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TB: The Epidemic to Truly Worry About

As AIDS and SARS dominated the headlines, has TB made a stealthy comeback?

March 25, 2004

As AIDS and SARS dominated the headlines, has TB made a stealthy comeback?

At the height of the 2003 SARS epidemic, I found myself sitting in the waiting area of Boston's Logan Airport. Right next to me was an Asian family, who I later learned were traveling from their native Korea to Detroit to visit family members, with a layover in Boston.

Around us were several rings of empty seats because — while the flight we were waiting to board was crowded — few of the other passengers wanted to "risk" breathing the air of anyone who came from a part of the world where SARS might be a problem.

Of course, this family was perfectly healthy. We also know, that while SARS was a public health emergency, there have been fewer than 9,000 cases worldwide — and the risks of contracting it are steadily diminishing with each passing day.

With all due respect to the Corona virus, there are a number of other epidemic threats on which we ought to focus.

Indeed, my airport adventure reminded me of an infectious episode that occurred some months earlier, when I visited one of my colleague's tuberculosis clinics in New York City.

There, in a small examination room, I spent more than eight hours interviewing three patients who were being treated for the world’s most serious infectious threat.

One was an illegal immigrant from South America. Another was a man from the Middle East who had been a U.S. citizen since 1990. And the third was an impoverished young woman who grew up in the Bronx.

All of them were taking potent anti-tuberculosis medications. But if one of them had decided not to take these pills, he or she could have easily transmitted the disease to me — and I, in turn, could have passed it on to yet more people.

Tuberculosis is a disease that is slow and patient, relentless and effective — and year in and year out, sends millions to their graves as it travels around the globe.

It is transmitted by the simple act of breathing, coughing — and even singing. It is, without peer, the world’s most serious infectious threat.

More ominous, in many parts of the world there are multi-drug-resistant strains of TB that are invulnerable to a broad menu of drugs designed to halt the disease.

Today, more than two billion of the planet's six billion people are infected with the latent form of tuberculosis. There are several hot zones of tuberculosis in the world today.

China — the putative home of SARS — has a much greater problem on its hands in the form of TB. Much the same is true for most of the rest of Asia, the former Soviet Union and parts of South America.

But here's some epidemiology that is often neglected: In the United States, there are 15 million people infected with tuberculosis.

Ironically, one glaring problem that makes tuberculosis a threat in places like China is mirrored in the United States: Lack of access to basic health care.

A report on National Public Radio about China's tuberculosis problem documented how its poorest citizens simply could not afford the antibiotics needed to defeat this infectious foe. Instead, they opted to use their paltry resources to feed their families.

Sound familiar? How many uninsured Americans have to make the same type of decision every day?

The irony is that these pills, while a seemingly large amount of money for a Chinese villager, are not all that expensive — perhaps $10 a week. But some entity greater than the impoverished individual has to care enough to provide them.

The issue, of course, is far more than merely a humane gesture: Defeating tuberculosis — or at least, stemming its tide — is a social imperative. And such health imperatives do not end at national boundary lines.

Wealthy countries must help in preventing and treating these infectious diseases, because the poorer nations simply do not have the resources to do it themselves. Ignoring such a demand will, inevitably, affect the health of the wealthy as well as the poor.

Not only do we have a deadly germ on our hands, but now we also have one that for at least one out of 10 cases (and for more in certain parts of the world, such as Asia and the former Soviet Union), the germ is resistant to the menu of powerful drugs we have developed to kill it.

And with modern transportation, the microbes can travel from one place to anywhere else in a matter of hours. All of these factors have created the conditions the tubercle bacillus needs to thrive once again.

It is hardly an understatement on the part of the World Health Organization when it classified TB, beginning in the 1990s and repeatedly since, as "a global health emergency."

Apathy — accompanied by funding cuts for public health programs directed at tuberculosis control around the world — has set in motion what one public health expert, Dr. Lee Reichman, has called "a tuberculosis time bomb."

But unlike just a few decades ago, when many were announcing the "conquest" of tuberculosis, few public health experts today are so quick to declare a victory.

We still have a mammoth job of disease control in the poorest nations of the world. Given the globalization that marks the 21st century, TB will otherwise rear its ugly head once again with disastrous results.

We must act on the fact that the health of Guangdong or Beijing — as demonstrated a few months ago with SARS — has a direct impact on those living in Hong Kong or Toronto.

The complacency of the developed world, the too-quick impulse we humans have to forget about the public health threats that incited such panic only weeks prior has health care professionals most concerned.

So far, luck has been largely on our side. The trouble is we may not be so lucky in the future.

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