Intended for healthcare professionals


Eradicating TB

BMJ 2018; 362 doi: (Published 25 September 2018) Cite this as: BMJ 2018;362:k3918
  1. Michael J A Reid, assistant professor of medicine1,
  2. Eric Goosby, professor of medicine1 2
  1. 1Division of HIV, Infectious Diseases, Global Medicine, University of California, San Francisco, USA
  2. 2United Nations Special Envoy for Tuberculosis
  1. Corresponding author: Michael J A Reid Michael.Reid2{at}

Governments must work together within a clear framework of accountability

On 8 May 1980 the World Health Organization declared the world rid of smallpox. Success in eradicating smallpox was achieved because governments worked together and considerable resources were devoted to the fight. On 26 September the United Nations will convene the first ever high level meeting to commit to ending another global epidemic, that of tuberculosis (TB).

TB has exacted an awful toll, it has been responsible for more than 1 billion deaths over the past two centuries and is still the leading infectious disease killer globally.1 The success of the smallpox effort provides valuable insights into how substantial declines in TB incidence can be achieved, despite differences between the two diseases.

Progress towards smallpox eradication occurred when sovereign nations agreed to be accountable to working collectively to end the epidemic, and to be accountable for their contribution to this effort. Global accountability is also necessary to secure the political and financial investment to end TB. Accountability for Reasonableness2 —an ethics based approach to legitimate and fair priority setting that can be applied to health policy—provides a framework that can facilitate the political consensus and investment to end TB. Here we present the case for why global leaders should implement such an approach.

The economic case for ending the epidemic

The global eradication of smallpox was a unique achievement in the history of international cooperation.3 This success is even more remarkable when we consider how great the economic gains have been, relative to the original costs. Overall, low income, high burden countries and their donor partners provided around (inflation adjusted) $1.1bn (£843m; €947m) for the eradication effort. The United States, the single largest donor, recovers its investment every 26 days, considering the funds saved from vaccination programmes and healthcare.4

The sums of money proposed to end the TB epidemic are substantially greater, but by no means unaffordable. A plausible cost trajectory towards ending TB by 2030 would be a rise in current expenditure of around $7bn a year, to $13bn a year, for the next five years.5 This will require a marked increase in investment from both high burden countries and their donor partners. Like smallpox, however, there are compelling reasons to assume that this investment will return substantial benefits.67 Evidence on the cost effectiveness and benefits of TB control suggests a return of up to $56 for every dollar spent.6

Further, like smallpox eradication efforts, this investment should be weighed against the economic threat of inaction. Recent analysis performed by the consulting firm KPMG suggests that deaths from TB will cost the global economy a trillion US dollars between now and 2030 if trends in mortality continue at current rates of decline.8

No free riders

Another key lesson of the smallpox endgame was the importance of political leadership. Although eradication was in the interests of all high income countries that were called upon as international donors, the problem of “free riding” led many countries to expect that they could withhold resources while others covered the cost. It was only as the global cost of failing to end the epidemic was fully acknowledged by global leaders that sufficient funding for eradication followed.

The challenge of free riding was successfully overcome when there was a clear convergence of global interests, and when the costs to those who benefited least were minimised.9 The convergence of global interests necessary to drive down TB incidence demands political recognition of the economic cost of inaction, as well as the important cross border threat that TB, especially drug resistant forms, represents.10

Accountability for Reasonableness

Accountability for Reasonableness (AFR),2 frequently applied to healthcare priority setting in both high income and low and middle income settings over the past 30 years,111213 offers an ethical framework well suited to the complex diplomatic challenges of bringing consensus among sovereign states with diverse self interests.

AFR is a process that holds decision makers accountable for their decisions. These are judged legitimate and fair if decision making processes meet four conditions: all stake holders agree that the problem under consideration is relevant; decision making is public; decisions and targets are routinely reviewed and can be revised; and leaders commit to enforcing targets when the first three criteria are met.

While not developed to guide governance for global public good, such as TB elimination, AFR could be used to ensure that political commitment is matched to financial investment and that programmatic progress is linked to an iterative process of review and revision. AFR can empower a more focused public and global deliberation around TB, while also ensuring that ultimate authority for tackling the epidemic rests within each country’s own political economy.

We must move beyond the narrow view that TB is the problem of the world’s poorest societies, and recognise that it is a universal health problem for an interdependent global population. A transparent, global accountability framework to ensure concerted, coordinated investment for TB is imperative if we are to end this epidemic once and for all.



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