Totally Drug Resistant Tuberculosis

In our book and this blog we give considerable attention to the threat posed by avian influenza, which also attracts a great deal of media coverage. But there is another, and older, threat that also deserves attention. Tuberculosis has been a growing problem. As Paul Farmer’s work has described, it flourished in Russia after the collapse of the Soviet Union, and drug resistant tuberculosis has been a growing threat from Peru to Haiti. The challenge is that if patients are not properly diagnosed, or if they fail to take a long course (a minimum of six months) of medication, the disease becomes resistant.

This problem has combined with the spread of HIV/AIDS, which decreases people’s resistance to TB. This led to a terrifying outbreak in KwaZulu-Natal province of South Africa, where an epidemic of extensively drug resistant (XDR) tuberculosis (TB) began spreading in 2006. From South Africa, the disease was moved into neighboring countries, such as Lesotho.

A recent news article in South Africa gives some insight into why TB was so difficult to treat. After a woman was diagnosed with XDR TB, she required intensive, inpatient care. Her family had to conduct a (successful) fund-raising campaign before she could be admitted to a hospital, where she is finally receiving the care she needs. In this case, the woman’s family rose to the challenge, and obtained care for her. But what if she had not been so fortunate?

Even if patients receive a correct diagnosis, it can be difficult to afford a full course of medicines. In India, patients are supposed to be able to receive these medications for free. But a recent article in the Hinustan times described the experience of a man with Multiple Drug Resistant tuberculosis who went to great lengths to obtain his medications, but ultimately failed to do so because of bureaucracy. In this case, he went into debt to cover the initial treatment, but this was not sustainable. His experience makes the point that people do not fail to complete treatment because they are ignorant. They fail to do so because there are severe obstacles to doing so. And so people fail to be healed, and go about their daily lives, and infect others.

It is not only developing countries that face this challenge. In 2010 Canada had a serious outbreak of tuberculosis in Nunavut, a northern territory that has a primarily Inuit population. The health crisis drew attention to larger social issues, such as substandard housing, in Nunavut. Social conditions amongst First Nation’s people in Canada’s subArctic and Arctic have long been disturbing. But every nation has issues of inequality, and tuberculosis preys upon people living in poor housing and with health care in many nations, as New York learned in the early 1990s. It responded aggressively to the problem, and is in many respects a model: “New cases of MDR-TB have declined 98% since the early 1990s, due to the expansion of directly observed therapy programs (which ensure all patients take medication by monitoring the patient taking each dose), improved case management and better infection control practices in hospitals.” But it is very expensive and resource intensive to respond to a TB outbreak.

And now comes news of totally drug resistant TB. As Maryn McKenna writes: “Well, this is a bad way to start the new year.” McKenna (who wrote about a book about infectious diseases called Beating Back the Devil) reports that Indian doctors have a forthcoming article in Clinical Infectious Diseases describing the emergence of a form of TB (totally drug resistant or TDR; also known as Super Extensively Drug Resistant Tuberculosis), which cannot be treated with any medications. There are twelve cases in one hospital alone. The outbreak seems to have begun in Iran, which means that it has likely already spread elsewhere in the region. Health officials and the government are working hard in India to respond to this threat. But they have very few tools with which to respond.

Very few public health officials are likely to be surprised by this development. It has been coming for a long time, and people like Paul Farmer have been warning about this threat since the 1990s. We are now effectively back into the antibiotic era. In a public policy context in which American farmers routinely feed antibiotics to livestock to promote growth, tuberculosis may not be a unique threat. But it is a severe one, and it will be a matter of time before it arrives in Europe or the United States. We can likely expect the same stigmatization of immigrants that accompanied the arrival of HIV in the U.S. Remember when “Haitian” was a risk-category for giving blood. And there will be broad political and social issues to address. Will people infected with TRD TB be quarantined? If so, for life? Who decides, and how is that implemented.

The situation is not hopeless, but it requires an early, coordinated and well-resourced response. It will be much more cost-effective to respond to this challenge early, as New Yorks’ experience shows. And this is one area in which U.S. foreign aid would pay a large dividend, and is as worthy as the truly impressive contributions that the U.S. had made in the fight against HIV.

Shawn Smallman, Portland State University