‘We Need a Sense of Urgency’.
C. Robert Horsburgh Professor of Epidemiology and Global Health
Hometown: Cleveland, Ohio
Breakfast: A bagel with cream cheese and a cup of coffee
You recently became president-elect of the North American Region of the International Union Against Tuberculosis and Lung Disease. What is the Union?
It’s an organization that has been around for nearly a hundred years, the premier international organization combating tuberculosis from the beginning. About 40 years ago they expanded their scope to all lung disease.
I’m looking forward to the opportunity to help raise the profile of TB in North America, which is where a lot of the resources will come from to help us fight TB around the world. TB kills 1.8 million people a year around the world. People need to be 100 times more concerned about tuberculosis than they are about Ebola, that’s really the bottom line.
What is the current narrative around tuberculosis?
Well, it really makes a difference where you live. If you asked my parents’ generation about TB, they would say, ‘”It’s a terrible disease, I knew somebody who had it and they died of it.” My mother would always say, “Please don’t work on TB!”
If you go to other parts of the world, that’s what they’ll say, too. They’ll say, “It’s a dangerous disease. People die of it. I don’t want to get it. If I had it, I wouldn’t tell anybody about it.” Because there is a huge stigma related to TB. It is a serious disease. People know it’s a serious disease. That’s why they’re so worried about it.
But in the United States, people have forgotten about it. In the United States, if you ask people about TB, they’ll say, “Oh, I thought that went away? We don’t have that anymore, do we?” It’s really relatively uncommon in the United States. People don’t encounter it on a day-to-day basis. But it is a huge problem. It is the largest single cause of infectious disease mortality in the world. It is in the top 10 list of killers globally, which is not a place you want to be.
I would like people in the United States to be more aware of it, and I would like the people in the rest of the world to be less afraid of it. Those would be my wishes.
What’s behind the stigma?
Well, people know that it’s a disease that can kill you. They’re not necessarily aware that it can be cured, and if they are there, they may not be aware that the cure takes a long time. It involves a lot of medicine. People are scared of it, and that’s appropriate.
It’s also spread through the air, so you can’t do something yourself—you can wear a condom and not get HIV, but you can’t do anything to avoid getting TB. If somebody is in your proximity and is coughing up germs, you may inhale them. It’s not that easy to catch, but it’s definitely hard to avoid. That’s really the problem. We all have to breathe, so we all are at risk.
Once you find the people with TB and get them on treatment, they become noninfectious almost the day you put them on treatment. Therefore, it is something we can do something about.
What led to your work with TB?
My first interaction with tuberculosis was at a hospital right downtown in Boston where I was working in the ER. A fellow from Jamaica came in. He had a cough. He had lost weight. He had a fever. We took a chest X-ray, and he had a big cavity in his lung. We did a few tests and identified him as having TB. We put him on the treatment. He got a lot better.
I followed him, and he was eventually cured. I thought to myself, Wow. This is a disease that affects a huge number of people in the world, and we can treat this and cure it. This guy gained weight back. He went back to work as a construction worker. It really gave me a feeling of having helped somebody get their life back on track from a life-threatening disease.
That made me want to get moving. I thought, Well, we have the tools. We just need to get out there and do it. Unfortunately, 40 years later, we still have not gotten out there and done it completely despite many people’s best efforts. It’s been a very tough bug to lick.
What makes it so challenging—beyond stigma?
It’s a combination of things. Part of the problem is people don’t always know when they have TB. Most of the people that come to see us with TB have had it for anywhere from 4 to 12 weeks. That’s a long time, and while they didn’t know they had it, they’ve been spreading it. That I think is the real crux of the problem.
Then, the treatment takes a long time. Usually people feel better after a month or two, but if they stop the medicines then, it’ll come back on them.
It’s a combination of things, and it really is a social disease: It takes the whole community. If you’re not willing to tell people you have it, then nobody else knows you have it. Then, when you stop taking your medicines, nobody knows you’ve stopped taking your medicines.
It really should be the other way around: The community should be getting behind you and helping you complete the medicines, because it’s as good for them as it is for you. But that’s not the way it’s seen. I’ve done some community work around TB, and I think that really is one of the places we can make the biggest impact, helping combat the stigma and convince communities that this is something where they can get together and they can beat it. It has to be a community effort.
What does this kind of community effort look like?
I worked in a community in South Florida where we there was a shopkeeper who had gotten TB. She had the shop in the middle of town, where everybody knew her. She was willing to go on TV in a video that everybody saw. She said, “Well, I have this. You might have it. But it’s curable. You should come in and get treated.”
That really helped us. We got community members behind it, somewhat begrudgingly in some cases. Businesses don’t want to be seen as hotbeds of TB, but they do want to be seen as part of a community that has its act together. You just have to really help them understand that this is a battle they can win.
You also chair the steering committee of RESIST-TB, which focuses on drug-resistant tuberculosis.
TB has a worse cousin, and that’s drug-resistant TB. Some of the new drugs work against it, but we still don’t have very good treatments—they’re much more toxic than treatment for drug-susceptible TB, and they take longer.
We really need to get out there and start getting drug-resistant TB under control. There’s some very exciting research going on, but there’s not enough of it. Only 20 percent of the patients with drug-resistant TB get started on drug-resistant TB treatment, so the other 80 percent of them are out there spreading TB in their communities.
It’s not a disaster waiting to happen, it’s already happening. We’re starting to see increasing numbers of cases of MDR TB—multidrug-resistant TB. The genie is out of the bottle. We have it circulating in our communities. We need to do something about it.
There’s good research going on, but more resources have to be put towards finding and treating people with MDR-TB. That’s what RESIST-TB advocates for.
What are your hopes for the future of tuberculosis?
I want the rest of my career to be devoted to making the world free of tuberculosis. We may not get there. Certainly, there is a lot of room for improvement. I’ll settle for improvement—I’m a practical person. But I went into this because we had the tools, and we now have better tools. We need more money. We need more good publicity. We need more of a sense of urgency.
March 24 is World TB Day.