Coughing to Death: If the Cure Exists, Why Are People Still Dying?
by Mahesh VidulaI would argue that a social justice approach should be central to medicine and utilized to be central to public health. This could be very simple: the well should take care of the sick.
-Paul Farmer, Co-founder of Partners in Health
Jay hated breathing. Every time he took a breath of air, the very substance that was supposed to keep his mind working and his heart beating, he coughed up a storm. Sometimes he even coughed up blood, which frightened him, since five students in his college dormitory had already died after coughing up too much blood. This isn’t right, Jay thought. He remembered the cool breeze on his face while playing cricket with his friends in his Indian college. Air was supposed to be a source of joy and happiness, not of immense pain. He came to my uncle, the town doctor, and pleaded, “Help me, sir. I want to breathe.” My uncle realized this wasn’t going to be easy; Jay had tuberculosis.
Credit: World Health Organization
Mainly a disease of the poor, tuberculosis severely strikes in developing countries in Southeast Asia, Africa, and the Western Pacific.
A highly contagious disease, tuberculosis is caused by bacteria that travel through the air. Globally, TB is the fourth largest killer among infectious diseases, with nearly two million people dying from it yearly. Currently, two billion people (roughly one-third of the world population) are infected with tuberculosis bacteria; the World Health Organization (WHO) estimates that 1 in 10 will develop the disease in their lifetime.1
Despite these statistics, it is no surprise that many Westerners are unaware of tuberculosis and the lives it threatens. Mainly a disease of the poor, tuberculosis severely strikes in developing countries in Southeast Asia, Africa, and the Western Pacific (see map).2 The disease often makes the poor even poorer in these regions; tuberculosis is most prevalent in adult males aged 25-44, and thus frequently disables the breadwinners of families.3 On the other hand, the United States experiences about 25,000 cases every year; most are elderly immigrants.4
Although tuberculosis mainly affects developing countries, the Western world was reminded of its vulnerability in July 2007. Andrew Speaker, an Atlanta lawyer with multi-drug resistant tuberculosis, took a trans-Atlantic flight from Europe to the United States, endangering the lives of hundreds of fellow passengers with this airborne disease. Fortunately, no one became infected. However, Speaker’s case brought the spotlight back to tuberculosis, and reminded the developed countries that this terrible disease was still a public health threat and action must be taken to cease its progression.5
Scientists and medical anthropologists estimate that tuberculosis has existed since the dawn of man, with the first evidence of the disease found in a 17,000-year-old bison.6 Close examination of Egyptian artifacts shows evidence of tuberculosis in the spinal cords of mummies from 2400 BCE.7 By analyzing documents from 460 BCE, anthropologists know that the Greeks termed the disease “phthisis” or consumption, since the illness weakens and literally consumes the body.8 Throughout the long history of this disease, people have held several misconceptions of tuberculosis. For example, after noticing that patients coughed up blood, looked pale, and had swollen eyes, some Americans in nineteenth-century New England thought that the disease transformed its victims into vampires.9 Others believed tuberculosis resulted from immoral sexual activities. Due to fear of spreading the disease, officials at Ellis Island prevented immigrants with tuberculosis from gaining access to America in the early 1900s. After Robert Koch’s breakthrough in 1882 in isolating the infectious bacteria, scientists initiated the search for a treatment by studying the mechanism of infection; Koch received the Nobel Prize in 1905.
Unfortunately, the immune cells continue to destroy the neighboring tissue while trying to annihilate the bacteria, which results in several large holes in the lung. If untreated, this leads to coughing up bloody mucus; fever, weight loss, and eventually death can result within a few weeks.
When a person breathes, air goes into the lungs and into small pouches known as alveoli. Here, the oxygen in the air is exchanged into the blood. When tuberculosis bacteria are inhaled, they travel down into the alveoli, but are immediately consumed by macrophages, large cells that act as part of the immune system. These cells will destroy anything that they think is going to hurt the body. Then the macrophages transport the bacteria to the lymph nodes, and alert all other immune system cells to the intruders. Here, immune cells surround the bacteria, and launch a brute force attack that also destroys the surrounding cells and tissue to prevent further bacterial growth. After the attack, however, some bacteria are still alive, waiting to come out when the body is most vulnerable.
At this stage, the person does not yet have tuberculosis. Out of the two billion people with the bacteria in their body, 90% are in this state. However, for the other 10%, it is a different situation: the bacteria somehow are able to come out and roam free. Whenever the patient breathes, talks, or coughs, the bacteria are propelled to new destinations in the lung. Wherever the bacteria go, immune cells launch the same defense, surrounding and attacking the bacteria. Unfortunately, the immune cells continue to destroy the neighboring tissue while trying to annihilate the bacteria, which results in several large holes in the lung. If untreated, this leads to coughing up bloody mucus; fever, weight loss, and eventually death can result within a few weeks.
