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Speaker 1: Welcome to willness A mass I'm doctor Nicole Sapphire, and

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Speaker 1: we're going to talk about something that's a little funny

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Speaker 1: this week because I got a couple of radio requests,

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Speaker 1: and you know, usually I get an email or a

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Speaker 1: text message or a phone call saying, hey, doctor Sapphire,

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Speaker 1: are you available to talk about this? And in the

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Speaker 1: subject line it said what they wanted to talk about?

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Speaker 1: They're like, are you available to talk about the white plague?

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Speaker 1: And I just found myself sitting there, I'm like, white plague?

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Speaker 1: What the heck is the white plague? Am I really

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Speaker 1: that out of touch with reality that there's a plague

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Speaker 1: going around and I don't even know about it. Maybe

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Speaker 1: you've seen these headlines, maybe you haven't. They're definitely out there,

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Speaker 1: and they sound dramatic. Certainly grabs attention. That's what these

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Speaker 1: headlines are for. And yes, it's definitely a bit of

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Speaker 1: a scare factor baked into that language. But good news,

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Speaker 1: here's the reality. Okay, So, first of all, they're not

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Speaker 1: entirely wrong. There are cases of white plague going on

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Speaker 1: about that around here. But white plague is not some

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Speaker 1: new emergent bacteria parasite virus that we don't know about.

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Speaker 1: We're talking about tuberculosis. Apparently it's called the white plague.

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Speaker 1: I had no idea. I'd actually never heard it before.

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Speaker 1: Maybe you have. Maybe I'm the only one who's never

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Speaker 1: heard that tuberculosis was called the white plague. I didn't

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Speaker 1: learn that in medical school. I haven't seen it in

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Speaker 1: the hospital. But you know, maybe it's a thing. The

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Speaker 1: truth is, when we talk about tuberculosis cases are in

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Speaker 1: fact they're actually rising. So since there are headlines out

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Speaker 1: there about this, I thought maybe we talk about it

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Speaker 1: a little bit. So after decades of steady decline, the

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Speaker 1: United States has now seen multiple consecutive years of rising

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Speaker 1: tuberculosis cases. In twenty twenty three alone, there were nearly

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Speaker 1: ten thousand, ten thousand reported cases. That's a fifteen percent

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Speaker 1: jump from the year prior, one of the largest increases

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Speaker 1: really in recent years. And looking at the data, it

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Speaker 1: suggests that unfortunately that wasn't a fluke, that the trend

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Speaker 1: of rising cases it's continuing. With over ten thousand cases

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Speaker 1: in twenty twenty four, that was the highest levels we've

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Speaker 1: seen in more than a decade. So it does seem

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Speaker 1: that higher cases are here to stay. At least for

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Speaker 1: right now. It's a trend. So, yes, the White plague.

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Speaker 1: The headlines may sound sensational, but underneath that language there's

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Speaker 1: real public health story unfolding. So let's unpack that a

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Speaker 1: bit today. That's what I want to talk about. In

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Speaker 1: the eighteenth and nineteenth centuries. That's right, We're going to

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Speaker 1: go way back. Tuberculosis. It wasn't just a disease. It

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Speaker 1: was a defining force of life and death. At its peak,

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Speaker 1: tuberculosis accounted for up to twenty five percent of all

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Speaker 1: deaths in Europe, one in four deaths because of TV

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Speaker 1: in Europe. It was called then the white plague. I

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Speaker 1: guess I didn't read that in my history novels, but

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Speaker 1: it was called the white plague then because of how

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Speaker 1: it made people look. They looked pale, gaunt, they were

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Speaker 1: wasting away. You've heard the term consumption. That all came

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Speaker 1: from that time. It came from how slowly it just

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Speaker 1: consumed the body. This wasn't a fast illness. It was

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Speaker 1: a slow decline months, sometimes years. It's still that way today.

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Speaker 1: By the way, it wasn't until eighteen eighty two that

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Speaker 1: it was discovered the bacterium was responsible for it a

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Speaker 1: certain bacteria. It's called michael Bacterium tuberculosis. So when you

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Speaker 1: hear TV or tuberculosis, it's caused by a bacteria. It's

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Speaker 1: a very specific kind of bacteria. It's called an acid

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Speaker 1: fast bacteria. I learned all about this when I studied

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Speaker 1: microbiology and undergraduate degree. It was kind of hard to isolate.

