- The Washington Times - Monday, December 13, 1999

“We are well into the midst of a global TB public health crisis and there is no time to lose.”
That warning the latest official confirmation of a serious tuberculosis threat came two weeks ago from U.S. Surgeon General David Satcher.
He and numerous other physicians say the danger this time originates with multidrug-resistant TB, or “MDR-TB” meaning strains of tuberculosis bacteria that have mutated. They no longer die when assaulted by the antibiotics normally used against them for the past 50 years.
In an article for the Journal of the American Medical Association, the surgeon general has joined others in suggesting broad and far-reaching medical measures to stymie the disease.
But if the history of TB is a guide, those measures may not be enough to finally eliminate the contagion. Nonetheless, health officials say the ancient scourge can and must be controlled. Otherwise it will run wild, killing and debilitating great numbers of people. The officials note that preventing an epidemic like the one that threatens allows only hard choices.
For one thing, dealing with drug-resistant TB involves huge costs. Suggested measures also require the kind of international collaboration and unified effort between governments and philanthropic groups that is difficult to achieve.
There’s another thing too. The TB bug is wily. It has succeeded for centuries in defeating man’s best efforts to exterminate it.
“Mycobacterium tuberculosis (the TB-causing bacterium) has proven capable of developing resistance to all antibiotics developed to date,” one recent study notes. Thus the imperative for finding new antibiotics or discovering that old ones can be effective against the TB infection.
The new strains of TB now entering this country are coming mainly via travelers from overseas areas where drug-resistant TB now is spreading. And although the United States has a vaunted federal-state TB-control system, Dr. Satcher cautions, “the United States is not immune to the global TB epidemic.”
He calls for quick implementation of comprehensive steps that he says can “reduce the world burden of TB.”

Resources in wrong places

“Reduce” is the word to emphasize. Some argue the disease won’t be abolished. Like crime, it is ingrained in society. It breeds in unsavory social situations created in prisons, homeless shelters and mean streets. It flourishes in poor countries with primitive hygiene and rampant poverty, and it spreads easily on the breeze of a disease victim’s sneeze or cough.
“It’s easier and cheaper to build prisons where there is a huge MDR-TB population than to deal with the conditions that cause crime. And it’s hard to eradicate poverty and homelessness to provide people with opportunity and the like,” says Smithsonian Institution scholar Katherine Ott.
Miss Ott is convinced society is unwilling to commit the vast resources required to deal with such basic issues. In her book “Fevered Lives: Tuberculosis in American Culture since 1870,” Miss Ott points out that TB has flourished in scruffy environments almost forever. Indeed, a recent Harvard Medical School study titled “The Global Impact of Drug-Resistant Tuberculosis,” reports that, “At the close of the 20th century, the central irony of TB control is that resources are concentrated in precisely those settings in which they are least needed.”
Trained personnel, laboratories, drug manufacturers, pharmaceutical distributors and diagnostic clinics mostly exist in highly developed countries. And in those countries they mostly serve the middle class people who are generally healthy and have a reduced risk of exposure to the disease. Because they’re healthy they often can withstand the infection without developing symptoms and passing the disease on.
Dr. Satcher says, “Renewed commitment to research on vaccines, diagnostic tools, and new drugs is absolutely essential” along with an “interim response” to cope with the crisis until research yields more effective drugs. Among others, Dr. Barry Bloom, dean of the Harvard School of Public Health, Dr. Lee Reichman, executive director of the National Tuberculosis Center in Newark, N.J., and Dr. Jim Yong Kim, one of the authors of the Harvard study, have a prescription for the interim response.
They say that since there is no vaccine that keeps people from being infected, the United States and other affluent countries must deal with the disease overseas, finding and treating every known case of MDR-TB and thereby making easier to cure “regular” TB too.
Dr. Reichman explains this requires a change in thinking about foreign aid and “enlightened self-interest.”
“Deterring the MDR-TB threat has to be seen as a national defense program. But I don’t see the National Security Council having a crisis meeting deciding what we ought to do as it did when the Russian ruble dropped in value,” said Dr. Reichman.
“This disease has put everybody in a bind,” Dr. Bloom says, and explains:
“If you believe that foreign aid is like pouring money down a rat hole, then we know what will happen a U.S. epidemic.
“If you believe in foreign aid to provide health and education and if there is sentiment that we do that for humanitarian and enlightened self-interests, then we can cope with this disease at a cost. But I hear no champion saying, It’s in our self-interest. It’s a good thing. Let’s do it.’ “

Diminishing funding

There is no outcry for action partly because the alarm and appeal comes at a time when concern about TB has ebbed in this country. The U.S. tuberculosis rate has been declining. Last year it hit a record low of 6.8 cases per 100,000 persons.
The perceived success in controlling TB has fed a growing lack of concern about it. That in turn has led to cuts in funding TB control.
That has happened elsewhere too. The Harvard study states that, “Free treatment of TB is part of the social contract’ of most modern societies, whatever their basic economic and political structures. [Yet] in recent years, there has been significant erosion of support for public investment in health problems.”
In the United States, however, the case-rate decline and subsequent funding cuts followed a major push to quell a flare-up that between 1985 and 1993 increased the national TB rate by 20 percent. The Harvard study states that the costs of subduing that “resurgence of tuberculosis have been phenomenal.”
In the outbreak, New York City was hit with 20,000 additional cases. As the authors of the Harvard study see it, the way health officials handled those cases illustrates two points:
First, it’s expensive to fight TB once it starts rampaging. And, second, the cost is worth it. For failing to nip an epidemic at its start leads to even more astronomical expenditures. The study states:
“In New York City … each case cost more than $20,000 in 1990 dollars, for a total exceeding $400 million. In addition, as many as one third of patients with tuberculosis were rehospitalized because of inadequate follow-up… . There were additional expenditures for renovation of Rikers Island [where facilities had to be built to isolate and treat TB victims and for] … the renovation of hospitals… .
“These costs easily exceed $1 billion and may reach several times that amount. Thus, despite their cost, efforts to control tuberculosis in the United States are likely to be highly cost effective.”
They add, “It is unlikely that conventional notions of cost-efficacy will serve us well as we seek to curb this epidemic now, before it becomes truly impossible to control.”
TB-control officials and doctors agree “greater investments in international TB control are needed urgently.” They argue that in industrialized countries TB is most prevalent among the foreign-born, and they declare this is a reminder “that the pandemic calls for transnational investments in TB control.”
The doctors recommend that, especially in hotbeds of the drug-resistant disease, ways be found to supply the rarely used and expensive drugs that in combination can sometimes cure MDR-TB patients. However, arrangements must also be made to have health officials supervise administration of the remedies. Because from 18 months to two years monitors must actually watch the patients take the drugs. If the wrong drugs are taken or if treatments are prematurely stopped, the bacteria become resistant to the rarer drugs too.
The Harvard study concludes that, “Although there is no tested blueprint for this strategy,” it’s clear that “public and private sources” must establish coalitions able to implement “a technically sound strategy to detect and treat all TB patients.”
These unnamed sources also must create new, international standards for TB-control projects and somehow fund them. “To delay such response will only lead, ultimately, to increasing outlays and greater loss of life,” the Harvard study concludes.
Yet even if the wished-for response comes, history indicates the TB bacterium well may avoid extinction. Mycobacterium tuberculosis is, after all, a predator. And humans provide plenty of prey.



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