What a lack of breastfeeding support is costing the world

By Dylan Walters (Nutrition International) and Sandra Remancus (Alive & Thrive)

Every year, a lack of concerted support for breastfeeding from governments around the world costs the global economy more than US$570 billion. These losses, the cumulative result of child and maternal mortality, increased healthcare costs, and depleted human capital potential, are preventable through proactive efforts to support, protect and promote breastfeeding.

Breastfeeding saves lives and safeguards development. It serves as a child’s first immunization, provides protection against common childhood illnesses like diarrhoea and pneumonia, improves cognitive development, and is associated with a reduced prevalence of obesity and diabetes later in life. Breastfeeding also offers protective benefits for mothers, helping to prevent breast and ovarian cancers, as well as type 2 diabetes.

These benefits all translate into economic gains – and not breastfeeding results in immediate and future costs, from the family level to the national level. Not breastfeeding drives up healthcare costs when it becomes necessary to treat illnesses that could have been prevented. Household expenditures increase as families must purchase breastmilk substitutes for their children, which are often expensive. And children’s future productivity is curbed, leading to lower future earnings, and lost economic contributions.

The World Health Organization (WHO) recommends early initiation of breastfeeding within the first hour of birth, exclusive breastfeeding for the first six months, and continued breastfeeding with complementary feeding until at least two years. In 2012, The World Health Assembly set a global nutrition target of 50% exclusive breastfeeding by 2025 – but most countries are currently off track to reach this target.

Calculating the cost of not breastfeeding

The Cost of Not Breastfeeding Tool is an evidence-based modelling tool that uses open-access data to estimate the health and economic costs of not protecting, promoting and supporting breastfeeding. First launched in 2019, the tool was the first of its kind and used by organizations around the world to inform new guidelines and make recommendations to increase breastfeeding rates globally. The methods and results of the analysis from the tool were published in the Health Policy and Planning journal which became the most cited paper of the year.

A new and updated version of the tool, available on both the Nutrition International and Alive & Thrive websites, contains updated datasets, new indicators, a new function to calculate results for different scenarios or targets, and online access to the results for more than 180 countries. Using this tool, we can calculate exactly how much a country’s lack of support, promotion and protection of breastfeeding is costing – not just in healthcare spending, but in mortality, IQ points and future human capital.

For example, using the tool, we can determine that breastfeeding according to the WHO’s recommendation can prevent more than 500,000 deaths of children and mothers and nearly 4.6 million cases of childhood obesity globally each year – and save $23.8 billion in healthcare costs. Breastfeeding can also prevent the loss of 200 million IQ points and 70.5 million years of education.

These results speak not just to a child’s potential future earnings and economic contributions, but also to their quality of life and ability to achieve their full potential.

Government protection and promotion of breastfeeding is critical

Our goal with this tool is to make this information as accessible and user-friendly as possible, so that policymakers and advocates can determine the economic, health and human capital impacts of investing in policies to support and promote breastfeeding. The evidence generated with the tool will be integral to raising awareness with governments, industry and donors about the urgent need to scale up breastfeeding.

The first version of the Cost of Not Breastfeeding Tool was used by the Global Breastfeeding Collective in the development of the investment case for breastfeeding, in support of their seven recommended policy actions, which lay out the concrete steps that governments can take to increase the global rate of early, exclusive and continued breastfeeding.

Government investment is fundamental to supporting women and families and driving necessary action to scale up breastfeeding globally – to save lives, protect growth, development and economic health, and provide a better future for their countries.

The Cost of Not Breastfeeding Tool provides the evidence needed to generate that action.


The Cost of Not Breastfeeding Tool was first developed between 2017 and 2019 by Dr. Dylan Walters and Alive & Thrive, with funding from the Bill & Melinda Gates Foundation. In 2022, Nutrition International updated and developed the second version of the tool (led by Sameen Ahsan, Sakshi Jain and Dylan Walters) in partnership with Alive & Thrive and Limestone Analytics, with funding from the Government of Canada.

Image credit: Nutrition International

Sir Humphry Davy : illustrious former owner of a book on the plague now in LSHTM Library. LSHTM Rare Books Blog series No. 5. August 2022.

