While COVID-19 began its march through humankind barely half a year ago, TB is as old as humanity itself, infecting us for at least 5,000 years. (Illustration: C R Sasikumar)
The world has been spooked by COVID-19, the novel flu-like virus which emerged from the slaughter-houses of China and is now sweeping across the planet, propelled by the very engine of the global economy that it now threatens to pull asunder. Thanks to the waves of news engulfing us, including all shades of fake news, we are all now becoming experts in preventing this infection. Masks and hand-washing dispensers are flying off the supermarket shelves faster than a sneeze. Amongst the pure, there is a run on cow urine. Gobi Manchurian is off everyone’s menu. The government has swung into a military-style operation, marshalling every resource at its disposal. The prime minister avoided Holi celebrations, setting an example for all of us not to hang out in crowds. Airports have ramped up screening and health care systems are on heightened alert. Globally, many countries are monitoring the spread of the bug on an hourly basis, have banned all international meetings, ordered healthcare staff to cancel holidays and quarantined entire sections of the population. Economists are busy calculating how many trillions will be wiped off the global economy.
This phenomenal response by almost every sector of society, local and global, will undoubtedly help halt the epidemic in its tracks, being aided by the natural history of epidemics and, one hopes, the onset of summer in the northern hemisphere (where most of the community-level transmission has occurred), which rings the death-knell of most flu viruses. Then, we will all breathe without masks, stop consuming cow urine, return to shaking hands and hugging, and board planes and cruise ships without batting an eyelid. The panic of this deadly infection will rapidly fade into a smug memory, just like every other flu-epidemic which has threatened our lives in the past decade.
But, of course, Indians will still have to contend with other deadly respiratory tract infections which spread via airborne transmission. We will still have to contend with one particular bug which kills millions of us and which has been around for millennia. Tuberculosis. But all comparisons between COVID-19 and TB end with the superficial observation that they are both deadly respiratory tract infections. COVID-19 began its march through humankind barely half a year ago and, in record time, scientists have identified the virus and hundreds of millions of dollars have been allocated to controlling its spread, developing vaccines (at last count, more than a dozen candidates) and testing medication regimens for those infected. While the virus has spread to over 100 countries, the epidemic already shows signs of waning in the Asian countries where it hit first and hardest.
On the other hand, TB is as old as humanity itself, infecting us for at least 5,000 years. The infecting agent, a bacterium, was identified way back in 1882, by Robert Koch, signalling one of the landmark discoveries which laid the foundation of modern medicine. The subsequent response to this disease, which was infamously called the White Plague and was a leading cause of death globally at the start of the 20th century, is similar to what we see today for COVID-19, but played out over decades rather than months. TB was made a notifiable disease, campaigns were launched to prohibit spitting and containment policies, including sequestering infected persons, were implemented. The first vaccine was produced over a hundred years ago, and the first curative treatments available by the 1950s. TB was largely beaten in the rich world, not only because of these medical miracles but also thanks to the dramatic reduction in poverty and improvement in living standards. There is compelling evidence that addressing these social determinants was even more impactful than medical interventions in the war against TB.
TB has always been, and this is even more true now than ever before, a disease of poverty and squalor. And no country is more affected than India. Every TB statistic is grim: We are home to 1 in 4 of the world’s TB patients, over 2.5 million Indians are infected and, in 2018, over 4,00,000 Indians died of the disease. To put this in stark perspective, more people died of TB in India last week than the entire global death toll of COVID-19 to date. Given our urgent, energetic and multifaceted response to the latter bug, one is left wondering why we have failed so miserably for another bug, particularly one which has been around for so long, which has been exquisitely studied and characterised, which is preventable and treatable, and which most of the world has conquered.
It is because those who suffer from TB are not likely to be boarding international flights or passing through swanky airports to attend conferences. It is because TB infects people in slower tides, slow enough for industries to replace the sick with healthier recruits without endangering the bottom line. It is because TB does not threaten the turbines that keep the global economy throbbing. It is because TB no longer poses a threat to rich and powerful countries. It is because those who have TB live on the margins and have little political influence. It is because TB control requires society to address the squalid environments, which shroud the daily lives of hundreds of millions of Indians. It is because TB is a medieval scourge that reminds us of our shameful failure to realise a just, humane and dignified life for all our people.
Charles Dickens compared the deprivations in his home city of London with the events which led to the French revolution in his classic novel, A Tale of Two Cities, noting that degrading conditions of life for the poor in London were a recipe for insurrection. The UK, like much of Europe, did heed the importance of addressing social injustice, through major welfare reforms to improve the living conditions of the poor, which in turn earned much of the credit for the control of TB, as indeed most other infectious diseases. Of course, the cruel irony is that they did so even while they plundered the rest of the world, creating and worsening the social conditions which led to penury and disease in their colonies. And today, TB is largely a disease of poor people and poor countries, with none more affected than this country which fashions itself as a superpower in waiting.
If there is one lesson from COVID-19, it is that India, and the global community, has the political will, technical capacity and financial resources to act in a committed and concerted way to control infectious diseases. It needs to marshal these assets to eradicate TB, the most pernicious and pervasive infection of all, both through addressing its social determinants and scaling up effective biomedical interventions. But, for this to happen, we will have to be as concerned about the health needs of those who travel by foot and bicycle as we do for those who board cruise ships and international flights.
This article first appeared in the print edition on March 14, 2020 under the title: ‘COVID-19 and TB: A tale of two bugs'. The writer is Pershing Square Professor of Global Health at Harvard Medical School