Consumption (51 page)

[UNPUBLISHED MANUSCRIPT]

The Patient Predator

The creature arrived in the Arctic in the same way it spread itself around the world. It lay dormant in the lungs of someone apparently healthy enough to undertake such a journey, and then, when they were weakened, perhaps by hunger, or cold, or simple loneliness, it revived explosively. The sailor, or the missionary, or the trader found himself febrile and coughing paroxysmally, in some little iglu or tent, the bacteria streaming through his blood to all his organs—and then a local Inuk had the misfortune to enter the shelter.

In Rankin Inlet I knew a woman who carried the descendants of the creature within her. She was my patient and we were acquainted for most of three decades. Mostly we had quiet consultations about such things as contraception and bladder infections, but what dominated her medical chart were the pages and pages that describe the ordeal she endured as a young girl as a consequence of tuberculosis. She had been evacuated to a dismal hospital in the south for six years. She has been beautiful as long as I have known her, with a gangly incandescent energy that I’ve always been inclined, however unreasonably, to attribute to her illness. The febrile and gangly beauty of consumptives has long been a trope in Europe. All I knew was that Victoria stirred me more than any New York City fashion model could.

In my early days there, Rankin Inlet was populated by eighteen hundred people, almost all of these Inuit, and its houses clung to the low rocks that stretched into the Arctic Ocean. The wind scoured this place. Everyone here knew everyone else and most of their problems.

There have been outbreaks of tuberculosis here ever since the first coughing sailor or missionary arrived, the infection smouldering on long after the advent of antibiotics. The disease was firstly an expression of poverty and its consequences, especially crowding, and in the Arctic, these were usual. Latent infection endures in almost everyone older than forty—the creature has its hand on these people still. By the time a new outbreak is recognized there are usually dozens of new infections, some apparent, most already gone dormant. Victoria did not know from whom she caught her illness.

When she was diagnosed, half her left lung had been taken up by a giant cavity full of the organism. Every time her sputum was analyzed in her first year at the sanatorium, it was packed with the little rods of
Mycobacterium tuberculosis
, which stain crimson when examined under the microscope. She coughed constantly and became so thin she was cold even huddled in her bed, wrapped in blankets. After months of unsuccessful treatment with antibiotics, she underwent savage deforming surgery. The scar on her chest looks like a mauling.

The bacteria inside the cavity in her lung had walled themselves within the surrounding scar tissue; blood did not flow there, and so antibiotics and the two arms of the immune system—white blood cells and antibodies—did not reach it. The operation Victoria underwent is called a thoracoplasty, and involves excising ribs in order to collapse cavities of infection within the lungs. After the Second World War, with the development of effective antimicrobial therapy for these infections, chest surgeons were thrown out of work en masse (only to have their futures brightened anew by the postwar rise in cigarette smoking and consequent lung cancers). Such operations are almost never done now. Many experienced thoracic surgeons in the developed world today have never had to operate on a tuberculous lung. This is an astonishing and improbable state of affairs, really: chest surgery was born of tuberculosis, and occupied itself almost entirely with the problem until fifty years ago. A chest surgeon then would not have believed the problem could disappear for good, so quickly. He would have been right.

Among Victoria’s friends in Rankin Inlet are always a handful of men and women who have developed resurgent infection. They endure their coughing and weight loss for a time and then they come into the nursing station, seeking
attention. By the time they do, they’ve always infected a few dozen of their friends and family members. We track them down and treat them too. No one pretends that we find everyone. And every year, around the world, in this lingering brushfire of a disease, we identify more and more strains of the bacterium that are resistant to the available antibiotics. There hasn’t been a new antituberculosis drug released since 1968. And the frequency of resistance had increased tenfold in that time. There is trouble brewing—here and all over the world.

Viewed over any time frame longer than the last half-dozen decades, tuberculosis is the most common cause of death among young adults anywhere. It remains a principal killer—is still the single most common infectious cause of death certainly—throughout most of the world, and two billion people, a third of those living, carry TB, alive and waiting, within them.

Tuberculosis infection has been so common for most of our history, it has been almost a normal, if periodically lethal, part of the human bio-niche, like a taste for intoxicants, perhaps. Modigliani died of tuberculous meningitis, infection of the linings of the brain. Keats, a former medical student, remarked famously on the foreboding bright-red colour of his sputum. Chopin, Orwell, Vivien Leigh: all dead too young of TB. Then, for a mere fifty anomalous years, in North America and Europe, it ebbed back and a lingering cough became no longer cause for immediate terror. In retrospect, the complacency with which rich people have viewed tuberculosis is difficult to understand. When the enormous historical toll of the disease is considered, it becomes almost incomprehensible.

We claim to have forgotten it—the appearance of pallid coughing men and women, the idea that even the young and wealthy may sicken and die—but study the perfume ads: these are not archetypes of beauty formed
de novo
. These are Katherine Mansfield and Modigliani: so young, so thin, so pale. “Love us now, for soon we will be gone,” is what those faces say to us. “And while you’re at it, buy some of this cologne,” they add. “It comes in this nifty spritzer bottle.”

