- The Washington Times - Monday, December 13, 1999

The United States is curtailing efforts to control tuberculosis just when new, lethal strains of the airborne scourge are threatening what one doctor calls “a public health catastrophe of the first order.”
Harvard Medical School researchers report finding cases of multidrug-resistant tuberculosis, or MDR-TB, in 100 nations, including cases in the United States. And increasingly, they say, foreign visitors and immigrants are bringing the disease into this country. The TB carriers come mostly from underdeveloped countries where MDR-TB is epidemic.
The contagion has not yet caused dramatic spikes in health statistics or generated a stampede of concern. That’s because TB develops slowly and not everyone who is infected develops symptoms.
Then too, most Americans know little about tuberculosis, an infection that can affect various parts of the body, producing lesions and sometimes attacking the brain and spinal cord. Typically TB lodges in the lungs. It makes breathing difficult; induces a fierce, nagging cough; and causes exhaustion, weakness, a steady fever, nighttime sweating and bloody phlegm.
Before the 1940s, “consumption,” as it was called, devastated many families and communities. In those days, families were split and incomes imperiled when a parent was forced into a hospital isolation ward or “TB sanitarium” to undergo harrowing treatments for months or years.
Many patients had portions of their lungs collapsed or removed to save them from the disease that for decades was the nation’s leading cause of death.
Katherine Ott, a Smithsonian Institution scholar who authored a history of TB, writes that one patient summed up the prevailing sentiment of those days: When told he had tuberculosis, he says, “the words might just as well have been followed by the Lord have mercy on his soul.’ “
Then in 1945, antibiotics arrived. The wonder drugs revolutionized treatment.
Doctors eventually determined that treating patients with a combination of antibiotics over the course of six to nine months could cure victims 70 percent to 90 percent of the time. That’s still true for the prevalent type of TB that antibiotics still usually cure. Indeed, cures were expected in most of the 18,371 active TB cases reported to the U.S. Centers for Disease Control and Prevention last year.
However, multidrug-resistant TB is something else. With its rise, doctors say the world is regressing to “a pre-antibiotics era,” as one puts it.

MUTANT BACTERIA

Drug-resistant tuberculosis refers to forms of the infection that are no longer fazed by the antibiotics normally used to kill them. Those TB bacteria have mutated and can now fend off conventional medicines.
Such TB strains are much harder to cure. Often they are incurable.
Physicians explain they treat MDR-TB by administering various combinations of expensive, infection-fighting drugs over long periods. Treating a single drug-resistant patient costs about $250,000. It can cost considerably more in extreme instances when a patient must be quarantined actually isolated for life.
In October, a Harvard Medical School study titled “The Global Impact of Drug-Resistant Tuberculosis” reported that drug-resistant TB is spreading farther and faster than previously thought.
Although some 8 million people around the globe contract TB each year and some 3 million die, no one knows for sure how many now have drug-resistant TB.
Based on incomplete data, the World Health Organization three years ago reported 50 million cases. That number was understood to be low at the time.
Nonetheless, it served as a sort of indicator that researchers could expect to find at least 2.5 percent of TB victims infected with drug-resistant tuberculosis.
Since then, physicians studying hot spots of TB infection in such places as Argentina, China, the Dominican Republic, India and Russia have found that from 7 percent to 22 percent of all those with the disease actually had the drug-resistant variety. That’s roughly three to 10 times the expected rate.
Consider that currently only 60 percent of all TB cases worldwide are ever diagnosed and fewer than 60 percent of those are cured, and the seriousness of the problem comes clearer.

