A lil' about TB in South Africa

Tuberculosis is a major public health problem in South Africa and, due to its high infectivity, is posed to become a larger threat than HIV/AIDS. The incidence of TB infection continues to increase dramatically. According to the World Health Organization’s (WHO’s) Global TB Report 2008, South Africa had nearly 453,929 new TB cases in 2006, with an incidence rate of an estimated 940 per 100,000 population – a major increase from 1998’s incidence rate of 338 per 100,000 population. The spread of the epidemic has been greatly exacerbated by the development of both MDR (Multi-drug-resistant) and XDR (extensively-drug-resistant) strains, primarily documented in the KwaZulu Natal (KZN) province.

South Africa adopted the DOTS (directly observed treatment, short course) in 1996, after the National Department of Health realized that its previous TB control efforts had been ineffective. The DOTS strategy is the only that is globally recognized for effective TB control and is embedded in five principles, as described by the Tuberculosis Management Plan for South Africa:
1. Government commitment to sustained TB control activities.
2. Identifying infectious patients via sputum smear microscopy.
3. Direct observation of treatment for at least the initial two months of standardized short-course anti-TB treatment.
4. A regular, uninterrupted supply of standardized drug combinations.
5. A reliable, standardized reporting system which allows assessment of treatment results and overall program performance.

A multi-faceted approach to the TB epidemic is crucial due to its highly infectious nature via aerosol transmission. Identification of infectious patients is the necessary first step. If a patient has been in contact with a person with infectious tuberculosis, they are most often diagnosed via smear microscopy sputum examination after presenting with the appropriate symptoms. If acid-fast bacilli are detected, the patient is diagnosed with smear positive tuberculosis. Other diagnostic procedures, which are not commonly in use in South Africa, are chest x-rays, TB culture, and the tuberculin purified protein derivative (PPD) test.
It is crucial to initiate treatment of infectious patients as soon as possible in order to prevent further transmission. Standardized drug combinations include bactericidal, sterilizing, and resistance-prevention drugs.
Patients who are diagnosed with TB should also be tested for HIV as over 44% of new TB patients also test positive for HIV. Not only are HIV-positive persons far more likely to develop TB post exposure to TB bacilli, it is evidenced that TB infection also accelerates the progression of HIV disease. Patients who are simultaneously diagnosed with HIV and TB begin ARV treatment post-completion of the prescribed TB treatment regimen. HIV-positive patients who test negative for TB can be given TB preventative therapy, in the form of isoniazid prophylaxis, in order to reduce their risk of infection by up to 60%.

Even with DOTS policies in place, the emergence of MDR-TB and XDR-TB is an indicator of the poor implementation of South Africa’s TB Control Program. The number of laboratory-confirmed MDR-TB cases in South Africa has more than tripled from 2,000 cases in 2005 to 7,369 in 2007. The KwaZulu Natal (KZN) province, the epicenter of South Africa’s HIV/AIDS epidemic, has also been the most acutely affected by the emerging drug-resistant TB strains. In 2006, the WHO announced that a new extensively drug-resistant strain of TB (XDR-TB) had been detected in Tugela Ferry, a rural town in KZN. Of the 544 patients studied in the area in 2005, 221 were determined to have MDR-TB as defined as Mycrobacterium tuberculosis that is resistant to at least rifampicin and isoniaizid – two of the frontline drugs used to treat TB in South Africa. Of these 221 MDR-TB cases, 53 were determined to be XDR-TB as defined as MDR-TB plus resistance to at least three of the six classes of second-line agents. The median survival time from collection of the sputum specimen was 16 days for 52 of the 53 infected individuals – a previously unprecedented fatality rate for XDR-TB. A 2008 study that examined isolates collected from 2004-2007 showed that 5.6 percent of 17,615 TB cases were XDR-TB. The actual reported cases of XDR-TB have increased from 74 in 2004 to 536 in 2007. KZN continues to be the epicenter of the MDR/XDR-TB explosion; as of 2007 XDR-TB had been reported in at least 39 hospitals throughout the province with well over 30 new cases of XDR-TB being diagnosed each month in KZN alone.

It could be argued that the emergence of MDR/XDR-TB is evidence of a systematic failure of the global community to tackle a curable disease; in this case the South African government’s initial lethargic reaction to the crisis could be held accountable. The factors that have contributed to the emergence of MDR/XDR-TB are avoidable and merit urgent remediation. Well-documented factors include high treatment interruption rates and subsequent low cure rates due to inappropriate treatment regimens, irregular drug supply, incompetent health personnel, and/or non-adherence. Another significant factor fueling the MDR/XDR-TB outbreaks in South Africa is the lack of infection control in institutions. Not only are advanced and expensive environmental control procedures such as negative pressure rooms rare, the most basic measures of triaging patients and use of personal respiratory protection are under-utilized at best. Tuberculosis is recognized as a disease that preys upon social disadvantage causing infections to be concentrated in poverty-stricken areas. Observance of the Marianhill clinic in Durban showed that not one health care worker wore personal respiratory protection when attending to symptomatic TB patients – neither in the clinic nor at home visits.

