December 7, 2008
Op-Ed Columnist

A Killer Without Borders
By NICHOLAS D. KRISTOF

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YEREVAN, Armenia

As if you didn’t have enough to worry about … consider the deadly,
infectious and highly portable disease sitting in the lungs of a
charming young man here, Garik Hakobyan. In effect, he’s a time bomb.

Mr. Hakobyan, 34, an artist, carries an ailment that stars in the
nightmares of public health experts – XDR-TB, the scariest form of
tuberculosis. It doesn’t respond to conventional treatments and is
often incurable.

XDR-TB could spread to your neighborhood because it isn’t being
aggressively addressed now, before it rages out of control. It’s being
nurtured by global complacency.

When doctors here in Armenia said they would introduce me to XDR
patients, I figured we would all be swathed in protective clothing and
chat in muffled voices in a secure ward of a hospital. Instead, they
simply led me outside to a public park, where Mr. Hakobyan sat on a
bench with me.

"It’s pretty safe outside, because his coughs are dispersed," one
doctor explained, "but you wouldn’t want to be in a room or vehicle
with him." Then I asked Mr. Hakobyan how he had gotten to the park.

"A public bus," he said.

He saw my look and added: "I have to take buses. I don’t have my own
Lincoln Continental." To his great credit, Mr. Hakobyan is trying to
minimize his contact with others and doesn’t date, but he inevitably
ends up mixing with people.

Afterward, I asked one of his doctors if Mr. Hakobyan could have
spread his lethal infection to other bus passengers. "Yes," she said
thoughtfully. "There was one study that found that a single TB patient
can infect 14 other people in the course of a single bus ride."

Americans don’t think much about TB, just as we didn’t think much of
AIDS in the 1980s. But drug-resistant TB is spreading – half a million
cases a year already – and in a world connected by jet planes and
constant flows of migrants and tourists, the risk is that our myopia
will catch up with us.

Barack Obama’s administration should ensure it isn’t complacent about
TB in the way that Ronald Reagan was about AIDS. Reagan didn’t let the
word AIDS pass his lips publicly until he was into his second term,
and this inattention allowed the disease to spread far more than
necessary. That’s not a mistake the Obama administration should make
with tuberculosis.

One-third of the world’s population is infected with TB, and some 1.5
million people die annually of it. That’s more than die of malaria or
any infectious disease save AIDS.

"TB is a huge problem," said Tadataka Yamada, president of global
health programs for the Bill and Melinda Gates Foundation. "It’s a
problem that in some ways has been suppressed. We often don’t talk
about it."

Ineffective treatment has led to multi-drug resistant forms, or
MDR-TB. Scarier still is XDR-TB, which stands for extensively drug
resistant TB. That is what Mr. Hakobyan has. There were only 83 cases
of XDR-TB reported in the United States from 1993 to 2007, but it
could strike with a vengeance.

"We always think we live in a protected world because of modern
medicines and the like," Dr. Yamada said. "But if we get a big problem
with XDR, we could be in a situation like we had in the 19th century
when we didn’t have good treatments."

If we were facing an equivalent military threat capable of killing
untold numbers of Americans, there might be presidential commissions
and tens of billions of dollars in appropriations, not to mention
magazine cover stories. But with public health threats, we all drop
the ball.

Because of this complacency about TB, there hasn’t been enough
investment in treatments and diagnostics, although some new medication
is on the horizon.

"Amazingly, the most widely used TB diagnostic is a 19th-century one,
and it’s as lousy as you might imagine," said Dr. Paul Farmer, the
Harvard public health expert whose Partners in Health organization was
among the first to call attention to the dangers of drug-resistant TB.

In Armenia, the only program for drug-resistant TB, overseen by
Doctors Without Borders, can accept only 15 percent of the patients
who need it. And the drugs often are unable to help them.

"After two years of treatment with toxic drugs, less than half of such
chronic TB patients are cured, and that’s very demoralizing," noted
Stobdan Kalon, the medical coordinator for Doctors Without Borders
here. And anyone who thinks that drug-resistant TB will stay in places
like Armenia is in denial. If it isn’t defused, Mr. Hakobyan’s XDR
time bomb could send shrapnel flying into your neighborhood.

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