Apocalypse or redemption: responding to extensively drug-resistant tuberculosis.

a Joint Centre for Bioethics, University of Toronto, 88 College Street, Toronto, ON, Canada. b Centre for AIDS Programme of Research in Africa, Durban, South Africa. c School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. Correspondence to Ross Upshur (e-mail: [email protected]). (Submitted: 10 June 2008 – Revised version received: 8 October 2008 – Accepted: 5 January 2009 ) Responding to drug-resistant tuberculosis is possibly one of the most profound challenges facing global health. Leading experts have used apocalyptic language in describing the scope of the challenges posed by extensively drug-resistant TB (XDR-TB), even suggesting that we resort to prayer as a solution.1,2 Recent reports indicating that aggressive treatment confers benefit raise hope that the situation may not be so dire.3 However, the structural and political changes and resources needed to prevent and treat XDR-TB on a large scale are not sufficient to assure that the tide of XDR-TB will be stemmed any time soon. Drug-resistant TB is not the result of catastrophic natural forces such as earthquakes, tsunamis and hurricanes. It is not caused by malign human intent, as are terrorism and war, nor is it fostered by our dysfunctional relationship with the animal kingdom as are severe acute respiratory syndrome (SARS) and avian influenza. The locus of risk and control is entirely within the human domain. Our response to the emergence of drug-resistant TB is profoundly ethical as it raises issues of how justice and human rights are realized in our collective response to a disease. It also underscores how the global community responds to its most disadvantaged members. The progressive worsening of resistance of TB to pharmacotherapy has raised the spectre of a response to TB without medication – what some have labelled the dawn of the post-antibiotic age. The combination of high rates of TB infection with high seropositivity rates for HIV in sub-Saharan Africa adds new levels of complexity to diagnosis and treatment and has raised the ante of global TB control.4 WHO has launched an eight-point plan to respond to XDR-TB.5 This paper provides an elaboration of these recommendations and adds some additional considerations as moral correlates to the current WHO plan (Box 1).