The World Health Organization (WHO) violated sound standards of medical care and human rights by nudging poorer countries to follow less expensive, untested and largely ineffective treatment protocols for tuberculosis patients, a new paper by researchers at Duke, Brandeis and Harvard universities argues.
The authors say the WHO violated its own constitution and international law from 1993 to 2002 by recommending and supporting a double standard of care for multidrug-resistant tuberculosis (MDR-TB), an airborne infectious disease.
Tuberculosis is the leading infectious killer of adults in the world, claiming roughly 4,000 lives every day. Multidrug-resistant strains of the disease are particularly difficult to diagnose, treat and prevent.
The authors describe the role the WHO played in Peru as the country worked to defeat MDR-TB in the late 1990s. WHO recommendations steered Peruvian health practitioners away from implementing a known, effective, yet more costly treatment, resulting in thousands of avoidable deaths, the authors argue. The authors also note the similar experiences of other low- and middle-income countries including India, Russia and Belarus.
WHO asserted that treating MDR-TB patients according to protocols proven successful in U.S. patients would be prohibitively expensive, and therefore advised focusing on preventing the emergence of new cases of MDR-TB. In addition to steering countries toward easier cases, WHO recommended less expensive but untested regimens for patients failing first-line treatments.
WHO based its advice on erroneous and anecdotal cost estimates of wealthy countries from the earliest years of the MDR-TB epidemic, rather than more rigorous cost estimates for care in both wealthy and poorer nations, the authors say.
The paper, “Double Standards in Global Health: Medicine, Human Rights Law and Multidrug-Resistant TB Treatment Policy,” by Thomas Nicholson, Catherine Admay, Aaron Shakow and Dr. Salmaan Keshavjee, was published online June 21 in the Health and Human Rights Journal.
“It is simply impossible to stop the spread of MDR-TB in families and communities without using medicines that can kill the resistant strains,” said Keshavjee, an associate professor of global health at Harvard Medical School. “This scientific fact was ignored for poor and middle-income countries because of concerns about cost. The result was the enshrinement of bad biomedicine into global policy."
Without effective treatment, most people who are sick with any form of TB will infect people in their families and communities, and will eventually die from the disease.
The authors also argue that because the WHO acts as technical adviser for providers of foreign aid -- funds that poorer countries need for their TB programs -- the countries had little choice but to adopt the faulty protocol.
“With half a million MDR-TB cases occurring each year, and most of these cases not detected or receiving treatment, this issue is still extremely important,” said Nicholson, the paper’s lead author and an associate in research at the Duke Center for International Development.
“Unscientific recommendations for any disease, be it TB, Ebola or Zika, are unacceptable and dangerous. We hope the authors of global policy recommendations will focus less on whether to extend the highest standard of care to poor countries, and more on how to achieve it,” Nicholson said.
The impact of the double standard of care extends worldwide, said co-author Shakow, a lecturer in history at Brandeis.
“The irony is that in a global society, advocating different standards of treatment for poor countries and rich ones actually makes a public health problem much worse,” Shakow said. “By failing to live up to its own constitution, the WHO put everybody at risk.”
In 2002, second-line drugs became available for treatment of MDR-TB in mid- and low- income settings through a “Green Light Committee” co-sponsored by the WHO. However, the WHO guidelines on treatment of MDR-TB patients were not rewritten until 2006. Keshavjee served on the committee that rewrote the guidelines and chaired the Green Light Committee from 2007 to 2010.
“We hope WHO will keep sound medical care and human rights accountability front and center going forward,” said co-author Admay, a lecturer in Duke’s Sanford School of Public Policy. “When it’s institutionalized and systemic, when you don’t see the patient dying in front of you and the suffering is either invisible or normalized, accountability is elusive.”
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“Double Standards in Global Health: Medicine, Human Rights Law and Multidrug-Resistant TB Treatment Policy,” by Thomas Nicholson, Catherine Admay, Aaron Shakow and Dr. Salmaan Keshavjee, Health and Human Rights Journal (18:1), June 21, 2016. Available online: https://www.hhrjournal.org/2016/06/double-standards-in-global-health-medicine-human-rights-law-and-multidrug-resistant-tb-treatment-policy/.