Like most books in the Library’s Special Collection our copy of A Treatise on the Plague by A.B. Faulkner, published in 1820, was acquired secondhand. This was probably purchased from an antiquarian bookseller by our first librarian, Cyril Barnard, who was actively adding books of importance to the history of tropical medicine and public health to the library. This particular copy is especially interesting because it contains internal evidence showing its provenance can be traced back to its first owner, the eminent British scientist Sir Humphry Davy, before it passed to his wife, Lady Jane Davy.

A Treatise on the Plague, 1820, was written by Arthur Brooke Faulkner (1779-1845).  Faulkner was a military physician, serving with the British forces in Malta where there was an outbreak of plague in 1813. There was no known treatment but by introducing a system of quarantine to control the spread of the disease Faulkner averted a disaster. For his swift action Faulkner was knighted in 1815.  Afterwards Faulkner wrote A Treatise on the Plague based on his experience in Malta. The copy in the library is inscribed on a flyleaf : ‘To Sir Humphry Davy Bart with the authors (sic) respects’.

Figure 1: Title page. A Treatise on the Plague

Sir Humphry Davy (1778-1829) made a number of significant scientific discoveries, with the invention of the coalminers’ safety lamp being the one for which he is best known. Davy trained as a physician but his expertise was in chemistry and he experimented with many substances.  There were many accidents but these were considered to be part of the course in the race to get the right results.Davy discovered the anaesthetic properties of nitrous oxide by testing it on himself in 1795 and suggested the gas could be used during surgical operations to relieve pain (Davy 1800).   Davy also disproved that the gas was a contagium of plague as some physicians alleged (Boulton 1998).

Figure 2: Gillray cartoon of Humphry Davy demonstrating nitrous oxide at the Royal Institution in 1802 – Davy is seated on the right working the bellows
Figure 3: Sir Humphry Davy, Bt by Thomas Phillips (Source: National Portrait Gallery London)

In 1820, when Faulkner published his book, Davy was poised to be elected the next President of the Royal Society following the death in 1820 of the naturalist Sir Joseph Banks (1743-1820).

Lady Davy (née Kerr) (1780-1855) was a wealthy widow, Jane Apreece, when she married Davy in 1813. ‘Her wealth enabled Davy to retire from routine work (in 1813 he resigned his Royal Institution professorship) and devote himself, … , to chemical researches’ (Forgan 2004 : 512). The couple travelled in Europe but increasingly their lives went in different directions.  After Davy died in Geneva in 1829 Lady Davy had her bookplate pasted inside the front cover of Faulkner’s book.

Figure 4: Lady’s Davy’s bookplate

 Lady Davy lived another 26 years and died in London in 1855. The whereabouts of the book remained unknown after it left Lady Davy’s Library until 24 September 1925 when it was acquired by this Library. Although now 200 years old, the book is still in excellent condition in an olive-green full leather binding with blind tooling decorating the boards and some gold tooling, raised bands and a red leather lettering piece on the spine.  Inside the binding is completed by marbled endpapers and a similar marbled pattern on the edges of the text.  


BOULTON, T.B., 1998. Pain and analgesia for operative interventions – from the beginning up to 1846, pp. 35-55, in SCHULTE AM ESCH, J. & GOERIG, M. (editors),  The History of Anaesthesia : The Fourth International Symposium on the History of Anaesthesia : Proceedings.  Lübeck : DrägerDruk. (Not seen).

DAVY, Humphry, 1800. Researches, chemical and philosophical, chiefly concerning nitrous oxide. London : J. Johnson. (Not seen).

FAULKNER, Arthur Brooke, 1820. A Treatise on the Plague, designed to prove it contagious, from facts, collected during the Author’s residence in Malta, when visited by that malady in 1813. With observations on its prevention, character and treatment. To which is annexed an Appendix , containing minutes of the author’s evidence, given before the Contagion Committee of the House of Commons, accompanied by their Report. London : Printed for Longman, Hurst, Rees, Orme, and Brown.  (LSHTM Library *JN 1820)

FORGAN, Sophie, 2004. Davy [née Kerr] Jane, Lady Davy, pp. 512-513, Oxford Dictionary of National Biography 15.

LSHTM Library Rare Books Collection Blogs is an occasional posting highlighting books that are landmarks in the understanding of tropical medicine and public health.  The Rare Books Collection  was initiated by Cyril Cuthbert Barnard (1894-1959), the first Librarian, from donations and purchases, assisted with grants from the Carnegie United Kingdom Trust. There are approximately 1600 historically important rare and antiquarian books in the Rare Books Collection.      

