The Drugs Don't Work

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James Nachtwey for TIME

Patients in a TB isolation ward in impoverished Bihar state, which has one of India's highest infection rates

A girl swings her legs from the examination table and glances out the small square window of the doctor's office. The breeze rolling in off Mumbai's Mahim Bay ruffles the papers on the desk, where the girl's grandmother has laid out her upturned hands imploringly. "Please help," she says to Dr. Zarir Udwadia, a chest doctor. "I don't know what to do."

Udwadia glances through the papers that document the family's months of attempts to treat the girl's virulent case of tuberculosis. A lab has just delivered the test results that explain why she's not getting better: the disease that has settled in the girl's lungs is multidrug-resistant, or MDR, tuberculosis, and most medicine is useless against it. "Ten years ago, you would have been horrified," Udwadia tells TIME, scratching out a prescription for yet another combination of TB drugs that may — or may not — work. As cases that are harder and harder to treat emerge, Udwadia says, patients who finally respond are a relief. "Now we say, At least she's only MDR."

Some of the people waiting their turn to see Udwadia won't be so lucky. Once a week, patients who have tried and failed to treat their tuberculosis line up, frustrated and frightened, outside his small office in Hinduja Hospital in India's financial capital. Hinduja is where the first Indian cases of totally drug-resistant (TDR) TB were reported in late 2011, making the hospital a key battleground in India's new war against a very old disease. What happens there concerns us all. For while the wily bacterium has been around for millennia, trade, migration, urban overcrowding and air travel mean that the disease has been able to spread like never before. And if TDR strains take hold in global populations, the resulting contagion could be catastrophic.

Doctors have been effectively fighting M. tuberculosis and other bacteria with antibiotics for decades. The global TB mortality rate has gone down 41% since 1990. But poor diagnosis and the misuse and mismanagement of powerful drugs have created strains that are getting harder to fight. When a TB patient is given the wrong prescription or starts but does not complete the full course of drugs, the bacterium can grow stronger. Nearly 4% of new TB patients have MDR strains of TB; among patients who had been treated for TB before, about 20% have MDR TB, according to the World Health Organization (WHO).

A paper published last August in the Lancet reported that worldwide rates of MDR and extensively drug-resistant (XDR) tuberculosis are higher than anyone previously thought. (WHO identifies the cases that were reported at Hinduja as XDR, saying complete drug resistance in TB has not been clearly defined.) XDR TB has been found in 84 countries. East and Southeast Asia, Eastern Europe, South Africa, Russia and India have alarmingly high rates of drug resistance, and though only India, Italy and Iran have reported cases of TB that do not respond to any drugs, many experts believe that's simply because more haven't been found. "We are on the brink of another epidemic, and it has no treatment," says Dr. Shelly Batra, president of Operation ASHA, a New Delhi — based NGO that fights TB. "If TDR spreads, we will go back to the Dark Ages."

Tuberculosis — once known as consumption because of the severe weight loss it can cause — is a contagious, airborne disease that thrives in overcrowded places. It typically settles in the lungs but can attack other parts of the body as well, and its symptoms include coughing (often producing blood), fever, night sweats and chills. Malnourished people are particularly vulnerable to TB, as are those with HIV. Most TB infections are latent and asymptomatic, but once the infection becomes active, the mortality rate is high. A third of humans alive today carry TB bacteria. Only a relatively small number of them will get sick and become contagious, but it is still one of the world's deadliest diseases, killing 1.4 million people in 2011. WHO estimates there will be over 2 million new cases of MDR TB from 2011 to 2015, yet today only 10% of new MDR cases get proper treatment. The ones who don't inevitably spread the disease: a person with active TB can infect up to 15 others in a year.

India, where about two people die every three minutes from TB, is on the front line of this global battle. Some 2 million Indians develop TB each year, leaving the Indian government with the unenviable task of managing roughly a quarter of the world's TB cases. The more drug resistance, the more money must be spent on treatment, diverting funds and staff from addressing rampant but run-of-the-mill TB. That means the conditions creating drug resistance — when treatable cases go unnoticed or patients receive bad medicine — could get worse. "I've seen the resistance pattern changing," says Udwadia. "Basically, we're screwed."

By we, he means all of us.

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