Q and A with Neil Schluger

How TB has remained a relatively neglected disease

Published on April 30, 2013by Joshua Brooks

Since New York City’s tuberculosis (TB) epidemic in the early 1990s, Dr. Neil Schluger, a professor of medicine, epidemiology and environmental health science at Columbia Medical School and the Mailman School of Public Health, has worked to inform policy, prevention and control of TB, with comprehensive scientific and epidemiological research. Despite advances in diagnostics, care and prevention, however, TB continues to be the second-most deadly single infectious agent behind HIV/AIDS. And, with the emergence of multi-drug resistant tuberculosis (MDR-TB)—bacterial strains of the disease that are untreatable by existing drugs—the risk from its spread significantly increases. Yet, in comparison to other diseases, TB has remained relatively neglected, receiving less funding for new treatments, diagnostics and control programs. Dr. Schluger explains why—and why he thinks this trend should change.

What drew you toward the epidemiological approach to TB?

I was a fellow at Cornell at New York Hospital and I worked in a lab for the research portion of my fellowship at Rockefeller University looking at animal models of pneumocystis pneumonia, this opportunistic infection that AIDS patients got. At the time—this was late ‘80s, early ‘90s—it [TB] was very, very common. It was before antiretroviral therapy was around, so we saw tons of patients with this disease. I went into this lab and spent some time at NIH understanding basic aspects of lung biology. Then I got a job at Bellevue Hospital at the height of the TB epidemic in 1992. I was director of the outpatient chest clinic and the outpatient TB treatment program, so I shifted my focus from pneumocystis to TB because when you’re up to your ears in alligators, you’ve got to learn about alligators.

It seems like it’s a constant trend for TB that people forget about it for some time until it resurfaces as a serious epidemic.

Right. In 1992, there were about 500 cases of TB in the hospital, which seems like an incomprehensible number. It seemed like an out-of-control problem.

It’s interesting because, looking back at TB in the ‘30s and ‘40s, the decline actually occurred well before there were antibiotics. It seemed there was some sort of restructuring of society that allowed it to decline.

Absolutely. TB is a social disease more than anything else. It’s really a reflection of lots of other things going on in society.

One question you’ve been asked before is, “Why is TB research not as sexy as HIV/AIDS research?” Why do you think that is?

Well, I think that’s unfortunate wording, but TB has suffered from that a bit. What AIDS benefitted from mostly was this advocacy community that grew up around it. That community really accomplished a lot and we haven’t had that in TB. Other groups have learned from the AIDS advocacy community. The one I think of the most is breast cancer. Women really got organized and demanded more funding for breast cancer research. It was all modeled after HIV—like the AIDS walk and pink months in sports leagues. It’s actually very amazing how much support they have been able to get.

TB has never had that. There has been this kind of romantic history with TB. Every famous writer in the 19th century had TB. “La traviata” and “La bohème” both had characters with TB, so it’s been in our consciousness. But, it hasn’t captured people’s imagination or developed an advocacy organization around it.

Do you think that’s because it’s a disease primarily of populations or countries that are usually marginalized or very low income and don’t have that ability to mobilize as easily?

I think that part of it is that [TB] is in countries that people in public health don’t think about that much—mostly poor countries or distant countries. Second, TB is not seen as a huge concern worldwide.

If you look at drug development, the leading causes of death in the world have drugs in clinical development for those diseases. For heart disease and stroke… there are almost 300 for COPD [chronic obstructive pulmonary disease]. For TB, there are somewhere between five and eight drugs in development and six in malaria. For AIDS, we have 70 drugs in development. There are 40 AIDS drugs approved and 70 that are in development. For TB, with only five to eight drugs in clinical trials—people in pharma will tell you—only about 10 percent will make it through. So, this is telling: If you’re unlucky enough to get a disease, like tuberculosis, that tends to only affect poor people, you’re out of luck.

Policy-makers and health officials seem to recognize MDR-TB as a larger risk. Do you think that should be driving the discussion about TB?

MDR-TB is a very frightening thing because there are half a million people who have it and at best, only 10 percent are being treated because most of the countries with high TB rates lack either the ability to diagnose it or treat it or both. So, you have half a million people who will die as a result. But before they die, they will spread the disease around to others. It’s pretty far from our borders, but it’s a serious concern.

Some of the concern is that if MDR-TB does spread, many countries are not vaccinating for TB and often can’t treat multidrug-resistant forms, correct?

At the rate we’re going, if MDR-TB really takes off around the world, it’s going to far outstrip our ability to treat it. Everywhere you look, you find more MDR-TB. A long time ago in Africa, people had no idea, because the countries were too poor to do cultures and drug-susceptibility culturing. Now, people look and they’re finding a lot of MDR-TB. It’s a complete disaster in the former Soviet Union.

There seems to be this tension between understanding the extent of the problem and treating the problem. Do governments and TB organizations spend money on knowing the extent of the problem, when they still don’t have the means to treat the patients they discover?

Well, WHO has very recently endorsed the use of this modern technology to diagnose TB and detect drug-resistant TB, called Gene Xpert. They hope to distribute the technology. But, in most of the world, TB is diagnosed the way it was diagnosed 100 years ago. That is just inexcusable really. So, I don’t think we’ve been aggressive enough there and could really use these tools. We also need to convince governments that it’s in their enlightened self-interest to develop TB diagnostics and tools that will be used far away from their own country. Sometimes you run into the other argument that social determinants are so important to TB that the real answer is economic development. That’s true, but that’s going to take something like 50 years to occur and we can’t wait that long.

Edited by Jordan Lite. Additional research by Lauren Weisenfluh.