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“Africa is Lost”—The White Plague Returns

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden S. Lundgren
November 4, 2022

In 1885 Willard Parker Hospital became the third hospital in New York City and the only one devoted solely to the care of patients with infectious diseases. It closed in 1955 amidst a general optimism that the age of infectious disease was over—an optimism that died with the first cases of AIDS. But the optimism was unjustified even at the time. The incidence of tuberculosis (TB) has waxed and waned but never fallen anywhere near zero. In 2020, 10 million people became infected with tuberculosis. One and a half million people died from it. One fourth to one third of the world’s population may be carriers of the disease in its latent form.  

Those harmless looking rods (Mycobacterium tuberculosis) in the picture were first identified as the causative agent of TB in 1882. The genus may be 150 million years old. The dating of the first tuberculosis cases is uncertain with DNA evidence suggesting an age of 6000 years and other findings indicating a much older origin. Thought to have originated in Africa, the bacteria were carried to all parts of the world by human and animal migration.   

The results were devastating. Evidence of the disease has been found in neolithic remains, in Egyptian mummies, in ancient India and China and in pre-Columbian America. Hippocrates wrote of the disease. From the 16th to the 19th centuries, 25 percent of all deaths in Europe were due to TB. By 1900, TB had killed 1 in seven people who had ever lived on earth. 

But rather suddenly in the latter part of the 19th century, TB deaths began to decline. Why? TB is caused not only by the bacillus, but also by poverty, overcrowding and poor nutrition. It is thought that the later developments of the industrial revolution combined with strenuous public health efforts once the contagiousness of the disease was recognized helped bring the disease under some control. Those developments also brought a modest possibility of cure in what had always been a terminal disease. Patients could be treated in sanatoria: TB hospitals usually located in rural areas that offered plenty of fresh air, rest and nutritious meals optimizing the body’s ability to fight the bacillus.       

A vaccine was developed in the 1920s, but it has low efficacy in children and almost none at all in adults. It was not until the 1940s that the first effective anti-tubercular drugs were developed. But drug treatment has brought its own problems. Patients must be treated with a combination of drugs over a course of months. The side effects are not trivial. Once patients feel better, they often discontinue the drugs—which leads to the development of resistance by the pathogen. Nearly 20 percent of patients with resistance to multiple TB drugs die during treatment.

Despite its troubled history, by the 1980s tuberculosis researchers believed the disease was on track to meet a 2030 goal of reducing deaths by 90 percent—until 1990 when cases in America jumped 10 percent—with similar increases seen worldwide. AIDS had arrived. The cells that keep TB infections in check are the very cells that AIDS destroys. Once populations were infected with the HIV virus, millions of latent cases of tuberculosis exploded with the same results we saw with COVID, another air-borne pathogen. As one WHO expert remarked at a 1992 meeting on tuberculosis, “Africa is lost.”  

Quelling the HIV virus meant quelling TB too. But in 2020, control again became a problem. There is some evidence that the COVID virus can activate latent TB, but the main reason for the increase seems to be that less attention was paid to the disease during the pandemic. Case identification and reporting and access to care dropped dramatically with a concomitant increase in deaths. Just as important, the pandemic pushed 100 million people into poverty. Undernutrition comes with poverty, and nearly 20 percent of global tuberculosis is attributable to undernutrition—more than 50 percent in some parts of the world.

Now you may be feeling safe in America. At a cost of nearly $15 billion this century, reported TB cases here number about 7000-9000/year and deaths about 500/year. But we have just had a sad lesson in what happens when we ignore infectious diseases not on our shores. Just as we are nervous about new COVID variants coming here, we should also be concerned about new drug resistant TB cases also coming here.

According to the authors of an article in the April 21st New England Journal of Medicine, we should look to the AIDS model for global TB control. That is, we need to control COVID first. High-income countries need to share COVID vaccines and the knowledge needed for vaccine production with the goal of having at least 70 percent of the global population vaccinated. Technical advances are also needed: better TB drugs, better testing, better reporting, better public information—and, just as important, we need to address poverty, overcrowding and poor nutrition, the elements that cause this disease (and so many others) to thrive.        

Author:  Burden S Lundgren, MPH, PhD, RN practiced as a registered nurse specializing in acute and critical care.  After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk VA.  She has served as a consultant to a number of non-profit groups.  Presently, she divides her time between Virginia and Maryland. She can be reached at [email protected].

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