Human catastrophe

Public Health | Far from going the way of the sanitarium and the tenement house, tuberculosis has found a drug-resistant new life of its own

Issue: "Ideal Idol," June 2, 2007

Kathleen Moser has a speech ready for when people ask her what she does for a living. "When I tell people that I work with TB, over and over again, they say, 'Well, is that still around? What could you possibly do all day?'"

Moser, director of San Diego County's Tuberculosis Control Program, explains to surprised acquaintances again and again that TB is an airborne infectious disease that takes six months to two years of supervised therapy to cure. She tells them how she works to prevent and treat TB in San Diego County along with a staff of 60 people-eight of whom watch people take TB medicine all day long.

Once the world's leading cause of death, tuberculosis, or TB, still infects one in three people around the world.

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Most of those infections, however, are latent TB, which does not make people sick. But one in 10 TB infections leads to the kind of wasting illness that gave the disease the name "consumption" in the 18th and 19th centuries.

Better public health care along with discovery of a cure made TB rates plummet in the 20th century. By the 1980s it appeared to be disappearing altogether. But the AIDS epidemic and the birth of drug-resistant strains of the disease set the stage for a worldwide resurgence.

Now, as a new kind of super drug-resistant TB threatens to go global, the World Health Organization (WHO) is calling on countries to dedicate billions of dollars to kill TB once and for all. As expensive as curing the world of TB is, the cost of doing anything less could prove much higher.

TB is the oldest known human disease. Archaeologists have found evidence of TB in Egyptian mummies. Bubonic plague, cholera, typhoid, and smallpox all have come and gone during TB's lifetime. When enough TB bacteria invade a person's lungs, the immune system attacks them by encasing them in a nodule of white blood and muscle cells. The nodule strangles the bacteria inside it along with any other living tissue. This lung damage may heal over time, but if TB is not treated it can lead to a slow death from bleeding in the lungs.

TB is the hippopotamus of infectious diseases; it moves slowly and has a thick, waxy cell wall, or skin. Its cells, called bacilli, divide only once a day. By comparison the common bacteria E. coli divides every 20 minutes. TB spreads from person to person in tiny droplets expelled in the coughs of infected people.

As an airborne contagion, the infection can silently cross ethnic and socioeconomic boundaries. But a person has to inhale many bacilli for hours at a time to acquire latent TB infection. Those bacilli have to multiply many times over to cause damage and become active TB. Doctors do not fully understand the relationship between latent TB, active TB, and the immune system, but active TB often develops in people who are immuno-compromised with diseases like HIV/AIDS.

For much of the 18th and 19th centuries, TB was the world's No. 1 killer. It thrived among the urban poor, who spent their lives on filthy factory floors and in cramped tenements.

"Everybody was exposed," said Andy Vernon, a physician in the Centers for Disease Control's TB Elimination Department. "There was no control. It would have been almost unusual for people to go through life without being exposed."

German physician Robert Koch identified the TB bacilli in 1882, but it took more than 60 years for science to discover drugs to treat the disease. In the meantime, doctors realized they could control the spread of the disease through isolation and quarantine. TB hospitals called sanitariums developed as places where the sick could retreat from society. By 1950, three years after the first TB drug was administered, the TB incidence rate in England, which kept records of TB infection, had declined by 66 percent in 50 years.

By the 1980s, TB had dropped off the radar screen of public health in the United States. The CDC stopped allocating a line item of its budget to TB. New York City cut its number of TB clinics from 24 to eight.

But TB had not disappeared. Just as TB bacilli can lie latent in a body, waiting for the right conditions to multiply and activate, TB in the United States was waiting for the right social conditions to mount another attack on the population. A combination of poor housing for immigrants and the homeless in urban centers and the rise of the HIV/AIDS epidemic fueled a resurgence of TB cases in the United States and around the world starting in 1985. Many patients had a new form of the disease that did not respond to the most common drugs.


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