The surprising history - and current dilemma - of TB

The Deadliest Infectious Disease of All Time (00:00:00)

• Tuberculosis (TB) has existed for 3 million years, predating Homo sapiens.
• Evidence of TB has been found in ancient Egyptian mummies and mentioned in the Hebrew Bible.
• Despite medical advancements, TB killed more people than malaria, typhoid, cholera, homicide, and war combined in 2022.
• TB has various names throughout history: "waiu" (destroyed palace) in ancient China, "Shaka" (wasting away) in ancient Hebrew, and "consumption" in the 19th century.
• TB highlights fundamental aspects of human nature and historical changes.
• Humans have achieved significant technological advancements but still struggle to eradicate TB.
• The focus on wars, empires, and trade routes in history education overshadows the impact of diseases.
• Virginia Woolf noted the absence of illness as a central theme in literature, unlike love, battle, and jealousy.
• People tend to believe in personal control over fate, leading to rumors like Alexander the Great's poisoning instead of accepting his likely death from typhoid or malaria.
• TB affects everyone but not equally in terms of risk and mortality.
• Understanding TB requires examining how early understandings of the disease evolved alongside culture, leading to the current challenges.

Tuberculosis is Weird (00:03:36)

• Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium tuberculosis.
• Approximately 25% of the world's population is infected with TB, but only 5-10% develop active disease.
• Active TB usually occurs within 2 years of initial infection but can lie dormant for decades.
• Risk factors for progression to active TB include malnutrition, lack of medical care, crowded housing, and a compromised immune system.
• TB can be fatal if left untreated.
• The bacterium has a thick cell wall that makes it difficult for the immune system to destroy, leading to the formation of tubercles.
• TB has a slow growth rate compared to other bacteria, resulting in a longer incubation period.
• TB is not like a plague that spreads rapidly through a community.
• It is not like cancer or heart disease that affects one person in a household but rarely spreads to others.
• It is not like an E. coli infection that causes sudden and severe illness.

Man Got to Tell Himself He Understand (00:07:05)

• Tuberculosis (TB) was once believed to be caused by various factors such as genetics, contagion, foul air, and disharmony of body fluids.
• Stigma is a common response to illness, and TB patients have historically faced discrimination and been labeled as "invalids."
• TB was highly stigmatized despite not always being understood as infectious or a result of personal choices.
• In the mid-18th century, the prevalence of TB in northern Europe challenged the sole reliance on stigma as an explanation for the disease.
• TB was once romanticized as a disease of beauty, refinement, and intellectual sophistication, which can be harmful as it leads to stigmatization and marginalization of those affected.
• Both romanticization and stigmatization are strategies for excluding individuals from society and creating a narrative that explains their illness.

The Allure of Consumption (00:14:46)

• In the 19th century, tuberculosis (TB) was romanticized as a disease that enhanced creativity and beauty, particularly among male artists and writers.
• Consumptives were seen as paragons of brilliance and beauty, and TB was believed to bring creative powers to new levels.
• Women with TB were considered more beautiful and ethereal, with rosy cheeks, alabaster skin, and wide eyes.
• Consumptive chic influenced European beauty standards, with women using belladonna and red paint to mimic the symptoms of TB.
• Despite its romanticization, TB was a violent disease that caused immense suffering and death, often involving drowning as blood and pus filled the lungs.
• The romanticization of TB is a harmful trend that ignores the true horrors of the disease.

The White Man's Plague (00:21:07)

• Consumption was seen as a disease of civilization, leading to its racialization in Europe and the US.
• White doctors believed TB could only infect white people, calling it "The White Man's plague" or "a disease of the master race."
• African-Americans were thought to contract a different disease, and extensive illness and death from consumption in colonial South Asia and Africa went undetected and uncounted by colonial authorities due to the reliance on white supremacy.
• The romanticization of consumption declined in the late 19th century as it became evident that it was not primarily a disease of the rich and brilliant.
• Instead, it was observed among the impoverished living in overcrowded industrial cities, leading to a shift in understanding the cause of the disease.
• In 1882, Robert Koch identified the bacterium M. tuberculosis, leading to the understanding of TB as a germ disease associated with filth, overcrowding, and poverty.
• The Industrial Revolution caused cramped living conditions and malnutrition, making workers vulnerable to TB, and its rise paralleled industrialization in various communities.
• Racialized stigma shifted from seeing black and brown people as incapable of getting TB to blaming them for it due to the association of TB with poverty.
• Black people were more susceptible to TB not because of race but due to racism and marginalization.
• Racialized medicine was challenged, especially by black healthcare workers, who argued against blaming individuals for their susceptibility to TB.
• The bias against marginalized people and their healthcare workers has facilitated the spread of tuberculosis over the last century.

