As Kenya Bleeds, Tourism Also Suffers in Land of Safaris

Lel Cartwright, a tourist, with Isaac Rotich, a safari guide, at the Cottars 1920s Mara Safari Camp in Kenya’s Masai Mara. (Guillaume Bonn for The New York Times)
KEEKOROK, Kenya: March 1st. (NY Times) — Nancy Holan just had the safari of her life. She and a friend flew to Kenya from Detroit and as they cruised the wide open plains, they had the lions, zebras and elephants all to themselves. "It was wonderful," she said. Not far away, Isaac Rotich, a high-end safari guide, paced an empty game lodge in freshly polished safari boots. He can spot a six-inch lizard 50 feet away, and tell you the name — in Kiswahili, English and Latin — of the plant it is sitting on. He has spent years building this career and was making $30,000 a year, a king’s ransom in these parts. Now he is afraid of losing it all. “We’re hurting, big time,” Mr. Rotich said. This is what Kenya’s legendary safari business has become: wonderful for tourists, disastrous for just about everyone else.

Tourism is one of Kenya’s biggest industries, but the violence that exploded after a flawed election in December has eviscerated the business, with bookings down 80 to 90 percent in most areas. Even after a peace deal was signed Thursday, government and tourism officials worried that it could take months — if not years — to recover. Kenya’s rival politicians have agreed to share power, and on Friday many people here praised them for finally calming the country down. But the long-term economic consequences are just beginning to sink in. “We will work very hard to see what we can salvage,” said Rose Musonye Kwena, an official at the Kenya Tourist Board, who estimated that even if there was no more major violence this year business would still be down 50 percent. The images of machete-wielding mobs caused a tourist stampede, and the lingering uncertainty over the country’s direction has caused a wave of cancellations, leaving dozens of hotels closed and thousands of guides, drivers, cooks, waiters, masseuses, wood carvers and bead stringers out of work. Many of them support a vast network of relatives. A continued tourism meltdown could push millions of Kenyans toward poverty, which was one of the underlying causes of the violence in the first place. The downturn also threatens to reverse the momentum that Kenya has made in recent years to protect land and animals. Government officials are worried about out-of-work guides and trackers poaching game. Village elders in animal-rich areas who had been persuaded that conservation and tourism would be profitable have been re-examining this equation and considering selling off their land. Sales mean farms, and farms mean fences, which could block the millions of zebra, wildebeest and antelope that migrate across the famous Masai Mara game reserve each year, possibly endangering one of the most spectacular gatherings of animal life on the planet. “It’s absolutely catastrophic,” said Calvin Cottar, the owner of an upscale safari camp.

Kenya’s billion-dollar tourism industry, which injects critically needed foreign exchange into the economy, is hardly the only victim. The election crisis, which started when Kenya’s election commission declared the incumbent president, Mwai Kibaki, the winner of a closely contested race, despite widespread evidence of vote rigging, has killed more than 1,000 people and balkanized Kenya, with hundreds of thousands fleeing their homes and resettling in ethnically homogenous zones. The violence punched a hole through the economy, disrupting coffee and tea production, knocking down the stock market’s value and bruising transport, manufacturing, construction and nearly every other industry — except maybe the funeral trade. Tourism could take among the longest to bounce back, because it is especially sensitive to perceptions, and the well-publicized bloodshed of the past two months has badly dented Kenya’s image. Last year, the country had more than two million tourists. In January, there were only 55,000 new arrivals, well below projections. The truth is that most of the violence has subsided and it never really touched the tourist areas, like the Masai Mara.

