The Coming Plague (92 page)
Authors: Laurie Garrett
They were partly right; tuberculosis was an enormous, and escalating, problem in the developing world.
In 1990 Africa's most famous contemporary hero, Nelson Mandela, developed acute tuberculosis during his twenty-sixth year of imprisonment. Spitting up blood during the bitter Cape Town winter, Mandela was gravely ill. At the age of seventy at the time, Mandela fit three classic risk groups for active tuberculosis: elderly, living in cramped, densely populated quarters, and black. In South Africa, 15 percent of infected blacks went on to develop active TB, compared with only 3 percent of whites, largely because of inequities in housing and health care.
As early as 1984, Project SIDA researchers in Zaire had seen a direct link between rising TB rates in that country and the HIV epidemic. Five years later, the World Health Organization's TB and AIDS programs issued a joint statement calling attention to the linkage and warning of growing parallel pandemics. In particular, the WHO report noted that 60 percent of all AIDS patients in Haiti had active TB, as did 20 to 60 percent of all African AIDS patients (rates varying geographically across the continent).
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Though many developing countries quickly took steps to follow the WHO recommendations, the United States and most of Western Europe were unmoved.
There were several disturbing facets to Africa's new TB epidemicâagain, offering clues that should have served as warnings to officials in the wealthy nations. Some HIV-positive patients seemed to suffer not only activated disease from long-dormant
M. tuberculosis
infection but also new infection. That meant the disease was spreading and could be posing an increased risk for general populations, not just those who were infected with HIV.
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Where endemic tuberculosis rates were high, TB was “the
single most important opportunistic disease related to HIV infection in the developing world,” according to researchers based in Côte d'Ivoire.
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HIV-positive patients did not respond well to the two cheapest antituberculosis drugs, thiacetazone and streptomycin; the drugs were four times more toxic in people with HIV, even lethal. This posed enormous problems in terms of the cost of tuberculosis treatment.
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And the relative severity of tuberculosis in HIV-positive people did not vary appreciably with the stage of HIV disease. Indeed, for many Africans tuberculosis was the first ailment that tipped off physicians that they might have AIDS. Thus, hundreds of thousandsâperhaps millionsâof people in developing countries, who didn't yet realize that they were infected with HIV, were at tremendous risk for tuberculosis.
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M. tuberculosis
infection but also new infection. That meant the disease was spreading and could be posing an increased risk for general populations, not just those who were infected with HIV.
140
Where endemic tuberculosis rates were high, TB was “the
single most important opportunistic disease related to HIV infection in the developing world,” according to researchers based in Côte d'Ivoire.
141
HIV-positive patients did not respond well to the two cheapest antituberculosis drugs, thiacetazone and streptomycin; the drugs were four times more toxic in people with HIV, even lethal. This posed enormous problems in terms of the cost of tuberculosis treatment.
142
And the relative severity of tuberculosis in HIV-positive people did not vary appreciably with the stage of HIV disease. Indeed, for many Africans tuberculosis was the first ailment that tipped off physicians that they might have AIDS. Thus, hundreds of thousandsâperhaps millionsâof people in developing countries, who didn't yet realize that they were infected with HIV, were at tremendous risk for tuberculosis.
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By 1990 public health experts in some African countries were predicting not only utter defeat in their decades-old tuberculosis control efforts, but also potentially dire economic impacts that would further compound the grim damage the AIDS epidemic was expected to cause.
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On the wall of the Geneva headquarters of the Global Programme on AIDS hung a graph tracking the AIDS and TB epidemics of Burundi, Malawi, Zambia, and Tanzania. The two epidemics tracked in clear tandem, each growing at exactly the same rates.
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On the wall of the Geneva headquarters of the Global Programme on AIDS hung a graph tracking the AIDS and TB epidemics of Burundi, Malawi, Zambia, and Tanzania. The two epidemics tracked in clear tandem, each growing at exactly the same rates.
Despite all these observations the CDC concluded in early 1989 that the goal of eliminating tuberculosis from the United States by the year 2010 remained attainable and the nation's TB control efforts were essentially on track.
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The following year, however, the CDC's tone changed to one of alarm as fuller assessment of American TB reports revealed that the decade of the 1980s had witnessed a 28,000-person excess caseload of tuberculosis. Indeed, the downward slope TB had been following since 1953 plateaued in 1984â85 and climbed steadily, so that by the end of the decade the United States had almost as many cases of the disease as had been seen in 1980. The biggest increase was among inner-city African-AmericansâTB cases in that group skyrocketed by 1,596 percent between 1985 and 1990.
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Between 1985 and 1991 there was an overall 18.4 percent increase in tuberculosis cases in the United States,
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most of it attributable to the HIV epidemic.
