"It is a long-standing and unfortunate American tradition to blame outbreaks of infectious diseases on the foreign-born. This tendency remains evident today in the case of tuberculosis. ...The prevalence of tuberculosis in the United States has declined to its lowest level ever, from 26,673 cases in 1992 to 16,377 cases in 2000, a drop of 39 percent. The rate of multidrug-resistant tuberculosis is down by 70 percent. However, the Centers for Disease Control and Prevention report that 50 percent of the cases are now found among foreign-born persons, up from 27 percent in 1992, and that the proportion of cases of multidrug-resistant tuberculosis occurring in foreign-born persons has increased from 31 percent to 72 percent.

"At face value, these increases might be considered alarming, and might even lead to calls for dramatic action to keep foreigners harboring tubercle bacilli from entering and thereby threatening our country. However, the data show clearly that the number of cases of tuberculosis among the foreign-born has remained constant for almost a decade. What has changed is the rate of active transmission of infection within this country. We have learned how to treat and block new transmission of tuberculosis, but we do not yet know how to prevent the reactivation of dormant infections.

"This new reality suggests two important courses of action. ...One of them should be a serious research effort to develop effective drugs or vaccines targeting persistent or dormant Mycobacterium tuberculosis infection. With such interventions, we might someday be able to prevent reactivation in those who are tuberculin-positive (about a third of the people on the globe). However, 95 percent of cases of tuberculosis occur in poor residents of developing countries, and there are few market incentives to develop such drugs. It is encouraging that new public-private collaborations -- such as the Global Alliance for Tuberculosis Drug Development to develop new antituberculosis drugs and the Global Drug Fund to purchase and distribute existing drugs -- have been created.

"Our second overarching priority should not be to target either healthy visitors or healthy immigrants who harbor dormant infection for exclusion from the United States. Instead, we should lead a global effort to control tuberculosis in developing countries -- to provide existing drugs and to support directly observed treatment, as well as training. The goal should be to detect at least 70 percent of all cases and cure 85 percent of all patients identified. Such an effort would greatly reduce the transmission of tuberculosis and the emergence of drug resistance globally, just as we have successfully done in our own country. This program would save about 16 million lives and $6 billion by 2010. It would be the most effective public health action we could take to protect people in our country from tuberculosis. And it would create models for similar programs of supervised treatment for human immunodeficiency virus and the acquired immunodeficiency syndrome in developing countries."

The author is affiliated with the Harvard School of Public Health in Boston.

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