The White Plague Is Reemerging
By Dr. Syed Amir
Bethesda, MD
In a recent issue of the New England Journal of Medicine, an Indian doctor, Vikram Paralkar, quoted John Keats, the celebrated nineteenth century English romantic poet, exclaiming: “I know the color of that blood, I cannot be deceived in that color. That drop of blood is my death warrant.”
Trained as a physician Keats had accurately diagnosed his own fatal illness, long before modern diagnostic tools existed, by noticing a drop of blood in his handkerchief as he coughed. He died of tuberculosis (TB) in Italy in 1821 when he was only 26 years old. The disease has often been referred to as the White Plague, because of the loss of skin color it causes.
Not so long ago, the best treatment for TB, an airborne disease, was limited to fresh air, rich food, rest and exercise, luxuries only the rich could afford. Despite these measures the disease often returned, following a brief respite, with tragic outcome. It claimed the lives of many famous and powerful persons in history. These included the founder of Pakistan, Mohammed Ali Jinnah, whose illness had been kept such a closely guarded secret that not even his personal physician Lieutenant Colonel Ilahi Bakhash knew about it until the last few days of his patient’s life. Kamala Nehru, the wife of India’s First Prime Minister, Jawaharlal Nehru, succumbed to the disease at a sanatorium in Lausanne, Switzerland, having undergone years of state-of-the-art treatment at various expensive European spas.
The disease struck writers and poets, as well as lay people with equal ferocity. The list of its famous victims included Russian, American and English writers - Anton Chekhov, Edgar Allan Pope and D. H. Lawrence - among many others.
Although the causative agent of TB, mycobacterium tuberculosis, had been isolated and identified by the German scientist, Dr. Robert Koch in 1882, there was no effective defense against it. Tuberculosis was considered an incurable disease until some sixty years ago. However, the discovery of antibiotics following the Second World War revolutionized its treatment as medical science acquired powerful new weapons to vanquish it. By the fifties, three potent drugs, streptomycin, PAS and isoniazide, came into wide use and were highly successful in curing it. The availability of these drugs revolutionized the general prognosis of TB patients. Several of Mrs. Indira Gandhi’s biographers have noted that she caught TB at an early age from her long exposure to her mother’s illness. However, unlike the mother, she fortunately lived in the era of antibiotics and was successfully cured of it.
The incidence of TB sharply and steadily declined throughout the world in the later half of the twentieth century, resulting from the availability of antibiotics, relative prosperity and improvement in general living conditions. In the rich countries of Europe and North America, the disease was virtually wiped out, except for sporadic cases spotted among immigrants coming from the countries of Asia and Africa. The strategies for diagnosis and treatment of the disease proved so successful that the medical establishment in the West became somewhat lax in monitoring its occurrences; governments directed attention and resources to other more pressing and menacing diseases, such as cancer and heart disease. In time, TB came to be known as the forgotten disease.
Then in the last decade of the twentieth century came the shocking realization that a new and deadly strain of TB had surfaced that was resistant to standard anti-TB drugs. This form of the disease was named “extensively drug resistant-TB” (XDR-TB). In 2006, the World Health Organization (WHO) was sufficiently alarmed and concerned to issue an urgent alert, drawing attention to XDR-TB and calling for steps to curb its spread around the world. However, WHO may have issued its warning too late. It is estimated that fifty million people worldwide may have been infected by XDR-TB. In February 2008, WHO reported that XDR-TB had been detected in 45 countries, including Pakistan. The highest incidence of XDR-TB has been found in the countries of the former Soviet Union; for example, in Kazakhstan 23 percent of all TB patients harbor the drug-resistant variety. In Pakistan 3.2 percent of all TB cases have been found to be drug resistant, as compared to 4.1 percent in India and 2.2 percent in Bangladesh. One of the highest incidences of ordinary TB, representing some 29 percent of all reported cases worldwide, is found in the countries of Africa. Accurate statistics of how many among these carry XDR-TB are not available. Much of the pandemic in African countries, however, is fueled by the high prevalence of human immune deficiency virus or AIDS, which ravages patients’ immune system.
In the United States, TB is still a rare disease; in 2005, only 124 cases were reported, mostly among immigrants, with 1.2 percent of those cases resistant to two drugs. However, any report of TB has become cause for much consternation. In May 2007, people were alarmed by the media reports that a 31-year old trial lawyer from Atlanta, Andrew Speaker, had been diagnosed with XDR-TB. While under treatment, he left the hospital and traveled with his fiancée to Europe to get married, returning to the United States via Canada, and in the process exposing hundreds to the TB bacteria. Meanwhile, the American Center for Disease Control (CDC) concluded that he had the most lethal form of drug-resistant TB. Speaker was placed under forcible isolation, a practice used for the first time in nearly half a century. Meanwhile, much effort was focused on locating the people who had come in contact with him during his extensive travel in Europe and North America so that they could be tested for the disease. Nobody knows for sure how Speaker contracted TB, especially as he never appeared sick or unhealthy. The story took a bizarre turn as it was eventually discovered that he had not had the most severe variety of infection, and did not pose as much risks to others as originally thought.
Why normal TB microbes develop drug resistance in not entirely clear. However, it is generally believed that drug resistance in most cases arises when the patient with ordinary TB fails to either complete his full course of treatment or is not prescribed proper treatment to begin with. In any given population of TB bacteria, there always lurks a small percent of drug-resistant varieties. When improperly or incompletely treated, these few germs are able to multiply and generate a large population of similar resistant microbes. Patients who carry these resistant forms can then infect others who are in prolonged contact with them.
Unfortunately, the emergence of drug resistance in not confined to TB bacteria. Some scientists blame the liberal and sometime indiscriminate use of antibiotics for this problem. In recent years, a particularly deadly form of a common bacterium, known as staph, has emerged that is resistant to broad spectrum antibiotics. It has been named MRSA. Paradoxically, it has most often been detected in patients who have spent some time in a hospital or nursing home. Normally, staph infections can be readily treated with antibiotics. In contrast, MRSA can be deadly, especially in patients with weakened immune system or older people, since even powerful antibiotics are helpless in combating it. Empirical evidence has shown that one of the most effective and simple defense against all infections is to frequently wash hands with soap.
The battle for supremacy between bacteria and humans has been going on for thousands of years, even before Homo sapiens evolved on earth in their present form. Bacteria, however, existed billions of years before us and once represented the only form of life on earth. As they learn new tricks to evade natural and man-made defenses, medical science will be challenged to seek ingenious and effective ways to defeat them. We hope that we will always stay ahead of them.
