Results 1 to 2 of 2

Thread Information

Users Browsing this Thread

There are currently 1 users browsing this thread. (0 members and 1 guests)

  1. #1
    Senior Member butterbean's Avatar
    Join Date
    Feb 2005
    Posts
    11,181

    Defusing The Global Timebomb

    http://www.rednova.com/news/health/1524 ... _timebomb/

    Defusing the Global Timebomb

    Almost 20 years have passed since the unprecedented resurgence of tuberculosis (TB) in the United States. From 1985 to 1992, TB cases increased almost 20% nationally (1) and increased more than 35% in children (2), along with dramatic changes in the nature and magnitude of the disease (3). Despite many contributing factors, including the acquired immunodeficiency syndrome (AIDS) epidemic, increases in substance abuse and homelessness, increased immigration, and lack of patient compliance, concerned observers felt that the TB resurgence was directly due to policy-maker neglect of appropriate TB control mandates, which led to the dismantling of programs that had previously and quietly kept TB under control (4,5).

    The societal response to this resurgence was an unprecedented initiative, a veritable "war" against TB. The Centers for Disease Control and Prevention (CDC) organized a multi-agency governmental task force to coordinate the effort (6); huge increases in congressional appropriations for direct support were obtained (5); major research efforts by government and industry were started; new cost-effective strategies, including directly observed therapy (DOT) (7), fixed-dose combination drugs (, nurse case management (9), educational innovations (10), and, when necessary, long-term hospitalization (11) were established or reintroduced. Ultimately, this acute public health crisis led to rapid adoption of long- needed solutions that were extraordinarily effective in turning the crisis around.

    Multidrug-resistant TB (MDRTB) is strong evidence of public health failure. It was the unexpected recognition of MDRTB in the late 1980s in conjunction with the AIDS epidemic that first alerted health officials to the TB resurgence (12). However, MDRTB is almost entirely man-made and occurs solely because of inappropriate prescription or ingestion of drugs (13).

    Tuberculosis is a unique disease. For most other disorders, achieving cure is primarily the patient's concern. With TB, the responsibility for cure rests with the health-care professional and, ultimately, with society. When, by virtue of lack of compliance by the clinician, patient, or community (note, far more than just the patient is at fault here), cure does not ensue, disease spreads and drug resistance may occur. Potential transmission, often of resistant or MDRTB, continues until, and only until, the patient dies or treatment is completed successfully. However, the average of nine contacts per case of TB whether it is sensitive or resistant, certainly perpetuates the cycle of transmission (14).

    In 1972 Annik Rouillon, former Executive Director of the International Union Against Tuberculosis and Lung Disease (IUATLD), wrote a very perceptive article in the Bulletin of the International Union Against Tuberculosis. She analyzed the use of the term "default":

    Default by the patient is in fact rarely an isolated phenomenon; in reality it follows or flows from other failures, insufficiencies or imperfections in the people or the system to whom or to which the patient has instructed his fate.... His behaviour is... in large measure the result of the long chain of influences which he has undergone consciously or unconsciously within his system. It is the system that is mainly at fault if there is a large default of patients (15).

    She went on to point out that:

    ... to default is the natural reaction of normal, sensible people: the person who continues to swallow drugs or have injections with complete regularity in the absence of encouragement and help from others is the abnormal one.

    Although TB is easily preventable and treatable with well- characterized and well-accepted interventions, this disorder, paradoxically, remains the largest cause of death of any single infectious disease (16). When difficult patients require incarceration for lack of a more appropriate location for treatment and for lack of appropriate services, when the scope of MDRTB is spreading, when the worldwide standard of TB treatment must have a duration of at least 6 months with direct supervision of taking medication because there is not yet an effective one-week treatment or vaccine, any improvement in the situation is difficult at best. When TB continues to be described by the World Health Organization (WHO) as a "global health emergency" (16), with increasing cases outside the United States, so that US multinational corporations increasingly are fearing transmission of TB in their host countries, and with 53% of all US cases of TB occurring in the foreign-born, the job is nowhere near done.

    The recent resurgence has taught us that we cannot consider TB control just another "social problem" explainable or not by underlying poverty and related concerns. We must continue to treat TB control, as a defense program, which has been fairly successful in combating the resurgence. In defense programs, critical strategies are not abandoned for budgetary reasons prior to winning the last battle.

    With the increasing saturation of health-care markets by health- care reform, there may be a desire for good TB control, but fiscal and other constraints might make participation in the specialized labor-intensive aspects of TB care and control difficult or impossible, and we urgently need to re-foster and maintain the political will that will allow enhancement of such public health programs (16). Only this strategy will lead us toward TB elimination and thereby allow us to defend, maintain, and improve the public's health.