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Speaker 1: It requires a very specific environment to grow. That's why

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Speaker 1: it took a while to identify what it was. But

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Speaker 1: they were able to prove back then that this was

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Speaker 1: in fact an infectious disease. It wasn't a virus, but

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Speaker 1: it was a bacteria. Remind you, this is before antibiotics,

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Speaker 1: so bacterium were scary because they didn't have a way

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Speaker 1: to treat them. Patients were isolated in santoriums. They literally

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Speaker 1: took patients who were infected with this bacterium and just

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Speaker 1: said here, you go go live in isolation because we

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Speaker 1: have no way to rid you of this infection. So

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Speaker 1: just go live and die out here, please, and don't

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Speaker 1: give it to the rest of the community. People were

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Speaker 1: sent there for months or even years. For most people.

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Speaker 1: Wasn't necessarily a treatment, It was just a place to wait.

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Speaker 1: Some recovered, many died, But even today you kind of

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Speaker 1: see some of that echoing of that history from over

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Speaker 1: a century ago. I remember early in my training, I mean,

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Speaker 1: we had TV isolation rooms. We still have rooms that

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Speaker 1: we have. We put patients in if they're suspected of

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Speaker 1: having tuberculosis negative pressure mass required limited contact, because yeah,

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Speaker 1: this is not something you want to come in contact with.

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Speaker 1: It's not easily treated. It's not like, oh, I'm just

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Speaker 1: going to have a five day course of antibiotic and

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Speaker 1: I'm going to rid myself of this. No, no, no treatment

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Speaker 1: for tuberculosis. It's not like that. But you know, it's

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Speaker 1: just it's interesting to see that these headlines that these

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Speaker 1: cases are increasing, because well, you know, when I was

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Speaker 1: in training and early on in my career, we talked

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Speaker 1: a lot about it. You don't hear much about it

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Speaker 1: these days. You know, inside of these isolation room it's

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Speaker 1: usually a patient who's thin, not doing so well, coffee,

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Speaker 1: they're exhausted, they probably haven't been feeling well for months.

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Speaker 1: And so when I would see these patients, and what

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Speaker 1: struck me the most, it wasn't just the illness, it

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Speaker 1: was the isolation. What we did to these people It

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Speaker 1: really took us back, you know, way before modern medicine.

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Speaker 1: Is what it felt like, you know, meals left at

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Speaker 1: the door, no visitors care, delivered at a distance. Does

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Speaker 1: the sound familiar? It kind of reminds me of COVID.

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Speaker 1: We did the same thing during COVID. COVID has kind

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Speaker 1: of come and gone, we don't do the same thing anymore.

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Speaker 1: But tuberculosis we still do. We understand why tuberculosis it's airborne,

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Speaker 1: similar to COVID, similar to other infectious diseases like smallpox

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Speaker 1: travels in the air, measles travels in the air, very

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Speaker 1: contagious because all you have to do is be in

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Speaker 1: the general vicinity of someone who's positive. You breathe the

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Speaker 1: air they're breathing, and you have the potential to be infected.

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Speaker 1: But the humans of that experience, you know, the separation,

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Speaker 1: the stigma. I guess that hasn't really changed nearly as

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Speaker 1: much as we think. But here's the part that we

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Speaker 1: don't talk enough about tuberculosis. It didn't decline because of

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Speaker 1: one singular breakthrough, one singular modern medicine. Sure, yes, antibiotics helped,

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Speaker 1: but it really declined because of layered public health measures. First,

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Speaker 1: and foremost yes, antibiotics an amazing discovery. Obviously saves a

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Speaker 1: lot of lives. It's also wreaked a lot of havoc.

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Speaker 1: We've talked about what it's done to our gut health

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Speaker 1: and antibiotic resistance bacterian stuff, but that's an entirely different episode.

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Speaker 1: Talking about tuberculosis. The layered public health measures that have

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Speaker 1: led to the decline of cases. Antibiotics for sure, improving

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Speaker 1: of just housing and nutrition screening programs, making sure people

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Speaker 1: who are higher risk we are able to to ask

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Speaker 1: some questions about their symptoms, their lifestyle, and detect early cases,

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Speaker 1: contact tracing, isolation protocols, and really just directly observed therapy

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Speaker 1: to ensure that patients are completing their treatment. All of

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Speaker 1: these systems they worked. In the United States, tuberculosis cases

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Speaker 1: felled dramatically over decades, from tens of thousands every single

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Speaker 1: year to under ten thousand, and globally, TB efforts since

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Speaker 1: two thousand, so about a quarter century have saved tens

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Speaker 1: of millions of lives. This is one of the greatest

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Speaker 1: public health successes stories that we rarely highlight. But here's

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Speaker 1: the concern we're now seeing. I mean, mind you. It's

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Speaker 1: you know, it's slight, but we are seeing a reversal

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Speaker 1: of some of that progress. In the United States, cases

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Speaker 1: have been rising since twenty twenty one. So let's talk

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Speaker 1: about that for a second. You had decrease of like

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Speaker 1: flu in twenty twenty, a decrease in most other public

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Speaker 1: health infections early twenty twenty twenty twenty one because people

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Speaker 1: were kind of sheltering in place because of COVID. But

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Speaker 1: all of a sudden, we started seeing tuberculosis cases rising.

