Captain of All These Men of Death
Some years ago, while doing a chest X-ray for a routine pre-employment medical examination, I found a curious little lesion at the apex of my right lung. For the medically inclined, this will ring alarm bells as the location of this lesion commonly points towards pulmonary tuberculosis. It’s of no surprise really, as healthcare workers are at higher risk of tuberculosis, and I’ve spent a good number of years around patients and while serving in a street clinic for the urban poor, interacted with some of the highest-risk populations for tuberculosis.
I went through the motions diligently, including more imaging of my lungs, blood tests (no sputum culture because I wasn’t coughing!) and a procedure called bronchoalveolar lavage (essentially washings of the lungs to obtain samples for bacterial culture). I was feeling fine with no symptoms, but protocol dictates I start treatment, so I was on a 6-month regime of anti-tuberculosis drugs.
As tuberculosis is a notifiable communicable disease, public health officers soon were knocking on my doors for contact tracing, to see if any of my close contacts were also infected. Most of my family members were required to be screened and I am happy to report none of them were positive for the disease, and this includes my barely 2-month-old baby girl (at that time). Access to testing and medicines for a relatively straightforward disease has been a smooth process for me, but that cannot be said for the millions afflicted by it.
World Tuberculosis Day is on 24th March every year so just 2 days ago, the global community called for increased access to diagnostics and treatment and greater awareness for a disease which is very curable. But for a disease that we have a good understanding of, it remains a leading cause of mortality globally.
In 1834, Johann Schönlein coined the term ‘tuberculosis’ and subsequently, in 1882, Robert Koch discovered the offending bacteria. But the disease has existed since time immemorial. There were records of a lung disease described as “wasting disease” as early as the second millennium. Hippocrates in 400 BC wrote it as the “weakness in the lungs with fever and cough”.
In the 1600s, John Bunyan memorably called tuberculosis the “Captain of all these men of Death” and described this in a passage in his book, “Yet the captain of all these men of death that came against him to take him away, was the consumption, for it was that that brought him down to the grave.”.
Consumption was the layman's term for TB in the 17th century, a disease that consumes from the inside, leaving the afflicted to waste their lives away. Tuberculosis persisted throughout the centuries, permeating our culture and society such as the design of our hospitals (or sanitoria) and even on television, with scenes of characters dramatically coughing blood.
Fast forward to the present, the WHO reports 10.6 million people with tuberculosis in 2021, with a large proportion in South East Asia (45%) and Africa (23%). The number of mortalities from TB either as a direct cause or contributory cause (mostly in people living with HIV) in 2021 was 1.6 million, increasing from 1.5 million people in 2020 and 1.4 million people in 2019.
The geographical distribution is not a coincidence.
Today, tuberculosis is undoubtedly the disease of the poor. Centuries of social injustice widening the gap of socioeconomic inequality has caused tuberculosis, once a disease thought to be eradicated, to be one of the oldest, most persistent diseases in the world. Vidya Krishnan in her book, Phantom Plague: How Tuberculosis Shaped History wrote “Poverty is the disease, TB is the symptom”. It is a pestilence of injustice.
Until we understand and accept this, tuberculosis will cling to us despite clarion calls every 24th March.
I am deeply aware of the privilege I had when I was diagnosed with tuberculosis. Privilege millions do not have but instead should have been a human right. Never more been a time when tuberculosis, a highly curable disease but suffused in social injustice, requires more than just access to testing and medicines. It requires mending the deep structural and political systems. If there is a good starting point to fix all that is wrong with the world, we must start with tuberculosis. If we do not, it will very well remain the captain of all these men of death.