TB advocacy report 2003 

1.Tuberculosis, Pulmonary - therapy
2.Tuberculosis, Multidrug-resistant – therapy
Cover title: Tuberculosis

ISBN 92 4 259070 3
(NLM classification: WF 310)

What is Tuberculosis? (page 2)
DOTS (page 12)
DOTS Expansion (page 20)
Poverty (page 32)

Developed Countries (page 42)

Community (page 48)

Private Practitioners (page 54)
HIV and Tuberculosis (page 58)
Multidrug-Resistant TB (page 66)
The Green Light Committee (page 74)
Money and Donors (page 76)

© World Health Organization 2003
All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int).
  Printed in Italy

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This report is intended to show the faces of TB. Thus, we have deliberately selected images and texts that depict the suffering of people affected by this disease, in full respect of the dignity of those who agreed to be portrayed.  All individuals featured in this report gave their consent to the inclusion of their photographs. Most of them gave interviews.  In every case a doctor was present and usually a translator, who can verify that this consent was freely given.  While we have chosen to depict in detail several countries in this report, TB is not specific to these national borders. TB is a worldwide threat. It is a major health issue that affects us all. Its impact is being felt in every community across the globe, from the poorer developing states to the wealthy industrial economies.  material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. 

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What is tuberculosis?

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"I don't have a clue.  I live in the nice area of Battersea, not where they have this kind of thing."  John, UK

Are you breathing?
Good. Then you can get tuberculosis. A disease that  A disease that every day, throughout the world, stops 5 000 people from ever breathing again. Bon. 

A person infected with active tuberculosis is sitting next to you. Every time he or she sneezes, coughs or even just talks, bacteria called Mycobacterium tuberculosis are released into the air. The liquid surrounding the bacteria evaporates and they hang around in the air for up to six hours. You’re breathing that air, so the rodshaped bacteria, or bacilli, travel down into your lungs, where they like to lodge in the alveoli of your lungs that contain air. Your body reacts. White blood cells surround the bacilli while the bacilli eat away at the tissue—turning it into a cheese-like substance (this is called caseation). When the bacteria are contained inside granulomas—microscopic lesions—you have inactive or latent TB. You can’t give it to anyone else. It’s estimated that about 2 billion people, a third of the world’s population, are latently infected. If your immune system is compromised—if you are HIV positive, for example—the "cheese", which normally calcifies, becomes liquid and more bacteria are produced. The body reacts by sending more defenders and the lesion begins to get bigger. If the bacteria overwhelm the defenders the lesion can burst, sending thousands of bacteria throughout your lungs. You’ve now got active TB and you’re ready to start spreading TB to everyone around you. Gradually—TB likes to take its time to kill you—you’ll begin to find it almost impossible to breathe, you’ll lose weight, suffer night sweats and persistent fever, and find yourself with haemoptysis (coughing up lots of blood). You’ll either suffocate because there are no longer any working alveoli or, if you’re unlucky, the lesions will eat into blood vessels—and you’ll drown in your own blood. And you thought TB was a thing of the past.

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Symptoms of TB
Symptoms of TB sickness include coughing, weight loss, chest pain, fever and night sweats. The coughing may last for weeks and may produce bloody sputum. Left untreated, 50% of TB patients will die within five years and most others will be seriously debilitated. TB is deadly, but it can be cured.

How is TB spread?
Tuberculosis is spread by people—not by insects, blood supplies or water. Like the common cold—and unlike AIDS—TB is spread through the air and by relatively casual contact. When someone with active TB coughs, sneezes, talks, sings or spits, the TB bacilli inside their lungs are propelled out into the air, where they can remain suspended for hours.

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The cure? DOTS

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Nursing technicians watch patients take their medicine at Canto Grande Hospital, Lima, Peru.

By spring 2003, 10 million patients had been treated with DOTS Karel Styblo, a Dutch doctor, contracted tuberculosis in 1945; he spent the rest of his life researching the disease. In the late 1970s he began a pilot project in the United Republic of Tanzania—using a new way of tackling TB based on "shortcourse chemotherapy" for patients who are observed while they take their drugs. Styblo’s work raised cure rates in two pilot districts from 43% to 80%—and it cost little more than conventional treatment. He had proved that the prototype of a new approach worked. That approach was to become the DOTS strategy. DOTS is now recommended by the World Health Organization (WHO) for treating TB. Since the approach was introduced throughout the world in 1994, 10 million people have been successfully treated. DOTS works not only by making patients take their medication, but also by creating an environment (different in each country) where everyone—from governments to health workers to patients—works together to fight the disease.

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The five elements of DOTS

Political commitment
DOTS programmes need government support—not just funding, but also letting people know that the government is behind the campaign. "You can have as much medicine and money as you need, but if you don’t have the support of the family, community and society then you’ll lose the fight," says Fernando Carbone, Peru's Minister of Health. "You have to make this the people’s fight, make them realize that people are suffering and dying and each one has a name and a family, has dreams, could have had a future. They are not just statistics."

Case detection by sputum smear microscopy (SSM)
Sputum smear microscopy (SSM) is the most effective way of positively diagnosing TB. X-rays are useful, but the shadows that TB leaves on X-rays can be confused with signs of pneumonia or cancer. SSM confirms that the bacilli are present and detects the most infectious patients so they can be treated and cured, to prevent the spread of TB to others in the community. 

Standardized drug regimens for six to eight months with regular SSM tests, with Directly Observed Therapy (DOT) during at least the first two months
The same four drugs are used across the world—isoniazid, rifampicin, ethambutol and pyrazinamide—and patients are directly observed taking them. This is vital, not only because the drugs can have side-effects that often lead patients to discontinue treatment, but also because it’s all too easy to skip doses when you start to feel better. With DOT, patients are watched taking their medicine—no missed doses, no drug interruptions. As little as US$ 10 per patient can buy a sixmonth supply of drugs.

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A regular, uninterrupted supply of all drugs
Mycobacterium tuberculosis quickly becomes resistant to drugs, and if treatment is inadequate or interrupted for any reason—if the supply of drugs runs out, for example—it is almost certain that patients will develop multidrug-resistant TB (MDR-TB). Treatment for MDR-TB costs more than 100 times as much as initial treatment, and the drugs have to be taken three to four times longer.

A standardized recording and reporting system
For health workers or observers who watch patients take their drugs, a standardized system means that fewer patients slip through the net. It also means knowing the patients’ stories and building a relationship with them. "Our patients are like a book," says Dr Ludmila Mityunina at the Ivanovo TB dispensary in the Russian Federation. "The more you read it, the more you know."

