The Age of the Unthinkable (28 page)

Tony Moll, a tall and cheerful British doctor, is the Chief Medical Officer at the Church of Scotland Hospital, serving a
region of 600 square miles. A dozen nurses in outlying clinics support Moll, but the serious cases quickly filter into the
main hospital, where he and his team see them during workdays that are rarely shorter than twelve hours. Moll’s house is on
the campus of the hospital, a five-minute walk from the admitting rooms. He came to Tugela Ferry in the 1980s, just as AIDS
was beginning to massacre much of the population of southern Africa. The Tugela Ferry hospital, like most hospitals in KwaZulu
Natal, simply couldn’t handle or treat the flood of patients sick with the disease. Moll’s job became one of managing their
slow, inevitable decline.

Moll is an energetic, optimistic, and inventive man — as you’d have to be to practice medicine in Africa for decades. He did
the best with what little he had, and when I first got to know him in 2001, he already had a reputation as a sort of superhero
of triage. He had pioneered one of the best programs in the world for managing the pain of dying AIDS patients. He had helped
develop nutrition strategies for his poor patients and assisted in aggressive disease prevention campaigns — everything from
poster blitzes to roving minibus tours. It was all weak medicine. But starting in 2004, he began to see the first hints of
real good news. That year the South African government finally agreed to let doctors prescribe antiretroviral drugs (known
as ARVs), the miracle pills that promised to roll back AIDS symptoms. Though global pharma companies were still pricing the
best of these drugs above the reach of South Africans, Moll began prescribing the basic ARVs he could get his hands on (he
bought the first ones with his own money) and enjoying the
this is what I got into medicine for
experiences that AIDS doctors in the United States had enjoyed a decade earlier. Patients who had been wheeled into the hospital
crippled by infection, covered with tiny cancers, or twitching with AIDS-related nerve corrosion, each with eye-blinkingly
high loads of HIV in their blood, progressed to better health. Their immune systems began to snap back. In some cases, they
were sent home with viral loads that were barely detectable.

Better still, Moll found, the patients seemed to stick with the complicated ARV treatment. This was the crucial accomplishment.
One of the most persistent arguments against providing ARVs to people in places like Tugela Ferry had been that the effort
was a waste. African AIDS patients were too poor to care for themselves, critics said, too illiterate to manage the cocktail
of medications, and too ill with opportunistic diseases to respond to treatment. Moll’s thriving AIDS patients were discrediting
that view. You couldn’t yet say the AIDS crisis was ending or even turning. After all, as late as 2008 South African AIDS
patients were still dying at a rate of about one every minute. And there was little sign that infection rates were slowing.
But the daily life of Moll’s practice offered a sense of progress. In fact, his patients were doing so well that a team from
Yale University arrived in Tugela Ferry to track their progress. So it was particularly jarring when, one day in the winter
of 2005, many of those same patients, without warning or explanation, started dying.

To Moll and his nurses, the deaths made no sense. All of the patients had been relatively healthy. Most had recovered from
their dangerous AIDS-related illnesses. Stranger still, whatever was killing them looked, at first glance, very much like
drug-resistant tuberculosis — but that was impossible. To begin with, none of the dead patients had a history of regular TB.
(In fact, the ones in the Yale study had been admitted precisely for that reason.) So there was no way they could be developing
that particular form of the disease — as if a man had developed ovarian cancer, something simply beyond the possible biological
explanations. On top of that, even though the disease looked like TB, with its night sweats, tight lungs, and rib-breaking
coughs, Moll’s patients failed to respond to the usual foolproof TB treatments.

Moll, right before the deaths began, in what he admits was a stroke of pure luck, had taken sputum samples from all of the
patients in his hospital and sent them to the regional testing center in Durban. He now rang the center to see if they had
any answers. When they got back to him, the news was chilling. Moll’s patients
did
have TB, but there was a reason it had fooled the doctors: the type of TB in Tugela Ferry had never been seen before — and
it was so virulent that it had beaten six different anti-TB drugs, the complete armory of medications available in South Africa.
Tugela Ferry, the lab results suggested, was the center of an outbreak of a superbug.

