I blogged earlier about the Georgia man who globe-trotted while infected with XDR-TB. I wrote that post late Tuesday evening, and since then, a number of other details about his case have come to light–and they’re not encouraging. In fact, this serves as a nice example of a convergence of a number of areas I’ve written about before–obviously, the evolution of antibiotic resistance and the terrible position it leaves us in, the politics and policies of quarantine/isolation (and how they’d be enforced), and the global spread of infectious disease, so I figured this would warrant another post on the topic.
First, the “compelling personal reason” he had for traveling that was mentioned in early articles was this: that he he was getting married in Greece and then honeymooning in various stops around Europe. Now, I’m probably just unsentimental and maybe a bit too practical at times, but it seems to be a really poor idea to potentially expose not only your future wife (who apparently was tested in January and negative for TB) but also your relatives and other loved ones to a highly deadly bacterium on what’s supposed to be one of the happiest days of your life. I mean, sure, you want people to remember your wedding, but not because they contracted tuberculosis there.
That’s only the beginning of the dumbassery, unfortunately–it gets worse. More after the jump.
As the story broke, the unidentified man at the center of it wanted to defend himself, so he spoke with the Atlanta Journal-Constitution about his experience and his reasons behind what he’s done. He claimed:
“I didn’t want to put anybody at risk,” the Fulton County man, who declined to be identified because of the stigma attached to his diagnosis, said in a telephone interview with The Atlanta Journal-Constitution. “We just wanted to come home and get treatment.”
Of course, the problem is that he did put people at risk. What’s worse is that, while he hadn’t been given a diagnosis of XDR-TB specifically before embarking on his trip, 1) he still knew he had TB; and 2) he knew that the TB strain he had wasn’t responsive to the treatments he’d been given:
The man at the center of the international health incident said his TB ordeal began in January. Because he has felt healthy, the disease was detected by accident, during a chest X-ray for something else. It uncovered a small mass in one lobe of his lung. A sputum test came back negative for TB, but a more sensitive culture test confirmed the diagnosis.
“So they started putting me on the standard four-drug treatment,” he said. And they tested his fiancÃ©e and other close contacts for the disease: None of them had it.
But it turned out his TB was resistant to the first-line drugs — and the second-line drugs. So county officials stopped treatment. The man said he and his private doctor — with the agreement of government health officials — made plans for him to undergo cutting-edge treatment with specialists at National Jewish Medical and Research Center in Denver after his honeymoon.
He knew his strain was **resistant to all the drugs they’d thrown at it thus far**. He knew that it was going to require “cutting-edge treatment” to get it under control. To make matters worse, the New York Times write-up notes that the man claimed “…He knew he had a form of tuberculosis and that it was resistant to first-line drugs, but he didn’t realize it could be so dangerous.” However, the article also states that “…The man told a newspaper he took the first flight from Atlanta to Europe for his wedding, then the second flight home because he feared he might die without treatment in the U.S.”
So he didn’t know how dangerous the bacterium could be, yet feared he’d die in Italy (where he refused to enter isolation after receiving the official XDR diagnosis). Fearing that, and finding out that his passport had been flagged and he was placed upon the “no-fly” list, he hopped a flight from Prague to Montreal (to circumvent U.S. airline travel) and then drove back across the border, turning himself in at a New York hospital.
This tidbit of information also brings up all kinds of public health and national security issues. Obviously, this guy shouldn’t have been able to just get back into the country. I suppose it should be encouraging that at least he didn’t fly in directly and make it through, but his backdoor route of entry again just exposes our weakness in keeping out potential “bad guys,” even if they’ve been identified and flagged. It also highlights our lack of any kind of real policy with regard to quarantine or isolation. (Note that these are not the same things: quarantine is for those who have been potentially exposed to an agent but don’t yet show symptoms, while isolation is for those who are certainly infected and may be shedding the pathogen). Now, the man claims that the public health officials he contacted told him that they “preferred” he not travel, but he informed them that he was going to anyway, and they didn’t tell him to take any precautions. The health officials, however, give a slightly different version:
Dr. Steven Katkowsky, director of public health and wellness for Fulton County, said it’s his understanding that the man was “advised not to travel.”
