Features

Human catastrophe

"Human catastrophe" Continued...

Issue: "Ideal Idol," June 2, 2007

"Multidrug-resistant TB tends to arise where wealth and poverty are mingled, where poor people get some treatment but not enough," journalist Tracy Kidder wrote in his biography of physician Paul Farmer, a now-famous advocate for proper TB treatment for the poor who founded the Boston-based global health agency Partners In Health. The New England Journal of Medicine stated that before 1989, fewer than half of patients who started TB treatment in New York City completed it. By 1992, TB incidence in New York had tripled, and one in five cases was drug-resistant.

Physicians have known about TB's propensity to drug resistance since the first successful TB drug, streptomycin, was administered in 1947 by England's Medical Research Council. Doctors there documented the "fall and rise" of TB in patients who would get better for a time but fall ill again. That was because not all the bacilli in the patients' bodies were susceptible to streptomycin. The first wave of treatment reduced the total number of bacilli, leaving those resistant to the drug. The remaining bacilli multiplied until the patients got sick again, but then the drug was useless against the resistant strain of TB.

Doctors quickly learned that one drug was not enough to cure TB. They also learned that the disappearance of symptoms did not mean TB was cured. Today, TB treatment requires six months of treatment with at least three drugs that each attack bacilli in different ways. The treatment works if patients take their medicine when, how, and for as long as they are supposed to take it. But many patients' devotion to their medication regimens wanes once their symptoms start to go away, usually after a month of therapy.

"If someone is very sick, they take their medicine," Moser said. "But if three months later they don't have a symptom at all, it's hard."

WHO and the CDC both recommend some form of supervision in all TB treatment. It is not enough to simply prescribe TB medication; a health-care worker must also watch patients swallow every dose. In that treatment model, called directly observed therapy, or DOTS, patients can come to a clinic for medicine or have it delivered to them by a health-care worker. Moser's program even includes video phones for workers to watch patients as they take their medicine.

"The best programs in the U.S. and in most of the world use directly observed therapy as standard of care," Vernon said.

In 2006 WHO released a plan for implementing DOTS in the corners of the world that need it most. The Global Plan to Stop TB focuses on 22 countries whose populations include 80 percent of the world's TB patients. The Global Plan aims to reduce the worldwide prevalence and death rate of TB by half by 2015.

Directly observed therapy programs require trained health-care workers and either a clean space for a clinic, transportation for getting to patients' homes, or both. Some TB-ravaged areas of the Third World are not even accessible by road. Places already exposed to shoddy TB treatment, particularly areas of Russia, need more than just directly observed therapy. Facilities to test strains of TB for drug susceptibility and access to good-quality, second-line drugs are a minimum for treating drug-resistant TB.

WHO estimates the plan will cost $56.1 billion. That amount is more than the gross domestic product of 10 of the 22 high-burden countries (view chart) targeted by the plan. WHO also predicts the plan could save 14 million lives, at a cost of only about $150 per year per life saved.

About half of the cost of the plan would go toward implementing DOTS and improving existing DOTS programs. The other half would be divided among treating drug-resistant TB, treating HIV/TB co-infection, and developing new TB tests, medicines, and vaccinations.

WHO would not directly implement the changes; it provides a blueprint for countries to follow. A worldwide partnership of private, public, and nonprofit organizations has committed funding and resources to the plan.

Moser oversees one of the programs that is a partner in the Global Plan to Stop TB. CureTB helps coordinate health care for patients who start TB treatment in the United States but move to Mexico before their therapy is finished. About 200 patients a year are referred to the program, which forwards the patients' treatment records to doctors who will take care of them in Mexico. CureTB started locally in San Diego but expanded to act as a communication hub for the United States.

The program began because public health officials treat TB patients who return to Mexico, "and we wonder what ever happened to the individual and hope they were able to tell doctors what medications they were on and hope they figured out where to go," Moser said.

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