The Church of Scotland Hospital in Tugela Ferry, South Africa, sits in an arid valley among the mountains of KwaZulu-Natal. Occupying a dozen or so tin-roofed, low-slung buildings, the hospital serves its rural patients well: Women come to have babies, H.I.V. patients register to receive their medications, and those infected with tuberculosis check in for a chance to recover from an ancient scourge.
But in 2005 a physician noticed that some of those TB patients, many of whom were H.I.V.-positive, were not getting any better, despite being on anti-TB medications. Nothing he provided them seemed to control the tubercle bacillus flourishing in their bodies. Of the 53 who were sickest, 52 died, most within a month of entering the hospital.
The bacterium responsible for these deaths was nothing the doctors at Church of Scotland had ever seen before. It had found a way to evade not just the first-line antibiotics commonly used to treat the disease but several of the drugs of last resort as well. KwaZulu-Natal, and the world, had seen its first outbreak of extensively drug-resistant TB.
Thousands of years after tuberculosis ravaged ancient cultures stretching from Greece to Egypt, more than a century after the bacillus responsible for the disease was first identified and decades after the first antibiotic treatments, TB continues to survive, even thrive, in ever more aggressive forms. In 2006, 9.2 million more people were diagnosed with the disease, almost exclusively in the developing world, and 1.7 million people died from it. More alarming is a growing subset of TB cases, estimated at half a million, that are resistant to more than one of the handful of anti-TB drugs. While they still make up only 5% of the total annual TB burden, these cases of multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB are mushrooming, fueled by both the surge in H.I.V./AIDS and health systems that have ignored the threat of TB for too long.
But it doesn't have to be this way. TB is an entirely preventable and treatable disease. And the drug-resistant strains beginning to emerge in Africa, Russia, China and India, say experts, are epidemics of our own making. Unlike H.I.V., the tubercle bacillus succumbs to powerful medications. But the drugs are not where they need to be, and when they are, spotty monitoring and poor health infrastructure make it hard to ensure that patients take the daily pills or frequent injections they must receive for six months to eradicate the infection. Stopping treatment too early allows the small population of drug-resistant strains to survive and keep the infection going. "We are still in denial about how bad this problem is and how much worse it's going to get," says Dr. Jim Kim, head of Social Medicine at Harvard Medical School and a co-founder of Partners in Health, a global-health aid organization. "We are at the pre-antibiotic era for TB again. We've been afraid of getting there, but guess what? We're there."
The biggest threat, XDR TB, is currently resistant to the most potent classes of first- and second-line anti-TB drugs available and there is no third line of pharmaceutical defense. While some promising candidates are being tested, even if they prove effective, they will not be available for at least five more years. There is also no easy way to detect drug-resistant strains of TB; current sputum-based screens can take anywhere from two weeks to two months, during which time doctors protectively place infected patients on first-line drugs too weak to battle the aggressive strain effectively rather than risk the overuse of last-resort medications that would only feed drug resistance. And in Africa in particular, tuberculosis is nurtured alongside AIDS in a deadly double hit: The weakened immune systems of H.I.V. patients make them more vulnerable to TB infection, and because their crippled immune systems can no longer mount proper responses, H.I.V. patients infected with TB often don't produce the recognizable symptoms of the disease such as coughing or visible lesions on chest X-rays. Their abnormal immunity also renders the myco-bacterium difficult to detect in blood-based assays.
In response, the World Health Organization (WHO) in June recommended widespread use of a new, faster test that can screen for drug-resistant TB in the blood in one or two days. But it requires sophisticated lab facilities for amplifying genes that are beyond the limited resources of most developing nations. "It will be very difficult to bring expensive technologies, machines and trained technicians on a wider scale," predicts Dr. Arvinder Pal Gill, district TB officer in Moga, in India's Punjab region. In addition, the test can detect only MDR TB, not the emerging XDR strains. But both WHO and the Global Fund for H.I.V., TB and Malaria are betting that investing in such facilities will boost these nations' ability to combat not just TB but other infectious diseases too. UNITAID, the international drug-purchasing organization, has pledged $26.1 million to the effort, while the Global Fund promises to entertain grant proposals from countries eager to build such labs. "We don't have the luxury of having a simple saliva test that tells you in one minute if you have MDR TB," says Dr. Mario Raviglione, director of WHO's Stop TB program. "We have to work with what we have."
To document the ongoing TB epidemic, TIME's James Nachtwey traveled to seven countries over the last five months, photographing the diverse and changing face of the disease. As his images show, controlling the epidemic requires investing not just in new technologies but also in expanding existing programs to control and detect TB before it even becomes resistant. And dots (Directly Observed Treatment, Short Course) is a critical part of that strategy. Developed in the 1990s, the program requires health officials to be present to watch their patients take their complete course of medications, even if it means visiting them in their homes. In many regions, these officials are now recruiting a host of nonmedical personnel, including family members and religious and community leaders, to become DOTS enablers. In Punjab, retired teachers, shopkeepers and cured patients are paid $6 for each patient they observe completing an entire course of treatment.
Officials in Africa's Lesotho, where 10% of the population is infected with MDR and 30% is H.I.V.-positive, are relying on a collaboration between the government and Partners in Health, which provides private funding, to address another challenge in TB care: the need to isolate the sickest patients to prevent them from spreading the disease. Lesotho now boasts its first 10-to-15-room facility equipped with negative airflow, which contains and filters air circulating through TB wards. A single such center is hardly enough, but it is a start. "It shows you it is possible," says Raviglione. And that is the most powerful lesson in TB today. The bug can adapt; if we're smart, so can we. with reporting by Megan Lindow/Cape Town, Madhur Singh/New Delhi and Yuri Zarakhovich/Moscow