---
description: >-
  Tuberculosis reflects societal structures, and tuberculosis control reflects
  the competence of government.
---

# Tuberculosis

Forgetting is the key challenge in tuberculosis control. Political leaders forget the poor and disenfranchised, who are most likely to contract and die of tuberculosis. Health leaders forget simple, low-technology interventions and therefore neglect the core work of treatment observation, field supervision, and cohort monitoring and evaluation. Patients forget how sick they were and may stop medications when symptoms subside.

Dr. Frieden sounded the alarm on the emergence of drug resistant tuberculosis. For more than a decade following this, Dr. Frieden led investigation and control of tuberculosis, first in New York City, then, in support of national and state governments, in India.

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## Featured article

#### **Frieden TR**, Fujiwara PI, Washko RM, Hamburg MA. [Tuberculosis in New York City — turning the tide](https://www.nejm.org/doi/full/10.1056/NEJM199507273330406).  New Engl J Med 1995;333:229-233.

![Frieden TR et al. Tuberculosis in New York City: turning the tide.  New Engl J Med 1995;333:229-233.](https://724596002-files.gitbook.io/~/files/v0/b/gitbook-legacy-files/o/assets%2F-MM_NcG2xx568SeAPre2%2F-MOOttst4xML24TZr305%2F-MOOv36StbmnqemKX53-%2FNYC%20TB%20Control.png?alt=media\&token=8973fd8e-6036-4554-82f3-28fc748329c0)

In New York City, Dr. Frieden documented explosive spread of multidrug-resistant tuberculosis in hospitals and elsewhere. In a [seminal article](https://www.nejm.org/doi/10.1056/NEJM199302253280801?url_ver=Z39.88-2003\&rfr_id=ori:rid:crossref.org\&rfr_dat=cr_pub%20%200pubmed), he and colleagues described the citywide emergence of drug resistant tuberculosis. This study led directly to a massive increase in city, state, and federal resources for and commitment to the control of tuberculosis. Dr. Frieden also conducted one of the first [molecular epidemiologic studies](https://www.sciencedirect.com/science/article/abs/pii/S0962847996901124?via%3Dihub) of tuberculosis ever done, documenting the importance of spread in hospitals and of laboratory contamination.\


### Interventional Epidemiology

Dr. Frieden coined the term, “Interventional Epidemiology,” and emphasizes the importance of using data to drive progress protecting health. In New York City, he led efforts that rapidly stopped the largest outbreak of multidrug-resistant tuberculosis ever to occur in the United States, and [drove tuberculosis case rates down](https://www.nejm.org/doi/full/10.1056/nejm199507273330406) with a program that became a national and international model. Dr. Frieden has consistently emphasized the importance of public health [tuberculosis clinics](https://www.atsjournals.org/doi/pdf/10.1164/ajrccm.150.4.7921458), of [patient-centered services](https://www.ingentaconnect.com/content/iuatld/ijtld/2002/00000006/00000005/art00002;jsessionid=4i2envavv8t2i.x-ic-live-03), and of recognizing and addressing the [need for social change](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615199/pdf/amjph00462-0011.pdf).&#x20;

In addition to documenting the spread of multidrug-resistant tuberculosis, Dr. Frieden led an [extensive review of how these organisms spread and what treatment is effective](https://jamanetwork.com/journals/jama/article-abstract/409561).\* Learning from [the legendary Dr. Karel Styblo](https://en.wikipedia.org/wiki/Karel_Styblo), Dr. Frieden also emphasized the importance of [accountability for the outcomes](https://pubmed.ncbi.nlm.nih.gov/17044207/) \[REPRINT] of every patient.

