Tuberculosis is a multi-faceted disease caused by a mycobacterium, and which has been a part of human illness and medicine since Ancient times, as evidenced by its presence in Egyptian mummies, and in Egyptian medical treatises from 1500 BC. The Indian Vedas of the same era and the Chinese medical texts as ancient, testify to its universality in time and space. While infection of the lungs, and of the skin are the forms that are most common, any organ system can be affected. The site of the primary infection determines some of the symptoms but others are systemic, eg fever, night sweats, fatigue, pallor, and weight loss.
La miseria (1886) by Cristóbal Rojas (1857–1890) portraying the 19th century conditions leading to the spread of tuberculosis, particularly among poor artists.
Other names for tuberculosis, usually based on symptoms and signs, as well as historical period, are consumption, phthisis, scrofula, Pott’s Disease, and the White Plague. As a key feature, especially in later stages, is weight loss to the point of cachexia (extreme emaciation), many of the names in various languages including the Latinate consumption, and the Greek phthisis, but also the Indian yaksma and the Incan chaky oncay refer to this sign of illness.
"O soave fanciulla", the aria from Puccini's La Bohème, celebrating the love of the poet Rodolfo and the seamstress Mimi, who will later die of consumption
The writings of Hippocrates, Aristotle, and Galen among the Classic physician-writers, and those in the Old Testament as an illness affecting the Jews while in Egypt, give an indication of the duration and range of the disease as an illness phenomenon. The Great White Plague refers to a 200 year period in Europe from the mid-17th to the mid-19th century when tuberculosis was a major scourge. From the mid-19th to the mid-20th century advances in both public health and infectious diseases--which the effort to control and treat tuberculosis helped to advance--resulted in a dramatic decrease in tuberculosis prevalence, morbidity, and mortality in Europe and North America. The discovery of the antibiotic streptomycin in 1944 was a major turning point.
Ward in a Sanatorium for Tuberculosis
Since then tuberculosis, while remaining a problem in underdeveloped nations throughout, has become a new focus of medical attention due to its associations with poverty and AIDS. Tuberculosis is quintessentially a disease of poverty with its combination of malnutrition, overcrowding, and poor sanitation, and of a weakened immune system. As such, it is now again drawing major research efforts through The Global Fund to Fight AIDS, Tuberculosis and Malaria, and through the American Center for Disease Control, specifically the National Center for HIV, STD, and TB Prevention. In particular, drug resistant strains, now a major problem since the 1980’s, are a prime focus.
The novel, and the film based on it, focus on testing of TB drugs on Africans, and the threat of a pandemic of drug-resistant TB
As a disease which profoundly affected individuals (death rate of 50%, and high morbidity), families, and societies, tuberculosis also became a cultural phenomenon, much as AIDS did in the latter part of the 20th century--featured as a motif in literary, dramatic, operatic, dance, and art works. This was especially true during the Romantic Period (early 19th century) when the consumptive, and death by consumption, were a particularly “romanticized” character and theme, respectively. Some of them serve as illustrations here.
La dame aux camélias/The Lady of the Camellias--ballet to Chopin's Piano Concerto no.1
Stop TB Campaign--A Personal Learning Curve
I first became aware of the Stop TB Campaign to eradicate tuberculosis around the globe when it appeared on the CV’s of two extremely bright MENA physicians on government scholarship to Canada. I was helping them to prepare their applications to residency programs, and so we discussed their participation in a way similar to what might happen in an interview for a position.
It was a reminder that although we think tuberculosis has been eliminated in the West, in fact it remains a problem throughout the world, and particularly where poverty and overcrowding combine with climate to create perfect conditions for it being endemic. In medical school I was taught that tuberculosis is a disease of poverty, one where poor nutrition makes people susceptible to illness, inadequate public services aren’t able to meet needs for prevention and treatment, its highly contagious nature makes tuberculosis easy to contract, and poor hygiene due to inadequate facilities along with overcrowding makes spread rampant. Though medication is now available for successful outpatient treatment, it is a long course of treatment (up to 1 year depending on the protocol), and compliance is poor.
