Researchers, scientists, activists, doctors, nurses, the World Health Organisation, the United Nations and other agencies agree that the sheer numbers will become so big that it will be impossible to continue putting patients in hospital beds for six months.
There is also agreement that the prospect of a six month incarceration in a drab hospital, the high death rates and unstimulated environment at these institutions is dissuading people with drug resistant TB from presenting for a test or completing their treatment.
Many delegates at the 38th Union World Conference on Lung Health agree that most of the MDR TB patients are not defaulters and will take their treatment if it is offered within their communities.
‘The responsibility is taken away from patients and they are sent into isolation,’ said Vuyiseka Dubula, a TB-HIV activist in Khayelitsha.
‘How can you tell a single mother of five, who has no support, that she will be sent away for treatment and she has to leave her children,’ Dubula told a satellite meeting co-ordinated by Medecins Sans Frontieres (MSF).
‘Centralised care is a death sentence. People will rather die at home undiagnosed that go to a place where they often don’t come back from,’ she said.
Head of the MSF mission in South Africa Dr Eric Goemaere said the recent protest by patients at the Sizwe hospital in Gauteng, where MDR patients were incarcerated, illustrated the ‘total breakdown we are facing’.
‘These were not activists, these were people demanding to be treated like human beings,’ he said.
Goemaere said the 9 000 MDR TB cases currently reported as part of South Africa’s statistics was only the tip of the iceberg. ‘We need to learn from antiretroviral treatment and decentralize MDR TB treatment to the primary health care level,’ he said.
Goemaere said patients were anyway infectious in the community for four to six months before they were being diagnosed.
‘The number of undiagnosed MDR and extensively drug resistant TB people living in the community far outnumber the diagnosed ones,’ said Goemaere.
‘Institutions are saturated and cross infection is occurring in these hospitals. By quarantining them we are increasing the stigma and pushing it underground,’ he said.
Goemaere said district based programmes would increase case detection and reduce stigma. He said the way forward was district based MDR and XDR TB complemented with training and reference centres.
Goemaere said health workers and families of the patients could be trained and educated in infection control.
Dr Salmaan Keshavjee of Partners in Health said they had great success in Lima, Peru where over 6 000 MDR-TB patients have been treated successfully in the community. Keshavjee said there were many measures that could be put in place including building an extra room for the patient. In Peru they were able to do it at a cost of U$80.
Dr Pheello Lethola, an MSF doctor in Lesotho, where there is high number of TB-HIV patients and the defaulter rate has been high, said they had created a ‘one stop shop’ at primary health care and hospital level. Patients are seen on the same day for both their TB and HIV and nurses are trained to diagnose HIV patients for TB, which is not easy as their sputum smears often present as negative.
‘Low tech’ improvements such as ventilation, cough etiquette and separating those patients who cough from those who don’t cough have been introduced.
Indications are that the South African government is opposed to the decentralisation of MDR TB. Instead the Director General of the health department Thami Mseleku said more hospital beds would be made available. Currently MDR-TB patients are facing waiting lists for beds.
Dr Mario Raviglione, Director of the Stop TB Department at the World Health Organisation said the main reasons the world was now grappling with MDR TB was failure to prevent it in the first place, incapacity to diagnose it and a lack of drugs.