Madhukar Pai on how the 'know-do' gap undermines health goals

According to a new UN report, progress on the Sustainable Development Goals (SDGs) is far behind schedule. Of the 140 SDG targets, from reducing maternal mortality ratio to less than 70 per 100,000 live births to ending preventable newborn deaths, only 12% are on track to meet the 2030 deadline.

To explore why this is the case when there have been so many advances in healthcare, including in areas such as diagnostics and treatment, Exemplars News spoke with Dr. Madhukar Pai, Canada Research Chair in Epidemiology and Global Health at McGill University, and Associate Director of the McGill International Tuberculosis Centre.

“When I started my medical career, we were focused on achieving health for all by 2000,” said Dr. Pai. “Then we shifted to achieving the Millennium Development Goals by 2015. And now we are striving for the Sustainable Development Goals by 2030.”

“And we will miss these targets as well,” said Dr. Pai. “The problem is, we always approach these challenges with the understanding that knowledge is the problem. But in reality, we know how to achieve many of these goals. For example, we know how to cure TB. Knowledge isn’t the problem. The problem is the ‘know-do gap,’” the gap between what we know and what we deliver in practice.

We asked Dr. Pai about the know-do gap in delivering tuberculosis (TB) healthcare services and how understanding it could help us better understand the gap for many of our other health challenges.

Tell us more about the know-do gap in TB globally.

Dr. Pai: The know-do gap in TB is huge. And it causes us to fail, decade after decade. Consider these statistics: 40% of the 10.6 million people around the world with TB remain undiagnosed or not notified (reported). About 1.6 million people die each year of TB – a disease that is curable – and the case fatality ratio is over 5%. This is outrageous given that it requires just $20 to be on antibiotics for six months to cure the disease. It is simply not logical or rational that so many people are going undiagnosed or dying.

So why is this the case at a time when we have achieved breakthroughs in prevention, diagnosis, and treatment of the condition? The 2020 Step Up For TB report by Médecins Sans Frontières and the Stop TB Partnership provides one surprising reason. The report surveyed the 37 countries most impacted by TB and found that too few countries are consistently updating their national policies in a timely manner to align with new WHO guidelines and recommendations. As a result, novel and efficient innovations in prevention, diagnosis and treatment are taking years to reach people who need them, which minimizes the impact of these innovations and enables TB to continue to spread undetected.

Those of us working on TB used to think that getting the WHO to endorse a new approach or a tool was the end of our work. That once you got the WHO to release a policy, we thought it would then be rolled out around the world. But now we see that the WHO policy is just the start of the journey. How do you get country X to acknowledge the WHO policy, adopt the policy, and roll it out and ensure that people on the ground can access it? Those are the key issues.

Currently, many WHO recommendations are simply not getting adopted. For example, many countries are still using the century-old sputum smear microscopy test, even though WHO has recommended molecular testing. This is a massive know- do gap.

There is clearly a know-do gap in national policies. Is there a similar know-do gap in doctors’ offices and healthcare clinics when it comes to how they manage TB?

Dr. Pai: The research done or inspired by our Qutub project in China, India, Indonesia, Kenya, Nigeria, and South Africa is particularly interesting when it comes to this issue.

We and our colleagues sent mystery patients who reported two to three weeks of productive coughs, fever, night sweats, and weight loss – all of the symptoms of presumed TB – to providers’ clinics in those six countries. What we found was striking. In private clinics across many countries, only one in three standardized patients with textbook symptoms of TB were properly managed. Instead, they received lots of medicine, including antibiotics, cough syrups, steroids, etc.

After these patient visits, we sent field workers to interview the same health care providers and tested their knowledge by asking them how they would treat patients with typical TB symptoms. Across the countries, we saw that doctors’ knowledge about tuberculosis was far superior to their actual practice. They knew the recommended protocol to follow when presented with a hypothetical patient. But they didn't follow that recommended protocol with real patients. This is a direct measurement of the gap between providers’ knowledge and their actual clinical practice in the real world. Jishnu Das and others have shown that this know-do gap is seen across various diseases and across countries.

Nobody is thinking about test and treat. That’s because the default process of primary care is empirically treat first then test later if necessary. This amounts to an inversion of the recommended approach. Why? Because their process is based on their resources. Primary care facilities often do not have diagnostics. All they have is medicine, and medicine is often cheaper than diagnostic tests. And because that’s what they have, that’s how they work.

