20 March 2009

Quarantine controversy

Critics say enforced quarantine is a violation of medical ethics and individual human rights. Health authorities say they have no choice.

Behind high wire fences patrolled by security guards to prevent escape, a drab building used more than a century ago for smallpox victims houses patients with the latest virtually incurable disease: super-drug-resistant tuberculosis.

Among them is a minibus taxi driver who reluctantly agreed to be admitted after exposing hundreds of people every day to his potentially lethal germs.

Enforced quarantine is highly controversial. Critics say it is a violation of medical ethics and individual human rights. Health authorities - who resorted to the courts to compel patients to stay at the hospital - say they have no choice.

"There are challenges without answers," said Simon Moeti, medical superintendent of the Brooklyn Chest Hospital. "There are people who are refusing treatment, people who want to abscond," he told journalists visiting the clinic on the sidelines of an international TB conference.

Moeti and other health professionals say that facilities like Brooklyn are like a Band-Aid to a gaping wound, given the spread of Aids and a related upsurge in TB cases, including multi drug-resistant (MDR) and the even more untreatable extensive drug-resistant (XDR) strains.

South Africa reported 343 000 TB cases in 2006, of which an estimated 6 000 were multi drug-resistant. The government says that there have been about 400 cases of XDR-TB, but groups like Medecins Sans Frontieres say this is a big underestimate.

Testing is inadequate
Testing methods are hopelessly slow and out of date - and it is particularly difficult to diagnose TB in HIV-positive people - nearly 60% of TB patients have the Aids virus; many people with drug-resistant TB die before they are tested and treated - having probably infected other people in the meantime.

The drugs are also woefully outdated and inadequate. The Global Alliance for TB Drug Development told the conference that trials of two possible drugs were promising. One of them, antibiotic moxifloxacin, could shorten treatment time and the other, PA-824, had potential for drug-resistant strains. But even if clinical trials are successful, it may take years for the drugs to reach the market.

"We can't wait that long. We need new drugs now," said Winston Zulu, a Zambian Aids and TB activist who lost four brothers to TB.

Drug multinational Eli-Lilly is offering hard-hit TB countries the technology and know-how of two of its antibiotics used in a four-drug cocktail for drug-resistant strains, and is training health workers.

But experts worry that the drug-resistant strains will continue to spread - largely the result of people not sticking to the six-month course of treatment.

64 cases in Western Cape
In the Western Cape province 64 cases of XDR-TB were identified last year, according to local health officials. Twenty of the patients have died and 39 of the survivors are currently being treated at Brooklyn - some in the fenced-off ward and others elsewhere in the hospital.

The youngest is just a year old. Her mother died a year earlier, before local authorities started testing for XDR-TB although that was most likely the cause, said clinic chief Moeti.

"But she's doing OK," he said, picking up the child who was sitting with other infants. He refused to divulge identities because of confidentiality, and journalists were not allowed to speak to patients in the 308-bed clinic.

The clinic - a collection of small scattered buildings - was purchased from a farmer in 1872 because of its isolated location. It was initially used for smallpox, then for the big influenza epidemic and now for TB.

Structurally there have been few changes in the past century. Although the clinic is in dire need of a coat of paint, Moeti says its design allows for good ventilation - TB thrives in closed spaces.

Patients hate it
Patients hate going there - because of the stigma of TB and its association with Aids. The hospital constantly struggles to get staff.

It was bad enough before, but the arrival of XDR-TB has made it even worse, said Moeti.

Hospital authorities reluctantly decided to erect the fence around the XDR-TB unit after four patients absconded.

Two guards, both wearing protective face masks, stand by the fence. Any patient wanting to go to another part of the hospital has to be accompanied. Family visits are allowed but are strictly controlled.

Patients sleep or sit listlessly in the 12-bed women's ward, which is equipped with a TV, a fridge and a table with a couple of loaves of bread. It's a similar scenario in the men's ward.

"We are dealing with very depressed people. They feel like they are in prison, but it's the only way," said nursing sister Joan Blackburn.

The patients need intensive hospital care for at least six months.

Critics have pointed out that enforced quarantine may in fact be counterproductive by causing some patients not to report their illness in order to avoid being quarantined.

Refusing admission
Moeti said the minibus taxi driver initially refused to be admitted, saying he couldn't afford the loss in earnings. But he eventually accepted Moeti's arguments that he was endangering the lives of countless of his passengers.

Moeti hopes that the uproar about Andrew Speaker, the American man diagnosed with drug-resistant TB who caused an international health scare when he flew to and from Europe, has increased awareness of the scale of the problem facing South Africa and other hard-hit countries.

"Problems, problems, no solutions," mutters Moeti. "At least our patients won't be able to get on a plane and fly around the world." – (Sapa-AP/Health24)

For more information on care and support of tuberculosis visit South African National TB Association (SANTA) or phone them on 011 454 0260.

Originally published: November 2007
Updated: March 2009


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