Many of the LSHTM Library’s rare books were digitized as part of the UK Medical Heritage Library. This provides high-quality copyright-free downloads of over 200,000 books and pamphlets for the 19th and early 20th century. To help preserve the rare books, please consult the digital copy in the first instance.

If the book has not been digitized or if you need to consult the physical object, please request access on the Library’s Discover search service. Use the search function to find the book you would like to view. Click the title to view more information and then click ‘Request’. You can also email library@lshtm.ac.uk with details of the item you wish to view. A librarian will get in touch to arrange a time for you to view the item.

Researchers wishing to view the physical rare books must abide by the Guidelines for using the archives and complete and sign a registration form which signifies their agreement to abide by the archive rules. More information is available on the Visiting Archives webpage.

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20th anniversary reflections on dissemination: building tours and Open House

As part of our 20th anniversary celebrations, we are reflecting on how the service has developed in a number of ways, this blog focuses on dissemination and how our approach has changed since the service was established in 2002. I have been looking through the Archives of the service and remembering many of the projects that we have worked on. There is also reflection how these activities have changed due to Covid-19 and new ways of working. This was originally intended to be one blog post but I found that we had worked on so many projects that it has turned into a series featuring exhibitions, events and building tours.

We participated in our first Open House event in 2005, I had taken part in this project when I worked at the Royal Society of Arts in 1998 so had the idea that the School would be a wonderful place to provide access to. The Open House weekend is a celebration of contemporary and renowned architecture across London which provides free public access to 100’s of buildings and attracts 1000’s of visitors.

Open House group entering the building, 2011

In the first year, we did not know what to expect and we were overrun with visitors, I had to call my husband to come in and help, and the three tour guides had to take groups of about 40 visitors around the School which was problematic. We became more organised over subsequent years with a rota and a limit on the number of visitors on each tour. I remember that it has always been hard to recruit volunteers to work at the weekend although we were always helped by Open House volunteers which was very much appreciated. After a few years, the organisation was taken over by the Events team which was a relief as creating the tour rota was a complete headache.

Open House London is a great opportunity to connect with the public who would not normally be able to visit our beautiful Keppel Street building. Over the years, we have received positive feedback on our tours and have met many interesting people, some of whom are related to key figures from our history such as the daughter of one of the building architects and also people who live locally who have always wondered what happens in the School. Some days, we welcomed over 400 visitors to the School. I was always exhausted at the end of the weekend but it was a rewarding experience that was worth the effort.

Open House visitors in the Library, 2013

 In 2005, I used the archives and secondary sources to develop the tour script, this has been revised over the years to include information on new parts of the building and recently information has been added on our colonial origins to acknowledge how the institution was established. We also run tours for staff induction day, graduation, student open day, VIP events, student groups and external groups such as the University of Third Age and Camden tour guides. After a two year break due to Covid-19, I recently ran a couple of tours and realised how much I had missed them and interacting with people and seeing their response, rather than talking through a screen. During lockdown we developed a powerpoint presentation for staff induction day, which introduces new staff, many of whom will have never visited to the building, to the history of Keppel Street and LSHTM.

Visitors in the John Snow Lecture theatre, 2011

Conducting tours of the building is a great way to promote the archives and our knowledge of LSHTM to internal and external stakeholders and to connect with colleagues in other departments. We are looking forward to running more tours for various groups in the future as we start to welcome more visitors back to the School.

For more information on tours, please contact archives@lshtm.ac.uk

Children in low-income countries 16 times more likely to die from most common eye cancer

Children with the eye cancer retinoblastoma in a low-income country are at 16 times  higher risk of dying at any time within three years of diagnosis than those in high-income countries, according to a new study published in The Lancet Global Health.

The research, led by the International Centre for Eye Health (ICEH) at the London School of Hygiene & Tropical Medicine (LSHTM), found stark differences in survival for children with retinoblastoma, the most common form of childhood eye cancer, between high-income and low-income countries.  

Retinoblastoma is the most common and devastating eye cancer that affects children worldwide, and early diagnosis and treatment are critical to prevent death or the loss of an eye.

In high-income countries this risk has dropped dramatically over the last few decades, with death now rare due to robust diagnosis and treatment pathways, including specialist retinoblastoma centres.

The study, which is the largest and most geographically comprehensive on retinoblastoma to date, looked at survival data in 4,064 children with retinoblastoma from 149 countries (categorised as high, upper-middle, lower-middle and low-income) globally. These are estimated to be 50% of all new cases worldwide in 2017.