Patients suspect that their doctors objectify them, reduce them to a compilation of symptoms and diagnoses, and in this they are wholly correct. (“I’m sending you an acute stroke,” conversations with my colleagues will begin.) Each of the different diagnoses carry a certain characterization. The vascular
diseases are clean and lethal; the cancers, darkly menacing. Smoking and obesity-related processes are viewed with a certain impatient contempt. The psychiatric diagnoses are all considered in their own light. TB is different somehow, has always been different—though it would be as perilous to love a patient because of her diagnosis as it would be for any other reason.

Everything about her is special, different; just watch the way she holds herself, head high even as she is ignored by the people around her. Her perfectly erect neck as she turns to me at the grocery store and those black eyes shining. But knowing her as I do, it seems only expected that her illness was this storied and anachronistic malady that refuses to submit even when antibiotics are thrown at it by the fistful.

Mycobacterium tuberculosis
is descended from similar organisms that have inhabited cattle for eons. Four thousand years ago, about a week and a half after cattle were domesticated, the organism spread to humans. It has since adapted to us, tweaked its genetic arrangement to optimize its capacity to spread and persist. Its virulence is largely a consequence of the thick, waxy cell wall that surrounds it like a rind, making it substantially resistant to the effects of the immune system. When the organism is inhaled, white blood cells called macrophages (“big eater,” from the Greek—one pictures a pie-eating contest) engulf and bathe the invaders with toxic chemicals like hydrogen peroxide and protein-dissolving enzymes. Despite the macrophage’s attempts to poison it, the creature often survives because of its thick rind, and will slowly replicate itself until the macrophage is so full of tuberculosis bacteria that it bursts and dies. The daughter organisms drift on, to be engulfed in turn. Most of the time, an equilibrium is attained: about as many organisms are killed as survive and the spread of the creature is checked. This is the latent phase, which can last decades until for some reason, or no reason at all, the balance is tipped.

Perhaps the immune system is weakened by stress, or by pregnancy, or by another infection—especially HIV—or by starvation, or simply by age. In any case, when the balance does tip, the bacteria overwhelm the immune
system. They begin to fill the adjacent alveoli and block the transfer of oxygen and carbon dioxide to and from the blood. The patient notices that she is more easily winded than normal. The increasing concentration of foreign protein within the lungs stirs the immune system to maximal activity and the quantities of not-quite-toxic-enough poisons inflame the walls of the airways, which come to bleed easily. The patient develops a fever, and she notices streaks of blood in her sputum. Initially, as Keats knew, this blood will be dark red and venous; later, as infection erodes its way into arteries, it becomes bright crimson. If the affected artery is a large one, this may be what doctors dryly describe as a pre-terminal event. Katherine Mansfield expired in a great geyser this way. Keats, crediting his instruction, foretold his own death as his sputum became brighter and brighter.

Even if the artery isn’t large, now the seed is in the wind and the creature in the blood—it swims to every organ system: the brain, the kidneys, the intestines, the bones, the ovaries, the skin, the uterus, the heart. The modern understanding of organ systems and how they fail was largely gained through observing the consequences of their involvement by
Mycobacterium tuberculosis
. Failure of the adrenal glands, called Addison’s disease today, was then a consequence of tuberculosis eroding the adrenals from within; this is what killed Jane Austen. Any medical textbook more than a generation or two old lists tuberculosis as a possible cause of almost any organ dysfunction, and usually high up on that list. Pott’s disease was tuberculosis of the spine, which most commonly affected hunchbacks such as Victor Hugo’s bell-ringer of Notre Dame.
Lupus vulgaris
was infection of the skin; the systemic wasting syndrome was consumption, or phthisis. The history of medicine, until fifty years ago, was largely the history of tuberculosis.

One of the great calamities for all mankind, tuberculosis was simply the worst thing that ever happened to the traditional Inuit, and to indigenous Americans more generally. Nobody knows why it has been so bad among them. There are many potential explanations: the small, crowded snow and skin dwellings they lived in, the co-existent lung diseases from the smoky fires
they lit their dwellings with, a genetic vulnerability, and most persuasively, the chronic, recurrent famine that lurked always on the edge of the ice floes.

The Inuit called it
puvaluq
, or bad lung, and it infected most of them. Across the continent it killed many millions more Aboriginal people, contributing to the clearing of the American Plains. When settlers spread out across them in the late 1800s, they commented often on the wide open and fertile grasslands, uninterrupted by signs of human habitation. But for the effects of the creature (and its other infectious companions), those plains would have been alive with children and hunters and women growing corn. One hundred million people lived there, before the plagues came.

Where I worked, the Inuit were compelled by the Canadian government to move into the desperate little settlements it erected on the shore of Hudson Bay, largely to facilitate attempts to control the infection. Throughout the 1950s and 1960s, ships with mobile X-ray units visited every summer and men, women, and children found to have active disease were evacuated to sanatoria in the south. The cultural disruption that ensued from these years-long exiles decisively interrupted the thousands of years of traditional teaching and knowledge of the land that enabled the people to remain independent of southern culture. The children, returning to parents they barely remembered, were often unable even to speak to them, having lost their language in the south. By the late 1960s, the last of the nomadic hunting families had come in off the land to settle in the clapboard houses provided them by the government, there to begin the cycle of acculturation that continues today.