The global killer that will not die

In our age of high-profile infectious diseases such as HIV, severe acute respiratory syndrome and the recent alarming human cases of bird flu in Asia, tuberculosis is the silent and formidable global killer noticeably absent from the headlines. The Return of the White Plague addresses the re-emergence of the TB pandemic.

The sheer magnitude of the challenge is highlighted on the book's jacket in a quotation from the World Health Organisation: "It is estimated that between 2002 and 2020, approximately 1,000 million people will be newly infected, over 150 million will get sick and 36 million people will die of TB."

These numbers are stunning. How can it be that a global disease that some decades ago was believed to be controllable now affects a third of humankind?

This excellent book deals with all aspects of the TB complex, a jigsaw of intertwined scientific disciplines (including microbiology, immunology and the social sciences) and politics (business and health), and sets the theme in historical and political contexts. The 13 chapters, which are written by established experts in their fields, analyse and dissect the crisis. They are conveniently divided into three parts: "History and context", "The 'new' tuberculosis" and "Advocacy and action".

The re-emergence of tuberculosis is terrifying in itself, but equally so is the underlying scientific and political ignorance and inertia that has allowed this scourge to return. Richard Lewontin and Richard Levins make an interesting point in the book's prologue: "In the 1950s, the common sense view of public health leaders was that infectious disease had been defeated in principle... Medical students were told to avoid specialising in infectious diseases because it was a dying field."

One may wonder how such naivety could dominate the discussions among specialists for so many years. Although it is generally accepted that the demise of the science of infectious diseases was announced prematurely, the question remains whether today we funnel enough resources into training medical doctors and scientists to help tackle infectious diseases in the Third World, as well as providing enough research money for such projects.

As many of the contributors so forcefully argue, there is a lack of political will to address the TB threat in earnest.

In the chapter "Rethinking the social context of illness: Interdisciplinary approaches to tuberculosis control", Christian Lienhardt, Jessica Ogden and Oumou Sow discuss the wisdom of historical and current international TB control. While it is important to ensure that the patient complies with the prescribed regimen for drug intake, usually by directly observed therapy (Dot), it is equally important to ensure the patient's total wellbeing. A visit to the health clinic may not be without social stigma, not to mention the loss of wages in taking time off to seek medical assistance. One must, therefore, consider the pandemic as not solely a medical problem but as a multifaceted challenge, requiring a concerted interdisciplinary approach.

It appears that the WHO is now rising to that challenge.

The recent outbreaks of Sars and avian influenza in Asia have spurred an almost unprecedented intellectual effort, backed by political fervour and financial commitment. Is this because they constitute an acute risk of uncontrolled dissemination also in the wealthy part of the world? It is a tempting allegation. It should be remembered, however, that the emerging multiresistant strains of TB could also spread among the affluent in the rich world; point sources are already present in many derelict inner cities throughout the world.

The book addresses with great insight the pure microbiological and immuno-logical aspects of TB. Although better (and affordable) vaccines and drugs are needed, it is undoubtedly clear that the medical sciences and the medical-industrial complex by themselves will not provide the coup de grâce to this formidable enemy.

TB is a disease predominantly of the Third World and also of the poor and the destitute in the industrialised world. "TB impoverishes, and poverty attracts TB," as noted by Leopold Blanc and Mukund Uplekar of the WHO in a particularly informative chapter, "The present global burden of tuberculosis". In 1997, the incidence of the disease in southeast Asia was 44 per cent.

The grim sub-Saharan African experience is described in a chapter by Anthony Harris, Nicola J. Hargreaves and Alimuddin Zumla. Again, it is a dispiriting story of a withering fabric of impoverished and fragile societies. TB and HIV/Aids feed on each other, each sustained by poverty.

The decaying infrastructure of the world's metropolitan inner cities, the increasing number of internal and international refugees caused by wars and poverty, and the appearance of multidrug resistant strains of TB, all point to a future global disaster even more devastating than today's epidemic.

This book is highly recommended to students and professionals of infectious diseases and the social and political sciences. Decision-makers, opinion leaders and health providers, particularly in the wealthy countries that provide financial resources to TB programmes, should all set aside time to read this well-written, well-informed book.

Lars R. Haaheim is professor of immunochemistry, University of Bergen, Norway.