    In order to attack the global TB problem, an entire team is required. Physicians only rarely exhibit competence in TB. Uplekar and Shepard (17) studied 102. private physicians in Bombay, who prescribed 80 different regimens, most of which were inadequate and unnecessarily expensive; 67 of them used pharmaceutical company representatives for their primary TB information source. Sumartojo et al. (1 questioned 3,600 US physicians and found only 75% were aware of any TB treatment and control recommendations; only 50% would use recommended treatment regimens, 71% would incorrectly interpret skin test results, 16% would use an incorrect regimen for preventive treatment, and 35% would use incorrect laboratory tests before treatment of latent TB infection.

    In 1977 Richard Byrd et al. (19), also in the United States, reported almost exactly the same physician practice deficiencies that Mahmoodi and Iseman (20) reported in 1993, 16 years later. In both studies, delays in diagnosis and errors in TB treatment and follow-up resulted in increased risk and likelihood of disease transmission, more advanced and complicated disease, and lengthened hospital stays with increased medical costs as well as the development of MDRTB. There is no evidence that any of these problems have improved since these articles were published.

    Since so much depends on each patient taking his drugs properly, it should be a crime to allow a patient with TB to take medication incorrectly. Increasingly, monotherapy equals resistance! Prescribing any drug combination that allows any patient to take monotherapy, whether inadvertently or deliberately, should not be permitted. Even though controlled clinical trials of DOT are lacking, it is intuitive that watching each patient taking each dose of his medication (DOT) prevents monotherapy and therefore prevents drug resistance and MDRTB. But even with the WHO and the CDC stressing DOT, it is used only in a minority of cases. If DOT cannot be given, then fixed dose combinations of demonstrated bioavailability must be required because they make monotherapy impossible (. It has been recently suggested that single formulation TB drugs should not be allowed at all (21). The bottom line is that compliance, more often than not, depends on the physician or the system.

    As would be expected, much of this lack of compliance on a ministry or government level can be ascribed to politics as much as to neglect or ignorance. In the United States, a very effective national TB control program was decimated when the government, in their "wisdom", chose to give discretion on the spending of public health funds to state governments. In 1972, when this change was first contemplated, informed observers testified to the US Congress, predicting that giving discretion on TB public health funding to state governments would lead to a public health disaster: a resounding resurgence of TB! These experts were roundly ignored, yet this "block grant" exercise of the 19703 directly led to the 20% resurgence of TB in the United States (35% in children) in the 19805 and 19905, which required a huge outlay of new funds to return to control (5). Not having learned their lesson, high officials in the US government continue to try to reintroduce this concept. The early epidemic in New York City had demonstrated the disastrous results of weakened TB control (5), and that the reduction in MDRTB directly following occurred under strong leadership by securing adequate resources and emphasizing and rebuilding basic public health principles of TB control.

    The other common reaction of government, especially in developed nations is what I called in 1991 "The U-Shaped Curve of Concern" (21). When, with any disease, rates are high, resources are provided to bring the rates of the disease down. When the disease rates fall, rather than eliminate the disease, governments eliminate the programs that could potentially eli\minate the disease, thus ensuring that the rates go back up. Because governments invariably operate from crisis to crisis in response to short-term political priorities, chances for any meaningful long-term program remain slight; any diminishing of case rates invariably leads to uninformed politicians clamoring to cut funds (23). When queried about how this can happen, their invariable answer is "my constituents do not get TB".

    In this issue of the Journal, Atre and Mistry (24) demonstrate clearly that the occurrence of MDRTB is dependant on far more than patient non-compliance. Several biosocial determinants such as poverty and other biomedical factors are certainly causal. There is no question that this is true; these background factors enhance and promote illnesses like tuberculosis. In other words, if we were to give everybody a house, a car and a computer, they literally would have less TB. But it would seem likely that alleviating global poverty in the near term, as desirable it may be, is tragically becoming less of an option, and even less so after the recent US election.

    As proven, albeit suboptimal, strategies do already exist to treat TB effectively while diminishing MDRTB, these strategies should be scaled up and maintained while the solution to the underlying poverty is being sought and perhaps, I hope, ultimately attained.

    Journal of Public Health Policy (2005) 26, 115-121.

    doi: 10.1057/palgrave.jphp.3200005

    REFERENCES

    1. Comstock G, Cauthen G. Epidemiology of tuberculosis. In: Reichman LB, Hershfield E, editors. Tuberculosis: a comprehensive international approach. New York: Marcel Dekker, 1993; pp. 23-48.

    2. Starke JR, Jacobs RF, Jareb T. Resurgence of tuberculosis in children. J Pediatr. 1992;120:838-55.

    3. Snider Jr DE, Roper W. The new tuberculosis. N Engl J Med. 1992;328:703-5.

    4. Reichman LB. The U shaped curve of concern. Am Rev Respir Dis. 1991;148:741-2.

    5. US Congress. Office of Technology Assessment. The continuing challenge of tuberculosis. Washington, DC: US Congress, Office of Technology Assessment; September 1993. Document OTA-H-574.

