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ONE: Facing Tuberculosis
One afternoon a month and a day after the terrorist attacks on the World Trade Center and the Pentagon, I was in a crowded subway car making its way down Manhattan's Upper West Side. Only seven miles south of the 125th Street station, where the train was delayed temporarily, rescue workers and firemen were searching through the rubble and carnage of September 11, 2001. Yet on the subway that afternoon-and around the country-a different form of terror was on our minds.
Directly above me on both sides of the train were bright posters advertising a new and improved detergent that "eliminates 99.9% of all bacteria lurking in your clothing." (Parenthetically, all soaps pretty much accomplish this task.) Sitting next to me was a heavyset woman rubbing her hands over and over like some modern-day Lady Macbeth. Only instead of washing off the blood of her royal rivals, she was slathering her hands with a pinkish red anti-bacterial moisturizer "guaranteed to both soften the skin and rid you of nasty germs." Seated next to her were two older men who appeared to be breathing less deeply and far more rapidly than I suspected they might otherwise be doing. At the very end of the car was a young woman wearing a surgical mask and rubber gloves.
If these signs were not enough to alert the casual observer to what was going on, all one had to do was glance at the newspapers many were reading. Every publication, from the lowly tabloids to the august New York Times, screamed the same headline in bold print: ANTHRAX! Inside their pages were all the sordid details of the infection-laden letters sent earlier that week to Senator Tom Daschle and others. That very morning, an assistant to NBC anchorman Tom Brokaw, who received a similar missive in late September, was confirmed to have a bona fide case of cutaneous anthrax.
In the weeks that followed, several more cases of anthrax popped up, some easily explained (such as those among the postal workers handling the tainted mail) and some not (such as the fatal case in an elderly woman from Connecticut whose mail was, unluckily, mixed in with contaminated envelopes meant for others). And we all worried if the Pandora's box of germs that appeared to have been opened by terrorists would ever be closed. The sudden appearance of a frightening, infectious agent was, perhaps, one of the few things that could have so successfully taken the nation's collective mind, albeit temporarily, off the stunning events at ground zero. Government officials searched to find the source of the infection, to the accompaniment of television pundits pointing fingers and calling our public health mechanisms inadequate. Sales of Cipro, one of several antibiotics effective against anthrax (and by far the most expensive), went through the roof. Emergency rooms and clinics across the country were inundated with people wondering if every scrape, wheeze, or contact with something as harmless as the crumbs of a powdered sugar doughnut was an incipient case of anthrax.2
That the public would focus with a laser beam intensity on anthrax, a strange scourge that killed only a few in spectacular fashion, while paying little attention to the more common contagions that literally plague us on a daily basis, is a phenomenon hardly unique to our era. Healthy human beings frequently worry more about frightening, unexpected infections than about diseases we know all too well, such as tuberculosis, a disease that is slow and patient, relentless and effective, and year in, year out, sends millions to their graves.3 If the forces of evolutionary biology could have imbued the tuberculosis germ with the capacity to feel neglect, it was probably used to it by now.
Today, more than 2 billion of the planet's 6 billion people are infected with the latent form of tuberculosis. In the United States alone, 10 to 15 million are infected with it. Of this multitude, at least 10 percent of them will go on to develop the active form of tuberculosis sometime during their lives. The period between latency (with no signs of disease at all except a positive TB skin test) and active illness can range from weeks to years after the microbe Mycobacterium tuberculosis settles into the human body. Much has to do with the health of the particular host, his nutritional status, living conditions, and the coexistence of other diseases. But when considering the many influences that enable the TB bacillus to transform good health to ill, it is wise to recall the French chemist and microbiologist Louis Pasteur's warning to respect the "infinitely great power of the infinitely small."4
Every year public health officials across the globe diagnose more than 8 million active cases of TB. These are the people who are most infectious to others. The sicker someone is with active TB, the greater the number of microbes in his or her body; and with every cough, shout, or breath, that individual becomes a more significant risk to the public health. The average person with active TB will infect twenty other people before he or she dies or is adequately treated. What surprises many is that during every twelve-month period, about 3 million people die of tuberculosis, making it the leading infectious cause of death in the world today. In fact, more human beings will die of TB in our era than at any other point in recorded history.