But many Western governments seem to think otherwise. Australia is still warning its citizens traveling to Kenya to stay indoors, not exactly the greatest plug for game watching. “These warnings are a real problem for us,” Mr. Cottar said. Even if the game lodges have been perfectly safe, he said, people have not wanted to come to Kenya if they think “they will be drinking Champagne while somebody is getting hacked to death over the hill.” His resort is as good an example as any. Cottars 1920s Mara Safari Camp is one of the most luxurious lodges in Kenya, charging up to $710 a night per person, and is usually booked solid at this time of year. Now it is deserted. It is nestled in an especially picturesque corner of the Masai Mara, overlooking the green hills of Africa that inspired Ernest Hemingway and so many others. The lodge plays up the old-school theme, decked out with leather trunks, brass telescopes and pith helmets. On Sunday, the only guests were a couple from Kenya who paid cut-rate local prices, which allow the lodges to stay open — but just barely. The couple, James and Lel Cartwright, arrived in their own plane. For once, the air over the Masai Mara was clear as glass. “It was stunning,” Mrs. Cartwright said. “There’s usually a wall of dust from all the minibuses.” The staff at Cottars threw on their fezzes and best smiles. But underneath they seemed down. Their salaries have been halved. The tips have dried up. Daniel Lanke, a waiter at Cottars, just enrolled his ninth child in private school but now, he said, “I can’t even buy him socks.” In the villages around the lodge, it is the same story. At the sound of a truck, Masai women dash in from the fields and set up tables full of souvenirs. Some have not sold a necklace for months. “We are going to go hungry,” said one woman, Nalarame Noloswesh, who has seven children.

Many lodges have teamed up with local communities, sharing a slice of their profits in exchange for using the communities’ land. The whole point was to make tourism more profitable than agriculture, so villagers would have an incentive to set aside their land for animals. Kenya’s tourism officials seem to appreciate the stakes. They are planning to begin a huge marketing campaign to reassure potential visitors that Kenya is safe. Mr. Cottar says that he will donate some of his proceeds to the Kenyan Red Cross to emphasize that “if you go on safari now, you’ll be helping the country.” But those with the means may not wait. Mr. Rotich, the safari guide, is fully aware of his skills. He is an expert game spotter, speaks impeccable English and seems genuinely interested in every form of life on the veldt, from the towering giraffe to the lowly dung beetle. “This is all I know,” he said. The other day, he found a herd of 150 elephants eating grass in a clearing. Babies wrestled with one another as their enormous mothers lumbered past. The elephant train was headed south to Tanzania, where the safari industry is booming because many tourists are flocking there instead. Mr. Rotich said he might join them. “I love Kenya,” he said. “But I have my dreams.”
by Jeffrey Gettleman
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Kenya Rivals Reach Peace Agreement

Kenyan President Mwai Kibaki, left, and Raila Odinga, the opposition leader, with Kofi Annan in Nairobi, Kenya, on Friday. (Simon Maina/Agence France-Presse -- Getty Images)

NAIROBI, Kenya: Feb. 29th. (NY Times) — Kenya’s rival leaders broke their tense standoff on Thursday, agreeing to share power in a deal that may end the violence that has engulfed the nation but could mark the beginning of a long and difficult political relationship. The country seemed to let out a collective hooray as Mwai Kibaki, the president and Raila Odinga, the top opposition leader, sat at a desk in front of the president’s office, with a bank of television cameras rolling, and signed an agreement that creates a powerful prime minister position for Mr. Odinga and splits cabinet positions between the government and the opposition. There are still many thorny issues to resolve, among them how the government will function with essentially two bosses. There is also a deeply divided country to heal. More than 1,000 Kenyans have been killed and hundreds of thousands driven from their homes in an uncharacteristic burst of violence set off by a deeply flawed election in December. Much of the fighting, like the voting, has been along ethnic lines.

But the two-page agreement, which came after intense international pressure and mediation by Kofi Annan, the former UN secretary general, seemed to serve as a contract to pull Kenya back from the brink. Both leaders urged their supporters, who have battled viciously across the country in recent weeks, to respect it. “I call on Kenyans to embrace the spirit of togetherness,” Mr. Kibaki said. Mr. Odinga was beaming next to him. “We should begin to ensure that Kenyans begin to celebrate and love each other and that we destroy the monster that is called ethnicity,” he said. Kenyans were glued to their television sets and radios across the country as the news broke. In downtown Nairobi, the capital, a crowd poured into the streets and danced and cheered until they were run off by tear-gas shooting police officers. In offices across town, business executives, who have watched their profits fall and the investments tank over the past two months, finally exhaled. “Yes, I’m relieved,” said Ngovi Kitau, the manager of a large car dealership. He had just come from a meeting where his company had decided to let 10 people go a month because business was so bad. “You don’t know what we’ve been through.” But he injected a note of caution that many Kenyans seemed to feel: “It’s a marriage of convenience, and it’s the best way out because it’s going to get the country moving again. But it’s not a solution.”

