To Be or not TB

The eradication of this ancient disease has continued, urgent relevance

Tuberculosis: The very name of the disease evokes images of antiquity, a footnote in dusty encyclopedias of human sickness overshadowed by the abbreviated diseases of the present—SARS, HIV/AIDS, H1N1. Few students would be able to guess that one third of the world’s population is infected with TB or that more than 12,000 cases were reported in the U.S. in 2008. Transmitted by coughing, sneezing, or spitting, TB thrives in the humid and closely-packed quarters of slums and urban outskirts.

However, just last week, a Harvard student was diagnosed with TB, with roughly 40 identified as at risk for exposure as a result of this case, reminding us of its startling proximity to our privileged community. Instead of dismissing it as a disease of the developing world, we should take this opportunity to recognize TB’s continued relevance on the public health advocacy agenda and engage with the actors that have long stalled progress.

After a long period of decline, TB incidence has risen dramatically since the 1980s, despite the improvement of sanitary conditions, the development of anti-TB drugs in the 1950s, and the introduction of the World Health Organization’s directly-observed treatment short-course program for more effective treatment. In 1993, the WHO declared TB a global-health emergency, setting ambitious goals which it later conceded could not be met by 2003 or possibly even 2015. That is to say, the consequences from the years of inadequate treatment and low attention to disease control in resource-poor regions have become increasingly clear.

First, the current treatment regimen requires patients take a cocktail of four drugs, all nearly half a century old, for at least six months. The logistical and financial hurdles associated with paying for and completing treatment, however, virtually guarantee noncompliance and relapse. Second, in a cascade effect, noncompliance selects for drug-resistant strains of the mutated pathogen, precipitating the rise of multi-drug resistant and extremely drug-resistant tuberculosis. Treatment for drug-resistant TB with second-line drugs is astronomically more expensive, more time-intensive, and associated with more toxic side effects. Third, the rise of TB and human immunodeficiency virus coinfection means TB is leading cause of death among HIV-positive patients: In Africa, HIV is the single most important factor contributing to the increasing incidence of TB over the last 10 years.

Moving forward, progress in developing new drugs has long been stalled by a combination of inadequate funding, regulatory bottlenecks, and tepid support from the pharmaceutical industry. Thanks largely to years of advocacy and the establishment of innovative public-private partnerships spanning the two sectors, new drugs and new models of clinical development are finally in the pipeline. Instead of developing new drugs one-by-one, the Critical Path to TB Regimens Initiative would bring together drug developers, under a “patients-first” commitment, to test their compounds together as an entirely new four-drug combination—a process that would take six, rather than 24, years.

New therapeutic regimens represent, however, only half the solution. Without commensurate scale-up of community-based treatment programs—the “social” dimension of treatment—or reform of inefficient drug delivery mechanisms in developing countries, TB treatment will remain inaccessible, ineffective, and ultimately futile. To finally turn the clock back on the spread of TB and its even more dangerous resistant strains, we need a concerted effort spanning industry, state, the public sector, and citizenry.

All stakeholders, pharmaceutical companies, academic institutions, multilateral organizations, and national governments shoulder part of the blame and bear hope for progress. As students, we must stand up to ensure that drugs and essential technologies created and licensed at Harvard are made openly available. As citizens, we have a right to demand that our government understands that the eradication of TB is more than a charitable cause: It is a national-security, economic-policy, public-health, and moral issue. Finally, as human beings, we have an obligation to open our eyes to the many forgotten faces of suffering and poverty, some of whom are among us today, ravaged by the continued and lingering specter of tuberculosis.

Thomas J. Hwang ’13, a Crimson editorial comper, lives in Canaday Hall.

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