The most critical factor in addressing MDR/XDR-TB is prevention through strengthening basic DOTS management and improving management of patients requiring re-treatment with second line drugs. An unprecedented strengthening of overall TB control is not just recommended – but imperative. In 2006, WHO urged a response to the XDR-TB outbreak akin to global efforts to control SARS and bird flu. XDR-TB poses a more serious global health-threat than HIV/AIDS due to its aerosol mode of transmission. There are many complicating factors at play including the ethical and human rights ramifications of mandated isolation and insufficient funding to reduce hospital crowding and improve DOTS management at all levels. As Singh argues, “Given the South African government’s poor track record in dealing with the country’s HIV/AIDS epidemic and what is at stake if it adopts a similar lethargic and denialist response to the country’s XDR-TB outbreak, the international community must be vigilant in monitoring the government’s response to this emerging crisis.” International complacency paves the way for the predictable next phase – a global pandemic of completely drug-resistant TB.

References:
Child Family Health International. Tuberculosis Management Plan for South Africa. HIV/AIDS and Health Care; Durban, South Africa. No date given.
Singh JA, Upshur R, Padayatachi N (2007) XDR-TB in South Africa: No Time for Denial or Complacency. PLoS Med 4(1): e50. doi:10.1371/journal.pmed.0040050.
USAID Health, Infectious Diseases, Tuberculosis, Countries, South Africa. www.usaid.gov/our_work/global_health/id/tuberculosis/countries/africa/safrica. Accessed 16 April, 2009.

Zodwa's Birthday Braai Pics

Day 21 - Isu Labasha Workshop @ Marianhill

Vusi's House; the detached building outside is the toilet







Day 21
Friday
4/24/09

“As a woman, I have no country. As a woman, I want no country. As a woman, my country is the whole world.”
— Virgina Woolf

Had a very inspiring and thought stimulating day today! Last time we were at the Marianhill clinic a few of us had promised Vusi we would come help him put on an educational workshop at the local high school. Due to multiple changes in plans we were unable to meet with Vusi before workshop-day and headed up to Marianhill this morning with no idea of what we were getting into.

At the clinic Vusi informed us that apparently we were solely responsible for presenting to one of the most intimidating audiences I can think of – 200 high school students. Especially a tough crowd when discussing sex-related issues such as HIV/AIDS, STIs, and teen pregnancy. We also learned that there was no transportation planned – a bit of an issue since the school was a ways away and Vusi only had his walker. With no use of his legs Vusi gets around with his walker by doing pretty much half a tricep dip with each step; his mobility is impressive but it’s no way to get more than a block. In midst of arranging transportation three Zulu girls, appearing to be in their late teens, arrived. Vusi introduced them as the members of the Isu Labasha (Youth Vision) organization that had organized the workshop and were going to accompany and translate as necessary.

We eventually got a taxi to take us through a complex maze of dirt roads to the high school, a horse shoe shaped arrangement of three buildings surrounded by barbed wire. Curious faces peered out the windows as we walked by – later I found out that we were the first white people to visit the school for as long as anyone could remember. We separated into two groups: Caroline, Nicole, and I covering HIV/AIDS, STIs, and teen pregnancy and Sean and Isaac covering TB and drug/alcohol abuse. As soon as we entered the packed classroom about 50 teenagers in yellow and green uniforms exploded into loud laughter, shrieks, and chatter. We eventually calmed them down long enough to do our spiel, which was mainly composed of true/false questions. Every few minutes the room would erupt from blank stares into peals of laughter, reason unbeknownst to us. We fielded the few questions they had and switched classrooms. It was hard to tell if they were paying attention to anything we were saying or if we were telling them anything they hadn’t heard a thousand times before. However, after we finished and the students were released for lunch, one girl came up to Sean and I to thank us. She shyly explained that she had TB and wanted to teach her fellow classmates but was afraid they would be scared of her. Another girl, about 15 years old, approached me to tell me she had been coughing and sweating at night for a couple months but the doctor told her she didn’t have TB or HIV – and what should we do? She kinda stumped me with that one – like many other times here, I really wished I had more medical knowledge. I think I gave her a sufficient answer.