Kenya used to be considered one of the most prosperous countries in Africa, known as an oasis of stability in a turbulent region. But the country spun into chaos in late December after the national election commission declared Mr. Kibaki the winner of a closely-contested election over Mr. Odinga, who claims to have won the most votes. Election observers have been unanimous that the election was tainted by irregularities, with some saying that the government rigged the tallying of votes to give Mr. Kibaki a slender, 11th-hour edge. The controversy spawned bloodletting across the country, with supporters of Mr. Odinga and Mr. Kibaki fighting one another in brutal battles. Mr. Odinga and Mr. Kibaki are from different ethnic groups, and the election seems to have kicked the lid off a set of simmering political, ethnic and economic issues. The violence cooled down in the past few weeks, but the tension and displacements continued, with many Kenyans saying that the country would not return to peace until the dueling politicians agreed to some sort of solution.

Mr. Annan took the lead in trying to bring the two sides together. For the past month, he has been meeting nearly every day with negotiators for Mr. Kibaki and Mr. Odinga, searching for a political compromise. More than anyone else, he has been the hope of this country. A newly-born baby rhino was even named after him. This week the talks nearly collapsed altogether. Negotiators deadlocked over whether they would share responsibilities or share power, with the government refusing to give Mr. Odinga substantial authority or to amend the constitution to create the position of prime minister, which had not existed in Kenya’s system. Mr. Annan then decided to bypass the negotiation teams and go directly to Mr. Odinga and Mr. Kibaki. He met with them behind closed doors for six hours on Thursday. At 4:30 p.m. local time, Mr. Annan, Mr. Kibaki and Mr. Odinga emerged. The two leaders signed the agreement with Mr. Annan standing behind them, his hands clasped, as a crowd of diplomats, cabinet ministers and political supporters clapped.

The deal creates a government of national unity, melding the president’s party with Mr. Odinga’s. Mr. Odinga will become prime minister and will “coordinate and supervise” government affairs. The cabinet positions will be divided, based on parliamentary strength. Mr. Odinga’s party has a slight edge in Parliament. This is not the first time Mr. Kibaki, 76, and Mr. Odinga, 63, have vowed to work together. The two were close political allies in 2002, when Mr. Kibaki was elected president, but they soon had a falling out. Under the deal, the two sides will work together on constitutional reform, land reform, electoral reform and a complete overall of Kenya’s political system. “Today we have reached an important staging post, but the journey is far from over,” Mr. Annan said. “Let the spirit of healing begin today. Let it begin now.”
by Jeffrey Gettleman with Kennedy Abwao contributed to this report
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Ten UN Agencies Target Female Mutilation

Female genital mutilation is deeply rooted in many societies
UN, New York: Feb. 27th. (BBC News) A range of United Nations agencies are calling for the practice of female genital mutilation to be ended within the space of a generation. An estimated three million girls a year are thought to be at risk from this practice, many of them in Africa. The practice of cutting off the clitoris of a young girl - and often more - is deeply rooted in some cultures. Ten UN agencies want a major reduction in the tradition by 2015. The practice is seen in some countries as a way to ensure virginity and to make a woman marriageable. Yet it also leads to bleeding, shock, infections and a higher rate of death for the women's new-born babies, say the UN groups.

