Changing Reward Systems

Directly Observed Therapy (DOTs) for tuberculosis. Side effects often tempt patients to skip doses, leading to drug resistance [Image: Jose Cendon]

I was recently moved to tears by this story of a patient receiving test results from Doctors Without Borders (MSF). He was receiving news that his tuberculosis was recurring despite treatment, and that his treatment was going to have to be changed and intensified. He replied, "Twenty months of treatment? Fifteen to 16 tablets a day, right? No, I would rather die. All I need is a metre of rope". The piece then goes on the share how he cries, likely wishing that he could spend time with his friends, doing what they could. He cries because it isn't fair. He's right; he is just 19 years old. I recall a similar evening with my dad, who was a tuberculosis patient himself. After realizing that he once again needed to go to bed in the early evening without visiting, eating, laughing, or enjoying the company, he said angrily whispered through tears, "I just want to watch the Red Sox with you." Grossly unfair. Tuberculosis is a terrible disease. During active, end-stage disease patients' lungs fill with fluid often to the point of hemorrhage, they are unable to eat or drink well, and often they waste away. Medical treatment for tuberculosis is often nearly as miserable. The drugs are laden with side effects that nearly all patients suffer intensely from. These are debilitating nausea and vomiting, constant ringing in their ears that not uncommonly leads to hearing loss, extreme vertigo, and blurred vision. Treatment lasts anywhere from six to twenty seven months, depending on the stage of disease and chosen drug combinations. With 6 million cases of active tuberculosis disease in 2014, and up to 2 billion people (somewhere between and quarter and a third of the world's population) infected, one would think we would have a better solution. 95% of those affected by tuberculosis live in developing countries, where the profitable potential of newly developed medications is minimal. Private industries take their lead in drug development from profit margins. This makes some sense; after all, they cannot ignore the realities involved in production and development costs, and are unlikely to persue a project that has a high probability of failure and a low probability of just breaking even. University-led endeavors for novel treatments have been slow to develop as well, and I understand why this is the case too. Mycobacterium tuberculosis is jokingly referred to as a career killer. It takes weeks to months simply to grow a culture in the laboratory, and there are very few genetic tools available to study the bacteria in ways that would lead to the discovery of new medications. We are evaluated based on how many papers we publish, how many students we mentor, and how many grants we receive. It is difficult to acheive these ends when performing the simplest experiment routinely takes months. What will it take, then, for new tuberculosis treatments? Barring a breakthrough from a research institute with very patient donors, it comes down to this: either academe or the private sector must be prepared to change their reward system, if only for this problem. I hope for the best. [Note: if this topic interests you, considering following the MSF Blog TB in Uzbekistan}