PART C

The challenge of tuberculosis

Earlier this month, global experts gathered in Hyderabad for the 50th Union World Conference on fighting tuberculosis (TB). When the first meeting was held in 1867, it was the leading cause of death in industrialised nations. Can it really be the case that despite all the progress in medicine and public health over the past 150 years, one quarter of the world’s population is infected with TB, and the disease is still the most common and lethal of all infectious diseases, responsible for over 1.5 million deaths a year?

One likely explanation for the slow progress made in eliminating the scourge is that TB is a disease of the poor, as the statistics clearly show. But to successfully target the most vulnerable to the disease, it is vital to understand the web of social, environmental, and biological determinants, and to understand that they are difficult to tease apart. Low body weight and indoor air pollution (caused by burning biomass fuel in poorly ventilated rooms) are the greatest risk factors for the disease in India. In wealthier income groups, diet plays a different role: diabetes is the greatest risk factor.

Cases among the middle class are rising in urban India. Dr Raja Dhar, a physician at the West Bengal Fortis Hospital in Kolkata, says that around 70 percent of his TB patients are middle class or affluent professionals, many of whom react with anger or disbelief when they hear his diagnosis. “There is a far greater taboo about people in the affluent class saying that they have TB,” Dhar said. “It’s like having leprosy years ago.” The stigma associated with TB contributes to it being hard to diagnose. That, too, makes what should generally be a straightforward disease to cure more complicated, according to Dhar. But the more fear and shame associated with TB, the less likely that is to happen. For the poorer members of society, diagnosis is further complicated by the inaccuracy of most of the tests, which are more than a century old and not very effective, picking up half the cases of active TB. Modern, more accurate tests certainly exist but are prohibitively expensive with results taking weeks.

Another issue is the cost of TB treatment, which can be catastrophic for the poor. Although a recent pricing agreement which has seen the price of Rifapentine, a key antibiotic that stops the development of latent TB into active drop by two thirds, may be grounds for cautious optimism. “The detection and treatment of people, particularly children, with latent TB is an important part of fighting this disease and ultimately ending TB,” said Lelio Marmora, Executive Director of Unitaid a global association dedicated to reducing contagious diseases in middle and lower-income countries. “It has potential to be the game changer” added Marmora. Available to those who could afford it since 2017, Rifapentine has until now been out of reach for those in developing countries.

But not all TB infections are easily treated. drug-resistant tuberculosis, multiple-drugresistant (MDR), and extensively-drug-resistant (XDR) are one of the world’s most urgent challenges. Drug-resistant TB is multifactorial and is fuelled by improper treatment of patients and poor management of drug supply. In 2018, of the estimated half a million people who developed multi-drug-resistant TB, only one in three was taking medication. To make matters worse, cure rates are abysmal and drug-resistant TB is increasingly spread by direct human-to-human transmission, meaning that people are catching strains that are already resistant.

There are newer, oral-only drugs on the market, and with treatment lengths of six months compared to up to two years for older, more toxic, injectable drugs, they are critical to improving the cure rates of drug-resistant TB. In spite of a number of recent manufacturer-government arranged price deals, however, they are not accessible to the most economically disadvantaged. Dr Stobdan Kalon, a medical advisor for Médecins Sans Frontières in India, said “As long as these new drugs are priced out of reach for TB programs, an all-oral treatment regimen for people with pre-XDR-TB and XDR-TB and children with MDR will remain a distant reality’’.

Médecins Sans Frontières are not alone in calling for countries to take effective measures, including overriding patents through compulsory licenses, to enable manufacturers to enter the supply chain and bring the price down further. Such measures are rare but have great impact. Successful AIDS programmes, such as those in Brazil and Thailand, have only been possible because key pharmaceuticals were not patent protected and could be produced locally at much lower cost. And while pharmaceutical companies claim pricing reflects the need to recoup investment costs, researchers from the University of Liverpool have calculated that if the drug Delamanid, a key drug used to treat MDR-TB, is widely used by national TB programs, it could be produced and sold at a profit for as little as $5 to $16 per month. Until its price drops, however, there’s little chance that national programmes will adopt it.

Reading C: text 1: questions 7-14
Read the text and choose answer (A, B, C, or D) which you think fits the best according to the
text.

7.In the first paragraph, the author suggests that…

8. In paragraph two, the writer uses the word scourge to emphasise that TB…

9. In the third paragraph, Dr Raja Dhar suggests that wealthier residents in West Bengal…

10. In paragraph four, what is the game changer Leilo Marmora refers to?

11. In paragraph five, the author says that drug-resistant tuberculosis…

12. In the sixth paragraph, the author says that compared to older medication, modern TB medication…

13. In the final paragraph, the writer believes that in the fight against TB it is necessary for governments to…

14. In the final paragraph, the writer refers to the researchers’ findings to suggest that…

Reading C: text 2: questions 15-22

Read the text and choose answer (A, B, C, or D) which you think fits the best according to the text.

