The Star-Ledger

The Star-Ledger

To defeat global TB, doctors should get back to basics

Posted by Lee Reichman/ NJ Voices Guest Blogger January 12, 2009 5:33AM

Categories: Policy Watch

AP Photo/Karin Schermbrucker

A doctor examines chest X-rays at a tuberculosis clinic in Gugulethu, Cape Town, South Africa.

When it comes to global health, it is usually the most sensational cases -- such as West Nile Virus or SARS disease -- that grab the public's attention. But our focus on the scariest outbreaks also can blind us from seeing the root of the problem.

Tuberculosis is a case in point. TB kills 1.7 million people each year around the world. Yet much of the recent focus has been on drug-resistant strains of the disease. What has gotten less attention is ensuring that those who have TB get the drugs they need, and more importantly, take those drugs as prescribed.

This is a serious problem. It is often forgotten that the global failure to control basic TB is spurring the emergence of drug-resistant strains that are as potentially lethal as any weapon of terrorism. Not only are we increasingly seeing multiple-drug-resistant strains of the disease but we are seeing more cases of extremely drug-resistant TB, which is a very highly virulent form that killed 52 of 53 HIV-infected patients in one hospital in South Africa in 2006.

What is troubling is that the emergence of extremely drug-resistant strains such as the one in the South African hospital could be limited if we invested more of our efforts into preventing these strains in the first place. In other words, 1.7 million people are dying each year of usually, easily curable TB, but inadequate and inappropriate treatment is causing the strains of tuberculosis to become resistant to the very drugs that can and do work.

What can we do? We should be working to ensure that infected patients follow their basic treatment regimens. At a cost of about $20 per patient compared to hundreds of thousands of dollars for someone with multiple or extremely drug-resistant TB, this is a worthwhile investment that obviously will pay off in the long run for the world.

For AIDS patients this is crucial. It is also often forgotten that TB is the biggest killer of AIDS patients worldwide, but we know that if you properly treat an AIDS patient for his or her TB you can prolong their life for several years. TB is a preventable and curable disease. We know what causes it; we know how to treat it. We know how to prevent it. But we're failing on all fronts, and when this occurs, and we don't do this properly, we manufacture resistant strains.

Here at the New Jersey Medical School Global Tuberculosis Institute in Newark, we have documented the effects of effective treatment and follow through. We collaboratively work closely with TB patients making sure they take their medications properly by deploying field workers to observe TB patients at work, at home, or even on the streets of Newark or "crack" dens. We make sure they are ingesting their prescriptions and staying on those medications for as long as they are required. Through Directly Observed Therapy, or DOT, we achieve 98 percent adherence, and more importantly, we haven't had a case of multiple drug resistance in any of our patients in several years.

Why the focus on basic treatment? We know that every person with drug- resistant TB, here or abroad, either wasn't treated properly or didn't take their drugs properly or were infected by someone who wasn't treated appropriately or failed to follow their prescription regimen.

This is critically important in the globally connected world we now live in. There are more than 9 million new active cases of TB around the world that may be feeding these drug resistant strains. We obviously need new drugs and diagnostics to combat them. But with 9 million new cases that aren't yet drug-resistant, we cannot afford to steer resources or attention away from basic TB control. We also need to be devoting resources to training medical professionals and health workers around the world to make sure patients are following their medication regimens so they don't develop drug-resistant strains. We risk creating a much bigger problem for the United States and the world if we fail to do so.

The Institute of Medicine in December called on the federal government to double its support of global health, an effort I wholeheartedly support. I also support the investment in global health research that continues to sustain every step we take in the clinic or on the ground. But another important message from the leading scientists who crafted that report is the critical role of the United States as a global citizen and promoter of better health around the world.

One of the most fundamental ways we can showcase our role as such an ambassador would be on how we as a nation direct the care and treatment of the millions of people with tuberculosis around the world.

Lee Reichman, MD, MPH, is executive director of the New Jersey Medical School Global Tuberculosis Institute in Newark and author of "Time Bomb: The Global Epidemic of MDR-TB."