Outlook: Old Plagues Don't Die, They Evolve

Howard Markel
Washington Post Metro Reporter
Monday, June 11, 2007; 11:00 AM

Howard Markel, a communicable diseases and history of medicine professor at the University of Michigan, was online Monday, June 11 at 11 a.m. ET to discuss his Sunday Outlook article on extensively drug resistant tuberculosis and the threat it and similar once-vanquished diseases pose.

Return of the White Plague (Post, June 10)

The transcript follows.

Archive: Transcripts of discussions with Outlook article authors

Markel, a professor of pediatrics and communicable diseases and the history of medicine at the University of Michigan, is the author of " When Germs Travel: Six major epidemics that have invaded America since 1900 and the fears they have unleashed."


Howard Markel: Good morning. I must confess this is my first online chat with readers. At any rate, I am delighted to take your questions and look forward to a great discussion.


Seattle: Thank you for the detailed information about the re-emergence of tuberculosis and its potential impact on our society. I am concerned, however, that the article did not give information about what we can do to keep this disease at bay. The Stop TB Now Bill (HR1567 and S968, .pdf file) and The Comprehensive Tuberculosis Elimination Act of 2007 (HR1532, .pdf file) will provide funding to address the global and domestic aspects of this health crisis. We must all urge our elected officials to enact this important legislation.

Howard Markel: You are absolutely right. Alas, word count issues pre-empted your important point, but I am so glad you brought it up here. The Stop TB Now Bill -- and others like it -- must be passed. Everyone should contact their elected officials about doing something about this global threat.


Fairfax, Va.: Because of their susceptibility to TB, could we come to a situation where the HIV community has to be identified and possibly separated from the general population?

Howard Markel: My knee-jerk response as an American citizen is to reply "it can't happen here," to lift a phrase from the novel by Sinclair Lewis, but there is always that risk if we are not careful in how we contain infectious diseases.

The issue of stigmatization, from temporary isolation to permanent exile, of specific groups in American society has been one of the central concerns of my work. Indeed, I have written two books about the stigmatization of so-called "socially undesirable" groups at different points of American history -- "Quarantine!" and "When Germs Travel."

These books tell many unflattering stories about the many social abuses of quarantine, and other public health measures that occurred in the 19th and 20th centuries, with reference to TB, AIDS, trachoma, cholera, typhus, and the role they played in the American immigrant experience.

There have been many wonderful books on the AIDS crisis and the social risks to the HIV-positive community that are worth reading, such as Mirko Drazen Grmek's "History of AIDS" and of course Randy Shilts's "And the Band Played On."

In short, the premise of your question is a great one. We always have to be on guard against the potential misapplication of such measures.


Fairfax, Va.: Do you know how and where Speaker acquired his type of tuberculosis, or will it never be known or publicly disclosed?

Howard Markel: No, I do not. As time progresses, I expect there to be more and more information released about the natural history of Speaker's illness. But pin-pointing where precisely he contracted TB might prove to be difficult, if not impossible. He did travel to many places around the world, including some locations where TB and XDR-TB have been a problem; but he also may have contracted the infection in his hometown.

It is a common question I often hear as a historian of epidemics: where did the infection originate? who was the so-called "Patient Zero"? And while our detective tools have progressed immensely in terms of the ability to DNA fingerprint and analyze specific strains of almost any microbe, finding the precise spot where Speaker first encountered the Mycobacterium tuberculosis may prove as unenlightening as a parlor game.


Richmond, Va.: His father-in-law is a TB expert; does he work in the lab, and could he have carried a spore home and infected his son-in-law?

Howard Markel: That possibility, according to media sources reporting on the event, has been ruled out.


Columbia, Md.: Are there any prospects for a tuberculosis "vaccine"?

Howard Markel: There is a vaccine, a very good one called BCG (Bacillus Calmette-Guerin). It is used in many nations of the world and may be as much as 50 percent (some reports say more) effective in preventing pulmonary TB. Here in the United States, the medical and public health community have not elected to vaccinate individuals with BCG, preferring instead to diagnose exposure with TB skin testing and medically treat those found to be TB-positive. This may change in the decades to come, if drug-resistant strains of TB continue to proliferate.


Bridgewater, Mass.: How common is it simply to stumble on a case of non-symptomatic TB? Is the prognosis much better if it's caught before symptoms develop? I ask because the father-in-law-to-be didn't seem particularly concerned about his daughter being infected -- that seems the most peculiar thing about the whole story. Are the health authorities making a bigger deal out of this, taking the opportunity to catch the public's attention, than the medical facts actually warrant? (That is, because it was caught so early it really wasn't a risk to anybody.)

Howard Markel: The definitive diagnosis of TB takes six to 10 weeks (sometimes more) because the microbe grows so slowly. I cannot address the concerns or thoughts of  Speaker or his family or his precise medical history because I have not examined or spoken to him.

What I do insist, however, is that tuberculosis is a contagious disease. It is particularly a problem on long flights, where people breath recirculated air for hours on end.

The medical facts most certainly warrant the need to ask such a person not to travel on an airplane -- and if that person does not comply, I would hope he would be prevented boarding by some other means. My question for you is, are you willing to sit next to this gentleman on the next flight to Europe? Would you want your child sitting next to him on the flight?


Maryland: Do you anticipate another era of mass mandatory quarantines in TB sanitariums? I think the vast majority of people are compliant, but if they won't comply voluntarily, then the involuntary segregation might be our only option. That said, how do we ensure that the CDC clearly communicates its expectations and requirements to an effective individual? I have to say I don't doubt Mr. Speaker's version of events, given my own dealings with governmental bodies.

Howard Markel: No I do not anticipate another era of mass mandatory quarantines. This is a rather unusual case in so many ways -- which, I think, is why we are all so fascinated by it.

Sadly, history demonstrates that while the vast majority of people may be compliant, there are often a few who are not. Given that contagious diseases are socially mediated -- depending on the virulence of the microbe they carry and who they are able to communicate it to -- when it comes to epidemics, one person really can make a difference!

I like your point of using this episode to better improve how we coordinate, communicate and activate public health measures to contain or prevent the spread of such terrible infections as XDR-TB. It is a critical aspect of disease control and demands constant attention to detail. There are many agencies involved in this effort, from the CDC to your local health department. But a critical point I had hoped to make in my op-ed was the individual responsibility we all have when told we have a contagious disease.


Arlington, Va.: Could XDR-TB turn into a worldwide pandemic that would make our fears of the bird flu look minor? Does this have the potential to kill tens of millions of people?

Howard Markel: Sadly, tuberculosis already is a worldwide pandemic. Each year 8.8 million people are newly infected and 2 million die of it. The XDR-TB strain is only the newest wrinkle in this devastating infectious disease crisis.


Seattle: The New England Journal of Medicine reported that our investment in TB control abroad has as much as a 3:1 return on investment. There are two bills in Congress that address domestic control HR 1532 and foreign control HR 1567. Do these Bills address what we need to do to confront this adaptable disease?

Howard Markel: They are a start; we need to do so much more. All American citizens need to get informed about this issue and to contact their elected officials to sponsor and pass such bills that address both domestic and foreign control of tuberculosis.


Howard Markel: This has been just a wonderful experience. Thanks so much for your interest and I am sorry I could not get to everyone's questions. But I hope that you all stay informed about the risks of microbial threats and take heart in the fact that there is so much we can do to prevent these crises from ever occurring.


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