The disease, often referred to as the white plague in deference to the infamous bubonic, or black plague, typically strikes adults during their most productive years of life, ages eighteen to fifty-five. Fortunately, since the late 1940s medicine has been blessed with a wide range of potent antibiotics that can treat TB and, in most cases, cure it. At the same time, these medical miracles have given rise to premature declarations of victory over tuberculosis. Especially over the past decade, public health specialists have grown concerned about the rise of multidrug-resistant strains of tuberculosis around the world. In layman's terms, this means that not only do we have deadly germs on our hands, but, in at least one out of ten cases (and far more in Asia, South America, and the former Soviet Union), the mycobacteria are resistant to the very menu of powerful drugs we have developed to enter and kill them.
Only recently have we begun to recognize the folly of extensive funding cuts in tuberculosis surveillance and treatment programs, and the unintended consequences of not investing in the basic health care needs of the most impoverished citizens of the world. Moreover, with the rise of HIV/AIDS over the past two decades, there is now a significant population of immunocompromised individuals who are highly susceptible to TB and can potentially spread the disease like an uncontrollable wildfire. Major social upheavals during these years have also resulted in mass migration movements around the globe. Each of these factors has created the conditions the tubercle bacillus needs to thrive once again, inspiring the World Health Organization to classify tuberculosis as "a global health emergency."5 My fellow subway passengers that afternoon may have been worried about the off chance of meeting an anthrax spore. A few may have been contemplating the risk of a terrorist delivery of smallpox virus or even the highly unlikely importation of Ebola virus. I was, and am, far more concerned about contracting TB.
Few stories of tuberculosis demonstrate its unpredictability better than that of one of the immigrants I met in a professor's office near the New York-Presbyterian Hospital Tuberculosis Clinic. Alejandro, a fifty-year-old laborer who came to the United States illegally from Ecuador in 1999, was a relatively new patient at the clinic and had just been declared "noncontagious" after a four-week hospital stay.6 In Quito, he had been employed as a building contractor's assistant and "worked twelve or more hours a day, six to seven days a week, for over twenty-nine years." As with many immigrants before and since, economic insecurity was his major impetus for leaving Ecuador: "The price of food in Quito-the price of everything-is very high. We simply could not make it in my country. So I decided I had to go to America alone, whatever the cost, to bring in more money for my family."
In the late summer of 1999, Alejandro left his wife and three sons to begin a dangerous and illegal trip to the United States. The trip actually began months before when he procured the services of a coyote, a nefarious "travel agent" who specializes in smuggling human cargo across international borders. Alejandro met the coyote through some friends in Quito, although he noted that these "professionals" advertise in newspapers and are relatively easy to find. Alejandro's coyote was "a well-dressed, slick guy who promised a safe journey using his extensive network of contacts, the best means of travel, good food, everything." But the "travel package" came at a steep price: $7,000. This sum, several times more than Alejandro's annual income, required him to take out a mortgage on his family home. However, the financial transaction was not executed at a bank. The entire deal, even down to a payment plan that charged 5 percent interest per month, was completed between the two men on the street in front of Alejandro's house. Each month since he signed the paperwork for this deal, Alejandro has wired the coyote $250.
From Ecuador, without passport, visa, or luggage, Alejandro flew in a tiny propeller plane to the desert in southern Mexico. He then traveled across the interior toward Ciudad Juárez over a four-day period. For this leg of the journey, his means of transportation was the back of a dilapidated pickup truck squeezed in between forty-nine other illegal immigrants. To avoid the Mexican authorities, they drove a circuitous route along bumpy back roads. Alejandro rubbed his rear end as he recalled this part of his trip and remarked, "I can still feel every rock and pothole." Each night they slept outside and were sold a ration of food. A plate of rice and beans, Alejandro recalled, cost "about ten dollars."
