Genealogy Makes History - Tuberculosis |
|
|
ContentsThe magic bullet -- It came too late for Amy Utter The magic bullet backfires TB in South Africa poses threat to millions Lethal TB threat hits airline flights Lethal TB threat update |
The dark ages of TB -- from the beginning to 1882by Fred EdwardsTuberculosis, it seems, has always been with us. Evidence of tubercular decay has been found in the spines of Egyptian mummies thousands of years old, and the disease was common both in ancient Greece and Imperial Rome. While it may have lessened its grip during some periods of history, TB never completely let go.Attempts at cures were varied, but uniformly ineffective. Roman physicians recommended bathing in human urine, eating wolf livers, and drinking elephant blood. Fresh milk -- human, goat, or camel -- figured in many treatment regimens. Depending upon the time and country in which they lived, patients were exhorted to rest or to exercise, to eat or to abstain from food, to travel to the mountains or to live underground. We find that Amy Utter was given "hot shots," which the staff at today's Missouri Rehabilitation Center could not identify. She also received "throat treatments" as well as pneumothorax treatments, all of which I will describe in a subsequent article. And yet, tuberculosis continued to claim victims by the millions. When, in 1820, the poet John Keats (who had schooling in medicine) coughed a spot of bright red blood, he told a friend, "It is arterial blood. I cannot be deceived. That drop of blood is my death warrant. I must die." Within a year, at just 25, he did. Other artists and writers who succumbed to tuberculosis in the 19th century included Frederick Chopin, Anton Chekov, Robert Louis Stevenson, and Emily Bronte, while 20th century victims included Franz Kafka, George Orwell, and D.H. Lawrence. Called "consumption," the disease became romanticized in the popular imagination as a disease of the young, pure, and passionate. The heroines of Alexandre Dumas' 1852 novel, Camille, and Giacomo Puccini's 1896 opera, La Boheme, were among the fictional characters whose deaths from tuberculosis were imagined to result from thwarted love affairs. The variable course of TB only served to make it more baffling and terrifying. Physicians could not easily predict whether a consumptive patient would succumb within months, linger for years, or somehow manage to overcome the disease altogether. According to the 19th century American physician William Sweetser, the first stage of consumption was marked by a dry, persistent cough, pains in the chest, and some difficulty breathing, any of which could be symptoms of less dire illnesses. The second stage brought a cough as "severe, frequent, and harassing" as well as a twice-daily "hectic fever," an accelerated pulse, and a deceptively healthy ruddiness in the complexion. In the final, fatal stage, wrote Sweetser, "the emaciation is frightful and the most mournful change is witnessed...the cheeks are hollow…rendering the expression harsh and painful. The eyes are commonly sunken in their sockets...and often look morbidly bright and staring." At this point, throat ulcers made eating difficult and speech was limited to a hoarse whisper. (We find this happened to Amy Utter as she neared her death.) Once the distinctive "graveyard cough" began, diagnosis was certain and death inevitable. Rarely, wrote Dr. Sweetser, "life, wasted to the most feeble spark, goes out almost insensibly." More typically, severe stomach cramps, excessive sweating, a choking sensation and vomiting of blood preceded the victim's demise. As long as the cause of tuberculosis remained unknown, efforts to cure it were based more on trial and error than on any scientific reasoning. In general, consumption was not thought of as a contagious disease. Rather, most believed it to be hereditary, resulting, at least in part, from an individual's mental and moral weaknesses. This gave rise to the attitude of patients that they were a special brand of "TBers," as Amy Utter called herself, and to the feeling by many friends and family members that TB patients were better off "out of sight and out of mind" in a sanatarium. The English physician Benjamin Marten was among the first to propose an alternative in his 1720 publication, "A New Theory of Consumption." Marten believed that "wonderfully minute living creatures," which could be spread by prolonged close contact between infected and healthy individuals, caused tuberculosis. His conjecture would remain just that for another century and a half. Then, on an extraordinary evening in March 1882, an obscure German country doctor astounded the European medical establishment and became an overnight sensation with his proof that the dread disease that had felled so many was caused by a microscopic organism. The doctor was Robert Koch and the announcement opened the way to an age of optimism in the battle against TB. (Background material for this article was provided by the National Institute of Allergy and Infectious Diseases (NIAID)) Tuberculosis - - the magic bulletIt came too late for Amy Utterby Fred EdwardsThe TB Microbe is IsolatedAs the 19th Century wore on, Scientists discovered the microbes that caused other infectious diseases, but they hadn't even been able to prove that tuberculosis was caused by a microbe. Then, on the evening of March 24, 1882, before a skeptical audience of Germany's most prominent men of medicine, Robert Koch announced a breakthrough. Koch had found the TB organism by staining cultures with two dyes instead of one. "Under the microscope the structures of the animal tissues, such as the nucleus and its breakdown products are brown, while the tubercle bacteria are a beautiful blue," he wrote in the paper that followed his presentation. Once Koch found the bacteria, he had to grow colonies in order to discover how they lived and migrated. He discovered that they are extremely slow-growing, requiring two weeks before clumps of them could be seen without a microscope. Then he found that TB was spread from person to person, which meant it could be controlled. In another key step, he discovered that the bacteria were carried on droplets from an infected person's cough. Sanatoriums are Substantiated Then came a public health movement that isolated the sick in TB sanatoriums-- sometimes by force. By trial and error, sanatoriums actually had been used since 1849, when a consumptive German doctor, Hermann Brehmer, traveled to the Himalayas and returned cured. He became convinced that life at high elevation, continuous exposure to fresh air, sun and cold, along with copious amounts of food, could turn TB from a death sentence into a curable disease. In the United States, sanatoriums adopted Brehmer's treatment except for the emphasis on high elevations. So we find in Amy Utter's Journeys -- TB and Other Tragedies in Rural America's Heartland that the Missouri State Sanatorium staff followed a similar regimen in 1930. The 87-acre site counted on its own vegetable gardens, poultry farm and dairy for food. Coincidentally, the sanatorium was perched on a 1,260-foot high mound called "Chigger Hill" that overlooked the town of Mt. Vernon. The next step in finding a magic bullet came when a young doctor named Edward Livingston Trudeau established a sanatorium at Saranac Lake, in New York's Adirondack Mountains. Trudeau, a "TBer," had been informed by his doctors that he would not live long. In 1882, he learned of Koch's experiments with TB bacteria, and established a small laboratory at Saranac Lake to experiment. He inoculated five rabbits with TB bacteria and set them loose on a small island where they were provided with fresh vegetables in addition to the naturally occurring grasses. After four months, one rabbit died, but the others remained robustly healthy. It seemed that the four rabbits' healthy life had saved them from infection. Trudeau instituted many of the European regimens in the "cure cottages" he established at Saranac Lake. Patients were under strict and constant supervision, with every aspect of their lives detailed in individual rule books. Typically, a newcomer spent a minimum of three months on complete bed rest. The patient was exposed to fresh air for most of the day and was required to consume enormous amounts of food, including many servings of milk each day. In Amy Utter's Journeys, we find a similar health regimen with the exception of the strict rules. Amy's 1930 diary made no mention of such rules at the Missouri sanatorium. A Vaccine In 1908, French scientists Albert Calmette and Camille Guerin took a batch of Mycobacterium bovis (which causes TB in cattle) from a dead cow. Every three weeks for the next 13 years, they grew a new batch in a solution of beef bile and potatoes. Each new generation was weaker than the one before. Eventually the bacteria lost the power to cause disease, but the scientists hoped it could provoke the immune system to protect a person from TB. The first dose of vaccine Bacille Calmette-Guerin (BCG) was administered in 1921 to an infant whose mother had died of TB. Since then, more than a billion people have been inoculated with the cheap and safe BCG vaccine. The magic bullet? No. The vaccine can prevent TB infection in the brain among children, but it is nearly useless in preventing adult pulmonary TB. It would have been no help to Amy. The Magic Bullet For more than a decade after Amy Utter died in 1930, scientists worked to find a drug therapy for TB. Finally, the American scientist Selman Waksman produced streptomycin, a relatively non-toxic antibiotic derived from a soil fungus. On November 20, 1944, a critically ill TB patient received streptomycin. Within days, he began a near-miraculous recovery. A host of drugs followed on the heels of streptomycin and, when used in combination, they could usually cure TB without creating drug-resistant bacteria. Some of the most important drugs introduced during the 1940s and '50s were isoniazid, rifampin, and ethambutol. Drugs brought the sanatorium era to a close. Confidence arose that TB, like other infectious