[part 1, TB: The Problem]
Is there a solution? The short answer is yes, if we give it the time, attention, and money it needs. So the long answer is, “No.”
I’m not really joking. People do have a way of getting their act together when faced with death, but the problem here is that once we’re faced with it, it’ll be too late to do anything effective.
Short term, for instance, we could be doing what the WHO says: prevent global transmission with a SARS-type effort, and make sure everyone with TB is successfully treated. That’s including if it costs actual money and requires actual aid. All I can think is, “What are the chances of that?” (Those of you who have better ideas than me about how we can take our little teaspoons and start digging at the mountain of stupid, help us out in comments.)
What I’m so pessimistic about is people having the sense to take preventive measures. Those are the only kind that will really do us any good long term, because the usual solutions to a disease crisis, drugs, are becoming ineffective as we speak. If we wait for outbreaks, drugs may not save us.
The sinister thing is that bacteria learn a lot faster than bureaucrats. Drug resistant TB is a symptom of broken medical care. Cost-cutting results in anemic anti-TB programs without adequate follow-up to make sure patients take the full course of treatment. Taking only some of the antibiotics, enough to kill the susceptible bacteria but not enough to kill all of them, very quickly leads to populations of drug-resistant TB. MDR TB (multiply drug resistant) began appearing in the early 1990s. By the late 1990s, XDR TB (extremely or extensively drug resistant) had appeared. In 2006, people noticed that XDR TB was appearing everywhere, but they took heart from its low infectivity. Then the South African cluster appeared among AIDS patients. We don’t know whether it would spread as easily among people with healthy immune systems. But now that we’re breeding lots of XDR TB, it’s only a matter of time before one of those is highly infective for everybody. Maybe it’s already here. Maybe it isn’t. But the matter of time is on the order of a year, or three.
The only way to deal with a disease that has no cure is to prevent it. And the only way to do that for TB is to have a vaccine. We have no really good vaccines. If a full-scale effort started now, and was successful, it’ll be a decade or three before it’s ready for use.
There are some good scientific, reality-based reasons why vaccine development takes time. But there are also some regulatory reasons which are nothing but bureaucratic inertia. (For a taste of the complexity, read this Nature commentary.)
For instance, since the early days, the only way to get regulatory approval was to incubate some of the essential components in chicken eggs. Once upon a time, that was the only way to do it, but for the last decade or more, tissue culture and yeast incubation have been the cheaper, better, and much faster method. But regulatory approval stayed stuck in the chicken era until (I believe) the SARS scare. I think at that point they got off their duffs and tried to streamline procedures a bit, but I’d be surprised if there wasn’t still a lot of room for improvement.
The vaccine that we do have right now has issues.
In the US, there’s very little TB, comparatively speaking, so most people haven’t been exposed. That means a very cheap and simple skin test can identify the few people who have been exposed. However, after vaccination, the skin test comes up positive. It can’t tell the difference between people with the disease and people who have fought it off (which is what a vaccine actually does). It takes a more expensive and time-consuming test to make that distinction. Needless to say, the public health authorities would rather keep things simple. For them.
There are also real reasons why it’s not that good an idea to get vaccinated. The effectiveness of the usual BCG vaccine varies. Sometimes in children it gets up to about 85%. However, in a 1966 US government study, it was as low as 14% in adults. Those aren’t very impressive numbers. (Although, maybe, if you’re flying long distances and there are lawyers from Atlanta on the plane, you’d prefer to have some chance of immunity rather than none?) Furthermore, surviving an actual case of TB does not guarantee immunity against new infections, so it’s not surprising that the BCG vaccine can’t either.
Then there’s the fact that unless you’re traveling to a country with serious TB problems, US doctors don’t hand out the BCG immunization. The CDC’s recommendations go so far as to say that if you’re going overseas to spend time in hospitals or prisons, you should get tested before and after to see if you caught TB. No suggestion that immunization might make sense, even if all it does is reduce the chance of catching it. So getting the vaccine probably involves traveling to a country where they do provide it.
Other vaccines besides BCG have an even bigger disadvantage. They’re not available yet. MVA85A is the closest to delivery. It’s a virus engineered to carry important bits of TB and to improve the effectiveness of BCG vaccination. It’s in testing, and although a Nature article makes it seem it’ll be out Real Soon Now, a 2004 BBC report said actual use was expected in 2014.
If effective vaccines aren’t there yet, then what do we do when an outbreak happens? (Note the “when.” It’s intentional.) There is one preventive measure that antibiotics have allowed us to forget about: quarantine.
Forcible quarantine has been mentioned recently only in connection with AIDS (and, of course, the TB lawyer). For a sexually transmitted disease, it makes zero sense. STDs are simple to stop IF you can get people to cooperate. (You see why I’m so pessimistic about anything that depends on cooperation.) But for a lethal disease that’s transmitted like a cold, quarantine makes a lot of sense from an epidemiological standpoint.
Quarantine also makes a whole hornet’s nest of civil liberties and humanitarian issues.
Can you deprive anyone of liberty who has committed no crime? Who’s responsible for the person’s welfare? That’s a non-trivial question when you’re putting a sick person into surroundings with other sick people, who may have different strains of the disease that can cause infections on top of existing infections. Who pays for the enforced hospital stay? If it’s a disease with a high fatality rate (as drug-resistant diseases tend to be), what are the merits of taking someone from her or his family, incarcerating them in a perhaps distant facility, and never allowing direct contact so that the person has to die surrounded by strangers? Who pays for the extra medical personnel and enforcers to look for sick people being hidden by their families?
I’ve put those things as questions because I honestly don’t know the answer. In my healthy, unthreatened state, I want to make sure the sick person is helped to the full extent of modern medicine.
On the other hand, if I’d been on that plane with Mr. “TB Lawyer” Speaker, I’d be livid at him. And at the CDC for not preventing him from flying in the first place.
So, I don’t know how to answer those questions. But what I do know is that all of us, you, me, everyone, have to figure out those answers now. If we wait until people are dying, the answers will be ugly and panicked. Which is the same as saying they’ll be ineffective.
So what would you do?