Twenty-two high-burden countries (HBCs) account for 80% of the world’s TB cases. Until 2000 this list included Peru, but since DOTS was introduced in the country in 1990 Peru has not only dropped off the list of HBCs but has also reduced its TB rate by 6.5% per year. And it has managed this despite extreme poverty. "I still have in my mind the face of a woman I met in a hospital in 1983," says Peru’s Health Minister, Fernando Carbone. "She was the mother of three children and we could do nothing for her. She lost the battle and died. It’s a tragedy to lose someone to TB in the 21st century." For Carbone, fight poverty and you fight TB, fight TB and you fight poverty. "Anyone can become ill, but the poor will always be more vulnerable." On one of the peaks in Lima Nord sits a shantytown of shacks painted yellow, green and pink. No one is sure how many people live here, but one thing is certain: this area of Huascar has one of the highest TB rates in Peru. "People come from the provinces and can’t afford to live anywhere with running water or drains," says Donato Arroyo Flores, a nurse at Huascar Dos health centre. "They live in shacks and there is terrible overcrowding, with three or four families living in one house—20 people living in 90 m2." In other words, a perfect breeding ground for TB. "The Silverio family is a classic example," says Flores. "Two in the family have died. They’re too infectious to come to the clinic so we take treatment to them. We tell them it’s curable, but only if they follow the DOTS treatment."

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If DOTS works so well, why isn’t it everywhere?

d0552a35s.jpg (21577 bytes) I thought he'd never be cured.  I made his burial clothes.
Wei Hua with Feng Ming Gui, Juang Wing village, Xinyi county, China

Only 32% of TB patients worldwide were being treated in DOTS programmes in 2001. The story’s the same around the world. If you want to implement DOTS successfully you need one thing above all else: commitment. Commitment from governments, health services, health workers and patients. Particularly if the WHO targets for 2005 of 70% case detection and 85% cure rates are to be reached. The way expansion is going at the moment, it will be 2013 before that happens. And of course, for every year of delay, millions are infected. 

Dr Solange Cavalcanti is currently working to expand DOTS in Brazil, where coverage has risen from 7% in 2000 to 32% since the programme’s introduction in 2001. Despite proof of DOTS’ success, health workers were hesistant when the scheme was first introduced. "It took a long time to start," she says. "With DOTS you build up a relationship with patients, they’re not just numbers. The concept can scare health workers because they’re not used to it. When we implemented the scheme, there was real resistance—but now they really like it."

Governments can help not only financially and by collaborating with WHO, but by letting the public know what’s being done. "Human resources are important," says Dr Lia Selig, who works at the Rio State Health Department. "People working in TB are paid low salaries, and I can’t get people to come and work. Doctors feel undervalued. In Peru, there’s a TB commercial on TV and it makes TB important—and makes the doctors feel important too. People were actually applying to work with TB in Peru because of that commercial." 

Dr Jorge de Oliveira, who is the director of Ary Parreiras Hospital in Rio de Janeiro, agrees that a concerted government media campaign is needed. The people most in danger from TB are often the most uninformed. "There’s a lack of awareness of how you catch it. People need to be aware that TB kills, but many people don’t know how to read. We have great doctors here. The drugs are the same here as in the UK or the USA. What’s missing is the social desire. We don’t need to change the drugs—we need to change people’s attitude."

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DOTS Expansion from 2000 to 2001 in the 22 high-burden countries.  Almost 900 million people in India and China alone do not yet have access to DOTS.  page_22_23.jpg (371843 bytes)

India—the country with the world’s highest number of TB cases: 
more than 4.5 million people.
India is faced with a huge challenge in implementing DOTS—and it’s not just financial. "A lot of people in Mumbai are migrants," says Jayashree Parab, who runs Karm, a nongovernmental organization (NGO). "They come here from other cities, other villages, to look for work. Many work in the textile industry, thousands work as porters, thousands are members of the vegetable-sellers’ association. These people stay together in groups, live in congested and unhygienic environments and stand a high risk of contracting TB." India—with 1.8 million new cases of TB a year and people moving between cities and the countryside—represents the most challenging environment in the world for DOTS expansion. India has the most rapidly expanding DOTS programme in the world. Government efforts there have resulted in considerable progress in DOTS expansion.

Total number of TB cases: Over 4.5 million
New cases of TB each year: 1.8 million
Number of people killed by TB each year: 460 000
Percentage of population with access to DOTS in 1998: 9
Percentage of population with access to DOTS in 2002: 55
Number of patients starting DOTS treatment every month: 50,000
Estimated number of lives saved by DOTS since 1998: Over 200 000
Indirect cost savings to the Indian economy since 1998, attributable to DOTS: US$ 400 million

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Since 1993, active TB cases in China have dropped 35% in areas where DOTS is applied, but only 30% of all infectious cases are detected.
"Since most of the rural population has to pay for medicine," says Dr Xu Weiguo, head of TB control for Jiangsu province in south-west China, "it means that the moment they get ill they’re immediately poor." Over 75% of Jiangsu’s population is rural (in China as a whole the average is 63%). TB rates in China are more than three times higher in rural areas than in urban ones, and the health system can’t cope. "The primary health care service is suffering," says Dr Dan Chin, who works for WHO in Beijing. "With economic reform, the government has pulled back most subsidies to health institutions. Doctors at the village, township and county levels are on their own. If a patient comes to the doctor, it is actually a disincentive for the doctor to send him to the TB dispensary and to tell him that the drugs are free," says Dr Chin about the situation in China, where drug resistance is developing as patients are often not referred to TB dispensaries. If you’re a sick rural worker, like Feng Ming Gui (preceding page), you spend all the money you
have on medicine—and then sell everything you own. Feng and his wife, Wei Hua, live in a straw-roofed shack in the small village of Juang Wing, in Xinyi county. While Jiangsu province has expanded the DOTS programme to cover 69% of its 73.8 million population—the aim is to achieve 90% coverage by 2005—it hasn’t yet arrived in Xinyi county. When Feng became ill he spent 2 000 yuan (US$ 240) on penicillin and glucose water before he was diagnosed with TB. "I thought he’d never be cured. I made his burial clothes," says Wei. The couple spent all of their savings and were forced to sell their remaining food stocks to buy drugs. In areas with no DOTS coverage, cases of bankruptcy, like Feng’s, are all too common, says Dr Lin Yan, a WHO doctor. "The government can’t do anything because there are too many of them." It was the same in neighbouring Lianshui county until DOTS was introduced in September 2002. Since then about 20 people a day have been arriving at the TB dispensary in Lianshui. After diagnosis, their free treatment is controlled by their village doctors, who also act as observers. Dr Xue Tongming, head of the Lianshui TB dispensary, says it is vital that TB drugs are "kept by the village doctor and not the patient," but that it’s still easy for patients to get to their doctor for their drugs.

