Dilemma over TB
South Africa tries to balance individual rights versus public good as it faces an epidemic of drug-resistant tuberculosis
By Mariette le Roux, Agence France-Presse
CAPE TOWN
A guard in a surgical mask patrols a wire fence designed to keep dozens of patients with a lethal form of tuberculosis at Cape Town's Brooklyn Chest hospital isolated from the rest of the world. Inside the ward, sufferers of extreme drug-resistant tuberculosis (XDR-TB), a near untreatable strain of the disease, battle boredom, depression, and the side effects of a daily palmful of pills. None know how long they have to live.
As doctors and government officials scratch their heads over the inherent clash between individual freedom and the public-health risk posed by XDR-TB, patients are more concerned about when, if ever, they can return home.
"I feel like I'm in prison," a 25-year-old bookkeeper complained from her hospital bed in the female section of the ward. "I am bored and I want to get out of here." She's in her seventh month of hospitalization.
A two-meter-tall fence was erected around the XDR-TB ward recently in a bid to dissuade anyone from fleeing the hospital, even as doctors lack the legal tools to forcibly confine patients or compel them to take medication.
"We encourage them not to leave-by law, you can't force them," said an exasperated Dr. Simon Moeti, senior medical superintendent at Brooklyn Chest.
The facility set a national precedent last year by obtaining a court interdict against four of its patients who absconded repeatedly and put their loved ones at risk. The court ordered the four to return to hospital, to be discharged only once they have tested negative for three consecutive months. One has since died and the other three ran away again.
But health facilities still need to apply for individual court orders that are both costly and time-consuming, and therefore essentially rely on the goodwill of patients to remain isolated from the rest of the world.
"The court interdict was really a painful decision," said Dr. Krish Vallabhjee, the health-department official responsible for TB hospitals in South Africa's Western Cape province, of which Cape Town is the capital.
Refuse and die
Some of the occasional absconders were breadwinners who felt they had left their families in the lurch.
"There are two aspects to it," said Vallabhjee. "One is the public-health risk. The other is, having confined them, getting them to comply with treatment. If they refuse, they will die here. It is a very awkward situation."
Resistance to TB drugs can develop when patients fail to take their medication as prescribed, and in a minority of cases through direct transmission from person to person. Multidrug resistant TB (MDR-TB) fails to react to the two most powerful anti-TB drugs, while XDR-TB is resistant to these and at least two others.
While six months of outpatient treatment for non-drug-resistant TB costs about US$55, XDR-TB drugs cost around US$13,750 and patients require up to 24 months in hospital.
At a recent lung-health conference, South Africa's health department said 391 cases of XDR-TB were diagnosed between January and October last year, compared with 74 in 2004. And it said it was mulling legislative amendments to deal with the issue of mandatory isolation and treatment.
"What you have at the moment in terms of the South African constitution, is that in each case we want to deal with we have to seek legal recourse," said director general for health Thami Mseleku. "It is a process that takes a lot of time and energy. We are looking at whether we can find clauses in our legislation that will allow a general approach to the matter."
About 120 MDR-TB and XDR-TB patients escaped from hospitals in the Eastern Cape province in December alone. At Brooklyn Chest, 60 XDR-TB patients were admitted since September 2006. Twenty have died, but none have been cured or discharged.
"It is too early in the XDR epidemic to know exactly what the cure rate is," said Vallabhjee. "But it is fair to say the prognosis is not good." He cautioned against steps that patients could perceive as punitive, saying this would discourage the afflicted from seeking help in a country where stigma and fears of bewitchment already complicated TB treatment.
Instead, institutions like Brooklyn Chest were doing what they could with limited resources to make their facilities as friendly as possible. The female XDR-TB ward sports a television and a few centrally placed chairs around a rickety table decorated with a plastic cloth and a clutch of flowers that attempts to offset the sterile environment and heavy aura of doom. But most choose to spend their days in bed and a recreational area with scanty gym equipment, a pool table, dart board, and a reading nook goes mostly unused.
"The patients are depressed," nursing sister Johanna Blackburn, 54, says through her mask. "The medicine upsets their stomachs, it makes them dizzy. And they feel like they live in a jail."
With hopes for a new drug still years off, people like Blackburn do what they can to balance patients' needs with those of society at large. "We are chasing our tail, basically, trying to keep up," said Vallabhjee.
M
TEEN THREAT
Obesity among American teenagers could lead to double-digit increases in cases of heart disease
CHICAGO
The epidemic of obesity among American teenagers could lead to double-digit increases in cases of heart disease and heart-disease-related deaths by 2035. In a paper published in the New England Journal of Medicine, researchers said today's epidemic was setting the scene for tomorrow's public-health crisis, one that doctors will not be able to head off with traditional drugs for blood-pressure and cholesterol lowering.
"Today's adolescents are the young adults of tomorrow, young adults who would ordinarily be working, raising their families, and not worried about heart disease until they are much older," said Kirsten Bibbins-Domingo, assistant professor in medicine, epidemiology, and biostatistics at University of California at San Francisco. "Our study suggests that more of these young adults will have heart disease when they are 30-35 years old, resulting in more hospitalizations, medical procedures, need for chronic medications, missed work days and shortened life expectancy."
Using computer modeling, the researchers projected that up to 37 percent of men and 44 percent of women who will be 35 in the year 2020 will be obese, based on the numbers of teenagers who were overweight in 2000. These young adults are expected to have more heart attacks, more chronic chest pain and more premature deaths before they reach age 50 than previous generations.
The researchers said the lifestyle-driven disaster could increase the number of people with heart disease 16 percent-100,000 more cases-over today's levels by 2035. The increase in obesity-related heart-disease deaths could shoot up by as much as 19 percent, according to the projections in the study.
"We must recall that we all tend to gain weight as we age, so overweight in adolescents means even higher weights later on," said Lee Goldman, senior author of the paper and dean of Columbia University Medical Center in New York. "Although the general findings of our analysis are not surprising, we were struck by the sheer magnitude of the impact of adolescent obesity and, as a result, how important it is as a public health priority."
Some nine million US adolescents are overweight, according to the National Center for Health Statistics of the Centers for Disease Control and Prevention. Childhood obesity rates have tripled since the 1970s, and studies show that 80 percent of overweight adolescents become obese adults.
The findings also suggested that aggressive drug treatment would reduce but not eliminate the projected cardiac complications.
M AFP
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