The White Plague

It was once the biggest of all killers. Of the disease it was once said, by John Bunyan, “The captain of all those men of death that came against him to take him away.”
Or the full quote: “The captain of all those men of death that came against him to take him away was consumption, for it was that that brought him down into the grave.”
And though still with us, and on the return, both these states of affairs are sufficiently little known to be worth describing in terms of parables.
Imagine a race, humans in every respect like us, where every individual is a recovering alcoholic – except that the alcohol itself is a distant memory,
The world of alcohol, the damage it wreaked, is still recorded in ancient pop songs, in literature, in folklore, in 21st century history books – stories of binge drinking, accident and emergency visits, the slow lingering deaths, the broken promises, the broken families, the desperate negotiations with the disease, the month-long drinking bouts that cause total passivity, the relapses and dry periods. But it is hard to imagine, and no one much cares. And then someone rediscovers the formula for alcohol, and reopens the first bar in a century…
Or: imagine today’s contemporary human world suddenly struck down by a malady that doesn’t have the name of disease, because it appears not to be measurable by science: there are no germs to be isolated; indeed it seems to be an act of God.
There are enormous variations in susceptibility between individuals, and those afflicted support a huge growth industry in osteopaths, allopaths, homeopaths and practitioners of dozens of other medical – and, since it was unattributable to known science – religious practitioners. Its symptoms are many and varied, sharing signs with curable diseases and is sometimes, but not always, fatal, and in many cases the patient recovers without treatment. Eventually, since no cure is found, employers are resigned when workers take time off, for months, occasionally not returning.
Those stricken are often racked by terrible coughs, and feel exceptionally weak, and are very emaciated, but, its sufferers acquire a certain attractiveness: eyes of pearly brightness, the hair fine and silky, and skin that is white, soft and delicate; in both sexes, in the early stages, the cheeks have an attractive red flush. Writers wax how since this act of God struck mankind many a man has turned into a hawknosed romantic hero and every woman into a Victorian romantic heroine. Eventually the nation gives up looking for a cure: It became part of life itself, scarcely worth mentioning, any more than that inevitable death from old age itself; and it was universal: almost everybody autopsied from natural death had some lung-scarring suggesting they too had been struck by the malady. The mystery killer affected everyone.

These two parables are an attempt to explain to a person living today or in the near future the very ubiquity, mortality and cluelessness about the causes of TB 120 years ago, when it was estimated that every European was infected with “the white plague”, and a huge number developed he active infection – though it often went into remission, waxed and waned – for some never being more than a chronic bronchitis that enabled the patient to continue infecting everyone. The causes were attributed to miasma in the atmosphere, a failure of the individual constitutions (the theory of vitalism was strong at the time),or even heredity, but no one knew for sure, except that it was the biggest killer in Europe. The discovery of germ theory in the late 19th century, Robert Koch’s isolation of the tuberculosis bacterium in 1882 led to a hugely better approach towards TB treatment; and large sanatoria opened up in the early 20th century where TB patient were kept out of the way where they could infect others and told to rest so sthat the lung cavities that are the symptoms of the disease could heal. (The writer Betty McDonald describes the principle at one sanatorium she stayed at in the 1930s: you don’t walk on a broken leg; you don’t use a broken lung, tearing up fragilely healing fissures by too much exertion. They were told to lie absolutely still for days at a time in narcotically cold conditions, windows open in winter ) Then, in 1946, the first antibiotic, streptomycin, was discovered and TB treatment was truly revolutionised. Other drugs followed in quick succession.
While it remained common in the third world, rates fell to an all time low in the 1980s in Europe and the US.
Now, however, it’s on its way back to Europe and the UK – and in a multi-drug resistant form (MDR TB), immune to safest and most effective drugs, . Worse, waiting in the wings, in the shanty towns of India and the villages of southern Africa, is extensively drug resistant TB, immune to virtually all drugs. As this XDR is transmissible between person and person, in other words, you could potentially arrive at the situation where you’re back to square 1, as if antiobiotics had never been invented.


