TB or Not TB: Or Least Not XDR-TB

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The Centers for Disease Control misdiagnosed runaway lawyer Andrew Speaker's type of tuberculosis. It's MDR-TB (multi-drug resistant) TB. That's good news for Speaker. Nevertheless, the CDC insists that it would have raised the same hullabaloo had it known that Speaker suffered from the less serious (though still quite serious) version of tuberculosis.

The World Health Organization recommends:

People known to have infectious TB must not travel by public air transportation until at least two weeks of adequate treatment have been completed. Patients with MDR-TB should not travel until they have been proved to be non-infectious (i.e. culture-negative).

Speaker was apparently culture-postive, so he should not have gotten on an airplane. On the other hand, if the CDC wants to quarantine people, suggesting to them that they charter a $140,000 private plane for a return flight seems like a counterproductive way to talk them into it. And there is some question whether or not CDC officials were clear about how contagious Speaker was.

Speaker is certainly no hero here, but the CDC's keystone cop antics during this episode are worrying too.

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  1. “On the other hand, if the CDC wants to quarantine people, suggesting to them that they charter a $140,000 private plane for a return flight seems like a counterproductive way to talk them into it.”

    That’s obviously ridiculous, but what alternative would you suggest? You don’t want him on a normal flight (with good reason), and I agree that a chartered flight is out of the question for most of us mortals.

    Seems like the best thing would be for him to have been treated in Prague, or earlier in his itinerary. I’m sure it would have disrupted his life, but likely not more than has been the case anyway. I have to admit that when it comes to things like incurable fatal diseases, I’d rather that the CDC err on ther side of caution- you can’ty expect them to get it right, but you can at least hope they will get it wrong in the way that is least likely to lead to disastrous consequences, and they seem to have done so here.

    At any rate, though I at first thought that Speaker might well be a dangerous, silly bastard, I am not so sure now. If he is to be believed, he was acting in accordance with his doctor’s orders.

    Just to get the obligatory dig in, in the US at least, these strains of TB are largely the result of having such a large inmate population… we all know that kids are walking vectors because we pack them into classrooms. Prisons are like kindergartens with a high percentage of IV drug using rapists.

  2. The worst case scenario is all the rage.

  3. The lawyer knew he should not have flown back. He did out of his own self interest and fear. Active TB is serious enough, and his was thought the worst. He is a lesson in what others will do when pandemics are possible. He flew to Canada, rented a car and came home, all without even a simple bandana mask. Damn those exposed, every man for himself.

    The government failed at every proactive measure. The health people didn’t take control despite having the power. The man acted deliberately. The family didn’t cooperate. Foreign cooperation failed. US border guard ignored order and knowing let him re-enter the country. CDC has now caught another error, they say.

    Lessons:
    Even an educated, wealthy, informed individual will act selfishly when faced with a world wide threat.

    The state will fail to use its power.

    The medical establishment will err.

    Chance will determine the outcome.

    Who is confident in the CDC now?
    Will government save us from a pandemic?
    Who believes the man will act in the best interest of the many?

  4. “Who is confident in the CDC now?”

    Note that Mr Bailey’s article appears on a website that cannot, after several years, manage a commenting system that works reliably. There’s something about group dynamics that makes people entirely incompetent. I don’t trust the CDC to do a damned thing. Got an alternative?

  5. If some writer wants to win a Pulitzer Prize,
    try solving the many mysteries of this story:

    that a daughter of a world CDC TB specialist
    would happen to marry a man with MDR-TB;

    that the initial diagnosis was even worse,
    that it was also somehow in error, for a month,

    that the wedding & diagnosis be simultaneous,
    with the one in Greece and the other in the US;

    that international travel would thicken the plot;
    and, too, was he told to not to fly, or NOT told?

    But he was told not to fly back to the US,
    and was put on an international no fly list,
    but flew to Canada, then drive into the US,
    yet was admitted by a guard at the border
    despite knowing the man was flagged;

    and that all this was simply coincidental, or not!

  6. Doesn’t scan.

  7. On the other hand, if the CDC wants to quarantine people, suggesting to them that they charter a $140,000 private plane for a return flight seems like a counterproductive way to talk them into it.

    Umm… wasn’t this basically the CDC saying “don’t come home, get treated over there” ?

