund Zika research.) The United States, as a wealthy country, has a “moral obligation” to take action, Fauci says, but investing U.S. dollars in the fight against tuberculosis is also a practical matter of protecting Americans.