Wellness Unmasked: “White Plague” Explained — Why Tuberculosis Cases Are Rising Again
3/31/202618 mincomplete
0:00This is an iHeart Podcast, Guaranteed Human.
0:08Welcome to Wellness and Mass.
0:10I'm Dr. Nicole Sapphire, and we're gonna talk about something that's a little funny this
0:14week because I got a couple of radio requests and usually I get an email
0:20or a text message or a phone call saying, hey, Dr.
0:23Sapphire, are you available to talk about this?
0:26And in the subject line, it said what they wanted to talk about.
0:30They're like, are you available to talk about the white plague?
0:33And I just found myself sitting there.
0:36I'm like, white plague? What the heck is the white plague?
0:39Am I really that out of touch with reality that there's a plague going around
0:43and I don't even know about it?
0:46Maybe you've seen these headlines, maybe you haven't.
0:48They're definitely out there and they sound dramatic.
0:52Certainly grabs attention. That's what these headlines are for.
0:55And yes, it's definitely a bit of a scare factor baked into that language.
1:01But good news, here's the reality.
1:03Okay, so first of all, they're not entirely wrong.
1:06There are cases of white plague going on about that around here.
1:11But white plague is not some new emergent bacteria, parasite virus that we don't know
1:18about. We're talking about tuberculosis.
1:21Apparently that's called the white plague.
1:23I had no idea. I'd actually never heard it before.
1:26Maybe you have. Maybe I'm the only one who's never heard that tuberculosis was called
1:31the white plague. I didn't learn that in medical school.
1:33I haven't seen it in the hospital.
1:34But, you know, maybe it's a thing.
1:37The truth is, when we talk about tuberculosis, cases are, in fact, they're actually rising.
1:43So since there are headlines out there about this, I thought maybe we'd talk about
1:47it a little bit. So after decades of steady decline, the United States has now
1:54seen multiple consecutive years of rising tuberculosis cases.
1:59In 2023 alone, there were nearly 10 ,000, 10 ,000 reported cases.
2:06Now that's a 15 % jump from the year prior, one of the largest increases
2:12really in recent years. And looking at the data, it suggests that, unfortunately, that wasn't
2:19a fluke, that the trend of rising cases, it's continuing.
2:24With over 10 ,000 cases in 2024, that was the highest levels we've seen in
2:30more than a decade. So it does seem that higher cases are here to stay,
2:36at least for right now.
2:37It's a trend. So yes, the White Plague.
2:40The headlines may sound sensational, but underneath that language, there's real public health story unfolding.
2:47So let's unpack that a bit today.
2:50That's what I want to talk about.
2:51In the 18th and 19th centuries, that's right, we're going to go way back, tuberculosis,
2:56it wasn't just a disease, it was a defining force of life and death.
3:01At its peak, tuberculosis accounted for up to 25 % of all deaths in Europe.
3:08One in four deaths because of TB in Europe.
3:11It was called then the White Plague.
3:13I guess I didn't read that in my history novels, but it was called the
3:17White Plague then because of how it made people look.
3:20They looked pale, gaunt, they were wasting away.
3:24You've heard the term consumption.
3:26That all came from that time.
3:29It came from how slowly it just consumed the body.
3:32This wasn't a fast illness.
3:34It was a slow decline, months, sometimes years.
3:37It's still that way today, by the way.
3:40It wasn't until 1882 that it was discovered the bacterium was responsible for it, a
3:49certain bacteria. It's called Mycobacterium tuberculosis.
3:53So when you hear TB or tuberculosis, it's caused by a bacteria.
3:59It's a very specific kind of bacteria.
4:01It's called an acid -fast bacteria.
4:03I learned all about this when I studied microbiology in undergraduate degree.
4:08It was kind of hard to isolate.
4:10It requires a very specific environment to grow.
4:13That's why it took a while to identify what it was.
