March 25, 2008 The Pump Handle 0Comment

Rachel Nugent at Global Health Policy reminds us that it’s World TB Day. She’s got good news and bad news about tuberculosis around the globe. On the plus side, tuberculosis control funding has reached an all-time high, and the number of TB cases per capita has dropped. On the minus side, the number of cases is increasing, and more and more of these cases are turning out to be resistant to many of the drugs generally used to fight them.

In today’s New York Times, Celia W. Dugger looks at the lives of South Africans with MDR and XDR TB (MDR is multi-drug-resistant, XDR extensively drug-resistant). Many of them are held in a hospital that’s essentially “a prison for the sick”:


“We’re being held here like prisoners, but we didn’t commit a crime,” Siyasanga Lukas, 20, who has been here since 2006, said before escaping last week. “I’ve seen people die and die and die. The only discharge you get from this place is to the mortuary.”

Struggling to contain a dangerous epidemic of extensively drug-resistant tuberculosis, known as XDR-TB, the South African government’s policy is to hospitalize those unlucky enough to have the disease until they are no longer infectious. Hospitals in two of the three provinces with the most cases — here in the Eastern Cape, as well as in the Western Cape — have sought court orders to compel the return of runaways.

If patients feel that a diagnosis will lead to imprisonment, they may stay underground and avoid treatment – and thus keep spreading a disease that’s very difficult to treat. Some experts argue that it’s better to treat patients at home, and part of the reason is a lack of sufficient hospital facilities:

But other public health experts say overcrowded, poorly ventilated hospitals have themselves been a driving force in spreading the disease in South Africa. The public would be safer if patients were treated at home, they say, with regular monitoring by health workers and contagion-control measures for the family. Locking up the sick until death will also discourage those with undiagnosed cases from coming forward, most likely driving the epidemic underground. …

Further complicating matters, South Africa’s provinces have taken different approaches to deciding how long to hospitalize people with XDR-TB. In KwaZulu-Natal, the other province with the most cases, the main hospital is discharging patients after six months of treatment, even if they remain infectious, to make room for new patients who have a better chance of being cured. The province is rapidly adding beds, part of a national expansion of hospital capacity for XDR-TB. …

At Jose Pearson [Hospital], patients who have different degrees of drug resistance — with XDR-TB being more deadly than multidrug-resistant TB — live in different quarters, but they mix on the grounds. Infectious disease experts say that some of the multidrug-resistant patients are likely to catch the more severe XDR strains of tuberculosis directly from their fellow patients.

Peter Jantjes, the chief professional nurse in Jose Pearson’s XDR-TB unit, said that multidrug-resistant patients were turning into XDR-TB patients at an “intense rate.”

In the Washington Post earlier this month, Stephen Glain looked at TB-fighting efforts in North Korea, where the gulf between needs and facilities is tragic. Glain profiles Stephen Linton, who travels to North Korea regularly to distribute medicines and other supplies to tuberculosis patients and the hospitals that treat them. Here’s one snapshot from a recent trip:

The patient is a young woman whose lower spine has been corroded by tuberculosis. She is lying on her side on the operating table, and an orderly is coating her lumbar region with disinfectant iodine. The surgeons will try to repair the damaged vertebra by grafting onto it a slice of bone taken from the patient’s pelvis. There is no heat. Barring complications, the operation should take two hours, which would be plenty of time during the summer months, but could be a close call this late in the year.

Linton, 57, stops to peer through a window from the operating room’s antechamber.

“I’ve seen doctors who tried to capture sunlight by reflecting it from a mirror,” he says.

By North Korean standards, the patient is fortunate. She’s been given a local anesthetic, which is rare in a country where surgeons routinely etherize patients, strap them down and try to finish the operation before they come to. The operating table is less than a year old, as are the surgeon’s instruments and the handcarts on which they’re arrayed. Also new are the hospital’s X-ray machines, electrocardiogram, oxygen tanks and wheelchairs. All this is courtesy of Linton’s Eugene Bell Foundation, a Maryland-based nongovernmental organization that has spent the past decade battling a raging tuberculosis epidemic in areas of North Korea where few foreigners have been allowed to travel.

It’s been 126 years since Dr. Robert Koch discovered the TB bacillus, and we still have a lot to learn about how to defeat the disease.

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