René-Théophile-Hyacinthe Laennec (February 17, 1781 – August 13, 1826) inventor of the stethoscope, and major figure in the history of medicine, himself died of tuberculosis aged 45, seen here in a painting, auscultating a patient
However, this learning was mainly a hypothetical. Although tuberculosis had been a problem in Canada through the 1st half of the 20th century, it was considered eradicated. The sanatoriums, the great hospital complexes that served as the treatment centres where children and adults would spend years resting, taking in the fresh air wrapped in blankets and seated in wheelchairs parked on verandas, and being fortified with good nutrition, were long gone, and had been transformed into medical, and often major psychiatric hospitals (I trained in 2 different ones, interviewed in a 3rd and attended a talk in a 4th). Our greatest concern was to be aware of those Canadians who had been vaccinated by BCG (Bacillus Calmette-Guérin) inoculation with attenuated live vaccine, usually as children in Britain, and thus would have a positive result to the standard and mandatory Mantoux skin test. Canadians normally test negative to this, showing no previous contact with the tubercle bacillus; and, if they do test positive, it usually means that they had had contact with the illness, but successfully fought it off without ever becoming ill. Their chest x-ray as a follow-up to a positive skin test would be normal.
Kiefer Sutherland's screen debut as Donald in The Bay Boy (1984), a semi-autobiographical film of the director's, Daniel Petrie's, coming of age in Glace Bay, Cape Breton Island, Nova Scotia, during the Great Depression. This clip shows the ravages of tuberculosis (in the brain and spine) on the once brilliant, athletic Joe, and his family. Later, Joe (19) will commit suicide.
It was during that time that I had a discussion with a former professor, now friend, whose older sister died about 1955 after being ill for some years with tuberculosis. My first reaction, after offering condolences, was to ask whether she had drunk unpasteurized milk, and contracted the disease that way. My friend said no, they lived near a dairy farm in rural England, and she caught it from the tubercle particles released into the air by infected cows. Being both a musician and a literary scholar she described beautifully the sound one would hear in the evening of the cows breathing, and blowing heavily. Sadly, their exhalations carried bovine tuberculosis through the air to nearby humans, including her sister. Due to her sister's illness, she spent a number of years living with her maternal aunt's family in France, so that she would be protected and that her parents could cope with the care-giving necessary. This marked her profoundly, in mostly positive, but some negative ways, as did her sister's death--not only for her own loss, but for her mother's failure to ever fully recover from the death of her firstborn.
Fantine's death from tuberculosis, in Les Misérables, the musical based on Victor Hugo's 19th century French novel of the same name
As a clinical clerk (final year of medical school spent on hospital wards, also called an externship), tuberculosis would be a rare discussion point--most memorably of a patient confined to isolation in a hospital room because he had been non-compliant with the year long medical protocol for outpatient treatment. He looked forlorn, lonely, and bored, and hovered in the doorway of his room, as if craving normal company, and wishing to escape. Tuberculosis is so contagious and such a public health hazard in any community that it is one of the few conditions where the government has the power to confine, to quarantine, and to treat a mentally competent patient against their will.
Oil poster, by Mucha Alphonse, Sarah Bernhardt in Alexandre Dumas' La dame aux camélias
When I was an intern, tuberculosis became a more pressing topic, because recent immigrants were arriving in greater numbers from places where tuberculosis was endemic, and so it had to be considered part of a differential diagnosis. This was accompanied by a certain “THEY are messing up our tuberculosis eradication” on the part of some staff. Since many immigrants were also from former British colonies where the live attenuated BCG vaccine was still administered, the diagnosis of tuberculosis was more challenging than a simple scratch test to start.
One particular case stays in mind because the patient, a recent immigrant from an area where TB is endemic, had the classic night sweats, fatigue, and weight loss of tuberculosis, but no respiratory symptoms nor skin lesions, which are the most common forms and the ones with which most are familiar. Ah, but TB is a multi-organ disease and he had TB of the abdomen. Only the infectious disease specialist was delighted with this finding--as a matter of professional interest, while being professionally compassionate and caring of the patient himself.
John Keats (31 October 1795 – 23 February 1821), the youngest of the great English Romantic Poets, died young of tuberculosis, as did his brother
During my residency, TB was making a comeback. There were 3 hypotheses as to why: brought in by recent immigrants who were infected but didn’t show symptoms and had a clear x-ray during their medical approval for a visa; reactivation of strains dormant in old sanatoriums which were now bustling hives of medical and psychiatric care, usually affiliated with teaching hospitals; relaxed public health measures, made compliance by a false belief of immunity. Alas, one needs to add to these the HIV/AIDS epidemic which caused sharp increases in the incidence and prevalence of a number of infectious diseases and cancers due to the increased susceptibility of these immuno-compromised patients.