Paul Thorn was a young HIV positive nurse treated for his HIV in an open ward at Westminster and Chelsea hospital in 1995 when a Brazilian came in, coughed up his sputum – the standard test – and, because the nurses failed to take precautions, infected the others. Six died. Paul survived – due, he says, to consultant Richard Croker at St Mary’s Paddington, who saw him through his treatment, insisting he take his course of “heavy chemotherapy”. He was obliged by the medical authorities to stay in an isolation chamber for a long period.
I recently obtained a “first look” at copies of his diaries of the period, which will be published in March. This is what he says in his preface.
“For some time experts had been predicting that it was only a matter of time before an outbreak of TB/MDR-TB occurred in such a way. Three months after exposure to the deadly bacteria, I was told of the outbreak. My health had already been deteriorating prior to my knowledge of the exposure. During that time the bacilli multiplied slowly in my lungs without me knowing. My slowly advancing chest pain and breathlessness finally explained. Then without warning I lost my liberty and found myself locked away from society in a negative pressure isolation room so that I didn’t infect anyone else
Paul couldn’t leave the room – “you might not get out alive”, one doctor told him - and his contact with visitors was restricted. He found himself being visited by a succession of doctors and nurses in masks, and was given medication that made him woozy, confused and angry. He once threw a jug at one of his carers. When his story appeared in the media; he started getting letters of support – but also critical letters, asking why the taxpayer should pay for he mistakes owning to his lifestyle choice, since HIV exacerbated his condition.
But things got better: by October 1995 he was putting on weight, had started fitness routine.
When he was set free, he had to comply with several conditions: Though he was sputum negative and therefore very unlikely to be infectious, he still had to be careful. His doctors told him:
“You should sleep in a single room with the door closed at night, and should spend the majority of your time inside. It is relatively safe for you to go out for short periods assuming you will not be in close contact with anyone for longer than quarter of an hour or so. This means you will not be able for example, to go to restaurants, clubs, or use public transport. The flat should be properly ventilated. You will need to comply with daily direct observed therapy and will be advised to attend our out-patients' clinic once monthly. You should have no new social contacts and should not have contact with anyone who is HIV positive or otherwise immuno-compromised. You should also not have any contact with pregnant women or children."

Over the next three years Paul lost a lot of friends. His MDR TB course continued, a daily dose of five drugs taken under supervision at his local medical centre, under the internationally recognised standard of DOTS treatment, for which he says he was glad. “A lot of people, even middle class ones, lapse, forget to take doses.” As some-one who can barely remember to keep a daily dose of Vitamin B pills for a week, I sympathised with the three year marathon.