I earn 1000 yuan [US$ 120] a year and still owe more than 20000 yuan [US$ 2400].
Wang’s father
Yu Guoan is the doctor in Diannan village, Lianshui county. Among his patients—none of whom has yet missed a visit—is Wang Haibo, 16 (opposite page). His mother died from TB in 1992, and 10 years later Wang began to feel ill. "I originally had a cold and a cough," he says, "I was really scared when I found out it was TB." The expansion of the DOTS programme to Lianshui county means that Wang now receives free drugs to fight the disease that has spread from his lungs to his lymph nodes and his ears. "I spent 30 000 yuan [US$ 3600] on my wife’s treatment," says Wang’s father. "I borrowed money from a friend and we had to earn extra. I still haven’t paid back the hospital. I earn 1000 yuan[US$ 120] a year and still owe more than 20 000 yuan [US$ 2400]." China has had financial help through a World Bank loan and several donors, but there’s still work to do to expand DOTS nationwide. "We need more staff and we need to educate the public
more," says Dr Xu. "And we need to improve our equipment, some of which is very old and is affecting our diagnoses." For some patients, though, the scheme arrived too late. "Some are already very seriously ill when they come here," says Dr Xue at the TB dispensary. "Ten of our original 166 DOTS patients have died." Back in Diannan village, Wang dreams of following his sister to Shanghai and earning enough to pay off the family debt. WHO doctor Lin Yan isn’t sure this will happen: "He’s getting better," says Dr Yan, "but this is a very serious case."

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Fight poverty and you fight TB.

d0552a41s.jpg (10817 bytes) "I haven't spent much time in any homeless shelters, which are notorious for TB.  I must have gotten it on the outside from an acquaintance, someone I was sitting next to.  I don't mickey around with a whole lot of people, but I must have been talking to the wrong person at the time."  Dave Rollins, 61 a homeless Viet Nam War veteran is now taking observed treatment for TB at the Lemuel Shattock Hospital in Boston, USA.  The homeless - their immune systems often compromised by alcoholism, drug dependence, malnutrition and exposure - are easy targets for TB.

Rough sleepers, Boston, USA

Afghanistan is still recovering from 23 years of conflict and the repressive rule of the Taliban—and so is its health system. There remains little infrastructure, and the country—among the poorest in the world—is on the list of high-burden countries. TB control in Afghanistan is supported by WHO and by international NGOs such as Medair and Médecins Sans Frontières, in collaboration with the newly re-established Ministry of Public Health. DOTS coverage is patchy because there is no real health system outside of Kabul and people are too poor to be able to afford the costs involved in traveling to TB centres. The harsh restrictions on women’s freedom meant that women suffer unusually higher rates of TB than men. They were forced to remain at home—where poor ventilation allowed the bacilli to spread. Even if they could have afforded treatment (with no public health system, private doctors were the only option) women were allowed outside the home only if they were accompanied by a male "minder". And TB was considered the "devil’s disease". "During the Taliban regime, we lost the infrastructure of TB control," says Dr Abdullah Fahim, of the Ministry of Public Health in Kabul. "So now we have to start from the beginning." Foreign aid and debt relief to countries can fight poverty by paying for TB control. The disease is intimately linked to poverty—poor living conditions, malnutrition and lack of education. With fewer TB sufferers forced to stop working, there are more active workers, lower health costs and less poverty. TB patients who survive have to do without an average of 20–30% of their annual income because of lost productivity.

TB costs poor households an estimated US$ 12 billion a year
"I was 15 when I started drugs. I started with ganja (marijuana) and then mixed it with heroin. After a month I was shooting up every day. Now I’m addicted to heroin—the doctor says that if I don’t take the TB medication I will die, but I just don’t have the strength to get it. I’ve given up already. Anyway, I can’t go to the hospital because I don’t have an ID card and I’m scared that they’ll send me to get off drugs. If I can’t get heroin, I’ll be so sick. Sometimes the police come, break down the door and ask me when I’ll finally die. They don’t care that I’m sick, that I’ve got TB."—Dtou, 28 (opposite page), lives in Bangkok, Thailand. Drug dependence and alcoholism weaken the immune system, leaving addicts at a higher risk of catching TB and making it far more likely that they will interrupt treatment when they are sick.

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Under Soviet rule, you would never find people looking for food like dogs and cats.
Dr Helen Kiryanova, Orel TB dispensary, Russian Federation "So many people lost their jobs," says Dr Helen Kiryanova, of the TB dispensary in Orel, 300 km south-west of Moscow. "They were smashed by the crisis—and many of them started drinking." After the collapse of the Soviet Union in 1991, poverty rose and even more unemployed men fell into depression, alcoholism and petty crime, filling Russia’s prisons and providing ideal breeding grounds for TB. Infectious prisoners were released, returning into a community where they had no job (and no chance of getting one) and often no home. Ivanovo is about 250 km north-west of Moscow. "The number of homeless patients has been increasing," says Dr Valeriy Shapkin at the Regional TB Hospital, where most patients are ex-prisoners. "Some sell their houses for money to spend on alcohol." His patients drink anything from homemade vodka to cleaning fluid and face lotion. Alcoholism makes the already difficult job of keeping patients on their medication almost impossible. "As a rule it’s useless to say anything to patients because they’re always drunk," says Dr Shapkin.

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Surgery was often the only remedy.
Dr Boris Kazionny, TB dispensary, Orel, Russian Federation
"The man we're operating on is called Valery Alferov, who’s 41. He’s one of three operations we’re doing today. Before DOTS there was more surgery because we had no second-line drugs. Surgery was often the only remedy. About 9% of all new cases are operated on here"—Boris Kazionny, chief TB doctor at the Orel TB dispensary. The Russian Federation’s use of surgery—which intensified with drug shortages during the 1990s—reflects a more case-by-case approach to TB treatment. WHO hopes that the world TB epidemic will ultimately be brought under control totally by drugs. 

