TB's Comeback

Not gone but almost forgotten

The disease evokes images of pale, suffering poets like Keats and Shelley or wanly beautiful heroines like La Boheme 's Mimi and Camille wasting away in the arms of their lovers. Indeed, during the 19th century, tuberculosis-or consumption, as it was then called-exacted a horrifying toll; up to 20% of the population in Western countries died of it before the age of 50. But by 1882, when the German bacteriologist Robert Koch demystified the disease by identifying the tiny rod-shaped tubercle bacillus that caused it, the tide was turning.

Thousands of TB patients sought out mountain air and were put on regimens of nutritious food. Chest X rays helped spot infected patches of lung. Finally, with the development of such drugs as streptomycin and isoniazid in the 1940s and 1950s, tuberculosis seemed on the way to being vanquished.

Not so. While many of the Magic Mountain sanatoriums have closed and the Christmas Seal drives have turned mostly to other causes, TB still thrives. In the U.S., nearly 3,000 Americans died of the disease in 1977. Each year about 30,000 new cases are reported nationwide; last year 21 states noted a rise in cases. Almost 3 million more cases occur in the rest of the world. Says one concerned pulmonary specialist, Dr. Lee B. Reichman of the New Jersey Medical School in Newark: "It's a classic case of what happens when we eradicate a disease but we don't eradicate it. We know everything about it, yet it's still there."

Tuberculosis strikes all segments of society, but hardest among the poor who live in crowded, unsanitary conditions and subsist on inadequate diets. While the annual rate is only about 14 cases per 100,000 among the population as a whole, in Harlem, for example, it climbs to about 64 per 100,000. Alcoholics and drug addicts are especially vulnerable because their immune systems may have been weakened. Found in the bodies of about 7% of the populace, the bug makes only a small proportion of them ill.

At an international conference on TB in Orlando, Fla., last month, doctors noted that many carriers of the disease have no outward symptoms. Others suffer from fatigue, weight loss, night sweats or intermittent low-grade fever, which can signify any number of disorders. Only when the patient develops TB's brassy cough does the disease become contagious. Fortunately, the chances of catching TB are low. One study showed that it took as long as six months of daily exposure to become infected.

Unlike their 19th century predecessors, today's doctors rarely see the disease; medical schools do not stress it. A 1977 study at Scott Air Force Base revealed that of 130 patients referred there for TB, 73 had been misdiagnosed or given inadequate therapy by their original physician.

In the 1950s and '60s, the U.S. conducted mass screening programs; hundreds of thousands of people were given skin tests and chest X rays at a cost of millions of dollars. Reichman, for one, believes that such a blunderbuss approach is not justified on either medical or economic grounds. Nor, he says, are sanatoriums, hospitals or clinics that treat only TB patients. Though most have been closed, they survive in several states and are extremely expensive to run. Until a few months ago, for example, the Mercer County Chest Clinic outside Trenton, N.J., was spending $180,000 to care for about 100 TB patients a year. Reichman would rather have these people treated in doctors' offices or in outpatient clinics that also handle such common ailments as diabetes, hypertension and heart problems.

That is possible, he says, because treating TB is now relatively simple. Those who are at high risk, especially those recently exposed to the disease, may be put on isoniazid for a year as a preventive measure. If the disease develops, U.S. doctors now have eleven drugs to choose from, the most potent new one being rifampin. Within two weeks, most patients are no longer infectious, but must continue medication for at least nine months, sometimes up to two years, and get monthly checkups by their doctor or clinic. One major problem: keeping patients on this strict regimen after they feel well again. Sometimes doctors take to grandmotherly inducements. Reichman's clinic provides coffee and doughnuts. In Denver, where there are many alcoholics among TB patients, a clinic offers stronger stuff: balky patients may be given a drink or two in hopes that they will return.

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