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Timebomb : The Global Epidemic of Multi-Drug Resistant Tuberculosis

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I liked Lee Reichman's new book "Timebomb" on so many levels. As someone who writes about public health issues for a living, I already knew there was big trouble brewing in Russian prisons, where a virtually incurable form of TB has been brewing for years. The trouble is that TB treatment, though highly effective, is fraught with troubles, among them the extremely lengthy and often unpleasant course of treatment; and the acute lack of resources in the very places they're needed the most. What this book does is flesh out, in finely-wrought detail, why these problems have proven so intractable, and why Russia continues not to do the right thing. You can hold this book up as a mirror for any number of other gigantic, slow-moving demons now stalking the planet, from global warming to over-population to the AIDS epidemic ravaging sub-Saharan Africa, and see why we're in the state we're in. As "Timebomb" so tragically depicts, even the best solutions can get distorted in the lenses of culture, ego, and plain old human inertia. I'd heartily recommend "Timebomb" as a must-read to anyone in public health, as well as to anyone interested in how public health works. Recent terrorist attacks on the country make it all the more relevant, sometimes chillingly so. --Alice Alexander

This shocking book focuses on the emerging public health threat associated with the rise of multiple drug resistant (MDR) strains of tuberculosis, especially in the former Soviet bloc of countries. In an age when worldwide travel can be accomplished in days if not hours, the connectivity between what is transpiring in the underdeveloped world and within our own borders is more striking than ever before. Therefore, we must recognize the threat posed by the emergence of such strains, and prepare to deal with the almost inevitable outbreaks of such strains of TB as they begin to occur in modern western societies.

This is not an easy read, but it is a quite fascinating and eye-opening one. The spread of MDR tuberculosis with the populations of Russia and the former satellite countries is shocking, and the total number of individuals latently infected now number some two billion people, or over one third of the total world population! Given the inability of modern medicine to counteract the course of the disease or to easily cure people infected with these new strains, the threat posed by them for people in all countries cannot be over-dramatized. Tuberculosis is indeed highly contagious, spreading freely through the air from infected individuals when they speak, cough, or sneeze. The authors refer to it as the "Ebola with wings", making a tacit reference to this most deadly form of hemorrhagic fever which is quite lethal when contracted, but which is thankfully more difficult to spread since (unlike tuberculosis) it is not airborne.

The predictions of its consequences are dire indeed; MDR tuberculosis is anticipated to kill 30,000,000 in the next decade alone. It festers in the more humid and warmer reaches of the earth, from Brazil to India, from Russia to China, and it is especially dangerous in those area of the world that have the poorest existing public health infrastructures. The economic collapse of the former USSR condemned millions to conditions of enforced cohabitation with infected individuals in the most congested, least sanitary, and most poorly equipped social structures in the world. Given such an alarming rise ion incidence and prevalence of the disease entity, the risk for cross-cultural contamination is only a short air-flight away from a looming public health disaster in the small towns and mega-cities of Europe and North America. Indeed, it is hard to engage in hyperbole here to overestimate the threat.

This book is indeed a call to arms, a plea for enlightened action on the part of governments, public health agencies, pharmaceutical research conglomerates, and the general public in order to avoid the terrors that await us if we sit by without doing all we can do to ensure better safeguards and better screening find, isolate, and treat infected individuals before they can lay the groundwork for a tragic and unstoppable epidemic. This is an important and worthwhile book, and one that I heartily recommend.

Anthrax, shmanthrax. To come down with good, productive anxiety, read about "Ebola with wings"-drug-resistant TB. And no, tuberculosis is not a thing of the past: It's here, it's now, it kills 2 million people every year. Several chapters of this book read like a detective novel. Timebomb starts by showing us Nicolay, a Russian, as he flies into New York in 1998, coughing highly infectious, drug-resistant TB bacteria into the plane's air. Then Timebomb looks into risky-to-work-in TB labs; a Siberian prison (where much of the world's TB is generated); a lung operation; the Russian medical system that's failing to control the bug; and takes us along on the dangerous rounds of an unsung heroine, a public-health worker. The book is not only well written, it's about a threat that individual members of the public can actually do something about-if they know the problem exists.

This lively and well-written book is packed with fascinating nuggets of historical and medical information. From the "dark, Satanic mills" of the Industrial Revolution to the squalid prison cells of contemporary Russia, from Egyptian mummies to DNA fingerprinting, you will follow the trail of the TB bacillus and the heroic researchers and public health workers who remain committed to conquering it.