4:16But they were able to prove back then that this was in fact an infectious
4:21disease. It wasn't a virus, but it was a bacteria.
4:24Remind you, this is before antibiotics.
4:26So bacterium were scary because they didn't have a way to treat them.
4:31Patients were isolated in santoriums.
4:35They literally took patients who were infected with this bacterium and just said, here you
4:40go. Go live in isolation because we have no way to rid you of this
4:45infection. So just go live and die out here, please.
4:49And don't give it to the rest of the community.
4:51People were sent there for months or even years.
4:54For most people, it wasn't necessarily a treatment.
4:57It was just a place to wait.
4:59Some recovered, many died. But even today, you kind of see some of that echoing
5:07of that history from over a century ago.
5:11I remember early in my training, I mean, we had TB isolation rooms.
5:16We still have rooms that we put patients in.
5:20And if they're suspected of having tuberculosis, negative pressure.
5:25mass required, limited contact, because, yeah, this is not something you want to come in
5:30contact with. It's not easily treated.
5:33It's not like, oh, I'm just going to have a five -day course of antibiotic
5:36and I'm going to rid myself of this.
5:38No, no, no. Treatment for tuberculosis, it's not like that.
5:42But, you know, it's just, it's interesting to see that these headlines, that these cases
5:47are increasing because, well, you know, when I was in training and early on in
5:51my career, we talked a lot about it.
5:53You don't hear much about it these days.
5:55You know, inside of these isolation room, it's usually a patient who's thin, not doing
6:02so well, coughing, they're exhausted, they probably haven't been feeling well for months.
6:08And so when I would see these patients and what struck me the most, it
6:13wasn't just the illness, it was the isolation, what we did to these people.
6:17It really took us back, you know, way before modern medicine is what it felt
6:23like. You know, meals left at the door, no visitors, care delivered at a distance.
6:30Does this sound familiar? It kind of reminds me of COVID.
6:33We did the same thing during COVID.
6:35COVID has kind of come and gone.
6:36We don't do the same thing anymore, but tuberculosis, we still do.
6:40We understand why. Tuberculosis, it's airborne, similar to COVID, similar to other infectious diseases like
6:48smallpox travels in the air, measles travels in the air, very contagious, because all you
6:54have to do is be in the general vicinity of someone who's positive.
6:59You breathe the air they're breathing and you have the potential to be infected.
7:03But the human side of that experience, you know, the separation, the stigma, I guess
7:09that hasn't really changed nearly as much as we think.
7:12But here's the part that we don't talk enough about.
7:16Tuberculosis, it didn't decline because of one singular breakthrough, one singular modern medicine.
7:25Sure, yes, antibiotics helped, but it really declined because of layered public health measures.
7:31First and foremost, yes, antibiotics, an amazing discovery, obviously saves a lot of lives.
7:38It's also wreaked a lot of havoc.
7:40We've talked about what it's done to our gut health and antibiotic resistance, bacteria and
7:45stuff, but that's an entirely different episode.
7:49Talking about tuberculosis, the layered public health measures that have led to the decline of
7:55cases, antibiotics for sure, improving of just housing and nutrition, screening programs, making sure people
8:02who are higher risk, we are able to ask them questions about their symptoms, their
8:07lifestyle and detect early cases, contact tracing, isolation protocols, and really just directly observed therapy
8:16to ensure that patients are completing their treatment.
8:19All of these systems, they worked.
8:21In the United States, tuberculosis cases fell dramatically over decades from tens of thousands every
8:29single year to under 10 ,000.
8:32And globally, TB efforts since 2000, so about a quarter century, have saved tens of
8:39millions of lives. This is one of the greatest public health successes stories that we
8:44rarely highlight. But here's the concern.
8:47We're now seeing, I mean, mind you, it's, you know, it's slight, but we are
8:53seeing a reversal of some of that progress.
8:55In the United States, cases have been rising since 2021.
9:00So let's talk about that for a second.
