(March 2007) The global fight against tuberculosis has become more complicated by the emergence of new strains of TB that are resistant to many standard drugs. Many public health specialists are deeply concerned that without greater attention to the disease worldwide now, there is a risk that drug-resistant strains will spread, extraordinary sums will have to be spent combating drug-resistant TB, and important investments in treatment for HIV/AIDS will be rendered ineffective.

In a globalizing world, TB anywhere really is TB everywhere. Commerce, tourism, and immigration are sources that enable it to spread. Last year in the United States, for example, there were 9,000 new cases.

Tuberculosis is a contagious disease, which spreads from person to person in the air, when people cough, sneeze, speak, or sing. TB can affect any part of the body but it usually affects the lungs. Its symptoms include feeling weak or sick, fever, night sweats, and weight loss. They also include chest pain and the coughing up of blood. People can die of TB if they are not treated properly and completely for it.

About 15 million people in the world are sick with the disease, and last year another 9 million people became ill with active TB. Each person with TB can infect 10 to 15 people a year. As importantly, about one-third of all the people in the world carry the TB germ, although they are not actively sick. They represent an extraordinary reservoir of people who can develop active TB as their immune systems become weak due to aging, malnutrition, or HIV. TB is the eighth-leading cause of death in low- and middle-income countries. Last year, almost 2 million people died of it.

Why TB Has Become an Urgent Global Health Priority

There are a number of reasons why the World Health Organization declared TB a “global emergency” and made it a priority for the global fight against disease. First, an important share of TB has become resistant to one or more of the standard drugs used to treat it, and people with drug-resistant TB spread that deadlier form of the disease. Of especially great concern to many of those involved with TB control is the fact that some TB is now resistant to most of the drugs normally used against it. This version of the disease is called “extensively drug resistant TB”—XDR TB—and it is extremely difficult to treat, if it can be treated at all.

Last year in South Africa, 53 patients were diagnosed in a single hospital with XDR TB and within two weeks, all but one of them had died. Curing TB in Kenya costs about $400 per patient. However, treating a case of drug-resistant TB in Kenya costs about $18,000, or more than 40 times as much, something few low-income countries can afford.

TB also poses an enormous threat to the success of AIDS treatment programs. There has been considerable progress in expanding access to antiretroviral therapy for people in developing countries with HIV/AIDS. The United States, for example, is supporting a $15 billion program to prevent and treat HIV. Other funds for treatment of HIV/AIDS are coming from the Global Fund to Fight AIDS, TB, and Malaria, and from the World Bank, among others. If drug-resistant TB continues to spread and if TB is not brought under better control among HIV-infected people, then important parts of the expenditure on AIDS treatment will be wasted, as those treated for HIV die from TB. Tuberculosis is the leading cause of death of people who are infected with HIV.

In addition, about 200 cases were resistant to at least two standard TB drugs. Treating a case of multidrug-resistant TB in the United States could cost an astounding $300,000 per patient, an expense almost always borne by the public sector. New York City spent $1 billion in the early 1990s treating only 300 people for this type of TB.

Inexpensive Steps Could Prevent a Crisis

The development of drug-resistant TB is a problem that we brought upon ourselves. Resistance to drugs develops when treatment for TB is not carried out properly and people do not take all of their drugs. The world faces a potentially devastating threat of extensively drug-resistant TB that is actually of our own making.

March 24 is World TB Day. The world faces stark choices about how it will address TB. It can operate as it has been doing, continuing to provide important support to global TB control efforts that have made significant progress but which are not sufficient to control TB in the era of HIV and XDR TB. In this case, many more new TB cases will arise, many more of them will be resistant to standard treatment, and the risk of extensively drug-resistant TB—a “superbug”—will grow.

The other option is to take urgent steps to strengthen TB control in all countries where it is having a major impact. These steps are well-known and include strengthening the quality and number of health personnel, enhancing surveillance, improving laboratories, providing TB drugs, and ensuring that all treatment is properly supervised. As recent efforts in China and India, among others, have shown, with the resources and political commitment to expand effective strategies, more people with TB can be identified and a larger share of them treated appropriately and inexpensively until they are cured. This approach will also reduce the growth of drug-resistant TB, slow the emergence of potentially untreatable TB strains, and continue to protect the enormous investments and progress made in AIDS treatment.

Richard Skolnik is director of international programs at the Population Reference Bureau. Joanne Carter is the associate executive director of Results and RESULTS Educational Fund.

For more information on TB, visit the Disease Control Priorites Project website, www.dcp2.org.