The Captain of All These Men of Death or Why You Aren't Infected With Mycobacterium Tuberculosis
In 1992-1993 I was treated for tuberculosis. Tuberculosis is caused by the bacteria, Mycobacterium Tuberculosis. You aren’t infected with the Great White Plague in the United States of America because TB control in the United States is a success story. It’s a success story that highlights the importance of public education and of funding promising research. The story of people taking action to stop the spread of TB is long and it started a long time ago in 1904 when Dr. Edward Livingston Trudeau founded the National Association for the Study and Prevention of Tuberculosis. He realized the treating and funding disease prevention means understanding how interconnected our world is. Although the disease is largely controlled in the United States, it remains a tremendous problem worldwide.
On March 24, 1882, Dr. Robert Koch announced the discovery of Mycobacterium tuberculosis, the bacteria that causes Tuberculosis (TB). During this time, TB killed one of out of every seven people living in the United States and Europe. TB was known as the Great White Plague due to the paleness of the patients infected with TB. You might know TB as Consumption. It was also frequently known as “Captain of all these men of death.” Today, our names for TB tell us where TB is located, pulmonary or extrapulmonary. Our names also tell us how to treat it, drug susceptible, drug-resistant, multi-drug resistant, and extensively drug-resistant.
I lived in south Florida during the Tuberculosis (TB) outbreak of the early 1990s. The incidence of TB in the Unites States was steadily increasing in the late 1980s. Florida ranked fourth in the nation with 1,707 tuberculosis case reported in 1992 for a rate of 12.7 per 1000,000 population. The Florida Department of Health and Rehabilitative Services in collaboration with allied agencies utilized several initiatives in their response to the outbreak. There were latent TB infections (LTBI) driving new case infections as well clusters of multidrug-resistant TB (MDR-TB) in the state of Florida at the time. Identifying and treating people with LTBI is an important public health measure since it not only prevents active TB from developing in LTBI infections, but it also prevents the interpersonal spread of the disease. These MDR-TB strains of TB were resistant to Isoniazid, Rifampin, and Fluoroquinolones. Those are our big gun antibiotics that we use to save lives. The goal of treatment is to keep resistant strains of TB from establishing here in the United States.
TB is spread from person to person through the air. If an infected person coughs, speaks, or sings, then the bacteria is expelled into the air. The bacteria settle in the lungs of people who breathe in the bacteria. Once inside the person’s lungs, the bacteria begin to grow. From there the bacteria can move to other parts of the body. It usually affects the lungs, but it can also affect other parts of the body such as the brain, the kidneys, or the spine. The hallmark of a fully established TB infection is thick and bloody discharge from the lungs.
Not everyone who is infected with TB bacteria becomes ill upon infection. When a body keeps the growth of the TB bacteria somewhat in check for a while, we call this Latent Tuberculosis Infection (LTBI). Sometimes TB bacteria can overcome the defenses of the immune system and begin to multiply making a person sick after infection has occurred. Sometimes this happens relatively quickly, sometimes it occurs years after infection, or sometimes this happens later in life or during a time when the immune system is weak.
When I moved from South Florida, where I was working for The American Swim Coaches Association (ASCA) to Cleveland Ohio in 1993, I was hired for a job with MetroHealth Hospital in their family planning counseling and HIV counseling/outreach program that was funded through several public health grants. I underwent an extensive physical that included TB testing and titer testing for other diseases for which I had been vaccinated. One of the results from my physical was a very positive Mantoux test, also known as a PPD test or TB skin test. The test was repeated. It was still very positive.
A positive Mantoux test is indication of two things: latent TB infection (LTBI) or active TB infection. I had been exposed to a person who had the TB bacteria and I was infected with it. My doctors did several things at this point. They sent me for a chest X-ray, and a sputum sample test. When they realized I had been living in South Florida for a year and a half, they referred me to the Ohio Department of Health for extensive risk assessment, contact tracing and testing/treatment monitoring. The goal of TB and LTBI testing and risk assessment is to identify people who are at increased risk for developing TB and who would benefit from treatment of the infection.
I delayed the start of my job while the Ohio Department of Health worked with the Florida Department of Health and completed contact tracing efforts in South Florida. Back then, this took quite awhile because there was no internet and no really easy ways to communicate rapidly. Using my daily planner (which was on paper back then), I listed all of the places I had been in South Florida. I was in my early twenties then, so I had been plenty of public places. After extensive investigation, hundreds of phone calls, it was clear that I had been several places where there was an increase in active TB infections and I had been several places where the Florida Department of Health was tracking folks who had not been compliant in treating their active TB cases.
Because of the resurgence of TB in the United States in 1987, the Advisory Committee for the Elimination of Tuberculosis recommended strengthening of TB surveillance to improve monitoring and to assist in targeting groups at risk for disease. I was really at risk for disease given where I had been, who I had been exposed to, and the level of compliance of these individuals in their TB treatment regimens.
