health care system in South Africa to be severely overburdened. In contrast, some of the data from Russia are promising, he said. TB has declined in prisons and in the civilian sector. Still, the total numbers of TB patients in the country are staggering.

The situation with respect to the treatment and diagnosis of children also remains stark, said Keshavjee. Representing 10−25 percent of patients, children demonstrate the complexity of the challenge, especially since diagnostics still cannot identify many cases of pediatric TB. Keshavjee emphasized the importance of making children a priority in the fight against TB.

The addition of MDR TB cases to the current pool of TB cases is cumulative, said Keshavjee. Patients are being diagnosed earlier and are being given effective treatment, but for that reason they also are present in the health care system longer. And because MDR TB is much more expensive to treat than drug-susceptible TB, budget pressures are severe.

Moreover, the data regarding amplification of resistance are compelling, according to Keshavjee. If the right regimen is not initiated from the beginning, resistance is amplified. A one-size-fits-all approach is not advisable given the existing data. But ensuring that people are receiving the treatment they require through tailored therapy will not be easy.

Finally, Keshavjee emphasized that TB is striking particularly hard in socially vulnerable populations, such as people who abuse alcohol (see Chapter 7). Delivering care to these populations is a daunting task, although it can be accomplished through careful planning.

Keshavjee cited PEPFAR as a model for what can be accomplished. In the case of PEPFAR, a disease was viewed as an emergency, resources were made available, boots were put on the ground, and outcomes were produced. These outcomes may not be perfect, but people are on treatment.

Coetzee stressed that countries need to strengthen their health systems to deal with the TB epidemic, but it is difficult for them to establish complex laboratory networks, multiyear treatment programs, monitoring of adverse effects, and so on. In South Africa in particular, for example, it is very difficult to scale up successful approaches with limited resources, especially limited human resources. Coetzee explained that money can usually be found without difficulty through such sources as PEPFAR; the biggest problem is finding and attracting the individuals to carry out the work.

Keshavjee suggested that the provision of technical assistance needs to change. Many places in the world require experts who can work with the local system for months to build up a health infrastructure, yet long-term onsite technical assistance is rare. Even New York, with a well-developed health system, required many inputs to counter TB.

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