Despite the dangers of tuberculosis, the disease can be treated if diagnosed early enough. The most common examination for TB is the Mantoux test, developed in 1907 and still used in clinics today. The nurse pricks a small region of your arm with a tiny needle, circles the site of injection with a pen, and then tells you to come back if you feel a bump in the circle. Why? The nurse is actually putting a small amount of tuberculosis bacterial protein into the body. If you have tuberculosis, immune cells will cluster around the injection site and form a bump. Unfortunately, the Mantoux test is not very accurate, since it often indicates tuberculosis when a person is actually free from the disease. Since some tuberculosis patients cough up bloody mucus, known as sputum, some diagnostic procedures take this sputum and directly test it for M. tuberculosis bacteria.
A proper diagnosis leads to effective treatment. If a person has tuberculosis, he or she must follow a schedule of four medications for up to six months. These drugs, isoniazid, rifampin, ethambutol, and pyrazinamide, all work to fight the bacteria over this long period of time. If a patient either stops taking the drugs in the middle of treatment or fails to take the medications regularly, he will only get worse. For instance, if Jay had stopped his regimen early because he felt better after taking the medications for a month, the cunning bacteria would have taken this break to evolve into a better enemy and become resistant to the medications. These drug-resistant forms of tuberculosis are even harder to treat since doctors cannot use the typical medications. Also, since tuberculosis is easily transmitted, if one person gets drug-resistant tuberculosis, he or she can infect many others with the same strain. Following the schedule of medications can be challenging, but it is a must for tuberculosis patients. People with epilepsy, liver, or kidney diseases must check with their physicians, since the standard medications will not cure their tuberculosis.
Some studies show that tuberculosis patients often feel stigmatized and refrain from either pursuing treatments or completing their medication regimen.
We clearly know a lot about tuberculosis in the scientific arena. But why are so many people still dying? A main reason is the rise of drug-resistant strains. In many poor countries, people cannot afford the expensive medicines to treat their tuberculosis. Others may take prescribed medications for a short time, and then, after they feel better, discontinue them to save money. However, besides poverty, culture and lifestyle may also exacerbate this problem. Some studies show that tuberculosis patients often feel stigmatized and refrain from either pursuing treatments or completing their medication regimen. In developing countries, men often cannot leave their jobs to obtain treatments for extended periods of time, since they must provide for their families. Moreover, some cultures may trust traditional medicines and treatments more than Western medicine and substitute those for modern drugs. Another factor is the advent of AIDS, or acquired immunodeficiency syndrome. AIDS essentially shuts down the immune system, making a person more susceptible to other diseases, especially tuberculosis. The World Health Organization reports that tuberculosis is the leading cause of death of AIDS patients, killing 200,000 per year.
Despite the complexity of the problem, public health officials agree that the best way to make significant progress in eradicating tuberculosis is to ensure that patients receive proper treatment. American doctors have recently traveled to places with high rates of tuberculosis to pursue this goal. Harvard physician Salmaan Keshavjee traveled to Azerbaijan and gave free bus vouchers to patients so that they could travel to the city to pick up their medications.10 Even though this strategy will not prevent tuberculosis, taking these steps will save lives. As Washington State Public Health Officer Scott Lindquist describes, “We have the tools to diagnose and treat TB [tuberculosis]. But until we use the principles of social justice and put these tools within the reach of everyone in the world, we won't be able to control TB.”11
However, the responsibility of eradicating tuberculosis does not lie solely on the shoulders of public health officials. We all must take action by educating each other. By spreading awareness of tuberculosis to our local politicians and businesspeople, we can raise money to distribute resources more effectively. Through education in clinics, shelters, developing countries, and other places affected by tuberculosis, patients like Jay can learn to take their medications for the complete time period to avoid drug resistance, and we can make significant progress in the global fight against tuberculosis.
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6 Rothschild, B.M., Martin, L.D., Lev, G., Bercovier, H., Bar-Gal, G.K., Greenblatt, C., Donoghue, H., Spigelman, M., and Brittain, D. Mycobacterium tuberculosis Complex DNA from an Extinct Bison Dated 17,000 Years before the Present. Clinical Infectious Diseases (2001) 33 (3): 305-311.
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10 Tweed, Katherine. "What's the Rx for Drug-Resistant Tuberculosis?" Hard Work and Imagination." 23 Feb. 2009. Scientific American. http://www.scientificamerican.com/article.cfm?id=rx-for-drug-resistant-tuberculosis
11 Quoted in Farino, Lisa. "Drug-resistant TB." MSNBC. http://health.msn.com/health-topics/infectious-diseases/drug-resistant-tb.aspx?cp-documentid=100214452&page=2