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  • BOOK REVIEW

Rise of drug-resistant tuberculosis is hidden in plain sight

Residents, one covering her mouth and nose with a cloth, sit in a narrow alleyway in the Dharavi slum of Mumbai

Tuberculosis thrives in Mumbai’s cramped slums.Credit: Atul Loke/The New York Times/Redux/eyevine

The Phantom Plague: How Tuberculosis Shaped History Vidya Krishnan PublicAffairs (2022)

In 2020, while all eyes were on COVID-19, tuberculosis infected nearly 10 million people globally and killed 1.5 million. It was also the first year since 2005 that the number of deaths from the disease had risen. That increase was probably driven by COVID-19’s impact on testing and treatment services.

The wealthy world still eagerly awaits a return to normal, pre-pandemic life. For many, “normal” was already deadly before 2020, global-health reporter Vidya Krishnan reminds us in The Phantom Plague. COVID-19 isn’t the only infectious respiratory disease knocking on the door: the threat of drug-resistant tuberculosis still hangs over the globe. As in the coronavirus pandemic, it is people with the least social, economic and historical capital who bear the brunt. “Poverty is the disease,” she writes; “TB the symptom.”

The greatest strength of The Phantom Plague is its highlighting of the forces that keep low- and middle-income countries hungry for medicines and at the mercy of Mycobacterium tuberculosis, the cause of tuberculosis. But first, the reader must meander through a familiar history of infectious-disease research, some only loosely tied to tuberculosis. Interesting nuggets do emerge: Dracula was an immigrant bearing a disease that polluted the blood of London residents; Arthur Conan Doyle might have been one of the first to recognize the spectre of drug resistance in tuberculosis, while researching a newspaper article.

The pay-off for persevering beyond those early chapters is worth the wait, however. Krishnan takes a chronological leap to recent years, and focuses on India, home to many of the world’s drug-resistant tuberculosis infections. She brings to life the darkness and stale air of life in Mumbai’s slums. There, seven-storey buildings are set just three metres apart — much closer than housing codes allow in areas away from these public-housing developments.

These buildings are hotbeds for tuberculosis. People who become infected, in Mumbai and across India, often wait months before they are properly diagnosed. In the meantime, they are given a hotchpotch of sometimes ineffective antibiotics, some of which have toxic side effects and nurture drug resistance.

This is an infuriating world, in which a tuberculosis infection that has spread to her ankle could threaten a young woman’s life, and the old antibiotics available in India, such as kanamycin, do nothing to help and could ruin her hearing. Better antibiotics to treat drug-resistant tuberculosis in India are expensive and in limited supply. Until 2019, they were strictly rationed and available only to people who fitted a specific disease profile and lived near one of a handful of hospitals.

Krishnan rails against India’s rationing of new tuberculosis drugs, such as bedaquiline, and backs up her arguments with horrifying personal stories. But here, the book’s chronology can be confusing: for example, the rationing of bedaquiline is introduced and condemned, and Krishnan expresses bewildered outrage that the drug is, for a time, limited to those who live near certain hospitals. Only chapters later does she clearly lay out a key rationale for this restricted access: that researchers were still conducting trials to evaluate the drug’s possible toxic effects on the heart. This organization of information creates some confusion.

Still, Krishnan makes a passionate case against the reasoning — trotted out all too often when it comes to treating infectious diseases in resource-poor regions — that people with tuberculosis cannot be trusted to take their medications and therefore should not be given the drugs they need. The conclusion of this flawed argument is that these newer, more effective drugs should be withheld from these populations because misuse could give rise to resistant pathogens that could then threaten richer countries. Krishnan argues effectively against this discrimination and labels it for what it is: racism.

She also takes on charities whose donations of crucial medicines, she says, foster dependence and allow countries to defer the need to establish sustainable supplies. She challenges patents and the biomedical monopolies they protect. Innovation scholars, predominantly at Western universities, spend careers analysing patent data and debating the relative values and costs of a strong patent system. Krishnan is not having it. She dubs support for strong international patents “fact free”. To her, their only value is in wringing every cent from countries that lack the resources to fight back.

I sympathize with her passion. Her reporting has led her to people who have lost their hearing, their livelihoods, their loved ones — because, as she argues, they were denied access to vital medicines produced in their own country. But I was disappointed to find no real rebuttal of the counterargument — that those medicines might not exist without the intellectual-property system that enables companies to profit from them. I yearned for her to take such arguments head-on and win.

The book is nonetheless a powerful look at the social determinants of health, and the lasting imprint of colonialism and segregation on public health. There is a desperate need for new drugs to combat drug-resistant tuberculosis. Meanwhile, as Krishnan reminds us, existing drugs are not being used effectively or fairly. It is this injustice that will feed the spread of drug-resistant tuberculosis.

Nature 605, 417-418 (2022)

doi: https://doi.org/10.1038/d41586-022-01342-6

Competing Interests

The author declares no competing interests.

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