The Threat of Drug-Resistant Tuberculosis

Question: What is XDR-TB?


Neil Schluger: So the really frightening thing about multidrug-resistant TB and extremely or extensively drug-resistant TB, XDR, I think is that we don’t really know how prevalent it is. We know that drug-resistant tuberculosis now has been seen in all regions of the world and these extensively drug-resistant cases have also been observed in most parts of the world. We have a patient we’re treating in our clinic in New York who has that sort of an unusual case. In general, in New York and in the United States extensively drug-resistant tuberculosis is not much of a problem. In New York City last year there were only nine cases of multidrug-resistant TB, much less extensively drug-resistant TB, so at the moment it’s not much of a problem in the U.S. but around the world it clearly is. In Russia and countries in the former Soviet Union as many as ten, 15 or 20% of cases can be multidrug resistant and then some of those are extensively drug resistant. In Africa we have very little idea because most African countries don’t have enough money to do cultures of TB and do drug-susceptibility testing on a routine basis so we don’t really know. If you look at the WHO’s map of XDR-TB, most of Africa is just this big blank because we don’t know, and to me that’s one of the most frightening things. Our inability to get sophisticated diagnostic testing in to places where TB is most common really prevents us from knowing exactly how bad this situation is so that’s worrisome. And then of course the other worrisome aspect is for people with XDR-TB essentially we have no treatment. Drug development for economic reasons as I mentioned earlier has really lagged and if someone comes in with XDR-TB it’s sort of throw the kitchen sink at them and hope something works.

Question: How did tuberculosis become drug-resistant?

Neil Schluger: So drug resistance in tuberculosis usually comes about because of erratic administration of medicine or erratic use of medicine. Tuberculosis has to be treated with multiple antibiotics and they really have to be taken all together in a very precise schedule and if that falls apart, if patients don’t take their medicine just the way they need to, then drug-resistant strains will predominate. They’ll sort of out-compete the drug-sensitive strains and you’ll develop drug-resistant TB so most of the time when we see drug-resistant TB it’s a reflection that the local TB control program somehow is not doing a great job of getting the right patients to the- the right medicines to the patient and getting the patients to take them in the right way. Once you’ve sort of created this reservoir of drug-resistant cases though then they just spread in the usual way that TB spreads. Someone with drug-resistant TB starts coughing next to someone who is healthy and the next thing you know that person’s infected with drug-resistant TB. So it starts because of sort of poorly functioning TB control programs where patients somehow are not getting the message that they need to take their medicine in a particular way, and then it just starts to spread around to vulnerable people.

Question: How big of a threat is it in the U.S.?

Neil Schluger:  So multidrug-resistant tuberculosis cases in the United States have been pretty steady at about 1% of the most of all TB cases for the last several years and in fact in New York City in 1992 about 16% of all cases of TB were multidrug resistant and as I mentioned last year that went down from 400 cases to nine. So at the moment we’re doing quite well I think in MDR-TB. The danger is that as budgets everywhere are being cut people will say, “Oh, TB’s not much of a problem anymore. We don’t need to fund the TB control program nearly as much as we’ve been funding it,” and clinics will close and TB services will be dismantled and then we’ll get behind the eight ball. That’s what all of us are worried about. That’s what happened in the ‘70s and early ‘80s. People thought TB had went away, the money was taken out of TB control programs, and the next thing you know, “boom,” there’s a huge TB epidemic. So I think in the United States at the moment we’re doing well with drug-resistant TB by and large. The cases that come in mostly come in from outside the United States. We have the capacity to diagnose them and treat them but we need to be vigilant about our TB control program budgets.

Recorded on: 04/25/2008




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Politics & Current Affairs

Political division is nothing new. Throughout American history there have been numerous flare ups in which the political arena was more than just tense but incideniary. In a letter addressed to William Hamilton in 1800, Thomas Jefferson once lamented about how an emotional fervor had swept over the populace in regards to a certain political issue at the time. It disturbed him greatly to see how these political issues seemed to seep into every area of life and even affect people's interpersonal relationships. At one point in the letter he states:

"I never considered a difference of opinion in politics, in religion, in philosophy, as cause for withdrawing from a friend."

Today, we Americans find ourselves in a similar situation, with our political environment even more splintered due to a number of factors. The advent of mass digital media, siloed identity-driven political groups, and a societal lack of understanding of basic discursive fundamentals all contribute to the problem.

Civil discourse has fallen to an all time low.

The question that the American populace needs to ask itself now is: how do we fix it?

Discursive fundamentals need to be taught to preserve free expression

In a 2017 Free Speech and Tolerance Survey by Cato, it was found that 71% of Americans believe that political correctness had silenced important discussions necessary to our society. Many have pointed to draconian university policies regarding political correctness as a contributing factor to this phenomenon.

It's a great irony that, colleges, once true bastions of free-speech, counterculture and progressiveness, have now devolved into reactionary tribal politics.

Many years ago, one could count on the fact that universities would be the first places where you could espouse and debate any controversial idea without consequence. The decline of staple subjects that deal with the wisdom of the ancients, historical reference points, and civic discourse could be to blame for this exaggerated partisanship boiling on campuses.

