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T

uberculosis is the

world’s deadliest infec-

tious disease: Between

2007 and 2017, an esti-

mated 94.5 million peo-

ple caught tuberculosis, and more

than 14 million died from it. Rising

numbers are being infected by

strains of the disease that are resis-

tant to all known antibiotics. Yet un-

til recently, no new classes of drugs

for tuberculosis had been brought to

market for 46 years.

Against this dire background, a

rare piece of good news came this

week from the Food and Drug Ad-

ministration, which on Wednesday

approved a new drug, pretomanid,

for treating patients with highly

drug-resistant tuberculosis. It was

the first time a nonprofit research

organization, TB Alliance, had de-

veloped a new treatment, sponsor-

ing clinical trials all the way

through FDA approval. This success

story points to the potential for fu-

ture public-private partnerships to

meet the urgent need for new ther-

apies for infectious disease.

The approval of pretomanid

hinged on results from the Nix-TB

trial, which included clinical trials

at three sites in South Africa, in-

volving 109 patients with highly re-

sistant tuberculosis. The cure rate

was 89%. “Without a doubt, this

marks a watershed in our treat-

ment of drug-resistant TB,” said

Francesca Conradie, a researcher at

the University of Witwatersrand who

served as chief investigator in the

trials. “If we play our cards right, ex-

tensively drug-resistant TB will be a

thing of the past within 15 years.”

Tuberculosis has afflicted human-

ity for thousands of years. The

Greeks called it phthisis (“wasting

away”), while later generations of Eu-

ropeans and Americans knew it as

the great white plague or consump-

tion. The microbe that causes the dis-

ease, Mycobacterium tuberculosis ,

was discovered in 1882 by Robert

Koch, but it took another six decades

to discover streptomycin, an antibiotic cure. In

time the microbe developed resistance, first to

streptomycin and then to the few new drugs

that followed.

When Pauline Howell, the senior medical offi-

cer at one of the three South African sites, began

enrolling patients in the Nix-TB trial in 2015, her

waiting room filled up with young people

stricken with drug-resistant disease. “They were

18, 19, 20 years old, and had gotten infected

through no fault of their own—just by breath-

ing—on their way to school or work,” she re-

called. “All of them expected to die.”

For years, patients with highly resistant dis-

ease had been prescribed a two-year course of

treatment that involved a total of up to 14,000

pills, along with painful injections that could

result in deafness, psychosis and liver damage.

Initially, Dr. Howell felt skeptical that TB Alli-

ance’s novel treatment, which required less

than 750 pills in just six months of treatment,

could succeed. But participants responded

strikingly quickly to the new regimen.

“There’s still TB?” That is the question that

Neil Schluger, chief of pulmonary care at Co-

lumbia University Medical Center and one of

the world’s top tuberculosis experts, says he of-

ten gets when he introduces himself in the U.S.

The question reveals a sharp split: In the U.S.

and Europe, the incidence of tuberculosis re-

mains low and well-controlled, while across

vast swaths of the rest of the world, it is a dev-

astating contagion. (The worst-hit countries are

India, China, Indonesia, the Philippines, Paki-

stan, Nigeria, Bangladesh and South Africa.)

Dr. Schluger faults the traditional

model of drug research and develop-

ment for the failure to invent new

cures for tuberculosis. “Progress in

HIV research far outpaced progress in

TB and malaria,” he explained.

Roughly 10 times more money is

spent on developing new drugs for

HIV than for tuberculosis. “Since

there are significant numbers of HIV-

infected persons in high-income

countries, there’s a substantial mar-

ket for those drugs, and companies

can get a good return on their invest-

ment since treatment is lifelong.”

Tuberculosis, in other words, gets

shorter shrift because it is a curable

rather than chronic condition, and be-

cause most of the suffering takes place

in poorer countries. A new model for

drug research, tailored to long-or-

phaned diseases such as tuberculosis

and malaria, could pair the depth of

scientific knowledge among research-

ers from profit-making pharmaceutical

companies with the public-health ori-

entation of nonprofit partners.

TB Alliance received support from

governments, including Australia,

Germany and Indonesia, and collabo-

rates with universities as well as

pharmaceutical giants such as Jans-

sen, a division of Johnson & Johnson,

and Mylan. GlaxoSmithKline has col-

laborated on preclinical testing of a

new compound with the Bill and Me-

linda Gates Foundation. (The founda-

tion, which spun off a research arm

of its own last year, is already the

world’s second-largest investor in tu-

berculosis research, surpassed only

by the combined contributions of

eight U.S. agencies.)

In October, French Presi-

dent Emmanuel Macron

will host an international

conference in Lyon that

aims to raise $14 billion for

the Global Fund to Fight

AIDS, Tuberculosis and Ma-

laria. Those funds would

support public-health sys-

tems creaking under the

weight of these modern

plagues. It won’t do any

good, after all, to invent

new cures if more people

aren’t diagnosed properly and of-

fered appropriate treatment. What

the world needs most is entrepre-

neurial ingenuity and sustained com-

mitment to match the scale of a pre-

ventable and ongoing catastrophe.

