As soon as antibiotic treatment for TB was introduced, resistance evolved; as each new antibiotic was introduced, resistance to that drug also emerged, observed Paul E. Farmer, Partners In Health, Harvard Medical School, and Brigham and Women’s Hospital. The story is not much different for most pathogenic bacteria, parasites, and viruses: The “crisis of antibiotic resistance” is not new, and preventing or slowing its emergence calls for better infection control and for new delivery platforms that permit treatment of patients with multidrug regimens in a manner that is convenient to them. Given the long duration of therapy, the best approaches are usually community based, Farmer argued. All this is called for as the tubercle bacillus, like other pathogens, continues to adapt. The challenge to medicine, said Farmer, is to catch up with the microbe. “Are we going to win this struggle, or is the mycobacterium?”

MDR TB IN NEW YORK CITY

In the past, increasing wealth has had the effect of helping to reduce the burden of TB. For example, TB rates fell dramatically, albeit unevenly, in the United States and in other countries even before therapeutics became widely available. But the disease remained a ranking killer of young adults, especially those living in poverty, well into the 20th century. The decline in TB rates, hastened further by the introduction of effective therapies, led to a divestment from the TB control system. From 1944 through 1976, the U.S. Public Health Service continued to invest in TB control, but “block grants” to fund many TB services ceased in the 1970s (Figure 3-1). At that point, it was difficult to obtain funding for clinics or staff; research focused on the disease, including basic science and clinical trials, also faltered.

In the late 1980s, the incidence of TB in the United States began to rise in several major cities. The AIDS epidemic was believed to have a central role in this rise, although public health experts still debate exactly what caused the resurgence. Other contributing factors included a rise in homelessness, persistent urban poverty, immigration from TB-endemic regions, a weakened public health infrastructure, and limited access to medical care for the poor and marginalized—conditions that exist in many other cities around the world. A series of policies termed “the war on drugs” also led to a sharp rise in the prison population. The incidence of TB increased 132 percent in New York City from 1980 to 1990, with 14 percent of all U.S. TB cases occurring in New York by 1990.

The social determinants of TB epidemics also contribute to conditions that interrupt care; weaken the laboratory infrastructure needed for prompt diagnosis and for surveillance; lessen patients’ ability to complete therapy once correctly diagnosed; and worsen infection control practices in clinics, hospitals, homeless shelters, and prisons. This, of course, is a recipe for



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