diseases of previous centuries, could be completely conquered by drug therapy. Indeed, the United Nations predicted the worldwide elimination of TB by the year 2025. But this ancient enemy was not so easily routed, and it would make a disastrous return. (Background material for this article was provided by the National Institute of Allergy and Infectious Diseases (NIAID).) Tuberculosis -- the magic bullet backfiresby Fred EdwardsThis is the third and final installment in my overview of the history of tuberculosis. The first is "Tuberculosis, the dark ages of TB -- from the beginning to 1882," which describes the terror of this mysterious disease that hit humankind from the beginning of recorded history. The second is "Tuberculosis, the magic bullet -- it came too late for Amy Utter," which relates that drug therapy might indeed be "the magic bullet." This third installment reviews the terrible recurrence of TB worldwide. All installments are at www.frededwards.net.Following the discovery of how to prevent the spread of TB and the creation of the magic bullet of drug therapy, health authorities were hoping that tuberculosis would be vanquished by 2025, but medical and social factors brought the disease back as a major cause of death. So today, somebody in the world is newly infected with TB every second. And two billion people -- one-third of the world's population -- have been exposed to TB bacterium. By 1985, the number of TB cases had begun to rise in the United States. Causes included an explosion in prison populations, populations of long-term care facilities, homeless sub-communities, injection drug use, and crowded living conditions, as well as increased immigration from countries where TB is endemic. The deadliest causes, however, were the HIV/AIDS epidemic and increases in multi-drug-resistant TB (MDR-TB). How it spreads When people with active TB cough, spit, or simply talk, bacteria that cause the disease are propelled into the air. A person who inhales just a few TB bacteria can become infected. Without treatment, an individual with an active case of TB will infect between 10 and 15 others a year. Infection, however does not always lead to disease. In a person with a healthy immune system, TB germs take up residence in lung cells, but enter a kind of suspended animation and may never break out. Thus, only between 5 and 10 percent of all healthy people infected with the germ will develop active TB. The odds jump, however, for people with decreased immune function, which can be due to HIV/AIDS infection, poor nutrition, or old age. One person out of ten who is infected with both HIV and TB, for example, will develop active TB each year, compared with a one-in-ten chance over a lifetime for people without HIV. Once again a worldwide epidemic TB kills between two and three million people a year. Just as in Amy Utter's lifetime, it is once again the leading cause of death among young adults and a major cause of death among women of childbearing age. (See my book, Amy Utter's Journeys - TB and Other Tragedies in Rural America's Heartland.) So great was the concern about the worldwide epidemic of TB that in 1993, the World Health Organization (WHO) declared tuberculosis a global emergency, the first time ever for a disease. Birth of a superbug A most alarming aspect of the present epidemic is the jump in multi-drug-resistant TB (MDR-TB) cases. According to a survey conducted by the WHO, up to four percent of all TB cases worldwide are resistant to more than one anti-tuberculosis drug. In parts of Eastern Europe, however. nearly half of all TB cases resist at least one first-line drug. Most of the burden of MDR-TB falls on poor countries that cannot easily counteract MDR-TB, but the United States also has seen outbreaks. For example, in the early 1990s, New York City had an epidemic of MDR-TB that cost nearly $1 billion to control. A cure exists, along with loopholes Today, almost all cases of TB are curable with proper treatment, but such treatment is not always easy to attain. Ideally a patient should use several drugs simultaneously to prevent naturally occurring mutations in the TB bacteria from escaping. Accordingly, a TB patient might be prescribed four different antibiotics for at least two months, then two drugs for four more months. However, the drugs often cause unpleasant side effects. In addition, patients start feeling better after a month or two. So not every patient completes the full course of treatment. In addition, patients who return to substandard, crowded living conditions continue to infect and be infected. Furthermore, in many less developed countries, where TB is most common, drug supplies may be inadequate and medical services spotty. To complicate matters, partial treatment for TB is worse than no treatment at all, because TB bacteria that linger following incomplete therapy are likely to resist anti-tuberculosis drugs in future flare-ups. Meanwhile, people with active cases of MDR-TB can pass those superbugs on to new victims. The ultimate answer Staff officials