Pulmonary Tuberculosis, or TB, has long been described as a disease that causes profound impacts on the human body. Historical terms such as consumption – describing how TB seems to literally ‘consume’ the affected – and phthisis (from the Greek term for ‘wasting away’) were in common language until the 19th century. Rudy’s List of Anarchic Terms (G. R. W. Rudy) describes ‘Pulmonary Consumption’ as a disease that “causes more deaths than any other,” leading to “cough, emaciation, debility, and hectic fever,” and describing the later stages of disease as a “formidable malady” leaving “little hope of successful treatment.”

We have come a long way in our understanding of TB, with key moments including the discovery by Robert Koch in 1882 that this disease is caused by a specific bacterium – now known as Mycobacterium tuberculosis; the development of a widely used vaccine – the BCG, first used in 1921; and later, the discovery of the first antibiotic – streptomycin – found to be effective in treating people with TB. Challenges remain, however, including the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB, which greatly hampers efforts to eradicate TB as a public health problem. Furthermore, the HIV pandemic led to a huge increase in HIV-TB coinfection, which has been particularly devastating, as the immune dysfunction caused by HIV leaves the body especially prone to TB’s destructive effects.

Despite history informing us of the impact that TB has on the human body, it is notable that very little modern research has investigated its effects on muscle mass and function. In most areas of the world today, TB treatment consists of taking antibiotics for six months, with very little consideration of whether patients recover their full strength and productivity after treatment. In a similar vein to how Covid-19 brought home to the medical profession the reality that infectious diseases can cause long-term problems even after apparent recovery, interest is now turning to whether the same is true of TB.

I am currently working at the Health Research Unit, Zimbabwe – a multilateral collaborative research unit in Harare, Zimbabwe. Following emerging reports that TB patients were living with significant impacts of their disease long after they were theoretically cured, under the supervision of Professor Katharina Kranzer and Professor Celia Gregson, and in collaboration with the study Principal investigator Edson Marambire we have launched a study to closely examine the lasting effects of TB on human muscle. This study nicknamed the SIMBA study (SIMBA means strength in the local language, Shona), uses modern research techniques such as DXA scans (Dual X-ray Absorptiometry – see Image 1) to accurately measure the amount of muscle and fat people have at TB diagnosis, and as they recover. The study also includes techniques such as jump plate mechanography, whereby participants are asked to jump as high as they can on a mechanical plate that measures the force they generate. Together with blood tests and nutritional scores we are investigating how and why TB causes such a ‘consumptive illness’ in humans.

Why does this matter? Current guidelines for managing TB understandably focus on the essential goal of completing antibiotic treatment. However, in much of the world, there is still limited attention given to more holistic, patient-centred aspects of care – such as nutrition, rehabilitation, and occupational support. This is beginning to change, particularly with the recent publication of new World Health Organization nutrition guidelines that emphasize the importance of nutritional care in TB management. If we can better understand how and why TB causes such a destructive impact on muscle, we may be able to enhance care by integrating nutritional support and rehabilitation or physiotherapy into standard treatment protocols.

It would be inaccurate to consider this a new idea – before the advent of antibiotics, the original ‘sanatoriums’ were potential models of holistic care. Returning to Rudy’s List of Anarchic Terms, reminds of a time when management of ‘pulmonary consumption’ involved advising “a mild but nutritious and strengthening diet,” “exercise in the fresh and open air,” and, “when the strength of the patient is such… gentle exercise on horseback is especially to be recommended”. As is often the case, the key to improving care for TB patients may lie in the past – and with modern research methods, we are striving to uncover how best to deliver this shift in care.

The SIMBA study is currently underway at the Health Research Unit, Zimbabwe (THRU-ZIM). The mission of THRU-ZIM is: “To improve health and wellbeing across the life-course through research that influences policy and practice. We achieve this by cultivating equitable partnerships and nurturing the next generation of global health leaders in Africa.” THRU-ZIM relies solely on grant funding and philanthropic support. Funding for Global Health Research is entering a challenging and uncertain time. There is much work to do to push forward research into holistic care for those suffering from the devastating impacts of tuberculosis.

All are welcome to also attend Angus’s Upcoming talk in person or online 'Revisiting Consumption: Bridging Ancient Concepts and Modern Research to Uncover the Devastating Impact of Tuberculosis' on Friday 30 May (7pm), Uffington Village Hall, Uffington, Oxfordshire.

Those interested in hearing more about the work of THRU-ZIM, the upcoming talk, and discussing ways to support future research in Zimbabwe, are encouraged to contact Angus.