"Timebomb" is a winner!

For those of you unfamiliar with tuberculosis: TB is a life-threatening disease that is caused by bacteria. It is treatable, but the treatment is lengthy (at least 6-8 months) and relatively costly (around $900 in the US). If patients do not receive the correct combination of antibiotics, or if they stop treatment prematurely, they may develop (or transmit) multi-drug-resistant tuberculosis, a disease which is nearly impossible to treat, treatment requiring up to 2 years of taking very expensive (up to $250,000 for 1 case of multi-drug-resistant TB) antibiotics that have a lot of side effects.

In Timebomb Lee Reichman gives a very clear description of all the factors involved in Tb, its treatment, the ways in which such treatment may fail and the dire consequences of failure. He also gives personal account of his experiences with multi-drug-resistant tuberculosis, with an emphasis on the situations in the United States and Russia. In the beginning of the 1990s there was an outbreak of (multi-drug-resistant) tuberculosis is New York: a team of very dedicated public health officials, doctors and community health workers fought the outbreak by treating patients as much as possible at home and were capable of reversing the situation, be it at very high costs (1 billion dollars in excess spending on health care). These costs would have been unnecessary if policy makers had in the past realized the threat that TB poses to the society once you become complacent.

In Russia, on the other hand, doctors are far more influential and there are a lot of very perverse incentives that stigmatise patients to such an extent that they actually do not come forward with their TB: they are locked in hospitals for up to 2 years for treatment and 1 in every 5 TB patients is operated upon, even when these operations are absolutely not necessary. And in prisons everything goes wrong that can go wrong with regard to transmission and control of TB and the emergence of multi-drug-resistant TB: overcrowded prisons, interrupted treatment and amnesty for TB prisoners that have not finished their treatment, And all this combined with an unjustified national pride that prohibits the Russians to ask for help or to accept evidence-based interventions that are promoted by the World Health Organization.

I have worked in a few of the prisons in Russia myself to try and improve the diagnosis of TB and the descriptions are very recognizable for me. I wish I had read this book before I started that job, because it had given me a better understanding of the forces I had to fight against.

This book is captivating and reads well, however I have found myself overcome with rage and anger while reading. Here's a couple of thoughts. First of all intellectual imperialism. Russia lost the cold war -- therefore the achievements of Soviet research, science etc are useless, primitive, unscientific. The author says, for example, that "English is the language of science", and that Russian doctors who speak English and can therefore read scientific literature in English are far more advanced than Russian doctors who only read literature in Russian, since Russian methods of medicine are at least 50 years behind Western ones. (I have never heard of an American scientist, however, who had learned Russian and studied Russian scientific and medical literature.) The author dismisses Russian treatment methods as barbaric just because they are different from the orthodoxy of treatment prescribed in the States. That's one point. Secondly, extremely frustrating is the absense of numerical data or statistics. DOTS is always more effective than the methods used by Russian medics, but no stats or studies as to this issue are ever sited. The one time the author does site a study (Tomsk) where 50 patients treated with DOTS were compared with 50 patients treated with the classical Soviet method, he is forced to admit that the cure rates were equal!!!!!!! So what then of his argument that Soviet medical treatment is not based on evidence and is barbaric? Also, TB was on a steady decline throughout the Soviet period, -- isn't that evidence enough that the Soviet way to treat TB is not entirely bogus?

Thirdly: the comparison between TB treatment in the US and in Russia is entirely inappropriate. It would make far more sense to compare Russia with a country that has similar rates of TB infection in the population, as well as similar economic conditions.

Fourth: The author talks about TB as if all there was to it is inhailing the bacteria. Meanwhile, the facts are that 80-90% of the people exposed to the bacteria never develop the disease. It is only when their immune systems are weakened (by poor nutrition, homelessness, stress, etc etc) that people actually get sick with TB. The author completely ignores the role that the social chaos of post-Soviet times and the sky-rocketing rates of poverty, starvation, malnutrition that followed the establishment of "democracy" play in the tuberculosis epidemic.

Finally: behind the fancy DOTS programme, all that is asked for is a dismantling of the social networks of support. Instead of putting people into hospitals where they will be fed, cared for, and constantly observed by a trained professional for signs of negative reactions to drugs -- make sick people walk to clinics to get anti-TB drugs. Obviously this method of treatment is "more cost effective". But is it really more effective? I would highly doubt it.