Young people seeking an education are given a disservice when fed biased ideology, even if such ideology is presented with the best of intentions. Politics are but one small sliver for society and the human condition at large. Universities would do well to instead teach the principles of healthy discourse and engagement across the ideological spectrum.

The fundamentals of logic, debate and the rich artistic heritage of western civilization need to be the central focus of an education. They help to create a well-rounded citizen that can deal with controversial political issues.

It has been found that in the abstract, college students generally support and endorse the first amendment, but there's a catch when it comes to actually practicing it. This was explored in a Gallup survey titled: Free Expression on Campus: What college students think about First amendment issues.

In their findings the authors state:

"The vast majority say free speech is important to democracy and favor an open learning environment that promotes the airing of a wide variety of ideas. However, the actions of some students in recent years — from milder actions such as claiming to be threatened by messages written in chalk promoting Trump's candidacy to the most extreme acts of engaging in violence to stop attempted speeches — raise issues of just how committed college students are to
upholding First Amendment ideals.

Most college students do not condone more aggressive actions to squelch speech, like violence and shouting down speakers, although there are some who do. However, students do support many policies or actions that place limits on speech, including free speech zones, speech codes and campus prohibitions on hate speech, suggesting that their commitment to free speech has limits. As one example, barely a majority think handing out literature on controversial issues is "always acceptable."

With this in mind, the problems seen on college campuses are also being seen on a whole through other pockets of society and regular everyday civic discourse. Look no further than the dreaded and cliche prospect of political discussion at Thanksgiving dinner.

Talking politics at Thanksgiving dinner

As a result of this increased tribalization of views, it's becoming increasingly more difficult to engage in polite conversation with people possessing opposing viewpoints. The authors of a recent Hidden Tribes study broke down the political "tribes" in which many find themselves in:

  • Progressive Activists: younger, highly engaged, secular, cosmopolitan, angry.
  • Traditional Liberals: older, retired, open to compromise, rational, cautious.
  • Passive Liberals: unhappy, insecure, distrustful, disillusioned.
  • Politically Disengaged: young, low income, distrustful, detached, patriotic, conspiratorial
  • Moderates: engaged, civic-minded, middle-of-the-road, pessimistic, Protestant.
  • Traditional Conservatives: religious, middle class, patriotic, moralistic.
  • Devoted Conservatives: white, retired, highly engaged, uncompromising,

Understanding these different viewpoints and the hidden tribes we may belong to will be essential in having conversations with those we disagree with. This might just come to a head when it's Thanksgiving and you have a mix of many different personalities, ages, and viewpoints.

It's interesting to note the authors found that:

"Tribe membership shows strong reliability in predicting views across different political topics."

You'll find that depending on what group you identify with, that nearly 100 percent of the time you'll believe in the same way the rest of your group constituents do.

Here are some statistics on differing viewpoints according to political party:

  • 51% of staunch liberals say it's "morally acceptable" to punch Nazis.
  • 53% of Republicans favor stripping U.S. citizenship from people who burn the American flag.
  • 51% of Democrats support a law that requires Americans use transgender people's preferred gender pronouns.
  • 65% of Republicans say NFL players should be fired if they refuse to stand for the anthem.
  • 58% of Democrats say employers should punish employees for offensive Facebook posts.
  • 47% of Republicans favor bans on building new mosques.

Understanding the fact that tribal membership indicates what you believe, can help you return to the fundamentals for proper political engagement

Here are some guidelines for civic discourse that might come in handy:

  • Avoid logical fallacies. Essentially at the core, a logical fallacy is anything that detracts from the debate and seeks to attack the person rather than the idea and stray from the topic at hand.
  • Practice inclusion and listen to who you're speaking to.
  • Have the idea that there is nothing out of bounds for inquiry or conversation once you get down to an even stronger or new perspective of whatever you were discussing.
  • Keep in mind the maxim of : Do not listen with the intent to reply. But with the intent to understand.
  • We're not trying to proselytize nor shout others down with our rhetoric, but come to understand one another again.
  • If we're tied too closely to some in-group we no longer become an individual but a clone of someone else's ideology.

Civic discourse in the divisive age

Debate and civic discourse is inherently messy. Add into the mix an ignorance of history, rabid politicization and debased political discourse, you can see that it will be very difficult in mending this discursive staple of a functional civilization.

There is still hope that this great divide can be mended, because it has to be. The Hidden Tribes authors at one point state:

"In the era of social media and partisan news outlets, America's differences have become
dangerously tribal, fueled by a culture of outrage and taking offense. For the combatants,
the other side can no longer be tolerated, and no price is too high to defeat them.
These tensions are poisoning personal relationships, consuming our politics and
putting our democracy in peril.

Once a country has become tribalized, debates about contested issues from
immigration and trade to economic management, climate change and national security,
become shaped by larger tribal identities. Policy debate gives way to tribal conflicts.
Polarization and tribalism are self-reinforcing and will likely continue to accelerate.
The work of rebuilding our fragmented society needs to start now. It extends from
re-connecting people across the lines of division in local communities all the way to
building a renewed sense of national identity: a bigger story of us."

We need to start teaching people how to approach subjects from less of an emotional or baseless educational bias or identity, especially in the event that the subject matter could be construed to be controversial or uncomfortable.

This will be the beginning of a new era of understanding, inclusion and the defeat of regressive philosophies that threaten the core of our nation and civilization.