I’ve had no job for four years. I used to work in a metalwork factory making illegal guns, but I decided to quit in case I got caught and sent back to prison"—Leonid Formin, 42, is recuperating after surgery in the Orel TB dispensary. In the Russian Federation tattoos can be a sign of how long a person has spent in prison.

With the introduction of DOTS in Ivanovo, patients at the Regional TB Hospital are now observed by three people when they take their medication. But there’s nothing doctors can do to force patients to stay—especially when they’re violent. "There are always attacks," says Dr Shapkin. "One patient cut another’s throat. A patient was raped. All this happened in the last six weeks. We need guards here to stop patients from leaving if their treatment isn’t over—47% leave prematurely. They are not cured, so they go and spread infection." But there is hardly enough money to pay the staff here, never mind guards. A junior nurse at the hospital earns just 500 roubles (US$ 15) a month, a senior doctor only 1500 roubles (US$ 45). "The staff is afraid," he says "and with the current conditions—low wages and violent patients—it’s almost impossible to hire new staff." Despite problems, the staff’s hard work and the introduction of DOTS in both Ivanovo and Orel are beginning to pay off. "When we started with WHO," says Dr Olga Medvedeva, head of the Ivanovo TB dispensary, "it was hard to see the results straight away, but in the last two years, death rates have started going down. It’s the same for TB incidence." In Orel, the dispensary has been using DOTS since October 1999 and TB rates as a result have since dropped dramatically. More than 150 000 Russians are diagnosed with TB each year, and after years of discussion between WHO and the Russian Federation government about DOTS implementation, the country currently has only 26% coverage. However, with the recently agreed Prikas—a policy document—adopting DOTS as the country’s TB control method and with a doubling of TB spending (to US$ 51.2 million), the government has begun to move forward on TB control. Dr Perelman, TB specialist at the Ministry of Health, is proud of the achievements so far, but remains realistic. "Unfortunately, drugs can only do so much. If social conditions were better we wouldn’t need medicine."

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One area in London has a rate of TB higher than China’s.
"In the globalized world that we live in, where travel and communication are easy, where there’s a greater social mix between individuals, increasingly over the last eight or nine years you find people like me getting tuberculosis."

Ian McCartney (opposite page) is a member of Parliament in the UK and a senior member of the governing Labour Party. He contracted extrapulmonary TB of the testicles about 1992; he's not exactly sure when and he’s not sure how. During the 19th and early 20th century TB was the leading cause of death from infectious disease in Britain (as it was in much of Europe and the USA). Improving social conditions meant that it became increasingly rare. Over the past 10 years, however, the UK has seen rates rise sharply again: there were 7300 cases in 2002, and cases in London have risen 80% (one area in London has a rate of TB higher than China’s). The highest rates have often been seen in areas with high numbers of immigrants—usually refugees or asylum seekers—leading some newspapers and politicians to warn that immigrants "will probably claim more British lives in the long run than terrorism". The British Medical Association (BMA) disagrees, saying that the diseases—such as TB—associated with asylum seekers are diseases of "poverty and overcrowding". A 2002 BMA report states that the "average physical health status of asylum seekers on arrival is not especially poor, when compared to the average fitness of UK residents". It is the conditions in which immigrants find themselves living in the UK that pose the real danger. "There is evidence to suggest," says the BMA report, "that the health status of new entrants may worsen in the two or three years after entry into the UK." 

Improving conditions for immigrants and refugees will help cut cases, but perhaps a greater threat lies in some doctors who think of TB as a thing of the past. "The doctors were looking at this white, well-paid, middle-aged, middle-class man in a high-powered job," says McCartney, "and so they thought that [my symptoms] must be related to stress." McCartney was finally diagnosed correctly. His TB wasn’t infectious, but for pulmonary TB sufferers, misdiagnosis can mean spreading the disease to everyone they meet. 

Janeann Gunson, now 29, of the UK, developed a cough and began to feel ill in May 1998. Her visits to doctors and specialists continued through seven months of frustration and increasing pain. Doctors called her a "silly girl" and a hypochondriac, prescribing steroids and sedatives. She was told that she had "too much stomach acid" and was twice diagnosed as asthmatic. She had X-rays, which showed nothing unusual. Her boyfriend at the time tested positive for TB, but even then a doctor told her that there was no chance of her having the disease. She was finally told what was wrong with her on 26 December 2002. Not long afterwards her lung collapsed because the damage was so severe. She has since recovered, at least physically. 

"I missed out on three years of my life, three important years," says Janeann. Did you have DOTS treatment? "I had the ‘bugger-all’ treatment. I had the classic symptoms. I was coughing up blood, sweating. I was so skinny, I had bedsores. But no! I’m a ‘silly girl.’ I look back now and I’m not bitter—I was just dealing with a bunch of idiots."

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"Within Massachusetts, we have something called the ‘Menace Law’,"
says Stanley Slotnick of the Shattuck Hospital in Boston, USA. "If a person has infectious TB and is refusing treatment, we have the legal right to lock him away in a unit and force him to take medication." Shattuck has a locked TB ward of 12 beds where about 175 patients are treated with DOTS every year. The majority of the patients are foreign-born, like Mr Osai (opposite page). Originally from Ghana, he has been living in the USA for the past eight years. He doesn’t know where he caught TB. Enforced treatment is controversial, but to Slotnick it’s just common sense. "Why would someone refuse to take medication if they know they have a deadly and infectious disease?" he says. "So you have someone out in the community who’s not taking their meds, who is drinking, drugging, or who maybe has a psychiatric disorder and doesn’t believe they have TB. They’re ‘menaced’ and then stay with us for 15 days. We evaluate them, get them on board. If we think that they can’t make it on the outside, then we can go to court and hold them for the duration of their therapy." All TB drugs are free in Massachusetts, but John Bernardo, director of TB control for the state, is concerned that funding may be cut, as the perceived threat of terrorism moves the focus away from TB toward biohazards such as anthrax.

On 22 November 2001, a 24-year-old woman from Moldova arrives at a hospital in Modena, Italy. She does not appear to speak Italian. She is immediately admitted and approximately 30 minutes after her arrival she gives birth to a baby boy. After delivery the woman is placed in the maternity ward, where she remains for four days. During this time a patient in the neighbouring bed complains to a nurse that the woman "has been coughing all night". 

A week after she is discharged the woman returns to hospital. She is described as being "really pale, with heavy bags under her eyes and very thin". After tests, it is found that the woman has multidrug-resistant tuberculosis (MDR-TB). The hospital decides that all patients and staff who came into contact with the woman during her stay in the hospital must be tested. Eighty-eight mothers, newborn babies and visitors are tested for tuberculosis. Only the woman’s boyfriend was infected. 

