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We Know How To Conquer Tuberculosis

We Know How To Conquer Tuberculosis

Op-ed in The NY Times in line with a letter sent in by Aurum Institute's Professor Gavin Churchyard:

In 1962, the renowned epidemiologist George Comstock had a realization that would help rid modern America of one of the world’s enduring scourges. Despite the advent of antibiotics, tuberculosis had remained endemic in parts of the country. Those miracle drugs were good at curing individual cases of TB, but people could pass the disease on to others long before they developed obvious symptoms, received proper diagnoses or were effectively cured.

But when Mr Comstock looked at data from rural Alaska, where 30 percent of adults were still infected with the disease nearly a decade after a cure became widely available, he saw a path forward: Antibiotics could eradicate tuberculosis, but only if they were given to people before they became contagious. In other words, doctors couldn’t just treat the people who were visibly sick. They would have to test all of the people that person came into contact with, and treat the ones who tested positive — even if they didn’t have symptoms yet. That way, the bacteria that caused the disease would be killed before it had a chance to spread.

In richer countries like the United States, Britain and Canada, that strategy has long since become a norm of public health. It’s helped eradicate TB from all but the poorest quarters — and, in some cases, even from there. And it’s kept some serious outbreaks from becoming epidemics. In poor countries, though, the approach has been deemed impractical. Tracking down all of a given patient’s contacts is difficult in the best of circumstances, the thinking goes, and resources are scarce enough that giving drugs to people who are not yet sick sounds extravagant.

And so, tuberculosis remains the world’s leading infectious disease killer, by far. It infects some 10 million people around the world every year, killing roughly 1.5 million. That’s some 4,000 deaths per day. By comparison, Ebola killed four people in 2017. America’s opioid epidemic kills about 115 people a day.

Dying of TB is a miserable way to go: Once inhaled, the bacteria that cause the disease eat away at the lungs — literally consume them — replacing healthy tissue with blood and liquid waste. As the chest cavity fills with fluid, the patient drowns, slowly, from the inside.

Still, tuberculosis is rarely the stuff of headlines. It’s ancient. It normally affects only the poorest people in the poorest countries. And when it does spread through wealthier areas, it’s generally curable with antibiotics. But a contingent of doctors, scientists and public health officials have spent the past two decades battling a global epidemic of the disease. And on Wednesday, they got their first hearing at the United Nations General Assembly. In a high-level meeting exclusively about tuberculosis control, those experts called on world leaders to devote more attention and far more resources to the disease. Both are urgently needed. Tuberculosis receives significantly less funding than H.I.V. or malaria, even though TB kills more people each year than both of those diseases combined. The World Health Organization estimates a $3.5 billion funding shortfall for TB control efforts and says that gap could double in five years.

But policymakers, industry leaders and doctors on the front lines might also consider a change in strategy: Treat tuberculosis outbreaks in poor countries the same way they are treated in rich ones. That is, don’t just treat those who are sick; find and test their household members, neighbors, classmates and colleagues — and then treat the ones who test positive. Give them medications to kill the bacteria before they develop symptoms and before they pass the bacteria on, through their own coughing, to the next victim.

America’s own experience and nearly a dozen randomized control trials show that this is how to stop TB in its tracks. The United States not only implemented this strategy in Alaska in the 1950s, but also in New York City in the 1990s. But because in lower-income countries such measures have been deemed too expensive, millions have needlessly suffered and died.

In recent years, several anti-TB initiatives have pushed beyond this cynicism to forge a new consensus. For example, the Zero TB Initiative, a global alliance that works with cities to get outbreaks under control, has trained teenage girls in Pakistan to work as case finders: approaching neighbors who may have been exposed to TB through a friend or family member and persuading them to seek medical care. So far, some 40,000 girls have shepherded nearly 50,000 people to local clinics for testing and treatment.

This past spring, the World Health Organization followed suit. The organization’s newest treatment guidelines now include a strong recommendation that all people living in households where one person has active tuberculosis receive preventive treatment. If countries implement that guideline, and if doctors abide by it, some 30 million more people should have access to preventive care in the next five years. If that happens, an untold amount of human suffering may be prevented, and a disease that has plagued the world’s most vulnerable people for far too long could finally be wiped out.

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