Meet the Solutionists, with Mark Scott

You probably think TB is a disease of the past. But that’s not because we’ve beat it. It’s because we’ve moved it elsewhere. 

Every year, over 10 million people fall ill with tuberculosis and it's concentrated where people are poorest, where overcrowding helps it spread, and where a six-month treatment course can mean losing your job, or even your social life.

Professor Greg Fox is an infectious diseases physician who treats TB patients in Sydney and leads research across Southeast Asia. 

Greg outlines Australia’s responsibility to its neighbours in battling TB, and explains why cultural barriers like stigma make treatment so difficult in countries like Vietnam. 

Read more about tuberculosis in Everything is Tuberculosis by John Green.

Mark Scott  00:01

This podcast is recorded at the University of Sydney's Camperdown campus on the land of the Gadigal people of the Eora nation. They've been discovering and sharing knowledge here for 10s of 1000s of years. I pay my respects to elders past and present, and extend that respect to all Aboriginal and Torres Strait Islander people.

Greg Fox  00:30

Tuberculosis connects to so many different parts of history, so many parts of society. People like John Keats and Anne Brontë, Franz Kafka, George Orwell, Erwin Schrödinger, Louis the 13th and Edward the 6th, all died of tuberculosis. So TB has had a major effect historically. But if you look today, tuberculosis really falls in the dividing line between rich and poor, between people who have access to health care and who don't. In a way it's shocking, because we have treatments that can work. The main problem is that in those countries, people don't get diagnosed early, and so often they spread the disease before they come to the attention to healthcare services.

Mark Scott  01:26

It's killing millions of people, impacting more than 10 million new people every year, and yet, you probably almost never think about it. Maybe you didn't even know it was still around. Tuberculosis, or TB, is ancient. It's a bacterial disease that attacks the lungs, and it shaped human history, even influencing our architecture and urban planning. In the 20th century though, TB rates plummeted in wealthy countries. We developed treatments. We thought we'd won, but TB hasn't gone away. It's just concentrated in the places where people are poorest, where overcrowding helps infectious diseases spread rapidly, and where taking time off work for treatment often isn't an option. So what's preventing the solutions we already have from reaching the people who need them the most? And how can Australia help its neighbours defeat this deadly disease? This is the Solutionists, I'm Mark Scott. Professor Greg Fox is an infectious diseases physician who treats TB patients at Royal Prince Alfred Hospital in Sydney, and leads tuberculosis research across Southeast Asia. For the past 17 years, he's been working between Australia and Vietnam, training local health staff, running clinical trials, and redesigning how communities detect and treat tuberculosis. So Greg, I imagine that some of our listeners might be surprised that we're doing an episode on tuberculosis. Most Australians of this generation probably don't know much about TB, let alone know anyone who's had it. Can you tell us what tuberculosis does to the body, and then talk about the scale of the problem?

Greg Fox  03:18

Tuberculosis is a bacteria that's been around as long as human civilisation. It's caused by bacteria that lives mainly in the lungs, and it can spread through the air in small droplets. And so that means that in places where people are living close together, it's easy to spread. And if you're living in Sydney in 2026, then you probably never met anyone who had TB. But back in the 18th century, about 1/3 of the young population died of tuberculosis, and it was really only until the mid 1960s that the problem in Australia had been brought under control. So, our experience now in Australia is that we really protected from the effects of TB. But that's not the case around the world. In fact, in in the last year, there's more than 10 million people who develop TB, so it's actually as common numerically now as it ever has been,

Mark Scott  04:06

And the reason that we largely sold it in Australia was because of drug products that effectively treated TB?

Greg Fox  04:15

Look, it's fascinating that the decline in TB in Australia happened before drugs became available, and so we think it has a lot to do with the fact that the general health of the community improved, and also that people who were sick were were isolated from from other people. And in the mid 60s, there was a community screening program in Australia where X-Ray vans went round every year, and people had these TB screens. And we think that at that time, it really dramatically reduced the rate of TB in Australia, and so by the 1970s there was hardly any transmission.

Mark Scott  04:45

And do we see any incidences of TB in Australia today? 

