History of tuberculosis and drug resistance

To the Editor: In their historical overview of global efforts to control tuberculosis, Keshavjee and Farmer (Sept. 6 issue)1 argue that the prioritization of global health funding based on measurable outcomes and high-return investments contributed to the fragmentation of primary health care. We agree but acknowledge that it can be difficult to strike the right balance between the improved efficiencies provided by vertical programs and comprehensive primary care. Importantly, international funding should not erode local ownership or investment in comprehensive primary care, which serves as the bedrock of a well-functioning health care system. Global implementation of the DOTS (directly observed treatment, short-course) strategy eliminated the chaos that reigned in tuberculosis treatment during the early 1990s, curing 50 million people and averting some 7 million deaths.2,3 The absence of laboratory infrastructure, the unavailability of second-line drugs, and the failure to appreciate the epidemic potential of the disease motivated the initial exclusion of drug-resistant tuberculosis from the DOTS strategy, which was subsequently corrected with the formulation of the Stop TB Strategy.4,5 Urgent and bold action is required to curtail the threat of drug-resistant tuberculosis, including a major step-up in resources, political commitment, and unity of purpose from all involved in tuberculosis control.