Cluster Headache

When cluster headache was last reviewed in the British Medical Journal (BMJ) some 50 years ago, the authors stressed the importance of covering the topic in a general medical journal to aid recognition. Despite this remarkably prescient view, and the extreme and stereotyped nature of its presentation, cluster headache is still commonly misdiagnosed. Without a clear diagnosis, affected patients can wait many years before receiving adequate help from medical professionals.

Cluster headaches are known, colloquially, as suicide headaches. Attacks are episodic or chronic, and cause excruciating pain. Many describe it as being worse than anything they have experienced, including childbirth. Though on the notion that it brings the “worst pain known to medical science,” Dr Mark Green, professor of neurology at the Mt. Sinai School of Medicine and director of the school’s Center for Headache and Pain Medicine says, “it’s terrible but I think sometimes people can get a little carried away.” Green does confirm that “most headache doctors have had patients with cluster headaches who have committed suicide from the pain’’ adding “that’s more likely in the chronic form, (when) they know that they’re going to get one or two or three of these headaches, every day, forever.’’

Even in less extreme circumstances, sufferers say the severity of the pain has changed their
friends, family, or bosses. “For a few months a year, I am woken at exactly 3 a.m. with a cluster headache. I’m always exhausted after an attack and going to work is draining.’’ says Taiyeba. Though her previous employer apparently had a flexible working policy, were aware of her condition and had agreed to her working from home, after a year Taiyeba discovered that such days were being counted as sick days. “I later began to be docked pay, as I had used all my annual sick leave.” Now with a more understanding employer, Taiyeba is convinced that her experience in her former post resulted in her headaches spiralling out of control.

Cluster headache is often referred to as rare, though it has a similar prevalence to other neurological conditions such as multiple sclerosis. While the causes are not clear, poor diet and smoking can be contributory factors. Less well known is that the condition presents differently in the sexes, with women often reporting symptoms of nausea and vomiting. These have often been attributed wrongly to migraine and thus treated inappropriately, calling into question the oft-held notion that cluster headache is a man’s condition. The ratio of men to women, which stands at around 3:1, has more than halved over the years as more women are diagnosed.
There is even a suggestion that chronic cluster headache may, in fact, be experienced more frequently by women.

“Cluster headache is often poorly recognised in primary care’’ says Professor Lisa Dikomitis, director of research at Keele’s School of Medicine and academic lead of Keele’s Institute for Global Health. GPs who took part in a survey conducted by Dikomitis acknowledge the effect of cluster headaches on their patients’ ability to remain in employment, and on their mental health, though nonetheless they are reluctant to send the patient to a neurologist. Common reasons given when they did, included patient anxiety, the need to reassure the patient that they do not suffer with a life-threatening illness and/or the patient’s insistence. The study also found GPs occasionally override the specialist advice and prescribe cheaper drugs, such as oral triptans, instead of injectable or nasal triptans.

Many patients undergo unnecessary procedures, such as teeth extraction or sinus washouts before a correct diagnosis. Others, such as Bob Wold, founder of the non-profit cluster headache research and advocacy organization Clusterbusters, reach a point when extreme procedures seem the only answer. “I had pretty much tried all of the different medications that were available, and I was contemplating having gamma knife surgery. They clamp your head down and shoot radiation into your brain, killing off part of your brain.” He decided to try one last thing first, something he’d read about online. A couple of doses of psilocybin mushrooms, a hallucinogenic drug, broke a cycle he says he’d been stuck in for months, when nothing else could. “I cancelled the surgery and never looked back” he says.

Controversial and in its infancy, research into hallucinogenics and cluster headache has shown promise, though Dr Mark Green is cautious: “No one should quote the efficacy of the trials, because they’re ongoing” he says. While funding for a clinical trial seems remote, Wold is nonetheless optimistic that successful treatment for the crippling pain of cluster headache will be found. Clusterbusters has turned its attention to other research, including working with Yale University on surveying the efficacy of the many medications cluster headache patients use, and is also working on a genetic study to investigate the possibility that the headaches come from expression of a certain gene.

15. In the first paragraph, the writer suggests that the authors of the article on cluster headache in the BMJ…

16. In paragraph two, the word it refers to…

17. In the third paragraph, the writer uses Taiyeba’s story to highlight…

18. In the fourth paragraph, the author suggests that women…

19. The writer refers to Professor Dikimitis’s survey to highlight…

20. What point is being made about treatment for the condition in the seventh paragraph?

21. In paragraph seven, Bob Wold uses the phrase never looked back to suggest that…

22. It is suggested that hallucinogenic drugs as a treatment for cluster headaches..

That is the end of Part C and the end of the Reading test.