All people with TB should be treated with antibiotics

Let's start off by looking at some facts. One-third of the world's population is infected with TB, the vast majority of these outside the U.S. Still, about 10,000 cases a year happen in the U.S., and the amount is declining.[1] The number of cases abroad, however, is growing by 9.2 million each year, and each presents as a possible source of spread in the U.S.[2] An untreated infection can lead to a person infecting 10-15 new people every year, as it is highly contagious.[2] It's a leading infectious killer among those with HIV/AIDS, which continues to be a major threat to the U.S., infecting over 1.1 million people.[2][3] This isn't unique to HIV, since anyone with a depressed immune system is at higher risk.[4] The majority of people can be cured of their tuberculosis with basic antibiotic treatment. This is mainly because doctors do actually prepare for antibiotic resistance, mainly by treating with 4 antibiotics at once " isoniazid, rifampin, ethambutol, and pyrazinamide. These were discovered 50 or more years ago in each case, and are both widely available and effective in the vast majority of instances.[6] Now, onto his points. I accept all of his points under background, as these are the realities behind TB. However, his evaluation of treatments is somewhat concerning, mainly because he's conflating a number of antibiotics, and leaving a large number out. Here's the full list (note that these are not all individual antibiotics): thioamides, cycloserine, aminoglycosides, PAS (4-aminosalicylic acid), cyclic peptides, and fluoroquinolones.[6] That huge list of side effects is accurate only if you look at certain subsets of these. I'll explore the specifics of these drugs' side effects more as I get into some rebuttal of his case proper, but any of these have their side effects listed on rxlist.com, drugs.com, and several are explained on Wikipedia. They are not nearly so deleterious as Con makes out. So let's look at the case. Note that, while he backs up his background analyses with links, he doesn't have any sources for his actual argument. And that's seriously important, mainly because I have no clue how he would plan to implement this. What suffices as low enough socioeconomic class in order to state that someone should be denied antibiotic treatment? Does someone on Medicaid not count as having the means to afford this treatment? How about anyone with subsidized health care? How would we determine if someone is a substance abuser, what substances must a person be abusing in order to be denied treatment, and how badly must that person be abusing said substances? How much nephrotoxicity and hepatotoxicity (not heptictoxicity, couldn't find that) must a person have in order to deny them access to treatment? Why can't the person make that decision themselves instead of the doctor? How will this toxicity be determined and assessed ahead of treatment? Beyond that, I don't know how he means to implement this. Would doctors now be required to deny patients access to these antibiotics, even if they ask? Should they have the ability to arbitrarily decide who gets antibiotics and who doesn't? If they decide to give everyone antibiotics, could they be sued by some government agency or group of doctors? Con's case is extremely vague. I don't know the answers to any of these questions, and I won't assume them. I invite Con to clarify his case in the next round by answering these questions. However, I still have responses to the case as given. 1) By denying treatment and effectively allowing these people to die, doctors would be spurning their duties. Con would like to assume that doctors should focus on the larger picture, but their duty is to their patients. Given his analysis, a patient entering the emergency room would be required to show proof of income before receiving antibiotic therapy. They would have their background checked for drug abuse, and probably have to have their bodies checked for signs of said abuse before treatment. Many of these people may be on the verge of death, and will be told that their treatment endangers others, so they can't get it. 2) From a basic logical perspective, doctors have incentive to prescribe. Patients who die or suffer as a result of a doctor's decision not to prescribe are incredibly likely to sue, and no matter what policy the government has in place, this is going to lead to a lot of substantial losses on the part of doctors. Con's putting them in a very bad place. He's either forcing them to reduce their overall prescriptions, denying access for many patients, and thereby inviting hundreds or even thousands of lawsuits, or he's encouraging them to ignore the policy, which means that it becomes completely ineffective and Con loses all solvency. 3) Con completely disregards the importance of transmission. The more people in the country who have TB, the more people will have TB as a result of transmission. These patients need to be treated in order to prevent its spread, that's part of the reason that the spread of TB has gone down so effectively. Even if you don't care about the patients themselves, these cases can easily spread the disease to others (10-15 people a year) while they live, and they get a tremendous number of opportunities to spread it to patients who are immunocompromised, thus threatening more lives severely. 4) This case is blatantly classist. Suddenly, only those that can afford to pay for the treatments (not necessarily even all those covered by insurance, though Con may clarify that that's the case) deserve to survive and flourish. Everyone else can suffer. 5) Apparently, alcoholics and smokers, who have legal access to the drugs they use, will be told they are now too much of a risk to receive adequate treatment for a deadly disease. Someone who receives regular injections as treatments for any number of diseases may be mistaken as a junky. The system would deny access for many who have no such history, and Con provides no basis for denying to this group whatsoever. 6) The vast majority of resistance is engendered abroad, and not in the U.S.[7] This isn't just due to the amount of cases we have (though that is a factor), but also a result of improved medical treatment and monitoring. We have an extensive system for keeping track of patients and ensuring that they are using their medication in the short and long term. 7) As for nephrotoxicity and hepatotoxicity, the sheer number of drugs I cited shows that there are a lot of options. Just looking through the side effects of each, I found several effective treatments that don't have one or the other: No recorded nephrotoxicity: rifampin, ethambutol, thioamides, cycloserine, aminoglycosides, and lassomycin (cyclic peptide) No recorded hepatotoxicity: aminoglycosides (includes streptomycin), PAS, lassomycin, and fluoroquinolones That's not to mention that many of the drugs that do have these toxic effects can be titrated to a specific dosage in order to ensure that the toxicity is minimized. But more importantly, recognize that many of these patients are in dire straits. They don't have a choice here, as TB is practically assured to kill them without treatment. It's better to suffer the uncertainty of toxic outcomes than it is to deal with the certainty of pervasive infection robbing them of their ability to breathe. So I propose a counterplan. This plan has three planks, which are explained below: 1) Improve access to antibiotics by making treatment more affordable. A nationwide program instituted by the CDC and NIH could ensure that we completely eliminate TB in this country by making these antibiotics available for cheap or even free to patients. 2) Improve the monitoring program in the U.S. The best way to do this is to uses directly observed therapy (DOT) in order to ensure that patients are taking the recommended dosage every weekday. These have been shown to be very effective.[8] Dosages can be modified to ensure more rapid completion of treatment or to reduce the number of times a patient has to take their antibiotics. Patient education can be improved. In the case of the poor, I would suggest improving access by providing free bus tickets and even food vouchers for those infected with TB that agree to participate.[8] This would include extensive monitoring over the first week or so, ensuring that patients who are susceptible to nephrotoxicity and hepatotoxicity are protected from possible harms and shifted to other antibiotics in the instance that they do present with symptoms. 3) Focus on improving the system of treatment. New detection methods are coming to the fore that are capable of rapid early diagnosis and even detecting drug resistance. This particular device, which can produce results in 2 hours, is called Xpert MTB/RIF.[9] We should endeavor to advance this technology, funding research with its parent company Cepheid to reduce its cost and improve its design. This would mean that fewer antibiotics would have to be used, and the duration of their usage could also be reduced. These would all far more effectively solve the problem without allowing patients to die or increasing the spread of this disease. It allows doctors to do their job without discriminating, as they should. With that, I hand the debate back to my opponent. 1. http://www.cdc.gov... 2. http://www.cnn.com... 3. http://www.cdc.gov... 4. https://www.clinicalkey.com... 5. http://report.nih.gov... 6. http://www.niaid.nih.gov... 7. http://www.medscape.com... 8. http://www.uptodate.com... 9. http://www.nih.gov...