Treatments and the Cure (00:27:29)

• Tuberculosis (TB) was initially recognized as an infectious disease caused by bacteria, but its transmission methods were not fully understood.
• Public health efforts focused on improving living conditions, hygiene, and social habits to reduce TB spread, including the establishment of sanitariums in places like Southern California that promoted dry air, sunshine, and rest as treatments.
• Despite overall improvements in TB mortality rates, disparities existed among different population groups, with African-Americans, Chinese Americans, and indigenous people experiencing lower decline rates.
• Between 1940 and 1965, eight classes of drugs to kill TB bacteria were discovered, leading to the first curable treatment for tuberculosis.
• Combination therapy involving three different drugs was tested and approved in the mid-1950s, revolutionizing TB treatment.
• Challenges remained in providing effective TB treatment to impoverished communities, resulting in continued high mortality rates in those regions.
• Dr. Peter Mueni highlighted the global failure to distribute HIV drugs to impoverished communities, emphasizing that the drugs were available where the disease was not and vice versa.
• By the mid-1960s, curative therapy for tuberculosis (TB) was accessible everywhere except in the areas where it was most prevalent.

Where the Drugs Are Not (00:34:06)

• Between 1940 and 1965, eight different classes of drugs were developed to treat tuberculosis.
• Between 1965 and 2012, no new drugs were synthesized to treat tuberculosis.
• The decline of TB in rich countries reduced the profit incentive for researching new drugs, leading to a lack of funding.
• TB ceased to be romanticized and was no longer seen as a problem in the minds of many.
• A pharmaceutical research system driven solely by profit incentive is not the only way to develop drugs.
• The failure to develop drugs for unprofitable illnesses is a human-made problem that requires a human solution.
• If medications were a public good, the burden of disease would drive industry priorities, and TB treatment would be varied and plentiful.
• Developing drugs that lengthen eyelashes is more highly rewarded than developing drugs that treat tuberculosis.
• As a result, TB death rates remained steady in much of the developing world while declining in rich nations.
• In the early 1980s, physicians and activists in the global South raised concerns about an increase in uncommonly swift and severe tuberculosis deaths.
• This explosion was associated with the new pandemic of HIV/AIDS.
• Untreated HIV lowers resistance to infection, making TB infections more likely to progress to active disease as the immune system weakens.
• Despite recognizing this connection in the mid-1980s, insufficient action was taken to expand access to TB or HIV medications.
• This inaction contributed to tens of millions of deaths from the intertwining pandemics of HIV and TB.
• Between 1982 and 2005, when HIV deaths in poor countries finally started to decline, approximately the same number of people died of tuberculosis as in World Wars I and II combined.

A Fundamental Mistrust (00:36:48)

• Fuma, a South African woman, was misdiagnosed with TB and her condition worsened due to limitations in TB diagnosis.
• Directly observed therapy (DOTS) creates challenges for patients due to transportation and potential spread of the illness, leading to complexities in patient compliance.
• Fuma's eventual diagnosis of pre-XDR TB resulted in ineffective treatment and permanent hearing loss.
• Despite available treatments that can cure drug-resistant TB, many patients face delays due to various barriers.
• Fuma and Nandita Vasin's lawsuit against Johnson & Johnson led to generic competition and reduced prices for the critical drug bedaquiline, providing treatment for over 50,000 people with MDR-TB annually.
• The World Health Organization previously recommended supportive care for MDR-TB patients, which meant isolating them until death.
• Partners in Health demonstrated that similar cure rates for MDR-TB can be achieved in poor communities as in the world's finest hospitals.
• Many effective drugs for highly resistant tuberculosis remain expensive due to high prices set by pharmaceutical companies and concerns about antibiotic resistance.
• The speaker advocates for equitable access to powerful and efficacious drugs and rejects a world where bacterial infections cannot be treated.

The World We Choose (00:45:34)

• TB is curable, yet 1.5 million people will die from it this year due to lack of access to proper healthcare.
• Choosing a world where no one dies of TB requires long-term investments in strengthening healthcare systems, training healthcare workers, and developing new treatments.
• The real causes of TB in the 21st century are poverty, poor housing, sanitation, working conditions, and nutrition.
• Unlike in the 1800s, we now have the knowledge and treatments to eradicate TB.
• TB deaths have declined significantly in the past decades due to efforts in research, activism, and healthcare.
• Treating TB is complex but curable, and we can create a world where no one dies from it.
• TB Fighters community (TBfighters.org) has achieved success in lowering treatment and diagnostic costs.
• Raising awareness and attention to TB is crucial in addressing the problem.