Mr. Foster is an associate profes-

sor of journalism at Northwestern

University and the author of “After

Mandela: The Struggle for Freedom

in Post-Apartheid South Africa”

(Liveright).

“Tuberculosis

may get shorter

shrift because

most of the

suffering takes

place in poorer

countries.

BYDOUGLASM.FOSTER

A New Dose of

Hope in the Battle

Against Tuberculosis

This week’s FDA approval of a new therapy for drug-resistant strains

of the disease shows the potential of public-private partnerships.

A pharmacist

in Johannesburg

shows the difference

between the old

(right) and new

(left) regimens of

TB-fighting drugs.

JAPANESE ART AND CULTURE have been

profoundly shaped by Zen, a philosophy

that promotes the recognition of emptiness

and impermanence. In aesthetic terms, this

translates into an emphasis on simplicity

and a recognition of the transience and im-

perfection of things. In “Zen in Japanese

Culture,” which will be published next

month by Abbeville Press, the journalist

Gavin Blair draws together full-color pho-

tographs that highlight the influence of

Zen principles on everything from calligra-

phy and origami to the martial arts. In

bonsai , miniature trees are cultivated in

containers; here, a juniper has been trained

into a long, twisted shape using the shari

technique of stripping

away the bark and bleach-

ing the exposed wood

with lime sulfur. The

effect can take

years to achieve.

— Elizabeth Winkler

A juniper tree

cultivated using the

traditional shari

technique.

Dogfights in the

Danger Zone

“TOP GUN” is back. The

1986 film about Navy

fighter pilots is getting

a sequel next year, with

Tom Cruise reprising his

role as Lt. Pete “Maverick” Mitchell,

the sexy flyboy who can’t stay out of

trouble. Judging by the trailer re-

leased by Paramount in July, the

new movie, “Top Gun: Maverick,”

will go straight to the heart of cur-

rent debates about the future of aer-

ial combat. An unseen voice tells Mr.

Cruise, “Your kind is headed for ex-

tinction.”

The mystique of the fighter pilot

began during World War I, when

fighter planes first entered military

service. The first aerial combat took

place on Oct. 5, 1914, when French

and German biplanes engaged in an

epic contest in the sky, watched by

soldiers on both sides of the

trenches. At this early stage, neither

plane was armed, but the German pi-

lot had a rifle and the French pilot a

machine gun; the latter won the day.

A furious arms race ensued. The

Germans turned to the Dutch engi-

neer Anthony Fokker, who devised a

way to synchronize a plane’s propel-

ler with its machine gun, creating a

flying weapon of deadly accuracy.

The Allies soon caught up, ushering

in the era of the dogfight.

From the beginning, the fighter

pilot seemed to belong to a special

category of warrior—the dueling

knight rather than the ordinary foot

soldier. Flying aces of all nationali-

ties gave each other a comradely re-

spect. In 1916, the British marked the

downing of the German fighter pilot

Oswald Boelcke by dropping a

wreath in his honor on his home air-

field in Germany.

But not until World War II could

air combat decide the outcome of an

entire campaign. During the Battle of

Britain in the summer of 1940, the

German air force, the Luftwaffe, dis-

patched up to 1,000 aircraft in a sin-

gle attack. The Royal Air Force’s suc-

cessful defense of the skies led to

British Prime Minister Winston

Churchill’s famous declaration, “Never

in the field of human conflict was so

much owed by so many to so few.”

The U.S. air campaigns over Ger-

many taught American military plan-

ners a different lesson. Rather than

focusing on pilot skills, they concen-

trated on building planes with supe-

rior firepower. In the decades after

World War II, the invention of air-to-

air missiles was supposed to herald

the end of the dogfight. But during

the Vietnam War, steep American

aircraft losses caused by the acro-

batic, Soviet-built MiG fighter

showed that one-on-one combat still

mattered. The U.S. response to this

threat was the highly maneuverable

twin-engine F-15 and the formation

of a new pilot training academy, the

Navy Fighter Weapons School, which

inspired the original “Top Gun.”

Since that film’s release, however,

aerial combat between fighter planes

has largely happened on screen, not

in the real world. The last dogfight

involving a U.S. aircraft took place in

1999, during the NATO air campaign

in Kosovo. The F-14 Tomcats flown

by Mr. Cruise’s character have been

retired, and his aircraft carrier, the

USS Enterprise, has been decommis-

sioned.

Today, conventional wisdom again

holds that aerial combat is obsolete.

The new F-35 Joint Strike Fighter is

meant to replace close-up dogfights

with long-range weapons. But not

everyone seems to have read the

memo about the future of air war-

fare. Increasingly, U.S. and NATO pi-

lots are having to scramble their

planes to head off Russian incur-

sions. The knights of the skies can’t

retire just yet.

PARAMOUNT/EVERETT COLLECTION

HISTORICALLY SPEAKING

AMANDA FOREMAN

Tom Cruise as a fighter pilot in the

1986 movie ‘Top Gun.’

EXHIBIT

The Beauty of

Imperfection