WASHINGTON -- On an eight-hour plane ride from Paris to New York last fall, a Ukrainian emigre repeatedly coughed. Unbeknown to fellow passengers, the man was sick with infectious tuberculosis.
And it wasn't just any tuberculosis. His was a strain of TB that had mutated into an organism able to fight off six common anti-tuberculosis drugs.
Two days after the flight, the man walked into a western Pennsylvania health clinic. Doctors diagnosed the illness. Health investigators called the airline and quickly tracked down 40 passengers who had sat near the man.
They were glad they did: 13 passengers were found infected with the bacteria.
This case, and others like it, illustrates an emerging global health threat that has received surprisingly little public attention: In this age of unprecedented global travel and trade, many U.S. health specialists foresee the deadly strains of drug-resistant tuberculosis easily carried across air, sea and land borders, including the United States'.
The heart of the crisis -- which a Centers for Disease Control and Prevention doctor last year called "probably the worst situation for multidrug-resistant tuberculosis ever documented in the world" -- lies in the former Soviet states, particularly in Russia, Belarus, Moldova and Ukraine.
Russia's financial meltdown is playing a direct role in the spread of resistant TB. Because of a lack of money, doctors stop treating patients. When treatment is interrupted, the worrisome bug grows especially hardy and in close, unsanitary quarters such as Russian prisons jumps from person to person.
High numbers of cases also are being reported elsewhere, including central India, Bangladesh, Latvia, Congo, Uganda, the Philippines, Afghanistan, Peru and South Africa.
The World Health Organization will spotlight the resurgence of drug-resistant TB next week, holding news conferences in New York, Washington, Paris and other cities with a warning that if the problem isn't attacked in the next two years it could become the "principal epidemic of the next decade" in Europe and the United States.
As the crisis grows abroad, the odds grow of outbreaks at home, says Lee Reichman, director of the National Tuberculosis Center in Newark, N.J.
"You can't keep this TB out of the United States," he says. "There are 8 million cases of active TB occurring each year, and there are 49 million international travelers coming to the United States every year."
At the urging of billionaire financier George Soros, Hillary Rodman Clinton quietly convened a meeting in October of top administration health officials, a National Security Council official, the heads of the World Bank and the WHO, and tuberculosis experts.
Since then, the United States has given $1 million to fund a TB-control effort in the Russian city of Ivanovo; the World Bank is considering a loan to the Russian government to fight TB; and the WHO has endorsed several treatment programs in the former Soviet states.
Yet, health specialists say, much more help is needed. The Russian prisons have become breeding grounds for the disease with about 100,000 active TB cases, about a third of them with multidrug-resistant TB.
Mycobacterium tuberculosis was pinpointed more than a century ago as causing TB, which now ranks as the world's most deadly infectious disease. Three million people die from it annually. Scientists have yet to discover a vaccine.
The TB bug settles in a person's lungs and begins to destroy them. It can move to the brain, liver, kidney and spine, setting off a battle between the bug and the body's immune system.
When an infected person coughs or sneezes, the bacteria are passed through the air in what are known as "droplet nuclei" to be inhaled by others. On average, a person with active TB will infect 10 others annually. Infection occurs within families or to others in close quarters -- prisons, hospitals, sometimes poorly ventilated workplaces. A few years ago, one person passed it to several fellow members of a Newark, N.J., church choir.
On airplanes, the CDC estimates that risk occurs only on flights lasting eight hours or more, and then only to those in the vicinity of the TB carrier.
In the United States, fighting tuberculosis has mostly been a success story. In 1953, 84,304 people had TB. Except for an outbreak in the early 1990s in New York City, TB incidence has steadily fallen the last half-century, to 19,851 cases in 1997. Multi-drug-resistant cases account for 1.3 percent of all TB cases in the United States.
Such mutated strains of TB emerged only about two decades ago. These types of bacteria developed when doctors prescribed the wrong drugs, the supply of drugs was cut off, or patients stopped taking their medicine. When treatment lapsed, the organism grew stronger.
The cost of fighting resistant TB soars. A single case can cost more than $250,000 in the United States and Western Europe because it involves a cocktail of drugs, lengthy hospitalization and preventive measures for health care providers. The New York City outbreak of about 2,000 cases earlier this decade cost $1 billion. In contrast, a six-month treatment program using common drugs costs as little as $50.
In economically strapped Russia, even such bargains are unaffordable.
At the 216-year-old Vladimir Prison, about 140 miles north of Moscow, Dr. Larisa Chernyatyeva estimates that treatment for the 106 TB patients would cost the equivalent of $56,521.
Moscow's central government gave her just 1 percent of that -- $565. If she gives prisoners incomplete dosages, she risks creating more cases of drug-resistant TB.
"We couldn't cure the people because we couldn't give them strong enough dosages," says Chernyatyeva, who runs the prison's TB program.
Russia has more people in jail per capita than any other country in the world. Deputy Minister of Justice Yury Kalinin said he feared that the TB epidemic was turning prison cells into "gas chambers" because there is "no way of separating or sorting prisoners with tuberculosis from healthy ones."
When prisoners are released, the problem "stops being another public health or humanitarian issue and is converted into the category of a threatening issue for the West and the rest of the outside world," says Alex Goldfarb, head of the Russian TB program, which is funded by Soros and the New York-based Public Health Research Institute.
The Ukrainian emigre's case is just one of several examples of global transmission. Reichman, the director of the national TB center, cites cases in North Carolina and in the Washington area in which adopted babies from Siberia tested positive for multidrug-resistant TB.
Jim Yong Kim, director of Partners in Health, a Cambridge, Mass.-based group that has had high cure rates for drug-resistant cases in Peru, Mexico and Haiti, cites the case of a nanny from Lima, Peru, who infected her employers, a family in a northern New York City suburb.
"We have to put whatever money it takes to treat the worst situations in the world now," Kim said.
Bill Barry, coordinator of the tuberculosis-control program at the Pennsylvania Department of Health, doesn't need convincing. He oversaw the investigation of the Ukrainian refugee, whose TB is now under control with a seventh TB drug. Of the 13 passengers who tested positive for the TB bacterium, none had the full-blown disease, meaning they could not transmit it. The 13, all foreigners, either had been exposed before they boarded the plane or were infected by the Ukrainian.
Barry says he was very lucky in the case.
"What if he hadn't gone into the health clinic in the first place? He would have infected others," he says. "And what about other cases, of illegal immigrants coming into the country, all those people we don't know about? The potential is there for a huge public-health problem."
Pub Date: 3/20/99