And the Western world, which three decades ago believed it had conquered the disease, is hardly immune from these aggressive new versions of it in a globalized economy. Atlanta lawyer Andrew Speaker generated a national uproar last year after gallivanting around the world with a resistant strain of TB that he might have picked up while doing charity work in Vietnam, but even more troubling cases involve itinerant immigrants like Robert Daniels, who probably contracted MDR-TB while serving time in a Russian prison for marijuana possession.
Daniels told National Public Radio that he stopped taking TB drugs because he was "feeling fine." After leaving a wife and small son behind in Moscow, he wound up in a Phoenix hospital under quarantine with XDR-TB. So far, only 1 percent of the 13,148 TB cases reported in the U.S. in 2006 involved drug-resistant strains.
"We're all connected by the air we breathe," says Thomas Frieden, New York City's health commissioner who won plaudits for successfully combating an MDR-TB outbreak in the city's jails in the 1990s. "MDR-TB is a serious problem. It can spread explosively. But it's a symptom of a larger problem—that we're not treating susceptible TB well even though we have the tools to make tremendous progress."
In Tomsk, the tools he's talking about—drug treatments and a comprehensive model for delivering them—are finally being deployed, although only after a concerted campaign over more than a decade by global health authorities, along with nonprofit, nongovernmental organizations (NGOs) including Boston-based Partners in Health (PIH). These groups have marshaled international aid to help rebuild the local prison and the public health infrastructure for combating TB, which had nearly collapsed after the fall of Soviet communism in 1989.
The program's architects claim that by getting the local authorities to focus on treating MDR-TB, they have also reinvigorated the community's response to susceptible TB. It is a model that is now being taught to TB physicians throughout the Commonwealth of Independent States (CIS), an organization made up of Russia and some of the other former republics that comprised the Soviet Union, and one that is exportable to other countries, the advocates say. They believe it could help the world public health community meet the goal established in 2006 of halving TB's global prevalence and mortality by 2015.
The reality is that the overall rates of TB here have only recently begun to drop, and the country as a whole remains far behind meeting the 2015 goals. "The problem in Russia is only growing," says Michael Kimerling of the Gorgas Tuberculosis Initiative at the University of Alabama at Birmingham, who helped kick off the TB-treatment push here in the late 1990s and this month takes over managing the Bill and Melinda Gates Foundation program for treating TB around the world. "There's been a lot of money spent but it is really every bit the problem it was 10 years ago."
This In-Depth Report will explore these efforts to combat TB: at a hospital that has dramatically lowered the reinfection rate in Tomsk's prison; in civilian hospitals and rural settings that have gone from ignoring MDR-TB cases to successfully treating them—even though a single patient's drugs can cost several thousands of dollars a year; and through a door-to-door campaign that delivers DOTS to hard-to-reach cases in their own homes. A final article will look at the new diagnostic tools and drugs in development that could simplify treatment of the disease.