Tuesday, March 20, 2012

Drug-resistant TB: a growing man-made problem needing better medical treatment

By Kate Kelland, London Reuters, in Globe and Mail, March 19, 2012
Tuberculosis is often seen in the wealthy West as a disease of bygone eras – evoking impoverished 18th or 19th century women and children dying slowly of a disease then commonly known as “consumption” or the “white plague.”

But rapidly rising rates of drug-resistant TB in some of the wealthiest cities in the world, as well as across Africa and Asia, are again making history.
London has been dubbed the “tuberculosis capital of Europe”, and a startling recent study documenting new cases of so-called “totally drug resistant” TB in India suggests the modern-day tale of this disease could get a lot worse.
“We can’t afford this genie to get out of the bag. Because once it has, I don’t know how we’ll control TB,” said Ruth McNerney, an expert on tuberculosis at the London School of Hygiene and Tropical Medicine.
TB is a bacterial infection that destroys patients’ lung tissue, making them cough and sneeze, and spread germs through the air. Anyone with active TB can easily infect another 10 to 15 people a year.
In 2010, 8.8 million people had TB, and the Geneva-based World Health Organisation (WHO) has predicted that more than 2 million people will contract multi-drug resistant TB by 2015. The worldwide TB death rate currently runs at between two and three people a minute.
Little surprise, then, that the apparently totally untreatable cases in India have raised international alarm.
The WHO has convened a special meeting on Wednesday to discuss whether the emergence of TB strains that seem to be resistant to all known medicines merits a new class definition of “totally drug-resistant TB,” or TDR-TB.
If so, it would add a new level to an evolution over the years from normal TB, which is curable with six months of antibiotic treatment, to the emergence of MDR-TB, then extensively drug-resistant TB (XDR-TB).
What’s so frustrating about that progression, says Lucica Ditiu of the WHO’s Stop TB Partnership, is that all drug-resistant TB “is a totally man-made disease.”
Like other bacteria, the TB bug Mycobacterium tuberculosis can evolve to fight its way past antibiotic medicines. The more treatment courses patients are given and fail to complete, the stronger and more widespread the resistance becomes.
“The doctors, the health-care workers, the nurses, entire health-care systems have produced MDR-TB. It’s not a bug that has come from nature. It’s not a spontaneous mutation. It came about because patients were treated badly – either with poor quality drugs, or not enough drugs, or with insufficient observation so the patient didn’t finish the treatment course,” said Ms. Ditiu
So the medical profession, in treating patients badly, is responsible for the drug-resistant variety of TB....so, who is patrolling the profession?
Over-the-counter drugs, over-medication of patients with antibiotics, failure to monitor patients on prescribed drugs...these are some of the overt reasons for the development of this new form of TB and once again, we are looking at "human error" on a rather large scale.
Just as in the case of prevention, in medicine, or in social ills, follow-up treatment is boring, time-consuming and much like watching grass grow, or paint dry-not very exciting.
How many times have you been asked by a medical professional, "Did you finish taking the medication?" Can anyone remember even once? Not likely.
And yet, on many vials of prescription medication, one finds the words, "Do not stop taking this medication until finished!" Clear, unambiguous and forthright instruction....and for those who actually complete the instructions, a small insurance policy against cases like the drug-resistant TB that seems to be gaining a foothold in many large urban areas of the world and spreading to the rest of the world very easily.
Nations are, of course, responsible for the practice of medicine; however, there is a commonly held view that TC has been wiped out, so there is very little public consciousness about its potential return, in a more virulent and less treatable variety. Doctors are less trained and much less consciousness of its potential, perhaps even less likely to be able to diagnose it. Furthermore, with so many "urgent" cases of more publicly "acclaimed" diseases, injuries and conditions, TB has virtually slipped off the radar both in the public and in the medical profession.
Does that sound a little like how individual patients slip off the radar of the individual practitioner?
We have made an icon of busyness, of intervention, of getting the medical profession paid...and the monitoring of patients, including the monitoring of prescriptions is often left to the coroner's court, after the patient has died and even then many of the recommendations of such courts are left languishing in the archives of those court documents, whether in "hard copy" or now in digital format.
In short, there is no newsworthiness in many of those recommendations. And consequently, there is also little monitoring of their implementation, unless the case has public attention and the public demands implementation.
Some of the best ideas on both large-scale public controversies and medical monitoring can be found in documents no one reads after they have been prepared. We move on! As if that phrase were a mantra for "not obsessing on the past" a trap into which no one, least of all the medical or political professions, wishes to fall.
Quality control is not needed only on the manufacturing floors of our large industries, or on our freeways. Quality control is an essential part of all of our human systems, and we need to be vigilant to generate and to implement quality control strategies and tactics with some vigor and some imagination and some teeth if we are to move toward a more comprehensive and more vigorous health care delivery system.
And, like the growing regimen of hand-washing, and removal of carpets in hospitals, we are still in the dark about demanding more stringent quality controls of the medical profession, so trusting and so naive and so "politically correct" are we in attempt to "fit in" that we abdicate our responsibility to be more like sandpaper in the way we approach omissions in the practice of medicine....apparently to our peril!

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