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23rd January 2004 at 00:00
Once one of the world's most virulent diseases, tuberculosis is on the rise again, beating predictions that it would soon be wiped out. Reva Klein reports

The ancient Egyptians were racked with it. So were the Greeks: the physician Hippocrates called it "the greatest and most terrible disease." Its spread through civilisations, across continents and over centuries has been inexorable and unrelenting. It destroyed a quarter of the population of Europe in the early 19th century.

And now, after a relative dip over the past 50 years in the industrialised world, tuberculosis has come back with a vengeance. Contrary to all epidemiological forecasts, it has become one of the fastest growing and rapacious diseases in the world. According to the most up-to-date figures, one third of the world's population, 1.86 billion people, now carry the TB bacteria: 10 per cent will go on to develop active, potentially fatal TB.

It is increasing at an alarming rate: every year there are 8.4 million new cases of active TB.

It will kill more people worldwide this year - an estimated two million - than at any time in recorded history. While the vast majority of cases, about 80 per cent, are in the developing world, the incidence in Europe and North America is rising and London is one of the hottest spots for TB in western Europe. The borough of Newham in east London has the dubious distinction of having a higher rate of TB than India.

Called "the white plague", in contrast to the black one, or "consumption" because of the way it consumes its victims, it is an airborne bacteria that spreads through droplets - a sneeze, a cough, an exhaled breath. Its main victims are young adults. The most common form, pulmonary tuberculosis, attacks the lungs. But there is an increase in other forms that eat away the brain, genitals, bones or skin if left untreated. Whatever form it takes, it is a ghastly torment. New Zealand writer Katherine Mansfield, who had TB of the lung, described it like this: "When one thinks: 'now I have touched the bottom of the sea - now I can go no deeper' one goes deeper."

Its symptoms are weight loss, persistent cough, lack of energy, copious sweating, anaemia and coughing up blood. If left untreated, the sufferer's lungs deteriorate, resulting in breathlessness, haemorrhage and suffocation.

It is estimated that each person with TB infects up to 20 people before they receive treatment or die. Its virulence has earned it the label "Ebola with wings" by a World Heath Organisation official as well as the status of global health emergency. It is the only disease that has been designated in this way by the WHO.

Why is this happening? And why now? In an age of unprecedented medical advances, why should an ancient plague come back to strike down so many? First and foremost, for the majority of the world's inhabitants, TB hasn't returned: it never went away in the first place. In the developing world, in large swathes of urban and rural Asia, Latin America and Africa, it is endemic and has been so for as long as people have been able to identify it. This is because, above all else, tuberculosis is a disease of poverty, attacking people who are poorly nourished or packed together in cramped housing and therefore susceptible to cross-infection. Another major factor is HIVAids. When poverty is compounded by a devastating virus such as HIV, as it has been for millions in Africa and elsewhere, TB runs rampant. An immune system laid waste by HIV has little hope of withstanding a disease as virulent and ubiquitous as tuberculosis. TB and HIV have a fatal attraction to each other; tuberculosis is the cause of death of a third of all people with Aids.

But Aids in the West has not assumed the proportions it has in the developing world and generally, sufferers have had access to life-extending anti-retroviral drugs. So what is the reason for TB's spread westwards? There are a number of factors.

For a start, more people travelling has been a boon for such an easily transmittable bacteria. Along with the poor and dispossessed, this includes backpackers, students on gap years, business travellers and middle-aged holidaymakers. But brief encounters, unless your immune system is not in good shape, aren't going to harm you. Transmission usually involves prolonged and close contact with someone who has active TB. However, the World Health Organisation has warned that flights of more than eight hours present a risk of transmission. If you're very, very unlucky, as four people documented in a US Centres for Disease Control study were, you could find yourself sitting near someone with active TB and you could get off the plane burdened with more than duty free. TB knows no national borders and does not differentiate on the basis of class, race or gender.

Anti-immigration talk about asylum-seekers and immigrants contaminating towns and cities distorts and over-simplifies the picture. Studies in the US show that it is often once people settle in their new countries that active TB occurs, largely because of poor housing and other factors associated with poverty and displacement.

Just as important a factor in TB's spread is deterioration in health care, specifically services specialising in TB control. In the late 1800s, long before the advent of antibiotics, European doctors used simple, if contradictory, measures to treat consumption. The most important was sending patients to sanitoria. Their location varied depending on doctors'

views and fashion. So someone with TB might be sent to the mountains or the desert, to cold climates or hot ones. It didn't terribly matter as long as it was away from cities, to breathe clean air and eat nutritious food. Even before doctors understood that the disease was highly contagious, they sent those who could afford it away, which helped control the disease's spread, even if it didn't cure the sufferers. While the poor in Europe died miserable deaths in the mean tenements and slums of newly industrialised cities, the wealthy took the air in remote institutions, far from the disease-ridden crowd.

By the beginning of the 20th century, an understanding of how the disease spread destroyed the patina of glamour that the sanitorium movement had engendered. TB became the disease of the great unwashed. But the efficacy of segregating TB sufferers led to the mushrooming of public sanitoria across Europe and the US. There, the poor enjoyed or endured a strict regimen of fresh air, rest and exercise, as well as a range of therapies including "heliotherapy" (sunbathing) and being made to sleep outside.

