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Reviews Personal views

Tuberculosis: story of medical failure

BMJ 1998; 317 doi: (Published 31 October 1998) Cite this as: BMJ 1998;317:1260
  1. Chris Holme,
  2. Lawrence Cranberg,
  3. James Owen Drife
  1. Herald newspaper, Glasgow
  2. consulting physicist, Austin, Texas, USA
  3. professor of obstetrics and gynaecology, Leeds

    Western medicine's conceit is such that most doctors remember streptomycin only for giving birth to randomised controlled trials. They have a far clearer recall of the wider intellectual revolution it spawned than of the disease originally targeted.

    The streptomycin trial was the first of many conducted by the British Medical Research Council (MRC) to engineer effective chemotherapy for tuberculosis. Failure to implement the resultant standardised regimens has led to an international resurgence of tuberculosis. Despite the effective treatment developed nearly 50 years ago, tuberculosis now kills more people than ever.

    This should trigger some questions from the public, which funds all medical research. For example, why, after an estimated one million controlled trials on every treatment under the sun, have we failed to apply the results of the initial ones on tuberculosis chemotherapy? Why do so many countries still lack basic drugs and microscopes, and why is the principal curative distillation of all this effort still available to only one in six patients with tuberculosis throughout the world?

    Tuberculosis certainly had a higher priority in 1948. The MRC owes its existence to public clamour over the disease. Tuberculosis was also responsible for Austin Bradford Hill's career switch from medicine to statistics.

    We had the chance to control this disease and we blew it

    The success of the streptomycin trial spawned a string of others by the MRC's tuberculosis research unit. The unit's overseas collaborations showed how rigorous science could be specifically modelled to meet the needs of individual developing countries in order to provide affordable and effective treatment. Its work remains a paragon which has yet to emulated.

    A trial in India showed that people in the worst possible conditions could be cured just as well at home as in hospitals. At a stroke the entire purpose of sanatoriums disappeared, wiping billions of dollars off European and North American healthcare budgets. The …

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