An Ancient Marauder Looms Again

For the first time since the introduction of anti-tuberculosis drugs in the 1950s, the world faces the threat of incurable TB, a disease that destroys the lungs, dooming its victims to drown in their own blood. This deadly infection is airborne; it spreads like the common cold. Worst of all, highly resistant strains have been discovered in 34 countries by the Global Project on Anti-TB Drug Resistance.

If tuberculosis were a newly emerging disease rather than an ancient marauder, it would be making headlines almost daily. However, in the four years since the World Health Organization declared TB a global emergency, there has been little international alarm. Inexpensive, generic medications have long existed to cure tuberculosis, yet 3 million people die each year, making TB the greatest infectious killer worldwide, responsible for one-fourth of the world’s preventable deaths.

In October, an unprecedented report released by top U.S. and international health agencies issued the ultimate warning: Multi-drug-resistant strains of tuberculosis (MDR-TB), which can be virtually untreatable, have emerged worldwide and threaten to overwhelm the public health systems of India, Russia, Latvia, Estonia, Argentina, Ivory Coast and the Dominican Republic. In these countries, poor TB control programs misuse antibiotics and ineffectively treat patients, practices that foster drug-resistant strains. These MDR-TB “hot-zones” pose a grave threat to global health, as international travel and migration put all areas of the world in close contact.

Few people recognize the danger that MDR-TB poses to Americans. It is very difficult and expensive to contain, and the industrialized world is by no means immune. Since 1991, when these strains were found in only 13 states, MDR-TB has spread to 42 states and the District of Columbia. In September, a new strain of highly contagious TB that multiplies at 1,000 times the normal rate was identified along the Tennessee-Kentucky border.

Transmission of tuberculosis can occur anywhere, from planes to schools to neighborhood bars. In 1994, a South Korean woman with MDR-TB infected four Americans on a plane.

The importation of TB across international borders is very common. In this country, 37% of TB patients are foreign-born, 25% of them from one of four “hot zones”: India, Korea, Vietnam and the Dominican Republic. In the Dominican Republic, where 9% of TB cases are MDR, one out of every seven residents has obtained a visa for travel to the U.S.

The U.S. learned a harsh lesson when the dismantling of TB control infrastructure in the 1980s led to sharp increases in tuberculosis. According to New York City’s director of TB control, the explosion of MDR-TB required more than $700 million between 1992 and 1996 to quell the outbreak.

The World Health Organization spends $11 million annually on TB control, of which the U.S. contributes only about $500,000. WHO estimates that, in addition to commitments from developing countries, $100 million more is needed annually to control the epidemic and prevent the spread of MDR-TB. Surely, Americans would be willing to foot some portion of that bill to prevent a disease that WHO’s Richard Bumgarner called “Ebola with wings” from descending on our shores.

Congress has approved additional money for the Agency for International Development, which channels funds to WHO, to combat infectious diseases worldwide. If only the Clinton administration would follow through more comprehensively. Some of the proposed new funding for biomedical research and for the National Institutes of Health also should be channeled into TB research. Furthermore, the U.S. must pay its dues to the United Nations if WHO is to be effective in fighting TB and other such deadly diseases. Unless this funding is sustained over the long term, TB programs will be ineffective, treatment of patients will be incomplete and our temporary good intentions will only fuel the spread of drug-resistant strains.

The only way to protect Americans against multi-drug-resistant tuberculosis is to support effective treatment and control programs that prevent MDR-TB from developing. It is a war that must be fought internationally, before this country becomes a primary TB battleground.