Tuberculosis

"Phantom Plague

By Vidya Krishnan

PublicAffairs, 300 pages, $27

In 1992, a blue-ribbon panel commissioned by the Institute of Medicine published "Emerging Infections: Microbial Threats to Human Health in the United States." The report was a broadside aimed at the "complacency of the scientific and medical communities, the public, and the political leadership of the United States toward the danger of emerging infectious diseases and the potential for devastating epidemics." A stream of like-minded books followed -- Laurie Garrett's "The Coming Plague," David Quammen's "Spillover." But the risks were hard to calculate, and despite some near misses (including Ebola and SARS-1), the possibility of a new plague seemed remote from day-to-day life. The warnings went unheeded.

The Institute of Medicine report mentioned tuberculosis, which had started a resurgence by taking advantage of patients suffering from AIDS. In the years since, a chorus of voices has been gathering strength, warning us of a looming microbial threat that can seem as esoteric and far away as bat viruses once did: multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB).

Add Vidya Krishnan's "Phantom Plague" to the chorus. Covid-19 is a new infectious disease, but old foes have not gone away. Antibiotic resistance by the tuberculosis bacterium represents a continuing evolutionary arms race between biomedical science and one of the great killers of all time. In the middle are millions of victims, mostly poor, caught in the ancient vice grip between destitution and disease.

Tuberculosis -- "consumption," the "white plague" -- could rightfully claim to be the great infectious disease. Bubonic plague, smallpox and influenza were more explosive, but only malaria can contend with tuberculosis for the steady, relentless toll taken on our species. The keys to TB's success are tenacity and stealth. Most of history's notorious germs cause acute infection -- short and dramatic. TB is one of a handful of really successful agents of chronic infection. It lurks inside the immune cells meant to protect us, then patiently grinds down its victims.

TB is primarily a disease of the lungs, spread via the respiratory route. It thrives where human hosts are crowded together in squalor. Probably no infectious disease has killed more humans throughout history, but as Ms. Krishnan vividly reminds us, TB is not a disease of the past. Up to one quarter of the global population carries the bacterium in a latent state. Every year, some 10 million people fall sick, and in 2020 more than 1.5 million died of a disease that is preventable and treatable. Indeed, the TB bacterium was the deadliest microbe on the planet before it was dethroned by SARS-CoV-2. It is a safe bet that TB will soon resume its place atop the rankings.

The subtitle of Ms. Krishnan's book -- "How Tuberculosis Shaped History" -- undersells what is inside. The only history to be found consists of anecdotes from the 19th century. It is unfortunate that the deeper history of tuberculosis does not seem to interest Ms. Krishnan. As we have recently learned, the bacterium that causes TB has not existed time out of mind. Both ancient bacterial DNA recovered from archaeological skeletons and massive data sets of modern DNA are allowing us to piece together the hidden back story of TB (and so many other human pathogens). The TB bacterium is only 4,000 to 5,000 years old, a product of the Bronze Age. It emerged when humans first built cities and long-distance trade networks, and it has opportunistically thrived on human progress ever since.

Over the centuries, the bacterium diversified into geographically distinct lineages in different parts of the world, some strains more virulent than others. European expansion in modern times helped to disseminate a particularly deadly lineage world-wide. And nothing played into the hands of TB like industrialization. As people left the countryside for factory work and tenement life, TB became the overwhelmingly pre-eminent cause of death.

When bubonic plague, smallpox and typhus were brought under control, TB was left to claim a larger share of the victims. Children, especially of the working classes, suffered most. Thomas Malthus gave voice to the widespread recognition that the "closeness and foulness of the air" in places like London was especially "unfavourable to the tender lungs of children." In the early 19th century, TB came to account for upward of one third of all deaths in industrial cities, an almost unfathomable share.

The decline of TB in the West was late but miraculous; accomplished between about 1870 and 1940, it has been the subject of one of the most resonant debates in the history of health. Mortality from TB was reduced thanks to a combination of three factors: improved living standards that liberated people from desperate poverty; public health measures (such as bans on spitting, a government-driven behavioral change that Ms. Krishnan colorfully narrates); and biomedical interventions (from the BCG vaccine to antibiotics).

