Tuberculosis, once a romantic 19th-century disease, has returned, reaching epidemic proportions worldwide. One only need remember New York City's 1991 epidemic. Over one-third of the world's population has latent tuberculosis; 15 million Americans are infected with this highly contagious, airborne respiratory disease. TB chooses hosts indiscriminately; average middle-class Americans are not immune, say the authors. Reichman (professor of medicine at the New Jersey Medical School and director of its National Tuberculosis Center), with medical writer Tanne, discusses a virulent strain, multi-drug resistant tuberculosis, or MDR-TB. This hard to treat, if not incurable, incarnation is believed to have entered the U.S. via immigrants often from the former Soviet Union, designated a TB epicenter by the World Health Organization. Reichman often undermines his warnings by lapsing into shrill xenophobia. "Just think how many legal and illegal immigrants from these countries are now in Western countries! And just think, in our global society, how many more are contemplating coming!" Stereotypes run the gamut: in an airport he observes "well-tailored, trim" French people "equipped with cell-phones and lap-tops," "culture crammed and shopped out" Americans, and a group of "shabby" Ukrainians. In the early 20th-century, the Irish, often living five to one room, worsened their condition with malnourishment and alcoholism. Despite these noxious problems, the book serves an important function, relaying statistics and TB hot spots, proposing funding and international standardized treatments. Government officials, researchers and nonprofit health organizations will likely cast this as the authoritative book on the subject. (Oct. 5)Forecast: Endorsements by the Global Health Council, several congressmen, the American Lung Association and former Secretary of Health Donna Shalala and MDR-TB's worldwide headlines will win the book ample media attention.
Copyright 2001 Cahners Business Information, Inc.
If you wanted to cause an epidemic of multidrug-resistant tuberculosis in a country, what would you do? First, you would create a social and economic environment that promotes poverty and inequity. Second, you would temporarily subject those who have infectious tuberculosis to squalid and overcrowded conditions, let them mix with an uninfected population, and then release them back into the general population. Third, you would provide just enough treatment to prevent those who have the disease from dying but not enough to cure them, so that they would remain infectious longer. Fourth, you would provide inadequate treatment, guaranteed to create drug resistance. Fifth, you would add the possibility of infection with human immunodeficiency virus (HIV) to increase dramatically the risk of progression from infection to active tuberculosis disease.
Timebomb, written by Lee Reichman with Janice Hopkins Tanne, shows that this desperate situation has already occurred. Though clearly unintentionally, a combination of politics, economics, the emergence of a new infectious disease, and scientific belief has contributed to a major epidemic of tuberculosis in Russia. Multidrug resistance is a major component of this epidemic in prisons and parts of the civilian population. What makes the situation so worrisome is that the epidemic was well under way even without the added boost of HIV infection. Recent statistics from the World Health Organization and the Joint United Nations Programme on HIV/AIDS confirm that the pandemic of HIV infection is growing faster in Russia than anywhere else in the world. This appalling combination of HIV infection and multidrug-resistant tuberculosis is -- as the authors quite rightly assert -- a deadly time bomb, with consequences that reach far beyond the borders of any one country.
This is not a scientific analysis of the global dimensions of multidrug-resistant tuberculosis. In fact, the title is something of a misnomer, since in geographic scope the book mainly covers events in Russia and New York. Having set the scene with a description of a tuberculosis outbreak caused by a Ukrainian man traveling to the United States in 1998, the authors provide an excellent introduction to the science and history of tuberculosis, written primarily for the lay reader with little or no knowledge of tuberculosis. They then return to the main theme: recent attempts to help Russia adopt modern tuberculosis-control strategies.
Reichman, who is executive director of the New Jersey Medical School National Tuberculosis Center, has been involved in issues related to tuberculosis in Russia for the past few years, and his insights into what he calls a world of "smoke and mirrors" make compelling reading. Indeed, the authors are at their best in telling a story, with vivid and often detailed descriptions of people and events. The personalities are diverse and memorable: a Russian baby who is infected with tuberculosis and adopted in the United States, a Hungarian billionaire, a Russian dissident, a New York community health worker, and a Russian thoracic surgeon.
There are several minor mistakes in the book. For example, the countries listed at the end of the book are not the "hot spots" of multidrug-resistant tuberculosis that have been identified by the World Health Organization but rather are the 22 countries that together account for 80 percent of the global tuberculosis burden; the London conference on tuberculosis was held in 1998, not 1997; and most historians of tuberculosis control would assert that the principle of directly observed treatment for people with tuberculosis was promoted before 1973. An exploration of the reluctance of the Russian government to adopt a policy of international competitive bidding for tuberculosis drugs, as required in the proposed World Bank loan, would also have been interesting.
Timebomb is an important book with many lessons for those involved in public health. First, history repeats itself; as the poet Steve Turner says, "has to -- no one listens." The epidemics of tuberculosis currently raging in Russian prisons were common in British and American prisons in the late 19th century. In 1882, on announcing his discovery of the tubercle bacillus, Robert Koch described the disease as killing at least one third of people in the economically active age groups. The fact that the same bacterium continues to kill nearly 2 million people worldwide each year, despite the availability of a cheap and effective treatment, reminds us that complacency is one of the greatest threats to public health.
Second, the book demonstrates the multifaceted and complex nature of modern epidemics. Mix an intransigent medical profession with a judicial system based on imprisonment, and add a couple of virulent microorganisms to an environment of socioeconomic upheaval and inequity, and the results will be predictably appalling. Third, self-interest on the part of medical professionals can thwart attempts to improve the health status of the poor. Historians of health and development have documented many examples from the past. That they continue to do so in the present is a reminder that none of us are immune to this temptation.
The story is unfinished. The time bomb has yet to go off. There is still time to act, and proven strategies for tuberculosis control are available that can work -- as long as they are adopted quickly and widely. Whether this time bomb will be defused remains to be seen. The fact that it can be defused is indisputable. I look forward to reading the sequel.
Ian Michael Smith, M.B., Ch.B.
Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
