Tuberculosis control programs have been starved for money for decades. Now, we're paying the price: between 2 million and 3 million deaths a year and an alarming emergence of multi-drug-resistant TB.
This TB, which is far more difficult and costly to treat than regular TB, has shown up in more than 100 countries, according to a report released last week by doctors from Harvard Medical School and the Open Society Institute, a George Soros foundation that financed the study. Multi-drug-resistant TB occurs on the average in 2 percent of victims, but in some regions of the world, including Russia, China, India and parts of Latin America, it is becoming far more prevalent than anticipated. We are not immune: About 400 people in New York City developed multi-drug-resistant TB in the early 1990s.
In 1993, the World Health Organization declared TB a global emergency and recommended that TB patients take up to four drugs, every day, for six to eight months, under the watchful eye of their health care providers. This is known as "directly observed therapy short-course," or DOTS. This strategy was developed to make sure patients got the right drugs and continued taking their medication even after they started feeling better. When patients discontinue their medication prematurely, the bacteria remaining in their systems becomes resistant to drugs.
TB is an airborne bacteria transmitted when a patient with active TB coughs or sneezes. The Harvard study concludes that multi-drug-resistant TB is spreading on its own to patients who have never had poor therapy for regular TB.
DOTS therapy costs about $10 a patient in the developing world. Doctors have successfully treated patients with multi-drug-resistant TB by administering seven drugs every day for 24 months in a therapy called DOTS-plus. The treatment in the developing world costs $300 to $4,000 a patient, which puts an enormous strain on fragile health care systems. The situation is particularly grave in sub-Saharan Africa, whose people and health care systems have been devastated by AIDS.
The Harvard study is touching off an important discussion among the world's TB experts about the best way to control both forms of the disease. At the heart of the matter is a lack of resources and a lack of international will to direct necessary resources to control TB, an effort that worldwide has a budget of only $100 million a year. Six years into the DOTS program, 84 percent of the world's people with active TB have not been treated. Experts fear a tug of war over limited resources, with one camp arguing the best way to control TB is through vastly expanded DOTS programs and the other warning that a second strategy, DOTS-plus, has to be put in place as well. The Harvard report recommends undertaking both.
"It's a fascinating debate," said Nils Daulaire, head of the Global Health Council, whose members include the major international health groups, universities, pharmaceutical firms and non-governmental organizations. "Both sides have an awful lot on their side."
DOTS was and remains a major strategy against TB because it provides a low-cost and effective way to treat TB, Daulaire said. "TB is a sleeper, and what we're dealing with now are infections that occurred 15 to 20 years ago," he said. "The advent of good drugs and then a manageable way of giving those drugs over time was a very big step forward."
Poorly administered programs in the 1970s and '80s are responsible for many of the multi-drug- resistant strains showing up now. "Where it's in 1 to 2 percent of the cases, then it's not a major factor, but in some places drug resistance is showing up in up to 22 percent of the cases," Daulaire said. "When you get up in that range, you've got a very serious problem. Treating them with DOTS has no effect. The danger is that in not dealing with multi-drug-resistant strains now, in 20 to 40 years, we could perhaps have a majority of cases be multi-drug-resistant, and that would be like starting over in the fight against TB.
"In an ideal world, we'd have enough resources to do both. The challenge is going to be to look on a country-to-country basis and see what is best. In sub-Saharan Africa, implementing DOTS is probably all those health care systems can handle at this point." On the other hand, Russia and some of the other former Soviet republics have the trained personnel to implement DOTS-plus, Daulaire said.
Part of the Global Health Council's role, Daulaire said, is "to make sure there is a good exchange of information and policy viewpoints among the researchers, practitioners and health advocates . . . [and] to identify the resources so we can use both strategies."
Foundations and the private sector are pouring money into global health and are moving toward setting up a $500 million trust fund to buy TB drugs. Daulaire, among others, estimates that more than $1 billion needs to be spent every year on regular TB control worldwide to maintain an effective program, and he cautions that unless countries have well administered DOTS programs this push toward using more drugs could lead to more multiple-resistant TB as surfaced already in poorly run programs.
There's a widespread misconception in the United States that TB is a thing of the past. But the Harvard study is a wake-up call, warning that even the two-pronged DOTS strategy leaves us looking at a best-case scenario of 171 million additional cases and 60 million deaths worldwide between 1998 and 2030.
The United States has strong detection and control programs, but it also gets close to 50 million visitors a year. Americans come in contact with them in offices, on buses, trains and airplanes. There's a growing recognition that multi-drug-resistant TB poses a serious threat to us.
WHO warned two years ago that if the drug- resistant TB is "unleashed, we may never be to able to stop it." Putting the necessary resources into treatment now for regular TB and for the multi-drug-resistant strains may save us from a worldwide epidemic we cannot control.