Covenant of trust

Whether Andrew Speaker goes down in history as a 21st-century Typhoid Mary depends on the fates of about 80 airline passengers whom he exposed to extensively drug-resistant tuberculosis (XDR) traveling to and from his honeymoon. Since his transatlantic travel ended in late May, the Centers for Disease Control and Prevention (CDC) worked with governments around the world to track down passengers from Speaker's flights to and from Europe, as well as his family and co-workers, to urge them to be tested for TB.

Meanwhile, members of the press accused Speaker and the health officials who knew about his infection of neglecting public safety.

"In many ways we balance individual freedoms and public good," said Martin Cetron, CDC director of global migration and quarantine. "And we depend on a covenant of trust, and not every one of these situations, in fact, the vast, vast minority of situations of infectious tuberculosis drug resistant or otherwise, require legal restraining orders in order to keep people from moving, in order to encourage them to do the right thing."

The CDC and the World Health Organization recently publicized the dangers of XDR on World TB Day, March 24. An outbreak of XDR killed all but one of more than 50 infected hospital patients in 2005-2006 in South Africa.

Now the CDC is working through the kind of scenario it warned might happen if global TB surveillance did not improve. In a May 30 press conference, CDC officials talked about the challenges in Speaker's case of coordinating between several countries' public health systems and getting access to international airline passenger information.

TB is a bacterial infection that slowly settles in the lungs, gradually damaging them over time. The disease only spreads from person to person after hours of contact in close quarters. Treatment requires at least a six-month course of antibiotics, many of which are not effective against XDR. A person can have TB for a long time without experiencing any signs or symptoms of the disease. So-called "latent TB" is not contagious.

But Speaker did not have latent TB; signs of the disease showed up on a chest X-ray that doctors originally took for an unrelated reason. It can takes weeks to determine whether a case of TB is drug resistant, and tests were still underway when Speaker left May 12 for his wedding in Greece. Speaker's family claimed in news interviews that doctors advised him before his wedding that he was not contagious, but he should still not travel. He found out about his XDR status while honeymooning in Italy.

He said he ignored the CDC's admonition to seek treatment in Italy and not to fly home on commercial aircraft because he feared he might die if he did not get medical attention in the United States. With the U.S. government's "no-fly order" against him, he flew to Montreal on May 24, then drove back into the United States.

When he arrived back at the CDC in Atlanta, doctors there said Speaker looked healthy and did not feel ill. His lack of symptoms helped him get through U.S. Border Patrol despite a government order to detain him.

Since his return, questions have swirled about who knew what, when, and what Speaker, his family, and the government could have done differently. Speaker's father-in-law, Robert Cooksey, is a TB researcher at the CDC. So far, officials have found no link, other than coincidence, between Cooksey's work and Speaker's illness.

"He wouldn't put us in harm's way and clearly he knew what Drew had and the level of severity and contagion," Speaker's wife, Sarah, said about her father in an interview with ABC News.