Battle against return of the White Plague Race is on to rekindle support for the fight against TB which once again threatens the West

New TB notifications in the city peaked that year at 1000, but there were just 600 beds and 400 patients facing long waits for admission. It was sufficiently alarming for the Edinburgh Kirk presbytery to organise a tuberculosis week to galvanise public opinion. This also was the city which, under Sir Robert Philip, had developed the model system for TB containment copied throughout the world.

However, Scotland and Portugal were the only countries in Europe with a rising incidence of the disease. Young women in Scotland were twice as likely to die from consumption than their English counterparts. Half of all adults diagnosed would die, and among infants of Blair's age, TB meningitis was an almost certain death sentence.

More than 40 years later, not only has the White Plague, a disease which brought more terror than cancer, never left us, it has also returned with a vengeance.

In 1993, the World Health Organisation took the unprecedented step of declaring TB a global emergency. This week, its leaders will gather in London to launch World TB Day in an effort to rekindle support to tackle a pandemic which, if uncontrolled, will engulf Asia as it has done Africa, and return to the developed world which thought it had won the battle long ago.

The original message of the Edinburgh Presbytery also will be echoed at a special service in Cape Town led by Archbishop Desmond Tutu, a former TB patient.

Tuberculosis killed three million people last year, more than Aids, malaria and tropical diseases combined. It is on the rise in Scotland, as yet marginally, and mainly due to reactivated cases among the elderly.

The germs are spread primarily through coughing. UK incidence is associated with poverty, homelessness, and contacts from the Indian sub-continent, but the bug can and does strike anywhere. The infection hit an East Lothian private school last December. All the youngsters affected were traced and treated. An estimated 170,000 children throughout the world this year will be less fortunate, according to WHO. They will die.

The nightmare scenario of untreatable strains of the disease returning is already with us. Increasing migration and the boom in international travel and tourism have opened up all borders. Most American cities have now reported major outbreaks of multi-drug resistant TB, and at least one has already struck London.

No other disease has wreaked so much havoc on mankind, but it could and should have been consigned to the dustbin of medical history 40 years ago.

The world's first 100% cure for tuberculosis was first applied in Edinburgh just as the young Blair was celebrating his first birthday in Willowbrae. A team of physicians, Ian Ross, Jimmy Williamson, Norman Horne, Ian Grant and John Crofton developed the therapy of simultaneous application of three new antibiotics: streptomycin, PAS and isoniazid.

It came too late for another left-leaning Blair, better known as George Orwell. Six years earlier, Williamson, then a registrar, treated him at Hairmyres Hospital in Lanarkshire, when he was writing 1984, and gave him streptomycin brought in from America via his New York publisher.

``He had the mother of all reactions. We had to stop it. We gave the rest of it to another patient who recovered in three weeks,'' Williamson recalls.

Eric Blair later went on to suffer the wretched fate of many consumption victims, a massive haemorrhage and drowning in his own blood.

Applied individually, particularly by greedy and unscrupulous doctors in private practice, the drugs worked for some patients but left others with resistant strains which became more difficult and sometimes impossible to treat.

The Edinburgh team decided to hit the bacillus with all three. Kill it once, kill it twice, and kill when it was dead, just to be sure. Critical to the success of this approach was the support of two bacteriologists, Sheila Stewart and Archie Wallace, who monitored the treatment of every patient and ensured they continued to take the drugs for 18 months.

It was the first, and probably remains the greatest single achievement of the National Health Service, but their results were so successful that no-one believed them, except for two scientists at the Pasteur Institute in Paris, Noel Rist and Georges Canetti. They set up the first pan-European trial of any treatment, using the Edinburgh TB cure as the model.

In this way, it became the gold standard for treatment in Western countries and remains, in a modified form, the cornerstone of WHO's strategy both to treat the infection and prevent its spread.

There it should have ended. In 1960, Crofton warned of the dangers of complacency if Governments did not apply the same measures in the rest of the world. The warning proved to prove tellingly prophetic. No-one listened.

The next decades were marked by indifference and apathy: no new drugs, textbooks or advances in diagnosis and detection. The Edinburgh group had been so successful it had made itself and its generation of TB physicians largely redundant.

By 1988, the only defence against TB at the World Health Organisation was one man and his dog. Without the dog. The UK Medical Research Council's TB unit was disbanded just at the time when its expertise in Africa was needed.