The medical historian Thomas McKeown, in the 1960s and '70s, argued that the lion's share of the credit should go to improved living standards. Ever since, there has been spirited disagreement. The question remains potent because it echoes contemporary development politics, where there is an enduring tension between investments in broader social welfare versus more targeted interventions that address disease directly.

What makes Ms. Krishnan's book worth the price of admission is the tableau she paints of the current plague. She writes with authority about the current state of TB globally, especially in her native India, which is the epicenter of the disease today. A 20-year veteran of medical journalism, Ms. Krishnan is a powerful storyteller, and her accounts of frustration, suffering, grief and resilience are moving.

There is the case of 11-year-old Piya, whose ankle bone was infected with an extensively drug-resistant form of tuberculosis. Her disease presented as a limp, which eventually led to a diagnosis that upended the lives of everyone in her family. For Piya, it meant a daunting regimen of ineffective pills that turned her teeth yellow and her face flush red. The side effects only added to the stigma and shame of the disease itself. Meanwhile, she had to undergo excruciating debridement surgeries, in which infected tissue is scooped out. Fortunately for Piya, her plucky father flew to Tokyo and managed to arrange an audience with Otsuka, the Japanese pharmaceutical company that sells delamanid, one of the two relatively new drugs used to treat the hardest cases. Against the odds, he was able to have his daughter qualified for a compassionate-use case, and she has recovered.

Piya was lucky; her middle-class family more resourceful than most. Ms. Krishnan also narrates the wrenching story of Shreya Tripathi, diagnosed with TB in 2012. Denied access to bedaquiline, the Johnson & Johnson drug that is the other major addition to the anti-TB arsenal, she fought back in Indian court and won. But it was too late, and in October 2018, the disease took her life. Ms. Krishnan is unsparing in her denunciations of the inefficiency and "callousness" of the Indian government, but she reserves even sharper criticism for patent-holders. The central chapters of the book depict patient-centered stories against the backdrop of the bureaucratic and material obstacles to effective care. Whatever one's ideology, these accounts of how legal, medical and economic structures play out in the lives of people with tuberculosis ought to be reckoned with.

Ms. Krishnan's book is self-consciously a work of activism. She does not believe in intellectual property rights; pharmaceutical companies are a source of exploitation, not innovation. These parts of the book cannot be accused of nuance. One would never guess that the United States government spends around $400 million a year on tuberculosis research, 44% of the global total, for a disease that only kills about 500 Americans each year (just slightly more deadly than bathtubs). Given that Bill Gates has "the morals of a thug," according to Ms. Krishnan, one might also be surprised that the Bill & Melinda Gates Foundation spends over $100 million annually on TB research, at last count about 13% of the entire global budget. Yet we are told to discount this. The author quotes Chinua Achebe: "Charity . . . is the opium of the privileged."

There has been hard-won progress against TB over the last two decades, with substantial decline in total mortality due to the disease. Still, recent progress has fallen short of World Health Organization goals. Now Covid-19 has reversed recent gains. TB remains a global plague in the here and now, and we are not on track to win in the foreseeable future. To make matters worse, drug-resistant forms of TB can be actively transmitted (that is, resistant strains do not just develop in patients who are struggling with a brutal pharmaceutical regimen of toxic pills), and infections caused by these nastier breeds are rising. Meanwhile, drug discovery is hard, slow, risky and expensive. The specter of a future in which the effectiveness of our limited antibiotic arsenal continues to decline is terrifying. TB is a scandal today, and it may be a catastrophe tomorrow. Covid-19 reminds us that nightmare scenarios seem remote -- until they aren't.

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Mr. Harper, a professor at the University of Oklahoma, is the author of "Plagues Upon the Earth: Disease and the Course of Human History" and "The Fate of Rome: Climate, Disease, and the End of an Empire."” [1]

 

Tuberculosis is spread like Covid through aerosols. Masks, good ventilation, meeting people outdoors will prevent a lot of suffering from tuberculosis also.

 

1.REVIEW --- Books: A Scourge Of the Past -- And Present
Harper, Kyle. Wall Street Journal, Eastern edition; New York, N.Y. [New York, N.Y]. 19 Feb 2022: C.7.