This is an archived document. The links are no longer being updated.
TB Notes 1, 2000
The Unusual Suspects
by Lee B. Reichman, MD, MPH
Professor of Medicine,
Preventive Medicine and Community Health
New Jersey Medical School National TB Center
A Founding Component of the International Center
for Public Health
TB people have always been an "in" group. They always
tend to talk to each other, and meet at their own meetings such
as the International Union Against Tuberculosis and Lung Disease,
the American Thoracic Society, and the National Tuberculosis Controllers
Association. Before 1992, if you went to meetings of other groups
(the Infectious Diseases Society of America, the American Public
Health Association, the American College of Physicians, the European
Respiratory Society to name a few), there was precious little TB,
if any, on the program.
But TB docs aren't the only ones who treat TB, and since TB remains
a serious global problem, they shouldn't be the only ones concerned
TB in the United States is now in a downward spiral. Even though
TB in the world remains rampant, in the United States TB rates are
down 7 years in a row including 1999. But, paradoxically, during
this period of decline, interest in TB seems to have markedly increased,
and such interest apparently has increased outside the parochial
TB community. This to my mind is the factor that is reinvigorating
TB and TB control worldwide. It leads me, on the basis of present
evidence, to humbly suggest that the salvation of TB control in
the world as well as in the United States will only occur when the
players are no longer exclusively from that "in" group.
The new outside players could be characterized as unusual
In the past I've been very publicly critical of the WHO's ex-Global
Tuberculosis Programme staff for all too often going it alone, but
I'd like to now commend them and their successes, tentatively at
least, for adopting and leading more of a team approach to deal
with worldwide TB. And their leadership in the "Stop TB"
Initiative, which necessarily requires partnerships, will hopefully
be one more important (if seriously overdue) example. There is now
increasing evidence that they have reached out to many other "unusual
suspects." In March 1998 WHO called together an Ad Hoc Committee
on the Global TB Epidemic (the London conference). This certainly
isn't big news. However, the Ad Hoc Committee of 19 consisted not
only of physicians; more importantly, it included several unusual
suspects: the Commissioner of the Securities Commission of Jordan,
an economist from Zambia, a civil service administrator from India,
a nonphysician university professor from Indonesia, and others.
When this group called on heads of state, parliamentary leaders,
finance, planning, and health minsters, as well as the Director
General of WHO, each to exercise his or her own pivotal role, it
certainly carried more weight than the opinions of a cadre of self-serving
TB doctors and nurses, TB controllers, or TB researchers. And when
the committee called upon governmental leaders to address TB as
an issue outside the health sector which, if not dealt with properly,
must increase costs for the labor force and reflect negatively on
tourism and foreign investment, it also carried important influence.
When they suggested that TB should be handled as a defense
program rather than a social program, such a theme stood
a better chance of success than if broached by the usual interested
For several years many in the TB community have pleaded with USAID
to get involved in international aspects of TB control, if only
because of the realization that this is the best way to control
TB in the United States, where increasing numbers of cases (now
42% in 1998) are in the foreign-born. But it wasn't until Ralph
Nader's Princeton Project 55 (unusual suspects, to say the least)
got involved, that USAID made a commitment to worldwide control
of TB and properly made the United States a significant donor nation
in the global fight against TB.
In a similar vein, the Public Health Research Institute of New
York and the Open Society Institute (the George Soros Foundation)
— again, at least for TB, unusual suspects — were able to get Russia
to mount significant TB involvement in Russian prisons, which will
necessarily require prison as well as civilian DOT, something that
WHO and CDC had been unable to do for years.
The recognition that DOTS works in drug-sensitive cases but may
amplify already existing drug resistance and that MDR TB can be
effectively treated by tailored second-line regimens was made not
by TB physicians, but by Partners in Health, a group from Harvard
University specializing in anthropology and human rights, and which
has led to acceptance by WHO of the so-called DOTS Plus movement
(tailored treatment of MDR TB).
We stand at a crossroads. Some of the players have now acknowledged
that teamwork and partnerships are needed to realistically deal
with TB. A fresh look at a thorny problem by unusual suspects can
have lively and useful results.
