Sunday, November 18, 2007

The restless sleep of TB in the arctic

A man walks into emerg. on a quiet Wednesday evening. His wife is with him and prods him towards the registration desk, he is reluctant. His face does not betray his age, but tells me he has spent much of his time working on the land. He moves with subtle economy and purpose. I notice that he is wearing beautiful kamiks, and wonder if his wife made these for him. The receptionist hands him a mask and he sits in the waiting room. A cough shakes through his chest and out his mouth, and his wife watches him with worry. Outside the snow is blowing hard, it's a bad night to make the walk to the hospital.

What brings you in tonight?
He is coughing blood, she says.
For how long?
Maybe 2 months.
Are you losing weight?
Some.
Sweats?
ii (ee)

He is wearing many layers of clothes, protection from the elements and from the gaunt figure that speaks volumes about his degree of weight loss. His chest has lots of coarse sounds except in the left upper lobe, where I hear no sounds at all. He coughs frothy red sputum into a cup as another cough rattles from within.

I think I know what the x-ray will show, what the sputum will reveal under the gaze of the microscope. It is treatable, curable even. He will be able to go hunting again. I think you have TB, I tell him, puvallunaqtuq. His face does not betray him, but his hand tightens over his wife's. There are many layers of meaning here.

Tuberculosis has been present in humans for thousands of years, it is ancient, evolved, and subtle. It stalks it's human prey like wolves on the edge of a caribou herd, preferring the old, the young, and the sick, but also taking what opportunity pushes into it's path. Unlike flamboyant young illnesses that kill at rates so rapid they at times limit their own spread TB is patient. It infects young healthy victims and when no opportunity exists it simply walls itself in, to lay latent, asleep, biding it's time and waiting for any subtle slip of the immune system, any opportunity to awake, to divide, and to spread. A TB death can be dramatic, as the infection erodes into the large blood vessels of the chest. More often however the process is slow, the resources of the victim consumed by the infection until the are exhausted, wasted and consumed by the disease (hence the name Consumption).

For most of history there have been no effective cure for TB, and it has been endemic to much of the world. Much of treatment has revolved around long term hospitalizations in sanatorium with programs designed to build the patients health and immune system, coaxing the Mycobacterium tuberculosis back into latency. In spite of sanatorium TB killed the young, the old, the famous and the infamous. In 1943 the antibiotic streptomycin was discovered and a new era of TB treatment, an era in which cure was possible, began.

In the 1950's and '60's Tuberculosis was endemic in the Inuit population. Like wolves circling the caribou it struck mainly at the edges, the old, the young and the sick. In the times of famine it broadened it's reach, and in many who seemed unaffected it lay quiet, biding it's time. The government of Canada instituted a program of screening and treatment for Inuit. The Canadian Coast Guard Vessel C.D. Howe cruised the arctic coastline bringing aboard those it encountered for chest x-rays. In practice those identified with TB were not allowed to leave the ship (for fear they would escape rather than submit to treatment), not allowed to say goodbye to families, and not allowed to undertake the difficult task of making arrangements for the families they were leaving behind. Gathered and transported to the south for hospitalization and treatment.

In spite of the often good intentions of hospitals to provide country food and a positive environment for patients the experience was often anything but. Many patients died in the south, and neither their bodies nor word of their deaths returned home. Treatment could take years, and among those who survived many lost their language, or drifted into new lives in the south. For those who returned home they sometimes found that their families, who didn't know if they were even alive, had moved on, spouses remarried, children grown. Like their language, skills necessary for living a difficult nomadic lifestyle had atrophied, unused for years.

I know what his chest x-ray will look like, I can imagine the cavity I will see in the left upper lobe. His face does not betray his emotions, but the tight grip on his wife's hand does. He is old enough that some of his own elders disappeared on the C.D. Howe, and some of his immediate family may have died, consumed by the disease. Canadians often think of Tuberculosis as a disease of elsewhere, confined to distant and remote regions of the globe. In Nunavut TB plods onwards at a rate an order of magnitude above the rest of Canada. In overcrowded houses there will be many family members who will need to be treated for latent TB infection. His own treatment will involve 14 days isolated in hospital and a further 12 months of treatment. It will involve the testing of all his contacts and and family, treating those with latent infection. He will recover, he will hunt again.

There are many layers of meaning here, the personal, the historical, and in the deepest layer there is an old and softly spoken story about a small bacterium that is as old and as evolved as human-kind. A story about a bacterium that has more patience than we will ever imagine, and that for unclear reasons has chosen this corner of the arctic as a place to rest, until conditions in the herd at large once again favor it's spread.


The patient presented in this story is fictional, but the flavor of the story is accurate. TB continues to be a significant issue here in Nunavut.

4 comments:

MedStudentGod (MSG) said...

That really sounds like a terrible disease up there. Not just because of the morbidity, but because of the lives destroyed in order to treat and contain.

Liana said...

Wow. This was a great post.... very informative.

I've seen lots of TB patients overseas... scrofula, TB spondylitis, TB urethritis, you name it. It's easy to forget though that it's still an issue here too.

Sharon said...

Hi,

Since 1980, Tuberculosis has skyrocketed from over 200,000 cases to over 500,000! This astonishing number is a sign that organizations, such as yours, are important now, more than ever. As I read through your website, it is clear that we share the same passion in fighting this horrible disease. Here at, Disease.com, we are dedicated to the prevention and treatment of diseases. If you could, please list us as a resource or host our social book mark button, it would be much appreciated. We may not physically heal the suffering, but lets support their cause.
If you need more information please email me back with the subject line as your URL.

Thank You,
Sharon Vegoe
Disease.com

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