  8. “The Centers for Disease Control misdiagnosed runaway lawyer patient Andrew Speaker’s type of tuberculosis.”

  9. Umm… wasn’t this basically the CDC saying “don’t come home, get treated over there” ?

    Maybe. OTOH, if the treatments were not available over there, then it was the CDC’s way of saying, “fuck you.”

    From Bailey’s links, it looks like drugs may be working to quell Speaker’s TB-style. Would he have had access to those drugs in Rome? I haven’t heard an answer to that. If he would not have had access to those drugs in Rome, then, once again, then it was the CDC’s way of saying: “You made a mistake, Flounder, you trusted us.”

    Hopefully, if Bailey chooses to dig a little deeper into this story, then some of Reason’s pharma contacts can tell him whether Speaker would have had access, in Rome, to the drugs he is now getting in the US. Inquiring minds, etc., etc.

  10. In other news . . .

    happy 4th of July!

  11. OTOH, if the treatments were not available over there, then it was the CDC’s way of saying, “fuck you.”

    And given a choice between Speaker dying of MDR-TB and any of the people that he knowingly exposed to a potentially fatal disease, that’s exactly the right thing to say.

    You. Do. Not. Sacrifice. Other. People. To. Save. Yourself.

    Every decent human being knows this. Speaker obviously does not. And I wonder about Dave W. (Also a lawyer, if I’m not mistaken. Hmmm.)

  12. As the patriotic staff and management of reason will be busy celebrating the greatest holiday in the history of the world, the birth of the USA, rather than posting stories, this should be the holiday open thread!

    Obligatory On-Topic Comment: The CDC could have arranged for the patent to be transported on a US or Allied military medical flight back to the USA. Perhaps their San Francisco values get in the way of working with the military, or it just never came to mind.

    Open Topic: I shall be celebrating the 4th by both attacking and defending an Indian reservation. Having a diverse background makes for strange alliances.

  13. Let’s not suggest that it was the CDC that did the initial testing. The CDC labs are not used for routine TB diagnostics for anyone including Fulton Co. The CDC rang the bells based on Fulton Co. DOH and then get the strain to reconfirm the susceptability testing results. They were only working one specimen from Speaker. Normally more than one culture is used and all suscept. results in some states have to confirmed by a second laboratory/test.

    But they just couldn’t wait the weeks that would take to let him roam Europe. Though I’m not suprised they boffed a bit on figuring out what to do with him when they did get ahold of him in Italy.

    Susceptability testing for these second/tertiary drugs is very difficult and the different methods produce slightly different results.

    When this hit the news yesterday they were initially implying that that MDR TB wasn’t dangerous or ‘the deadly form’! All TB disease can be deadly and MDR forms were a crazy problem in NYC in the 90’s killing hundreds of people (still is).

    The degree of infectiousness is also poorly understood by non-TB doc’s. His sputum didn’t have visible bacilli but since TB grew from his sputum, it was present, though in low amounts and hence still infectious but perhaps not highly so. The more TB in your spit, the higher degree of infect. though it’s a lot of qualitative calling rather than a definitive quantitative scale.

    And MDR TB, if not properly treated can become XDR very quickly. So Speaker is still far from out of the woods and still has a good chance of dying from the disease.

    Anyway, off to breakfast!

  14. Anyway, off to breakfast!

    Reminds me that I have not had pancakes in honor of Rachael Corrie in a while.

  15. And given a choice between Speaker dying of MDR-TB and any of the people that he knowingly exposed to a potentially fatal disease, that’s exactly the right thing to say.

    You. Do. Not. Sacrifice. Other. People. To. Save. Yourself.

    Every decent human being knows this. Speaker obviously does not. And I wonder about Dave W. (Also a lawyer, if I’m not mistaken. Hmmm.)

    I understand that he should not have flown commercial. I also understood what should have happened here. What should have happened:

    CDC: Speaker, don’t fly back to the US.

    Speaker: But I don’t think I can be treated in Rome and I will die.

    CDC: So?

    Speaker: So you said it was okay for me to come over here.

    CDC: You made a mistake, Flounder, you trusted us.

    Speaker: Why don’t you CDC guys fly me back.

    CDC: Gee that would cost money.

    Speaker: What would Jesus do?

