Tuberculosis: A Deadly Return

If an evil scientist wanted to concoct a perfect environment for spreading disease, he would do well to study the New York City Criminal Courts Building in Brooklyn. The basement houses 10 "pre-arraignment holding pens," where, on a typical day, more than 200 suspects contend for standing room as they wait to be charged with offenses ranging from turnstyle-jumping to murder. Cramped and windowless, each 10-by-15-foot cage holds at least a dozen detainees, many of them homeless, drug-addicted and sick. Thousands pass through the pens each month, some staying two or three days before returning to the streets or moving on to prison or jail. Yet no one screens them for conditions that might pose a health hazard. One of the city's few concessions to disease control, a ventilation system installed in 1932, hasn't worked for at least six years. A huge fan pushes the same fetid air through the cages day and night.

Until recently, the inhumanity of the holding pens drew little notice. Today, the conditions are inciting alarm-not just among the detainees but among many of the people who work in close contact with them. Merlin Batisto, a 35-year-old corrections officer, has taken to wearing gloves and a mask. The inmates talk of avoiding the toilets and drinking water-and lawyers talk of avoiding the inmates. The reason is embodied in a single word: tuberculosis. After declining for nearly a century, a disease once ranked as the nation's leading killer is back and poised to reestablish itself as a major cause of suffering and death.

Just eight years ago, the United States had the lowest TB rate in modern history. Improvements in nutrition, hygiene and hospital care had kept the disease in almost steady decline throughout the first half of the century, and the free fall had continued since the advent of antitubercular drugs in the 1950s. Then, in 1985, TB incidence started rising. It has risen ever since. By 1990, Americans were suffering 16 percent more TB than in 1984 (25,700 cases, up from 22,000), and nearly 40 percent more than previous trends would have predicted. Many cities are now living with rates five to seven times the national average of 10 cases per 100,000 people. In the poorest sectors of American society, TB rates surpass those of the poorest countries on earth. Young black men in New York City suffer 345 cases per 100,000. In North Carolina's migrant-labor camps, the rate among U.S.-born blacks is 3,600 cases per 100,000. That's more than 10 times the case rate in sub-Saharan Africa, where TB is still a leading killer.

The return of TB is not a fluke or a mystery but the predictable outcome of a glaring social failure. Over the past decade, homelessness, drug abuse and AIDS have left a huge population defenseless against the germ that causes the disease. By ignoring those people's medical needs-and crowding thousands of them into prisons, shelters and holding pens-America has essentially cultivated the contagion. "We knew how to cure it," says Dr. Michael Iseman of the National Jewish Center for Immunology and Respiratory Medicine, in Denver. "We had it in our hands. But we dropped the ball."

The consequences are growing ever harder to ignore. Drug-resistant TB-which is 50 to 80 percent fatal, even with intensive treatment-has shown up in 17 states since 1989, and experts agree that without major new control efforts, it could soon become the norm. Containing it won't be easy. Because TB is an airborne infection, the only sure way to prevent outbreaks in a high-risk setting is to isolate active sufferers. Yet the most vulnerable facilities are often ill-equipped to do that. In New York City, where one in five convicts is infected with HIV and nearly that proportion test positive for tuberculosis, not one jail has separately ventilated cells, Drug treatment is still the best way to keep TB from spreading, since it eliminates the contagious condition. But success requires months of meticulous pill taking. For people who lack homes, to say nothing of doctors, the obstacles are daunting.

So far, few middle-class Americans are directly threatened by the disease. But that is no argument for complacency. A TB epidemic will cost the nation dearly, even if it never reaches the middle class. And there is no reason to assume it won't. "The public doesn't have a sense yet of just how serious the TB issue really is," says Michael Osterholm, an epidemiologist at the Minnesota Department of Public Health. "When we look back at the '80 two social failures will stand out from all the others: the savings and loan crisis and the return of TB."

Worldwide, TB causes more deaths than any other infectious disease. An estimated 1.7 billion people (including at least 10 million Americans) carry the tuberculosis bacterium. Eight million of those carriers develop active TB disease each year, and 3 million die. The germ spreads on airborne droplets, released from deep within the lungs when a TB sufferer coughs (asymptomatic carriers aren't contagious). Anyone sharing a poorly ventilated space with a coughing sufferer can contract the infection. No consensual act is required. Just breathing. Unlike flu or measles, diseases one can contract just by walking through a room, the average TB infection results from six months of eight-hour-a-day exposure. The catch is that the risk of transmission varies greatly from one setting to the next. "Workers in shelters are converting after very little exposure," says Dr. Jeffrey Laurence, director of the Laboratory for AIDS Virus Research at the Cornell University Medical College in New York City. "If you work in a shelter, the chances are better than even that you'll acquire the organism."