Dr. Frieden then moved to India, where he supported the national and state programs to [implement a large program that substantially improved](https://www.nejm.org/doi/10.1056/NEJMsa020098?url_ver=Z39.88-2003\&rfr_id=ori:rid:crossref.org\&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov) detection, treatment, and monitoring of tuberculosis. One important component of this progress was [deploying national consultants](https://pubmed.ncbi.nlm.nih.gov/12971666/)\* to support district progress. Dr. Frieden also emphasized the importance of a rigorous assessment of how and [to what extent](https://watermark.silverchair.com/310894.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAApwwggKYBgkqhkiG9w0BBwagggKJMIIChQIBADCCAn4GCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMzIuFQOttR-3ZQKCuAgEQgIICT2zJ4QMUuWzplP3v8-QPn6NETAwRGiTA2FSSU89ooZ_Brvh0xcdy1WX2ZAjz61lsB0pFRQN_o4v0-1WES81sKWitl4kPQAF598LPT38wvmYoLbj5nvQbdM1SUuRpLdk8JWt4rMp1_e6MhGkLsXUAlTHRw0hA6DcFgZ8E9jyBPVjKtyWDhCRYCbiFnFSmzV1U8QvrvNgpfopvWReMnTuyRkgKuHPQMm-zLQbidLIc7ubR3quFamshUojEsVOF5I_XBOkpBK1RZmrUDxGPBsXpB9WM7TSdUGN6QGfQSjUOfR40qU7aaHqZs2dnByW5b5j_6edI9m9hALhdTGFDTY1QhrmNe3r_DsrS01-re2KZv3bDNIma76Ofiw_fnH-wul9YlyANdAjvOQ_c4ay6_86zwAvaApI9nmQM9TiAXVc2b78g7v-qQ4BkuIWJPPpQezC1hAe1aA-fqnuk0shpZAnr4GVw-PmjH8amTQaLvCCjyKqAPCKJk2tHLGWM3CDlTp9Ljt7yfHGjEz0N73Zvrdz-6nshH2P4zhGPcxntwEvj_0dJKuUJklyGVS-jFgg1I9srantOGEjbUx5NDEh7OLHXe6FG1PoqYfw0BYRDgABwm3o-KObY2_skzXy8div0r9nwiMvxI_h0MV45rRu70kdQjC74yXLSzP6RHNPtbk4tIReHHUo0gmQDg4R0RlGbvBL6MwBAMMWSIP364x3LXtRX2w7RWYwXJbSZ8EZGhRT2leFcAUo23xoDuVEClsm4XwNoH5_rSbMNMt3wBrW1nSPh3w) tuberculosis could be controlled, depending both on the epidemiological context and program performance. Working with the legendary Tuberculosis Research Center - now the National Institute for Research on Tuberculosis of the Indian  Council of Medical Research, the team in India implemented a Model DOTS Programme and documented [rapid decline in prevalence of pulmonary tuberculosis](https://pubmed.ncbi.nlm.nih.gov/18647451/).\* The team also showed that it was possible to increase case detection through a system of active monitoring of private laboratories, in a [public-private partnership](https://www.ingentaconnect.com/content/iuatld/ijtld/2005/00000009/00000008/art00009).\*&#x20;

As he was preparing to leave India after five years working there on secondment from the United States Centers for Disease Control and Prevention to the World Health Organization (WHO), WHO asked him to edit a class textbook on tuberculosis. Dr. Frieden completed this work in 2001; WHO published it in 2004, and it remains [available online](https://apps.who.int/iris/bitstream/handle/10665/42701/9241546034.pdf;jsessionid=60B3470BF7C0D50DF102109333E49B70?sequence=1) and through WHO.

More recently, Dr. Frieden and colleagues [reviewed areas where tuberculosis detection, treatment and monitoring have gone off course globally](https://researchonline.lshtm.ac.uk/id/eprint/2017858/1/Global%20Tuberculosis_GOLD%20VoR.pdf), concluding:

“Forgetting is the key challenge in tuberculosis control. Political leaders forget the poor and disenfranchised, who are most likely to contract and die of tuberculosis. Health leaders forget simple, low-technology interventions and therefore neglect the core work of treatment observation, field supervision, and cohort monitoring and evaluation. Patients forget how sick they were and may stop medications when symptoms subside.

The hallmark of tuberculosis is persistence—the persistence of M tuberculosis for life in most infected people and persistence of reproducing bacilli during the initial weeks of treatment. This must be matched by persistence with basic tuberculosis control principles, not just in planning but in actual implementation. Innovation in tuberculosis control programs is crucial, and new technology can and should be appropriately used, but must accompany effective core public health practice.”

Dr. Frieden has also emphasized the [many lessons that tuberculosis control has for public health](https://pubmed.ncbi.nlm.nih.gov/19335945/), concluding that, “By implementing evidence-based practices, ensuring operational excellence, using information systems that facilitate accountability and evaluation, and obtaining and maintaining political support, we can address the public health challenges of the twenty-first century.”&#x20;
