New The Union head says eliminating TB ‘doable’ but ‘expensive’

The International Union Against Tuberculosis and Lung Disease has been working to eliminate TB since its founding in 1920. It's still possible to add TB to the list of diseases humankind has totally eliminated, says the organization's new leader — but first, there's the issue of money. “It's absolutely doable. It's just that it's hard work, and unfortunately, it's expensive,” Dr. Cassandra Kelly-Cirino, who in early October took the helm of the membership organization known widely as The Union, told Devex in her first interview as its new executive director. Despite the fact that TB kills more people every year than malaria or HIV, efforts to fight it suffer from chronic underfunding — which makes it harder to find and treat cases and impacts the development and deployment of critical innovations. Kelly-Cirino said 3 million to 4 million cases of TB are missed every year, as people carrying it go undiagnosed and thus untreated. That may be because they don’t experience symptoms, care is inaccessible, or the stigma of TB keeps them away from getting a diagnosis. The underfunding plays into this, she said, because it means TB innovations are few and far between. There’s just one vaccine for the disease — and it’s more than a century old. In 2022, The Union published its five year strategy, with the No. 1 one goal being to end the epidemic transmission of TB. That means finding these millions of cases will require huge investments in research, testing, and health care infrastructure that can do outreach rather than waiting for patients to come to them. The Global Fund to Fight AIDS, Tuberculosis and Malaria provides 76% of the international funding for TB. But several advocates are pushing the fund to allot more to the disease, since currently it receives far less from the fund than malaria or HIV. “Any investments that countries are making in TB is not going to be enough. We're going to have to continue to rely on international support for a lot of the countries to be able to tackle TB in the coming decade.” Given the challenging fundraising environment for global health, she stressed that this will be hard. Funding for TB has remained mostly flat since 2018, but if international funding becomes more constricted, “I think we'd have to start to have a lot more conversations about the domestic funding pipeline for countries,” she said. Funding for innovations Two years ago, the Stop TB Partnership made a new TB vaccine by 2025 part of its plan to end the disease by 2030. One of the most talked about is the M72 vaccine, currently in phase 3 trials. “I think we're in that gray zone right now where we're still waiting on the data to understand what [the vaccine] would look like and how would we implement it as one of the important pieces in our toolbox,” Kelly-Cirino said. While most governments see value in investing in vaccination programs, she admitted that it can be tricky to get them to commit to do so. “It's always a little bit of the chicken and the egg. Nobody wants to really start talking about the changes that are needed, because what happens if [the vaccine is] not going to pan out?” she said. There are other innovations in the pipeline that will also require investments, such as tongue swabs, which could simplify TB testing and potentially be useful in contact tracing, and door-to-door campaigns in communities with high rates of TB. Many countries rely on sputum samples for diagnosing TB, which require the patient to cough deeply and spit phlegm into a container — a difficult task for some people, particularly children. Kelly-Cirino said tongue swabs still wouldn’t detect 100% of infections, and swabs still need to be brought to a health facility for testing. But it’s still an important tool for testing more people by bringing the sampling closer to them. “Global health is perpetually looking for perfect, right? We look for the 100%, and none of these give us 100%,” she said. Several groups are involved in generating the data on the use of tongue swabs, including those funded by the Gates Foundation. Some of that data is expected to be presented at The Union conference next month. Once that data is available, The Union will be involved in calling for a change in World Health Organization guidelines, which is critical in getting countries to actually adopt the swab tests, she said. Funding crunch Kelly-Cirino came to The Union after being vice president for health programs at FIND, the global diagnostics alliance. Before she came on board, The Union revamped its business model, seeking to diversify its funding sources and expand its membership base. At the 50th Union World Conference on Lung Health back in 2019, Guy Marks — who was interim executive director before Kelly-Cirino — admitted that the organization depended heavily on donor-funded projects, and that rethinking that model “will enable us to escape from deepening debt and deficit.” Kelly-Cirino said the shift is still a work in progress. “The Union faces a challenging financial, political, and physical environment,” she said. “One of our key strategies has been to diversify our funding sources. At the same time, we are working to reinvigorate our engagement with members to give them a meaningful role within the organization and provide opportunities to contribute to a global community focused on ending suffering due to TB and lung disease.”