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Between 1985 and 1991 there was an overall 18.4 percent increase in tuberculosis cases in the United States,
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most of it attributable to the HIV epidemic.
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When the crisis hit, Dr. Karen Brudney was one of those who could say, “I told you so.” Not that it gave her much satisfaction. She was far too overwhelmed with her huge tuberculosis caseload to spend a lot of time wagging her finger at public health bureaucrats. The street-savvy, tough-talking physician made up in spades with attitude for what respect her thin, wiry female frame might otherwise fail to muster from the kinds of clients she served every day in the city's Lincoln Hospital, located in the Bronx. Equally comfortable conversing in English, Spanish, French, or Haitian
Creole, Brudney barked her commands and castigations just as freely to the drug dealers, alcoholics, thieves, and ex-convicts as she did to New York's model citizens. If any of them took this thirty-something white lady for a pushover, they were in for a big surprise.
Creole, Brudney barked her commands and castigations just as freely to the drug dealers, alcoholics, thieves, and ex-convicts as she did to New York's model citizens. If any of them took this thirty-something white lady for a pushover, they were in for a big surprise.
On an icy late-winter day in 1992, Brudney paced the hospital's outpatient TB clinic, clearly agitated. The waiting room was packed with people of all ages who chattered loudly, mostly in Spanish, or watched the Puerto Rican soap opera flickering from the television that was secured to the wall by two separate sets of locks and chains. Unfortunately, none of the men, women, and children crammed into the Health Stat 10 waiting room were Brudney's patients.
As she angrily moved up and down the clinic hallway, avoiding the crowds and gurneys with the skill of an experienced rush-hour driver, Brudney grumbled.
“Clinic's been open an hour and not one single client is here. We'll be lucky if two out of the twelve clients that are supposed to be here actually show up for their TB checkups. We're only open once a week, they can't get their meds without coming to clinic, but we never get a better than fifty percent turnout,” Brudney said, taking yet another look at her client list. “If they don't show up, it means they're not taking their meds. And if they're not taking their medication, they're contagious.”
Her eye caught sight of a particular nameâ“Joanne”âand Brudney's aquiline face screwed up into an expression of disgust.
“This one! Ugh!” Brudney exclaimed. “This one is somebody they should lock up. She's out there infecting everybody. She's already been responsible for one outbreak, one where people died. And the strain she's carrying is multiply drug-resistant. If she showed up right now I wouldn't even want her in clinic, exposing everyone.
“What the hell would I do with Joanne if she did show upâwhich, of course, she won't. If I ordered a mandatory detention on her I'd need a bed here in the hospital. That's a whole day's work, a mountain of paperwork, a real nightmare. Then suppose I succeed in getting a bed, who's going to pay for the twenty-four-hour guard on her? And she's not going to stay, guard or no guard. What's security going to do, shoot her? Chain her in shackles in her bed?
“That woman is carrying a mutant TB strain that is virtually untreatable, 50 percent fatal. She's spreading it all over New York City. And there's nothingâ
nothing
âI can do about it,” Brudney exclaimed as she snapped Joanne's chart shut.
nothing
âI can do about it,” Brudney exclaimed as she snapped Joanne's chart shut.
Minutes later Vernon, a thirty-three-year-old African-American male, strolled in unannounced. He didn't have an appointment, but so whatânobody else had shown up. Even an amateur could tell that Vernon had tuberculosis: his six-foot-one frame was down to 149 pounds, his movements were slow, from deep in his lungs came periodic painful coughing fits, and
his eyes had that ghostly look that comes with acute illness. Characteristically, Vernon compensated for his illness with a forced kinetic energy that could be mistaken for an amphetamine high.
his eyes had that ghostly look that comes with acute illness. Characteristically, Vernon compensated for his illness with a forced kinetic energy that could be mistaken for an amphetamine high.
“You've lost more weight, Vernon. You taking your pills?” Brudney asked.
Vernon launched into an earnest, lengthy description of his daily medication routine, insisting that, despite all their side effects and the painful injections involved with one of his four medications, he was taking all fifteen pills and one shot a day, just as instructed. Brudney rolled her eyes, grunted a smirking sound, and let it be known that she'd heard all this before from Vernon.
“I'm not ashamed,” Vernon insisted. “I'm dealing with it. I really am. This time.”
“Yeah,
this time
,” Brudney responded. The physician called in a social worker and, in front of Vernon, told the patient's story. Vernon enthusiastically added details along the way, seemingly proud of his dubious battle with tuberculosis. In early 1989 Vernon had been hospitalized with what appeared to be pneumonia. Three weeks later the hospital lab returned a different verdict: tuberculosis. There was nothing special at the time about Vernon's strain of
M. tuberculosis
; it was garden-variety TB.
this time
,” Brudney responded. The physician called in a social worker and, in front of Vernon, told the patient's story. Vernon enthusiastically added details along the way, seemingly proud of his dubious battle with tuberculosis. In early 1989 Vernon had been hospitalized with what appeared to be pneumonia. Three weeks later the hospital lab returned a different verdict: tuberculosis. There was nothing special at the time about Vernon's strain of
M. tuberculosis
; it was garden-variety TB.
