March 22, 2010

Heaven on Earth. That’s the first impression of the vista outside the New Haven Clinic, one of 17 health centers overseen by Doctors Without Borders/Médecins Sans Frontières (MSF) in the Shiselweni region of Swaziland. At the top of a verdant hill, the clinic is not far from a village, a few dozen houses, a church, and a school surrounded by fields and prairies. In the shadow of a large tree, three women sell colorful fruits and vegetables.

The bucolic scene is deceiving, however. Behind the clinic, some 30 patients wait in line—men, women, and children, all of whom have come to renew their prescriptions for antiretroviral medicines or to be tested for tuberculosis (TB). Like most villages in Swaziland, New Haven is being ravaged by the double-edged sword of HIV/AIDS and TB. One in four adults is HIV-positive and, more importantly, 80 percent of the thousands of people in the country who develop active TB each year also have HIV/AIDS

“AIDS and tuberculosis have caused great sorrow in the community,” remarks 62-year-old Sam Simelane, one of the few elders in the village. “Many people have died; many have lost their entire family.”

In Swaziland, as in most countries in southern Africa, TB has become the leading cause of death for people with HIV/AIDS. MSF has been intervening in Shiselweni Province since November 2007, helping to treat several thousand patients affected by HIV and/or TB. By the end of 2009, more than 2,700 TB patients in Swaziland were receiving treatment in centers overseen by MSF, including 105 with a drug-resistant form of the disease (DR-TB).

Tuberculosis Returns

At one time, TB was considered on its way to being eradicated. However, the disease, which in the past afflicted hundreds of thousands of “consumptives” in Europe and drove the most privileged of them into Alpine sanatoriums for treatment, started a frightening comeback beginning in the 1980s. The main hotbeds of this resurgence are southern Africa, southeast Asia, and central Asia—three regions where MSF teams are treating TB patients.

MSF-Switzerland is most active in Swaziland and Kyrgyzstan, where it treats patients with the disease. But MSF volunteers also care for TB patients in countries from Myanmar to Djibouti to Mozambique. While in Swaziland the combination of HIV and TB is taking a terrible toll, in Kyrgyzstan hundreds of TB patients are concentrated in the prisons, where TB prevalence is 20 to 30 times greater than it is in the rest of the population. MSF has been intervening since 2006 in two Kyrgyz penitentiaries, diagnosing and treating more than 1,700 prisoners in the process.

Anti-tuberculosis treatments are very restrictive, especially in the increasing number of cases wherein the disease is resistant to certain medicines. In addition to medical follow-ups, MSF optimizes patient treatment support as well. In Swaziland, as in Mozambique, MSF has trained “expert patients” who help others correctly follow their treatment through to the end. In Kyrgyzstan a team of MSF social workers and a network of volunteers bring aid to approximately 70 former patients who are ex-prisoners, so they can finish their treatment against the disease. The assistance includes advice, information, and training, as well as food and money for transportation.

Umutai Dauletova, an MSF social services coordinator in Kyrgyzstan, explains that it can be difficult for former prisoners with TB to gain admission to public hospitals: “Our patients are stigmatized in their community not only because they have TB, but also because they were in prison. Some of them are homeless, jobless, alcoholics, drug addicts, and even undocumented. We’re now trying to implement a case management system, a communal approach that volunteers can use to help patients adhere to their treatment.”

Resistance

The return of TB to the dire honor roll of global epidemics is accompanied by an even more worrisome phenomenon: the emergence of forms of the disease that are resistant to standard drug regimens. In these cases, the treatments—antibiotics discovered in the middle of the twentieth century—are no longer effective. When confronted with the resistances developed by some patients, health workers must prescribe a much longer, more difficult treatment regimen. And recovery is not always guaranteed. “These patients receive injections every day for an average of six months, and their treatment, which is based on multiple tablets, can last up to three years with numerous side effects,” explains Dr. Hermann Reuter, an MSF volunteer in Swaziland. These side effects range from unpleasant to unbearable, or even dangerous. Several TB medicines have horrible gastric effects and may lead to sudden nausea or kidney or liver dysfunction. The only way to fight these side effects is to take even more medicines in addition to the already extremely high number of daily pills.

“It was a nightmare,” says Ruslan, a Kyrgyz ex-prisoner who was cured of his MDR-TB by MSF. “You can’t even imagine how hard it was to take the medicines. You want to sleep, but you can’t. You’re tired, you have heartburn. You vomit, but you don’t feel better. I took the medicines even if I was at my worst, but my former cellmate couldn’t continue. The side effects were unbearable for him.”

The number of patients with forms of DR TB is climbing. Every year 120,000 people around the world die from it, while nearly a half-million new cases are identified. Among those, 97.5 percent do not have access to appropriate diagnoses or treatments and must try to carry on with this contagious, likely fatal disease. Most contract MDR-TB because they are not properly treated. However, increasing numbers of people are now being initially infected with a resistant strain of the disease.

Faced with the resurgence of TB and its malicious alliance with HIV/AIDS in certain regions, MSF cannot just treat patients. The organization also acts to improve the speed and accessibility of treatment. “We’re fighting on several fronts in our discussions with governments, the WHO”—the World Health Organization—“and pharmaceutical laboratories,” asserts Dr. Frauke Jochims, a referent doctor for TB at MSF headquarters in Geneva. “On the one hand, better tools for detecting and diagnosing TB need to be developed, especially for resistant forms of the disease. On the other, it’s clear that current antibiotics are both ineffective and the cause of unbearable side effects for patients. We need new treatments and quickly, medicines that are effective and affordable for developing countries.”

In Djibouti, for example, many of the malnourished children being treated at MSF’s therapeutic nutrition center also suffer from TB. Children are the most neglected among TB victims because, at present, the prevailing diagnostic tools do not suit their needs. MSF is insisting that laboratories develop formulas suitable for children.

The fight against TB should, unfortunately, remain a priority for MSF volunteers in the field in coming years.

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