Drug-Resistant Tuberculosis: The Emergence of a Global Threat
London can now claim the indecorous designation as the ‘tuberculosis capital of Europe’. Long known in the West as a disease of poverty and bygone eras, tuberculosis (TB) cases are increasingly prevalent even in the world’s most affluent cities. More worrisome however are the rapidly rising rates of ‘extensively drug-resistant TB’ (XDR-TB) and ‘totally drug-resistant TB’ (TDR-TB). While drug-resistant strains have been periodically discovered since the 1960s, the incidence of multiple drug-resistance increased markedly during the 1990s. The World Health Organization (WHO) now estimates the presence of XDR-TB in at least 58 countries, with 25,000 infections occurring each year. The WHO predicts that by 2015 more than two million people will contract multi-drug-resistant tuberculosis.
According to the journal Nature, recent TDR-TB diagnoses in India make it the third nation in which a completely drug-resistant form of tuberculosis has been discovered. Documented cases were first seen in Italy in 2007 and later in Iran in 2009. The incurable strain of the bacterial infection truly presents a global threat to public health. Tragically, experts at the WHO describe TDR-TB as “a totally man-made disease.” Through the excessive use of antibiotics, incomplete treatment regimes, and counterfeit versions of TB drugs, the resistant strains of tuberculosis have become more prevalent and more virulent.
The Indian case is illustrative and particularly troubling. Over-the-counter antibiotic use is widespread in India. As noted in a recent Reuters article by Dr. Zarir Udwadia, a tuberculosis specialist at the Hinduja National Hospital in Mumbai, “To get to this stage, you have to have amplified resistance over years, with loads of misuse of (antibiotic) drugs. And no other country throws around second-line drugs as freely as India has been doing.” Consequently, India has more than 100,000 cases of multi-drug-resistant tuberculosis, more than any other nation. Not surprisingly, India is seen as the primary culprit in spurring drug-resistant strains of TB.
While inappropriate treatment and antibiotic misuse certainly contribute to the rise of MDR-TB, the availability of fake and substandard drugs significantly amplify the increased levels of drug resistance as well. It is not likely a coincidence that a recent study by the International Policy Network finds that most counterfeit drugs originate in India and China. The study notes that “data on levels of fake TB drugs is scarce, yet one reliable study . . . across six countries found the level to be 10%.”
Pharmaceutical counterfeiters prey on the sick and most vulnerable populations, profiting from the suffering of others. Moreover, their wares facilitate additional drug-resistance and escalate the prevalence of both MDR-TB and TDR-TB. Unfortunately flawed government policies and corruption only exacerbate the problem. The weak regulatory regimes and corrupt legal systems that characterize many developing countries are easily manipulated by counterfeiters.
As noted by the Julian Harris of the International Policy Network, “A free press, free courts, and free trade would actually increase the quality of medicines.” Free trade and the associated intellectual property protections, especially patent and trademark laws, inhibit the trade in counterfeit drugs and help to secure the drug supply. Clearly safeguarding our drug supply, by ensuring appropriate use and eradicating fraudulent drugs, will both protect today’s patients and reduce the emergence of additional drug-resistant strains of tuberculosis.