There are two forces working against us. The first is diminishing resources. The current trend in funding for TB control clearly shows a dangerous public health phenomenon at work: the “U-shaped curve of concern.”
When a serious disease like TB catches the attention of the public and policymakers, more resources are directed to control it. New cases drop as those resources take effect and a measurable impact on the disease is reported. As cases come down, resources get reduced or appropriated elsewhere – and cases rise again.
In other words, the program is eliminated rather than the disease. When this happens, the consequences can be dire.
In the late 1970’s and early 1980’s, TB rates fell nationally. Congress declared victory, cut funding, and the cost-effective programs that had worked so well were abolished.
Just as the U-shaped curve predicted, between 1985 and 1992 we witnessed the most rapid increase in TB rates of any industrialized country ever: 20 percent in adults, 35 percent in children. Hundreds of millions of taxpayer dollars had to be appropriated to contain a completely avoidable epidemic.
New York City was hit by an epidemic of multidrug-resistant TB, which cost more than a billion dollars to reverse. A frenzy on the floor of the New York Stock Exchange ensued after a stock trader was diagnosed.
Media reports described widespread panic among the city’s residents, with long lines of patients waiting to be tested.
America is woefully unprepared to face another TB epidemic today, particularly of the drug-resistant variety.
Accounting for inflation, domestic TB funding has dropped by half since 1994. As a result of the federal government’s “sequester,” the CDC’s Division of TB Elimination, which administers TB resources, will see additional cuts between five and nine percent this year. The Global Fund to Fight AIDS, Tuberculosis and Malaria, which protects Americans from TB by fighting it abroad, will see similar cuts.
This drop in funding has opened the door for another TB resurgence. We’re already seeing signs.
Take what happened last year in Florida. Though the state faced its largest TB outbreak in 20 years, it closed its last remaining TB hospital to save money. Thirteen people died in the outbreak and many more were infected. Officials continue to watch for new cases they might have missed.
Los Angeles is now grappling with the city’s largest TB outbreak in a decade, in which 4,500 people have been exposed. CDC is helping to contain the outbreak, but the agency may have to pull back if the sequester’s cuts go through.
The second force working against us is accelerating drug resistance. The World Health Organization reports that from 2009 to 2011 cases of multidrug-resistant TB doubled in the 27 countries most affected.
Meanwhile, the severity of the resistance is increasing. Since the last U.S. epidemic, we’ve seen the emergence of extensively drug-resistant TB. This strain of the disease overpowers not only the two most powerful first-line drugs, but at least two of the backup drugs used solely to treat resistant strains.
Totally drug-resistant TB was discovered in the last year, first in India then in South Africa. Such cases resist all available antibiotics and are sure to be found elsewhere – an unavoidable fact when one can travel almost anywhere by plane within 24 hours.
Americans are no less vulnerable. U.S. immigration officials are currently holding a Nepalese man with extensively drug-resistant TB in medical isolation. He’s merely one of more than 300 people in the U.S. diagnosed in the past year with some strain of drug-resistant TB.
The only way to protect the public from a dangerous disease like tuberculosis is by providing public health workers the resources they need to sustain the fight against it. For too long Congress has withheld these resources, putting the nation at risk of another TB epidemic.
Reichman is a professor of Medicine and executive director of the New Jersey Medical School Global Tuberculosis Institute and author of Timebomb: The Global Epidemic of Multi-drug Resistant Tuberculosis.