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Speaker 1: There has been a fifteen percent increase in twenty twenty

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Speaker 1: three alone, and now we're up, as I mentioned, ten

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Speaker 1: thousand cases annually. And now if you look around here

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Speaker 1: in the United States, there are about thirteen million people

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Speaker 1: who have what's called latent TB, meaning they have tuberculosis.

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Speaker 1: They may not be symptomatic, they may not be active.

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Speaker 1: It's not an active infection, but it's still kind of

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Speaker 1: brewing inside of them. And you know, during COVID, to

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Speaker 1: be honest, we lost momentum when it came to tuberculosis.

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Speaker 1: We had fewer screenings, we had delayed diagnosis, people were

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Speaker 1: interrupted in their treatments, and let's be honest, people only

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Speaker 1: cared about COVID during that time. They didn't care about cancer,

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Speaker 1: they didn't care about heart attacks, and they certainly didn't

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Speaker 1: care about tuberculosis. But let's talk about what else happened

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Speaker 1: during that time. Now, during that time early on in

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Speaker 1: the pandemic, people just stopped moving altogether across the globe.

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Speaker 1: You didn't have a lot of travel. There wasn't a

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Speaker 1: lot of migratory efforts whatsoever, because well there are travel restrictions,

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Speaker 1: but people were really just staying put. In the United States, specifically,

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Speaker 1: in about twenty twenty one, you started seeing a lot

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Speaker 1: more traffic happening at the southwest border. Most TB cases,

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Speaker 1: the reality is occur in individuals who are born outside

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Speaker 1: of the country to now migrate into the United States.

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Speaker 1: This isn't about blame. I'm not trying to point fingers

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Speaker 1: at anybody. I'm just talking about facts. When it comes

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Speaker 1: to epidemiology, that's what happens. TB is more common in

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Speaker 1: certain regions globally. Many individuals are exposed earlier in life,

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Speaker 1: and the infection it truly can just remain in their

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Speaker 1: system for years, decades. They may not even have symptoms.

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Speaker 1: That's latent. TB like I talked about later on, as

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Speaker 1: the immune system weakens. It happens to all of us

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Speaker 1: as we get older, or another illness develops and you

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Speaker 1: take some sort of medication whatever it is. For whatever reason,

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Speaker 1: your immunity decreases during time. At that point the infection

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Speaker 1: can become active. So this bacteria is kind of like

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Speaker 1: living inside of you, but they're silent, they're sneaky. It's

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Speaker 1: just waiting for your immunity to drop. For whatever reason

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Speaker 1: it can drop, maybe you're not eating enough fruits and vegetables.

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Speaker 1: Maybe you have the flu one year and it kind

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Speaker 1: of just wipes you out. Maybe you're taking biologics for

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Speaker 1: an autoimmune disease. Whatever happens, all of a sudden, your

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Speaker 1: immune system decreases your ability to fight off infection. You

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Speaker 1: have this latent or sneaky bacterium tuberculosis just hanging out waiting,

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Speaker 1: waiting for the right opportunity to activate. And so that's

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Speaker 1: what happened. And so once the infection becomes active, it

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Speaker 1: can be detrimental. And importantly, many cases occur years many

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Speaker 1: years after the arrival, meaning after the person has been infected.

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Speaker 1: Highlighting that this is a latent disease management issue. It's

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Speaker 1: not just simply border control, because people who are coming

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Speaker 1: across the border, if you're screening them solely for symptoms,

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Speaker 1: the majority of people who are crossing probably don't have

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Speaker 1: active tuberculosis because active tuberculosis makes you very sick and

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Speaker 1: you probably can't make that arduous journey across the Southwest

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Speaker 1: border in the desert and with all the other obstacles

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Speaker 1: you face. Doesn't mean that they don't have latent tuberculosis

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Speaker 1: that once they come into the United States, whether they

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Speaker 1: acclimate or don't, whatever it is, it can then activate.

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Speaker 1: Now the United States, they already have pre immigration screening,

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Speaker 1: targeted testing, and very small pockets of public health follow up,

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Speaker 1: but huge gaps remain. As I mentioned latent TB, it's

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Speaker 1: often silent. The treatments requires months of adherence. So even

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Speaker 1: if you identify someone who has either latent or active TB,

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Speaker 1: it's not that they're going to take that five or

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Speaker 1: seven day course of antibiotics. Oftentimes they need to be

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Speaker 1: on it for I mean really like six months. They

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Speaker 1: need to be actively monitored. So the real focus at

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Speaker 1: the border anywhere else should be better screening, stronger follow up,

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Speaker 1: and ensuring treatment completion, because that's what's important. It's one

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Speaker 1: thing to diagnose it. It's one thing to give someone

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Speaker 1: a prescription, but it's another thing to make sure that

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Speaker 1: they have completed that in higher course and it has

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Speaker 1: done the trick and has gotten rid of the infection.