Up to 140 million women are thought to have undergone this procedure in 28 countries in Africa, and a few in Asia and the Middle East. It is also happening to girls and women who have left their original countries and settled in the West. The UN agencies say traditions are often stronger than law and legal action by itself is not enough to tackle this. Change must come from within communities, they say, citing the example of West Africa, where villages have joined together to make pledges to abandon this practice.
by Laura Trevelyan
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Cubans Wary of Raúl Castro’s Hints at Change

HAVANA, Cuba: Feb. 27th. (NY Times) — In his first state reception as Cuba's president, Raul Castro met Tuesday not with leftist Latin American leaders like Hugo Chavez and Luiz Inacio Lula da Silva, nor with Chinese officials, but with the secretary of state of the Vatican, a traditional enemy of Communism and a critic of Cuba’s record on human rights. Mr. Castro’s decision to begin his tenure by meeting the Vatican’s top diplomat, Cardinal Tarcisio Bertone, a possible go-between with the United States and Europe, reflects his practical, no-nonsense style as well as his greater willingness to put ideology aside to achieve his goals than his brother often showed. Mr. Castro, who is 76 years old, is hardly a fresh face to Cubans, having served as the defense minister for the past half century. Many people doubt that he intends to upend his brother’s legacy. Yet he does seem inclined to govern more pragmatically than his more doctrinaire and romantic brother, who ran this country for 49 years as if it were his own business, signing off on almost every government decision. Raúl Castro has said the government needs to shrink and become more compact. He has promised “structural changes” and “big decisions.” “We have to make our government’s management more efficient,” he said Sunday, adding, “We have to plan well, and we cannot spend more than we have.”

Since he became acting president after Fidel Castro fell ill and disappeared from public view in July 2006, Raúl Castro has sought to improve public transportation and shake up the state-controlled dairy monopoly. He also shocked people when he acknowledged that the average salary of about $19 a month was too little to live on. As he took office Sunday, he raised the possibility of revaluing the Cuban peso to give salary-earners greater buying power. Raúl Castro’s decision on Sunday to put his closest friends and loyalists in the major positions of vice president and defense minister also suggests that he has control of the government, even though he has promised to consult Fidel Castro on important matters. Despite such steps, many Cubans say they see few signs of real change. Some say they suspect that Fidel Castro will continue to rule from behind the scenes. Others see little ideological difference between the ex-president and his brother. Still others argue that the centralized bureaucratic apparatus of the state is too rusty to be reformed. A young man stood in Havana’s central park on Monday, scanning the faces of the new government leaders, his face scrunched up in puzzled concentration. When a reporter asked him what he thought of the new president, he muttered, “It’s good,” rattled the paper shut and marched quickly away, casting a furtive glance at a nearby police officer. “Everyone is afraid to talk,” said a student sitting on a park bench nearby who identified himself only as Alejandro. “This is the time when the people should go to the street, but they are afraid. My country is like a prison.” A few blocks away, José, a store clerk in his 30s, was waiting in line outside a post office in Old Havana to send an e-mail message to a family friend through a secure Internet connection that allows no other contact with the outside world. “There was no change,” he said, echoing the views of others. “Look, if you paint this tile here and you paint it with the same color, there is no change. The brothers think alike.”

Many experts on Cuba, however, say the two brothers often have not seen eye to eye. They have clashed over the years on everything from Fidel Castro’s short-lived flirtation with the American public in 1959 to the necessity of allowing some private enterprise during the economic crisis here in the 1990s. Fidel Castro, who is 81, was renowned for his ability to recall arcane details and second-guess his cabinet members, fostering an atmosphere in which even high-ranking officials were afraid to act without the president’s explicit approval. Raúl Castro, who spent much of his life at the head of Cuba’s military, has a reputation for delegating authority and demanding results from managers, people who know him say. “He once said to me after I had given a report at a meeting, ‘All right, this is your report, if one word of this is not true, I’m going to cut you in half,’ ” recalled Vladimiro Roca, a former fighter pilot who fell out with the authorities and has become a leading dissident. Fidel Castro often rambled on for hours in sometimes dull but occasionally stunning oratory. Raúl Castro gives short, precise speeches, always going directly to the heart of his subject. Where Fidel Castro sought the international limelight, his brother focuses more on bread-and-butter domestic issues.