Susan Sontag's Illness as Metaphor, a philosophical essay on cancer as the paradigmatic 20th century illness, comparing it to tuberculosis as that of the 19th century was followed by AIDS and Its Metaphors, a reflection on the AIDS epidemic of the later fifth of the 20th century
While doing an elective in Morocco, I spoke with a respirologist who described tuberculosis as still a very active problem in the country. She also talked about seeing forms of tuberculosis and degrees of severity that were “only in text books in France, whereas here they are a regular clinical occurrence”. Later, when I was at a conference in Iran, the opening key note address emphasized that in Iran there were major health problems which required a broad approach to medical ethics, including attention to public health measures but also proper water and sewage systems even in remote areas. I was surprised to learn that tuberculosis was an important problem, in a country which also had the latest in reproductive technologies. However, it made sense that, given that a couple’s (often construed as a woman’s) infertility was a main cause of divorce, reproductive technology would be a main focus of medical interest and effort.
Davos, location of the Sanatorium setting of Thomas Mann's novel The Magic Mountain (1924)
So, back to the students with the Stop TB Campaign as an activity on their CV. In their part of the world tuberculosis is a more active concern for all rather than being a problem in Canada for AIDS patients, immigrants, and native peoples. It was a practical part of their GP training, and of their GP practice in rural villages. It is a national shame that while rates of tuberculosis are low among non-Aboriginal Canadians, they remain high among Aboriginal Canadians, because of living conditions and insufficient public health care. Most cases are new cases, and most occur in young children, which is unusual compared to the non-Aboriginal population.
Although the total percentage of Canadian cases is highest among the foreign born, and higher among non-Aboriginals, as a percentage of the population, it is markedly higher among Aboriginals, who are 30 times more likely to suffer from tuberculosis than is a non-Aboriginal Canadian. These statistics are much closer to those in the 3rd rather than the 1st world. In other words these students will be better prepared to deal with TB when they see it among the immuno-compromised and the foreign born who are most likely to come to their medical attention, but are unlikely, in the same way as most physicians are, to see its impact among Aboriginals particularly in the far north.
Stop TB Campaign--Globally
The Stop TB Campaign http://www.stoptb.org/ has as its long term goal the use of public health measures, and antibiotic treatment to eradicate tuberculosis. Its excellent website connects with information and resources from the World Health Organization, among others. Fact sheets on TB in English, Arabic, French, and Spanish are a good starting point for information as is the slideshow 10 fast facts on TB.
Official Stop TB photo of new Goodwill Ambassador Craig David
As for the 2010 campaign, which started mid-March and is now just ending, the same main site has statements from UN President Ban Ki-Moon, and Medical Chair of the campaign, Dr Espinal. Among other areas of interest is one showing the main research priorities and endeavours in prevention, treatment, and eradication. Among the Goodwill Ambassadors for the campaign is the newest, British R& B singer-songwriter, and actor, Craig David.
One of Craig David's most highly considered song videos
Craig David's brief but informative message about tuberculosis, including his personal connection to tuberculosis in Africa and in Britain, as well as his philosophy of prevention, treatment, and eradication
The campaign sponsors an annual photography contest which was won this year by David Rochkind for his photojournalism essay on Tuberculosis in Mumbai. An excellent video explains well and esthetically the myths and realities of tuberculosis prevalence, communicability, and treatment, showing misconceptions worldwide. Indeed tuberculosis affects most, if not all countries, such that the Stop TB campaign has 1331 partners worldwide, but the burden of illness is different nationally as the map below shows. These 22 countries alone account for 80% of the tuberculosis cases in the world:
The 22 countries with the greatest TB burden
Of these, those posing the greatest burden are India, China, Indonesia, Nigeria, and South Africa. On the other hand the countries with the highest numbers of cases per 100,000 are Djibouti (813), Somalia (249), Sudan (243), Pakistan (181), and Afghanistan (168).
MENA countries are not high burden countries which are mainly in S-E Asia, and a corridor of sub-Saharan countries running down the east side of the continent (not the Horn of Africa, except Ethiopia but still need to fight to lower tuberculosis prevalence. Of the MENA countries, Morocco (92), Yemen (76), and Qatar (70) have the highest number of cases per 100,000, while Saudi Arabia (46) occupies a middle ground with Iraq (56), and Bahrain (40). Interestingly the West Bank and Gaza Strip are lower (20) but more than double that of Israel (8, classified with European countries due to population composition).
