CDC History of Tuberculosis Control - Medical and Public Health ...

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 drugsensitive
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
TB Control at the Millennium
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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 problem.
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
21 st 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