9:03You had a decrease of like flu in 2020, a decrease in most other public
9:10health infections early 2020, 2021, because people were kind of sheltering in place because of
9:17COVID. But all of a sudden, we started seeing tuberculosis cases rising.
9:23There has been a 15 % increase in 2023 alone.
9:28And now we're up, as I mentioned, 10 ,000 cases annually.
9:32And now if you look around here in the United States, there are about 13
9:36million people who have what's called latent TB, meaning they have tuberculosis, they may not
9:43be symptomatic, they may not be active.
9:45It's not an active infection, but it's still kind of brewing inside of them.
9:49And, you know, during COVID, to be honest, we lost momentum when it came to
9:53tuberculosis. We had fewer screenings, we had delayed diagnosis, people were interrupted in their treatments.
9:59And let's be honest, people only cared about COVID during that time.
10:03They didn't care about cancer, they didn't care about heart attacks, and they certainly didn't
10:07care about tuberculosis. But let's talk about what else happened during that time.
10:13Now, during that time, early on in the pandemic, people just stopped moving altogether across
10:19the globe. You didn't have a lot of travel, there wasn't a lot of migratory
10:23efforts whatsoever, because, well, there are travel restrictions, but people were really just staying put.
10:29In the United States specifically, in about 2021, you started seeing a lot more traffic
10:37happening at the southwest border.
10:40In most TB cases, the reality is occur in individuals who are born outside of
10:45the country who now migrate into the United States.
10:49This isn't about blame. I'm not trying to point fingers.
10:52This is a lot of things, but it's only true.
10:52It's not a lot of times when you are in the United States.
10:52This is a lot of times when you are in the United States.
10:52I'm not trying to point fingers.
10:52It's a lot of times when you are in the United States.
10:52Thank you. anybody. I'm just talking about facts when it comes to epidemiology.
10:56That's what happens. TB is more common in certain regions globally.
11:00Many individuals are exposed earlier in life and the infection, it truly can just remain
11:06in their system for years, decades.
11:09They may not even have symptoms.
11:12That's latent TB like I talked about.
11:15Later on, as the immune system weakens, it happens to all of us as we
11:20get older or another illness develops and you take some sort of medication, whatever it
11:27is. For whatever reason, your immunity decreases during time.
11:32At that point, the infection can become active.
11:36So this bacteria is kind of like living inside of you, but they're silent, they're
11:41sneaky. It's just waiting for your immunity to drop.
11:44For whatever reason, it can drop.
11:46Maybe you're not eating enough fruits and vegetables.
11:49Maybe you have the flu one year and it kind of just wipes you out.
11:53Maybe you're taking biologics for an autoimmune disease.
11:56Whatever happens, all of a sudden your immune system decreases, your ability to fight off
12:03infections. You have this latent or sneaky bacterium, tuberculosis, just hanging out, waiting, waiting for
12:11the right opportunity to activate.
12:14And so that's what happened.
12:16And so once the infection becomes active, it can be detrimental.
12:21And importantly, many cases occur years, many years after the arrival, meaning after the person
12:29has been infected, highlighting that this is a latent disease management issue.
12:35It's not just simply border control because people who are coming across the border, if
12:39you're screening them solely for symptoms, the majority of people who are crossing probably don't
12:45have active tuberculosis because active tuberculosis makes you very sick.
12:49And you probably can't make that arduous journey across the southwest border in the desert
12:55and with all the other obstacles you face.
12:58Doesn't mean that they don't have latent tuberculosis, that once they come into the United
13:03States, whether they acclimate or don't, whatever it is, it can then activate.
13:08Now, the United States, they already have pre -immigration screening, targeted testing, and very small
13:16pockets of public health follow -up, but huge gaps remain.
13:20As I mentioned, latent TB, it's often silent.
13:24The treatment requires months of adherence.
13:27So even if you identify someone who has either latent or active TB, it's not
13:34that they're going to take that five or seven day course of antibiotics.
