Feature - tackling world's worst TB epidemic

South Africa is said to be facing one of the worst tuberculosis (TB) epidemics in the world, with disease rates up to 60 times higher than those currently experienced in the United States. The HIV/AIDS epidemic has compounded the problem. It is now estimated that out of the 13 of every 1,000 South Africans who will be actively suffering from TB by 2004, nine will also be HIV-positive. But patients at Tshepanong TB hospital are not interested in the statistics. For many of them TB is an illness - like HIV/AIDS - which they would prefer to keep quiet about. The hospital is situated on the outskirts of Pretoria, near the township of Atteridgeville, and is home to about 120 chronically ill TB patients. Tucked away behind Kalafong hospital, the buildings are protected by a razor wire fence and a stern security guard. "There are sick people here, you cannot just walk in," the guard told PlusNews. The flowerbeds and lawns dotted with colourful benches are deceptively cheerful. But a closer look reveals tired-looking patients who are anything but jolly. Taking advantage of the midday sun, they quietly chat among themselves, and look warily at passing visitors. The stigma and rejection they have encountered in their communities has made them reluctant to talk about an illness which is so closely linked to poverty and HIV/AIDS. "This place is now seen as a hospice, people don't want to come near it and of course it doesn't help that most of the TB patients are [HIV] positive," Matron Sibongile Mokwena told PlusNews. Mokwena warned that TB education campaigns need to address the cultural nuances of the disease. "There are still a lot of people who think that you have been bewitched or your badimo [ancestors] are unhappy with you. "We are still struggling to make people understand what TB is. Even after they are admitted here, they are still influenced by relatives from outside," said Mokwena. FREE TREATMENT AVAILABLE TB treatment, however, is "freely available" at all state health facilities, Phumlani Xhimiya, acting director of the health department's TB directorate told PlusNews. Xhimiya admits that there are "pockets" of people in the country who might not be aware that TB can be easily treated. Consequently, the government is embarking on a "huge advocacy campaign" to ensure that everyone receives TB treatment. Their first port of call will be traditional healers. "It is estimated that about 70 percent of South Africans go to alternative healers when they are ill. So it is very important that we strengthen our partnerships with traditional healers," Xhimiya noted. The South African Red Cross Society (SARCS) has also been active. It has implemented a community home based care project to provide care and support to around 5,000 people living with HIV/AIDS (PWAs) and other chronic diseases, such as TB. Once SARCS volunteers suspect that their clients might have indications of TB they refer them to the health service. If they are diagnosed with TB they monitor adherence to the prescribed drugs and keep the health workers informed of the progress of the disease. TREATMENT INTERRUPTED Despite these initiatives, however, TB treatment interruption remains a major problem. After the initial intensive phase, "a person feels so well and so much stronger" that continuing the treatment for four months seems unnecessary, Xhimiya said. But the tragedy is that three or four months later, TB infection sets in, and this time more resistant to the treatment. Multidrug resistance TB is more expensive to treat. The first time around, treating one patient with TB can cost up to R400 (US $49.9), the second time around, it could cost up to R1,000 (US $124.9). "The cost may escalate to R28,000 ($3,500), which includes hospitalisation for up to 18 months," Xhimiya noted. Health care workers "may not convey appropriately enough the importance of continuing with treatment," Xhimiya acknowledged. But Matron Mokwena and her staff feel they are sometimes powerless to prevent treatment interruptions. "When someone feels strongly that they do not belong here and don't need any more medicine, they become violent and start attacking us. So what else can we do?" She related how "on very rare occasions" patients have resorted to cutting the razor wire fence to escape from the hospital. POVERTY Clad in the regulation striped green and white hospital clothes, one TB patient who asked not be named shrugged his shoulders in resignation when asked about his condition. "Its better that I'm here. Matron and the sisters are good to us, and at least I get good food here," he told PlusNews. According to a Stop TB facstheet, poor nutrition can weaken the immune system and increase the chances of infection and the development of TB. "Poverty is inevitably an ever present phenomenon in TB - this is both a disease of poverty and lifestyle," Xhimiya noted. IMPACT OF HIV/AIDS To make matters worse, the impact of the HIV/AIDS epidemic is now being acutely felt at the hospital. "Our budget is exhausted from the extra antibiotics, food, napkins that we have to provide to patient who are positive," Mokwena said. The staff are overworked and need additional support. Two of the hospital's nurses recently left to work overseas. "I don't blame them, you can't work in such a place - after a while it depresses you," she added. The death rate has now increased to about two or three patient a day, she noted. HOPE But the bright colours of a window decoration, and the wildlife paintings laid to dry on the trestle tables in the therapy centre are a sign that all is not lost. "They need to be motivated and given hope, this [TB] is something that can be cured," Mokwena said. Community involvement and support was crucial to keep places like Tshepanong going, she added.