The team analysed the three-year survival rate for these children following their diagnosis, finding that over two-fifths (40%) of children die within three years of diagnosis in low-income countries, compared with fewer than one in 100 (1%) in high-income countries.

Professor Matthew Burton, Director of the ICEH at LSHTM, said: “This is a shocking result – highlighting the inequalities between high- and low-income countries for this disease. We cannot accept children having such a high risk of death in low-income settings from a disease that elsewhere is viewed as curable. We need to ensure that the reasons for this disparity are ascertained and policies enacted that close this survival gap.”

Despite the study showing that the main treatments for retinoblastoma (the removal of an eye, or enucleation, and intravenous chemotherapy) being available in all countries, several factors may be responsible for the reduced survival rate. Previous studies suggest that low-income countries are less likely to have specialised treatment centres containing sophisticated equipment and techniques such as MRI machines and targeted chemotherapy. Limited awareness among the general public and health care workers, and issues accessing treatment due to travel distance and cost are all suggested to contribute to worse outcomes and increased risk of death.

Dr Ido Didi Fabian, lead author and Principal Investigator of the Global Retinoblastoma Study Group at LSHTM, said: “We have always known there was a difference in outcomes between higher and lower income countries, but the differences we’re seeing in this study, the largest of its kind, are very worrying for children affected by retinoblastoma. Better awareness of the early signs, improving access to timely diagnosis, and implementing existing guidelines aimed at children in low- and middle-income countries, are critical to improving retinoblastoma outcomes worldwide.”

The work was made possible by the Retinoblastoma Network (Rb-NET), facilitated by ICEH, which allowed 260 retinoblastoma centres across the world to share data for the study. This collective data sharing could further lead to a live clinical data repository, strengthening evidence-based guidance on management of the condition.

The majority of existing evidence for retinoblastoma comes from high-income countries, despite patients in areas such as North America, Europe and Oceania representing less than 10% of global cases. The authors note that further research in low-income countries themselves is needed to identify the causes of this global disparity and improve outcomes.

The authors acknowledge limitations of the study, including that the cohort was a sample taken from a previous study (despite containing half of all cases worldwide for that year). The study also did not collect detailed data on treatment, for instance specific treatment protocols and complications. Future studies could include these sub-analyses.


The Global Retinoblastoma Study Group. Global Retinoblastoma Outcome Study: Prospective Analysis of 4,064 Patients from 149 Countries. The Lancet Global Health. DOI: 10.1016/S2214-109X(22)00250-9

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World Hepatitis Day 28th July 2022

The World Hepatitis Day is coordinated by the World Hepatitis Alliance and is one of several WHO global public health days that take place annually.

“World Hepatitis Day (WHD) takes place every year on 28 July bringing the world together under a single theme to raise awareness of the global burden of viral hepatitis and to influence real change. In 2022 the theme is ‘I Can’t Wait’.” (World Hepatitis Alliance).

“Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E. These five types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread.” (World Hepatitis Alliance).

“With a person dying every 30 seconds from a hepatitis related illness – we can’t wait to act on viral hepatitis.” (World Hepatitis Alliance).

You can use the library’s search tool Discover to find articles and books on aspects of Hepatitis and related subjects.

To find out more see: https://www.worldhepatitisday.org/


Images from: https://www.worldhepatitisday.org/

Health Policy and Planning’s Top 10 Articles Contributing to the 2021 Impact Factor

By Natasha Salaria (London School of Hygiene & Tropical Medicine)

The 2021 impact factors have now been released and we are pleased to announce we have seen another increase in our impact factor which has gone up to 3.547 with our 5-year impact factor coming in at 4.423. Our journal sits 25th out of 88 in the Health Policy and Services category. We as a journal published over 200 articles in 2021, had over 1 million downloads in 2021 and have published papers from more than 90 countries in the past 3 years.

The use of impact factors as measuring quality and impact of journals is widely contested, however, it is still recognised by authors, publishers, libraries and academic departments as an indicator of citation rates to journal articles and still used as criteria for authors when looking to publish their work.