Once infected, an otherwise healthy person will react to a skin test that gauges whether the immune system recognizes proteins from the TB bacterium. Because the body's defenses normally hold the bug in cheek, nine in 10 carriers never suffer any symptoms. But if a carrier's immune system falters, the germ may start to multiply, ravaging the lungs or even spreading to other organs, such as the liver, kidneys, lymph nodes and brain. Without drug treatment, half of all cases are fatal.

Until recently, the people most likely to develop active TB were the middle-aged and elderly. Today, incidence is rising most rapidly among young adults, whose resistance should still be high. "It's a different ball game," says Barry Bloom, Weinstock professor of microbiology and immunology at New York's Albert Einstein College of Medicine. "These are people with HIV, drug abusers, people living in shelters or on the streets."

Social deprivation has always been a risk factor for TB. High stress, poor nutrition, crowding and substance abuse all foster the illness, and a lack of medical care helps tighten its grip. Even when homeless people get their TB diagnosed, Bloom says, a third of them receive no treatment because health workers have no way to locate them. Migrant farm workers often recruited from shelters and soup kitchens, fare little better. They live in crowded, airless quarters, and they're often docked for taking time to seek care. In a study of occupational injuries among migrant workers, Stephen Ciesielski of the University of North Carolina, in Chapel Hill, found that one injury in three went untreated. "If they can't get attention for a broken leg, " he says, "they sure won't get it for a cough"--even though the cough may signal TB.

Poverty wasn't invented during the 1980s, but the AIDS epidemic helped amplify its effect. Unlike healthy TB carriers, with their one-in-10 lifetime odds of illness, HIV-infected TB carriers develop active, contagious disease at a rate of 10 percent a year. "If they don't die of something else first," says Iseman of Denver's National Jewish Center, "virtually 100 percent of AIDS patients carrying TB bacteria will develop the illness."

In fact, AIDS patients often develop TB disease as they contract the bacterium, skipping the latent stage of the infection altogether. The potential impact is clear from a recent account of an outbreak in a San Francisco residence for people with HIV. During a five-month period last year, 12 of the facility's 30 residents developed active TB. Analyzing bacteria drawn from the sufferers' lungs, researchers discovered that all 12 harbored the same strain, suggesting that one of them had infected the others. "Nobody knew how rapidly TB could occur in that kind of setting," says Dr. Gisela Schecter of the San Francisco Department of Public Health. Ordinarily, it would take years for a single case of illness to cause such repercussions.

AIDS is affecting TB incidence all over the world. In Africa, where an estimated 3 million people are coinfected with TB and HIV, many countries have seen tuberculosis incidence double since the mid-1980s. But AIDS is not entirely to blame for the, return of TB, at least not in the United States. "Even if bad things like HIV and homelessness hadn't occurred, TB would have come back," says Bloom. "People have treated this as a great surprise, but it's a predictable result of abandoning public-health measures that were working. "

As recently as 1969, the federal government was pumping $20 million a year into local clinics and hospitals in the form of TB project grants. States and cities invested heavily as well. By the early '70s, victory seemed imminent, and the control effort succumbed to what Dr. Lee Reichman, head of the New Jersey Medical School's pulmonary division, calls the "U-shaped curve of concern." Declining incidence triggered a loss of concern, a drop in funding and, ultimately, a resurgence of disease. As the federal government replaced TB project grants with block grants to be used at local discretion, states and cities set about dismantling successful treatment programs. In New York City alone, public officials eliminated 1,000 TB beds from municipal hospitals, supposedly to make way for more efficient outpatient programs. But lacking a TB crisis, and faced with a financial one, the city let the new efforts slide.

Congress has restored some earmarked funds since 1982, but TB has not been a priority under the Reagan or Bush administrations. Three years ago the Department of Health and Human Services (HHS) came up with a sweeping TB-elimination plan, complete with program guidelines and projections of a declining caseload. The Centers for Disease Control estimated that launching the effort would cost $30 million to $34 million a year. HHS never asked for the money. In two subsequent budget requests, the department sought only the $7 million to $12 million it was already spending. The new program languished, and incidence continued to rise. "What happened," fumes Rep. Henry Waxman of California, "was the equivalent of public-health malpractice." HHS Assistant Secretary James Mason defends the record saying TB funding might have declined rather than remaining flat "if we hadn't put it on high priority. " He adds that when the disease "really hit the fan, the budget was quickly accelerated. " The administration requested $28 million for TB control in its 1992 budget and is proposing to spend $66 million next year. Unfortunately, funds don't go as far once a disease like TB "hits the fan." The American Lung Association now estimates that bringing it under control will cost at least $90 million a year.