Greg Fox  04:49

We do. So, I'm a respiratory physician, and I run a TB clinic here in Sydney, and we see around Australia-wide, around 14-1500 cases of TB each year. But 9 out of 10 cases occur in people who've been infected overseas. So very much, in order to stop TB in Australia, we need to be looking at TB in other countries, because that is where the TB transmission is occurring. 

Mark Scott  05:13

And if in fact you're diagnosed with TB, are there drugs today that effectively work and treat that?

Greg Fox  05:20

TB treatment in Australia is about 98% effective. So we have really effective drugs which work for almost all forms of TB, and there are some people who have drug resistant TB, where the treatment success is not as high. But even then, there's been a lot of progress over the last 10 years in developing new, better tolerated treatments.

Mark Scott  05:39

So, it's not really a problem in Australia, but with our near neighbours, this is a real problem. Why is it such a challenge still across Southeast Asia?

Greg Fox  05:49

So two-thirds of the global TB burden occurs in the Indo-Pacific region. And, so people who come to Australia from that region often have been infected there and bring the TB bacteria with them in their body. And we think that the reason it's so common in the Asia-Pacific region is that TB has been there for a long time, and as these countries have often had lower socio-economic development, TB’s spread much more easily. So countries such as Indonesia, Vietnam, the Philippines, and Papua New Guinea have extraordinarily high rates of tuberculosis still, and that's, in a way, it's shocking, because we have treatments that can work. The main problem is that, in those countries, people don't get diagnosed early, and so often they spread the disease before they come to the attention of their healthcare services. So one of the things that we're doing through our research here in the University of Sydney is trying to detect TB earlier, so we can prevent that transmission, which is what we think worked so well in Australia in the 1960s and 70s.

Mark Scott  06:47

So let's talk about the research journey that you're on now to diagnose people earlier and get effective treatments to them earlier. What's the key to successful early intervention and treatment?

Greg Fox  07:00

One of the things that we've learned in the last decade is that, surprisingly, about a half of the tuberculosis in the world is not symptomatic. And so that means that a lot of people are carrying the TB bacteria, and they're infectious, but they don't have any reason to go to see a doctor to get screened. And so, we've discovered that in Vietnam, around 35% of the whole community has been infected with TB at some point in the past. 

Mark Scott  07:27

I mean, so they've had it, whether they've been aware of it or not. 

Greg Fox  07:30

That's right, that's right. And so when we screen people in the general community, the people who are infectious, only about a half of them have symptoms. So what our research program has been doing is saying, “how can we go out into the communities, and how can we detect TB earlier?” There's a lot of new technologies that help us to do that. One of the real breakthroughs has been rapid PCR testing, which is testing for the DNA of the TB bacteria in the sputum. 

Mark Scott  07:54

Like we all did with COVID. 

Greg Fox  07:55

Yeah, like we did with COVID, except TB is a little bit more tricky to pick up on a point of care test. So we have these machines now that can diagnose it in less than an hour, just by putting a bit of saliva onto a test cartridge and then testing it. So that's a real breakthrough. We also have ways of detecting drug-resistant TB early as well, using the same techniques. And in the last 10 years, AI-guided chest X-Rays have also been a real breakthrough. It means that you can take this portable device out into the community, you can do a digital chest X-Ray and get a reading within a few seconds, and then the doctors or healthcare workers can make a decision about what to do. 

Mark Scott  08:36

So what's the role of AI in that X-Ray then? 

Greg Fox  08:38

So an X-Ray is taken with this digital reader, and a laptop computer will have an AI algorithm on it, there's a number of different ones. And the AI will essentially give a probability that this person has TB, and if it's above a certain probability, then the person will get further testing.

Mark Scott  08:55

And once you've run that diagnosis, then you have an array of medical interventions, drugs that you can then give to that person that cures them of the TB? 

Greg Fox  09:06

That's right. So standard TB treatment for drug-susceptible TB is six months long, and we usually use four drugs to treat TB. So it's not an easy disease to treat, but as I mentioned, the disease response is usually very good, so long as people take the treatment. One of the challenges that we've had in many places though, is getting people to complete treatment.

Mark Scott  09:28

I was going to say, it's kind of quite a disciplined effort isn't it, to stick on it for six months, particularly if you're not feeling sick.