After taking a look into some of the citation data, we would like to share our top 10 most highly cited articles that contributed to the 2021 impact factor in Health Policy and Planning:

  1. Original article: The cost of not breastfeeding: global results from a new tool
  2. Original article: Mental health system costs, resources and constraints in South Africa: a national survey
  3. Methodological Musing: On discount rates for economic evaluations in global health
  4. Review: The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence
  5. Original article: Community engagement for health system resilience: evidence from Liberia’s Ebola epidemic
  6. Commentary: What role can health policy and systems research play in supporting responses to COVID-19 that strengthen socially just health systems?
  7. Original article: ‘LMICs as reservoirs of AMR’: a comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan
  8. Original article: Estimating a cost-effectiveness threshold for health care decision-making in South Africa
  9. Methodological Musing: Document analysis in health policy research: the READ approach
  10. Review: Health system resilience: a literature review of empirical research

Our top 10 contributions by organizations include high performing higher education institutions such as University of London institutions, Johns Hopkins, Harvard University, University of Cape Town, League of European Research Universities and the World Health Organization.

Our top contributions by country are from USA, England, South frica, India and Kenya.

In 2021, our blog audience included top readers from India, Kenya, Ghana, Indonesia, South Africa, USA, UK, Nigeria and China.


Altmetric is an alternative metric to the impact factor, used to demonstrate engagement with journals on an individual article level. Altmetric collects data on universal popularity and uptake, including within policy documents to show how research has influenced health policy as well as media outlets and social media platform discussions.

There have been over 155 Health Policy and Planning papers cited in policy documents over the past year including for the World Bank, the National Institute for Health and Care Excellence, Food and Agriculture Organization of the United Nations and the World Health Organization. Health Policy and Planning is helping bridge the gap between academic research and its real-life application and this collection provides recent examples of high-impact work in health policy and systems research focusing on low- and middle-income countries.

Here are the Top 10 articles from 2020 with the highest Altmetric score published in Health Policy and Planning:

  1. Original article: An assessment of geographical access and factors influencing travel time to emergency obstetric care in the urban state of Lagos, Nigeria
  2. Original article: Is the routine health information system ready to support the planned national health insurance scheme in South Africa?
  3. Original article: Health and politics in pandemic times: COVID-19 responses in Ethiopia
  4. Review: In search of ‘community’: a critical review of community mental health services for women in African settings
  5. Original article: COVID-19 Preparedness and Response Plans from 106 countries: a review from a health systems resilience perspective
  6. Commentary: Applied systems thinking: unlocking theory, evidence and practice for health policy and systems research
  7. Original article: Fifteen years later: moving forward Heller’s heritage on fiscal space for health
  8. Original article: Do efficiency gains really translate into more budget for health? An assessment framework and country applications
  9. Scoping Review: Modified scoping review of the enablers and barriers to implementing primary health care in the COVID-19 context
  10. Original article: Using system dynamics modelling to estimate the costs of relaxing health system constraints: a case study of tuberculosis prevention and control interventions in South Africa

Don’t forget to check out our latest outputs including:

  • [RESEARCH COLLECTION] Evidence to inform the COVID-19 Response
    -Power across the global health landscape: a network analysis of development assistance 1990–2015
    -Reimagining health systems for better health and social justice
    -How Systems Respond to Policies: Consequences of COVID-19 Lockdown Policies in Thailand
  •   [SUPPLEMENTS] Watch this space for a 2022 supplement publishing in November in collaboration with Health Systems Global

World Population Day

World Population Day is all about raising awareness of controlling the population and serves to highlight the growing problems that come with a growing global population. World Population Day was established by the Governing Council of the United Nations Development Programme in 1989. It was inspired by the public interest in Five Billion Day on July 11, 1987, the approximate date on which the world’s population reached six billion people. According to the United Nations, world population reached 7 Billion on October 31, 2011.

Overpopulation is a crucial issue, especially considering that world resources are depleting at an unsustainable rate. Awareness about the effects of overpopulation on development and nature is emphasized. The increasing population also sheds light on health problems faced by women during pregnancy and childbirth, making the need for family planning, gender equality, and maternal health more important than ever.  To raise awareness you are invited to share your views via a blog or other social platform on how to take precautions and combat population issues. WORLD POPULATION DAY – July 11, 2022 – National Today

The Library collections contain print and online resources on the topic of world hunger, nutrition and global food policy. Resources can be found by searching in the Library’s search tool, Discover. Print books on these subjects can be found in the Reading Room, shelf mark ZY09. A selection of books from this section are on display in the Library’s Reading Room.   

