John Green: "Tuberculosis Anywhere Is a Threat to People Everywhere"

Tuberculosis (TB) has a long and complex history, with the infectious nature of the disease not being understood until 1882. While effective treatments were developed in the mid-20th century, the lack of new drug development from 1966 to 2012 has contributed to TB remaining a major global health issue, causing over 150 million deaths since it became curable, according to John Green, author of "Everything Is Tuberculosis."

TB thrives in crowded conditions and may have emerged alongside the agricultural revolution. Treating TB requires carefully coordinated multidrug regimens, making patient adherence to the full course of treatment crucial to prevent drug resistance. Pharmacists play a vital role in educating patients on the importance of completing their medication, as treatment adherence is a common challenge. However, the dismantling of USAID's TB response efforts is concerning as it could lead to a resurgence of drug-resistant TB cases worldwide. Continued public health efforts are needed to maintain the progress made in controlling this persistent and deadly disease.

Pharmacy Times: Tuberculosis has a long and complex history. Can you discuss some of the key milestones in our understanding and treatment of this disease?

John Green: So tuberculosis has probably been with us, or a disease very much like it with us, for around 3 million years. So it's a long history. We didn't understand that tuberculosis was definitely infectious until 1882, when Robert Koch identified the bacterium that causes the disease, and then it wasn't until the early 1940s that we began to develop treatments for the illness, and then between 1945 and 1966, we developed several different classes of antibiotics and anti-TB drugs that are very effective. But then between 1966 and 2012, we developed no new drugs to treat tuberculosis, and that's a big part of the reason why we're in the mess that we're in today.

Pharmacy Times: Your book, "Everything is Tuberculosis," delves into the historical and societal contexts of the disease. What surprised you most during your research into its history?

Green: When I started learning about TB in 2019, I didn't even know that it was the world's deadliest infectious disease. I had no idea that TB was still a thing, for lack of a better term. I thought tuberculosis was a disease that killed 19th-century British poets, not a present-tense phenomenon. I think the biggest surprise for me is that since TB became curable, we've allowed over 150 million people to die of it. That's such an indictment of the way we distribute resources globally and the way we develop and distribute new treatments for disease.

Pharmacy Times: Currently, there is an outbreak of tuberculosis in Kansas. Historically, what factors have contributed to outbreaks and resurgences of tuberculosis?

Green: Well, we have almost 10,000 cases of active tuberculosis in the US every year. It's an airborne disease. Tuberculosis anywhere is a threat to people everywhere. Diseases, of course, don't know about political borders. But the key for tuberculosis is crowded living and working conditions. The more crowded people are, the more likely tuberculosis is to thrive. We have some limited evidence that maybe tuberculosis started to grow as a human problem during the agricultural revolution 10,000 years ago in Afro-Eurasia, and we've certainly seen that TB rises as industrialization rises. So in 18th-century England, for instance, about a third of all people died of tuberculosis as that country was industrializing, and we've seen what Vidya Krishnan calls TB's parallel journey with capital in outbreak after outbreak.

Pharmacy Times: Pharmacists play a crucial role in managing tuberculosis. Can you describe some of the key responsibilities of pharmacists in TB care?

Green: TB is a curable disease, but it's not easy to cure, and pharmacists are the people on the frontlines a lot of times distributing the drugs that we need to cure TB, and it's almost always drugs that are given in combination. Different treatment regimens have different orders of drugs, different drugs that you take every day in the first 6 weeks or the first 8 weeks. It's very complicated. It's above my pay grade, that's for sure, but the overarching theme, I think, is that we need to use our existing tools well, and we also need to be working on developing new tools.

Pharmacy Times: Beyond dispensing medication, how can pharmacists contribute to patient education about TB, including information about transmission, prevention, and the importance of completing the prescribed treatment?

Green: I think the importance of completing treatment is really an important focus for pharmacists, not just when it comes to TB, obviously, but when it comes to any disease. It's really common to hear that one of the main factors driving drug resistance and death from TB is, quote, unquote, patients failing to complete their meds. But as all pharmacists know and as most patients know, it's really common, regardless of what you're diagnosed with, to fail to complete your medication regimen. I've experienced that; I have severe [obsessive compulsive disorder] OCD and take 2 medications every day to control it, and I've stopped taking my medication a number of times, even though I know that that's life-threatening. So, I don't think TB patients are unique in this respect at all, but it's difficult. It's difficult to take medication every day for months. It's difficult to manage side effects, and it's difficult to take medication once we feel better, right? Like so many people stop taking their strep medication after 6 days because they feel better, even though they've been prescribed it for 10 days, and so I think pharmacists have a really important role to play in educating the public, both about one's individual health but also about society's health, that one of the reasons we complete our regimen of antibiotics is not just for ourselves but for our communities.

Pharmacy Times: How does the dismantling of USAID affect global efforts to curtail tuberculosis, particularly with risks for multidrug-resistant TB as a result of disrupted treatment?

Green: The dismantling of USAID is catastrophic for the treatment of tuberculosis. The United States has long been the most generous funder of TB response in the world, and what we're seeing right now is untold number of people having their treatment interrupted, and I don't need to tell this to pharmacists, but when you interrupt someone's treatment mid-course, the chances that they'll develop drug-resistant tuberculosis skyrocket, and as a result, that's obviously personally catastrophic because it's much more likely that that person will die. But it's also societally catastrophic because it means much more drug-resistant tuberculosis that we're going to have a harder time treating is circulating in communities. We've already seen some of this in the United States; some of the people who have TB in Kansas have drug-resistant TB, and we're going to see much, much more of it because we're just going to see much more drug-resistant tuberculosis throughout the world, and that really scares me and should scare all of us.

Pharmacy Times: Given the current situation with rising TB cases, what message would you like to convey to the public about the importance of TB awareness, prevention, and treatment?

Green: I think the most important thing is to remember that TB is preventable. It's curable, but we also have long enjoyed a world. I mean, really, since the 1950s, 1960s, we've enjoyed a world in the US and other rich countries where TB is not a significant public health problem, but we only enjoy that world because of the efforts of public health officials, pharmacists, doctors in controlling and preventing TB, and we are rare in the world. Tuberculosis is still the world's deadliest infection, and I think that's really important to remember, and the progress that we've made is not guaranteed; it's not inevitable, it's not natural, and there's every possibility, and I worry, unfortunately, that we're going to see regression when it comes to TB. We're already seeing more cases every year in the United States, and I really worry that we're going to see a resurgence of the disease globally.