Moll felt his stomach drop. He could barely concentrate on the last part of the call. His first thought, he told me later,
was about the way TB spreads. Unlike blood-borne HIV, which is rarely passed from patient to health-care worker, TB spreads
through the air. In that respect it is like the lethal African terror-virus Ebola, which kills 80 percent of the people it
infects. TB was known to linger in the air of an unventilated room for hours. A single cough could infect a doctor or nurse.
Two of Moll’s staff were already dead. What he was hearing on the phone might be a death sentence for many others, including
himself. As Moll and his colleagues raced to isolate their patients — and themselves — they reviewed the situation. Something
very dangerous was tearing through the jigsaw-tight TB wards in their hospital and in the scattered houses of Tugela Ferry.
Within weeks the World Health Organization (WHO) called an emergency meeting in South Africa to discuss the strain, which
they named XDR-TB, for “extensively drug-resistant TB.” Soon after his call Moll sat down to calculate the impact of the disease
and discovered that XDR-TB patients were dying, on average, just sixteen days after they arrived in the hospital. There was
no time to stabilize and treat them. And in one respect XDR made Ebola look mild: it killed 98 percent of the people who got
it.

Tuberculosis was first described by Robert Koch in 1882, and it’s one of the most common diseases on earth, infecting about
a third of the people in the world. In most cases the disease remains dormant, constantly fighting a losing battle with the
immune system. But in places like South Africa, which has millions of people whose immune systems are weakened by poverty,
hunger, or HIV, TB thrives.

An effective treatment for TB, called rifampicin, had been used for nearly fifty years and was available in South Africa.
The treatment course lasted six months and cost about twenty dollars. But there was a problem: rifampicin or the other first-line
TB medications were almost too good at their job. They cleared up the most brutal symptoms relatively quickly, and always
before molecules carrying the disease had been washed away. And since the treatment’s side effects included nausea and exhaustion,
the temptation to stop early was hard to resist. As many as 60 percent of TB patients in South Africa did stop early. Yet
even though they felt better, they were still carrying millions of supertough holdout bacteria in their bloodstreams. These
bacteria, now strengthened against the effects of rifampicin and similar medications, formed the basis of a new epidemic,
known as multidrug-resistant TB (MDR-TB). If you quit that initial TB treatment early, you were at risk. If you were unlucky
enough to get MDR-TB, it required a treatment that lasted a year and a half, cost the South African government $20,000, and
involved hospitalization and daily injections for the first four months. The side effects of treatment included deafness,
dizziness, and bursts of excruciating and unpredictable pain. This was awful enough that some patients said they would rather
risk dying than finish the treatment. So, having quit the first-line TB drugs, they “defaulted” off the second-line drugs
as well, which opened the door for another, apparently untreatable version of the disease. This was the plague that struck
Tugela Ferry.

Because, by chance, that Yale study was under way at the time of the outbreak, the XDR-TB incident provided a microscopic
look at one of the paradoxes of the story of TB and AIDS in Africa. In Tugela Ferry, you’ll recall, Moll was proving that
his very sick, very poor South Africans would stay on antiretroviral treatment for HIV. But many of those same patients were
defaulting
off
the TB medication, which was surprising. The South African government and international organizations had spent hundreds
of millions of dollars on TB education. Every health-care professional in the country had lumbered through a half-dozen mandatory
seminars about the disease and its treatment. Yet in 2005, the year of the XDR outbreak in Tugela Ferry, as many South Africans
would die of ordinary TB as were cured of it.

Unlike TB treatment, which lasted only six months, ARV treatment was a lifetime project. The pills also had unpleasant side
effects, in some cases much worse than the TB medication’s. And AIDS patients had a much less developed infrastructure of
support and monitoring. But — and here’s where we need to pay attention — even as they stopped taking TB drugs, the patients
stayed on ARVs. The split seemed nonsensical. It was like discovering that all the children in a school were failing arithmetic
but easily picking up calculus. Somehow an expensive, Ph.D.engineered policy to fight TB seemed unable to control the disease.
In fact, it had turned a manageably dangerous disease into a sort of airborne disaster-in-waiting. So why were South Africans
sticking with the complex ARV treatment and giving up on the easy TB course? On the surface, the problems looked identical:
sick poor people, a regimen of pills they needed to take. But there was one small, nearly imperceptible difference between
the way the two diseases were treated, and it turned out to be the difference between a revolutionary health-care program
that was saving patients and one that, to be frank, was doing something unthinkable: murdering them.

You may recall that earlier I said that radical newness is contagious. This is one of the reasons it is so useful to think
about Grand Strategy as if it were an immune system. Doing so prepares us for all of those flu-like features of an unstable
age and protects us well enough that we can thrive and grow amid real change. Contagion, of course, is a common trait of any
revolutionary era. In 1848, for example, changes in the urban composition of Europe and the nature of industrial labor (think
Dickens) conspired to catalyze economic shifts that triggered continental political revolutions (think Marx). But today this
whole process happens much, much faster and across a much wider network. As we’ve seen over and over again, all sorts of links
conspire to accelerate the propagation of problems. What I’d like to turn to now is the secret Moll’s ARV patients had unwittingly
discovered: how to propagate solutions.

We’ve seen how revolutionary seeing and thinking and acting works better in places like Silicon Valley or the Bekka Valley.
This is why Mike Moritz outperformed his investing peers, why Aharon Farkash lasted longer in his job than most Israeli intelligence
generals. But what if you could watch a test of two different schools of thought, side by side, in action? This was exactly,
by a quirk of fate, what was happening in Tugela Ferry when XDR-TB emerged. On the one hand you had a huge, centralized, old-school
approach to TB. On the other, an approach to HIV that was ad hoc in many ways. In the case of HIV, success; in the case of
TB, a now-familiar problem: a policy that not only fails (doesn’t stop TB) but makes the problem more dangerous than the one
you started with (creates a superbug). And in the deadly space between those two results, we’ll find an essential difference
between the way our governments and most employers do work and the way they ought to work. It’s the last essential piece of
a deep-security way of living. And you’ll be amazed at what it can produce.

First let’s talk about what exactly had occurred in that TB-versus-HIV treatment contest. From a standing start you might
have said that dying TB-infected South Africans had more “power” to deal with TB than with HIV. Look at all the resources
that had been invested in saving them: more than twenty years of government support, tens of millions of dollars in investment,
thousands of specially trained nurses and doctors, even a carefully developed idiot-proof program to monitor how they took
and stayed on drugs such as rifampicin. (Clearly lacking the mnemonic verve of the Pentagon folks who dreamed up cool-sounding
HARMS and LBADS, public-health planners simply called the program DOTS, for directly observed treatment, short course.) Health-care
workers
watched
as patients swallowed pills for two months — and then often defaulted anyhow.

Against this were arrayed the often ad hoc resources of the antiretroviral initiative: a few mimeographed pages about how
the drugs worked, a compliance program that asked relatives to keep an eye on patients, and a handful of overwhelmed doctors
like Moll. So why was the expensive program failing? The answer was that TB treatment in South Africa was failing, not despite
the huge amounts of money and time invested, but because of the way in which such huge amounts of money and time were being
invested. The very importance and cost of the TB program meant it was run with great care and intensity by the South African
government. Patients getting TB treatment were closely supervised by nurses — who often treated them like inert subjects in
a study. Doctors told patients what to do by reading off specially developed checklists. Even that business of watching patients
take pills carried a message: we don’t trust you. Often no one shared with the patients any details about how the drugs worked
or how they interacted with the disease. That information was left in the hands of health-care professionals. After all, it
was hard to imagine what an impoverished and half-literate dying South African really needed to know about how a TB drug functioned
in her body.