We met with the principal for a few minutes who explained that they would love to have this happen regularly as teen pregnancy and HIV/AIDS are huge problems within the student population. It’s scary to think about HIV/AIDS being a huge problem amongst these giggling 14-18 year olds in cheery school uniforms. We gave him the number of our local coordinator here and told him we would do our best to set something up.

On the way back I asked Pinky, one of the Isu Labasha girls, about the organization and the workshops they put on. I was blown away by her answers! Apparently Pinky, who’s only 21 and lives in the Marianhill township, was tired of seeing her community, especially the teenagers, being ravaged by HIV/AIDS, unemployment, poverty, and hopelessness and decided to do something about it. With a high school education and no funding or experience doing anything like this, she decided to start an organization to educate the community and “give them hope.” She came to Vusi who helped her get the organization off the ground. Now Isu Labasha has grown to six members, between 17-22 years old. They regularly present day long, standing-room-only, workshops to the Marianhill community about HIV/AIDS, education, TB, STIs, and other issues the community faces. They have no funding but are able to solicit enough groceries from local markets to provide a home cooked lunch for the attendees. Pinky says they are currently applying to become an official non-profit but they are struggling with the paperwork. She explained that there’s so much more the organization wants to do, such as helping train teens in marketable skills and providing food parcels, but they just don’t have the money.

I was amazed – here’s this young girl from this poverty-stricken community in a culture where women have minimal power who has been courageous and committed enough to do more than most people with a lot more education and resources will ever do. I have some great interviews with Vusi, Pinky, and the others on video – I can’t wait to edit it together. I was struggling with how to best help this community ever since our home visits with Vusi but I think this is my answer. Vusi and Isu Labasha have so many great ideas about how to help this struggling community and could be so effective with even a little financial support. I was so overwhelmed by Pinky and Isu Labasha’s determination, bravery, and wisdom beyond their years. They have such amazing potential and we, in the US, have an abundance of the resources they need. My heart is compelled to do whatever I can to support them as true change makers and leaders in the world.

Day 19 -- Chatswsorth Hospice

Day 19
Wednesday
4/22/09

Had another very intense and moving day yesterday. Not much time to write now but I want to get some of it down before the details escape me. Waiting for some of the others to get up so we can go pick up rental cars for the day. It’s a national holiday, election day, and we’re going to head to the beach -- an area we think will be low risk for a political uprising.

Spent yesterday at Chatsworth Hospice, in the Chatsworth area of Durban – a primarily Indian community. I was really looking forward to the day as hospice/end-of-life care is one of my primary interests in health care. Chatsworth Hospice, and all the people we met there, were absolutely lovely. Unlike the state hospitals, Chatsworth is well funded – by private donations, fundraising events, and the money they make selling cucumbers from their greenhouse – as well as clean and cheerful. Services are provided free of cost to patients. It’s amazing how the energy in the air changes when the staff actually wants to be there; there are only 23 paid staff members, most of them nurses who were burnt out from working at traditional hospitals, and the rest volunteers. Every few minutes someone new insisted we drank some more coffee or tea or tried a piece of cake or biscuit, all formally laid out on a tray for us with saucers and properly folded napkins. The hospice itself has only ten beds but they technically have over a hundred patients, all seen via home visits. The rooms themselves are primarily used for short symptom and/or pain-control stays, after which the patients are sent home to spend their remaining time with family. On Wednesdays many of the patients are brought in for day care which includes meals, arts and crafts, massage and reiki, and a variety of activities. It was so refreshing, after what I’ve seen in the last few weeks, to see health care personnel who truly care about the patients, talking about them as if they were dear friends.

We first attended the Interdisciplinary Team (IDT) meeting, where last weeks home visits were discussed. The IDT was composed of two sisters (nurses), two social workers, a psychologist, and the medical director – all of Indian descent. Patients were discussed with genuine compassion and even a bit of humor as they debated the merits of allowing certain patients to have a nip of alcohol here and there if they desired. I was surprised how much emphasis was put on “caring for the caregiver” and being conscious to not take it personally when family members displace their fear and anger onto you. I was very much reminded of Maitri, the Zen AIDS hospice I volunteered at in San Francisco. One social worker spoke of a fourteen year old lymphoma patient with whom she’s building a birdhouse in order to establish trust and a connection with him while giving his overwhelmed parents a break.

After the meeting we headed out with Sister Sybil to do her end-of-life oncology visits. We were to see five patients -- two patients with advanced stage breast cancer, one with advanced stage tongue cancer, one with a brain tumor, and another with colon cancer. On the way to each house Sybil gave us the lowdown on the patient and their social/family issues.

