India has incredible potential to adjust the global TB situation. They have 21% of the world’s cases, but more importantly they are a hotbed for innovation. And I’ll be moving to work on the Gates Foundation’s TB strategy to find ways to partner with the government and industry to develop innovative approaches to controlling TB.
What are some of the approaches?
Globally, TB control is challenged by antiquated and inadequate tools, diagnostic tests that are 125 years old, an 85 year old vaccine, and drugs that, fundamentally, have not changed for 50 years. And yet we’re seeing a real sea change in the development space for new TB control tools, and equally as challenging as their development is understanding how those tools could best be deployed to promptly diagnose and treat people with TB and interrupt this epidemic.
My whole family is moving to India. We’re all quite excited. I have a nine and a twelve year old. My wife is a documentary film maker. Her focus is mental health, so she’ll be working on a film on global mental health.
You and a co-author wrote a commentary on an article in the Lancet in 2009. Your comment was titled, “Scratching the surface of ignorance on MDR tuberculosis.” In what ways are we ignorant about multidrug-resistant TB?
I would say we remain largely ignorant on virtually every aspect. At the most basic level, we still don’t completely understand the mechanism by which the bacteria become resistant. At the patient level, we don’t understand the best ways of managing patients who have drug resistant TB, and at the global level we still have a relatively poor understanding of the ecological factors that are driving the epidemic and what can be done to control it. We don’t know what can be done to control it, but we do know enough to get started and it’s really working in the context of this imperfect data to address this emerging epidemic that I see as one of microbiology’s highest priorities.
In another article, this one in NEJM, you and your co-author contend that if emerging economies manage to tackle their own tuberculosis problems, tuberculosis might be eliminated by 2050.
I think the emerging economy thing is a really important point. I am hopeful that in the next decade, global TB control will demonstrate a new paradigm, which, in contrast with the old way (the rich world solving the problems and giving those solutions to the poorer countries) the emerging countries, specifically China, India, northern Africa, and Brazil, will solve their own problems and, in so doing, they will provide solutions for the rest of the world as well. We no longer look at these countries as recipients of aid, but more as innovators and donors.
I know that historically there has been a stigma associated with TB infection. Does that stigma persist in places like China, India, and Brazil?
The stigma remains a huge issue for TB patients everywhere. It’s a major impediment to people seeking care, and it makes the difficult treatment that people are required to take even that much harder.
Where do you see the study of tuberculosis population genetics in 10 years?
I think is an extremely exciting time, with the continued convergence of epidemiology, genetics, and the theory of population biology, which provides the potential to really turn our understanding of the TB epidemic to a more predictive science where we can go beyond largely describing what is going on to actually understanding the fundamental drivers of the epidemic in a way that lets us predict and get ahead of it.
If you had to change careers today and you could do anything, what would you do?
I think I would be an economist. As long as I didn’t have to work on the US budget. (Laughs)
What’s your favorite science book?
It’s a book that came out a few years ago called Monster at Our Door – about avian flu. I loved it. It was an extremely succinct and readable description of influenza, starting with the very basic molecular stuff and translating it into the global picture.
What is something about you that most people don’t know?
I contracted fish tuberculosis this year. I am an avid spear fisherman and I contracted Mycobacterium marinum [from fish]. I suffered through protracted diagnosis and treatment, including misdiagnoses and drug toxicity, and I ultimately abandoned therapy before completion, which really gave me a visceral feeling for what nearly 10 million people [with tuberculosis infections] go through every year. There are only about 150 cases of humans contracting fish tuberculosis reported to the CDC each year.