TuberculosisBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7149.1962 (Published 27 June 1998) Cite this as: BMJ 1998;316:1962
All rapid responses
In their clinical review of tuberculosis (27 June) Ali Zumla and John Grange highlight the fact that new approaches to tuberculosis control will be ineffectual if ‘wealthy nations fail to address the gross global inequities in healthcare provision.’(1)
But, as the epidemic of the late 1980s/early 1990s in New York City should have taught us, local intra-national factors beyond healthcare may play an important role in the development of an epidemic, and the enhancement and spread of drug resistant strains. By 1991 tuberculosis incidence rates among black males in the 35 to 44 year age group in New York, for example, were a staggering 469.7 per 100,000, almost 45 times the national average,(2) and the percentage of cases with an isolate resistant to at least one drug rose from nineteen percent in 1987 to 28 percent in 1991, while resistance to at least both isoniazid and rifampicin (MDRTB) rose from six percent to fourteen percent, most of it ‘home-grown’.(3, 4)
Failure of treatment compliance was at the heart of the New York City epidemic, with completion-of-treatment rates across the city in the order of only 60 percent, and approaching 90 percent in some areas (which begs the question, what are the rates of treatment completion in the UK?).(5, 6) The failing public health infrastructure, associated with gross underfunding, played an important part in the generation of this epidemic. But perhaps equally important the social transformation of the city through the 1980s, alongside the ideological shift emanating from the Reagan administration which emphasised individual responsibilities at the expense of societal obligations, compounded the problem. Inequality widened, poverty and overcrowding worsened, and communities and neighbourhoods became fractured. The sense of alienation which ensued amongst a minority of poor inner-city residents made tuberculosis control substantially more difficult - and ultimately necessitated the introduction of coercive measures, including the detention for prolonged periods of many persistently non-compliant non-infectious individuals.
The New York City experience teaches us that, even in affluent nations, social disintegration allied to a poor health infrastructure may result in disastrous consequences with costly implications. Ultimately it may not simply be political will that is necessary to control this age-old scourge, but a redistributive political mandate to eradicate societal inequities and enhance social cohesion. We should, perhaps, reflect upon Dostoevsky’s remark as it seems particularly germane to future tuberculosis control: ‘We are all responsible for all.’
WORD COUNT 390
1. Zumla A, Grange J. Science, medicine, and the future: Tuberculosis. BMJ 1998;316:1962-4.
2. Tuberculosis in New York City, 1991. New York City Department of Health, Bureau of Tuberculosis Control, 1991:
3. Sepkowitz KA, Telzak EE, Recalde S, Armstrong D. Trends in susceptibility of tuberculosis in New York City, 1987-1991. Clin Infect Dis 1994;18:755-9.
4. Frieden TR, Sterling T, Pablos-Mendez A, Kilburn JO, Cauthen GM, Dooley SW. The emergence of drug-resistant tuberculosis in New York City. N Engl J Med 1993;328:521-6.
5. Tuberculosis. City Health Information, The New York City Department of Health. 1996;15(4):12-13.
6. Brudney K, Dobkin J. Resurgent tuberculosis in New York City: human immunodeficiency virus, homelessness and the decline of tuberculosis control programmes. Am Rev Respir Dis 1991;144:745-9.
Competing interests: No competing interests