    CDC: You know, you are right. We want to be the good guys here. We told you that it was okay to come over. Now we change our minds. Tell you what, we will fly you back on a special CDC flight tomorrow.

    Speaker: Now I don’t even feel like I have some kind of horrible choice to make. I accept your reasonable offer and will be sure to stay off commercial flights.

    RCD: Curses, foiled again. *drinks cold milk, bops hottie*

  16. As the patriotic staff and management of reason will be busy celebrating the greatest holiday in the history of the world, the birth of the USA, rather than posting stories, this should be the holiday open thread!

    Yes, holiday open thread! Do we have to do everything around here?

  17. Why is everyone complaining about the cost of chartering an airplane? After all, that’s the price on the free market….

    Obviously Speaker should have just waited until competition had made a lower-priced alternative available.

    After all, the free market solves everything, doesn’t it?

  18. Italy is a (mostly) first world country. Why shouldn’t he be able to get the drugs there? Or at the least, have them shipped there?

  19. Italy is a (mostly) first world country. Why shouldn’t he be able to get the drugs there? Or at the least, have them shipped there?

    I don’t know whether they would have let him or not. It is easy to imagine the potential problems he might have had:

    – insurance company would not cover

    – Italian authorities wouldn’t let him import

    – us authorities wouldn’t let them export

    – patent issues

    – local Italian doctors aren’t trained to administer the drug

    – regulations bing practice of Italian doctors

    I imagined that after telling him he could travel and then changing their mind, the CDC could have solved a lot of these problems or potential problems for patient Speaker. Thing is, from what I can tell, they weren’t working with Speaker.

    I mean in theory, speaker could have run for Prime Minister of Italy and simultaneously worked his way up to CEO of the company that controls the drugs. Then as PM / CEO, he could have decreed that he would get that drug in Rome. Back on planet Earth, his actual course of action, while wrong, is pretty understandable. The CDC’s course of action is also wrong, but much less understandable.

  20. The more I read about this case, the more reasonable Speaker appears to me.

    Open Topic: I shall be celebrating the 4th by both attacking and defending an Indian reservation.
    Que?

    I shall be celebrating California style, with beer ‘n margies. Happy 4th, everyone!

  21. The more I read about this case, the more reasonable Speaker appears to me.

    Sorry, I disagree.

    Even if he had oldtime everyday garden variety TB he should not have been globetrotting around Euroland.

    One of the reasons TB gets into these untreatable conditions is leaving it too long.

    They used to lock infected people up without recourse as recently as fifty years ago. Do we need to return to those days because of some selfabsorbed yuppie?

  22. The point is that even oldtime everyday garden variety TB is extremely contagious.

    Why anyone would think he had a right to expose people to it is beyond me.

  23. Grumpy, if you would otherwise have many options open to you on the market (including regular commercial flights) but the government restricts you from choosing most of those available options, then that is not a “free market.”

    But generally, yes — the free market does solve everything. EVERYTHING! And it makes me want to sing and dance! Tra la la la diddy da!

  24. The more I read about this case, the more reasonable Speaker appears to me.

    Except for the part where he knowingly and wilfully put other people at the risk of a rather prolonged and painful death.

    Right?

  25. Except for the part where he knowingly and wilfully put other people at the risk of a rather prolonged and painful death.

    I don’t want to defend patient Speaker too much, but he was getting some pretty mixed signals from the CDC. First they tell him it is okay to travel. Then they are more concerned, but not quite concerned enough to put him on a special CDC flight back to Atlanta or quarantine him.

    “Knowingly” and “willfully” definitely seems like the wrong words to use in the face of such mixed signals from the CDC.

    Furthermore, real lawyers don’t use the phrase “knowingly putting somebody at risk.” Rather, real lawyers say “acted recklessly” or “acted negligently” in contradistinction to situations where “knowledge” or “willfulness” are present and/or required for liability. To a lawyer’s ears, you are saying that Speaker willfully acted recklessly. C’mon, RCD, you are a lawyer. You should know this stuff.

  26. grumpy_realist: “After all, the free market solves everything, doesn’t it?”

    I hope that not many advocates of free markets believe that. As most realists, grumpy or not, acknowledge, many problems can only be partially solved- and that is an optimistic take on things if you ask me. The argument is that markets tend to find “better” partial solutions (what better means is best left as an exercise). The evidence suggests that this is so in many cases.

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