In Milan, between October 1991 and July 1995, it’s a different story. The infection spread—and 150 HIVpositive people died after contracting MDR-TB. It remains the largest outbreak ever in Europe, but maybe not for long. "The question," says Dr Andrea Gori, of Milan’s Sacco Hospital, "isn’t if it will happen again—but when it will happen again and how serious it will be."

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If you don't have the support of the family, community and society, then you'll lose the fight. 
Minister of Health Fernando Carbone, Peru

There came a time of drought. The animals, including the lion and the leopard, were looking for water. All the animals gathered together to discuss ways of getting water. The tortoise suggested they dig a deep well. When they were finished, the tortoise produced a special kind of glue, which he left around the well, so that animals who hadn’t helped out couldn’t drink the water. The lion and the leopard were thirsty and rudely arrived at the well. But they got stuck and couldn’t get any water.

This is Mpatso Mangaya’s favorite story. Aged 10, he’s a TB patient in Lilongwe Central Hospital in Malawi. While in the hospital, Mpatso is looked after by Ulema Mpekansambo, 25, one of thousands of friends, family members or volunteers who act as guardians—and perhaps storytellers—to TB patients in the country’s hospitals. "Guardians just sit and talk to each other," says Ulema. "You end up meeting a lot of people, you hear their life stories, mostly they are sad." 

Guardians in Malawi watch patients take their drugs (and record that they have been taken), act as friends and give moral support. This is often done by health workers. But in developing countries where there may not be the infrastructure—or funds—to provide every patient with care by a health worker, other communitybased solutions are needed. In Navi Mumbai, India, according to Geeta Rakhakrishnan, who works for the Alert India NGO,"There are street-corner panwaalas [stallholders], tailors, quarry workers and housewives living in slums who act as observers and make sure that patients take their medicines in time." In South Africa it is often grocers and traditional healers who supervise treatment.

In Malawi, guardians—normally family members—stay at the hospital with the patient. John Muyare’s wife and guardian, Olivia, has to sleep on the floor beneath John’s bed on the hospital balcony. "It’s not comfortable and we get wet," says Olivia. She brings her own food for herself and John when she stays at the hospital. "The food here is not well prepared," she says. "The only vegetable they give us every day is beans—and they make you fart." 

According to WHO, patients without guardians are less likely to recover, but the exponential rise in AIDS-related deaths means that patients increasingly find themselves alone. One reason why the system works is that patients with guardians can be sent back to their communities as soon as it’s safe. Their guardians then collect and administer their drugs. Olive Kadzakumanja, or Sister 

Olive as she’s known, is a community TB nurse in Malawi, and she’s convinced that DOTS home-based care works. Before DOTS was implemented, she says, patients would often leave hospital and stop treatment because their families couldn’t visit them. "Everyone complained that transport was a problem," she says. "Look at it this way: if a sick man asks his neighbour to lend him money, the neighbour’s going to think, ‘If that man has TB, will he ever return from the hospital and give me my money back?’ But if a patient lives at home, the community is more likely to share what little they have."

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If there’s a gang war for a week, you can’t go in to check that patients are getting their treatment.  Solange Cavalcanti, coordinator of the TB Control Programme, Rio de Janeiro, Brazil
Solange Cavalcanti works for the Brazilian Ministry of Health, implementing DOTS for the 90 000 residents of Rocinha favela (below) in Rio de Janeiro, Brazil. "Safety is declining and crime has become more dangerous over the last two years. Gang fighting and narco-trafficking are on the increase. Corruption means we’re as afraid of the police as we are of the people in the favelas. This is a real limitation on the DOTS programme. If there’s a gang war for a week, you can’t go in to check that patients are getting their treatment. We’re currently training 40 community health workers, which will solve the problem of how to get in and out because they already live in the favela. They're selected from the community, then trained for one to two months. We’ll use the favela’s own TV and radio stations and newspaper to inform people. It’s challenging, but it should be successful. There are 6 million people here in Rio. It’s important as a pilot project because TB has such a high incidence—65 cases per 100 000 people. If we can implement the scheme here, we can implement it anywhere."

In India private practitioners—many with no medical qualifications—are often the first people TB sufferers go to see.
DOTS works only if everyone is involved. Unless both public and private doctors participate, the disease continues to spread. "A lot of TB patients feel that it is beneath them to go to a public hospital," says Rajesh Phale, a community worker with Karm, an NGO, in Mumbai, India. "For some poor people it is a matter of prestige to go to a private practitioner. This could be because sometimes the public hospital workers aren’t caring. Patients have to be spoken to with love; they have to be handled sensitively. All this means that people don’t get proper treatment because they get taken for a ride by private doctors." Public health care is also underfunded. (Many developing countries are suffering from the same problems. Afghanistan is perhaps the most serious example, with virtually no public health care system.) In India private practitioners—many with no medical qualifications—are often the first people TB sufferers go to see. Patients pay for any medication they are given—which means that private doctors may see DOTS as a threat. Patients enrolled in a free DOTS scheme are lost income. For patients, taking the wrong medication could lead to MDR-TB (see page 66). Dr Ambe is the secretary of the Mumbai TB Control Society. "I once met a private practitioner at a conference who said that the government’s measures were now taking care of diarrhoea, polio and diphtheria. ‘If this continues,’ he said, ‘and there’s perfect health in this country, how will we make a living?’"

For DOTS to work in India attitudes have to change—first in doctors and health workers, then in patients. An example is being set in Navi Mumbai. "Private practitioners are fully aware of the DOTS programme here," says Geeta Rakhakrishnan, project coordinator at the Alert India NGO. "You won’t believe it, but there are private practitioners"—which can include ayurvedic and homeopathic doctors—"who personally bring their patients to municipal hospitals. The approach in Navi Mumbai is different—the health authorities are more people-oriented, more service-oriented. It’s not as though there aren’t slums here—about 120 000 live in them. But even the doctors practising in the slums are DOTS providers. There’s an indirect benefit to these private doctors in being involved in the DOTS programme: the patients whom they help combat TB then become their regular patients and go to them for other ailments. The DOTS programme has been very successful in Navi Mumbai."

