- The Return of the White Plague: Global Poverty and the ‘New’ Tuberculosis edited by Matthew Gandy and Alimuddin Zumla
Verso, 330 pp, £25.00, October 2003, ISBN 1 85984 669 6
For something to return, it has first to go away. In Asia, Africa and Latin America, TB never did go away; in richer countries it was only driven down to lurk in the places inhabited by society’s rejects. It didn’t disappear completely from among society’s paid-up members: its germs sleep in me today. I have a Ghon focus in my left lung, a collection of cells, some from my immune system, which wall off the tubercle bacilli that infected me more than half a century ago during my childhood in the North of England. Calcium salts have built up and settled in it over the years, so it shows on a chest X-ray.
The tubercle bacillus grows very slowly; its epidemics take centuries and the disease it causes is usually chronic. The age of the celebrity sufferer or victim is long since over: George Orwell, Vivien Leigh and Eleanor Roosevelt were the last. It is not surprising, then, that it’s hard to attract media attention to tuberculosis. Every day, more than five thousand people die from the disease, most of them young adults, yet it barely registers on the political consciousness.
The mid-Victorian Anglo-Irish physicist, adulterer and writer Dionysius Lardner was the first to explain why this might be so. In an article on railway safety in The Museum of Science and Art (1854-56), he wrote:
In the modes of travelling used before the prevalence of railways, accidents to life and limb were frequent, but in general they were individually so unimportant as not to attract notice, or to find a place in the public journals. In the case of railways, however, where large numbers are carried in the same train, and simultaneously exposed to danger, accidents, though more rare, are sometimes attended with appalling results. Much notice is therefore drawn to them. They are commented on in the journals, and public alarm is excited.
Events in New York during the late 1980s and early 1990s played this role for tuberculosis, and Deborah and Rodrick Wallace recount some of them in their chapter in Matthew Gandy and Alimuddin Zumla’s book. Cutbacks in control programmes, reductions in treatment facilities, a decaying of the culture of infection control in institutions, the provision of giant ‘concentration’ shelters for the homeless and a decline in the quality and quantity of housing for the poor came together to reverse the long-term decline in the incidence of tuberculosis that in the 1960s had been seen as heralding the imminent extinction of the disease. HIV made things even worse. Its attack on the immune system converts tuberculosis from a chronic into an acute disease, of the sort that in the old days would have been called ‘galloping’. Many New York patients died within six months of being infected, not only because they were HIV-positive but because their TB had been caused by a strain of the bacillus that was resistant to all the main anti-tuberculous drugs. If ever there was a time to panic, it was now. The multi-drug resistant (MDR) strain got into 23 New York prisons, where it killed 34 people. It spread with ease in hospitals, and travelled from New York to Florida, Nevada, Georgia and Colorado. All this stimulated political action: the New York Bureau of Tuberculosis Control budget rose from $4 million to $40 million; Rikers Island, which holds 15,000 inmates and where the incidence of tuberculosis had risen from 152 per 100,000 in 1986 to 500 per 100,000 in 1990, spent $60 million on control measures. The New York outbreak peaked in 1992, with 441 cases. Their number then fell by more than 35 per cent per year. New York was lucky. Most of the MDR spread had been in hospitals, where infection control procedures could be effectively improved by technical measures; and there was money.