The stereotye TB patient is no more. Today, it can happen to a poor, emaciated malnutritioned housewife with seven children just as frequently as to a robust single multimillionaire male or to a 5-yr old child attending the most expensive schools in town. And it does not make any difference whether you live in Geneva or Hyderabad. TB, the "great white scourge," of great antiquity that has been around for Hippocrates to handle and which finds mentioned in ancient Hindu literature, has struck again--with vengeance.

No other disease has wrought more suffering to mankind than the bacteria, Mycobacterium tuberculus. Today, about three million people die every year from TB and that's more than all other pathogens combined, including malaria and AIDS. Over the past 200 years, over one billion people (equivalent to one-fifth of the current world population) have succumbed to TB.

The peak of TB occurred around the beginning of this century (London and New York were the worst hit cities). The decline in TB throughout this century was a result of improved disease resistance among the poor as food became more abundant and affordable. Now environmental factors such as pollution and stress which have caused a rise in the heart disease and cancer are also affecting our resistance to TB.

In 1993, the World Health Organisation declared a "global emergency" as TB began taking a stronger foothold again even in the West. But 95% of deaths from TB come in the developing countries like Pakistan, where TB is the most ill-managed disease causing the highest incidence of resistant TB organisms--almost 17% whereas in the UK, it is only 0.04%. The Indian subcontinent is rated along side sub-Saharan Africa as the highest risk area. What it means is that it is just about as easy to catch TB in Karachi as it is in London but it is much more difficult to treat.

One out of every three people around the world are infected with TB. Whereas in the West, it is mostly an old-age disease, in the East, it is mostly under 15 and adults who are most susceptible. The risk of TB is much higher in AIDS patients and in transplant patients receiving drugs like cyclosporine to suppress their immune system.

TB is not necessarily a disease of the lung. We find TB in liver, bones and joints, eyes, muscles, genital organs, meninges, lymph nodes, peritoneum, pericardium, larynx and just about any organ. One need not have classical chest symptoms to be a TB patient. Fortunately, both diagnosis and treatment of TB are relatively straightforward in most cases. (Diagnosis of TB outside of lung is a difficult task but not to a well-trained experienced physician). An skin test called Mantoux test where a small quantity of proteins from TB bacteria (called PPD or purified protein derivative) is injected in your forearm (the cost is about Rs. 50). If you react to more than 10-mm rash, you need to get a thorough check, you are a potential candidate for developing full-blown TB. Those who have received a vaccine against TB, the BCG vaccine, are likely to show a positive reaction but if it has been a few years since you got the vaccine and the reaction to the PPD test is intense, there should be no doubt that further investigation is warranted even if there are no symptoms present. A chest x-ray, sampling of sputum (if it is present) and other body fluids followed by biopsies of tissues (liver, bone marrow) may be needed to establish the nature and extent of your TB infection. Even if your doctor fails to find direct evidence of TB, you may be advised to begin treatment. Don't argue, take the treatment, though it may be for prophylaxis. The drug INH is generally used for six months for this purpose. For treatment there are about half a dozen well-proven drugs which are always given in combination to knock out the resistant bacteria; you will probably have to take the drugs for about nine months.

The required long treatment schedule is one reason why we have such large incidence of resistant organisms in Pakistan. People, once they begin to feel better, quit, often without telling their doctor and in many instances because of cost and that results in the resurgence of bacteria that had survived the treatment--the resistant type.

Prolonged use of anti-TB drugs is not without side effects; in many instances liver function is affected but only temporarily until you stop taking medicine. You will also be required to take some vitamins.

Several new drugs have recently been developed to treat resistant cases; these include quinolones like ofloxacin (but the dose required is too high), clarithromycin, sparfloxacin and fleroxacin (the last two drugs appear most promising but neither is currently available in Pakistan). A modified form of rifampicin, one of the most widely used anti-TB drug, rifabutin also shows promise.

People with TB infection do not spread disease to others unless they break out to full-blown lung TB when they begin to cough out TB germs. All other TB carriers are safe to work and live with. Unfortunately, the stigma that took centuries to develop regarding TB lingers on with us. TB is an infection no different than than typhoid or malaria.

The new findings about TB tell us that with extra care, we can curb the rise of TB. We need to improve public education, retrain physicians, improve management of public programs and change our belief that TB is a poor man's disease.

[Tuesday Review. The Daily Dawn. 1996]