at the Missouri Rehabilitation Center (called the Missouri State Sanatorium when Amy was a patient in 1930) told me that early diagnosis and modern drug treatments make it possible for most tuberculosis patients to be treated in their home communities. But they must follow the dosages prescribed and accept recommendations for lifestyle changes. In other words, do what your doctor advises. Incidentally, the center, which has earned the distinction of being a regional treatment center for drug-resistant tuberculosis cases, accepts confirmed tubercular patients whose disease has not responded to traditional medical treatment, as well as tubercular patients who have been referred as being noncompliant with recommended treatment. (Background material for this article was provided by the National Institute of Allergy and Infectious Diseases (NIAID).) TB in South Africa poses threat to millionsby Fred EdwardsThe third article I wrote containing an overview of tuberculosis explained that the magic bullet to cure TB backfired due to the growth of multi-drug resistant strains of the disease accompanied by social and health practices. How big a backfire? Let's look at South Africa.In Amy Utter's lifetime (visit http://www.frededwards.net/aboutamy.htm), medical problems in South Africa, or even South America, would have attracted no attention in rural America's heartland, but that changed with the airliner. Whereas Amy could hop on a bus or a train and travel all over the heartland unknowingly carrying TB bacteria, people today can fly all over the world. And they can carry their infections like stray dogs harboring fleas. So a TB epidemic in Africa not only would endanger millions of Africans, but also could spread worldwide. About a year ago, a virulent strain of TB known as XDR TB (extensively drug-resistant TB) killed 52 of 53 infected patients in Tugela Ferry, a village in KwaZulu-Natal Province in South Africa. XDR TB does not respond to most first- and second-choice anti-tuberculosis drugs. In fact, some in the medical profession have labeled it incurable. Since the XDR strain was detected last year in Tugela Ferry, 39 hospitals in South Africa's' other eight provinces have recorded 330 cases of the disease. On an ominous note, the New York Times reported that several TB experts believe the strain has migrated to Lesotho, Swaziland and Mozambique, three countries that border South Africa and provide migrant workers to the country. Perhaps it has even reached Zimbabwe, a focal point where hundreds of thousands of refugees flow back and forth. It's difficult to identify the extent of the disease because the countries mentioned lack the means to diagnose and track TB. They also don't have the ability to contain the disease if it begins to spread. Countries such as Russia and China already have been affected by XDR tuberculosis due to inadequate treatment programs, but the South African situation overshadows them by far for two reasons: (1) the scope of the outbreak; and (2) the infected area sits right in the middle of the world H.I.V. pandemic. Why is H.I.V. a deadly factor for TB? According to the World Health Organization, one third of the earth's inhabitants carry dormant tuberculosis germs, but relatively few suffer from a full-scale attack of the disease. BUT, when H.I.V. weakens the immune systems, that sets the stage for a full-scale onslaught. And two thirds of the South Africans stricken by the disease were H.I.V. positive. Think of five million South Africans who carry H.I.V., and the gravity of the possibilities becomes immense, with an eventual threat to tens of millions of Africans living in the sub-Saharan portion of the continent. Authorities believe that almost all of the 52 patients who died of XDR TB at Tugela Ferry had AIDS, and they died so quickly that officials fear that similar outbreaks are occurring unnoticed. W.H.O. is working with Pretoria to place a team of TB experts in South Africa. Lethal TB threat hits airline flightsby Fred EdwardsMay 31, 2007 -- U.S. federal and international officials are tracing down airline passengers and crew members who may have been exposed to a man infected with a dangerous strain of tuberculosis that is extremely resistant to most antibiotics. Four flights involved were: (1) Air France flight 385 (also listed as Delta Air Lines Flight 8517) from Atlanta to Paris, May 12; (2) Air France flight 1232 from Paris to Athens on May 14; (3) Czech Air 727 from Rome to Prague on May 24; and (4) Czech Air flight 104 from Prague to Montreal on May 24. Passengers sitting within two rows of him were advised to undergo a medical evaluation and testing with follow-up tests 8 to 10 weeks later.How did this happen? On May 10 he was notified in Atlanta he had multi-drug-resistant TB. According to the Centers for Disease Control and Prevention (CDC), he was advised not to fly abroad for his upcoming marriage and honeymoon. Nevertheless, he flew from Atlanta to Paris on May 12. He then flew to Athens on May 14, where he got married. On May 16 he went to Thira