DURBAN, SOUTH AFRICA — Tony Moll knew there was a problem, a grave problem. To tell him so, he had a ward full of patients who were sicker by the day.
But the gentle doctor, a veteran of 20 years of practice in a rural town in the low hills of KwaZulu-Natal province, never considered that he was looking at a problem that some public-health experts say may be the worst threat to humanity in the past half-century.
When the lab called to tell him just what was wrong with those patients, the news left him "in shivers." The Church of Scotland Hospital in Tugela Ferry, an old mission station of low, graceful stone buildings where Dr. Moll is the chief physician, now has the macabre title of "home of XDR TB" - extensively drug-resistant tuberculosis.
The TB bacillus, a bug that has been pesky but totally treatable since the advent of antibiotics in the 1940s, has suddenly morphed into something virtually incurable. And the disease is spread not with a complex exchange of bodily fluids, like AIDS or Ebola, but simply by laughing, talking, coughing or breathing.
Feeding off a vulnerable population and a health system staggering under the challenge of the AIDS epidemic, XDR may already have spread from South Africa, creating the danger of an uncontrollable epidemic on the continent.
After Dr. Moll got the call from the lab, he started keeping track of patients with XDR. In a matter of days, it killed 52 out of 53 people who had it, most within two weeks of arriving at the hospital.
Almost all of them were diagnosed posthumously, because the TB killed them before the lab ever got the diagnostics finished.
"We're losing ground again, facing another untreatable condition," said Dr. Moll, a veteran of the fight with AIDS. "It's put us in a hopeless situation."
Origin of an outbreak
The journey to Dr. Moll's terrifying discovery began in early 2005, when he noticed something peculiar. The staff at his hospital had become accustomed to the marvellous "Lazarus effect" of anti-retroviral treatment for AIDS: seeing desperately sick people quickly start gaining weight and return home or go back to work. But now, in his ward, he had two men in their 30s on ARVs whose HIV infections were suppressed to undetectable levels. Yet their TB, which would normally have cleared up in a matter of weeks, kept getting worse.
He suspected multidrug-resistant TB, or MDR, believed at the time to be as bad as the disease could get. So he collected sputum from 45 patients and sent it off to a lab in Durban for cell culturing. (The only way to tell if a TB strain is drug-resistant is to grow cultures from a patient sample, zap it with the different drugs and see which, if any, fail to kill it.) The process takes six to eight weeks. "In that time, we more or less forgot about it," Dr. Moll said. One of his two young men died.
But the phone call from the lab, when it eventually came, slammed the issue to the top of their agenda: Of the 45 samples, 10 were indeed drug-resistant. But they weren't resistant to just one or two of the drugs used against TB. They were resistant to all six medications available for use in Tugela Ferry. In other words, there was nothing to cure that TB at all.
"That was so scary," Dr. Moll said. His first thought, he confessed, was personal - for himself and his staff. "Because you're talking about airborne transmission, and this means if a patient has got it, you as a doctor or a nurse working with that patient are breathing it in ... you are breathing in XDR as part of your job." Four health workers were among the 52 people who had died.
Immediately, he called the provincial Department of Health and wrote to the national government, expecting a five-alarm response. In his head, he started making plans for how these emergency cases would be handled.
But he didn't get the urgent response he had anticipated. "We were shouting on deaf ears for quite a long time ... everybody just had another problem, cholera here or overwhelming HIV there."
No one seemed to understand the threat of an incurable strain of TB spreading through a community where up to 40 per cent of adults have HIV.
TB is already one of the most common infections in people with HIV-AIDS, and their weakened immune systems make them terribly vulnerable to XDR.
Health system under strain
Nearly two years after Dr. Moll's discovery, South Africa is still trying to come to grips with what's brewing in its midst. Some 340 people have been diagnosed with XDR, and more than half of them have already died.
Yet in Tugela Ferry and other communities, people with this highly contagious, lethal disease are still lying in hospital beds next to patients who don't have it, or they are being sent home to live with their families until a hospital bed in the main treatment centre in Durban becomes available, a wait that can last for months.
It isn't hard to figure out how they wound up with XDR in Tugela Ferry: the TB outpatient clinic has more than 750 patients on its roster, and only two nurses to supervise them. TB treatment needs to be taken for at least six months, or 18 months for MDR, but the drugs are toxic and make people feel terrible. Quite often, when patients start to feel a bit better, they stop taking the drugs and end up with resistant bacteria.
TB projects in other parts of the world run on a model called DOT, or daily observed therapy: A health-care worker watches the patient take the drugs each day. Obviously, that was a non-starter in Tugela Ferry. It is as hard-hit by staff shortages as the rest of the health system in post-apartheid South Africa, where nurses and doctors have been lured away to richer countries, have died of AIDS or have left their jobs due to chronic overwork and lack of support.
