Tuberculosis: The Forever Plague

Tuberculosis (TB) is a disease it has become easy to forget about.  Pria Anand reminds us that it has not gone away and we still don’t have effective means to deal with it.  Her article, The Plague That Won’t Die, appeared in the New York Review of Books.  It mainly focused on the volume “Phantom Plague: How Tuberculosis Shaped History” by Vidya Krishnan.

TB has been around as long as humans have been recording their history, perhaps even longer.  For much of its history it was better known as “consumption.”  TB was first identified as a bacterial disease by Robert Koch in 1882.  It is best known as a disease of the lungs, but it is more complicated than that.

“Tuberculosis can seem inscrutable, a protean disease that can settle in virtually any organ in the body. In the lungs it causes the bloody cough and gasping breath that ravaged the Brown family; in the lymphatic system it causes swollen masses that can press on the soft muscles of the vocal cords, robbing victims of their voices; in the guts it causes raw, bleeding ulcers and obstructed bowels. The disease is airborne: colonies of bacteria are exhaled from the lungs of a person with pulmonary TB in a fine mist of particles that can linger suspended in the air for hours. How long the bacteria survive in the air depends on the surrounding conditions; in spaces with poor ventilation—an enclosed car, for instance, or a windowless room—they can last hours or even days.”

“Our lungs are a strange paradox: they are protected by the hard carapace of our ribs but also tremendously exposed to airborne bacteria, which can slip in with a single breath. To prevent infections, the labyrinthine passages that make up each lung are lined with white blood cells. But Mycobacteria tuberculosis are impenetrable. Each cell is surrounded by a thick barricade made of fats and proteins. In the lungs they are consumed by white blood cells but not digested, surviving undisturbed as more white blood cells arrive to wall off the infection, forming scarred balls called tubercles. Here the bacteria can live for decades or even a lifetime, forming a latent infection and replicating slowly within an unwitting host, undetected until they take advantage of an aging or suppressed immune system to explode into full-blown consumption… Malnutrition, pollution, and illnesses like HIV and diabetes can all contribute to TB activation.” 

In the nineteenth century, when Koch identified the cause of the disease, TB was the primary cause of death.  Poor sanitation and overcrowding seemed to be contributing factors in infection rates.  In moving from the nineteenth to the twentieth century overall hygiene improved for most people and the disease became more closely identified with the urban poor and less of a threat to the financially well off.  Treatments were essentially nonsensical until the development of antibiotics in the 1940s.  In 1921 the BCG (Bacillus Calmette–Guérin) vaccine became available providing some benefits but it is incapable of controlling the disease.  It took 40 years to develop this vaccine.  A century later and we still have nothing better.  Even with antibiotics capable of treating an infected person the treatments are complex and last for several months.  To make matters worse, antibiotic resistant strains of bacteria have appeared and are becoming more common.

One gets the feeling that TB is not getting sufficient attention as a dangerous disease.  It suffers from being mostly a disease of the unfortunate, making it easy for the fortunate to ignore.  In addition, the need for vaccines and antibiotics face severe market disadvantages because they are one-time treatments when there is more money to be made in long-term treatments.  Pria Anand has similar feelings.

“The treatment regimen for an active tuberculosis infection is crude: months of toxic antibiotics that have the potential to harm nearly every part of the body. One of the treatments can strip the nerves and leave patients’ feet numb and tingling, while another turns both tears and sweat orange—patients are advised not to wear white T-shirts when taking the drug. Both medications can damage the liver. The treatment can take anywhere from three to nine months depending on the drug combination, and once it has begun, a patient cannot miss a dose. The first-line drugs we use to treat TB were all developed decades ago—one more than a century ago—and many of our second-line treatments for drug-resistant TB were originally developed to combat other infections before they were repurposed for the burgeoning plague of consumption.”

“…tuberculosis remains the leading infectious cause of death worldwide. Nearly a century and a half after Koch’s first attempts to devise an inoculation, we still have no effective vaccines. Globally, one in four people carries tuberculosis, though most are neither contagious nor symptomatic. In the United States, where the prevalence is closer to three in one hundred, the disease thrives primarily in the conditions created by social injustice: overcrowded prisons, for instance, or temporary shelters. Yet programs to curb the spread of TB are among those hit hardest by both the Trump administration’s closure of USAID and its assault on the National Institutes of Health, attacks that are projected to lead to millions of avoidable TB deaths over the coming decade.”

The three-in-one-hundred rate of infection means there are about 13 million infected people in the United States.  About ten percent are expected to end up with an active infection, predicting over a million tuberculosis outbreaks in our future.  This is not a negligible threat.  Perspective is provided by the article Recent Tuberculosis outbreaks in the U.S. are a call to action.

“Yet more than 30 years after an emergency declaration for TB - the world's next-most lethal infectious disease, which is both preventable and curable - progress has been woefully inadequate and there is no end in sight.”

“In just the last few months we've seen TB outbreaks in Alabama, Virginia, Arizona, New York and Canada. In Washington state, a woman with active TB disease who refused to isolate or be treated was imprisoned.”

“It is estimated that one person with active TB disease has the potential to infect 10 other people around them. Like COVID, TB could very quickly create a large scale public health emergency - one that can only be contained with robust TB infection testing and contact tracing.”

Anand finishes by telling us what Krishnan hoped to accomplish with her book.

