Season 4, Episode 2: La Consecuencia

In the first two episodes of this season of ReGenesis, drug resistant tuberculosis plays a significant role. Although the government's inferred ultimate solution to the problem - i.e. the bombing and extermination of the infected population - is beyond credibility, the concerns raised about how we as a civilization face the challenges of drug resistance are of immense importance.

Image provided courtesy of Shaftesbury Films.

David attends to an ailing Carlos while Isobel looks on.

Tuberculosis is one of the oldest know human illnesses. As the Episode 1 installment of this season's Facts Behind the Fiction described, it is caused by the bacterium Mycobacterium tuberculosis.

Our collective experience with TB dates back to ancient times. Much of what we know about how infections can cause disease in humans is based on our experiences with and understanding of TB. Not surprisingly, TB has featured prominently in literature and art over the centuries, a trend we see continued here in ReGenesis.

Those of us living in the developed world likely think that TB is not much of a health threat any more. This would be a sadly narrow vision. It is estimated that fully 1/3 of the world's population harbors a TB infection. These so called "latent" infections cannot be spread to other people; it is only people with TB in their lungs, coughing or sneezing large numbers of bacteria, who can spread the disease.

TB causes a wide range of symptoms, the most prominent of which is dramatic weight loss. People suffering from TB lack energy, are unable to work and without treatment waste away, which is why it used to be referred to as "consumption."

TB, drugs and drug resistance

In the 1940's, newly discovered antibiotic drugs were found to be effective against TB - it essentially became a curable illness. As time passed, the manner of treating TB required the use of multiple antibiotics for a prolonged (six month) period. Two drugs, the so-called first line drugs isoniazid and rifampin, are particularly important as they are well tolerated and inexpensive.

However, it has been found that many people find it difficult to take antibiotic medication for an extended period of time like six months. Indeed, we know many people do not even complete a week's course of therapy for less serious infections. Thus, new ways of helping people complete their course of therapy were created, including the use of direct observation by health care professionals. This occurs in many parts of the world as Directly Observed Therapy Short Course, or DOTS.

What is particularly alarming about the recent history of TB is the growth of multi- and extensive drug resistance. (Click here to learn how TB becomes drug resistant).

Recently released studies by the World Health Organization (WHO) indicate that the number of MDR-TB infections has grown considerably over the last 15 years, and certain parts of the world, such as Russia and the states of the former Soviet Union have particularly high rates of MDR-TB.

Rather than a six month course of therapy, as long as 24 months are required to treat MDR-TB. And unfortunately, the antibiotics that must be used - the so-called second line drugs - are less effective, much more expensive and have many more side effects.

In the new millennium, we have seen the emergence of what is called extensively drug resistant tuberculosis, or XDR-TB, against which many of the second line drugs are not effective. As a result, the death rate from XDR-TB is very high.

XDR-TB has become a particular problem in parts of the world where high rates of HIV/AIDS exist, but has the potential to profoundly impact the entire world. Experts in the control of tuberculosis are deeply concerned by the development of XDR-TB. They fear that we are entering a post-antibiotic age, and that we will soon have strains of TB for which no drugs will be effective.

Individual rights v. protecting the public

XDR-TB raises significant ethical issues in how we manage people with serious infections that are spread to other people. Should they be isolated until they die? Should we reinstitute the use of special communities such as the tuberculosis sanitaria that were so common in the 19th and early 20th centuries? Who will provide care for people who cannot be cured?

The recent and highly publicized case of Andrew Speaker, a personal injury lawyer from Atlanta who took several long distance flights while infected with a drug resistant strain of TB, indicates the ease with which infectious diseases can cross borders. While we recognize individual freedoms and rights to self-determination, some rights and freedoms may need to be curtailed in order to stop the spread of infections in the community and across the globe.

Drug resistant tuberculosis is not the result of catastrophic natural forces such as earthquakes, tsunamis, and hurricanes. It is not caused by malign human intent as are terrorism and war, nor is it fostered by our dysfunctional relationship with the animal kingdom as are SARS and Avian influenza. The locus of risk and control is entirely within the human domain.

Our response to the emergence of drug resistant tuberculosis is profoundly ethical as it raises issues of how justice and human rights are realized in our collective response to a disease.

-- Ross Upshur, MD, MA, MSc

About the Author

Dr. Ross Upshur is currently the Director of the University of Toronto Joint Centre for Bioethics, the Canada Research Chair in Primary Care Research at the University of Toronto, and a staff physician at the Department of Family and Community Medicine at Sunnybrook Health Sciences Centre in Toronto. His research interests include public health ethics, ethics and health information, communicable disease and environmental epidemiology. He has served on Advisory Boards for the International Joint Commission, Doctors Without Borders, and Scidev.net, and consulted with the WHO.

Want to read and learn more?

To read the WHO report Anti-tuberculosis drug resistance in the world (26 February 2008), click here:
http://www.who.int/mediacentre/news/releases/2008/pr05/en/index.html

To read the paper Critical reflections on evidence, ethics and effectiveness in the management of tuberculosis: public health and global perspectives (BMC Medical Ethics 2004, 5:2), co-authored by Dr. Ross Upshur, click here:
http://www.biomedcentral.com/1472-6939/5/2