In recent public speeches, Raúl Castro appears to have calculated for political reasons that he cannot distance himself too much from his brother, who, despite his long illness, continues to lead the Communist Party and to cast a large shadow over Cuban politics. For example, the new president made it clear in his first speech to the National Assembly over the weekend that he would continue to consult Fidel and even asked for a vote to authorize him to do so, drawing extended applause from party regulars. But the younger Castro’s actions show that he is willing to take Cuba in a different direction from that of his more dogmatic brother. Over the last year and a half, Raúl Castro has openly criticized state salaries as too low to live on, and speaking to the Congress, he raised the possibility of revaluing the Cuban peso to give salary-earners more buying power. Mr. Castro has taken steps to decentralize the production and distribution of milk. He has imported hundreds of buses from China to alleviate transportation woes and rid the streets of tractor-trailers fitted out for public transportation, eyesores known as camels. He has all but done away with the obligatory mass demonstrations Fidel Castro often organized to rally people against the United States. The younger Castro has even encouraged a measure of public debate about government programs, something his brother rarely allowed. Last fall, he authorized town hall meetings across the island to let people vent their frustrations with the system, though he made it clear that decisions about changes would rest with the ruling party.

Indeed, one of the two state newspapers, Juventud Rebelde, has done exposes on the filching of goods and food from state-run businesses that has become part of life here. Leading cultural figures, meanwhile, have called for dropping onerous visa requirements and other limits on personal freedom. Raúl Castro seems firmly in control of the Council of State, the main governing body. He named his old friends and military comrades — José Ramón Machado Ventura and Gen. Julio Casas Reguiero — as first vice president and defense minister, respectively. The upper echelon of the council is stacked with other military leaders who are considered close to the new president, among them Gen. Abelardo Colomé Ibarra and Juan Almeida Bosque. “This is Raúl’s team, the group of vice presidents,” said Brian Latell, a former C.I.A. analyst who wrote the book “After Fidel” and has studied the brothers for years. “I do think that Raúl is in charge. He’s going to pay proper homage to Fidel but not obeisance.” What is more, Raúl Castro says he will not officially appoint the rest of his cabinet until December at the earliest. Some political analysts says this gives him time to purge the cabinet members considered to be more loyal to his brother than to him if he wishes.

Still, after 49 years of living under Fidel Castro, many Cubans are skeptical of their new leader’s ability to get things done. They are waiting for Raúl Castro to do something concrete to improve their lives, like raise salaries. “His speech sounded more or less like more of the same,” said Alberto, a veteran driver for the official government taxi service. “There is a big gap between what is said and what is done.” Yoani Sánchez, who writes a political blog, said: “In general there is a sense of frustration because we had expected more. There is talk of changes, but he puts off defining those changes.” Still, many Cubans took heart that Mr. Castro had promised in his speech to lift some regulations and restrictions that stifle economic growth. For starters, he said it was time to revalue the Cuban peso, a step toward getting rid of the dual-currency system that has impoverished millions of Cubans. For years, the government has used a nearly worthless peso to pay government salaries while restricting the distribution of a so-called convertible peso that can be exchanged for foreign currency. The system has led to a kind of economic apartheid. Cubans with access to convertible pesos live far better than their compatriots. Those who live solely on government salaries can barely survive, even with free health care and subsidized rations of some basic foodstuffs and tobacco. Restrictions on travel and access to the Internet also rankle many Cubans, who believe the rules are virtually imprisoning them on their island. University students recently clashed with the president of the National Assembly over travel rights, a scene that was filmed and distributed clandestinely. Some Cubans expect Mr. Castro might lift some travel restrictions as a crowd-pleaser. Others said they hoped they would be allowed to own cellphones and to stay at tourist hotels, small but symbolically important steps. In the long run, however, his biggest challenge is revamping Cuba’s centralized economy. Raúl Castro said in his first speech to Parliament that the government needed to be streamlined and decentralized. No institution was safe from reforms, he said.