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We really need antiretrovirals. Otherwise HIV, it's just spiralling, spiralling. I don't know where it's going to end.
Dr Nombuleto Madala, Gugulethu Community Center TB clinic, South Africa

"Without HIV we could have won the battle against TB," says Grey Kachisi, TB administrator at Bottom Hospital, Lilongwe, Malawi. HIV and AIDS are not only infecting—and killing—millions of people across the world but are also allowing TB to make a deadly return. HIV attacks the immune system, allowing TB bacilli to multiply and spread more easily. Antiretroviral (ARV) drugs can help boost immune systems, and in countries where they are available—Brazil, for example—they are helping patients fight off infection. In Africa, where there is little or no access to ARVs, the number of patients with HIV and TB has reached epidemic proportions. 

From 1986 to 2001, TB rates in South Africa rose by 269%, from 51 013 to 148 257 cases. The disease kills over a third of all HIV-positive people in the country, and with over 11% of the population HIV-positive—more than 5 million people—the disaster is just beginning. With no ARVs to help, a new initiative aims to stop  TB infection a different way. ProTEST, coordinated by WHO, is searching out and testing people for TB and HIV. (It is thought that only 10% of HIV-positive people know they are infected.) HIV-positive patients are then given prophylactic TB treatment with isoniazid to keep them from developing TB—studies suggest it reduces the risk by 40%. 

ProTEST has also shown that AIDS programmes can find TB cases and send them along to DOTS services—but this only happens with TB and HIV programme collaboration at national and district levels. Antiretrovirals are needed, but they will not work alone.

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With or without TB, I don’t treat HIV. I’m just watching patients die on me.
Dr Nombuleto Madala, Gugulethu Community Centre TB clinic, South Africa

There are more than 610 000 HIV-positive Brazilians who have access to ARVs, but critics say the fight against TB is hindered by perceptions of the disease. The Stop TB Partnership says that HIV/AIDS is seen in the country as an "all-society problem" with the middle class putting pressure on government to deal with it. TB, on the other hand, is seen as a "poor people’s disease"; "of course political pressure made by the low-income population is weaker than the pressure of wealthier groups." With an absence of political will to educate people, infectious patients can spread the disease simply because they don’t know about it. In South Africa, Isabella, an HIV-positive patient at the Gugulethu Community Centre TB clinic in Cape Town, thinks that she contracted TB by walking on wet grass, while Virginia, also HIV-positive and being treated at the Brooklyn Chest Hospital in Cape Town, thinks drinking beer infected her with TB.

Behind the shocking figures on HIV and TB infection lie the lives of people—not only the victims, but also those left behind. In South Africa there are more than 660 000 HIV/AIDS orphans; in Brazil 130 000; in Malawi nearly 500 000. Olive Kadzakumanja (see page 51) works as a community TB nurse in and around Lilongwe, Malawi’s capital. She adopted a young girl whose parents had both died of AIDS. (There are about 850 000 HIV-positive Malawians.) "It [HIV] is sweeping across the nation," she says. "I have met so many orphans. How many orphans is it possible for me to keep in my home? We need to have another way of improving the situation."

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Then there are the HIV-positive children. At Casa Cazuza in Rio de Janeiro, Brazil, Cristina Moreira looks after 23 children with HIV. "In 1990 they didn’t live past the age of eight," she says. "Today, with antiretrovirals, we don’t really talk about life expectancy because there are always new drugs coming out." A major difference between most of Africa and Brazil is Brazil's use of ARVs. In 1996 the Brazilian government decided to launch a free nationwide programme of ARV treatment. As the drugs strengthened immune systems, TB infection dropped. Since the programme's introduction, cases of TB in HIV-positive patients have dropped by 76%. In South Africa, despite the introduction of ProTEST, the story is very different. "We’re getting snowed under," says Dr Nombuleto Madala at the Gugulethu Community Centre in Cape Town (not yet part of ProTEST), where about 80% of her patients arrive with both HIV and TB. "With or without TB, I don’t treat HIV. I’m just watching patients die on me. I just give them vitamins and look out for problems. And that’s one of the things that’s stressful about my job right now—not being able to do what I should."

The population in urban areas in less developed countries will grow from 1.9 billion in 2000 to 3.9 billion in 2030 (according to UN-HABITAT, the United Nations Human Settlements Programme). With development comes mobility and with mobility comes the spread of disease. In China, urbanization and rural migration to cities like Beijing (opposite page), along with growing numbers of truckers, prostitutes and drug addicts, are all creating the perfect climate for HIV and TB.

I don’t take the medicine because I’m dying anyway.
Jelena Mihjejeva has been at the Tallinn Sanitorium in Estonia for six months. She is HIV-positive and has TB. She is drug dependent and an alcoholic, and before arriving at the hospital was working as a prostitute. Her doctors say that visitors bring her vodka and wine in exchange for sex. She has two children, aged five and two, whom she no longer sees. According to UNAIDS, "Between 2000 and 2001, the situation in Estonia became alarming. In 2000, 390 HIV positive cases were reported. In 2001, 1470 new HIV positive cases were reported."

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What is MDR-TB?
With a little accidental genetic engineering, you can easily produce multidrug-resistant tuberculosis (MDR-TB). First catch TB. Then simply stop taking your drugs before you’ve finished the course of treatment. Or go to a doctor who misdiagnoses you and gives you the wrong drugs. Or take drugs that aren’t strong enough. Or just skip a few doses. It’s easy. And before you know it you can be carrying a strain of TB that will take three times as long to treat, costing you or health services up to 100 times more. Mycobacterium tuberculosis is a hardy bacterium. And it can acquire drug resistance. It can take as little as 50 days for the bacilli to become resistant, which is why the disease is treated simultaneously with a constant mixture of four different drugs. (If one drug doesn’t kill the bacteria, another will.) However, once the bacteria are resistant to the two main TB drugs—isoniazid and rifampicin—they are classed as multidrug-resistant. Taking the drugs, though, isn’t as easy as it sounds. Think about it: if you had to go and get your drugs every day, stop drinking, stop working, bankrupt yourself for drugs that were making you feel dizzy and turning your urine bright orange, and you were feeling better anyway, wouldn’t you stop? 

Yet when you stop taking your medicine you’re endangering not only yourself but all those you come into contact with. If you infect someone with your mutated TB, then they’ll immediately be infected with MDR-TB, not the "simple" TB you first caught. 

