The rise of drug-resistant tuberculosis is hidden in plain sight

Tuberculosis thrives in the cramped slums of Mumbai.Credit: Atul Loke/The New York Times/Redux/eyevine

The Phantom Plague: How Tuberculosis Shaped History Vidya Krishnan Public Affairs (2022)

In 2020, when all eyes were on COVID-19, tuberculosis infected nearly 10 million people worldwide and killed 1.5 million. It was also the first year since 2005 that the number of deaths from the disease had increased. This increase is likely due to the impact of COVID-19 on testing and treatment services.

The rich world is still eagerly awaiting a return to normal, pre-pandemic life. For many, “normalcy” was already deadly before 2020, reminds us Vidya Krishnan, a journalist specializing in global health. The Phantom Plague. COVID-19 is not the only infectious respiratory disease knocking on the door: the threat of drug-resistant tuberculosis still hangs over the world. As in the coronavirus pandemic, it is the people with the least social, economic and historical capital who bear the brunt. “Poverty is the disease,” she writes; “TB the symptom.”

The greatest strength of The Phantom Plague is its highlighting of the forces that keep low- and middle-income countries hungry for drugs and at the mercy of Mycobacterium tuberculosis, the cause of tuberculosis. But first, the reader must walk through a familiar history of infectious disease research, some of which is only loosely related to tuberculosis. Interesting nuggets emerge: Dracula was an immigrant carrying a disease that polluted the blood of the people of London; Arthur Conan Doyle may have been one of the first to recognize the specter of drug resistance in tuberculosis while researching a newspaper article.

However, the reward for persevering beyond those early chapters is worth the wait. Krishnan takes a chronological leap to recent years and focuses on India, home to many drug-resistant tuberculosis infections in the world. She brings to life the darkness and stale air of life in the slums of Mumbai. There, the seven-story buildings are spaced just three meters apart – much closer than housing codes allow in areas away from these public housing estates.

These buildings are hotbeds of tuberculosis. Those infected, in Mumbai and across India, often wait months before being properly diagnosed. In the meantime, they are given a hodgepodge of sometimes ineffective antibiotics, some of which have toxic side effects and promote drug resistance.

It’s a maddening world, in which a tuberculosis infection that has spread to her ankle could threaten the life of a young woman, and the old antibiotics available in India, such as kanamycin, do nothing to help her and could ruin his hearing. Better antibiotics to treat Drug Resistant Tuberculosis in India are expensive and in limited supply. Until 2019, they were strictly rationed and available only to people who matched a specific disease profile and lived near one of the few hospitals.

Krishnan rails against India’s rationing of new tuberculosis drugs, such as bedaquiline, and backs up his arguments with terrifying personal stories. But here the chronology of the book can be confusing: for example, the rationing of bedaquiline is introduced and condemned, and Krishnan expresses bewildered indignation that the drug is, for a time, restricted to those living near certain hospitals. . It wasn’t until a few chapters later that she clearly laid out a key rationale for this restricted access: that researchers were still conducting trials to assess the drug’s possible toxic effects on the heart. This organization of information creates some confusion.

Yet Krishnan argues passionately against the reasoning – repeated too often when it comes to treating infectious diseases in resource-poor areas – that people with TB cannot be trusted to take their medicines and should not therefore not receive the drugs they need. . The conclusion of this flawed argument is that these newer and more effective drugs should be denied to these populations because misuse could give rise to resistant pathogens which could then threaten wealthier countries. Krishnan effectively opposes this discrimination and qualifies it for what it is: racism.

She also supports charities whose donations of crucial medicines she says promote addiction and allow countries to defer the need to establish sustainable supplies. It challenges patents and the biomedical monopolies they protect. Innovation scholars, mostly in Western universities, spend their careers analyzing patent data and debating the relative values ​​and costs of a strong patent system. Krishnan does not have it. She describes the support of strong international patents as “fact free”. For her, their only value is to snatch every penny from countries that lack the resources to fight back.

I sympathize with his passion. Her reporting has taken her to people who have lost their hearing, their livelihoods, their loved ones – because, as she argues, they have been denied access to life-saving medicines produced in their own countries. But I was disappointed to find no real rebuttal to the counter argument – ​​that these drugs might not exist without the intellectual property system that allows companies to profit from them. I longed for her to take such arguments head-on and win.

The book is nonetheless a powerful look at the social determinants of health and the lasting imprint of colonialism and segregation on public health. There is a desperate need for new drugs to fight drug-resistant tuberculosis. Meanwhile, as Krishnan reminds us, existing drugs are not used effectively or equitably. It is this injustice that will fuel the spread of drug-resistant tuberculosis.

Competing interests

The author declares no competing interests.

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