“Her book, she writes, ‘has one intended audience: readers who have the good fortune to have remained ignorant of TB but can ill afford to be so any longer.’ To imagine that Black and brown people, incarcerated people, and poor and unhoused people are somehow uniquely vulnerable is to be ignorant of TB’s long history, forever linked with our own.  ‘No one is safe,’ she writes, ‘until everyone is’.”

 

College Admission in the US and China: Who Does It Best

Even though the term meritocracy was first popularized in a dystopian satire in which “meritocratic” elites take control of a nation that practices meritocracy, and the satire das been demonstrated to be highly predictive, nations still rely on the practice.  The path forward for individuals in advanced societies is usually by gaining admission to a top university.  Meritocratic practices are used in the US and in China to determine who gains entry to these schools.  Which nation has the best selection processes? 

Iza Ding provides a useful discussion of how meritocracy in university admissions is being handled in the two countries in a review of the book The Highest Exam: How the Gaokao Shapes China by Ruixue Jia and Hongbin Li with Claire Cousineau.  This appeared in the Londen Review of Books under the title Studying is harmful.

China provided the initial example of applying meritocratic methods to determine who was worthy of entering elite positions in society.

“The keju, or imperial civil service examination, selected scholar-officials who had mastered the Confucian canon – after years, if not decades, of study – for entry into the ruling elite. The exams were initially restricted to nominees, but by the early seventh century eligibility had expanded to most free men. This was centuries before European leaders began to debate whether to extend the franchise beyond propertied males.”

The exam persisted into the twentieth century into Mao’s era.  Apparently, he had trouble passing the test and the title of Ding’s piece comes from a quote attributed to Mao.  Soon after Mao’s passing the custom of testing to gain a position returned and the gaokao for university admission was back in business. 

“Today, more than thirteen million teenagers (and some adults) take the gaokao each June. The tests are conducted over several days, under tightly controlled conditions. Universities in China don’t look at personal statements or hold interviews. Only test scores count: in history, geography and politics for the liberal arts track; physics, chemistry and biology for the science track; and Chinese, maths and English for everyone. The questions are strictly guarded and double anonymity is enforced between the candidates and markers. For weeks, the gaokao dominates the news.”

There is no equivalent faced by US youth.  There are standardized tests like the SAT and ACT, but they are not the equivalent in being totally important in admission considerations.  While the Chinese system can be a brutally demanding experience for young students, US youth face a similarly demanding process to gain access to the best universities.  Rather than focusing intensely on a single exam, they must create for themselves a persona that the universities will find impressive.  Besides good grades and test scores, they must demonstrate, over several years, participation in extracurricular activities such as sports, topical club activities, and public service.  Evidence of competent participation and leadership potential is expected.  Introverts will thrive in the Chinese system; success is much less likely in the US.

“In his book Excellent Sheep: The Miseducation of the American Elite and the Way to a Meaningful Life (2014), William Deresiewicz writes of his students at Yale: ‘Look beneath the façade of affable confidence and seamless well-adjustment that today’s elite students have learned to project, and what you often find are toxic levels of fear, anxiety and depression, of emptiness and aimlessness and isolation’.”

The question of interest is which of the two approaches in fairest in providing opportunity to the best individual students.  In both countries there is an unfair advantage for urban students over rural counterparts.  A similar advantage goes to the wealthy over the poor.

“In spite of its flaws, the gaokao’s equalising power outstrips the admissions machinery of American universities by a wide margin. In China, children from the wealthiest families are 2.3 times more likely than the poorest to attend top universities; in the US, the gap is nearly elevenfold.”

China seems to be making progress in providing more opportunities for rural children to get a college education.

“According to Jia and Li, in 2003 only 7 per cent of children from the poorest rural counties entered any kind of college, against nearly half of their urban peers; six in a thousand rural high schoolers reached a top university. The figures have improved but remain stark: by 2015, 35 per cent of rural students were going to university, compared to 51 per cent of urban students.”

Consider what happens when the gaokao results are released in China.

“Performing well in the exam can be life-changing. The highest scorers become national celebrities, lauded in the press and given gifts – cash, cars, even flats – by eager patrons in the private sector. Top universities enter scholarship bidding wars to secure their enrolment. A degree from one of these universities offers entry to the upper rungs of Chinese society. The gaokao has been called a rite of passage, a great equaliser and a ritual of China’s secular religion, education. Its political weight and its status as a recurring spectacle of collective fervour have led to comparisons with the US presidential election. In a country plagued by corruption, the gaokao is remarkably clean. ‘Open and competitive’ are the watchwords of democratic elections, but they are also the defining features of China’s exam empire. Exams are its functional substitute for the ballot box. The gaokao is more than a test; it’s an enduring political institution.”

This system provides China with the scientists and engineers and other professionals needed to run its society and its economy, satisfying the wishes of its rulers.  Once thought of as being deficient in creativity and inventiveness, the world now fears the system will allow China to become the dominant power in the world.

The system is also a means of solidifying the leadership of the Communist Party.  Fostering the belief that the process is fair provides the leaders with support from the people.  Ding provides a comment that could never be applied to education in the US.

“More important, the gaokao has maintained faith in social mobility. A perception of fairness, especially among the less fortunate, has lent legitimacy to the political order. The system will continue as long as the losers believe that they, and not the system, are to blame for their lack of success.”