Globe-trotting to Fight a Worldwide Scourge

Bonita Mangura graciously ushers a reporter into her office, even though it’s clear she’d rather be doing almost anything else. She may have traveled the back roads of developing nations and faced down hostile bureaucrats in foreign capitals, but the director of international activities at the Global Tuberculosis Institute, part of Rutgers New Jersey Medical School, is, she admits, “shy about interviews.” Petite and soft-spoken, she’s an unlikely David fighting a Goliath of almost unimaginable proportions. Although Americans may view tuberculosis (TB) as a disease of the past, it is, in fact, a contemporary global scourge, responsible for 1.5 million deaths annually and infecting, in its latent stage, nearly two billion people—about a third of the world’s population.

A pulmonologist by training, Mangura has fought the war against TB—whose potential symptoms include a racking cough, fatigue, night sweats, and fever—on virtually all fronts. In addition to personally treating patients with the disease, she’s designed and managed clinical drug trials, researched TB’s insidious transmission patterns, and traveled to the former Soviet Union, the Philippines, Zimbabwe, and elsewhere to conduct research and consult with local health care providers to help them improve the way they diagnose and treat TB.

One of her specialties is the care and study of high-risk patients, such as substance abusers and the so-called “dually infected,” those who suffer from both TB and HIV and who are notoriously difficult to treat. She’s received accolades for her near-perfect recruitment and retention of patients from these groups. When asked about her success at something many others have found so daunting, she laughs. “It’s not because of my magnetic personality,” she says. In the early ’90s, she explains, there was a resurgence of tuberculosis in New Jersey; in Newark, many of the infected were also addicted to drugs or suffering from HIV. Treatment was complicated by the fact that a large percentage of this population had the disease in its latent (and noncommunicable) form: they carried the bacterium that causes TB but hadn’t developed active tuberculosis. When told they should take medication as a preventive measure, many balked. But Mangura found that they would sign on for the medication, and continue with the full course, if they were offered an incentive—specifically, a monthly supply of Sustacal, a nutritional supplement, liquid gold for people who often couldn’t afford to eat at all (and who sometimes, Mangura later learned, sold it on the street). Now, she says, offering an incentive to keep “difficult” TB patients on their meds or get them to participate in clinical trials is embraced by many as a best practice.

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Although Americans may view tuberculosis as a disease of the past, it is a contemporary global scourge, responsible for 1.5 million deaths annually and infecting, in its latent stage, nearly two billion people—about a third of the world’s population.

The ability of the tuberculosis bacte­rium to lie dormant for many years helps explain why the disease has been so difficult to eradicate. One undiagnosed case in a large family or a close community can, over time, become nine or 10, especially, says Mangura, “if countries with a high TB burden only focus on the active disease and not on prevention.” Researchers have yet to develop a reliable vaccine, in part, because there are multiple strains of the tuberculosis bacterium and also because refrigeration—essential to a vaccine’s efficacy—isn’t widely available in many developing nations. 

Instead, Mangura and her colleagues at the Global Tuberculosis Institute concentrate on treatment strategies that prevent the latent TB bacterium from becoming active. One of the most promising is a combination of two medications, isoniazid and rifapentine, which appear to cut treatment time from an average of nine months to 12 weeks, after which a patient’s risk of developing full-blown TB is significantly reduced. Not only is the regimen easier for patients; it also makes them more likely to agree to treatment.

Of course, that point is moot when patients aren’t diagnosed, or aren’t diagnosed early enough to be treated effectively or to prevent transmission of the disease, or when private practitioners don’t communicate with state-run TB services so patients miss out on the best care available. That’s why, in the winter of 2003, Mangura and Nisha Ahamed, the institute’s program director of education and training, found themselves on a series of unheated trains traveling from Moscow to the republics of Chuvashia and Ivanovo, where the unplowed snow often rose a foot or more above their heads, and on to Georgia and Kazakhstan. Wherever they traveled, the local ministers of health were as likely to consider them interlopers as colleagues. With support from the World Health Organization and the U.S. Department of Health and Human Services, Mangura and Ahamed SPH’02 had set out with the goal of addressing the gap in collaboration between primary health care doctors and TB specialists as the former Soviet republics began the process of health sector reform. To that end, they interviewed ministerial officers, TB specialists, primary care physicians, nongovernmental organizations, and health care funders with the goal of producing a kind of pocket guidebook to TB care. The women weren’t always welcome, Mangura remembers. “When we encountered heads of the ministries of health, they would say, ‘What makes you think you can write this book and we can’t?’ We had to prove ourselves.”

And for the most part, they have. On their return to the United States, they drafted the guidebook, which was designed to train primary caregivers to diagnose TB infections and then refer patients to their country’s specialized TB services. Later in 2003, they returned to the countries they’d visited previously to test-drive the guidebook, as it were. And Mangura has continued to travel to consult with practitioners on TB care, as she did in the Philippines from 2002 to 2005, Ecuador in 2005, Zimbabwe in 2012, and Ukraine in 2013. She passes along her doctrine of prevention, and additional lives are saved. Inch by inch, she and her colleagues at the Global Tuberculosis Institute are whittling down the Goliath that is TB. It’s a frustrating endeavor, Mangura says, especially when she encounters a medical professional who refuses to accept the latest thinking on prevention, but it’s also gratifying. Often, Mangura will find herself at meetings where she comes across physicians who’ve embraced the guidebook and have used it not just to treat patients, but also to convince other doctors of the efficacy of preventive medicine to help stop the spread of TB. “They say, ‘I’m so happy you came and worked with us,’” she says. “And that’s rewarding.”