The two nurses in Tugela Ferry had no vehicle to track down patients in their rural homes and check up on their drug adherence. Many patients didn't have phones. Even in the hospital, nurses were too overworked to stand at bedsides and monitor treatment.
"The cure rate nationally for TB is only 62 per cent," said Nesri Padayatchi, an expert on drug-resistant tuberculosis for a joint U.S.-South African research consortium on AIDS and TB called CAPRISA. "So if you're not curing, if patients stop taking treatment and very little is put into place to find those people, you know the organism is mutating and becoming resistant. Nobody who works in TB is surprised this happened."
At the international AIDS conference in Toronto this past August, Dr. Moll shared the news of his 52 dead XDR patients and finally got worldwide attention. Teams of international researchers soon flocked here: The World Health Organization sent advisers, while a European team traced all the contacts of the XDR patients.
In one of the few bits of good news in this story, they found that the XDR bug isn't as infectious as regular TB. Research has also found that the spread of the bacteria was almost certainly nosocomial -- hospital-related -- since virtually all of the cases to date have been people who had previously been hospitalized at a time when a then-undiagnosed XDR patient was also in the ward. Genetic typing shows that 89 per cent of the XDR patients have had the same bacteria.
But even in the King George V Hospital in Durban, the specialist referral centre for XDR, patients are still in mixed wards and staff rarely wear respirators or even masks, complaining that these are hot and uncomfortable and make it hard to communicate with patients.
Too little, too late?
Dr. Moll said his program has been given new resources in the past year, including staff to trace contact information for infected patients and vehicles to pursue those who default on treatment. But there is still no help in building space or hiring staff to isolate patients. "We can't isolate our patients here and that is still driving the epidemic on," he said plaintively. "I can't understand" why the government does not supply the funds to set up isolation facilities.
But Lindiwe Mvusi, head of the national TB program in South Africa, insisted the government is doing everything necessary. "Such things, it also comes back to managers. Why are they keeping them in the same ward?" she said. "If they apply their minds, they can isolate the patient. I blame them. They need to find a way of going around it."
The international experts who are here as advisers are nonetheless frustrated. "You would never know there is a huge crisis from the way the South Africans are responding," one doctor said. "It's hard to tell if they don't get it or they're just overwhelmed or what it is."
He and other experts interviewed said South Africa's reviled Health Minister, Manto Tshabalala-Msimang - best known for urging people with AIDS to eat traditional African vegetables rather than get treatment - has created a dysfunctional environment where anything seen as related to HIV is stalled or blocked. But she has been off the job on sick leave for several months, and the acting minister has galvanized new action on XDR.
"Finally in the past few weeks we are seeing some action," Dr. Padayatchi said. The government is now promising to act quickly on providing new bed space and isolation for those infected, although it is not clear who will staff those facilities, because health-care workers are justifiably reluctant to work in XDR settings.
Meanwhile Dr. Moll is planning to simply start treating people he suspects have XDR rather than waiting eight weeks for tests, because so many of his patients have died by the time the lab results come back.
The first patients from Tugela Ferry began treatment in December, 2006, so it will be another 18 months before there is any clue whether this type of TB can be cured here. In the meantime, two patients have died as a result of the side-effects of the treatment.
Doctors in KwaZulu are already worrying about what to do with people who "fail" treatment, that is, take the full course of drugs, but remain infectious. Currently, people who fail treatment for MDR are simply sent home, but a new debate is emerging here about the circumstances in which people with XDR could be forcibly confined if they fail to adhere to treatment or remain infectious.
"What will we do, how will we address that?" Dr. Padayatchi asked. "Is it any benefit to keep them in hospital for the rest of their lives? I don't see us keeping them in leper colonies for XDR somewhere. And who is going to look after them? Nurses don't want to go work in those hospitals and you can't blame them."
The Medical Research Council estimates there will be 600 new cases of XDR across the country this year, and says there may be other outbreaks that go undetected because patients die so quickly.
XDR was picked up in Tugela Ferry, but while most other hospitals have now been screened, there is no long-term surveillance under way to track the disease.
Meanwhile hundreds of thousands of migrant workers are moving in and out of the country from Mozambique, Lesotho, Swaziland and Botswana -- all countries with HIV prevalence rates as high or higher than South Africa's -- while millions of Zimbabwean refugees go back and forth across the border to South Africa. None of these countries have the capacity to screen for XDR or the ability to control the spread of a bug like this.
"It's everywhere; where you will look for it, you will find it," Dr. Mvusi said. "If you look for it in other countries, you will pick it up."
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