Go there with typical TB symptoms and they will give you a cocktail of antibiotics, steroids, and maybe a bronchodilator. Only if this treatment fails and you come back to them for a follow up visit, then they think to test for TB. Meanwhile, you may have lost two or three months and the transmission chain continues. And, obviously, this approach contributes to antibiotic overuse, drug resistant TB and makes the TB even harder to treat.

Why are doctors doing this if they know it isn’t recommended? Why does this know-do gap exist?

Dr. Pai: This is the nature of primary care in low and middle-income countries. The urgency of delivering rapid symptomatic relief overrides all other considerations.

How many doctors have prescribed an antibiotic for a sick child brought to their office by a worried parent even when you suspect the antibiotic isn’t going to have an impact because the child just has a viral infection? We do this because the parents are worried and have taken the time to bring the child in to be seen.

This happens all the time in countries with malaria. If the child with fever tests negative for malaria, doctors often give broad-spectrum antibiotics. Why? Because they can’t send the sick child home with nothing.

That’s why, if you walk into primary care offices with fancy guidelines that recommend three different tests, you will get nowhere. Because the patients judge their doctors based on how quickly they can relieve symptoms and how responsive they can be. Private providers also care about retention of clients, revenues, and their competitors. It’s a complex market.

Can you share with us the know-do gap when it comes to treatment for TB?

We can see the know-do gap for treatment of TB when we look at the data on cascades of care. For drug-sensitive TB, only one in two people with TB reaches the finish line. TB treatment is not rocket science. But even with that knowledge and those tools, we are not successful half of the time. And if you have multi-drug resistant TB, you are falling off a cliff. You have a one in five chance of getting to the finish line. This is disastrous.

Consider the difference between treatment protocols for HIV and treatment approaches for TB. For HIV, the approach is centered on people with HIV, and reflects design thinking. We put care ahead of control. Treatment is flexible, holistic, and respects patient confidentiality and agency. Meanwhile the treatment for TB is rigid, impersonal, and puts control ahead of care by relying on direct observation of treatment, whereby a patient has to ingest their medicine in front of another person. HIV shows that we know how to make treatment that is client-centered, flexible and accessible. But we don’t do this for TB.

Consider how that impacts people in South Africa. No country has a bigger challenge with HIV and TB than South Africa. To understand how rational the design of services is [in the country], we asked patients. They talked about how they have to go to one place for their HIV treatment and another place for TB treatment. And for each visit, they might waste an entire day. Is that a rational or client-centered design? Should we be surprised if people drop one of those treatments?

Another example of our failure to adopt design thinking is the absence, until about five years ago, of a child-friendly, pediatric syrup formulation for the treatment of childhood TB. Imagine parents around the world having to grind up adult pills, figure out the correct dosage based on their child’s weight, and then get their child to ingest the bitter powder, every day. This is absurd. We know how to do better.

Are you hopeful that we’ll be able to shift our approach, reduce the know-do gap and reach our goals?

Dr. Pai: Yes, I’m hopeful. There is a growing realization that the know-do gap results in poor quality care. The Lancet Commission on high quality health systems showed that poor-quality care is now a bigger barrier to reducing mortality than insufficient access. The commission estimated that 60% of deaths from conditions amenable to health care are due to poor- quality care, whereas the remaining deaths result are from non-utilisation of the health system. This commission and the conversations it sparked are helping to spotlight the issue of quality improvement.

I am hopeful about two big initiatives to improve TB care: the push to make molecular testing the primary test for TB, and the 1/4/6 by 24 campaign to scale shorter treatments for TB. If we wanted to, we could truly transform TB diagnosis and treatment.

Editor’s note: The 1/4/6×24 campaign, launched in January is named after its goals: that countries and health leaders take action to implement the shortest and most effective treatments regimens. That is one month or once-weekly treatment for TB prevention, four months of treatment for drug-sensitive TB and six months of treatment for drug-resistant TB. The campaign's goal is to achieve this global shift to leverage newer, safer, and more effective treatments by the end of 2024.

Learn more about the campaign here.

Dr. Pai’s remarks have been edited for length and clarity.