The bug had now embarked on a terrible counter-offensive. The impact of HIV and Aids opened up the floodgates. In suppressing the body's defence systems it also liberated dormant TB. Almost half the 600,000 Aids-related deaths, this year will be due to tuberculosis.

The one organisation which carried on the fight throughout the years of neglect was the International Union against Tuberculosis and Lung Disease.

It helped individual countries set up and run their own programmes. The most successful was Tanzania, which demonstrated that, with good organisation and careful surveillance, TB could be controlled in the Third World. At least in the pre-Aids era.

Orwell may have had additional prophetic insight in choosing 1984 as the title of his futuristic novel. It was both the year his namesake started making his name in Parliament and also the year the true threat of Aids materialised.

New York should have heeded the Tanzanian lesson. It was engulfed in an epidemic of multi-drug resistant TB in 1989. Although patients were given the proper medication, many of them did not take it for the required six months. Direct supervision was essential. In some states patients can now be compulsorily detained to ensure they complete the courses.

Almost every aspect of applying the WHO cure in practice is problematic: persuading governments to act, the sheer technical difficulties of identifying active cases, the cost and number of drugs, applying them correctly, and ensuring the patient complies over a six-month period.

Tuberculosis also prospered from its low public profile. Medical, media and political interest has concentrated on more fashionable diseases which then attracted research funding.

At the same time, routes of transmission for all infectious diseases have multiplied. Around 500 million people now cross some border on an aircraft every year.

However, since 1992 there has been a belated explosion of interest and concern. The World Bank identified TB treatment as the most cost effective of any health intervention and is now supporting a control programme covering half of China based on the Tanzanian model. The British medical charity Merlin is also running a programme in Siberia in conjunction with Russian medical authorities.

Self-interest has forced the West to take action in the Third World because it regards itself at risk, particularly from multi-drug resistant strains which will cost billions to treat.

Ironically, the solution may lie in the African plains and the beasts that graze there.

Research into bovine tuberculosis got off to a bad start when Robert Koch, the first man to isolate the TB bacillus, wrongly claimed bovine TB, very similar but not identical to the human version, was transmissable to man. Bovine strains were used to develop the human BCG vaccine tuberculosis which is partially effective in some countries, much less so elsewhere.

Initial studies in Tanzania by an Edinburgh team at the Centre for Tropical Veterinary Disease, Moredun Institute and City Hospital suggest some level of bovine TB in man. Unfortunately, funding for that project has recently dried up. But an outbreak in Paris, where an HIV patient rapidly infected five others, showed that bovine TB could be spread within humans.

Chris Daborn, a vet and honorary research fellow at the centre, said one puzzling feature of the disease is its distribution in Africa. It is virtually unknown in some countries and highly prevalent in others. The same applies within regions and districts of countries themselves.

That implies there must be some sort of natural mechanism which resists the bacillus. Bacteriologist Dr John Stanford, of University College London, has taken this idea several stages further.

Over the last 25 years he had been refining soil samples taken from at Ugandan swamp, which have shown promising results against TB and are now undergoing rigorous trials to test their efficacy.

``It is definitely worth further investigation,'' Daborn said. ``The obvious answer is environmental mycobacteria. It is purely hypothetical but it fits the bill.''

Many common antibiotics have been dervied from fungi or soil organisms. Streptomycin itself was the product of a sample from a sick chicken's throat and well-dunged earth.

Stanford's work might provide the vaccine the world has been waiting for over the last 40 years, but the history of tuberculosis has been littered by false dawns of optimism.

Meanwhile, the struggle continues on other fronts. Crofton and Horne's practical guide for health workers has now been translated into several languages, and Sir John, still indefatigable at 84, and newly recovered from a hip operation, is currently updating WHO's treatment guidelines at his home in Colinton.

Does he ever contemplate defeat by the bug?

``Certainly not. It is perfecly possible to win and I am very impressed by the WHO team. There is a dangerous situation in Asia, particularly in the Indian sub-contintent. They have a limited time to get their national programmes right. But I am certain we are going to win.''

n Chris Holme, a reporter in the Edinburgh office of The Herald, is the winner of the first Reuter Foundation Fellowship in Medical Journalism. He will shortly spend three months at Green College, Oxford, studying current international strategies against the resurgence of tuberculosis.