Lessons From Tuberculosis

I have had two concentrated periods of my career when I treated many cases of tuberculosis. The first as a resident physician in charge of the tuberculosis ward at Denver General Hospital for 6 months in 1949 and the second from 1968 to 1970 teaching medicine an Nangrahar University, JalalabadJalolabad, Afghanistan, where nearly half of our patients had tuberculosis.

During the Denver period in 1949, streptomycin became available. It was the first drug with activity against the tubercle bacillus hacillus. From that period, I remember particularly well a lady who had been dying with terrible pleuritic pain, aggravated by constant cough. Morphine for some weeks had given her considerable relief, but when she started making a remarkable recovery because of streptomycin treatment, we realized that she must get off the morphine. This was difficult because morphine is so short acting that she kept getting withdrawal symptoms, which she attributed to stomach flu. Methadone, a new synthetic narcotic with much slower action than morphine solved the withdrawal problem. We permitted her to believe she had just the stomach flu. A few years later, methadone mMebecame the standard treatment for “drying out” narcotic addicts.

In Afghanistan, when seeing a new patient with the medical students and house staff, we quickly learned to think, “Could this be tuberculosis?” So, a backache might be bone tuberculosis. Headache might be tuberculous meningitis. Tuberculosis occasionally affects the kidneys, tendons, heart and intestines. Fortunately, much of this is curable with prolonged treatment, up to two years in many cases, with relapse and less successful re-treatment being a frequent consequence of lapses in the prolonged course of medication. Of course, the vast majority of tuberculosis is in the lungs.

Government sources of free medications were not always available. We checked in the bazaar for the cost of the most basic drug, INH (isonicotinic acid hydrazide). A month’s supply cost 7 afghanis, about 10 U.S. cents. Almost everybody had an uncle or friend who could help to this extent, so we (Mary and I were partners in this endeavor) organized group therapy sessions for the patients. There was no problem finding their x-rays. Everybody owned them proudly and brought them to the sessions, so there was no need for a filing system. As we showed the x-rays with relapses obvious even to a casual, untrained observer, the patient would supply details about how long they had gone without medicine. There was remarkable give and take among the patients attending these sessions in the best spirit of group therapy. Word got out about the “American treatment of tuberculosis”. It was more un-American than not because of the lack of confidentiality, and the details were the same as the Afghan treatment except for the group therapy. It was extremely gratifying how effective and well received was this “American treatment”, the spontaneous name for it supplied by the patients. We were surprised how easily we overcame our culturally determined attitude about privacy. The Afghan physicians were impressed that “ignorant, illiterate, superstitious” people could stick to the treatment regimen when they thoroughly understood the issues. This was the salient accomplishment of our “secular medical mission” as United State Peace Corps volunteers in Afghanistan.

In America, we now have big trouble with multi-drug resistant tuberculosis, partly because of social problems of many tuberculosis patients here – just out of jail, mentally ill, alcohol or other drug abuse, to name a few social disadvantages. After all, our Afghan patients came to use with real hope of success and supportive family and village networks. A beneficial side effect of the war on terrorism has been a shoring up of public health infrastructure. These additional health workers can much more effectively supervise directly observed treatment which requires tracking down reluctant patients and watching them take the medicine with great benefit to our entire population because of minimizing the emergence of multi-drug resistant germs.

John A. Frantz, M.D.

Chairman, Monroe City Council Board of Health

2-25-02February 25, 2002