One reason TB-control programs are so important is that antitubercular drugs are such tricky instruments. Six months of treatment with several antitubercular drugs (isoniazid, rifampin and pyrazinamide are the most common) costs under $300 and will almost always cure TB. The trouble is that treatment can relieve the symptoms within a few weeks, prompting people to abandon their pills prematurely. And partial treatment is worse than none, for it helps cultivate drug-resistant strains of TB. When a patient takes only some of his pills, or stops treatment early, the most susceptible germs are eliminated but the most obstinate remain staked out within the body. If those germs get reactivated later, the second bout of illness is harder to treat-and the sufferer can pass it directly along to others. As the cycle is repeated, it quickly yields germs that the standard medications can't touch.

When TB was treated exclusively in hospitals and sanatoriums, health workers could easily ensure that patients took their medication. As outpatient care became the norm health departments grew lax. Instead of managing individual cases, clinics took to writing prescriptions and hoping for the best. Not surprisingly, fewer and fewer patients finished their medication. At New York's Harlem Hospital, a recent study of TB patients found that only 11 percent completed treatment once they were discharged. A staggering 89 percent drifted off their pills, and 27 percent were sick again within a year. Christopher Murray, a Harvard epidemiologist who has studied TB for the World Bank, says few places on earth can boast such a dismal record. In a "bad" developing country, he says, 40 percent of all patients complete treatment; in a "good" one, the completion rate is 90 percent. "Tanzania, Malawi and Mozambique all have 85 percent [completion rates] in very difficult circumstances," says Bloom. "Why can't New York City do what a poor country like Tanzania can do?

Whatever the reason, New York is now paying a high price for its negligence. The proportion of new TB cases resistant to at least one standard drug jumped from 10 percent in the early 1980s to 23 percent last year. Multi-drug-resistant tuberculosis (MDR TB) has increased just as dramatically, from 3 percent of all cases to 7 percent. In the past year alone, MDR bacteria have swept through two prisons and several hospitals in New York and Florida, killing a guard, a dozen inmates and scores of patients.

Drug resistance is not just an East Coast, urban problem. In a recent study, the Centers for Disease Control found that 13 states-including Hawaii, Arizona and Washington-had recorded cases of MDR TB during the first quarter of 1991 alone. So far, 90 percent of the cases have involved people with HIV or AIDS. But there is no reason to assume they're the only ones contracting the infection. Some of today's sufferers are no doubt passing drug-resistant germs on to others. "We're talking about people getting infected with strains for which there is currently no treatment," says Osterholm, the Minnesota epidemiologist. "There are people walking around with a 10 percent lifetime chance of developing drug-resistant TB. All we can hope for is that 20 or 30 years from now we'll he able to treat them."

Those people include not only the sufferers' family members and their fellow prison inmates, hospital patients and shelter dwellers but also the people who work in those settings: the cops, guards, lawyers, nurses and doctors. TB infection has become particularly common among inner-city hospital workers. Dr. Victoria Sharp, director of the Spellman Center for HIV-Related Disease at St. Clare's Hospital in New York, says a rising share of the center's 80 employees test positive for TB infection. Sharp herself has developed a positive skin test during the past two years and can only guess whether shell develop TB. At Brooklyn's Woodhull Hospital, a newly released survey shows that 78 staffers contracted TB infection last year alone. All 78 had tested negative in 1990.

No one can say just how rampant TB will become in this country. But the problem will likely worsen before it improves, for the AIDS epidemic now complicates every effort to control it. AIDS has created more TB sufferers, accelerated the course of the disease and made the infection harder to identify. Still, there is no question the TB explosion could be stopped. Tuberculosis is not an incurable illness, just an illness we're failing to cure. Experts agree that several features will be central to any plan of attack.

Since prophylactic treatment can rid the body of a latent TB infection, one strategy is to treat the most disease-prone TB carriers-indigents, prisoners, people with HIV-before they become sick and contagious. This is admittedly a crude measure. Because the skin test gauges the immune system's familiarity with TB, and not the actual presence of the germ, people with flagging immunity often produce false negatives. When the skin test does identify a TB carrier, it reveals nothing about the strain he carries. If the bug happens to be drug resistant, prophylactic treatment will accomplish nothing. Even so, many experts see prophylaxis as a necessary shot in the dark.

When someone develops active TB, the key to preventing a wider outbreak is to recognize and treat the illness promptly. Unfortunately, the early symptoms are often indistinguishable from those of AIDS, and other lung infections can obscure TB on a chest X-ray. The definitive test is to culture and analyze microbes drawn from samples of sputum (material coughed up from deep within the lungs). But these culture tests can take 12 weeks. If the bug turns out to be drug resistant, and the patient spends those weeks on a worthless treatment, the result can be a dead patient. Researchers are now working on several faster tests, but few are in clinical use. For now, some doctors are treating every AIDS-related TB case as if it were drug resistant. "Some think that may be overtreating," says Margaret Fischl, an AIDS researcher at the University of Miami Medical School. "The bottom line is, we don't have a good alternative."