So Vernon was released from the hospital and ordered to take two relatively inexpensive, extremely effective drugs every day for six months: isoniazid and rifampin.
“But you screwed up, didn't you, Vernon?” Brudney said.
Shrugging his shoulders, Vernon said, “I figured anytime I felt bad, I'd just go to the emergency room and get more pills.”
After a year of sporadic, improper use of the drugs, Vernon's tuberculosis bacteria mutated, becoming resistant to both drugs. Since he had long disappeared off the City Health Department's radar screen, investigators were sent out in search of Vernon.
But he had disappeared.
“I move around a lot,” Vernon said, vaguely referring to several emergency homeless shelters and the apartments of friends and relatives.
Then he had suffered a major tuberculosis relapse and in November 1991 ended up back in Lincoln Hospital, spitting up blood. For ninety-four days Vernon struggled at death's doorstep in Lincoln, his lung mucus coming up clear.
“That's bad,” Vernon said, though he deferred to Brudney for an explanation. The TB colonies in his lungs had formed a hard, calcified cavity inside of which they thrived, protected from his immune system and from the four powerful drugs that dripped via an intravenous line into his bloodstream all day, every day, for three months.
Since his discharge from Lincoln Hospital in January 1992, Vernon had been having night sweats and felt fatigued. “But I'm alive, and I'm gonna stay that way.”
“You are, if you take all of your medication,” Brudney scolded.
Vernon swore that every morning he was swallowing eleven pills, comprising three different antibiotics. And he insisted that he was always home after breakfast when the public health nurse came to inject amikacin into his shoulder.
“Man, that hurts,” he said. “Stings, man. Burns going in, and takes its time getting there.”
Brudney, for the first time since he arrived, fully agreed with something Vernon said.
“It's a four-cc injection, and it's excruciating. And you wouldn't have to be putting up with it if you had taken your pills in the first place,” she said.
Vernon was now living at home in the South Bronx with his mother and older siblings. He had a girlfriend and a fifteen-month-old daughter, both of whom, so far, were free of TB. Until he got well, Vernon would live on welfare and social security funds, but, he said, “I'm gettin' a job working on a movie that's shooting in Harlem, just as soon as I lick this TB.”
Brudney made a few notes on Vernon's chart, handed the patient his prescriptions, and shook her head as he exited.
“Everything that man says is a lie. It's amazing. Every single word,” Brudney insisted. “For months he's been checking in and out of homeless shelters, using false names so the Health Department couldn't find him. And why? So he could deal drugs. I don't know, he may even be selling his TB meds on the street. Some of the patients do.”
Brudney noted that since 1989 Vernon had missed more than 75 percent of his appointments, was hospitalized four times, and was found hiding under an alias on two occasions.
“That's what we're up against.”
Two years earlier, Brudney and Columbia College of Physicians and Surgeons colleague Dr. Jay Dobkin had warned government officials that men like Vernon were breeding drug-resistant tuberculosis. The pair studied TB treatment records for Harlem Hospital, a public facility located in the middle of one of New York's poorest neighborhoods, which, more than a decade earlier, Lee Reichman had identified as one of the communities with the highest incidence of TB in the United States.
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By 1985 it was also a neighborhood ranked in the top ten nationally for homelessness and narcotics use.
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By 1985 it was also a neighborhood ranked in the top ten nationally for homelessness and narcotics use.
Brudney and Dobkin examined the records of all patients hospitalized for tuberculosis between January 1, 1988, and September 30, 1988. Eight out of ten of the patients were men twenty-five to forty-five years of age, half of them were homeless, the remainder were listed as “unsteadily housed.” More than 80 percent of the patients were unemployed, 79 percent were alcoholic, and 40 percent were HIV-positive.
More than a quarter of the patientsâ26 percentâwere hospitalized for tuberculosis relapses, meaning that they had failed to properly take their
medications. And a startling 89 percent of the patients disappeared sometime after hospital discharge, never returning for their mandated checkups and drug prescriptions. A subgroup of the patientsâwomen who were addicted to crack cocaineâwere 97 percent noncompliant with tuberculosis medication.
medications. And a startling 89 percent of the patients disappeared sometime after hospital discharge, never returning for their mandated checkups and drug prescriptions. A subgroup of the patientsâwomen who were addicted to crack cocaineâwere 97 percent noncompliant with tuberculosis medication.
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