Editorial

As the time of reckoning for the Millennium Development

Goals (MDGs) approaches, it seems that there will be cause
for celebration in the domain of tuberculosis. The goal of
reversing tuberculosis incidence by 2015 has already been
reached, a testament to the eorts of organisations
from local providers to multilateral agenciesthat have
pulled together to combat this scourge.
But another, seemingly more insidious, epidemic is
threatening further progress with respect to global
tuberculosis control. The prevalence of obesityand
associated type 2 diabetesis rising faster than anyone
would have predicted only 30 years ago, and the
interactions between tuberculosis and diabetes are of
concern. These interactions are explored in depth in
three Series papers in this issue of The Lancet Diabetes &
Endocrinology.
Diabetes has long been known to be a risk factor
for active tuberculosis and reactivation of latent
tuberculosis. It is also associated with worse tuberculosis
treatment outcomes. Additionally, tuberculosis infection
in itself can worsen glycaemic control. Drugdrug
interactions can further complicate the picture, leading
to a reduction in the eectiveness of both tuberculosis
and diabetes treatments, and potential worsening of
drug side-eects.
Worldwide, the International Diabetes Federation
(IDF) predicts that the number of people with diabetes
will rise by 55% in the next 20 years. In Africa, the
increase is expected to be far greateraround 110%.
Africa also has an especially high burden of tuberculosis,
and thus is especially vulnerable. But the intersection
of these dual epidemics will probably aect individuals
and health systems throughout the world. If the IDFpredicted increase in diabetes prevalence to 101%
worldwide by 2035 does occur, modelling suggests
that this increase will reduce the fall in tuberculosis
incidence by about 3%; a more pessimistic estimate of
an increase in diabetes prevalence to 13% could reduce
the fall in tuberculosis incidence by 8% or more. Already,
the increase in diabetes prevalence in India seems
to have contributed to the absence of a decrease in
tuberculosis incidence between 1998 and 2008, despite
improvement in tuberculosis treatment.
For many health systems, coping with communicable
diseases alone can be dicult. On the one hand,
www.thelancet.com/diabetes-endocrinology Vol 2 September 2014

adding the increasing burden of diabetes and other

non-communicable diseases (NCDs) into the mix will be
an extra strain with which many countries will struggle
to cope. The fact that the NCDs will worsen the burden
of communicable diseases could be the straw that
breaks the camels back for some health systems.
On the other hand, this interaction between
communicable diseases and NCDs could provide the
wake-up call that health providers need to kick NCD
prevention programmes into action. Up until very
recently, the global health community had largely
ignored the rise in prevalence of obesity and associated
NCDs. Communicable diseases continue to receive
the lions share of funding, even after the 2011 UN
high-level meeting on NCDs set the target of a 25%
reduction in NCDs by 2025. The knowledge that a
strong reduction in communicable diseases will be
impossible to achieve without a concomitant reduction
in obesity and diabetes should provide impetus for the
global community and local providers to start to invest
in prevention and treatment for these conditions. It
is therefore timely that WHO has incorporated the
management of diabetes into its strategy to decrease
tuberculosis incidence by 90% by 2035. That NCDs are
explicitly mentioned in the health element of draft zero
of the Sustainable Development Goals (SDGs) is also
most welcomeit is absolutely essential that NCDs
remain a core part of the health targets of the SDGs.
Recommendations are a cry into the void without
actions, and the chronic nature of NCDs could be used as
an excuse for inaction. But the enormous success seen
in the treatment of patients with HIV has proven that
even nascent health systems can provide lifelong care.
The care models in place for dealing with patients with
HIV and tuberculosis can potentially be used to provide
a framework for those needed to treat people with
diabetes and tuberculosis.
Importantly, the intersection between communicable
diseases and NCDs should be used as a driver to strengthen
health systems, to ensure that they can provide access
to care with nancial risk protection for all disorders,
not just a select few. Illness, death, and disability do not
recognise the divide between communicable diseases
and NCDs, and nor should our delivery of health care.
The Lancet Diabetes & Endocrinology

Hugh Sitton/Corbis

Diabetes and tuberculosisa wake-up call

See Online for infographic

See Series pages 730, 740,
and 754
For the UN high-level meeting
on non-communicable diseases
see http://www.un.org/en/ga/
president/65/issues/ncdiseases.
shtml
For the WHO Stop TB Strategy
see http://www.who.int/tb/
strategy/en/
For the Sustainable
Development Goals see
http://sustainabledevelopment.
un.org/focussdgs.html

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