The recent agreement between Bayer and the TB Alliance offers a remarkable example of the industry embracing the spirit of wider access. Bayer has turned over its $500-million-a-year antibiotic moxifloxacin to the organization to test in clinical trials. If proven effective, Bayer will offer "expansive access" to the drug, despite the risk of the deal undercutting profits on the commercial side. Sources even say Bayer will allow the TB Alliance to check its books to ensure they are offering it at no profit. Says Freire: "I don't know of any other pharma company that has said, 'Yeah, we trust our drug, and yes, we are making a commitment to public health, and yes, we're going to make it affordable. And okay, maybe there's a risk of drugs coming back out [through diversion], but we don't believe so. So we're going to do it because it's the right thing to do.'"

DOTS-Plus: The Next Line of Defense

When it comes to multi-drug-resistant tuberculosis (MDR-TB), people are seeking second-line treatments where first-line defenses left off more than half a century ago. Streptomycin, the first TB drug, has become a second-line drug of desperation.

A patient waiting for his streptomycin treatment pulls down his pants, and slaps his right side, where he wants to receive today's shot. The injection is not only a strain on the resources at the clinic, it's an added expense: Although the TB drugs are free, the syringe is not, and he struggles to pay about 50 cents each day for a new one.

At the moment, most of the world's known cases of MDR-TB are in China, India, and Russia, where drugs were available early on and where compliance was a widespread problem. WHO believes that an MDR-TB epidemic won't be a problem in the near future for Africa, given the late introduction of rifampicin. But epidemiologists are debating over the transmissibility of certain drug-resistant strains. "The information we have for Africa is still very patchy," says Ernesto Jaramillo, a medical officer in WHO's TB/HIV drug resistance division.

In fact, some researchers are concluding that MDR-TB may be more advanced in Africa than previously thought. "In Africa, there's not a lot of surveillance for drug resistance because it requires drug sensitivity testing—which is not included in routine TB care," says Megan Murray, assistant professor of epidemiology at the Harvard School of Public Health, "With our surveillance study, we found outbreaks of highly drug-resistant strains that seem very infectious. Our predictions from mathematical models are that those mutations will proliferate and eventually dominate. It will take a while—maybe even decades—but if we don't focus on MDR-TB, we're going to see a rise, and even a replacement of, drug-sensitive TB."

In other parts of the world that have more advanced drug resistance, clinicians have begun using newer second-line treatments, including capreomycin and cycloserine. At one time, such therapies were quite expensive, costing up to $33,000 per patient, according to the CDC Foundation. They also have significant compliance challenges: MDR-TB drugs are more toxic and require 18- to 24-month treatments.