At the second home visit, to the man with advanced cancer of the tongue, we found a very frail man lying in a bed piled with blankets surrounded by his wife, two teenaged sons, and one daughter. The wife, a small, soft-spoken Indian woman, greeted us with a small smile through her red, watery eyes. I held on of the man’s bony hands in my own as she quietly explained to us how, the night before, she had knelt beside her ailing husband’s bed and told God that she was turning Ronnie over to him now, and to take his son back whenever God was willing. She smiled softly as she repeated to us what she had told him, “Don’t you want to see your mother and father? I am your wife. I love you and I will see you on the other side.” She explained that she was going to try her best to obey his last wishes and take the little bit of money they have saved and use it to start a business in order to support the children, a take-away restaurant. Ronnie had always loved her cooking and, as she explained, “I am not a proud woman, but I cook very well… I will call it Ronnie’s Take-Away” I nodded while the woman spoke and tried my hardest not to cry – the last thing I wanted was for her to feel as though she had to comfort me in her time of sorrow. She continued to explain that Ronnie was such a loving man; He was a brother to all who knew him and two of the teenagers in the room were not theirs but children he had taken in after their families couldn’t take care of them.

After the nurse asked her requisite questions and did a brief exam, we all stood to leave. Ronnie’s wife walked us to the door explaining that, even before he was sick, Ronnie was like a baby to her. She always loved to take care of him and always held him like a baby when he slept, especially when he had bad dreams. I didn’t know what to say but stayed behind to hug her and tell her to stay strong and follow her heart when it comes to the business – she will do the right thing. She hugged me back and thanked me. I barely made it out the door before tearing up.

The next house we went to was the man with a brain tumor. He has been a Chatsworth patient and regular day care attendee for a while and is like an old friend to the staff, especially the driver who came in with us just to see him. His wife, a friendly and energetic woman, greeted us at the door and ushered us up to her husband’s room. The man is unable to speak but had an unbelievable sparkle in his eyes, especially when the driver joked with him. His wife proudly showed us the view from their bedroom window, pointing out the lychee trees and the birds that stop by to “chat” with her husband. She asked us numerous questions about our trip and excitedly invited us to come for dinner to have Breyani, which we were very disappointed to turn down as it has become our favorite.

We finished home visits around 2pm and headed back to the hospice. Even though it was a wonderful day, I felt a little off the rest of the afternoon. Not sad exactly – we weren’t out witnessing horrible poverty and social injustices as on previous days – just very touched by the realness and the love I felt in the hospice and in the homes. Generally, hospice patients are beyond the point of any ‘fixing’ and all that’s left is the privilege of being with them and offering love and comfort as they close the book on their life. To be with someone at the end of their life, and think about all the lives they’ve touched, the laughs they’ve shared, the fears and hopes they’ve felt, touches the heart unlike anything else I know. I think that’s what draws me to end-of-life care; unlike other aspects of medicine there’s no fancy technology or promises of ‘getting better’ to hide behind. It’s just pure, raw humanity and, while it’s not for everyone, I think those who work in hospice see the beauty in that.

"Caring for those who are suffering, whether or not they are dying, wakes us up. It opens up our hearts and our minds. It opens us up to the experience of this wholeness that I speak of. More often than not, though, we are caught in the habitual roles and ideas that keep us separate from each other. Lost in some reactive mind state, busy trying to protect our selfimage, we cut ourselves off and isolate ourselves from that which would really serve and inform our work. To be people who heal we have to be willing to bring our passion to the bedside; our own wounds, our fear, our full selves. Yes, it is the exploration of our own suffering that forms a bridge to the person, we're serving." Frank Ostaseski

If you are interested in the Zen Hospice movement I highly recommend the following article:
http://www.zenhospice.org/8_writings_pho_media/print/intention_in_service.htm

If you're in the San Francisco area, consider volunteering at or supporting Maitri:
www.maitrisf.org

Cockroaches are gross

Since I left my zip drive with my serious blog about my very moving hospice home visits at home, guess what...?
There is a colony of the world's grossest and biggest cockroaches living underneath my bed. I think there is, at least. I'm too scared to lift it up and see but I keep seeing one at a time scurrying out from under there and I can only assume they travel in large, gross packs. Nicole is on sneaker crushing patrol since I'm a huge wimp, but we've yet to be fast enough. I don't mind them on the floor but I would prefer they do not decide to crawl into my mouth while I sleep.
Also, I climbed the world's tallest indoor climbing wall yesterday. A very nerve-wracking thing to do if you have hyperhydrosis of the hands and feet like I apparently do.
Much love,
Julie

Fun with the little guys...

Scary Ladder Pics