In addition, because of outbreaks of nosocomial (hospital acquired infections) multi-drug resistant TB (MDR-TB) in New York and Florida during 1990-1992, the National MDR TB Task Force recommended that drug-susceptibility testing be performed on all initial and final Mycobacterium tuberculosis isolates from each TB patient and that the results be reported to the CDC. In January of 1993, in conjunction with state and local health departments, the CDC implemented an expanded surveillance system for TB. Following the resurgence of TB in 1985 and the recognition of nosocomial (hospital acquired infections) outbreaks of MDR-TB in 1991 the Public Health Service increased funding to state and local health departments for TB prevention and TB control activities including directly observed therapy (DOT). DOT means that you meet with a healthcare worker every day or several times a week so side effects of medication and health problems can be dealt with quickly. Also, they ensure compliance of medication regimen.
Lastly, because of my compliance with the Ohio Department of Health and the Florida Department of Health we had a ton of very specific information about me, the status of my TB infection, and the people I had been around. The daycare workers I had worked with upon arriving in Ohio and the babies and toddlers I cared for during my time as a daycare worker had a chance to protect their own health appropriately. For this, I am eternally grateful.
Because of the requirements of my public health job, because of the actions of my doctors, because of the cooperation between the Ohio Department of Public Health and the Florida Department of Public Health, and because of the requirements of the Advisory Committee for the Elimination of Tuberculosis and the CDC, I recovered. It was a ginormous pain in my ass, but I recovered and I did not infect anyone from that point on because my infection was identified and treated properly.
Some of my life was delayed because of this infection and the treatment. I was on a regimen of several antibiotics for twelve months. There were side effects to be managed. I had to stop wearing contacts because my bodily fluids turned orange (side effect of the meds). My clothes were pretty easily stained as well when I exercised. I didn’t have much in the way of money at the time for replacing ruined clothes. I had to stop taking oral contraceptives (OCs) that were treating my painful ovarian cysts and what would be diagnosed as Stage 4 endometriosis two years later. I had several ovarian cysts that ruptured that year because I was unable to take OCs. I missed a lot of work because of this and suffered quite a bit as well. I had to start using a diaphragm for birth control, which caused a series of other problems that needed coping with. Luckily, I had health insurance coverage for the first time in my life through my job and I could finally get consistent and reliable treatment for these issues. I couldn’t drink any alcohol for a year and I had to have my weight, hepatic enzymes monitored frequently. I participated in DOT for a year and I don’t regret one minute of it.
There was a substantial decrease in the number of reported TB cases from 1992 to 1993 reflecting the effectiveness of prevention and control measures implemented during the 1989-1993 time period when the United States Public Health Services realized the threat from TB nosocomial infection and drug resistant infection that overlapped with the HIV outbreaks at the time in New York and Florida and California. Most states during that time period required that laboratories notify the health department about patients with cultures positive for M. tuberculosis. In response to an initial report, local health departments conducted investigations to verify diagnosis of TB and to collect information needed for completion of reporting. In 1993 79% of all reported TB cases were culture positive for M. tuberculosis. Public health intervention was absolutely effective at containing the outbreaks during that time period.
We shouldn’t fool ourselves into mistaking the world as we think we are experiencing it for the world as it really is. The two are related, but the relationship is complicated and its real work to figure it out. Fear is not part of that process. Fear is not a decent response to the world and the diseases that live in it. Any fear that comes upon you sudden enough will unfit you for thinking straight. Embracing bootstrapping or stark individualism wrapped in disconnected pseudoscience is also not an effective intervention for disease management.
I think its’s tragic how so many people embrace the notion that the biological world, the physical world isn’t an interconnected whole, while tiny bits of trees that were burned up a continent away lodge in their airways and a virus variant born on the other side of an ocean changes everything from their national economy to their personal health.
All of this happens while photons from a star 93 million miles away, captured by plants, animates the computer inside their heads to reject evidence of interconnection.
All of this happens while people first deny any mistakes, disasters, and even pandemics that descend upon them. When denial is no longer possible, then the mistake or disaster or the pandemic is assigned a source. I say source because usually the source is nothing of the kind.
Its just blame and blame is a form of make believe. I knew that even when I was very little. People who believe that the world is a disconnected mess and who take these ideas personally enough, will interview and air their grievances in excruciating detail, humiliating detail, spinning the narrative to create blame where none exists. To acknowledge this pandemic, to acknowledge the sickness, to acknowledge the tragedy of long Covid, to acknowledge death means that we must take another shape. We must acknowledge that we are interconnected.
*The photo of the painting is called Sick Child by Edward Munch. It draws upon Munch's memory of his sister Sophie's death from tuberculosis at the age of fifteen. The model was a young girl who Much had observed sitting distraught when he accompanied his father, a doctor, to treat her brother's broken leg. Munch worked on the painting for a year, developing the rapid brushwork and vivid color that suggest the painful memory of his sister's death. He made several versions over a period of about forty years. This was his fourth version.