Along with HIV/AIDS, MDR-TB is the most worrying development in the TB pandemic. (A pandemic affects a widespread geographical area and an exceptionally large part of the population.) It’s not that MDR-TB is more dangerous than normal TB, it’s just that treating it is so much harder. Treatment takes about two years, and MDR-TB drugs have far more unpleasant side-effects. And if patients interrupt treatment they can develop a form of TB that no drugs can cure—and that is certain to kill them. DOTS-Plus, or DOTS+, a recent WHO initiative, targets MDR-TB with a normal DOTS programme combined with second-line drugs. In developed countries, 60–80% of MDR-TB cases are cured, but treatment is expensive—costing between US$ 10 000 and 16 000; in developing countries so many MDR-TB sufferers are left with little or no hope of recovery.

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After the collapse of the Soviet Union and the ex-Soviet states gained independence, they were forced to rethink their health services. Estonia moved from universal free coverage to a western European-style insurance system. But in a country faced with rising unemployment—12% by 2001—about 70 000 people were left without insurance. "TB disappears with a stable society," says Manfred Danilovits, head of the Tuberculosis Unit at Tartu University Clinics, 100 km south-east of Tallinn. "In the 1990s, with the political and social changes, the disease came back." 

The number of new cases of TB doubled each year from 1992 to 1998. Treatment was available throughout this time, but, according to Ain Aaviksoo of the Ministry of Health, "Many of the people with TB were from the 5% of the population who weren’t covered by state health insurance." And even those who did get drugs often didn’t take them. "They were selling their drugs in the market for food." Estonia now has the world's highest rate of MDR-TB: 14% of all TB cases. When DOTS was introduced to the country in 1998, TB cases began to decrease, but MDR-TB continued to grow. "We were not prepared to handle the problem in the new health system," says Aaviksoo.

MDR-TB is now affecting all levels of Estonian society. "When they told me I had TB I was shocked," says Eva Oruste, 24 (following page), a university student being treated for MDR-TB in Tartu. "I knew what TB was, but I didn’t think I could get it. I thought that only people living in bad conditions and who drink could get it." The introduction of affordable second-line drugs—thanks to the Green Light Committee (see page 74)—has meant that patients like Eva can now be treated. "I’m young, I’ve never drunk alcohol in my life. I’m sure I’ll be better soon," she says. "I just blame the person who stopped their TB treatment so they developed MDR-TB. They’re responsible for what’s happening to me."

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TB kills 5000 people a day - that's 15 jumbo jets crashing or three or four Titanics sinking, or 50 outbreaks of the Ebola virus.  Every single day.  page_70_71.jpg (101489 bytes)

The poorest people on earth should have access to the best treatment in the world.
Dr Donald Berwick, Institute for Healthcare Improvement, USA 

Ica in south-west Peru is known as the traditional sanctuary of white witches. It became famous during the 1980s when one of the last surviving white witches cured a powerful politician of a terminal illness live on television. 

In Ica’s cemetery there are two reminders of a more ordinary consequence of illness. In 2000, José Poma, 15, and Javier García, 16, died after an outbreak of MDR-TB at the Fermín Tanguis School; 10 others were infected and five are still being treated. "We were afraid that it would spread throughout the whole school," says Gloria Soledad García Vilca, the school’s principal. "We have no ventilation in the classrooms, so TB spreads really easily."

Rosa Guerrero is 15 and caught the disease during the outbreak. She has been taking DOTS-Plus drugs nearly every day for more than two years. "I missed treatment for one week because I didn’t like taking the pills—they’re orange, yellow and too big—but the nurses came to my house and made me start again. I can’t get used to taking them. The hardest part is that I can’t do what normal people do—I can’t run and I can’t go to parties." Four of Rosa’s classmates are now being treated in Lima, where they receive lodging, food, and intensive treatment not only for their TB, but also for the depression and isolation that sufferers feel.

MDR-TB presents a new set of challenges, and with money from the Bill and Melinda Gates Foundation, Harvard Medical School and WHO, Peru is beginning to fight back. "The poorest people on earth should have access to the best treatment in the world," says Dr Donald Berwick, an American specialist helping to implement DOTS-Plus in Peru. "The Ministry of Health here has been really successful— the problem came up because MDR-TB cases were taking too long to be diagnosed." But Berwick remains impressed with the commitment he sees on all levels of the system in Peru. "Eleanor Roosevelt fell ill and went to Massachusetts General Hospital, one of the greatest hospitals in America," he says. "She died undiagnosed of TB. I would rather get TB in Peru." 

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The GLC made all the difference. When they changed the rules, they saved lives.
Dr Donald Berwick, Institute for Healthcare Improvement, USA

In 1998, WHO got together with Médecins Sans Frontières, Harvard Medical School and other partners and created the Working Group on DOTS-Plus for MDR-TB. One of the aims of the Working Group was to negotiate with international pharmaceutical companies to gain access to second-line drugs for MDR-TB and get the companies to cut the high costs of the drugs. An agreement was reached and it was announced that drug prices were to be slashed. For instance, the drug company Eli Lilly was not only willing to reduce prices, it was also keen to collaborate with the Working Group. Others, like Jacobus Pharmaceuticals, have also collaborated in reducing prices, as have a number of generic players in the market. As a consequence, the price of a course of drugs dropped from about US$ 15 000 to US$ 3000. To allow access to these drugs and prevent their misuse, the Green Light Committee (GLC) was created. Its current members are WHO, the International Union Against Tuberculosis and Lung Disease (IUALTD), Centers for Disease Control and Prevention (CDC), the Royal Netherlands TB Association (KNCV), Harvard Medical School and Estonia’s National TB Programme. 

Countries applying for the scheme are "green-lit" when they can prove that they have the necessary infrastructure to distribute the drugs. Between 2000 and 2003, the GLC saved countries such as Estonia, Peru and Russian Federation between 54 and 94% of pre-GLC MDR-TB drug costs. For Dr Donald Berwick, who is helping Peru implement DOTS-Plus, "WHO’s role is enormous and the GLC is crucial because they end up determining the cost of drugs. The GLC made all the difference. When they changed the rules, they saved lives."

Three years later, in 2001, WHO launched the Global Drug Facility (GDF) with funding from the Canadian International Development Agency (CIDA), the US Agency for International Development (USAID) and the Netherland0s government. The principal goal of the GDF is to meet the immediate drug needs of less developed countries during the expansion of DOTS, until they are set up to provide the drugs themselves. Drug prices have already fallen by about 30% as a result of competitive bidding, polled procurement and standardization of products, and six months of TB drugs can cost as little as US$ 10. The GDF requires US$ 25 million a year in order to assist 11.6 million patients.