Once a TB patient starts treatment, he quickly becomes noncontagious. But for hospitals and prisons, with their large, vulnerable populations, every new case of TB is a potential crisis. The drill for preventing institutional outbreaks is to place anyone with active TB in a closed, separately ventilated area until the infection is under control. Many large facilities are now scrambling to create or expand isolation units-but many have a long way to go. Four years ago a federal judge ordered New York City to start housing contagious inmates in a "medically appropriate manner. But the first isolation units won't open until May.

The greatest challenge in TB control is the seemingly humble one of getting patients to take all their medicine. The golden rule, confirmed by decades of experience, is that people can't be left to their own devices. As Bloom puts it, "You're committing murder when you hand someone a piece of paper and tell him to take it to the local pharmacy. " When health workers stay in touch with TB patients, whether by calling on them or luring them to a clinic, the vast majority do complete treatment. "Sometimes it takes a little imagination," says Reichman. "Give them a cup of coffee. Talk to them. Pay them an honorarium to come in and take the medicine. If the public doesn't want drug-resistant TB, and if bribing people is the way to get them to take their medicine, then I say bribe them."

There's no shortage of good examples to emulate. In China, TB patients get regular visits from a village doctor. In Newark, N.J., public-health nurses take them coffee and cookies. In L.A., the Homeless TB Patient Incentive Program draws street people to a tiny skid-row clinic each day. For taking their pills, the clients receive vouchers for meals and rooms at a nearby SRO. Given the cost of treating even one case of MDR TB ($180,000 or more, including hospital bills), the program could probably offer first-class hotel accommodations and still save the taxpayers money.

Unfortunately, neither SROs nor Hiltons are well equipped to manage active tuberculosis. Neither are homeless shelters. And as public hospitals overflow with TB patients, many experts are beginning to wonder if it isn't time to revive an old institution: the sanatorium. "There's a very good argument for reopening sanatoria," says Osterholm. "It's not an overstatement. All of us have talked about it. We want to provide the most compassionate, effective care. I think it's an obvious solution when the indigent TB patient poses direct risk to thousands of others living in shelters." California health officials are eying the creation of voluntary TB hospitals, where homeless patients could find what one official describes as "a warm atmosphere, three square meals a day and supervised therapy. " In New York, meanwhile, a task force for the New York City Health Department may soon propose building a secure facility where TB patients who refuse treatment can be held against their will. Few health officials relish the thought of locking people away. Yet few would argue against compulsory care. Refusing treatment is not just suicidal but a threat to public health.

Technological advances will eventually make treatment less troublesome. One possibility is a subcutaneous implant, similar in design to the contraceptive Norplant, that could release medicine directly into the body over a period of months. A more modest advance, already in use in many parts of the world, is a single pill that combines three medications that normally have to be taken separately. But TB is not just a technical challenge. It's an unmistakable symptom of broader social ills ranging from poverty, homelessness and AIDS to the collapse of the health-care system. "The conditions that cultivate this problem are getting worse," says Osterholm. "We're now dealing with TB in settings where compliance is always going to lag. " Poverty, homelessness, AIDS-they may still seem like other people's problems. But TB is one consequence we will all suffer together.

Tuberculosis rates vary widely from state to state, as do the numbers of cases recorded in major cities. But data show that the disease is affecting every region of the country.

Tuberculosis Rates State by State

New York City 3,520 Los Angeles 944 Chicago 705 Houston 522 San Francisco 334 Miami 272 Philadelphia 258 Detroit 233 Dallas 229 Atlanta 203 SOURCE: CENTERS FOR DISEASE CONTROL

TB has always hit hardest in poor areas. Few have been harder hit than central Harlem.

Tuberculosis Case Rates

SOURCES: K. BRUDNEY AND J. DOBKIN; NYC DEPT. OF HEALTH

Anyone can breathe the germs coughed by a person with active tuberculosis. People in frequent contact with TB sufferers should be tested regularly. ..L1.-

High-risk groups include people with AIDS or diabetes, workers or residents in nursing homes and prisons, and people from African or Asian nations with high TB rates.

A TB skin test, which is part of a routine physical, is the only way to tell if you have a tuberculosis infection.

For those who test positive, a chest X-ray or biopsy can determine whether the lungs are affected by disease.

SOURCE: AMERICAN LUNG ASSOCIATION

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