9/11 and TB

In the taut and tumultuous days after 9/11, the spectre of bioterrorism began to haunt the United States. Traces of anthrax were found in letters mailed to offices of senior members of the US Congress as well as to media organisations. This was a new sort of enemy. It didn’t come carrying a gun or even flying a plane. It arrived

surreptitiously in the post. The first line of defence was not a counterterrorism commando but, crazily, the person who collected and sorted out mail. Testing each individual envelope or parcel would set back delivery schedules of the United States Postal Service (USPS) by weeks. It would also drive down public morale.
The USPS and the US department of defence put out a contract — valued at $70 million, it is believed — for the development and manufacture of a device that could be put at the end of a postal chute, as it were, and tell you if a particular item had anthrax. A then small California-based technology company called Cepheid won the contract. The result was the Cepheid GeneXpert Biothreat Assay, a small device that tests and positively identifies bio-threats such as anthrax and plague in about 70 minutes.
Shortly after the device came into USPS sorting rooms, tuberculosis specialists began pondering the Cepheid machine. If it could detect the anthrax bacteria could it similarly identify its cousin, the tuberculosis (TB) bacteria?
The idea was put into motion. A philanthropic foundation gave Cepheid another $9 million to tweak its anthrax machine to work on TB. The result is Xpert, a molecular diagnostic device that is already being called a game-changer in the world’s fight against TB. Indeed, when the “Global Plan to Stop TB: 2011-2015” was released at a conference in Berlin in October, a World Health Organisation (WHO) release spoke of “eliminating tuberculosis through improved, quicker diagnosis, more effective drugs and vaccines and stronger health systems”.
All of those have to act together but Xpert could well be the accelerator. It identifies a sample/patient as TB positive in 90 minutes. To understand how revolutionary this could be, the history of man’s battle with TB is worth recounting. Hitherto, the most common way to identify TB has been to look for the bacteria under the microscope. This smear microscopy test goes back to the closing years of the 19th century.
A better detection method is to take a sputum sample and allow the organism to grow. In a solid culture medium, this could take six weeks. In a liquid culture medium it could take two to three weeks. “Liquid cultures began to be used in the 1980s”, says Bobby John, a medical doctor who has worked in global TB advocacy, “and the average time is nine days”.
What this has served to do is make TB case detection the “Achilles’ heel of TB control”, suggests Madhukar Pai, epidemiologist at Canada’s McGill University and co-chair of the New Diagnostics Working Group of the Stop TB Partnership.
For India, new TB diagnostics are of particular interest. TB kills about 1,000 Indians a day and is one of the biggest causes of mortality in the country. The national TB control programme has made a Herculean effort in the past decade to detect and bring patients to treatment. It has to reach the Millennium Development Goal (MDG) of halving the number of TB-related deaths by 2015 as against the toll in 1990. On its part, WHO aims to eliminate TB as a public health problem worldwide by 2050. India has achieved this with smallpox and to a degree leprosy and polio — but in today’s reckoning, TB would be the Big One.
The introduction of Xpert into the public health programme in India is still some way off. It will likely arrive in private clinics and hospitals earlier. The cost will have to be calculated. As a diagnostic tool it will be more expensive than the ones currently used. Even so, some public health professionals argue this is a front-loaded expense and much cheaper in the long run than the social and economic cost of misdiagnosis or treatment.
The government-funded TB medication programme costs $15 per patient but it requires strict adherence over six months. If a patient breaks off midway, he could develop multi-drug resistant, or MDR TB (a more virulent version of the disease), could infect others and, should his bodily systems start to get infected, spend up to $20,000 on medical care. Most Indian TB patients simply can’t afford this — only about 5,000 of the estimated 130,000 MDR TB patients in India are undergoing appropriate treatment — and would probably just waste away.
The big picture that emerges — and this is as true for TB control as for public health provision as for overall achievement of the MDGs — is that there will be no appreciable advance in the absence of investments in technology. TB itself is treated using a combination of four drugs, the last of which was discovered in the 1960s. The TB vaccine will not arrive, if it does at all, for about a decade.
Yet, for fighting TB or malaria or HIV/AIDS, eliminating hunger by addressing supply-side issues related to food, improving maternal mortality indices, universalising primary education, ensuring a greener, environmentally sustainable mode of economic growth — and all of these are among the MDGs — it will not be enough to simply pour in more money using existing templates. Technology has to come in as a catalyst.
That aside, the sheer beauty and interoperability of technology and technology development is stunning. A machine put together in the early years of the war against terror could now help human civilisation defeat a much older, more manipulative enemy and become a force multiplier in the war against TB. Who would have thought of that on that mad September day, nine years ago?

Ashok Malik can be contacted at malikashok@gmail.com [2]