World Population Day: National Today

Happy 20th Birthday LSHTM Archives Service

I can’t believe that it has been 20 years since I started working at the School! To commemorate this anniversary, this seems a perfect time to reflect on my time at the School, my work as an Archivist and the development of the service. I have been looking through the Archives of the service and remembering many of the projects that I have worked on, this has been a fascinating process and I have created a timeline of events which is a great way to reflect on the development of the service.

 In this blog I reflect on my first impressions of the School and compare it with how the service in 2022. More blogs will follow with reflections on the collections, dissemination and events, funding and other projects that I’ve worked on.

I arrived at the School on 2nd July 2002 as an enthusiastic Archivist, ready to establish my first Archives Service and to be the first professional archivist employed by LSHTM. This was not an insignificant challenge as there was little funding (my post was only funding for three years on a sliding scale of full time for the first year, part time for second year and third time for third year), eight of the collections had been catalogued to a high level by AIM25 staff and the Ross collection had been listed to item level but not catalogued to archival standards. The rest of the collections were in crates on the floor. There was no search room, no procedures and limited interest in the archives or the history of the School.

Archives strong room in 2002
Archives strong room in 2002

Fast forward 20 years and we are an accredited service with three permanent staff (two part time Archivists and one full time Assistant), with two storage areas, a new beautiful search room and an ever increasing workload!

Archives search room 2022

Over the intervening period, the service has developed in various ways and we have been spread pretty thin at times. We have taken on responsibility for Freedom of Information, aspects of Data Protection, image management and research data management. These services, apart from image management which is a shared responsibility with Comms, have now all moved to other areas which should have freed up our time, however it has been filled up with other activities.

The archives still face some of the same issues that it did when I arrived including lack of funding, we have to raise external funding for the core activity of cataloguing. We have been successful in raising external funding to catalogue five collections: Ross, Maps, Nutrition, HIV/AIDS and Whitehall Study. We have received over £250,000 from the Wellcome Trust’s Research Resources in Medical History fund which now sadly no longer exists. We are extremely grateful to the Wellcome for this funding as it has been invaluable to the service.

The external funding landscape has changed for archives and while we are keep a watching brief of schemes, we have acknowledged that we need to take a different approach to tackling our cataloguing backlog. We are going to trial a workshop approach where we schedule dedicated sessions to sort and appraise collections as a team rather than just one person face the daunting task of reviewing large collections.

There is still a lack of visibility for the Archives Service and we are continually trying to promote the service through dissemination activities, one area which has recently raised our profile internally is our Decolonising the Archives initiative. We have developed five areas where we are changing our practice, these are cataloguing, archival practice, dissemination, education and inclusivity. Through taking a new and innovative approach to these issues, and supporting the work of the School, we have shown the value of our service and of us as professionals who can use our professional skills to support the work of the institution in new ways.

If you’d asked me in 2002 if I would still be at the School in 2022, I would have said ‘no way’, I had no particular ambitions but thought I would end up back in business archives where I had started or working with women’s history collections which was where my interests lay during university. However, I find myself now with a fairly good knowledge of malaria and mosquitoes, HIV and AIDS, and I can do a tour of our Keppel Street building in my sleep. I have been fortunate to work with some amazing colleagues over the years and would like to especially thank our current Assistant Archivist, Claire Frankland, for her hard work and support.

Archival material on display

There are still many opportunities and challenges, including decolonising/inclusive practice, tackling the cataloguing backlog, promoting the collections and digital preservation and I am looking forward to working on these activities with the team in the future as well as providing an excellent research service for our users.

Watch out for more reflective blogs over the next month and please contact us at archives@lshtm.ac.uk if you would like any further information

People-centered strategies for the management of drug-resistant tuberculosis is not sexy enough science

By Uzma Khan (IRD Pakistan; Karachi, Pakistan and IRD Global; Singapore, Singapore)

Since 2011, the World Health Organization (WHO) has recommended treating patients affected with drug-resistant tuberculosis (DR-TB) using a clinic- or community-based ambulatory care model. However, low- and middle-income countries (LMICs) continue to struggle to implement this policy into practice. We recently published a study analyzing distance to health services as a factor contributing to poor treatment outcomes in peri-urban and rural areas of Pakistan and discussed pertinent challenges to decentralization of DR-TB care in high TB burden countries.