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Speaker 1: Because infectious disease they don't respect borders, but strong public

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Speaker 1: health systems can certainly contain them. So the pathboard it's

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Speaker 1: not really that complicated, but it does require commitment first

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Speaker 1: and foremost, it truly does rely on early detection, expands

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Speaker 1: straining in high risk populations, and that includes anyone who

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Speaker 1: is crossing our borders coming to the United States, because

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Speaker 1: they're significantly higher rates of latent and active TB everywhere

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Speaker 1: else other than our country. You also see them in

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Speaker 1: prison populations, in homeless shelters, anywhere where you have people congregating,

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Speaker 1: and it's important to be screening these individuals. Second, we

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Speaker 1: need to be treating latent TB. This is where most

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Speaker 1: cases originate here in the United States. Just because someone

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Speaker 1: doesn't have symptoms, that does I mean we don't treat them.

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Speaker 1: We need to be doing blood tests, we need to

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Speaker 1: be doing X rays, we need to be doing everything

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Speaker 1: we possibly can to ensuring someone doesn't just have latent

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Speaker 1: B that will be reactivated later in their life and

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Speaker 1: then they're able to spread it. And as I mentioned,

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Speaker 1: ensuring treatment completion but also making sure that the treatment

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Speaker 1: is accessible and affordable is equally vital. But making sure

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Speaker 1: someone completes their treatment, whether it is a weekly check in,

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Speaker 1: whether there is some sort of incentive to making sure

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Speaker 1: that they complete it, whatever it needs to be, that's

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Speaker 1: really important, and we have to reinvest in our public

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Speaker 1: health infrastructure. We see a lot of cuts when it

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Speaker 1: comes to public health, and I understand that there's a

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Speaker 1: lot of hostility when it comes to our public health

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Speaker 1: infrastructure ever since COVID specifically, But the reality is this

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Speaker 1: is the health of the nation that we're talking about.

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Speaker 1: I'm talking about contact tracing, community outreach, and any sort

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Speaker 1: of follow up systems. Public health nurses, social workers, and

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Speaker 1: those who are really making sure that people who have

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Speaker 1: been identified as high risk for TB or even having TB,

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Speaker 1: that they are followed continuously and we are ensuring that

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Speaker 1: not only they're healthy, they're family healthy, but everyone around

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Speaker 1: them is also healthy. Obviously, we want to talk about

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Speaker 1: global investments. You have the World Health Organization and some

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Speaker 1: other nonprofits, Doctors Without Borders and so forth, who are

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Speaker 1: in charge of that. I'm not really going to get

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Speaker 1: into the weeds of that, but it is more than

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Speaker 1: just a local problem. As I mentioned, the majority of

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Speaker 1: cases here in the United States originating people who came

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Speaker 1: from elsewhere in the world. So it would be with

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Speaker 1: us to make sure that we are working with our

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Speaker 1: global partners to decrease tuberculosis cases. And I guess again,

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Speaker 1: tuberculosis was once the don't quote white plague. White plague

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Speaker 1: does sound scary. It was a nice little history lesson

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Speaker 1: for myself to learn this new verbiage. The reality is,

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Speaker 1: I don't want to call it a plague today because

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Speaker 1: that makes me think of those plague mass and a

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Speaker 1: horrible time in our global history when it comes to

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Speaker 1: public health. But the reality is tuberculosis is alive and well.

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Speaker 1: It is a disease that we associate with history. But

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Speaker 1: if we look at data, walk through a hospital isolation unit,

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Speaker 1: we just zoom out globally and you'll realize it certainly

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Speaker 1: has not been eliminated. Yes, it's been controlled, but the

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Speaker 1: control requires vigilance because in medicine success isn't permanent. It

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Speaker 1: is maintained, and it's only maintained if we keep up

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Speaker 1: on our public health efforts. We have lagged a little

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Speaker 1: bit when it comes to tuberculosis, so we need to

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Speaker 1: get back to it. Thank you so much for joining

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Speaker 1: me on Wellness Unmass. I'm doctor Nicole Sapphire. Sure to

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Speaker 1: listen to Wellness on Mass on iHeartRadio, Apple Podcasts and

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Speaker 1: wherever you get your podcasts, and I'll see you next time.