It's more than 30 years since the tuberculosis sanitarium made its exit from the American landscape, and about as long since public health authorities talked confidently about the "white plague's" disappearing once and for all.
Antibiotics, the miracle of the 1950s, seemed likely to make that possible. It would have been the ultimate triumph of modern medicine: eradicating from this country an illness that, at the turn of the century, killed more people than heart disease, cancer or any other disease.
Not so fast.
As tuberculosis rates in the United States seemed headed toward the vanishing point, they made a surprising about-face. In 1989, TB rates increased 4.7 percent over the previous year. In 1990, the rate jumped another 9.4 percent.
The 25,700 people diagnosed with tuberculosis in the United States last year are one-tenth the numbers reported in the 1930s. But TB's sudden resurgence, in Maryland as elsewhere -- and the fertile breeding ground it has found among AIDS patients, immigrants and the poor -- have authorities concerned.
Particularly worrisome is the appearance of strains that have proved resistant to standard medications. This has some physicians fuming over what they consider the U.S. government's failure to anticipate the problem by funding research into new drugs when the disease was at its low point.
"We honestly thought TB was solved," says Dr. Lee Reichman, president of the American Lung Association, who accuses the federal government of forgetting about TB once it no longer seemed a crisis. "There was no need to develop new medicines when other diseases were pre-eminent."
Tuberculosis is caused by an airborne bacteria that infects the lungs and other organs. The infection usually lies dormant, held in check by the immune system. But it can erupt into a potentially deadly disease marked by intense coughing, chest pain, shortness of breath, fever and sweating.
Antibiotics are highly effective against TB, although the infection is more difficult to treat when it strikes people with immune system disorders such as AIDS.
Several forces are behind the re-emergence of tuberculosis:
* The disease is infecting large numbers of AIDS patients, people whose shattered immune systems are nearly defenseless against the TB bacteria.
* AIDS patients who catch TB are in the position to infect other people: family members, health care workers and friends who are regularly exposed to the characteristic coughing that comes with the disease. This stands in stark contrast to the myriad other infections that strike AIDS patients -- infections that people with healthy immune systems are quite capable of defeating.
* Many immigrants from Latin America, Asia and Africa -- continents where tuberculosis remains a colossal threat -- have been bringing the bacteria with them. Many of them lived with a silent infection for years, only to have their infection blossom into full-blown disease once they were subjected to the rigors of living in a new land.
* The infection is spreading rapidly among drug addicts, homeless people and others living in desperate poverty. The infection has always thrived in crowded, substandard conditions and among people with poor nutrition.
The epidemic has hit New York, Hawaii, California and Florida the hardest -- states with large numbers of foreign-born residents, AIDS patients or both. Although Maryland's TB cases remain below the national average, the trend here is decidedly upward. The number of cases jumped from 384 to 450 between 1990 and 1991 -- a 17 percent increase.
Most of the cases have been concentrated in Baltimore City, Prince George's and Montgomery counties. Dr. Diane L. Matuszak, who has overseen TB control programs in Maryland, attributes this to the AIDS epidemic in Baltimore; AIDS and the swelling immigrant population in Prince George's, and immigration in Montgomery.
Resistant strains have not arrived in force in Maryland, as they have elsewhere. Such strains have spread across populations of AIDS patients, drug addicts and prison inmates in New York, California and other states that have been hard-hit by tu
berculosis in general.
Last November, a resistant strain killed 12 prison inmates and a guard in New York, and infected dozens of health care workers who were taking care of them in a Syracuse hospital. Last year, physicians diagnosed only 13 cases of "multiply drug resistant" TB in Maryland, but experts said the problem is bound to emerge in Maryland.
"It's just inevitable," said Dr. Richard Chaisson, director of AIDS patient care at Johns Hopkins Hospital. "New York City is just a view of the future for the rest of the United States. All factors that produced this epidemic in New York will produce it elsewhere. All it takes is one person from New York coming to Baltimore and transmitting it to someone else."
Resistant tuberculosis is a vexing problem because it thrives among people who do not religiously take their medicine.