TORONTO - In the feeding frenzy that engulfs the case of Andrew Speaker, in all the heated debate over whether he was ordered or urged not to travel to Europe and who knew what when, a critical piece of this tragic story has eluded public attention much in the way Speaker slipped past border guards alerted to his possible arrival.
The din of outrage and demands for answers about culpability is muffling what should be a clarion wake-up call for citizens of the developed world, say some experts who have been watching with dread the emergence and spread of extensively drug resistant tuberculosis.
XDR-TB, as it is called, has been found in 37 countries so far. And if affluent nations ignore it in the way they initially ignored the spread of HIV-AIDS in Africa, the globe is facing a future where virtually incurable tuberculosis is a reality in both law offices in Atlanta and the slums of the developing world, they say.
"XDR-TB is a tragedy in the fullest sense of that word," says Dr. Ross Upshur, director of the University of Toronto's Joint Centre for Bioethics.
"For every day the clock ticks and we fail to take action or take seriously what we need to do to bring this under control and that means both in the drug development pipeline and in the public health response every death and every transmission is on our collective shoulders."
Since the advent of antibiotics, tuberculosis has been largely a disease of the dispossessed. XDR-TB in particular has been associated with the overcrowded prisons of the former Soviet Bloc, with HIV-AIDS cases in sub-Saharan Africa, and with other marginalized groups whose limited income or life circumstances make it impossible for them to follow a regimen of months of TB treatment.
Andrew Speaker doesn't fit this picture.
Healthy, handsome, affluent, educated, the Atlanta lawyer is an unlikely person to be infected with a strain of tuberculosis so drug resistant that it is not at all certain he can be cured.
"He is the anti-TB patient, actually," Upshur says.
Dr. Michael Osterholm, director of the Center for Infectious Diseases Research and Policy at the University of Minnesota, agrees.
"You don't think of this kind of guy having to go into surgery to take care of his TB," says Osterholm, referring to the fact that modern medicine is being forced to resort to the options of old - surgery to excise portions of infected lungs - to try to cure XDR-TB.
He says the Speaker case is a reminder that diseases that exist anywhere are only a plane ride or two away from any of us.
"It's the standard line: Infectious diseases don't know geographic boundaries," Osterholm says. "But the truth of the matter is it's true."
Dr. Howard Njoo, director of the Public Health Agency of Canada's Centre for Emergency Preparedness and Response, specialized in tuberculosis before heading up the centre. In talks he gives on the topic, he stresses that tuberculosis bacteria doesn't care about ethnicity or income.
"It really depends on where you spend time in the world," Njoo says.
"I guess the wake-up call I would say is that . . . if the point is that people (think): 'Oh, now it's in North America and he (Speaker) got it and I could get it,' I would say that he just represents an example of globalization and how much more accessible air travel is in general."
The World Health Organization issued a statement of concern over the emerging threat last September, after disturbing data on an outbreak in Tugela Ferry, in the South African province of KwaZulu Natal, were presented at the international AIDS conference in Toronto in August.
Researchers reported that 52 of 53 patients discovered to be infected with XDR-TB died, and died alarmingly quickly. In most cases the patients died within 30 days of giving a sputum sample for testing.
The horrific toll was fuelled by high rates of HIV infection among the patients; 44 of the 53 were tested for HIV and all of them were positive.
It's been known that TB and HIV make nasty companions; it's become clear the duo of XDR-TB and HIV is a lethal one.
For people who can afford extensive and extended medical care - or those with state-funded medical coverage - there are some treatment options for XDR-TB. But there are no guarantees.
The U.S. Center for Disease Control estimates that about 30 per cent of people who become infected with extensively drug resistant strains go on to be cured.
Treatment involves toxic antibiotics given over months and can include surgery. Experts fear the few drug options that are available will dwindle as the numbers of people being treated with these drugs rise.
In fact just last month a group of researchers in Milan reported on the cases of two middle-class Italian women whose tuberculosis strains did not respond to any of the antibiotics used to try to treat them. Both died.
In the report, published in the online journal Eurosurveillance, the researchers noted the strain that infected the first woman had been resistant to all antibiotics used to try to treat her, but it hadn't been tested against three drugs that were not used in her care.
The report of the second case was more chilling.
"Case 2 was found to be resistant to all the drugs with known anti-TB activity," they wrote.
New antibiotics take years to develop and bring to market. At a recent scientific conference in Toronto, Gail Cassell, vice-president for scientific affairs with pharmaceutical giant Eli Lilly, noted that while seven new potential TB drugs are in the global development pipeline, most are in the earliest phase of clinical trials.
"We will be lucky if we have a new drug by 2019," she said.
While the rise of XDR-TB is alarming many in the global public health community, until Speaker's case came to light it really hasn't hit the general radar in a meaningful way. And it remains questionable whether this flurry of concern will galvanize activity to try to address the looming threat, given the intense focus on Speaker's actions, not his disease.
"What will be the message that ultimately will be most remembered?" Osterholm wonders.
"The guy who put a lot of other people at risk as others might? Or the guy who is the face of every human who ever wants to think about their vulnerability to one of these kinds of illnesses?"