Stop TB Saudi Arabia
Saudi Arabia is among the countries which partners with the Stop TB Campaign, and has 2 partnerships listed, King AbdulAziz University (KAU), and Serafi Mega Mall. Stop TB Saudi Arabia also has a Facebook Group with 180 photos of the activities of this year's campaigns in Jeddah and Riyadh (some pictured below), including slides of all English and Arabic press items including these 2:
NATIONBy Fouzia Khan March 16, 2010
JEDDAH – A group of 40 professional scuba divers took part in the Stop TB campaign here on Friday performing an action of gathering at 60 feet under water in the Red Sea. They unfolded a banner which read “Keep our environment clean and Stop TB.”The 11-day Stop TB campaign was launched in the city on March 15.The Stop TB Group of Jeddah has sent a strong message to the world to “keep the environment clean and stop spreading the diseases,” said Mohammed Bakhriba, the founder of the Stop TB Group Jeddah.Dr. Nasha’at Nfouri, environmental specialist said that “our attitude would help or stop spreading of infectious diseases including TB, as we should avoid spitting on the ground, coughing on others’ face and make sure that sunlight enters our houses”. – SG
Saudi Gazette interview on the campaign and its objectives (8th Feb, 09), published on Feb 15th, 09.
(L-R) Dr. Nabeel Noura, Dr. Khalid Radwan and Eng. Mohammad Bakhrieba--quoted this year
NATIONBy Fouzia Khan March 17, 2010JEDDAH – The Stop TB (Tuberculosis) campaign was launched here Monday evening by a group of young Saudis with the partnership of the World Health Organization (WHO) and the cooperation of the Ministry of Health.“We are pleased and proud of the work that has been done by Saudi youth and of their involvement in last year’s Stop TB campaign. Mohammed Bakhrieba, the founder of the Stop TB Group of Jeddah, and his team did an excellent job in creating awareness and promoting the campaign,” said Dr. Sami Badawood, Director General of Health Affairs in Jeddah.Prof. Awad Abuzaid of the WHO projects in Saudi Arabia explained that the partnership of the community and different sectors of society with WHO and government organizations is very important to tackle both chronic and non-chronic diseases.“We are very pleased that we joined the Stop TB campaign not only for Jeddah but for the whole Kingdom,” he said.“This year’s campaign,” he said, “is aimed at containing the use of tobacco in the region. Saudi Arabia is really a tobacco consumption country and it is a grave problem. At the moment, we have two cities, Makkah and Madina, which are tobacco-free, and I hope that in Jeddah the remarkable work being done will bear fruit so that we can get rid of this big problem.”Dr. Naela Al-Judayel, director general and incharge of the national TB program in the Ministry of Health, said the national TB program has been working since 1970 and is progressing effectively.Mohammed Bakhrieba quoted WHO statistics showing that one-third of the world’s population is, one way or the other, exposed to TB bacteria. – SG
Among the activities were information booths in a number of main malls including games for children and pamphlets for adults, conferences, an art exhibit, with prizes for the winners of competitions, and certificates for volunteers. The Jeddah group included an underwater demonstration to draw attention to the campaign, as outlined in the article above, and in the pictures below.
Before the dive
Jeddah Divers for Stop TB
Underwater in Jeddah
More pictures from the Facebook Group's Photos, showing the other activities in Jeddah and Riyadh:
Opening of the Art and Photography Exhibit
Paintings on exhibit
Research Poster exhibit
A beautiful welcome
Sharing information and fun with all age groups, Jeddah
Looking for sweets
Display, Aziz Mall, Jeddah
Display South Mall
Closeup of information pamphlet
Close up of the rest of the pamphlet
Volunteer doctors, at the ready
Volunteers with certificates
Certificates close up
WHO Regional Director, Dr Jazayry
Interns looking at X-rays of chest TB
And to conclude...
One more Craig David video, because...well...how many chances does one get to hear an African-Briton R&B singer do a duet with an Italian contestant on an Italian version of American Idol? Not as good as Otis' recording of "Sitting on the Dock of the Bay" but interesting, especially for the remarks and the judges' comments after the song ended...oh and performed on March 22, 2010, just 2 days before International Stop TB Day, March 24, 2010!
Had you heard of this campaign before?
Has TB touched your life in any way?
Is it a major problem in your country? for whom?
Do you know of any former sanatoriums? What are their current uses?
How much awareness do you think we have of the less media magnetic public health problems in the world?
Have you been involved as a volunteer in analogous awareness campaigns?
Which of the cultural representations of TB are you familiar with?
Which do you enjoy esthetically?
Any other thoughts, comments, experiences?