“I didn’t hear that conversation,” Katkowsky said, “certainly the recommendation would be that if you have an active infection with tuberculosis, you ought not to be getting on a commercial airliner.”
Katkowsky said after that conversation, the department attempted to hand-deliver a medical directive, dated May 11, to the man telling him not to travel, but his home address was vacant and he was not at his place of business.
When they finally located him, the patient and his new wife were already honeymooning in Rome. An official from the CDC told him to stay put initially, and then that he needed to turn himself in to Italian authorities so that he could be isolated and treated, and that he most certainly shouldn’t fly on a commercial jet (and also that his passport had been flagged, so no goin’ back in through the U.S. for him). This is when he bailed:
To evade the no-fly list, which they assumed only involved jets bound for the United States, the man and wife flew into Canada and drove a car into the U.S. At every check of their passports, he said they feared being caught, but weren’t.
Why not just get treated in Italy?
The man said he wants people to understand he sneaked back into the United States because he feared for his life. An unsuccessful treatment in Italy would have doomed him, he said, because he said they lacked the expertise.
Now imagine this on a larger scale. Imagine dozens, or hundreds, of people infected with an organism that’s either incurable or difficult to treat. Imagine knowing that you may be put into isolation or quarantine if you admit you’re infected or exposed. It may be in an area you’d rather not be in; perhaps in a sub-standard medical facility, in an area many miles away from your loved ones, and you’re (understandably) scared and worried. This current story involves one person, who potentially exposed many people on two continents, who’s now locked away in isolation in Atlanta–and that wasn’t easy to accomplish. What would happen if many more people were ordered into quarantine or isolation? Could the government handle it successfully? I don’t think we know that. Or maybe we do, but it’s just the wrong answer.
“I’m a very well-educated, successful, intelligent person,” he said. “This is insane to me that I have an armed guard outside my door when I’ve cooperated with everything other than the whole solitary confinement in Italy thing.”
Mike notes that this guy acted bloody stupid. I agree that his actions were stupid, but it’s pretty clear he’s a smart guy. He was clever enough to get back in the country despite his flagged passport, after all, and the article mentions that he may have acquired the infection in the first place after work he carried out in Asia doing fund-raising for hospitals. He’s no dummy. But he was a coward, and put many other lives at risk to save his own neck (and even worse, to have his wedding and honeymoon go off as scheduled). I don’t think this escapade is a result of ignorance or scientific illiteracy as much as it is arrogance and self-centeredness (qualities that seem to shine through every step along the way of his ill-fated trip to Europe and back, and then continue when he called the paper to give his own side of the story). However, in addition to the intercontinental public health problems he caused, Tiffany notes he’s also subjected himself (and potentially his new wife) to a host of legal issues:
If you gave no thought to the fact that if you get on a commercial airline and expose someone to a rare, deadly form of tuberculosis after you have been told not only not to fly, but to go into isolation, that you might have opened yourself (and if you die, your lovely, but apparently equally stupid new wife) to a giant chunk of legal liability–well, then, you are not well-educated or intelligent. If someone who was on the flight to Montreal gets or dies of this particular disease, guess who the wrong-doer is?
While she argues it’s because he’s lacking intelligence, I still feel it’s more about arrogance–surely *he* couldn’t infect others; he’s intelligent! He’s educated! He’s important! Even having some understanding of the TB he’s carrying wouldn’t necessarily take away that feeling of personal exemption from the rules, of entitlement to go about his business that so many in society seem to feel. As Tiffany also writes, “Some people won’t do as advised for the protection of the rest of us.” That’s the heart of the matter–he knew of his condition, he knew it was pretty bad (even if he didn’t know the extent of just how nasty it was), he knew officials had advised him not to travel, he knew he could expose others, he knew he’d been ordered into isolation, he knew he wasn’t supposed to fly on commercial jets. He did all that anyway–and in any kind of an epidemic situation, are we really going to be able to count on so many of us “doing as advised” for the protection of the rest? I highly doubt it.