Greg Fox  09:35

Completely, and as you've taken, say, two or three months of treatment, you feel almost back to normal. And so there's a lot of reasons why people might stop taking treatment. Now, here in Australia, we have ways of maintaining very close contact with people during treatment, and in fact, in New South Wales, we have video observation of therapy every day for people who take treatment. But in many places, that's not feasible because of the case numbers.

Mark Scott  09:59

Can I just ask? The failure to complete treatment, is that a driver of drug-resistant TB? 

Greg Fox  10:09

Yes. So, if you don't take the treatment, or you don't take it regularly enough, what that means is that the level of the drug in the blood can become low enough that the TB bacteria can evolve to be resistant to it. So, we do think that acquired drug resistance is really driven by people who have intermittent treatment. And there's good research to show that if you can make treatment support better, then that can reduce drug resistance, and if you can detect drug resistance early, then you can prevent it from becoming more amplified, so having more extensive drug resistance.

Mark Scott  10:41

And do you see a pathway where drug treatment isn't dependent on a six month course, but is more targeted, more specific, more immediate, and shorter term?

Greg Fox  10:54

Absolutely. A lot of the work that we're doing is focusing on individualising therapy. So what that means is using some of these molecular tests to detect the drug resistance pattern of a particular individual early and give them targeted therapy. And for people who have taken therapy, to try and shorten the duration of treatment. So in Vietnam at the moment, we're working with international collaborators to evaluate a four month treatment for tuberculosis, and there's a number of trials ongoing for drug resistant tuberculosis to also shorten treatment as well.

Mark Scott  11:28

So, you're based in Sydney, a professor here at the University of Sydney, but so much of your research work has been in Vietnam. Tell us about what you've learned from your time on the ground in Vietnam, about the contribution you can make to improve the efficacy of treatment of tuberculosis.

Greg Fox  11:48

Tuberculosis is common in Southeast Asia, and Vietnam is one of the high burden countries. And so it makes a lot of sense to be studying tuberculosis in settings where it's more common. I had the privilege of living in Vietnam for four years when I was studying my PhD looking at tuberculosis screening. And during that time, I had the opportunity to travel around the country and to meet local healthcare workers, meet with patients, and to try and help me to understand how tuberculosis was affecting people in Vietnam. What I learned was that there is a huge interest in tackling tuberculosis, but they lack often, the tools and the investment to do so. And often there's not good evidence to guide best practice. And so, over the last 15 years, we've been working very closely with our partners in Vietnam to develop new methods to screen and treat and prevent tuberculosis. It's really important that our efforts are guided very much by collaboration. So we're working very closely to understand what they see as their priorities, and then to develop research that can address that.

Mark Scott  12:55

Yeah, and talk a bit more about how being on the ground gives you insights that that you wouldn't have picked up or understood just trying to do this from afar, from Sydney.

Greg Fox  13:06

Look, it's critical, when working in an international setting, to be there and to spend time with people. When I was living there, I learned how to ride a motorbike, and I have vivid memories of riding through rice paddies on the way to the TB clinic to go and see doctors there, and stumbling through my broken Vietnamese to try and understand what the patients that they were seeing were experiencing, and to try and build capacity in TB screening. And that experience taught me that it's one thing to have a plan on paper, it's another thing, very different, to implement it in practice. So one of the real insights that I gained from living there was that there's a huge role for trying to look at how we take the treatments and the approaches we know work, and how to make it work in practice, and that translational research is just as important as the discovery research to develop new treatments and screening approaches. We're heading out to do a screening with the screening team in Khóm Phố, in Cà Mau. So, I'm about to go into a house with one of the screeners to do some TB screens. 

Mark Scott  14:31

One of the things you see increasingly in health-related research, I think, is drawing on the experience of the patient. I suppose you probably wouldn't really call them a customer, but almost like the voice of the experience from the person who is unwell and receiving treatment. How is the voice of experience like that played a part in the research work you're doing in Vietnam on tuberculosis?