Yet his appointees are themselves members of the old guard, mostly men in their 70s. That disappointed some here who had hoped a younger generation of technocrats might rise. In some circles there is a feeling the veterans of the revolution can never dismantle the current economic system, which offers people little incentive to work. “Raúl has to make the country more efficient and give incentives to for work because really no one works in Cuba now,” said Juan, a man in his forties who acts as a consultant to importers. “How to you put a country to work that isn’t used to working? That is the trick.”
By James C. Mckinley Jr.
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Annan Tries to Spur Kenya Talks

NAIROBI, Kenya: Feb. 27th. (NY Times) - Kofi Annan suspended day-to-day mediation talks in Kenya on Tuesday and said he would now take up the remaining divisive issues with Kenya’s leaders directly. Mr. Annan, the former United Nations secretary general, seems to be growing increasingly frustrated with the pace of the negotiations, which have ground on for more than a month and are intended to solve a political crisis in Kenya that has cost more than 1,000 lives. “We cannot continue on the current basis,” said Mr. Annan, who is shepherding the talks. “It’s important for the leaders themselves to take charge.” Mr. Annan said it was crucial to reach a comprehensive solution and not “a patch-up job.”

Kenya’s troubles started in late December after the national election commission declared Mwai Kibaki, the incumbent, the winner of a presidential election over Raila Odinga, the top opposition leader, despite widespread evidence of vote rigging. The turmoil that followed pitted supporters of Mr. Odinga against those of Mr. Kibaki in brutal battles that spread across the country and split many areas along ethnic lines. Mr. Odinga and Mr. Kibaki are from different ethnic groups, and the election seems to have kicked the lid off simmering political, ethnic and economic issues. Mr. Annan has been meeting nearly every day with negotiators for Mr. Kibaki and Mr. Odinga, searching for a compromise that will calm the country. Mr. Annan said Tuesday that he was not giving up, but that a conclusion would be reached much faster by bypassing the negotiators and speaking with Mr. Kibaki and Mr. Odinga themselves. The two sides have agreed on many points. Last week, the government acquiesced to the opposition’s demand to create a position of prime minister for Mr. Odinga, who claims to have won the election.

But this week the two sides seem to have split over the details of that position, and Mr. Annan said that barely any progress was made Tuesday. The talks seem to alternate between promising and hopeless, and whenever progress is blocked, the two sides start hurling accusations at each other, as they did on Tuesday. The government now claims that the opposition is refusing to budge. From the government’s perspective, it has conceded much. Mr. Kibaki’s team rejects the accusations that the government rigged the elections to keep Mr. Kibaki in power, as some election observers have suggested. Mr. Kibaki’s team believes that offering the opposition posts in the government is a generous compromise. “We tend to feel we have been railroaded,” said Mutula Kilonzo, a negotiator for the government. But the opposition says that the government has been stubborn, and that beneath all the talk it does not want to share power in a meaningful way. “We have been extremely frustrated,” said Musalia Mudavadi, an opposition leader. “There are moments we believe we have made ground, but we realize the following day that there is a reversal.”

The pressure for a deal is increasing. Opposition leaders have threatened to resume nationwide protests on Thursday, and such events have turned bloody before. Foreign powers, like the United States, are demanding that Kenya’s leaders find a political solution fast. On Tuesday, Secretary of State Condoleezza Rice issued a threatening statement saying, “There can be no excuse for further delay.” “We are exploring a wide range of possible actions,” she said. “We will draw our own conclusions about who is responsible for lack of progress and take necessary steps.”
by Jeffrey Gettleman with Kennedy Abwao contributed reporting.
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Drug-Resistant TB at Record Levels

A ward for tuberculosis and HIV patients in Juba Hospital in southern Sudan. (Lynsey Addario for The New York Times)