In 1992 at the National Commission on AIDS, Joseph A. Califano,
Jr., who had been President Jimmy Carter's Secretary of Health,
Education and Welfare, warned that the conjoined epidemics of AIDS,
TB, and drug addiction form the most frightening threat to public
health America had ever faced. He likened the link of the three
epidemics to Cerberus, the mythological three-headed dog guarding
the gates of Hell!
Mr. Califano, another unusual suspect as far as TB is concerned,
would likely be pleased to know about the progress made in TB domestically
since introducing his metaphor, but global TB still remains a major
I'd like to suggest that the proper approach to dealing with the
global TB epidemic is also three-headed; however, not a Cerberus,
but a three-headed or three-pronged thrust into the 21st century,
reflecting a new collaboration between usual and unusual suspects.
I think we all must agree that government, whether it be WHO, CDC,
or individual ministries of health, cannot do the job alone, and
it is hoped that they will continue to reach out meaningfully both
for advice as well as assistance. Nongovernmental organizations
such as IUATLD, ALA/ATS, or KNVC (Royal Netherlands TB Association)
cannot do this job alone either, and need to include academe and
foundations, which are unusual suspects. But the third prong, previously
totally neglected except as a source of donations and therefore
a very unusual suspect as far as TB goes, is commercial industry!
Industry is the one potential player that has usually demonstrated
the ability to create and maintain an infrastructure, motivation,
expertise, and perhaps most importantly, an ability to get things
done. They get things done, to my mind at least, because they are
in it for profit, and profit still seems to be a stronger motivation
than "doing good."
In 1996 at the Lancet conference and then in 1997 at the IUATLD
annual conference in Paris, I castigated industry. I asked why,
currently, the most widely used diagnostic test for TB infection
was introduced in 1880. I also asked why there was essentially only
one drug company trying at that time to license a new drug with
admitted TB indications.
At that time I stated that drug companies don't sit with us at
the TB table because as public corporations they must ask, "What's
in it for us?" To a great extent, if we want them with us,
there must be something in it for them beyond "doing good,"
a virtue that shareholders and financial analysts probably understand
less well than even politicians.
I'm not the only one suggesting this. In Business Week,
April 6, 1998, the cover story stated: "Still, TB, like malaria,
attracts fewer resources than other infectious diseases. And it's
not hard to figure out why. . . There's been the least effort to
develop new anti-infectives (against these diseases) because of
the inability of the population in the most affected areas to pay.
That's just one reason the war with microbes may never be fully
won. Companies and nations need to launch — and maintain — effective
campaigns not only against strep and flu but also against the scourges
that ravage far too many of the world's people. Only then would
we have a chance of relegating these killers to the pages of our
So in response, we need to define strategies to allow drug and
technology companies to be full prospective players, along with
government and nongovernment organizations, academe and foundations.
Let's find out what they need and want, and then let's provide them
with incentives and enablers; let them promote their wares as well
as promote our needs. And let's let them earn a fair and proper
profit for what they do.
Many years ago, the IUATLD Council (I think it was 1979 in Brussels)
held an extensively prolonged discussion over whether the Bulletin
of IUATLD, the predecessor to the International Journal
of Tuberculosis and Lung Disease, would be irreparably corrupted
if it accepted paid advertising. But TB control is too fragile and
important to attack with only the usual suspects. Adding unusual
suspects as full participants, such as nongovernmental organizations,
academe, foundations and industry, is the only way we can ever implement
and carry out the global plan, rectifying the continuing worldwide
embarrassment and danger of TB.
In 1955, soon after the introduction of widespread use of TB drug
therapy, Professor James Waring at Colorado pointed out in JAMA
that TB was unique in that, essentially, it stayed around and spread
until it was properly treated. In other words, it doesn't go away.
The global situation with TB reminds me of the man who advertised
FRAM Oil Filters on television several years ago. In that commercial,
a scruffy garage-mechanic type approached the camera holding an
oil filter in one hand and a burned out car engine in the other.
He stated: "Last week the owner of this car could have had
a new FRAM Oil Filter for $4.95. He decided not to buy it. Today
he has to buy a new car engine for $1,275.00.
"You can pay me now. . . or you can pay me later."