There is an epidemic in the making. Its first victims have already died. It is caused by a well-known killer, once tamed but now, like Hannibal Lecter in The Silence of the Lambs, once more virulent in a new and menacing guise. It could have been controlled by common-sense precautions, and for years it was. While the rich and the healthy are not likely to be its victims, it can strike anyone. It went on a rampage in a New York state prison last year, killing a guard and twenty prisoners. It is loose again largely because of official dereliction. It is tuberculosis.
The reemergence of TB as a major public health concern in the United States should not be a surprise. Like our crumbling infrastructure and the rage in our inner cities, its reentry was evident years ago to those willing to look. Its spread was fostered in part by official neglect, by the increase of poverty and homelessness, and by the outbreak of HIV and AIDS. According to Dr. Anthony S. Fauci of the National Institutes of Health, unless there is a serious effort to contain it, the spread of new forms of drug-resistant TB could become a public-health threat as serious as AIDS.
Worldwide, TB causes more deaths than any other infectious disease. In the United States, however, thanks to the use of several highly effective drugs, TB had been brought largely under control over the last twenty years. These medications chiefly isoniazid, rifampin, and pyrazinamide-are not expensive: under $300 for the course of treatment. But the treatment can be long, from nine months to two years; and the effect of abandoning treatment before it has been completed can be catastrophic. Not only can the disease return to the carrier, but it may do so with a vengeance: made impervious by previous types of treatment, drug-resistant TB can ravage the patient and become highly contagious. According to a report in Newsweek (March 16), it can be 50 to 80 percent fatal. In 1990, TB in the U.S. rose 16 percent (25,701 cases) over ‘84, and in New York state it reached its highest level in twenty years. But more alarming: since the early 1980s, drug-resistant TB has increased from 3 to 7 percent of all cases. In the last three years it has been detected in seventeen states. An opportunistic, airborne infection, drug-resistant TB could become the norm.
Why this outbreak? Because proven methods of treatment were not maintained (monitored compliance gradually diminished as public-health staffs were cut back and defunded); because of overcrowding in prisons and shelters; because of the spread of HIV; and because health-care programs in poorer neighborhoods were gradually weakened. A recent study of one New York City hospital found that only 11 percent of those on TB treatment were completing the full regimen (in contrast, Tanzania, one of the world’s poorest countries, has a completion rate of 85 percent).
What then needs to be done? This is a public-health crisis and therefore demands a concerted, public response. That means both personal and governmental. Personal: individuals should be taught the effectiveness of covering their own sneezes and coughs (one sneeze can launch 1 million infectious droplets, only one of which is needed to infect a weakened victim); and of suspecting TB in themselves or others if such signs as persistent coughing, abnormal weight loss, and fever are observed. And governmental: broad-scale public education and screening; rapid diagnostic services; new attention to completing therapy (including more supervisory personnel, rewards that reinforce compliance, and efficient legal controls when called for); isolation of infectious patients, particularly in prisons, shelters, and hospitals, and improved means of purifying air in such settings; ongoing screening of health-care workers exposed in the line of duty, as well as HIV patients; and a massive effort to: (1) develop new and quicker diagnostic tests, and (2) find new, effective medications for drug-resistant TB.
The failure of the federal as well as other strata of government to contain this new outbreak may now be compounded by an unconscionable refusal to deal with the epidemic fully and forcefully. Three years ago, a Department of Health and Human Services report called for $30 million a year to eliminate TB. The Bush administration never asked for the money. In two subsequent budget requests, it sought a total of only $19 million. For 1993, it has finally asked for a substantive increase ($66 million); but because of the swift spread of the disease in the interim, experts are now calling for $90-$125 million annually. Clearly, for every dollar well-spent now, many more will be saved in the future.
When it comes to TB, the best defense is clearly a good offense. We must all take precautions; but we must attack the disease: in our legislatures, our laboratories, and in our health-care goals and practices.