Still, Paul is glad he only caught the multi-drugs resistant and not the fiercer yet extensively drug variant, XDR TB, and who jokes that, since being cured of drugs resistant TB three years after that fateful day in 1995, he has become a “one trick pony”. Apart from his diary, he has also published a TB survivors’ handbook; he speaks at TB conferences, where he brings the joie de vivre of the AIDS activist, which he also is, to the staidness of chest medicine symposia. (“TB professors are so old school,” he says.) Anything to raise TB’s profile, which remains disturbingly low in this country, despite the UK having the fastest growing TB epidemic in Europe, the highest number of TB infected: more than 7,000 cases a year, half in London, where numbers have almost doubled in six years. Worryingly, the UK also has Europe’s highest number of patients who fail to complete their treatment or disappear off the doctor’s radar
The UK’s rise is, to be it frankly, due to London’s magnetic appeal as an immigrant destination for countries that happen to have epidemic levels of TB: and the arrivals are infection carriers who don’t even know. In these countries, even if individuals do not carry the active disease itself, they will have been around disease carriers long enough to have latent TB: symptom less and non infectious, but tapt to break out if the immune system weakens – after the arrival has been in the UK some years. It is estimated that in some countries up to half the population has been infected with the TB bacterium. In the UK, in contrast, the figure is just a percent, mostly older people exposed when TB was much more prevalent. Peter Davies, director of the TB research Unit in Liverpool, has said: “The protective moat we are ringed with, ‘against infection and the hand of war’ so eloquently described by John of Gaunt in Richard II, offers no defence against tuberculosis.”
And about 80 a year are drug resistant, which doesn’t sound much, and is tiny compared to the figures in Africa and Asia, but the gold star drugs resistance treatment you get in rich countries, that Paul received, plus the costs to society of supporting dependants if the patient has family, can rise to £250,000, according to a scientific paper by prof John Moore Gillon, a consultant at Barts hospital and president of the British Lung Foundation. Though, as statistics show, about 20 percent have treatment failure, abscond and are lost to follow up; they disappear into their communities.
A patient with active TB begins to feel better within days of beginning his antibiotics treatment: it can be hard to put across the rationale for continuing to take a cocktail of several drugs for six months – the bacilli count goes down very quickly, but TB is hardy bacterium, and the full course is needed to clear out the resisters lodged deep in the recesses of the lungs which, if left alone, are likely to have re-multiply at some point and be drugs resistant. Et Voila.
A false sense of security is one reason why MDR develops:another reason sometimes the doctors dispense a faulty drugs regimen: adding single drugs to a failing regime is a recipe for MDR. A third is that people can’t afford their drugs. In many other countries patients are forced to pay for their own second MDR antibiotics off the street, from cigarette stalls.
A jolt to complaceny would be greater visual appreciation of what’s going on.
A flight of fancy here: Unlike some species of amphibians human beings don’t breathe through the skin. Maybe that is, for the purposes of dealing with TB, a shame. If the disease’s ravages were revealed to the naked eye people would surely push to complete their medication, if at all possible.
While the disease’s slow, chronic progression can be deceptively painless, apart from the racking coughs, a tubercular lung is a revolting sight: the lung is not air sack but looks like any slab of meat, perhaps a piece of liver. In the advanced case of TB, a cross section of this lung would show extensive cavitation interspersed with calcified fibrosis and waxy-coloured granulomas: the latter the result of the body’s attempts to wall in the bacteria with fibrous tissue and constantly replenished layer of active white blood cells. The Swiss cheese hole cavitations are a breeding ground for Tb bacteria, which are then expelled through the airways where they are infectious to others. Much of this damage, ironically, is not from the hardy but languid, slowly dividing, not very toxic TB bacterium but from the body’s immune system response, the macrophages and lymphocytes, trying to expel the invader. In trying to destroy the bacteria, the body destroys itself, as the once pristine lung becomes riddled with ulcerating holes, whose walls tense and contract under the breathing mechanism, expelling bacterium droplets into the air , where they look for new lungs to ravage.

TB was once the biggest killer. It’s still the second leading cause of infectious death in the world, and on a rapid rise in the UK after its 30-year period of postwar abeyance. But TB is not the only killer.
If it’s the captain of death, death has other officers. A few weeks ago, I was at the centenary conference of the Royal Society of Tropical Medicine. Fellows from across the world had converged at the Queen Elizabeth conference centre opposite Westminster Abbey in London. These academics and fieldworkers were disease buffs: each brought their own disease to presented to the audience. In presentation after presenta tion, I heard about the different ways nature chooses to punish Africans. Unlike TB, these diseases do not exist north of the tropic of Cancer, though global warming may change that.
I had not heard of many of them. There’s Chagas’s disease, Kuru, Leishmaniasis, onchocoriasis, schistosomiasis, filariasis. There were picture of grinning, living dead; of deformed or missing limbs. They could be just the tip of the iceberg: who knows what affects remote communities. There is the usual problem of funding, since the drugs companies see no payoff in m medicines that cannot be taken for a lifetime by rich people, such as the statin heart drug, or the frivolous Viagra. Traditional healers are not engaged by western NGOs for throughput of such health information and drugs that do exist; and a population of illiterates will see even malnutrition as an act of God. Germ theory has not penetrated into the heart of Africa. As you walked among the poster presentations that reminded you of science’s iterative, tentative nature you realised: if scientists don’t know, how can the locals?
Malaria and HIV are death’s chief lieutenants, usually set apart from the neglected diseases: along with TB, they form the big three. In a survey conducted by Gallup, malaria was cited as the biggest health problem by Africans: yet while it makes people ill, it tends not to kill them. HIV kills, slowly, but has had much more funding and attention in recent years. In statistical terms it is the biggest killer, but here is a problem of attribution, for how many actually died of tuberculosis disguised as an HIV related disease. HIV is the great multiplier of TB. An opportunistic infection that is caught early on in individuals with HIV immuno-compromised systems, TB can progress in weeks to a point normally attained only after several years in HIV negative individuals.
“The coinfection problem in South Africa is enormous, it’s a huge problem,” Gery Maarten, chief respiratory physician at Cape Town’s Groote Schuur hospital tells me over the phone. Maybe a third of the population of South Africa is HIV positive: most are undiagnosed. Few even among the diagnosed are on retrovirals, which are only given at a certain advanced state of HIV. They share bush taxis, clinics, shops, lean –to shacks with TB afflicted – and catch it, sometimes again and again. And sometimes in its extensively or multi drugs resistant form. There is an interesting symbiotic scenario here: the disease has found its perfect means of causing maximum havoc with the assistance of its lieutenant. A disease that kills its host too quickly is no good, for it kills its means of transmission and therefore survival. But in the South African township scenario, TB HV negatives act as plague carriers, surviving for years, wasting slowly away; while the HIV positives are defenceless population of victims, who catch he disease, die quickly – too quickly to transmit it, but no matter. And it’s not helped by the fact that African leaders say that safe sex message is a propaganda trick by the West to contain the natural, exuberant virility of the African man and reduce African populations and that the health minister is on the record as saying a good dose of garlic will cure HIV. Not that any amount of obfuscation on the need for condoms and antibiotics will work if the TB in question is one on which no antibiotic will bite.

