World TB Day 2017 (3) - lighting up the world in red ('dream, mirage or nemesis' and the 'McKeown Thesis')

As usual, March 24th was World TB Day and this year the Stop TB Partnership literally wanted to see the world ‘lit up’ for TB – meaning that they wanted to see as many iconic buildings around the world illuminated in red during the evening hours.

Well, how could we (as one of STBP’s many partners) not respond to such a call? So we shortlisted a few iconic buildings in our neighbourhood here in the UK’s West Midlands, and we approached them all accordingly. We’ll spare you the list of those who either refused, wanted ridiculous sums of money, or didn’t bother responding at all, but we can record with real gratitude that one did respond to our approaches positively – and it was our local University. (This was especially meaningful to us because two of our seven trustees happen to be alumnis but there are other reasons as well which we’ll explain below).

The university’s clock-tower (affectionately known as ‘Old Joe’) is the highest free-standing clock-tower in the world. It’s also over a hundred years old, meaning that when it was originally built there was a lot of mycobacterium tuberculosis being coughed up in the streets and buildings of this city (the so-called ‘workshop of the world’ that was at the heart of the industrial revolution).

                          'Old Joe'

                          'Old Joe'

March 24th is commemorated because it was the day in 1882 when the TB bacterium was first identified by Robert Koch in Berlin. Germany’s industrial revolution had followed close behind the UK’s and levels of TB had followed suit. In the course of his famous presentation Koch reckoned that one in seven deaths in industrialising Europe at the time were down to TB.

Birmingham University, by the way, is currently actively investigating new treatments for anti-microbial resistant disease (about a third of which currently is tuberculosis) – so we knew that we had a neat convergence of interests at hand. But we were also aware of another connection that made the idea of Old Joe being lit up in red on World TB Day something to be truly relished – this related to Professor Thomas McKeown who was professor of social medicine at the university from 1945 until his retirement in 1977. Amongst many other contributions he made tothe field he is particularly remembered for a controversial lecture he (rather provocatively) titled The Role of Modern Medicine: Dream, Mirage or Nemesis. The reason we identified him in connection with ‘Old Joe’ was this: the thesis that the professor developed through his professional years (and which he specifically discussed in this famous lecture) tells us an awful lot about TB - not just about TB back in 1882 when Koch identified the bacillus, nor when ‘Old Joe’ was constructed brick-by-brick by labourers who would have been more than familiar with the disease, nor even about post-war TB in the UK - but about the global situation of TB today.

In fact we think that Professor McKeown would have been pleased to see the clock-tower lit up in red on World TB Day, and might even be identifying the same important connections that we do in the event.

The ‘McKeown Thesis’ (as it became known) proposed some fresh theories as to why there had been such a significant population increase in Europe beginning in the 19th century. Some of his ideas have been challenged and some endorsed since, but one of his theories still remains largely undisputed (although it’s popularly ignored). This was that ‘curative measures’ actually played little part on their own in mortality decline in England and Wales, not only prior to the mid-20th century but also well into its second half. And by ‘curative measures’ he meant drugs and vaccinations.

It should be noted that McKeown was far from blind to the social misery that had accompanied industrialisation, not least in his adopted Birmingham. Such misery included grinding poverty, overcrowded slum housing, appalling working conditions and foul drinking water – and yet despite such Dickensian conditions according to all available records the national population had significantly increased. This seemed illogical given the appalling conditions people were living and working in but, after ruling out any other plausible explanation, he figured out why it must have happened. He concluded that it was fundamentally because of one of the few virtues of early industrialisation – because of farm machinery which (at the same time as it was effectively renedering most of the rural labour-force redundant and driving them from the countryside to the burgeoning cities in search of work) was producing more and better food than had ever been previously seen or (more importantly) widely consumed.

This is what had provided the primary impact on mortality rates in the mid 19th century – it was improved immune systems arising from better nutrition which in turn were protecting the population from the effects of simple infections that normally could easily become complcated and lead to death - and when these benefits in immune systems were followed by better housing, clean water supplies, proper sewage and sanitation systems (along with legislation that improved working conditions), the curve of mortality was driven downwards dramatically.

What McKeown in particular proved from the available data was that mortality from infectious diseases was already significantly lower BEFORE any effective treatments or vaccinations were introduced into medical practice (and by ‘significantly lower’ we're relatively speaking meaning very low indeed). What this suggested to the professor (very much contrary to conventional wisdom) was that much of the medical advancement of the 20th century actually had an insignificant impact either on mortality or population growth – most particularly in relation to infectious disease.

He particularly used tuberculosis as an example of this phenomenon, quoting the falling TB mortality in England and Wales beginning in the mid-19th century. Back in 1850 it was at frightening levels, but this was still a century before the first effective drugs were developed and introduced, and 120 years before the vaccine was rolled out. The following graph illustrates what happened:

In fact by the time that the first drugs arrived (something which had been dreamed about by physicians for centuries) nearly 80% of the mortality rate was already historic. It’s been calculated in fact that TB drugs and the BCG vaccination together may have contributed as little as 3.2% to the massive mortality reduction from TB in England and Wales since the 19th century.

So what does this imply for tuberculosis today – or rather (in the glowing red light of ‘Old Joe’ on March 24th) what might the late Professor be telling the new Director General of the WHO today (he had been, after all, a consultant to the Organisation in the decades prior to it declaring TB to be a Global Emergency in 1993). Well, as the late Professor Stephen Lawn also pointed out, it means that if we’re serious about ending this monumental pandemic we actually need to eradicate global poverty, clear the slums, and house and feed the poorer people of our world much better – and then the drugs can clear up what’s left of the disease and the job will be done. At least that’s what the history of TB in the industrialised world tells us very loud and clear according to the McKeown Thesis.

We should add that we’re also sure that he wouldn’t for a second suggest that we should let up on the search for new and better treatments or for a better vaccine. We suspect, however, that he would be advising the DG that we shouldn’t fool ourselves into expecting that the results of such heroic efforts will make the impression we’d logically hope for. What was the title of his lecture, after all? 'Dream, Mirage or Nemesis...'

Well let’s never stop dreaming, but let’s also never stop working for a fairer world if we seriously intend to end the scourge of tuberculosis.

(‘Old Joe’ was in good company on March 24th, by the way. Sadly there was only one other building in the UK that got lit up [The Gateshead Millennium Bridge in Newcastle] but elsewhere there were some spectacular buildings or locations: the Statue of Christ the Redeemer in Rio de Janeiro, the Inca Temple of the Sun in Cuzco Peru, the Jet d’Eau in Geneva, the Niagara Falls in Canada, the Palacio de Cibeles in Madrid, the Terminal Tower in Cleveland Ohio and the Mazar-e-Quaid national mausoleum in Karachi amongst others. So thank you so much, Birmingham University, for being part of this global light show!)