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Tuberculosis in Ugandan immigrants


Tuberculosis: early treatments and cases of resistance
Harold Lambert Physician
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There was still a lot of widespread pulmonary tubercle, and there was the beginning of anti-tuberculosis treatment, but it was still at the stage where there wasn't enough to prevent drug resistance and it was a big element on the chest department at UCH when I was a student, and still a big element when I was the registrar some years later so it was, it was big all right.

[Q] And presumably at that stage people weren't sure how long you had to treat for?

Oh, no idea. No idea.

[Q] So that actually small, short treatments were given and then resistance emerged and everybody was... how... was that handled?

Well that... that was really in a way the first... this was science, it really was. Almost the very first controlled clinical trial was the Medical Research Council's trials of streptomycin in tuberculosis. Streptomycin had been discovered by a soil biochemist, Waksman, who'd gone from the Ukraine, I think, to New Jersey, and he looked at all these soil samples and that was really, yeah, pretty well almost the beginning of... antibiotics, not quite. And the thing was what did it do? It killed the bug, nasty drug, as you know. And they did trials of streptomycin in pulmonary tuberculosis and also in tuberculosis and meningitis, which I was involved in later in Sheffield at the children's hospital and... and they found that it... it was amazing, it was, you know, people who had been dying, livening, getting awake, their sputum becoming negative, walking around the ward, absolute, really miracle and then a couple of months later started getting ill again, and then dying. And the reason was that the germ had become resistant to the streptomycin in quite a short time, six weeks, two months, three months. And, this was only alleviated when PAS, a horrible drug as you know, para-aminosalicylic-acid, came in in about 1949 or something, and then the big change was isoniazid which I think was 1952 because that was an extremely powerful drug, given by mouth, very non-toxic and if you gave two or three drugs - I don't think I'll go into the mechanism here particularly - but if you gave two or three drugs it prevented resistance developing and from then on the MRC did a classic series of trials over 30 years in many, many countries, which really solved the problem of how to treat tuberculosis. And to me one of the real tragedies of the last decade or so is that we know exactly how to treat this disease and it's running rampant because people... there are various factors, some doctor things and some patient things, which have led to widespread resistance, which is much, much more difficult to treat and yet... you see, I don't think we know how to treat, how long to treat a lot of illnesses, a lot of infections and, you know, I wrote this paper, I gave it to you, called Don't Keep Taking the Tablets because it was an iconoclastic assault on the convention of courses of antibiotics. But... but the MRC trials of tubercle, we know exactly how long, which ones, how, for this combination, for that combination, for the other combination and now it's all vanishing. Like malaria... we knew how to treat malaria. And it shows, you know, the important things about medicine are, you know, economics and anthropology, and we do the best we can but you really need to...

[Q] You, you, I mean, the patient things are in a sense more understandable, aren't they than the doctor things, which are destroying it? What, what...

Well, if you're in... in a poor place in Ghana or in Uganda and there's a, there's a market stall and there's a treatment for tuberculosis which, it might have isoniazid there and it might it'd be labelled isono it might have some, it might have none, and you know you're ill with a cough. I mean, what do you do? You take it. Absolutely reasonably, and then it gets resistant and you get ill again. But, but I think a lot of doctors were giving it the wrong way. Yeah, so I think it's both elements. And then, I mean, obviously hugely magnified in the last decade by AIDS because, as you know, AIDS and tubercle are really, really bad news as a combination, and one of the major causes of deaths from AIDS is tuberculosis.

[Q] Right, and did you find as an infectious disease physician that, that actually you were seeing tubercle getting out of hand and you, when you didn't... when AIDS wasn't fully worked out, was that something...?

No. No. I think it was in hand in rich countries then, but not in poor countries. And at that stage, which you may want to go onto later, much, much later, we had the Ugandan Asian immigration after Idi Amin and...  this was when I, a really fairly senior person. I mean, must have been, I must have been a consultant about eight or nine years, and we had a huge flood of non-pulmonary tuberculosis mainly and had to re-learn tuberculosis, but we could treat it very well.

British doctor Harold Lambert (1926-2017) spent his career tackling infectious diseases, helping in the development of pyrazinamide as an effective treatment for tuberculosis. He also published work on the rational use of antibiotics and was a trustee and medical advisor for the Meningitis Research Foundation.

Listeners: Roger Higgs

Roger Higgs was an inner city GP for 30 years in south London, UK, and is Emeritus Professor of General Practice at Kings College London, where he set up the department.

He gained scholarships in classics at Cambridge but changed to medicine after a period of voluntary work in Kenya in 1962. He was Harold Lambert's registrar for 18 months in the early 1970s, the most influential and exciting episode in his hospital training. He set up his own practice in 1975. He helped to establish medical ethics as a practical and academic subject through teaching, writing and broadcasting, and jointly set up the 'Journal of Medical Ethics' in 1975.

His other work included studies in whole person assessment and narrative in general practice and development work in primary medical care: innovations here included intermediate care centres, primary care assessment in accident and emergency departments, teaching internal medicine in general practice and establishing counselling services in medicine.

He was made MBE in 1987 for this development work and now combines bioethics governance, teaching and writing with an arts based retirement.

Tags: Medical Research Council

Duration: 5 minutes, 50 seconds

Date story recorded: October 2004

Date story went live: 24 January 2008