Once the truck reached Ciudad Juárez, it was simply a matter of crossing the Rio Grande into El Paso. But the U.S. immigration workers stopped the truck as soon as it attempted to pass the border, and the briefest of inspections justified their suspicions. All fifty illegal immigrants-Ecuadorans, Nicaraguans, Panamanians, and a few Mexicans-were taken to jail. Following their instructions from the coyote, each immigrant told the Immigration and Naturalization Service (INS) officers they were seeking political asylum.
Alejandro sat in an El Paso jail for almost six weeks, but recalled it as a far better living arrangement than what he had endured during his travels. He was brought before the immigration court and required to post a $3,000 bail bond. Fortunately, he was able to contact some relatives who had long ago settled in New York, and they wired this princely sum to the authorities. The judge questioned Alejandro through an interpreter and allowed him to be released provided he return for a more definitive hearing at a later date. Naturally, Alejandro agreed to these terms and promptly gave the bailiff a fictional address at which to contact him. Soon after, he assumed a false name and purchased a bus ticket to New York. He had no papers, no legal identity, not even claim to his given name. He was an undocumented immigrant. His is hardly an exceptional tale. At present, while two-thirds of the illegal immigrants arrested along the Mexican and Canadian borders voluntarily return to their lands of origin, of those who remain, 90 percent never show up for their hearings, and little if any effort is made to find them.7
A few weeks after Alejandro arrived in New York City, he found a job at a delicatessen in the downtown financial district. Alejandro's physician told me later that about half of the illegal immigrants in New York work in the food services industry. To be sure, those with active tuberculosis do not pose the same immediate health risks to unsuspecting diners as "Typhoid Mary" Mallon, the cook who caused several Salmonella outbreaks in New York City during the early twentieth century.8 Nevertheless, the possibility that an illegal immigrant harboring a contagious disease with little or no access to health care is preparing your next egg salad sandwich, at the very least, should seriously curb your appetite.
At the deli, Alejandro worked fourteen hours a day, six days a week performing tasks such as cleaning up the tables, making sandwiches, and restocking the bountiful salad bar that nourished the harried stockbrokers, lawyers, and office workers who came in for a quick meal. He was paid about $500 a week, always in cash. After covering his own room and board and the coyote's monthly fee, whatever money he had left over each month Alejandro wired to his wife in Ecuador.
Despite these hardships Alejandro observed, "Everything was working out fine until this past summer." At that point, the tubercle bacilli he may have inhaled in Ecuador or even in the United States activated with a vengeance, causing intense sweating, fatigue, and difficulty standing upright. "At first, I blamed it on the hard work," Alejandro explained, "the long hours, the summer heat. But these problems would not go away. No matter how much rest I got on Sundays, I still felt terrible. Worse than I ever felt in my entire life. I had these headaches, terrible, it felt like someone was hitting me over the head with a brick."
Alejandro lived in a small two-room apartment with eight other Ecuadoran men, all illegal immigrants, on the Harlem side of Morningside Park, just a few blocks from Columbia University. They fashioned cardboard partitions between their beds to give some sense of privacy, but there was little to be had. Victor, a middle-aged man who slept in the bed next to Alejandro and worked with him at the delicatessen downtown, insisted that he see a doctor. One Monday morning, the two men skipped work and made a visit to a Spanish-speaking physician on West Ninety-sixth Street. Alejandro later complained: "He didn't ask me to take my shirt off. He didn't take any blood, get an X-ray, nothing." Instead, the physician stopped his inquiry after hearing the words "terrible headaches" and prescribed a new anti-inflammatory pain reliever named Vioxx. The pills did little for Alejandro's headaches, but their $70 price tag plus the doctor's $50 fee wreaked havoc on his carefully calibrated budget.