A Ceaseless Battle: TB Flares Up Again

Phil Newell is an American who frequently travels back and forth between the U.S. and Taiwan. He once had an unforgettable experience--he contracted tuberculosis.

"At first it was only a cough. I had it for a long time before I got an X-ray--and then I found out it was TB." A busy young doctoral candidate, he had thought the cough was just a side-effect of working too hard in an air-conditioned office. When he was told it was actually tuberculosis, he could hardly believe his ears. His parents back in the U.S. were even more dumbfounded. In their minds, tuberculosis was a plague of centuries past. How could it strike someone today?

He returned to the U.S., took regular medication under a doctor's directions and was back to normal in six months. But the shadow of the disease still haunts him. According to a recent article in The New York Times, tuberculosis is on the rise in the United States, and some new strains are highly resistant to medication. "Whenever I come down with a cough now," he says, "I run off and get an X-ray."

Mummies once had it, tool Tuberculosis is one of the world's oldest communicable diseases. Traces of the tuberculosis bacillus have been found in Egyptian mummies and in the remains of early humans. During the 19th century, the disease was rampant in Europe and North America and took the lives of large numbers of people. It was the leading cause of death in the United States in 1911 and killed 500,000 people a year in India right up into the 1960s. But medication to cure the disease was steadily developed and by the 1970s, aller a specially effective medicine was discovered that needs to be taken for only six months, its threat to human life can be said to have dropped considerably.

On the rebound: In the early years after World War Ⅱ, some 80 percent of the adult population over 20 years of age was exposed to the disease on Taiwan. Adults nowadays have probably all had the experience of buying "TB control" postage stamps, which were one of the methods used by the Association for the Prevention of Tuberculosis to raise funds and spread awareness of the disease. At one time, the association managed to raise around NT$10 million a year for free treatment, which was a major boon for the uninsured. But following the steady decline in the number of patients over the years, sale of the stamps was abolished by the Department of Health in 1982, and the Chronic Disease Control Bureau began offering completely free treatment last September 2.

Of particular concern is the fact that the number of tuberculosis cases has not been declining as expected in recent years.

Seven large-scale surveys of the tuberculosis rate in Taiwan have been performed by the government since World War Ⅱ, and the results of the most re cent one, carried out in 1988, are similar to those of the one in 1983: both showed an incidence rate of around one percent. Compared with the substantial declines shown in previous surveys, that is startling news.

In fact, a report made by the Bureau of Communicable Disease Control in the Department of Health at the end of April this year shows that the number of cases of tuberculosis in Taiwan has in creased by 13 percent over the same period last year. Office Director Chang Yao-hsiung views this resurgence with great dismay. He urges people over 40 to have a regular X-ray examination each year. People who experience unusual coughing should be extra alert and have a checkup as soon as possible.

In cahoots with AIDS: The precise reasons for the resurgence remain unclear. What is particularly troubling is the question of whether it may be related to the worldwide spread of AIDS, as it seems to be in the United States.

"The rise in TB in the U.S. is probably related to the huge increase in AIDS," says Lin Tao-ping, director of the Taiwan Provincial Chronic Disease Control Bureau. Once their immune system breaks down, AIDS sufferers are defenseless against communicable diseases. Twenty to 30 percent of them contract tuberculosis, especially atypical forms of the bacillus that ordinary people are not readily susceptible to and which are highly resistant to medication.

The rise in tuberculosis in the U.S. has been attributed by some to immigration. Dr. Li Jen-chih, chief of internal medicine at the Tz'u-Chi Buddhist General Hospital in Hualien, says there is a theory that considerable quantities of the bacillus have been introduced by the large influx of immigrants from Latin America, Asia and Eastern Europe. The prevalence of TB is closely related to an area's economic conditions: Backward countries with poor environments and nutrition are often breeding grounds for the disease.

Of course, this theory plays right into the hands of xenophobes, and it would be best to adopt a cautious approach for now. Not dissimilarly, some people in Taiwan attribute the rise in cases here to the inflow of foreign labor and the frequency with which people are visiting the mainland. Former National Taiwan University Hospital Director Yang Ssu-piao says that the real causes remain to be found, but that the reason the situation is more serious here than in Europe and North America may basically be that most people are still insufficiently aware of sanitation and not alert enough.

