Speaking of Medicine

Jasmine Grenier and Madhukar Pai from McGill University review “Spitting Blood: The History of Tuberculosis” by Helen Bynum

Sputum microscopy, the method used by Koch, continues to be the most widely used test for TB in endemic countries.
Image Credit: Madhukar Pai

Tuberculosis is one of the oldest human diseases and remains to this day one of the world’s top killers. The WHO reported nearly nine million new cases of tuberculosis globally in 2011, with 1.4 million deaths worldwide. Even today, in India alone, nearly 1000 patients die of tuberculosis every day. Clearly, this is one ancient plague that continues to take a toll on humanity.

The WHO millennium development goal for tuberculosis is to achieve a 50% decrease in tuberculosis mortality by 2015. Recently, a Global Thematic Consultation on Health concluded with more ambitious post-2015 targets: zero new tuberculosis infections, zero tuberculosis deaths, zero tuberculosis suffering and zero tuberculosis stigma and discrimination.

Although much progress has been made in the past 20 years, there remains an enormous burden of disease and many countries are not on track to meet even the modest 2015 goal. In the past year, tuberculosis has received significant media attention, highlighting positive developments in our fight toward elimination, such as the roll-out of a rapid molecular test for TB, approval of the first new drug for tuberculosis in over 40 years.

But the media has also highlighted setbacks such as the emergence of ‘totally drug-resistant’ strains of Mycobacterium tuberculosis in countries like India and South Africa, and failure of the first novel tuberculosis vaccine since BCG. Several roadblocks still stand in the way of reducing the burden of disease, including challenges in early diagnosis of the disease, before transmission occurs in the community, as well as in providing effective shorter and more effective treatment regimens.

Spitting Blood by Helen Bynum is released at a pivotal time in the history of tuberculosis, where renewed efforts are being put into the control of this rampant illness. In her book, Bynum presents an in depth exposé on the history of tuberculosis, taking the reader through the medical, cultural and societal implications of the disease through time, highlighting just how much it has shaped history, and been shaped by socioeconomic development.

Starting the book by recounting George Orwell’s experience with tuberculosis and how it influenced not only his work but most of his life, Bynum draws in the reader and arouses curiosity while providing, through the narrative of Orwell’s life, basic scientific facts regarding tuberculosis. This is one of the book’s strengths, where the microbiological and medical concepts are not glossed over but rather fully explored with the help of clear, simplified yet accurate explanations. This will allow the book to reach a much wider audience.

In some ways similar to Dubos’ The White Plague, Bynum uses known cultural figures, such as John Keats and Charlotte Brontë, to better show the reader the complete hold that tuberculosis can have on a person’s life. Not limiting itself to an exposé of the European experience of tuberculosis, the book also details the scientific and cultural evolution of tuberculosis in other continents, adding a greater level of depth and providing a much broader account of historical facts. The level of detail in the anecdotes provided is truly impressive and shows the depth of research that went into creating this work.

Through the lives of artists, scientists and political figures, Bynum takes readers through the complete history of tuberculosis from the medieval period up until the 21^st century. Several critical moments of scientific discoveries are highlighted such as when Rene Laennec correlated the various granulomatous pathologies with a common etiology and when Robert Koch identified Mycobacterium tuberculosis, the causative agent.

The book also describes the evolution of the treatment for tuberculosis, until the seminal discovery of streptomycin by Selman Waksman. We learn how TB was once treated with mixtures of frankincense and myrrh, and that patients were encouraged to embark on sea voyages to warmer shores in order to aspire to a cure. We also learn that in the 19^th century, tuberculosis was commonly attributed to sedentary lifestyles and excess liquor and the author describes the emergence of the stigma associated with tuberculosis, which still exists today.

Toward the end of the book, we learn of the discoveries of the first anti- tuberculosis medications and how the drug regimens evolved to counter the threat of drug-resistant strains of bacteria. We also learn of the formulation of the DOTS strategy by the WHO – direct observed therapy, short-course – to enhance compliance and successful treatment outcomes.

Unfortunately, the portion of the book allotted to the modern challenges surrounding TB is much less extensive and detailed than the older historical accounts. There is little discussion surrounding the challenges with lack of significant decline in TB incidence despite the DOTS strategy, continued reliance on antiquated vaccines, drugs and diagnostics, the rampant use of suboptimal tests in high TB burden countries or the challenges in making newer WHO-endorsed tests more affordable.  The critical issue of declining budgets for TB control and research and development is barely discussed. A more lengthy discussion of current controversies and challenges surrounding modern tuberculosis control would have greatly enhanced the relevance of this fine book in 2013.

“Spitting Blood: The History of Tuberculosis” by Helen Bynum is published by Oxford University Press, Oxford, UK. ISBN 978-0-19-954205-5.

Jasmine Grenier is completing her medical training at McGill University in Montreal. She has worked on TB research projects and published on topics relating to TB diagnostics.

Madhukar Pai, MD, PhD, is an Associate Professor of Epidemiology at McGill University in Montreal and an Associate Director of the McGill International TB Centre. He also serves as a consultant for the Bill & Melinda Gates Foundation. Dr. Pai has previously served as co-chair of the Stop TB Partnership’s Working Group on New Diagnostics. He is also a member of the PLOS Medicine Editorial Board and the PLOS ONE Editorial Board.

The authors declare no conflicts of interest.

Books reviewed in Speaking of Medicine are independent of the book’s publisher. Reviewers do not receive a fee but are allowed to keep the review copy of the book.