In the arsenal used to fight COVID, there’s no doubt that vaccines are the non-human heroes of the pandemic.  A close second, though, is the once lowly, often stuffed-in-a-provider’s-desk-drawer, N95 mask.  Before the pandemic, not a lot of people outside of healthcare were familiar with it.  We healthcare providers kept our own N95s stored in a paper bag with our names scrawled on it, out of sight and usually out of mind. These masks had one sole purpose — to protect us from tuberculosis (TB) if we took care of a patient who had active TB. 

We were “fit-tested” once a year to make sure the mask would function.  The fit test was basically, well, weird.  You donned your N95 mask and the occupational health nurse would put a kind of plastic dome over your head.  Then they sprayed a chemical with a sickly-sweet floral fragrance under the hood.  If you could not smell it, you were good.  If you could, you needed a new, better fitting mask. And, we were cautioned, once the mask was used, particularly in a verified TB situation, it was to be thrown out. It was contaminated and should not be used again. 

For lack of a more nuanced reaction to this bit of history — Ha.  COVID made the lowly N95 mask a superstar, elusive and sought after.  Everyone wanted one. There were dire shortages.  People were stealing them and they had to be kept under lock and key.  And now apparently they could be used countless times even after contact with infected people. Just like that.  And we found that a properly fitting N95 was a very uncomfortable thing to wear all day.

But this post isn’t really about the N95.  It’s about public health and the role it still plays in mitigating another highly contagious disease in the community, the eroding concept of the common good, and vaccine hesitancy.

In the time before many vaccines were available, there were numerous outbreaks of dangerous diseases.  Typhoid, diphtheria and polio come to mind.  Health departments enforced quarantines, complete with signs nailed to front doors. No one questioned this because it was so obviously for the common good.  No one wanted themselves or their families to become sick and die.

Tuberculosis, while not as virulent or as lethal as the aforementioned diseases, was a bane nonetheless. Many people died of TB, including two of my grandparents, in the first part of the 20ieth century.  It was generally a disease that attacked people in poor health, living in crowded conditions, which then as now, unfortunately goes hand in hand with poverty. TB is just as contagious as COVID but here’s the big difference.  Most healthy people exposed will develop latent tuberculosis infection or LTBI, which does not make you sick or contagious. It will however, make a TB test positive, because the dormant bacterium that causes TB (mycobacterium tuberculosis) is still detectable, even though your immune system has walled it off and made it inactive.   

To this day, healthcare providers are tested once a year for TB.  If the test is positive, it signifies exposure but not necessarily active disease.  The next step after a positive test is a chest x-ray which would detect active, and thereby contagious disease.  I have known many providers who were exposed, some knew it, some didn’t, and their tests were positive, and remain so.  There is a treatment regimen advised for people with LTBI.  The reasoning is that that the disease lies dormant until the host weakens, whether from illness, old age or even pregnancy, and then reactivates, becoming a contagious and potentially fatal disease. The treatment for LTBI consists of daily meds for a few months and some of the medications are not well tolerated. If you are deemed young enough and well enough to take the regimen (some of the meds could be toxic to the liver), it is advised to do so in order to prevent reactivation in the future. While the incidence of tuberculosis has decreased in this country, the advent of HIV/AIDS produced drug resistant strains, which requires more discussion than feasible in this post.   

You might ask why I’m discussing tuberculosis at all when we are still in the midst of a pandemic of a much more dangerous disease. It has to do with my commitment to public health and my struggle to understand COVID vaccine hesitancy and anti-maskers. Public health authorities were instrumental to and successful at controlling TB.  And most people were grateful for it, which is so very different from what is happening today amidst a battle with much more dire consequences if lost.

There was a thought-provoking essay written by a community health physician (Anita Sreedhar) and a sociologist (Anand Gopal) in the New York Times last week (Behind Low Vaccination Rates Lurks a More Profound Social Weakness https://www.nytimes.com/2021/12/03/opinion/vaccine-hesitancy-covid.html?smid=url-share) that helped me understand that the points of view of some anti-vaccine and anti-maskers can be attributed in part to a number of factors, including: a distrust of a government which has not helped them in the past, a differing hierarchy of needs for people living on the edge vs the rest of us, and the rejection of the concept of the common good, which emanates from feelings of being abandoned by the powers that be. The resulting mindset is that everyone has to look out for themselves, and no one else.  Individual freedom above all else.  It makes sense as a rationale for this thinking but it doesn’t solve the problem.  Which brings me back to TB, specifically how public health departments handle TB to protect both the community and the individual.

If someone is diagnosed with active TB, they are mandated to take medication, and if they are not deemed reliable, they are brought in to a public health facility (or someone goes to their home) so they can be observed taking the medicine.  This is called Directly Observed Therapy (DOT).  It’s most definitely a thing as is the power of the health department to isolate contagious individuals and at times commit them to a facility until they have completed treatment (which is always a last resort and rarely happens.)  Ensuring that these individuals are treated is in everyone’s best interest.  It protects the infected by curing their disease and also protects the community at large from becoming infected.

So say one is anti-vax and anti-mask and anti-mandate and your next door neighbor who frequents all the public places you do and volunteers at your kid’s school has been found to have active TB. Would you fight for the individual’s right to sovereignty over their body even though they have the potential to infect the community and sicken the most vulnerable? Is it their right not to take the medication? If you are healthy, maybe you would only get LTBI if exposed, no big deal for now.  But what if you are still recovering from the flu (you don’t get the flu shot, after all) and your immune system is weakened.  What if one of your elderly relatives volunteers at the school too?  Now TB is not the scourge in terms of virulence that COVID is. It spreads in the same way as COVID, through airborne droplets, but is not going to cause a pandemic because TB is slow while COVID is fast, and in many cases TB can be cured with medication.  Also it can take a few weeks to become infected and contagious after a TB exposure, and as explained before, the latter might not happen if you are healthy.  Still it is a nasty, potentially deadly disease with drug-resistant strains and life-long effects on health. 

When I think of tuberculosis, I can’t help thinking of our public health departments and how important they are to the community.  Humans are drawn to community for protection and social interaction.  We naturally want to belong — to our families, our social groups, our local communities and yes, our country.  Today our country is so divided.  I wish more people could understand that the individuals working in public health, imperfect and strained as they all are, are doing the best they can to safeguard the health of as many people as possible, and this in the face of so many unknowns.  That essentially, is their mandate. That’s what the common good is, the best outcomes for the greatest number of people. It’s hard to argue with that.  Because if we are not all in this together, then what’s the point of being here at all?  #thecommongood, #vaccinehesitancy #N95s #WritingCommunity #weallwanttobehealthy #tuberculosis #LTBI #Covid #endthepandemic