SPREADING ACROSS BORDERS

The Harvard researchers warn that “the transmission of resistant organisms is ongoing.” They caution that no nation is immune to an epidemic.
In an interview, Dr. Lee Reichman, executive director of New Jersey’s National Tuberculosis Center, assesses the situation more bluntly. He says a new TB epidemic, “can’t not happen [in the United States] unless someone does something about it.”
Dr. Reichman is one of the 332 physicians, researchers and scholars who participated in the Harvard study, which was commissioned by the Open Society Institute of billionaire philanthropist George Soros.
Dr. Barry Bloom, dean of the Harvard School of Public Health, remarks, “I don’t want to be hysterical. I don’t want to say each of us is threatened. But there is no place from which we are distant and no one from whom we are disconnected when dealing with infectious diseases like TB.”
The dire prognosis rests on several realities.
Foremost is the fact that tuberculosis bacteria, including drug-resistant strains, spread with remarkable ease by the cough or sneeze of a TB victim.
“A person with the active disease can cough in a room and leave. Someone then entering the room and breathing the air can contract the infection,” explains Dr. Jim Yong Kim, who wrote the Harvard report with Dr. Paul Farmer, the principal author.
TB victims riding planes, buses, trains and other public transportation carry the disease across borders, infecting fellow travelers, customs agents and others on the way.
“We have had a half-dozen cases of persons on planes being infected. A major risk factor is breathing,” Dr. Bloom says.
He notes that, on an average, each person with active TB infects 20 others.
Also, tuberculosis flourishes in impoverished countries with poor living conditions and questionable health care. People from many of those countries are migrating to more-developed nations. And as the study reports, 30 to 80 percent of all diagnosed cases in Western Europe and North America occur among the foreign-born.
Tuberculosis is widespread in countries like Colombia, Guatemala and Mexico, from which immigrants to the United States are streaming in unprecedented numbers. Among such nations, China, India and the Dominican Republic are designated hot spots of drug-resistant TB.
Complicating efforts to control drug-resistant TB is that the tests used to verify tuberculosis in a patient do not indicate whether the infection is a drug-resistant variety. Drug resistance is diagnosed only when the patient becomes sicker and sicker despite standard chemotherapy.
In the Harvard study, Drs. Farmer and Kim state that “MDR-TB can emerge as a significant problem even in settings with excellent TB control.” It has done so in Peru, which has one of the world’s best TB-control systems.
Along with many others, the two Harvard Medical School physicians call for quick action to combat a worldwide epidemic, or “pandemic.” They acknowledge that the costs of fighting the new menace “are likely to be staggering” and must fall heavily on the developed nations and philanthropic groups.
However, they argue that since there currently is no way of immunizing against the disease, treating victims in nations where the disease already is epidemic provides the best protection for the United States. It limits the number of foreign visitors and immigrants capable of infecting Americans.

PREVENTING AN EPIDEMIC

While the peril posed by the slowly building pestilence has not pierced the U.S. public’s perception, none of the physicians, technicians or administrators in tuberculosis research or control questions the study’s findings or conclusions.
Indeed, an official of the White House Office of Science and Technology Policy says top U.S. officials have been aware of the problem for at least a year and “obviously are very concerned about it.”
Three years ago, in fact, the office released a statement that said in part, “The National Science and Technology Council has determined that the national and international system of infectious disease surveillance, prevention and response is inadequate to protect the health of U.S. citizens.”
Yet there still is no visible evidence the United States is preparing to respond to what Dr. Kim calls “an extremely frightening epidemic [that] needs government response.” So far, he confirms, “governments have not been appropriately concerned and generous.”
More important, says Dr. Bloom, the Harvard dean, “Both the states and the federal government are cutting [their] tuberculosis programs. They’re firing TB-control officers. We set up a fantastically effective [anti-TB] system from 1993 to the present, and now we’re in the process of dismembering it.”
The Centers for Disease Control and Prevention administers the money for tuberculosis control. Yet officials there have failed to answer 15 Washington Times’ requests for comment on the claim that its funding reductions jeopardize U.S. tuberculosis control.
Dr. Reichman confirms that funding for his National Tuberculosis Center has been trimmed. And correspondence from a reliable state TB-control official reports there have been across-the-board cuts.
In New York City, for instance, the TB-control budget was slashed by 30 percent. Massachusetts took a 10 percent hit that has resulted in dismissing four full-time workers and the elimination of money for “basics and travel.”
Funding for TB control in the Southeast has been reduced in various states from 7 to 20 percent, the official writes. She states that the cuts “decimate the TB elimination efforts of most of the Southeastern states and will necessitate cutting crucial staffing infrastructure.”
A Georgia Health Department official says the state’s TB-control budget was sliced 10 percent, necessitating firings and the closing of a lab. And Graydon Sheperd, Chief of the Bureau of TB and Refugee Health for Florida, says he received a 5 percent cut “that was the smallest” he has heard of. “The TB controllers in the Southeast generally have been reporting that extensive cuts actually are hindering their program activities,” he says.
What it comes down to, says Harvard’s Dr. Bloom, is a question: “How much is our country prepared to pay to protect the future?”
He asserts, “Protection means supporting treatment in poor countries to stop MDR-TB. Because when it comes here, it will be too late. There will not be much we can do at that point because the cure will be too expensive.”

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