The race to meet targets

Unfortunately, the global DR-TB situation continues to be alarming with only a third of the estimated cases of multidrug-resistant TB (MDR-TB) started on treatment in 2020. Thus, country TB programs are under pressure from donors and partners to identify missing DR-TB cases. The scale up of molecular diagnostic tests for TB has improved MDR-TB diagnosis, however when uncoupled from adequate laboratory and human resources to monitor and manage patients, close to where they live and work, it can be a recipe for failure. Sadly, such failures cost lives. These gaps in resources lead to several centralized health facilities to serve as treatment sites. For example, in Pakistan, at the start of routine DR-TB care services in the country, people would travel to different cities or even provinces to access the few facilities available to manage DR-TB. With access to rapid molecular tests, the number of treatment sites expanded which improved people’s ability to access care. However, many of these sites were neither close to where patients live, nor adequately equipped to monitor them.

Yes to newer drugs and new regimens but where are the TB laboratory services? 

With great enthusiasm, I along with many colleagues have welcomed the introduction of newer drugs and all-oral regimens. Albeit slow, these are now finally recommended for all MDR-TB patients. Yet, this recommendation cannot be appropriately implemented without access to adequate TB laboratory services. It is critical that patients infected with the most resistant bacteria are identified early and put on the correct treatment. This neglect in TB laboratory capacity has been an acceptable norm for far too long. For example, access to drug-susceptibility testing (DST) for fluoroquinolone – a core drug used for the treatment of MDR-TB – continues to be limited to national level or centralized labs.

It seems the TB laboratory network is always at least a step behind in terms of policy and certainly in practice. Now with access to newer drugs, it is imperative that testing for drugs used in these regimens, such as bedaquiline and linezolid, which form the backbone of WHO conforming regimens, be available in LMICs. However, apart from a few national or regional laboratories in high TB burden countries, DST to these drugs remains largely unavailable. To those in a high-income country – with access to the best diagnostics including sequencing – this would seem outrageous, but unfortunately TB patients in many LMICs continue to be managed in the absence of adequate tools to support their treatment.

Standardized approaches and protecting the drugs (NOT the patient)

Globally there is agreement to implement people-centered strategies. However, there is a dearth of investment in local, community-level leadership that includes TB-affected households to provide local solutions to local problems. In the absence of the most basic resources, physicians are not empowered to make reasonable, people-centered decisions. They are trained to deliver care using standardized approaches, unlinked to local realities, while astutely following guidelines. Such practices promote health inequities and further distance TB programs from the seemingly cumbersome and much-needed integrated health delivery to achieve the end TB targets.

For a long time, the TB community has injected fear of abuse of drugs; the misuse by the private sector, the inappropriate regimen designs, all leading to more resistant TB strains and thus the need to protect the drugs.’  While the concerns may be legitimate, the root cause of the problem i.e., drug regulation and access barriers remain unaddressed, and unfortunately the burden of such restrictions is borne by patients who are at times denied better, safer treatment to a curable disease. Living in conditions that limit accessible healthcare, affected individuals mistrust a fragmented system and often initially seek other avenues for care including the unregulated private sector, before finally reaching a designated treatment facility. However, this is often far too late. Thus, an untapped and unregulated sector results in incorrectly treating patients leading to unabated community transmission of highly resistant strains of TB. Further, the TB programs are ill-equipped to trace and track exposed contacts of patients or educate the community to prevent and mitigate these risks.

Dependency on the Global North

DR-TB financing is heavily dependent on the Global North. This has created an inequitable dynamic whereby, instead of patients, affected communities, country implementers being involved in decision making, external donors are in the driving seat, determining decision on key interventions and strategies for investment. The key buzz word is to propose ‘innovative’ solutions; colloquially speaking anything that seems sexy would bring the dollars pouring in. If it doesn’t fit into the local context and doesn’t fill all the identified gaps, that is not the primary decision-making factor. In fact, the donor’s pot only holds enough funds to support something that shows impact and is cost-effective. Thus, without any accountability, people-centered approaches that provide better care to DR-TB patients, alleviates their socioeconomic burden, improves their overall health outcomes and supports the decentralization of DR-TB services, do not make it to the priority list for financing. The most common argument is that the national governments should cover these costs. Agreed, ideally that should be the case, but as donors are well aware, this is far from reality and turning a blind eye to these facts is at best careless and at worst criminal negligence.

Yes, decentralization of DR-TB will require a rethink of the current model and cannot be done in the absence of local voices for input. Thus, decades of neglect can only be addressed by in parallel improvements and investments in community service delivery models.

Image credit: Uzma Khan (consent was taken prior to taking photo)

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