Return of the White Plague

By Howard Markel
Sunday, June 10, 2007; Page B01

Andrew Speaker, the 31-year-old Atlanta lawyer with a bad case of wanderlust and a worse case of tuberculosis, isn't just a media sensation. He's also the personification of a time machine, returning us to a not-so-distant era when diseases that we now casually assume are treatable claimed thousands of lives. And that grim part of our past could become our future.

Speaker got plenty of press as he was ordered into federal quarantine, having crisscrossed the Atlantic on commercial flights while infected with extensively drug-resistant tuberculosis (XDR-TB). But what hasn't garnered nearly enough attention is a sober consideration of just how deadly tuberculosis can be. The rising worldwide number of XDR-TB cases like Speaker's may herald the end of a glorious 60-year holiday from many common and highly contagious diseases -- such as polio, measles and cholera -- that once routinely ravaged vast swaths of humanity.

For those of you who consider tuberculosis a thing of the distant past, let me tell you a story. As a young man in 1913, Eugene O'Neill, the future playwright and winner of the Nobel and Pulitzer prizes, was confined for five months to a TB sanatorium. His family considered the initial diagnosis practically a death sentence. They had a point: Tuberculosis was then the leading cause of death for Americans ages 20 to 45. But by living under an enforced regimen of rest, fresh air and exercise, and by eating a diet rich in fat and protein, O'Neill recovered. A young woman he met and fell in love with in the sanatorium was not nearly so fortunate. Emaciated, pale and weak, she entered her last bloody round of violent coughing 18 months later. Writing about her death, O'Neill described tuberculosis as a cruel game of drawing straws, with more short straws than long ones.

The ancient Greeks had a wonderful word to describe tuberculosis's ravages: phthisis, which describes a living body that shrivels with intense heat as if placed on a flame. Later, the Romans applied the Latin word "consumere" -- to eat up or devour -- to the malady. Indeed, when O'Neill's TB was diagnosed, the disease was still referred to as "consumption." This is precisely what untreated (or untreatable) tuberculosis does. It consumes with a passionate and incisive energy; it slowly, inexorably devours the very structure of the lungs and other critical organs, with the single goal of conquering its host -- but not until its progeny have had the opportunity to travel to and settle in the lungs of another human, to start the horrific process all over again.

Ironically, there has long been a disturbing tendency to romanticize the white plague, as tuberculosis is also known. It is, after all, the malady that carried away the poet John Keats and the scribbling Bronte sisters; the illness that rang down the final curtain on Moliere, Voltaire and Chekhov. And, of course, there are those operas by Verdi and Puccini featuring heroines struck down in their prime by tuberculosis. When reflecting on this artistic history, the late literary critic Susan Sontag once called tuberculosis an "aphrodisiac," a disease with "extraordinary power of seduction."

But in real life, tuberculosis is a messy, agonizing and debilitating ordeal. Once the tubercle bacilli gain the momentum to proceed unchecked through the body, there is no romance to be found. The actual experience of tuberculosis is one of exhaustion, not literary inspiration; drenching bouts of sweating, not hypersexual allure; groaning, not arias; a cough punctuated by uncontrollable spurts of blood, not the lover's kiss. This is the nightmarish reality of tuberculosis that O'Neill and his peers understood all too well -- and the one we so easily forget.

As doctors have long known, and as the rest of the world is beginning to appreciate, TB is very much alive and well. It began to rise again in developed nations in the 1980s, largely as a result of funding cuts for TB prevention and treatment programs and the emergence of the AIDS pandemic. The reemergence of tuberculosis has been most devastating, however, in impoverished nations, particularly ones where HIV/AIDS is prevalent, because AIDS significantly increases a person's susceptibility to tuberculosis. As TB cases have multiplied, so have the numbers of people either inadequately or incompletely treated -- which, in turn, has led to the emergence of drug-resistant strains of the microbe that causes the disease.

Our understanding of the prevalence of XDR-TB is somewhat sketchy. Nevertheless, the transformation of a once treatable disease into an infectious foe as deadly as it was when Eugene O'Neill was confined to his 1913 sanatorium is the worst nightmare of those charged with protecting public health. XDR-TB has appeared 49 times in the United States between 1993 and 2006 and is of particular concern in Eastern Europe, South Africa and Asia.

In the fall of 2006, the World Health Organization declared XDR-TB to be a global emergency and beseeched the wealthiest nations to contribute $95 million by the end of this year to contain it. But many billions more are needed to thoroughly treat the millions of cases of drug-sensitive tuberculosis so that those patients don't become resistant to standard antibiotics.

Today, more than one-third of the world's more than 6 billion people have been exposed to the tuberculosis germ. Five to 10 percent of them, or at least 100 million, will develop symptomatic TB. Each will infect 10 to 20 people before they are either successfully treated or they die. Last year, active -- and contagious -- tuberculosis was diagnosed in more than 8.8 million people. Approximately 420,000, or 5 percent, of them have a drug-resistant strain that requires several more medications than drug-sensitive cases do; about 30,000 of these 420,000 cases are even more difficult and expensive to treat, the highly lethal XDR-TB.

TB is not the only disease once close to eradication that is experiencing a scary renaissance. Drug-resistant strains of syphilis have reportedly been on the rise; and strains of once-conquered germs such as staph and strep have developed powerful and broad resistance to just about every antibiotic known and, as a result, wreak havoc on unsuspecting hospital patients. In the never-ending dance between humans and microbes, we have been leading for only about half a century. These deadly germs are evolving, mutating and revising their structure to reclaim the upper hand in their powers of infection.

We live in a risky world menaced by war, terrorism, economic inequities and global warming, to name a few major threats. But ask any doctor what keeps him awake at night, and he will probably tell you about emerging and reemerging infectious diseases such as XDR-TB. Which brings me back to Andrew Speaker's not so excellent adventure.

Aside from the disagreements over which health officer said what, arguments about the loopholes between federal, state and local health regulations, or the media ruckus over whether Speaker was just a guy trying to have a nice wedding or a modern-day Typhoid Mary with a law degree, one obvious point demands our attention. Tuberculosis is a bad disease, and it's contagious. International air travel poses real risks in the spread of tuberculosis. Coughing, sneezing, singing, yelling and even laughing can spread TB germs. People contract tuberculosis after prolonged exposure (eight hours or more) to someone with the illness. This is the same length of time as most transoceanic flights, where passengers breathe re-circulated air for hours on end.

Those infected have a moral imperative not to put others in harm's way, even though it may mean postponing a wedding and a honeymoon. This has been a truism since Roman times. Salus populi suprema lex esto, went their saying: Let the public's health be the supreme law.

So, if you're confronted with the slightest chance of spreading a terrible infection (and with tuberculosis, that determination can take many weeks), assume that you are contagious until proven otherwise. Failure to follow that simple rule eats away at the foundation of public health surveillance and modern medical care. One only wishes that before Speaker embarked upon the first of many flights last month, he had recalled an admonition he must have heard from his mother or kindergarten teacher: If you are sick, stay home.

Someone's life may depend on it.


howard@umich.edu


Howard Markel, a professor of communicable diseases and the history of medicine at the University of Michigan, is the author of "When Germs Travel."