The disease is not new and neither is the cure. This poses a problem for the doctors of Khayelitsha. The means of diagnosing tuberculosis was established long ago, and the rigid regime of drug treatment that once led to predictions of its eventual eradication has been in place for 40 years.
But in Khayelitsha township, near Cape Town, rampant HIV/Aids is not only driving a TB epidemic but distorting the disease so that it bears only a faint resemblance to that which blighted developed countries until the 1950s.
”TB is a different disease now,” said Peter Saranchuk, a doctor at the Médecins sans Frontières (MSF) clinic in Khayelitsha. ”Twenty years ago, it was mainly of the lungs and you could diagnose it from a cough. Aids has changed that. If someone is HIV-positive, they’re more likely to get TB in other parts of the body. It constantly amazes me the places you can get TB in. There’s abdominal TB, TB meningitis, TB of the breast, TB of the kidneys. It can hit you anywhere between your feet and your brain. This is a new phenomenon.”
Khayelitsha sits at the heart of a worldwide TB epidemic that has hit South Africa hard. The level of infection in the township is now four times that at which the World Health Organisation declares a medical crisis, and is continuing to rise. But ask about tuberculosis on the streets of Khayelitsha, and almost everyone jumps to the same conclusion: what you are really talking about is Aids.
TB is the single largest killer of people with Aids.”TB and HIV are double trouble,” said Dr Saranchuk. ”The chances are that if you’re being treated for TB then you have HIV. One person with HIV has a 10% chance every year of getting TB because of the living conditions. People live on top of each other in shacks. If one person is coughing, everyone is affected.”
Nozyoho Wana, who has two children, takes 22 pills daily, at four different times, to treat HIV and the TB that almost killed her. She was diagnosed when she fell so sick that she had to be carried to hospital. Her CD4 count — an indicator of the immune system’s strength — was 31. The WHO recommends anti-retroviral treatment for Aids when the CD4 count falls below 200. ”I was really lucky because I was really sick. I had piles and I couldn’t go to the toilet, and I had sores on my feet and I couldn’t walk,” she said. ”I thought it was Aids, but I had no idea I had TB.
”Now I’m being treated for both. I have to take pills in the morning and evening and come to the clinic every day. They tell me that if I do not stick exactly to the programme I will die.”
Once Wana was established on the anti-retrovirals, she was permitted to take a fortnight’s supply of drugs home. But treatment for TB is traditionally much more rigid. The WHO insists that patients are closely monitored to ensure they take their drugs precisely on time by attending a clinic each day.
But MSF is treating more than 2 000 patients for TB and Aids at its Ubuntu clinic in Khayelitsha, and says there are not enough doctors and nurses to see the rising number of patients every day.
Saranchuk says the problems of TB are compounded by the means of diagnosis, which takes six weeks to produce a result. ”Our problem is that we are treating TB with tools developed 40 years ago for a very different kind of disease, and with drug regimes that were never designed for dealing with this scale of infection or for people who are also combating another major disease,” he said.
MSF established the Ubuntu clinic — the name means ”togetherness” — as the first in South Africa where patients see a single doctor for both TB and HIV.
”We had to construct it in the face of many political obstacles,” said Eric Goemaere, head of the MSF operation in the township. He is no stranger to political controversy. He opened the first clinic to provide anti-Aids drugs in South Africa in defiance of opposition from President Thabo Mbeki.
But the issue of treating TB is a fraught one. MSF wants to train nurses to take on the role of doctors in monitoring patients, and to ease the rigid monitoring of those people with a proven track record of taking drugs for HIV. It says the long waits at clinics each day for people trying to keep a job and look after a family are a major reason for dropout, particularly after the first month when TB symptoms disappear.
”The TB culture is the Stalinist public health culture,” said Goemaere. ”It is completely standardised. In the HIV culture, it is patient-centred, aimed at helping the individual. The TB world is not interested in the individual patient. It is interested in stopping transmission and the spread of the disease. We have to change this or we are never going to be able to cope with this disease.” – Guardian Unlimited Â