Déjà vu all over again? More of the same will not achieve the End TB 2030 targets on time

The definition of insanity is doing the same thing over and over again and expecting different results-attributed to Albert Einstein In the aftermath global World TB Day, a sense of déjà vu permeates. Merely presenting sobering figures and calling for increased resources and the usual interventions is insufficient. It is time for a wake-up call to break the silence regarding the likely failure to meet the 2030 End TB targets and to call for major changes in TB control strategy. The global TB response lacks traction. Despite three decades of costly efforts, TB incidence only declined from 143/100, 000 in 1990 to 133 in 2022. 1Dolin P. J. Raviglione M. C. Kochi A. Global tuberculosis incidence and mortality during 1990-2000. Bull World Health Organ. 1994; 72: 213-220PubMed Google Scholar, 2World Health OrganizationGlobal tuberculosis report 2023. World Health Organization, Geneva2023Google Scholar This equates to a meagre 7% reduction, roughly 0. 2% per year. WHO's TB elimination 1 case/million threshold would require a 99% reduction, a feat projected to take over two millennia at current rates. An optimistic 10-fold increase to 2% decline per year would still take 242 years. Global investments, although substantial, have not yielded commensurate gains. The 43 billion expended between 2003 and 2017 was accompanied by a marginal decline from 142 to 138 cases per 100, 000 population. 3Granich R. Gupta S. Two diseases, same person: moving toward a combined HIV and tuberculosis continuum of care. Int J STD AIDS. 2018; 29: 873-883Crossref Scopus (3) Google Scholar This persistent gap between lofty intentions and poor outcomes underscores the urgency for a paradigm shift in our approach. 1Dolin P. J. Raviglione M. C. Kochi A. Global tuberculosis incidence and mortality during 1990-2000. Bull World Health Organ. 1994; 72: 213-220PubMed Google Scholar, 2World Health OrganizationGlobal tuberculosis report 2023. World Health Organization, Geneva2023Google Scholar South East Asia Region (SEAR), with 25% of the global population, shoulders 45% of the estimated global TB burden. Progress towards ending TB is also inadequate, with an estimated ∼4. 85 million new TB cases and over 600, 000 deaths in 2022 alone. Regional rates of TB incidence had a negligible decline of around 1–2% per year since 2015 and disruptions during COVID-19 reversed these declines in many countries. Overall, declines in the low single digits over decades is unacceptably slow and should prompt us to find new approaches to sharply accelerate declines to meet the 2030 End TB Targets. 4World Health OrganizationThe end TB strategy. 2015https: //iris. who. int/handle/10665/331326Date accessed: March 20, 2024Google Scholar, 5World Health OrganisationTuberculosis profile: WHO South-East Asia region. Tuberculosis profile, 2024https: //worldhealthorg. shinyapps. io/tbₚrofiles/? ᵢnputs_ it detracts attention and resources from treating drug-susceptible cases, "7World Health OrganizationGroups at risk: WHO report on the tuberculosis epidemic. WHO, Geneva, Switzerland1996https: //iris. who. int/handle/10665/63468Date accessed: March 20, 2024Google Scholar to recommendations for newer diagnostics and short-term treatment regimes. However, despite the change, SEAR only detected and successfully treated ∼27% of the estimated hundreds of thousands of annual rifampicin-resistant and MDR-TB cases, underscoring the slow progress and looming threat of drug-resistant TB. 5World Health OrganisationTuberculosis profile: WHO South-East Asia region. Tuberculosis profile, 2024https: //worldhealthorg. shinyapps. io/tbₚrofiles/? ᵢnputs_ 157: 127-130https: //doi. org/10. 4103/ijmr. ijmr₃24₂3Crossref PubMed Scopus (2) Google Scholar Results of the India RATIONS trial showing the protective role of nutrition to prevent new TB illnesses among household contacts, highlights another important gap in our current TB control vision and strategy. 9Bhargava A. Bhargava M. Meher A. et al. Nutritional support for adult patients with microbiologically confirmed pulmonary tuberculosis: outcomes in a programmatic cohort nested within the RATIONS trial in Jharkhand, India. Lancet Glob Health. 2023; 11: e1402-e1411Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar We must explore newer approaches to increase and make better use of resources and ensure accountability. A few are below: •Academics and donors need to invest in proof-of-concept studies to show that ending TB is feasible using the recommended strategies in the 2017 SEAR and 2018 global declarations. 6World Health Organization Regional Office for South-East AsiaBending the curve: ending TB in the WHO South-East Asia region. World Health Organization, Regional Office for South-East Asia2017https: //iris. who. int/handle/10665/258693Date accessed: March 12, 2024Google Scholar, 8Bhatia V. Sharma M. Rijal S. Urgent need for increased investments to end tuberculosis in the South-East Asia region. Indian J Med Res. 2023; 157: 127-130https: //doi. org/10. 