The New York Times - September 14, 2006

The accelerated pace of resistance comes from the world's neglect of tuberculosis, which is best cured with a cocktail of four drugs, with medicines taken daily for six to nine months. But most patients who start this difficult regime fail to complete it, leading to resistance. Of the 9.5 million new TB cases globally every year, about 425,000 of them are resistant to the standard medicines.

While a course of these drugs costs as little as $11, the medicines needed to cure resistant TB can cost up to a thousand times as much, can have harmful side effects, and must be taken for as much as two years. The really bad news, however, is that even these backup drugs are starting to fail, as they have in KwaZulu-Natal. Globally, about 6 percent of resistant TB cases are also resistant to second-line drugs - 15 percent in the former Soviet Union.

The development of antibiotics had allowed wealthy nations to dismiss TB as a disease of the past. But H.I.V. and AIDS have changed that calculus. In Africa, active TB cases are rising by 4 percent a year, largely because H.I.V. activates latent TB infection. TB is the leading cause of AIDS-related deaths. Every patient tested in the KwaZulu-Natal study was H.I.V.-positive - and more than a quarter of those who died were taking antiretroviral therapy.

African health officials gathered in South Africa last week to discuss extreme tuberculosis, but they are hobbled by the world's indifference. It is crucial, for example, to find out quickly where else extremely resistant TB lurks. But surveillance in Africa is poor, there have been no new diagnostic tests invented in the past 50 years, and the tests in use can take months. Efforts to make sure patients complete their treatment reach less than a third of TB victims. New drugs are needed to replace current ones, which are all at least 40 years old. But TB drug research had dried up until a few years ago.

A group called the Global Alliance for TB Drug Development has six compounds in the pipeline, but a treatment for extremely resistant TB is not likely before 2012. Money for clinical trials would speed things. But donors have always slighted tuberculosis. According to a new report by Results International, an advocacy group, the World Bank spent only $3.5 million directly on TB in Africa in 2005. The Global Fund to Fight AIDS, Tuberculosis and Malaria and the Bill and Melinda Gates Foundation are big donors, but much more is needed. Stinginess created this problem. Generosity is needed to fix it.

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