Greg Fox  14:56

Involving patients in the research journeys are incredibly valuable. It's important to help us to see what is actually important for people with tuberculosis, and it's important for us to then be able to design the research in a way that will help them to engage with us. An example is in Vietnam, we have since 2019, had a consumer advisory board where we involve TB survivors and healthcare workers in a group that whenever we develop a new project, we talk to them about their project, get their feedback and input, and that is incredibly valuable for us. At the University of Sydney, we're hosting a Centre of Research Excellence in tuberculosis, supported by the National Health and Medical Research Council, and Professor Sarah Bernays, who's one of our academics, is leading the work into consumer engagement within tuberculosis, not just in Vietnam and Australia, but much more broadly. We've discovered that the more you involve consumers, the more you involve patients in these discussions, the better the research will be, and the more relevant it will be when it finally is completed.

Mark Scott  15:58

And can you think of examples where your approach has changed or been developed because of the insights you've had from patients?

Greg Fox  16:06

A trial that we've completed recently in Vietnam, the V-SMART trial, was looking at the use of mobile phone app support for patients with drug resistant tuberculosis, and we worked very closely with social scientists to understand how patients use the smartphone app. And you would think, well, you know, it should be obvious, if you give them an app, then it will work. But what we discovered was that there's a whole lot of other things around the app, you know, the way the app interfaces with the health system, the way that people who maybe have limited literacy use the app. There's many challenges that we need to evaluate when we're looking at how the how the app works. And so, we performed a series of studies before we started the trial and during the trial to see how we could optimise the use of the app. And so now that we've completed the trial, the qualitative research is really important to help explain our findings, and it will be important when we're developing the next technology-based study,

Mark Scott  17:08

I can imagine, if you got a diagnosis of TB in Sydney, you'd immediately get medical treatment and hopefully be on the road to recovery very quickly, but you've discovered through your research in Vietnam, there are deep cultural issues, including a stigma that is attached to the disease that can make identification and treatment more difficult.

Greg Fox  17:27

Stigma is a really major challenge for people who have tuberculosis. A PhD student of mine, Sarah Redwood, looked at stigma in drug-resistant tuberculosis in Vietnam as a part of her research, and she found that there are extraordinarily high rates of stigma. That is, people perceive that they will be excluded from society, that they may lose their job, and that their family may disown them if they have TB. And in the cultural context of Vietnam, it's seen as being a sign of moral failing, as well as physical weakness, to have tuberculosis. So you can imagine, if somebody gets that diagnosis, then all of these messages that they've grown up with through their cultural upbringing will influence the way that they think of their own disease. That's one of the reasons why here in Australia, it's so important that when we're providing clinical service, that we try and destigmatise TB, and not blame the person who has TB, but try and support them. And also, to try and make the health care experience one which is not stigmatising. The challenge is though, when you're in, say Vietnam, and you're wanting to screen people for TB, they often don't want to know that they have the disease, because of all of the secondary consequences that that brings. And that's where it's so important to develop health promotion campaigns like was done with HIV in the 1990s and 2000s to try and show people that there's a solution, that it's not a fatal condition if they take treatment, and that they will benefit themselves and their communities from doing so.

Mark Scott  18:52

You've done such important work in Vietnam. How significant are those findings and those insights and the success you've had applicable in countries like PNG and Indonesia and other places in the region that have significant rates of TB?

Greg Fox  19:07

In Vietnam, the work that we're doing is about developing evidence that is applicable beyond Vietnam. And in fact, some of the studies that we've done, looking at TB screening and TB prevention have influenced WHO policies, and then those policies are taken up in other countries in the region and globally. An example is the work that we've done looking at prevention of drug-resistant tuberculosis. Our VQUIN trial in Vietnam found that we could halve the rate of drug-resistant TB among people who are at high risk. And just last year, the WHO made the treatment that we evaluated, a six month antibiotic, the recommended treatment around the world. And so now that is being used throughout the Asia-Pacific region to prevent drug-resistant TB, and we're also using that treatment in Australia. 

Mark Scott  20:06

One of the very interesting things in the last year or so is this book by John Green. I know you've got a copy there. I mean, listeners probably know of John Green's work. I mean a phenomenally popular writer, particularly of young adult fiction, very popular on YouTube, and then all of a sudden, he develops a book on tuberculosis. Tell us about the book, and tell us why you think at this time, this book is of real significance.