Island, presumably for the honeymoon. Then he cut short his honeymoon, and went from Mykonos Island to Athens to catch the flight to Rome. While in Rome he was contacted by Dr. Martin S. Cetron of the Centers for Disease Control and told he had extremely drug resistant TB (XDR-TB). Dr. Cetron advised him not to take a commercial flight, and told him to obtain assistance from the U.S. Embassy, which would arrange an examination by a tuberculosis expert. Nonetheless, on May 24, he flew from Rome to Prague, then from Prague to Montreal. He then drove to Champlain, N.Y., on May 25 and entered a New York hospital. He did not interact with anyone in the hospital except trained medical workers, according to the New York City health department. On May 28, he was flown to Atlanta on an aircraft owned by CDC, and was subsequently placed in Atlanta's Grady Memorial Hospital under federally enforced isolation. The CDC identified several factors that allowed this debacle to unfold: one was time zone differences; another was lack of coordination between American and international authorities; yet another was how to quickly retrieve passenger manifests from airlines. Thus, by the time the center got his name on a no-fly list, he was already landing in Montreal. The man's bride is not infected, said officials. CDC director, Dr. Julie L. Gerberding, said doctors had not determined the source of the man's infection, nor had they been able to match it with any other known case. People who think they may have been exposed to TB or XDR TB can call (800) CDC-INFO for more information. For information about multi-drug-resistant TB (MDR-TB), visit the Library. Lethal TB Threat Updateby Fred EdwardsJune 4, 2007 -- This is an update to the bizarre sequence of events described in my library article of May 31, "Lethal TB Threat Hits Airline Flights." That article related that a man infected with multi-drug-resistant TB flew from Atlanta to Europe, jetted around the Continent, presumably was married in Greece, flew to Montreal, drove to a hospital in New York, and was ferried aboard an aircraft owned by the Centers for Disease Control and Prevention (CDC) to a quarantine room in an Atlanta hospital (see Library or details).The man has been identified as Andrew Speaker, a 31-year-old personal injury lawyer based in Atlanta. In another bizarre twist, his new father-in-law, Robert C. Cooksey, has worked at the CDC for 32 years. He is assigned to the Division of Tuberculosis Elimination, and has co-authored papers on TB. He has been tested negative for TB. Or is Cooksey his father-in-law? Mayor Angelos Roussos of Santorini, Greece -- where Speaker and his fiancee, Sarah Cooksey, a third-year law student at Atlanta's Emory University, say they were wed -- said a clerk informed him that the couple had not produced the necessary paperwork for a civil marriage, so a "wedding never happened." In a Newsweek magazine interview conducted Friday, June 1, Speaker said, "I know we went over and had a ceremony and that local officials (in Greece) had me sign all these documents. I know we exchanged rings." Why did he ignore warnings by federal health officials not to board another flight? He told the Atlanta paper he feared he wouldn't survive if he didn't reach the United States. He chose to sneak home by way of Canada instead of flying directly into the United States. Speaker was allowed back into the States by a border inspector who disregarded a computer warning to stop him and don protective gear, officials said. According to the Associated Press, the unidentified inspector explained that he was no doctor but that the infected man seemed perfectly healthy and he thought the warning was merely "discretionary." The inspector was removed from border duty. On Thursday, May 31, Speaker was flown from New York to Denver, accompanied by his wife and federal marshals. He was admitted to Denver's National Jewish Medical and Research Center, where doctors planned to isolate him and treat him with antibiotics. They also hope to determine where he contracted the disease. His care could cost as much as $350,000, said an official. In addition, the air ambulance flight and other costs of transporting him from Atlanta to Denver on Thursday morning came to $12,000. A spokeswoman for Kaiser Permanente, Speaker's health insurer, said the company paid the bill. So what will happen next? Of course we all hope Andrew Speaker will be cured. And we hope that he didn't infect anybody -- or if they did, they will be located and cured. We suspect to hear of lawsuits. And we expect to see a book or a TV special on the street. This chain of events would be hilarious to somebody not directly affected if it wasn't overshadowed by the deadly White Plague. The content of Genealogy Makes History may be copied or retransmitted for information purposes, but may not be used for any commercial purpose without my written permission. I retain all copyright and proprietary rights. Please include this notice and credit the source as Genealogy Makes History by Fred Edwards. |
|
|