13:37Oftentimes, they need to be on it for, I mean, really like six months.
13:42They need to be actively monitored.
13:44So the real focus at the border and anywhere else should be better screening, stronger
13:51follow -up, and ensuring treatment completion because that's what's important.
13:56It's one thing to diagnose it.
13:58It's one thing to give someone a prescription, but it's another thing to make sure
14:02that they have completed that entire course and it has done the trick and has
14:06gotten rid of the infection.
14:08Because infectious disease, they don't respect borders, but strong public health systems can certainly contain
14:15them. So the path forward, it's not really that complicated, but it does require commitment.
14:22First and foremost, it truly does rely on early detection, expands screening in high -risk
14:29populations, and that includes anyone who is crossing our borders coming to the United States
14:35because there are significantly higher rates of latent and active TB everywhere else other than
14:42our country. You also see them in prison populations, in homeless shelters, anywhere where you
14:48have people congregating, and it's important to be screening these individuals.
14:53Second, we need to be treating latent TB.
14:57This is where most cases originate here in the United States.
15:01Just because someone doesn't have symptoms, that doesn't mean we don't treat them.
15:05We need to be doing blood tests.
15:07We need to be doing x -rays.
15:09We need to be doing everything we possibly can to ensuring someone doesn't just have
15:14latent TB that will be reactivated later in their life, and then they're able to
15:20spread it. And as I mentioned, ensuring treatment completion, but also making sure that the
15:25treatment is accessible and affordable is equally vital.
15:30But making sure someone completes their treatment, whether it is a weekly check -in, whether
15:36there is some sort of incentive to making sure that they complete it, whatever it
15:40needs to be, that's really important.
15:43And we have to reinvest in our public health infrastructure.
15:46We see a lot of cuts when it comes to public health, and I understand
15:51that there is a lot of hostility when it comes to, you know, our public
15:55health infrastructure ever since COVID specifically, but the reality is this is the health of
16:00the nation that we're talking about.
16:02I'm talking about contact tracing, community outreach, outreach, and any sort of follow -up systems,
16:08public health nurses, social workers, and those who are really making sure that people who
16:13have been identified as high risk for TB or even having TB, that they are
16:18followed continuously. And We are ensuring that not only they're healthy, they're family healthy, but
16:24everyone around them is also healthy.
16:27Obviously, we wanna talk about global investments.
16:31You have the World Health Organization and some other nonprofits, Doctors Without Borders and so
16:37forth who are in charge of that.
16:39I'm not really gonna get into the weeds of that, but it is more than
16:42just a local problem. As I mentioned, the majority of cases here in the United
16:47States originate in people who came from elsewhere in the world.
16:51So it would behoove us to make sure that we are working with our global
16:56partners to decrease tuberculosis cases.
17:00And I guess, again, tuberculosis was once the quote -unquote white plague.
17:05White plague does sound scary.
17:08It was a nice little history lesson for myself to learn this new verbiage.
17:12The reality is I don't wanna call it a plague today because that makes me
17:16think of those plague masks and a horrible time in our global history when it
17:21comes to public health. But the reality is tuberculosis is alive and well.
17:26It is a disease that we associate with history, but if we look at data,
17:30walk through a hospital isolation unit, we just zoom out globally, and you'll realize it
17:37certainly has not been eliminated.
17:39Yes, it's been controlled, controlled, but the control requires vigilance because in medicine, success isn't
17:46permanent. It is maintained, and it's only maintained if we keep up on our public
17:52health efforts. We have lagged a little bit when it comes to tuberculosis, so we
17:57need to get back to it.
17:59Thank you so much for joining me on Wellness Unmasse.
18:02I'm Dr. Nicole Sapphire. Be sure to listen to Wellness Unmasse on iHeartRadio, Apple Podcasts,
18:07and wherever you get your podcasts.
18:09And I'll see you next time.