TB: Back with a Vengeance

There was a period of time in the late sixties and early seventies when public health specialists thought the war on infectious disease was being won. This over-confidence proved disastrous. Old scourges have re-emerged to become public health problems of enormous consequence. Tuberculosis, perhaps as old as man itself, is an excellent example. The Greeks referred to TB as "phthinein”, meaning “to waste away.” In the middle ages it was known as "White Death". Later, it became "Consumption". Considering the length of time it has been with us, the name "tuberculosis" itself is relatively new.

Compared to HIV/AIDS, TB is an elder scourge. Yet, it is HIV/AIDS that has allowed TB to prosper. To understand this, it is important to understand how difficult it is to contract tuberculosis. A healthy, well nourished person with a functioning immune system and good living conditions is very well protected against TB. Should a person become infected with the tuberculosis mycobacterium, the body can suppress it and it will become latent.

TB can and does affect every organ in the body. We most often associate it with the lungs and this is often the case. A healthy body can wall off the mycobacterium by forming tubercles, hence the name of the disease. A person can live this way for most of one's life without being affected by the latent form of the disease. Should the immune system become compromised, such as with HIV/AIDS, the tubercles give way and the TB takes an active form.

TB runs along societal fault lines of race and class. Those living in cramped living conditions with many others who are not well nourished and do not have access to care are much more likely to contract TB. In fact, when ill health is the norm, a person who does not receive a diagnosis form a health care provider may not realize that what he or she has is a serious but treatable disease.

It takes months to treat TB, usually around eight. Not so long ago, patients were expected to visit a clinic each day to receive medicines. Imagine having to visit your health care facility every day for eight months. Not appealing, especially when you need that time just to make sure your family can eat. Health is a priority, for most people, but it is only one of many priorities. Success rates were not high. After a month or two, people began to feel better and would often stop taking their medicines. In the long run this made people sicker, as the weaker mycobacterium were killed and the stronger ones left to multiply. Every last mycobacterium must be eliminated, or the stronger ones emerge more resistant to the drugs which were unable to kill them the first time. Multi-drug resistant TB is extremely expensive and much more complicated to treat.

Policy makers often blamed the poor themselves for lack of treatment success, giving a whole range of reasons/excuses such as that poor people were not dedicated to their health or unable to keep time. Several organizations proved how wrong the makers of policy were. One of these organizations is Partners in Health. Partners in Health was able to adapt and advance a new method of treatment by listening to the people they served and including them in TB control efforts, thereby making TB not an individual problem but a community problem. Stigma in communities with organized treatment programs is much diminished, just as we hope that treatment for HIV/AIDS will also combat stigma.

Partners in Health relies on a model known as Directly Observed Therapy. Instead of patients being expected to take time each day to visit a clinic, which may not be located anywhere near their homes, a team of well trained community members visits each of the patients in their houses each day. The team members observe the patients take their medicines, document the time, and provide emotional and medical support. In this way, patients are encouraged to stay on their medicines. For example, if a person had to leave in the morning for an emergency (and we all have emergencies), the health worker will find the patient later that day, or in extreme circumstances, travel to where they are to make sure the medicines are being taken. As many of the community health workers are TB survivors themselves, they understand very well the concerns of their patient population.

This method has proven to be effective and relatively inexpensive, one of the true public health bargains. DOT is being replicated around the world, often creating a human health infrastructure where none existed before. However, we are fighting a reinvigorated disease with extremely old weapons. The so called TB Vaccine (BCG) is mostly ineffective. Most drugs used to treat TB are decades old. Unfortunately, life saving medications for the poor are not nearly so profitable as hair loss pills and impotency drugs for the rich.

A number of public/private initiatives are now in place. Though DOT is an invaluable asset in this struggle, an effective vaccine would turn the tide. In the meantime, we must support the development of new medications using evidence based methods of treatment, such as DOT.

I encourage everyone to examine Partners in Health (www.pih.org) and Project Medishare (www.projectmedishare.org), each of which are involved in directly observed therapy programs for the poor.

Please consider sharing your thoughts on TB and other infectious diseases through our blog.

Bryan Schaaf
Haiti Innovation