Pakistan and Afghanistan are among the world's top 20 countries in TB cases. A relatively high proportion of the estimated 150,000 cases reported each year in Pakistan are resistant to most commonly used drugs, which complicates treatment regimens.

''We may soon be having large groups of refugees with high rates of TB moving into a country, Pakistan, where there has been poor use of TB-control programs and poor use of drugs,'' said Ian Smith of the Stop TB Initiative at the World Health Organization. ''It's a recipe for disaster.''

The WHO and World Bank will host a meeting in Washington Monday for the 20 countries with the highest number of TB cases to promote expanding the directly observed treatment program from 23 percent of TB cases worldwide to 70 percent in five years. The DOTS program is a six-month daily regimen under the observation of a health care worker.

''We've got to get the world to start taking this threat of TB seriously and putting the resources in to fight it,'' Smith said. Globally, $3.6 billion is spent on TB control, but only $200 million of that is from wealthier donor countries.

''The international aid spent on DOTS is pitiful,'' Smith said. The WHO is calling for an additional $900 million a year over the next five years to reach the 70 percent target.

The Afghanistan-Pakistan situation is bound to be a major topic for the next week's gathering of health and trade ministers in Washington. Pakistan's health minister, Abdul Malik Kasi, is expected to attend.

Past studies on refugee populations show that the majority of deaths are not from hunger, but infectious disease that flourishes among the malnourished.

''In fact, most people actually never starve to death,'' Andrew S. Natsios, administrator of the US Agency for International Development, testified before Congress last week. ''They die of communicable disease before they actually starve to death because their bodies, their immune systems, have been weakened from the hunger.''

Natsios said US officials hope that people displaced by the war will not travel far. ''We don't want them to leave for health reasons, nutrition reasons, and survival reasons,'' he said.

Relief agency officials in Pakistan said yesterday that many Afghan families are now moving from cities to the countryside, where three and four families are now sharing small homes. ''It's starting to get very crowded in the countryside now. With the shortage of food, and with cold weather coming, it's an excellent breeding round for TB and other diseases,'' one official said.

But one sign of hope has been Pakistan's fairly recent political support for DOTS expansion in the country, said Diana Weil, a World Bank senior public health specialist. ''That's a major step forward,'' she said. ''But the major concern now is that the underlying public health infrastructure will be tested in Pakistan and Afghanistan. And that's not just for the refugee population, but for the entire population in the region.''

© Copyright 2001 Globe Newspaper Company

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