Greg Fox  20:34

You're right John Green has really become a major advocate for tuberculosis globally, and it all began when he visited Sierra Leone about 10 years ago, and he was visiting a TB hospital and met a young boy called Henry who had drug resistant tuberculosis. And over the years after he met Henry, he went through the journey of treatment with Henry, and saw him go through the challenges of having to take these very long and complex treatments. And what John Green discovered was that tuberculosis connects to so many different parts of history, so many parts of society. So TB has had a major effect historically, but if you look today, tuberculosis really falls in the dividing line between rich and poor, between people who have access to healthcare and who don't. And so John Green has taken this really serious and widespread disease and used it to frame the broader conversation around inequality globally as well. 

Mark Scott  21:28

And do you think that will have an impact more broadly? You know, being such an influencer of public sentiment and public culture, what do you hope the impact of his work and and leadership of advocacy might bring?

Greg Fox  21:43

The big challenge that we have in tuberculosis is that often patients don't have much of a voice when it comes to investment and when it comes to global policy. And so John Green, by standing up and being willing to advocate for people with TB, I think raises awareness, and therefore can give permission for politicians and leaders to invest in tuberculosis. We're actually very fortunate in Australia that we are a major investor in tuberculosis globally. Our government gives to the Global Fund, and also we have significant investment through our national Department of Foreign Affairs and Trade, and also NHMRC in tuberculosis. And people such as John Green, I think, can help to show our leaders the importance of that investment. And the way that he illustrates in his story the effect on one individual, I think, helps to go and puncture that problem that we often have of looking at numbers and statistics and show that this is a real disease, it affects real people.

Mark Scott  22:35

And if we were looking to humanise TB in Australia and increase awareness of its impact on our neighbours, and therefore its impact on our part of the world, how would you have Australians think about TB in this era?

Greg Fox  22:51

Just like John Green's experience, I think we need to try and think of this disease as affecting individual people. I'm reminded of a patient of mine from my clinic. We'll call him Eddie, who came to me about six months after he had moved to Australia to work in a factory, and he had a six month old child, and he developed a cough, and about a week later, he was diagnosed with tuberculosis, and he was found to have the drug-resistant form of TB called multidrug-resistant TB. And that diagnosis, for more than 18 months changed his life. He had to stop working, he had to be isolated, he wasn't able to see his six month old child, and he had to take treatments which affected his eyesight and also caused nerve problems. In the end, he was able to be cured, but that journey was for him a real life-altering experience and for him, his wife and his child, you know has had major impacts. And if he had had that disease in another country, he may not have survived, but thanks to the availability of free treatment here in Australia, he was able to be cured, go back to a normal life, and you know, I saw his child five years later, and it was just lovely to see them together and to see how life had gone on. So I think from the Australian perspective, trying to relate to the experiences of people with TB is important. I also think it's important as Australians that we recognise we have a responsibility beyond our own shores as well. Because we have such bilateral trade and relationship with our region, I think we have an important responsibility to be working with them to look at tuberculosis. There's more than a million people from Southeast Asia living in Australia, and Southeast Asia is a place where there is a lot of TB, so it makes sense for us as researchers, as clinicians, to be trying to reach out and engage and see how we can contribute not just to the TB that occurs here, but also upstream to the TB that's occurring in poorer parts of our region.

Mark Scott  24:42

One of the fascinating things about working at the university is you come across brilliant people. You're one of our brilliant researchers, globally renowned for this work, but I'm very interested in how someone like you almost came to be almost enthralled by the intellectual challenge of this particular disease. Talk a little bit about your career and your research career, and what led you down the road of global leadership in the treatment of tuberculosis. 