While the practice of isolating sufferers in these sanitoria had some effect, the antibiotic revolution of the 1940s and 1950s, coupled with the introduction of the BCG vaccine, led to the death rate from TB in the industrialised world dropping by more than 90 per cent over a 30-year period. At a time when the disease raged throughout the developing world, medical experts in the 1980s predicted a total eradication of the disease in advanced countries by 2000.

But they were wrong. From the mid-1980s to the early 1990s, TB in the US increased by more than 20 per cent. New York, one of the world's wealthiest cities, found itself with a public health emergency on its hands. It started in high-density, low-income housing and spread to middle-class commuters living in the leafy suburbs of New Jersey. It coincided with the first appearance of Aids in the city, but analysts give multiple causes for its rapid spread: along with HIV, poverty and homelessness in New York had escalated sharply throughout the 1980s. The Reagan administration had cut federal housing programmes for poor people, resulting in a massive rise in homelessness, with large numbers living in shelters or on the streets, both of which are breeding grounds for the bacteria.

Other factors associated with the New York epidemic are replicated in the general increase throughout North America and Europe. Intravenous drug use, the deterioration of public health services and the emergence of multi drug-resistant strains of the bacteria (MDR-TB) have allowed the disease to spread in Russia, Romania, Portugal, Texas, London, Paris and the Baltic states.

MDR-TB is particularly problematic. Caused by ineffective anti-TB drug combinations, wrongly administered drug therapy and patients not sticking to the treatment because of side effects, multi-drug resistance has become a major challenge. Where once TB could be treated effectively over a few months with a cocktail of three antibiotics (streptomycin, isoliazid and rifampicin), MDR-TB is different. It can take up to two years of carefully monitored treatment with expensive and often toxic drugs. Multi drug-resistant TB is becoming more prevalent throughout the world, accounting for approximately 10 per cent of all new cases.

The reduction in efficient public health services has led to an acute state of affairs in the former Soviet bloc countries where TB is now rampant, particularly in Russia and Romania. The privatisation of those countries'

health care has been devastating for TB control. In Romania, where the economy has been in free-fall since the 1989 revolution, seven people die of TB each day and another 74 become infected, according to the director of its national anti-TB programme, who says: "There is not enough money in the budget for health care." The Russian Federation, which experienced a 69 per cent increase in TB cases in the 1990s, has more people dying of TB than any other country in Europe.

What is frustrating, not to say tragic, is that TB is as preventable as it is curable - if there is early detection to stop spread, if the drugs are available and if the treatment is immediate and comprehensive. While the BCG immunisation is not all it's cracked up to be - the US government doesn't include it in its immunisation programme and the effects appear to wear off after a few years - there are drugs that can make people better if given in the right combinations, over the right period of time and begun early enough.

A global anti-TB programme launched by the World Health Organisation in 1994 called DOTS (Directly Observed Treatment Short Course Strategy) has been designed to ensure a constant supply of effective and cheap drugs and to closely observe treatment and monitor outcomes. Those countries that have adopted DOTS comprehensively have seen dramatic reductions in the incidence of the disease. But there are big stumbling blocks to universal coverage of DOTS. Most countries in the developing world have only been able to set up piecemeal versions of the programme because of lack of proper management to implement it, lack of money and the expertise to allocate it to best use, lack of political commitment to ensure its smooth running, lack of public health infrastructure and lack of necessary training.

These factors go a long way to explaining why, at the end of 1998, only 21 per cent of people infected with TB had been through a DOTS programme. An international effort to boost DOTS expansion was declared in 2000. This fast-tracked DOTS will, it is projected, save 18 million lives by 2010 and prevent 48 million new cases by 2020. With the Aids pandemic wiping out large parts of the developing world and drug resistance becoming ever more widespread and with movement between countries at unprecedented levels, let's hope it's not too late to control this most virulent of plagues.


The popular view of TB is contradictory. On the one hand, it is associated with urban poverty, high density living and bad sanitation. On the other, it has been the stuff of romantic myth for centuries. Remember Mimi in Puccini's La Boh me coughing into her hanky? Or Nicole Kidman in Moulin Rouge (right), all languid and porcelain in her wretchedness? Think, too, of the soft-focus lens through which generations have imagined the departures of the Bront sisters, Keats (far right), Kafka, DH Lawrence, Chekhov, Dostoyevsky, Chopin, Modigliani, Orwell and most incongruously of all, Oscar winning actress Vivien (Scarlett O'Hara) Leigh. Neither were the wealthy and powerful spared: the only son of Henry VIII, 16-year-old Edward VI, succumbed to consumption in 1553. American First Lady Eleanor Roosevelt, wife of FDR, died of a drug-resistant strain in 1962.

Maybe TB's patina of glamour has something to do with the feverish creative surges that literary consumptives were famous for, along with the bright shining eyes and flushed cheeks that alternate with a deathly pallor. Or perhaps it's the poignancy of the well-off and famous desperately seeking comfort and clean air in plush sanitoria.

Due to TB's unexpected resurgence worldwide, we are sadly likely to be seeing more of those flashing eyes and pink cheeks for ourselves.

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