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Bacteria Don’t Respect Borders

Imagine for a moment that you are bacteria. Your only goal in life is to invade host cells and reproduce. When moving from person to person and country to country, do you stop and ask yourself, “What is the World Bank classification of the country I’m about to invade?” Of course not. You are a bacteria.

Diseases don’t respect borders. They don’t understand economic classifications, and they don’t care which political party is in power.

We all know this simple fact, yet we often refuse to acknowledge it when crafting global health policy. Donors often decide which country’s health programs to support based on how that country’s economy is classified using estimates of gross national income (GNI) per capita.

Based on this country income classification, many donors are starting to pull out of so-called ‘middle income’ countries (MICs), a classification that includes such growing economies as South Africa and Indonesia. On the surface, this would appear to make sense. After all, we should focus on supporting the poorest, right?

Yet this is flawed logic when it comes to combating infectious diseases like tuberculosis (TB). A majority of the world’s poorest people now live in MICs, countries which often have pockets of wealth dispersed among large areas of poverty.

Besides this, TB doesn’t care about economics. If we fight TB in only one country, it will just pop up in another. TB is airborne – ever heard of the phrase ‘TB anywhere is TB everywhere?’ – therefore, the only way to combat TB is to fight it everywhere it exists.

And finally, the top five high-burden TB countries in the world are all middle income: India, China, South Africa, Indonesia, and Pakistan. Collectively, these countries comprise 53 percent of global TB cases. When notorious bank robber Willie Sutton was asked why he robbed banks, he simply said, “because that’s where the money is.” It’s a rather sound argument: If your goal is to steal money, you might as well go where it’s most prevalent. This principle also applies to epidemiology; if you want to end disease, you need to fight the disease where it exists.

On Monday, March 24 we will commemorate World TB Day. The disease affects 9 million people each year, but approximately one-third are “missed” by public health systems and don’t receive the care they need. This World TB Day, the global TB-fighting community is rallying around a call to reaching these 3 million people. To reach the 3 million and accelerate global progress to fight TB, donors and MICs must work together to commit the political will and resources needed to address the disease.

Donors have been understandably hesitant to support MICs, arguing that these countries can now afford to fight diseases themselves. Yes, countries with higher income are better positioned to build strong TB programs, but they will need continued investment in public health infrastructure. Furthermore, many MICs have the additional burden of high rates of drug-resistant TB, which is far more expensive to diagnose and treat.

Additionally, more work needs to be done in MICs to elevate TB as a political priority. If we are truly interested in getting MICs to increase their own investments in fighting TB, we should invest in civil society and support the scale-up of in-country advocacy. Engaged citizens can hold their governments accountable.

This is an issue that should be further explored. The conversation won’t be easy, but it’s a changing world and we must find a way to adapt to new political and economic realities.  Surely we are up to this challenge if we can work across governments, civil society, and donor agencies to address these challenges and transform the fight against diseases like TB.

Too bad we’re not bacteria; then we wouldn’t have to think about any of this!