A book review of
Timebomb : The Global Epidemic of Multi-Drug Resistant Tuberculosis
Lee Hopkins Reichman and Janice Hopkins Tanne
From the New
England Journal of Medicine, April 18, 2002
"If you wanted to cause an
epidemic of multidrug-resistant tuberculosis in a country, what would
you do? First, you would create a social and economic
environment that promotes poverty and inequity. Second, you would temporarily
subject those who have infectious tuberculosis to squalid and overcrowded
conditions, let them mix with an uninfected population, and then release
them back into the general population. Third, you would provide just
enough treatment to prevent those who have the disease from dying but
to cure them, so that they would remain infectious longer. Fourth,
you would provide inadequate treatment, guaranteed to create drug resistance.
you would add the possibility of infection with human immunodeficiency
virus (HIV) to increase dramatically the risk of progression from infection
active tuberculosis disease.
Timebomb, written by Lee Reichman with Janice
Hopkins Tanne, shows that this desperate situation has already occurred.
Though clearly unintentionally, a
combination of politics, economics, the emergence of a new infectious disease,
and scientific belief has contributed to a major epidemic of tuberculosis in
Russia. Multidrug resistance is a major component of this epidemic in prisons
and parts of the civilian population. What makes the situation so worrisome
is that the epidemic was well under way even without the added boost of HIV
infection. Recent statistics from the World Health Organization and the Joint
United Nations Programme on HIV/AIDS confirm that the pandemic of HIV infection
is growing faster in Russia than anywhere else in the world. This appalling
combination of HIV infection and multidrug-resistant tuberculosis is -- as
the authors quite rightly assert -- a deadly time bomb, with consequences that
reach far beyond the borders of any one country.
This is not a scientific analysis
of the global dimensions of multidrug-resistant tuberculosis. In fact, the
title is something of a misnomer, since in geographic
scope the book mainly covers events in Russia and New York. Having set the
scene with a description of a tuberculosis outbreak caused by a Ukrainian man
traveling to the United States in 1998, the authors provide an excellent introduction
to the science and history of tuberculosis, written primarily for the lay reader
with little or no knowledge of tuberculosis. They then return to the main theme:
recent attempts to help Russia adopt modern tuberculosis-control strategies.
Reichman, who is executive director
of the New Jersey Medical School National Tuberculosis Center, has been involved
in issues related to tuberculosis in
Russia for the past few years, and his insights into what he calls a world
of "smoke and mirrors" make compelling reading. Indeed, the authors
are at their best in telling a story, with vivid and often detailed descriptions
of people and events. The personalities are diverse and memorable: a Russian
baby who is infected with tuberculosis and adopted in the United States, a
Hungarian billionaire, a Russian dissident, a New York community health worker,
and a Russian thoracic surgeon.
There are several minor mistakes
in the book. For example, the countries listed at the end of the book are
not the "hot
spots" of multidrug-resistant
tuberculosis that have been identified by the World Health Organization but
rather are the 22 countries that together account for 80 percent of the global
tuberculosis burden; the London conference on tuberculosis was held in 1998,
not 1997; and most historians of tuberculosis control would assert that the
principle of directly observed treatment for people with tuberculosis was promoted
before 1973. An exploration of the reluctance of the Russian government to
adopt a policy of international competitive bidding for tuberculosis drugs,
as required in the proposed World Bank loan, would also have been interesting.
Timebomb is an important book with
many lessons for those involved in public health. First, history repeats
itself; as the poet Steve Turner says, "has
to -- no one listens." The epidemics of tuberculosis currently raging
in Russian prisons were common in British and American prisons in the late
19th century. In 1882, on announcing his discovery of the tubercle bacillus,
Robert Koch described the disease as killing at least one third of people in
the economically active age groups. The fact that the same bacterium continues
to kill nearly 2 million people worldwide each year, despite the availability
of a cheap and effective treatment, reminds us that complacency is one of the
greatest threats to public health.
Second, the book demonstrates the multifaceted
and complex nature of modern epidemics. Mix an intransigent medical profession
with a judicial system based
on imprisonment, and add a couple of virulent microorganisms to an environment
of socioeconomic upheaval and inequity, and the results will be predictably
appalling. Third, self-interest on the part of medical professionals can thwart
attempts to improve the health status of the poor. Historians of health and
development have documented many examples from the past. That they continue
to do so in the present is a reminder that none of us are immune to this temptation.
The story is unfinished. The
time bomb has yet to go off. There is still time to act, and proven
strategies for tuberculosis control are available that can
work -- as long as they are adopted quickly and widely. Whether this
time bomb will be defused remains to be seen. The fact that it can
be defused is indisputable.
I look forward to reading the sequel."
Ian Michael Smith, M.B., Ch.B.
Copyright © 2002
Massachusetts Medical Society.
All rights reserved.
The New England
Journal of Medicine is a registered
trademark of the MMS.