Feature Stories: Extremely Drug Resistant TB, South Africa

The Jose Pearson TB Hospital In Port Elizabeth , South Africa, is like a prison for the sick. It is encircled by three fences topped with coils of razor wire to keep patients infected with lethal strains of tuberculosis from escaping.

"We're being held here like prisoners, but we didn't commit a crime," said Siyasanga Lukas, 20, who has been here since 2006, speaking before he escaped 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.

The public health threat is grave. The disease spreads through the air when patients cough and sneeze. It is resistant to the most effective drugs. And in South Africa, where these resistant strains of tuberculosis have reached every province and prey on those whose immune systems are weakened by AIDS, it will kill many, if not most, of those who contract it.

As extensively drug-resistant TB rapidly emerges as a global threat to public health - one found in 45 countries - South Africa is grappling with a difficult ethical problem: how to balance the liberty of individual patients against the need to protect society.

Most other countries are now treating drug-resistant TB on a voluntary basis, public health experts say. But health officials here contend that the best way to protect society is to isolate patients in TB hospitals. Infected people cannot be relied on to avoid public places, they say. And treating people in their homes has serious risks: Patients from rural areas often live in windowless shacks where families sleep jammed in a single room - ideal conditions for spreading the disease.

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.

Some 563 people were confirmed with extensively drug-resistant TB last year in South Africa and started on treatment, compared with only 20 cases in the United States from 2000 through 2006. A third of those patients in South Africa died in 2007; more than 300 remained in hospitals.

When news of South Africa's outbreak of extensively drug- resistant TB was announced in Toronto in 2006 at an international conference on AIDS, it sent shudders through the ranks of infectious- disease specialists. These virulent strains had rapidly killed 52 of 53 patients.

Drug resistance emerges in large part because health care systems too often have failed to ensure that patients successfully complete treatments with first- and second-line drugs, according to international health officials.

Exerpts from The New York Times article "Infectious TB Patients Held Like Prisoners in South Africa" by Celia W. Dugger