The Passing of a Hero for Tuberculosis

A man credited with saving tens of millions of lives died earlier this month in virtual obscurity. Just a few newspapers in Scotland recorded his passing. But for some of us who work in global health, Sir John Crofton was a hero.

Sir John, a humble, determined, Irish-born physician, pioneered the six-month treatment schedule for tuberculosis that we still use around the world today. His search for answers, his research, led, the way to what we have today, a massive decline in the numbers of people dying from TB.

When he returned from the battlefields of WWII to Edinburgh, a TB diagnosis was a virtual death sentence. Multi-drug antibiotic therapy didn't become available until the 1950s. Even then, it was available only to small numbers of patients mostly in rich countries, and it required 18 months of painful, toxic, injected treatment.

Sir John, and a small number of colleagues, changed this by cutting the duration of treatment by two-thirds, to six months. This created the possibility of widespread treatment delivery, not only in the UK but around the world.

Since 1993, when the WHO declared tuberculosis a "Global Health Emergency", an estimated 30 million people have been treated with the successor to the treatment he devised. TB remains a formidable foe, however, with 9 million new cases of TB occurring each year and more than 2 million people dying. At least a half-million people have a form of TB that cannot be cured by Sir John's combination therapy: Why? Because the bacteria living and proliferating in these patients are resistant to those drugs. These patients face 18 to 24 months of toxic, injected therapy. Some also require lengthy, complex surgery to remove diseased lung tissue, an intervention that is all too often unavailable in the poor settings where TB is most common.

One of those places is Lima, Peru, where I was visiting just last week and have worked for many years. Influenced by Sir John's example, the non-governmental organization Partners In Health and the Peruvian Ministry of Health initiated a treatment program for these resistant forms of TB in 1996.

With dozens of partners from the international community, and generous external funding initially, this collaboration has helped more than 10,000 patients advance through treatment for resistant TB. Patients receive nutritional, financial, and social support to facilitate the difficult-to-tolerate treatment process. Since 2000, more than 400 have also undergone surgery, reportedly the largest such group in the world. Despite these aggressive interventions, analyses reveal that it's very difficult to cure more than 70 percent of these patients.

On the day of Sir John's funeral, I visited a surgery ward in Lima where I met two such patients; both had been on treatment for resistant TB for more than a year. Both were awaiting surgery: a 27-year-old engineering student for his first operation, and a 54-year old industrial refrigeration worker his second. The young patient had been hospitalized, in anticipation of his surgery, for three months.

He stood weakly before me, his thin frame slightly hunched, a tube draining fluid from his chest into a glass jug held on a makeshift, wooden cart that was just inches off the floor. This young man didn't complain about his treatment, the delay to surgery, or even the difficulty of breathing.

I wondered how Sir John would have reacted, both as a clinician and activist. This patient, and millions like him, entirely blameless, has essentially been relegated to the pre-antibiotic era of more than 60 years ago. His 18 months of toxic treatment have failed to vanquish his disease.

Why? This is a consequence of decades of neglect of research in TB: No new anti-TB drugs have been developed since the 1960s. Diagnostic tests date to the 19th century; they are slow and not very accurate. Surgery, without which some patients' disease will never be cured, is rarely available; this is due to an estimated funding gap in global resources required for TB control of $1 billion each year.

Sir John Crofton is laid to rest, but his passing should ignite in those who remain his determination to bring effective treatment to patients with all forms of TB. I am hopeful that dedicated global health research, and committed health care workers, will lead the way for the next breakthroughs in beating back this ancient disease.

Carole Mitnick is assistant professor in global health and social medicine at Harvard Medical School and an Ambassador in the Paul G. Rogers Society for Global Health Research at Research!America.