Global Plan to Stop TB

2001-2005                         US$ million

Total Funding Needed             9126

Total Funding Gap                 3777

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Five Frequently Asked Questions:

How does WHO combat TB?
TB is an ancient killer but in recent years there has been an alarming increase in TB. With its rapid re-emergence, WHO took the unprecedented step in 1993 of declaring TB a global emergency. Within two years DOTS was accepted as the universal strategy to control TB. This helped create the momentum that fostered an international partnership to combat TB.

Who are the main groups involved in the global TB programme?
The Stop TB Partnership is a network of all those involved in TB. It brings into its fold the governments of rich and poor countries, donor agencies, industry and business sectors, and leading universities and hospitals. The campaign to stop TB was boosted in 2001 with the creation of the Global Fund to Fight AIDS, TB and Malaria.

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What else can be done?
The simple answer is: lots. As this report clearly states, the DOTS strategy works. But if we drop our guard the consequences could be catastrophic. It is vital that we expand DOTS to areas not currently covered. To do this we must have continued government commitment. We already face worrying developments with TB/HIV taking its toll on health systems. MDR-TB remains a major concern. It is critical that research continues into new tools such as drugs, diagnostics and vaccines.

What are the WHO targets on TB?
If we want to make a definite impact on the TB epidemic, we have set out a goal to detect at least 70% of all TB cases and cure at least 85% of those detected by 2005. These targets may appear ambitious but already we are seeing positive results. Most control programmes are now successfully treating cases. But we still have to go some way before we reach our 70% case detection target. Will we reach the 2005 targets? We genuinely hope so. But we need guarantees of continued support and commitment from everyone involved in the fight against TB. Given the current funding situation we face an uphill struggle. Just in technical assistance for countries alone there is a funding gap, per year, of US$ 23 million. On an account spreadsheet, such a figure may be easy to overlook. But translated in real terms, that is the cost in human lives, this shortfall makes for uneasy reading.

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WHO is grateful for the contribution to this project 
by the editorial and production staff of COLORS Magazine.

Amy Flanagan, London

Creative Editor
James Mollison, Oxford

Art Director
Helder Araujo, Belo Horizonte

Tom Ridgway, Paris

Copy Editor
Barbara Walsh, Rome

Pier Fichehfeux, Paris

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Production Designer
Paulo Condez, Lisbon

Editorial Director
Renzo di Renzo, Treviso

Executive Editor
Carlos Mustienes, Madrid

Design Direction
Omar Vulpinari, Rimini

Production Assistants
Daniela Mesina, Treviso
Simona Lettieri, Treviso

French Editors
Isabelle Baraton, Marseille
Maxime Chavanne, Paris

Spanish Editors
Clara Cabarrocas, Barcelona
Fernando Linares, Madrid

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Addditional thank you to:
Grégoire Basdevant, Marco Callegari,
Sonia Pastrello, Arianna Rinaldo

Bruno Ceschel, Italy and Estonia
Lauren Beukes, South Africa
Sean O’Toole, Malawi
Abdul Tawab Kawa Saljuki, Afghanistan
Mahesh Ramchaudani, India
Rose George, UK
Nicolette van der Lee, USA
Claudine Boeglin, Afghanistan
Glenn Luther, Afghanistan

Photo Credits (pages)
Tanya Braganti, USA 5,6,7,34,44
Pieter Hugo, Malawi 12,49,50,51,52
Jacob Langvad, Estonia 4, 5, 6, 7, 45, 46, 47, 65, 67, 68, 69
James Mollison, Brazil, Peru, China, Russia Cover, 2, 3, 4, 8, 9, 14, 15, 17, 18, 20,
26, 27, 28, 29, 30, 32, 35, 36, 38, 39, 41, 55,
56, 64, 73, 75, 76, 78, Back cover
Karen Robinson, UK 6, 7, 42, 66
Roshanak B. / Webistan, Afghanistan 33
Marc Shoul, South Africa 59, 60, 61, 62, 63
Rajesh Vora, India 13, 25, 54, 55

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Francis Adatu, Uganda
Dr Léopold Blanc, WHO, Geneva
Dr Solange Cavalcanti, Brazil
María Elena Charcape, Peru
Dr Dan Chin, WHO, China
Dr Manfred Danilovits, Estonia
Dr Chris Dye, WHO, Geneva
Dr Marcos Espinal, WHO, Geneva
Dr Andrea Gori, Italy
Dr Reuben Granich, WHO, India
Dr Malgosia Grzemska,WHO,Geneva
Dr Wieslaw Jabubowiak, WHO, Russian Federation
Georgina Kenyon, WHO, Geneva
Natasha Kheutornaya, Russian Federation
KNCV, Netherlands
Oxana Kosheleva, WHO, Russian Federation
Dr Malgosia Grzemska, WHO, Geneva
Dr Nombuleto Madala, South Africa
Dr Dermot Maher, WHO, Geneva
Thabo Mataboge, South Africa
Dr Olga Medvedeva, Russian Federation
Dr Giampaolo Mezzabotta,
WHO, Afghanistan
Sister Nonkonyana, South Africa
Dr Paul Nunn, WHO, Geneva
Dr Salah Ottmani, WHO, Geneva
Becky Owens, UK
Dr Yuri Pavlov, Russian Federation
Dr Mario Raviglione, WHO, Geneva
Dr Alasdair Reid, WHO, Geneva
Dr Luca Richeldi, Italy
Beatrice Selig, Brazil
Dr Lia Selig, Brazil
Dr Fabio Scano, WHO, Geneva
José Silva, Peru
Glenn Thomas, WHO, Geneva
Dr Edouardo Ticona, Peru
Dr Mukund Uplekar, WHO, Geneva
Dr Kai Vink, Estonia
Dr Catherine Watt, WHO, Geneva
Dr Xu Weiguo, China
Dr Lin Yan, WHO, China
Ludmila Yurastova, Russian Federation

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In 1993, The World Health Organization
(WHO) declared an international emergency for tuberculosis. This was unprecedented. WHO, the United Nations specialized agency for health, was established in 1948. Its objective is to achieve for all peoples the highest possible level of health. Health is defined as the state of complete physical, mental and social well-being and not only the lack of disease or infirmity. WHO is governed by 192 Member States through the World Health Assembly. The Assembly approves WHO’s programme, budget and major policies.

WHO is central to the global partnership to stop tuberculosis, the Stop TB Partnership, which helps countries implement the DOTS strategy, adapt DOTS where HIV and MDR-TB are frequent, and foster research for new tools to combat TB.

© World Health Organization 2003
All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int).
  Printed in Italy

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