Local Tuberculosis Control in a Global Health City

by David Fleming
May 1, 2009

This essay by David Fleming, Director and Health Officer, Public Health, Seattle & King County, is a part of the “2009 Summit Challenge—MDR-TB: Overcoming Global Resistance.”

If you were born in Seattle in 1909, the prevalence of communicable diseases such as TB would have led the smart gambler to bet against you ever celebrating your 45th birthday. Today, a century later, the smart bet now is that you will eventually see a birthday cake with a lot more candles. With proper sanitation, clean water, and antibiotics and vaccinations to prevent infectious diseases, our life spans have nearly doubled. Today, we face new challenges from non-infectious threats like tobacco and obesity.

Our century of successful work against TB is part of why we are living longer today. As a consequence, some might argue that we should put TB in the rear-view mirror and move on to new challenges.

Do not listen to them.

Only constant, active effort is keeping people in Seattle free from TB and living long enough to be affected by our new health challenges.

In King County, Seattle’s home, over 100,000 people are infected with TB, and that number is growing. Seattle’s emerging reputation as a global crossroads, for all its wonderful benefits, makes our residents more likely to have the disease that infects one third of the globe. Our local TB rate is 50 percent above the national average, and over 80 percent of those we identify with active disease are born outside the United States.

Our local TB control program is our community’s front line defense against this disease, working to ensure that people are diagnosed and treated and their contacts at highest risk of infection are identified and screened. This work is intensive. In 2008, our program evaluated and tested hundreds of contacts in dozens of investigations at worksites, schools, medical facilities, and homeless congregate settings. During the year, over 2,800 clients make nearly 12,000 visits to our clinic to treat their infections. This hard work has brought us success. Last year, in our highly diverse and vulnerable group of patients with active TB, no one discontinued or refused to complete TB treatment. And our prevalence of multi-drug resistance is very low, currently hovering below 2.5 percent.

So, some might argue, even though our fight against TB remains an active battle, we can rest easy because we are winning.

Again, do not listen.

Unfortunately, we face a major setback, not from a new strain or old drugs, but from a lack of resources. Across the country, including here in King County, health departments are struggling to deliver essential services, including TB services, as deficits loom, dollars are cut, and programs are eliminated.

TB will take advantage when we drop our guard. In the early 1990’s, the United States saw a resurgence of the disease as funding fell for TB control activities. But if learning means changing behaviors, we have not yet learned the need for maintaining active public health programs, including TB control. Public Health—Seattle & King County has cut our TB program twice in the last year—not because we do not know better, but because there is no public health money to support it.

Sadly, in these difficult economic times, cutting TB control activities is not only bad health policy, it is also bad economic policy. The inevitable result of less detection and effective treatment for TB today is more disease in the future, as well as time consuming and costly drug resistance.

This year’s Pacific Health Summit ushers in a new era of opportunity for global TB prevention. It is ironic that locally, in our city of increasing global health prominence, we face a crisis in delivery of proven TB control measures because of a lack of financing.

This state of affairs is an important reminder of our collective need to assure the integrity of the entire chain of discovery, development, and delivery if the promise of new science and technology is to translate into better health. And, perhaps more sobering, we must acknowledge that the soundness of this chain is not just an issue in Sudan, Somalia, and Sierra Leone, but in Seattle as well.

This essay is a part of the 2009 Summit Challenge—MDR-TB: Overcoming Global Resistance. To learn more about the 2009 Pacific Health Summit on MDR-TB, visit the Pacific Health Summit