Feb. 26th. (NY Times) - Multiple-drug-resistant tuberculosis cases in parts of the former Soviet Union have reached the highest rates ever recorded and could soar even higher, spreading the bacterial disease elsewhere, the World Health Organisation said on Tuesday in releasing findings from the largest global survey of the problem. The highest rate was in Baku, the capital of Azerbaijan, where 22.3 percent of new tuberculosis cases were resistant to the standard anti-tuberculosis drug regimen during the survey period from 2002 to 2006. That exceeded the previous high of 14.2 percent, in Kazakhstan. Studies in China also suggest that multiple-drug-resistant TB is widespread in the inner Mongolia and Heilongjiang regions, W.H.O. said. The new survey, the first in four years, shows that earlier predictions were correct and that governments have lost control of tuberculosis in many areas. The reason, health officials say, is that countries have failed to invest enough to build, equip and staff the laboratories needed to detect the disease. The countries also failed to assure sufficient amounts of standard drugs and then to monitor patients to ensure that they complete a full course of therapy. Inadequate therapy often leads to development of multiple-drug-resistant strains of the tuberculosis bacterium. Drug-resistant tuberculosis, like drug-sensitive TB, can be transmitted from an infected individual to a noninfected person in droplets through coughing, sneezing, singing and other activities. The drug resistant form can take two years to treat with drugs that are 100 times more expensive than the first-line regimen, the health agency, a unit of the United Nations said. The survey also found alarmingly high rates in Moldova (19.4 percent), Donetsk in the Ukraine (16 percent), Tomsk Oblast in Russia (15 percent) and Tashkent in Uzbekistan (14.8 percent). Those levels surpassed the highest levels that nearly all experts once thought were possible, Dr. Mario C. Raviglione, who directs the health organization’s Stop Tuberculosis program, said in an interview. “We are seeing levels of multiple-drug-resistant TB that we never expected — 20 percent is a very high level,” Dr. Raviglione, said. The Global Plan to Stop TB is a road map for reducing by half TB prevalence and deaths by 2015 compared with 1990 levels.

When W.H.O. started a drug surveillance project in 1994, he said, “the general thinking was that multiple-drug-resistant TB would never be a real problem since it was felt to be confined to immunosuppressed patients.” A decade ago, when W.H.O. first received reports of 9 to 10 percent rates of multiple-drug-resistant TB in some areas, many scientists thought the figure was inaccurate due to a misclassification that mixed new, previously treated and chronic cases together. Experts also said higher rates were not possible, Dr. Raviglione said, but “we see now it is possible, it tells you they are really doing something wrong in places where this form of TB is spreading.” Overall, about one in 20 new cases of tuberculosis in the world is resistant to first line drugs, which translates into nearly 500,000 of the 9 million new tuberculosis cases that are detected each year, according to the W.H.O. survey, which involved 90,000 patients in 81 countries.

The World Health Organization says that there is a financial gap of $2.5 billion of the estimated $4.8 billion needed this year for overall TB control in low- and middle-income countries. For the first time, the survey included analysis of extensively drug-resistant tuberculosis, or XDR-TB, a virtually untreatable form of the respiratory disease because the causative bacteria are resistant to virtually all the most effective anti-TB drugs. XDR-TB has been reported in 45 countries, but because few countries have the necessary laboratories to detect it, the data were limited. The true extent of the problem remains unknown in some pockets of the world because only six countries in Africa, the region with the world’s highest incidence of TB, could provide drug resistance data for the report, Dr. Raviglione said. Other countries in the region could not conduct surveys because they lack the laboratory equipment and trained personnel needed to identify drug-resistant TB. Outbreaks of drug resistance are likely going undetected, Abigail Wright, the principal author of the W.H.O. report, said. Although the W.H.O. report highlights the extent of drug resistance, Dr. Raviglione said there were successes where governments invested in control measures. He cited the Baltic countries of Estonia and Latvia as “the model” because they were the drug resistant tuberculosis “hot spots” 13 years ago. Today, following a substantial investment and a sustained assault on multiple-drug-resistant TB, rates in these two countries are stabilizing and rates of new TB are falling.
By Lawrence K. Altman
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