“ Medical education does not exist to provide students with a way of making a living but to ensure

1. “Medical education does not exist to provide students with a way of making a living but to ensure the health of the community” Rudolf Virchow Mid 1800s

2. Tuberculosis has been killing millions for centuries

3. Symptoms of untreated active TB Persistent cough and Low grade-fever Difficultyin breathing Night sweats Blood in sputum Cambodian TB patient Severe weight loss Picture: World Lung Foundation

4. TB is an ancient human disease! Recent evidence supports a diagnosis of TB in this 500,000 year old Homo erectus Bone lesions indicative of TB Credit: Marsha Miller, the University of Texas at Austin

5. TB is an ancient human disease! TB spinal lesions have also been found in Egyptian mummies

6. It is estimated that from 1700-1900, TB killed 1 billion people. The annual death rate in the late 1800s was 7 million. TB Ward, Ellis Island Waverly Hills Tuberculosis Sanatorium. Louisville KT 1926 "Forgotten Ellis Island,” photographer Stephen Wilkes

7. After urbanization up to 25% of all European deaths in the 1800’s may have resulted from TB TB Ward, Ellis Island http://www.birdchildsandgoldsmith.com/acatalog/slums.gif

8. The famous and the infamous died of TB Anton Chekhov John Keats Frederic Chopin Emily Bronte Simon Bolivar Henry Thoreau

9. The famous and the infamous died of TB along with countless millions known only to their families George Orwell Eleanor Roosevelt DH Lawrence Franz Kafka Eugene O’Neill

10. In 1900 TB was still the second leading cause of death in the US CDC

11. Now infectious diseases are much less prominent as causes of death and TB has dropped off the list CDC

12. In the early to mid 1900s TB remained a major public health challenge in the US "Prevent Disease: Careless Spitting, Coughing, Sneezing, Spread Influenza and Tuberculosis." Rensselaer County Tuberculosis Association (Troy, N.Y.), [ca. 1925] "'Stamp' Out Tuberculosis: Buy Christmas Seals." National Tuberculosis Association, 1924. American Red Cross. "The Next to Go: Fight Tuberculosis." [American Red Cross], 1919.

13. In the US TB is now an almost forgotten disease US TB deaths in 2009: 547 CDC

14. In the US TB is now an almost forgotten disease In 2009 US TB deaths: 547 US Influenza deaths: 2125 (90% age >60 years) US deaths due to dog bites: 30 CDC

15. But not in the developing world! TB KILLS 1.7 MILLION PEOPLE EVERY YEAR OVER 4600 EVERY DAY ONE PERSON EVERY 21 SECONDS Stats from WHO

16. TB is present world-wide but Incidence rates differ dramatically CDC

17. For this Peruvian family mourning a child dead to TB the disease is certainly not forgotten Partners in Health and Harvard Medical School Dept. of Social Medicine Program in Infectious Disease and Social Change http://www.hms.harvard.edu/news/releases/family_cemetery.html

18. Two billion people --one third of the world’s population-- are infected with the bacteria that causes TB World Lung Foundation (2008)

19. Worldwide TB causes: 5% of all deaths ~10% of all adult deaths Morocco India China South Africa Stats:NIAID/NIH Pix: World Lung Foundation

20. Left untreated, a person with active TB will infect 10-15 other people per year World Lung Foundation (2008) and http://pathport.vbi.vt.edu/pathinfo/pathogens/Tuberculosis_2.html

21. Left untreated, a person with active TB will infect 10-15 other people per year new infections occur at a rate of one per second! World Lung Foundation (2008) and http://pathport.vbi.vt.edu/pathinfo/pathogens/Tuberculosis_2.html

22. In most cases TB starts as an infection of the lungs = pulmonary TB http://library.med.utah.edu/WebPath/TUTORIAL/DRUG/DRUG022.html

23. X-rays used to be the primary means of diagnosis http://library.med.utah.edu/WebPath/TUTORIAL/DRUG/DRUG022.html

24. Now TB exposure is diagnosed by a skin test

25. A positive test result simply means you have been exposed to TB* at some point and have developed antibodies to it *=Active case Previously “cured” Inactive case Vaccinated with BCG

26. The next step is a sputum culture

27. The next frontier: DNA testing to identify different strains of TB and assess drug resistance Dbtechno.com

28. The next frontier: DNA testing to identify different strains of TB and assess drug resistance July 2008: WHO unveils $26 million program to create labs in poor nations that can do DNA tests Cost: $5 per test Time frame: 24 hours Rather than weeks to months!

29. However, the TB bacterium can also Infect many other organs, causing distinct “diseases http://library.med.utah.edu/WebPath/TUTORIAL/DRUG/DRUG022.html

30. However, the TB bacterium can also Infect many other organs, causing distinct “diseases Renal TB www.vetmed.wsu.edu

31. However, the TB bacterium can also Infect many other organs, causing distinct “diseases Lupus vulgaris Renal TB http://www.ecureme.com/atlas/data/Tuberculosis_of_Skin550_ab.htm

32. TB infecting the spine Pott’s disease = tuberculous spondylitis Credit: Dr Laughlin Dawes www3.shropshire-cc.gov.uk/. ../med/med_i03.htm

33. “Miliary TB” is disseminated throughout the body Here it is presenting in the eye www.aippg.net/forum/ viewtopic.php?t=11673

34. Scrofula: TB of the lymph nodes of neck King Henry IV of France touching sufferers of scrofula. André de Laurens, 1609

35. As late as the 1800s, causes and cures of TB remained mysterious www.nlm.nih.gov

36. TB sanitoria were built all around the US www.umdnj.edu/librweb

37. This may seem like ancient history to you Waverly Hills Tuberculosis Sanatorium. Louisville KT 1926 housed over 400 patients, from infants to adults. Waverly Hills closed in 1961 library.louisville.edu

38. But they remained in operation until after your professor was born Waverly Hills Tuberculosis Sanatorium. Louisville KT 1926 housed over 400 patients, from infants to adults. Waverly Hills closed in 1961 library.louisville.edu

39. Gravely Building on the other side of the hospital, torn down in 2010, was a TB sanitorium www.med.unc.edu