Jonathan Stillo is a medical anthropologist with the City University of New York who has been researching tuberculosis in Romania since 2006. The opinions expressed are his own.
Multi-Drug Resistant TB (MDR-TB) is a strain of TB which is resistant to the two most powerful known anti-TB drugs, requiring intensive and careful management if patients stand a chance of recovery.
In Romania, which sees around 1,300 new cases of MDR-TB annually, a small and lucky minority of patients have a 70 percent chance of treatment success, whereas the majority of patients can only hope for a 20 percent success rate.
For this second group of patients, chances of successful treatment are lower than in some of the poorest countries in the world, yet this is the European Union.
A grant from the Global Fund to Fight AIDS, TB and Malaria, the most successful global health financing mechanism to date, has enabled Romania to treat and often cure patients infected with multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant TB (XDR-TB) – further drug resistance that develops on top of MDR-TB.[i]
These patients receive modern, uninterrupted treatment and have access to drugs that are not available anywhere else in Romania.[ii]
They do not receive breakthrough experimental drugs, nor do they receive financial support while they are sick as is standard in many other countries.
In fact, virtually every aspect of their treatment is identical to the second group of patients not covered by the Global Fund grant, with the exception that they are able to access what might be called a minimal European standard of treatment.
Since 2006, tuberculosis drugs in Romania directly contributed by Global Fund have saved hundreds of lives. Unfortunately, they only cover a fraction of Romania’s MDR and XDR-TB patients.
Romania’s current grant only funds enough drugs to treat 300 patients in total, even though the World Health Organisation estimates that Romania has between 1,000 and 1,300 cases of M/XDR-TB every year.
Those patients not covered by the Global Fund programme are treated within the Romanian health system and receive drugs procured locally. Although their treatment is free, it usually does not meet European or even international standards and their chances of survival are dismal.
In Romania, all drug-resistant TB cases are reviewed by a commission of doctors: with Global Fund drug supply limited, new cases rather than relapsed cases are given the option of joining the Global Fund cohort and spaces tend to go to patients who have the best chance of being cured, namely younger, more educated and economically better off people.
The Commission members ultimately make a choice on who lives and who dies. This is an impossible choice described by one doctor as verging on malpractice—the knowing condemnation of patients to inferior medication because of budget constraints.
This terrifying process highlights the importance of the Global Fund in containing increasing rates of MDR-TB- Romania is proving that MDR-TB patients will get better with access to medicine we must now ensure that this treatment success is less of a lottery and more the result of the sound science we know to exist.
[i] Multi-Drug Resistant TB (MDR-TB) is resistant to the two most powerful anti-TB medicines, rifampicin and isoniazid. Extensively-Drug Resistant TB (XDR-TB) is MDR that is also resistant to an injectable second-line antibiotic and a fluoroquinolone.
[ii] Patients treated in the Global Fund cohorts have access to capreomycin and PAS which are unavailable to other patients as well as ofloxacin and amikacin which in practice are rarely available to patients treated outside of the cohorts.