Coughing is a disease! Most people think a cough is nothing to be concerned about and will get better after a time. They don't realize that it could be a sign of tuberculosis. One person with the disease can transmit it through the air to several others and they to dozens more: "Once it gets started, it's terrible!" Director Lin Tao-ping points out.

What frustrates him almost to tears is that some older people cough all day long without ever seeing a doctor; they just call it "old folks' cough." "Who says older people have to cough all day long!" he says with some pique.

Some people intuitively sense that the chief cause of the tuberculosis upswing must be dirty air and worsening air pollution, but most doctors dismiss that notion, because the TB bacillus is transmitted through saliva. "If you inhale too many fumes or chemical pollutants and there are spots on your X ray," Dr. Lin says, "then they're probably cancer, I'm afraid!"

The rise in tuberculosis naturally causes concern, but the image of tuberculosis as a killer affliction is after all a thing of the past. Generally speaking, most people recover as long as they take medication on time. The problem is that some people hate seeing the doctor or don't keep up with their medication, allowing the bacilli inside the body to build up resistance and become intractable. "The spread of that type of bacillus poses a grave danger," Dr. Li Jen-chih says, indicating that the threat of stubborn new man-made strains is receiving worldwide attention.

Goodbye, or hello again? Tuberculosis has been around as long as human history. For a long time, it was a device to add a poignant beauty to romantic stories. Just think how Liang Shan-po, in the famous Chinese love story, died coughing blood after he was thwarted in his love for Chu Ying-tai. And think of the pale and sickly Lin Tai-yu in Dream of the Red Chamber. She would wheeze and cough each afternoon, her cheeks flushed -- that too was tuberculosis.

In the West, tuberculosis has even been seen as a stimulant to artistic genius, increasing the tragic coloring of many writers. Keats, Shelley, Thoreau and the Bronte" sisters--all were weak, enervated and racked by fits of coughing. Of course, tuberculosis by itself won't produce talent. All that can be said is that many talented artists were poor at taking care of their health.

In the world of the late 20th century, the tragic aura of the disease has paled considerably with the advent of highly effective treatments, and the greatest concern of the medical world lies not so much in the disease itself as in its coupling with AIDS. Tuberculosis can be cured by man-made medicines in most patients, but in AIDS sufferers, whose immune systems have broken down, it is all too likely to prove fatal.

Most of the population in Taiwan (more than 80 percent) has been exposed to the tuberculosis bacillus, and the low rate of incidence is due to a modern living environment, adequate nutrition and strong immunity. But if AIDS comes into the picture, "the mortality rate from tuberculosis will be unthinkable," Dr. Li warns.

[Picture Caption]

Tuberculosis is on the rise! How come? This is a chest X-ray of a person with the disease. (photo courtesy of the Taiwan Provincial Chronic Disease Control Bureau)

Mobile units of the Taiwan Provincial Chronic Disease Control Bureau visit each county and village in the island twice a year, hoping that adults over 40 will have semiannual checkups and discover early on if they suffer from the disease.

Remember these anti-TB stamps? They were highly effective in funding prevention and cure. (stamps courtesy of the Association for the Prevention of Tuberculosis)

(Above) Did mummies catch it, too? This one is kept at the British Museum.

(Below) Don't be scared, kids. You'll only have to get a shot if your reaction is negative. (photo by Cheng Yuan-ching)

Mobile units of the Taiwan Provincial Chronic Disease Control Bureau visit each county and village in the island twice a year, hoping that adults over 40 will have semiannual checkups and discover early on if they suffer from the disease.

Remember these anti-TB stamps? They were highly effective in funding prevention and cure. （stamps courtesy of the Association for the Prevention of Tuberculosis）

Did mummies catch it, too? This one is kept at the British Museum.

（Below） Don't be scared, kids. You'll only have to get a shot if your reaction is negative. （photo by Cheng Yuan-ching）