The World Health Organization, and the drugs firms, are now on multi drugs resistant TB’s case. As field workers and academics pour into south Africa to examine a TB condition in the townships which a late Victorian doctor from the slums of east London would increasingly recognise, several companies are developing new, electronic diagnostic tools that cut detection time from weeks to days – long detection time means the patient can continue to infect others in the community before being treated.
Big Pharma are scanning their drugs libraries for new compounds that will attack enzymes in the bacteria that will leave those of human cells alone, finding targets against which bacteria have not evolved a defence for. Several drugs are in early clinical trials, though may take another 10 years before they have reached approval.
There’s a lot more money around. Although TB has been woefully underfunded as a disease of the poor, and because of complacency in he belief that the disease had been licked in the 1960s, the Bill Gates foundation has stepped in with funding; some governments, including Britain’s, have put up their airline taxes to fund an initiative to fight HIV, malaria, and TB. There’s a problem of drugs resistance should the new drugs come on stream, but there are moves by an international umbrella group to try and integrate the new drugs into a combination therapy regime.
In any brand new drug, drugs resistance will eventually emerge after a few years. But the theory of putting two drugs in one pill works on the principle that simultaneous mutations of a bacteria against two drugs mechanism is mathematically very unlikely. This has long been well known, but inertia by governments and inability of drugs manufacturers to agree to put their recipes together in one pill has meant single pill, single drug therapy has been the norm in many places. The new scenario could be different.
So much for the growing awareness and activity at the level of international high level experts and the pharmaceutical industry. Elsewhere, there’s less of it. While doctors in South Africa, who don’t advocate garlic as their political leaders do and make do with the modern medicines they do have, are staggering under the burdens, British doctors barely seem to know what TB is, according to Dr Peter Davies.
He is pretty scathing about the fact that the majority of chairs in respiratory medicine in he UK are held in – wait for it - asthma, and just one in TB... And young doctors coming through the schools are seldom properly taught about TB; nor do the medical journals provide an education. Davies blames the drugs firms, at least in the UK, who “educate doctors through their advertisements” for putting out adverts in the medical journals that say “Cough, think of asthma” (and then marketing their asthma drug). “I can’t imagine them saying ‘cough, think of Tb’.”

There are numerous cases of GPs who diagnose TB as asthma, bronchitis, even cancer, and the index case in one outbreak in north London took a year to be diagnosed properly, by which time he had infected dozens of others around him. Fortunately, it was only resistant to one drug. Paul was fortunate in his misfortune to catch TB while in hospitalisation for his HIV condition in one of the country’s top hospitals. Others are less lucky.
At least, as yet, the tuberculosis in this country is just about treatable. But in many countries XDR as a proportion of MDR cases has been up to about 10 percent, and with the UK having 80 cases a year of MDR, Britain’s first case of XDR is surely a matter of time – there are no compulsory checks for TB in arrivals, and even if they were they wouldn’t detect the large number of latent XDRs/MDRs. Statistically, forty thousand people a year immigrate to this country with latent TB. It’s a difficult problem, for who wants to stigmatise immigrants by even talking of the threat?

The captain of the men of death may have been made to retreat; he has not left the battlefield.