4103/ijmr. ijmr₃24₂3Crossref PubMed Scopus (2) Google Scholar This should include research on the impact of improved nutrition at population level as well as other innovative interventions. •Donors must be held accountable and self-report their TB funding and additionality as well as reductions of funding in other eliminable diseases. Transparently matching investments with activities and contribution to impact together is essential good practice. •The call for combined elimination of eligible diseases and the response is seriously delayed. WHO has not yet provided the leadership needed to develop a joint programme elimination framework and a common service approach. This delays gaining efficiencies by fostering unhealthy competition between departments and stand-alone national programmes and supports the continued siloed disease-specific approaches by the Global Fund, other donors, community-based organizations, and governments. 10Ramos-Horta J. Singh P. K. Ending communicable diseases requires a combined elimination framework. BMJ. 2023; 382p2181Google Scholar•Single disease-specific partnership bodies, often supported by the same board members of donor countries, remains a challenge for AIDS, TB, and Malaria. 10Ramos-Horta J. Singh P. K. Ending communicable diseases requires a combined elimination framework. BMJ. 2023; 382p2181Google Scholar ECOSOC should address the long overdue issue of improving efficiencies by potentially combining UN partnership bodies. •Innovative financing has been left to the goodwill and aspirations of donor countries. Undernutrition, hunger, overcrowding and conditions like diabetes directly contribute to the risk of tuberculosis. New approaches, such as considering a TB tax for every transaction that contributes to hunger, poverty, diabetes, or overcrowded living, need to be considered. Like a carbon tax or the law on reparations for war victims, countries, and companies selling and purchasing arms, or engaged in warfare and displacing people, or selling drinks contributing to diabetes must pay tax on each sale as well as an additional individual TB tax for every parent killed or child pushed to hunger or becoming addicted to diabetogenic drinks or food. 8Bhatia V. Sharma M. Rijal S. Urgent need for increased investments to end tuberculosis in the South-East Asia region. Indian J Med Res. 2023; 157: 127-130https: //doi. org/10. 4103/ijmr. ijmr₃24₂3Crossref PubMed Scopus (2) Google Scholar, 9Bhargava A. Bhargava M. Meher A. et al. Nutritional support for adult patients with microbiologically confirmed pulmonary tuberculosis: outcomes in a programmatic cohort nested within the RATIONS trial in Jharkhand, India. Lancet Glob Health. 2023; 11: e1402-e1411Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 10Ramos-Horta J. Singh P. K. Ending communicable diseases requires a combined elimination framework. BMJ. 2023; 382p2181Google Scholar, 11International Committee of the Red CrossHumanitarian law: reparation. https: //ihl-databases. icrc. org/en/customary-ihl/v1/rule150Date accessed: March 20, 2024Google Scholar, 12Stretton S. A simple methodology for calculating the impact of a carbon tax. https: //openknowledge. worldbank. org/handle/10986/34279Date: 2020Date accessed: March 20, 2024Google Scholar There are many hard questions to be asked about strategy, leadership, efficiencies, and the current colonial-era inspired service delivery models. It is high time that we establish an independent review body as proposed earlier by key leaders. 9Bhargava A. Bhargava M. Meher A. et al. Nutritional support for adult patients with microbiologically confirmed pulmonary tuberculosis: outcomes in a programmatic cohort nested within the RATIONS trial in Jharkhand, India. Lancet Glob Health. 2023; 11: e1402-e1411Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar The TB community cannot successfully do this review alone. The body will need to include powerful new actors including people from the affected community who can ask uncomfortable questions, bring new perspectives, and propose innovative solutions. It will be essential to embrace criticism, learn from past failures, gain strategic insight, and rapidly pivot from the current struggling global strategy to ensure the success of future TB control efforts in SE Asia and beyond. Next year's World TB Day cannot again report on another failure to act differently while expecting different results. SS and RG jointly conceptualised, drafted and edited the article. No competing interests to declare. Data support from Sandip Mandal (Johns Snow India, Delhi India) and editing support from Arkaprabha Gun (London School of Hygiene and Tropical Medicine, London, UK) are acknowledged.