work. Such a framework is in the process of being developed. The Stop TB Initiative is a partnership hosted by WHO that seeks to accelerate global tuberculosis control via a coordinated multisectoral effort. Funding provided by AID served to catalyze the development of the initiative.
The willingness of the United States to support the use of both patient-centered therapy and fixed-dose medications is vital to their adoption by countries experiencing high rates of tuberculosis, thereby strengthening efforts to eliminate tuberculosis within the borders of the United States. Immigrants, refugees, tourists, and students bring with them both their country's rates of tuberculosis and rates of drug resistance.
Ideally, all tuberculosis patients would be enrolled in well-organized and adequately funded programs. However, there will be occasions and circumstances in which directly observed therapy is not a viable option. The establishment of fixed-dose combination medications as the only acceptable standard of care when directly observed therapy is not available could benefit tuberculosis control both in the United States and throughout the world. Encouraging the removal of rifampin and other single-drug antituberculosis medications from the open markets of countries with a high incidence of tuberculosis and from direct access of physicians who are not trained as tuberculosis specialists could further enhance this tuberculosis control effort.
The United States can also assert leadership by the strategic use of technical and financial assistance. AID is critical in this regard. Only recently has AID begun to exploit its presence in high-incidence countries to address tuberculosis. Ongoing efforts are limited to India, El Salvador, Mexico, Kazakhstan, Russia, and South Africa. The largest effort to date has been the development of a center in Tamil Nadu, India, that is focused on the implementation and evaluation of a model DOTS program. A New Infectious Disease Initiative has identified tuberculosis as one of its four components. However, a rational plan for prioritizing and implementing these activites remains to be elucidated, and at this point, there is little central coordination of funding of tuberculosis control projects by AID, thus precluding a strategic approach. The agency should develop more effective mechanisms for internal coordination and develop its own strategic plan that will enable its assistance to be used most effectively.
United States-based foundations could also be used in a strategic manner to fund tuberculosis control programs or elements of programs in high-incidence countries. Given the wealth and power of some foundations, their involvement could have substantial impacts. The Stop TB Initiative that would target foundations with specific requests upon which there is a strong global consensus should develop a funding plan.
To again quote the IOM report on The Future of Public Health, “Our nation's vital interests are clearly best served by sustained and strength