Greg Fox  25:13

I think there's two aspects to it. There's the head aspect and the heart aspect. For me in 2000, when I was a medical student, I spent a couple of months in Blantyre, Malawi. And this was at the peak of the HIV epidemic there, where people were dying, mostly of tuberculosis, but of other diseases alongside HIV, which made the immune systems very vulnerable. And I could see at that point that this was such a contrast to the privileged, well-resourced setting that we lived in in Australia, where I'd done most of my medical training. So I think from the heart perspective, that motivated me to say, look, I have a responsibility as a doctor, as a future doctor, to do more than just treat patients that I see in front of me. And, I could see that it wasn't just purely about the treatment, it was about the health system and about the public health solutions as well. Then the second is the head component that is, tuberculosis is a really fascinating disease. It's been, as I said, present in human society for millennia, and despite the fact that we've spent a huge amount of time and resources looking at research into TB, we still don't know how to detect it early enough, and we still don't have a very good understanding of its biology. And so, tuberculosis provides a really fascinating area to study, because there are so many unanswered questions. One of the unanswered questions is, why is it that tuberculosis turns on at certain points in time? People can have the bacteria for years, and then suddenly it will wake up and affect them. Another unanswered question is, why is it that some people respond well to TB and other people don't? And also, how do we take the treatments and the evidence that we have from a setting where we know it works very well, and how do we translate it into other settings? So I find it fascinating from the perspective of having so many questions to still answer, I think that's the challenge.

Mark Scott  27:08

And if you look ahead in your career, and you think maybe, you're a young man Greg you know 25 more years at this, what excites you most about what's on the horizon? You think of technology, you think of drug development, you think of AI as a factor in all of that; what gives you hope of transformational breakthroughs in the treatment of TB?

Greg Fox  27:30

I think we know now a lot more about the problems that we need to solve, and so I think that it's exciting that we're now starting to take steps towards solving those problems. For the last 15 or 20 years, under the WHO’s DOTS strategy, the strategy was, wait till people come to the hospital and then we'll treat them. And we've discovered over recent years that that's just not enough, and so now there's a lot more recognition that we need to be much more proactive in going out into the community. We did a big study called the ACT3 study in Vietnam, where we screened around 100,000 people, and we showed that if you do screening every year for three years, that you can reduce the rate of TB in the community by about a half, which is a major breakthrough. Now building on that research, there's now a lot more investment in community mobilisation going into the community, to go and find people with TB. So I'm really excited that that shift in thinking has occurred, and now there's a lot more investment in that community-based approach. It's also exciting that we have new treatments that are much shorter and potentially much less toxic. There are trials underway at the moment of treatment for TB infection as short as one month. There's work being done looking at long-acting injectables, so maybe one shot, and then that's the end of your treatment. And there are new drugs that are coming on the market, which are next generation drugs that are likely to be less toxic for patients. So I think all of those things are very exciting. The challenge is we need to lift our ambition and lift our investment, like with the HIV pandemic. We need to have advocacy here in Australia and other western countries to mobilise the resources that are needed. Back in 2000 you wouldn't have guessed that HIV could become a problem that is soluble by large scale investment in antiretroviral drugs so that HIV becomes another chronic condition. We need to make tuberculosis the same, we need to invest majorly so that we can make TB history.

Mark Scott  29:27

That's Professor Greg Fox from the University of Sydney. He's the director of the Sydney Southeast Asia Centre and director of the Research Centre of Excellence in tuberculosis. And if you want to hear more about the future of medicine, you'll enjoy our episode with Professor David James, who's working on making medicine so precise that it can be matched to your DNA.

David James  29:51

What I would like to see is if we could do a test on people right at the get go, and that test would tell us “you should be taking drug Y”, so that you immediately prescribe drug Y, save all those problems, and you save the potential dangerous adverse effects from taking four medications instead of one.

Mark Scott  30:17

You can listen to that episode of The Solutionists right now, and if you want to hear how the best minds in the world are tackling the biggest challenges, make sure you follow the show in your favourite podcast app so you don't miss an episode. The Solutionists is a podcast from the University of Sydney, produced by Deadset Studios. 

The Solutionists is a podcast from the University of Sydney, produced by Deadset Studios. Keep up to date with The Solutionists by following @sydney_uni on Facebook and Instagram, and @sydney.edu.au on Bluesky.

This episode was produced by Liam Riordan with sound design by Jeremy Wilmot. Supervising producer is Sarah Dabro. Executive editors are Kellie Riordan, Jen Peterson-Ward, and Mark Scott. Strategist is Ann Chesterman.

This podcast was recorded on the land of the Gadigal people of the Eora nation. For thousands of years, across innumerable generations, knowledge has been taught, shared and exchanged here. We pay respect to elders past and present and extend that respect to all Aboriginal and Torres Strait Islander people.