    6. Centers for Disease Control. National action plan to combat multidrug resistant tuberculosis. MMWR. 1992;41(RR-11):1-48.

    7. Chaulk CP, Moore-Rice K, Rizzo R, Chaisson RE. Eleven years of community-based directly observed therapy for tuberculosis. JAMA. 1995;274:945-51.

    8. Moulding J, Dutt AK, Reichman LB. Fixed dose combination of antituberculosis medications to prevent drug resistance. Ann Intern Med. 1995;122:951-4.

    9. Mangura BT, Napolitano E, Passannante MR, Sarrel M, Glanowsky K, McDonald RJ, Reichman LB. DOT is not the entire answer. An operational cohort analysis. Int J Tuberc Lung Dis. 2002;6(:1-8.

    10. Reichman LB. The national tuberculosis training initiative. Ann Intern Med. 1989;111:197-8.

    11. Yeager Jr H, Medinger AE. Tuberculosis long-term beds: have we thrown the baby out with the bath water? Chest. 1986;90:752-4.

    12. Centers for Disease Control. Outbreak of multidrug resistant tuberculosis - Texas, California and Pennsylvania. MMWR. 1990;39:369- 372.

    13. Lambregts-van Weezenbeek KSB, Reichman LB. DOTS and DOTS- Plus: what's in a name. Int J Tuberc Lung Dis. 2000;4(11):995-6.

    14. Etkind SC. Contact tracing in tuberculosis. In: Reichman LB, Hershfield E, editors. Tuberculosis: a comprehensive international approach. New York: Marcel Dekker, 1993; pp. 275-89.

    15. Rouillon A. "Defaulters" and "Motivation". Bull Int Union Tuberc. 1972;47:68-73.

    16. Reichman LB. Tuberculosis elimination-what's to stop us? Int J Tuberc Lung Dis. 1997;1:3-11.

    17. Uplekar MW, Shepard DS. Treatment of tuberculosis by private general practitioners in India. Tubercle. 1991;72:284-90.

    18. Sumartojo E, Hale BE, Geiter L. Physician practices in preventing and treating tuberculosis: results of a national survey. Am Rev Respir Dis. 1993;147:A702.

    19. Byrd RB, Horn BR, Solomon D, Griggs GA, Wilder NJ. Treatment of tuberculosis by the nonpulmonary physician. Ann Intern Med. 1977;86:799-802.

    20. Mahmoudi A, Iseman MD. Pitfalls in the care of patients with tuberculosis. Common errors and their association with the acquisition of drug resistance. JAMA. 1993;270:65-8.

    21. Sbarbaro JA. Editorial: a challenge to our practices and to our principles. Tubercle Lung Dis. 1996;77:2-3.

    22. Reichman LB. Editorial: the U-shaped curve of concern. Am Rev Respir Dis. 1991;144:741-2.

    23. Reichman LB, Tanne JH. TIMEBOMB: The Global Epidemic of Multidrug Resistant Tuberculosis. New York: McGraw-Hill, 2002.

    24. Atre SR, Mistry NR Multidrug-resistant tuberculosis (MDR-TB) in India: an attempt to link biosocial determinants. J Pub Hlth Policy. 2005;26:96-114.

    LEE B. REICHMAN*

    * Address for Correspondence: New Jersey Medical School National Tuberculosis Center, 225 Warren Street, PO Box 1709, Newark, NJ 07101-1709, USA. E-mail: reichmlb@umdnj.edu

    Copyright Journal of Public Health Policy 2005



    Source: Journal of Public Health Policy
    RIP Butterbean! We miss you and hope you are well in heaven.-- Your ALIPAC friends

    Support our FIGHT AGAINST illegal immigration & Amnesty by joining our E-mail Alerts at http://eepurl.com/cktGTn

  2. #2
    Senior Member Judy's Avatar
    Join Date
    Aug 2005
    Posts
    55,883
    We are in for one heck of ride if we don't get troops on the border NOW!!

    WHAT IS WRONG WITH OUR OFFICIALS: are they blind, do not see the problems, think money and power are more important than Americans; think they'll be safe when this breaks wide open and intend to "watch" from "dug-outs" in Wyoming??

    Or did they sell their souls and our country to Globalists?

    Hmmmm....

    Yep....they sold their souls and our country to Globalists.

    Well, guess what....officials....you don't own it....it wasn't yours to sell....you've tried to pass "bad title" to our country and you're goin' DOWN!!
    A Nation Without Borders Is Not A Nation - Ronald Reagan
    Save America, Deport Congress! - Judy

    Support our FIGHT AGAINST illegal immigration & Amnesty by joining our E-mail Alerts at https://eepurl.com/cktGTn

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •