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As the world battles the deadly coronavirus, there is a lot we can learn from one of the great pandemics of recent centuries: tuberculosis.
Like the bug that has caused the newest global outbreak, TB is spread through the air. Every exhaled breath by a person with the disease can spread the tuberculosis bacteria to new individuals. TB is thought to have killed 1 billion people between 1800 and 2000. It attacks the human body more slowly than viral diseases like flu or COVID-19, but exacts a great toll. Untreated TB is a death sentence for 80 percent of those who fall ill.
Although TB still kills 4,000 people every day in poor countries, it largely disappeared in wealthy countries after the 1950s through a set of tried and tested strategies — which suggests important lessons for how to stop the newest plague.
Current efforts to battle COVID-19 focus largely on reducing transmission by quarantine and physical distancing and by providing hospital care for the severely ill. But as scientists discovered with TB, the secret is not to put the everyday life of the community on indefinite hold, but rather to make it progressively safer. The focus of stopping transmission and delivering care should not only be on hospitals, but also in the communities where people live and work: their homes, schools and workplaces. Using this approach, wealthy countries turned the airborne scourge of TB from the leading cause of death at the end of the 19th century to a tiny fraction of all infections only 60 years later.
How did public health agencies, municipalities and private partners do it? Aided by a flurry of diagnostic and treatment innovations in the early to mid-20th century, they stopped TB using a community-based strategy called "search, treat and prevent."
First they searched for contacts of known patients. In communities where TB was rampant, they went house-by-house looking for people who had the disease and were transmitting it to others. "Searching" meant giving thousands of people skin tests and chest X-rays, in many cases with mobile vans.
Then they treated the sick — first with food, rest and basic nursing care, and later with medicines. This was done in combination with social and financial support for those who were ill with TB. This freed people from the need to keep working to support themselves and their families, spreading the illness in the process. Finally, starting in the early 1960s, they stopped further spread of the microbe by giving preventive therapy to exposed individuals before they became sick.
In the U.S., all this was made possible through an infusion of resources from national, state and local governments and by voluntary contributions from organizations like the National Tuberculosis Association, as well as employers and labor unions.
The results were stunning: "Search, treat and prevent" helped the U.S. and other wealthy countries stop TB in its tracks. A disease which had been a plague on mankind since the beginning of the modern era was brought to heel in the period from the 1950s to the 1970s — fewer than 20 years.
The lesson for coronavirus? Community-focused mobilization using the "search, treat and prevent" approach could be transformative. Although physical distancing may indeed be necessary in the short term, its economic cost is devastating, particularly for those who cannot work from home or who work in industries that depend on social interaction. The dislocation caused by quarantines — the destruction of social bonds and livelihoods — may in the end be as harmful to health and well-being as the pandemic itself. Moreover, countries relaxing quarantines have seen transmission begin anew from carriers who are not showing symptoms.
So there is much reason to believe that physical distancing and quarantine alone will not stop the epidemic.
The announcement last Friday of a point-of-care test that can accurately diagnose the coronavirus in as little as five minutes is a game-changer. With such technology we can identify hot spots whose residents need to practice physical distancing, provide community-based care to those not sick enough to be in hospitals, and — when preventive medicines, new treatments and vaccines become available — deliver these tools to those who could benefit most.
After a few weeks of physical distancing, this approach would help to identify groups of individuals and even entire communities that could resume their regular economic and social life. Re-entry would require access to masks and other protective equipment for community members — as these items become more available — and more widespread application of tools like indirect UVC lamps in stores and closed work spaces. UVC light has been shown to kill tuberculosis, influenza, coronaviruses and other pathogens that linger in the air and on exposed surfaces in public spaces.
To implement this strategy we would need to give people access to free testing, treatment, medicines and the necessary resources to sustain themselves through any physical distancing. It would be carried out by neighborhood-based teams of professional and lay health workers trained to safely conduct screening, provide basic treatment at home, and give social and economic support to those in isolation. This is exactly what happened after 1963, when a wave of federal funding for the "approach to zero for TB" helped establish community-based health teams in every U.S. state and territory.
The organization and funding of these teams would vary in different national and local settings. In the U.S. during the 1960s and '70s, community-based TB interventions were overseen by municipal public health authorities with funding from federal, state and private sources.
Community-wide coronavirus teams would also, as health expert Dr. Joia Mukherjee has pointed out, employ thousands of people, helping to mitigate the economic impact of the pandemic.
A community-wide coronavirus strategy would require large-scale investment in manufacturing a variety of tests, personal protection equipment and UVC lighting, as well as rapid training and mobilization of community health teams. But given the potential contribution to restarting local economies put in limbo by the epidemic, the cost will be modest. We have entered a state of emergency that upends the logic of austerity that led to decades of public health cutbacks.
The federal coronavirus relief bill just signed by President Trump provides $500 million for patient tracking and data collection alone. States have also begun to open their coffers and are likely to make millions available to stop this epidemic. We have to ensure that these resources are spent on approaches that can help restore our daily lives and livelihoods.
The "search, treat and prevent" strategy that stopped TB in wealthy countries was never expanded to poor countries because of fear that it would be too difficult to do there. It would be a mistake to make this same decision with the coronavirus. This global pandemic has exposed the same truth as climate change: On an ecologically interconnected planet, piecemeal approaches are doomed. As soon as we have working models of this approach in the U.S., we should ensure that they are expanded to at-risk settings all over the world.
Using the full array of technological and programmatic tools at our disposal can help us bring the pandemic to a close with a minimum loss of life, while avoiding an economic crash that would throw millions of people around the world into poverty, with an equally devastating public health impact.
We need to lay a foundation that will ensure that when we leave our homes in weeks or months, we are better prepared and safer than when the outbreak began. The community-wide approach can ensure that we find the sick and begin the process of healing. And with the right resources, it can begin today.
Salmaan Keshavjee is a professor of global health and social medicine at Harvard Medical School and Director of the Harvard Medical School Center for Global Health Delivery. He is a physician at Boston's Brigham and Women's Hospital and senior TB specialist at the Boston-based nonprofit Partners In Health. He is a member of the Council on Foreign Relations. His twitter handle is @s_keshavjee.
Aaron Shakow is director of the Initiative on Healing and Humanity at the Harvard Medical School Center for Global Health Delivery and a research associate in the department of global health and social medicine. A historian by training, he focuses his research on the social and political history of epidemics and quarantine.
Tom Nicholson is executive director of Advance Access and Delivery, a North Carolina-based nonprofit committed to improving access to high-quality health care. He is also a research associate at Duke University's Sanford School of Public Policy in the Duke Center for International Development. He is a member of the board of directors of the Global Health Council.
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