The New York Times - July 29, 2009
Celia W. Dugger

She finally found the woman, Nolusindiso Vani, 23, in a one-room shanty of plywood and tin. Shy and soft-spoken, Ms. Vani huddled in a battered arm chair, wearing a tan coat against the wintry morning chill and a pretty pair of black patent leather shoes. In the dim light cast by a bare bulb, Ms. Vani explained that she had lost her baby in a miscarriage last month around the time she learned she was infected with multidrug-resistant tuberculosis, a potentially lethal strain whose spread poses a grave threat to millions of H.I.V.-positive South Africans with weakened immune systems.

"Sometimes I feel like I may vomit," Ms. Vani said, confessing that the new drugs she had begun taking made her nauseated.

Under South Africa's current policy, Ms. Vani would normally have been whisked away to a hospital after tuberculosis was diagnosed and isolated from the public for a grueling regimen of toxic, hard-to-tolerate pills and injections, lasting months.

In the neighboring Eastern Cape Province, patients have effectively been imprisoned in a hospital encircled by fences topped with razor wire, and dozens of them have escaped in desperate bids to reunite with their families. Both the Eastern Cape and Western Cape Provinces have sought court orders to compel the return of runaways.

But in this case, Ms. Vani is being treated in a local clinic and lives at home under a pilot program run by Doctors Without Borders and supported by both the city of Cape Town and Western Cape Province. The idea is to show that such patients can be successfully treated in an impoverished community like Khayelitsha even while they are still infectious.

For Ms. Vani to continue in the program, Ms. Beko had to ensure that the young woman could live at home during her treatment with minimal risk of infecting others. Tuberculosis spreads through the air when patients cough and sneeze, and the germs could get trapped in the tiny room where Ms. Vani lives alone.

"They may send you to the hospital, as there are no windows in the house," Ms. Beko said with a doubtful shake of her head.

Ms. Vani, eager to avoid a long-term hospitalization, promised that she would remain alone in the house and only see friends outside in the open air. "I already told my boyfriend it would not be good for him to sleep over," she said through a paper mask that covered her mouth.

Drug-resistant tuberculosis is a mounting global health threat. The World Health Organization reported the highest rates of it ever last year. Some 500,000 of the 9 million new cases of tuberculosis in 2007, the most recent estimates, failed to respond to the standard, inexpensive first-line drugs. About 150,000 people died of drug-resistant TB.

It is a particularly virulent problem in Africa, where AIDS has heightened the vulnerability of millions. Stopping the spread of these expensive-to-treat, hard-to-cure strains of TB is a daunting task. Ten African countries do not even have laboratories that can detect them, said Dr. Paul Nunn, coordinator of the drug-resistance unit in the W.H.O.'s tuberculosis department.

South Africa, the richest country in the region, has poured money into building more space in hospitals for drug-resistant TB patients, but researchers say the number of new patients will grow faster than the country can add hospital beds.

Even hospitalization is no panacea. The strains can spread within them, and the fear of being sent away to distant clinics -- especially for poor single mothers raising children alone -- may drive those with the disease underground.

"The moment you put somebody away for months, if not years, lock them up and put a fence around them, how are you going to get people to come forward?" asked Dr. Virginia Azevedo, who manages health services for the city of Cape Town here in Khayelitsha.

It is hard to imagine a more ideal place than this for the spread of tuberculosis, a disease that hovers in the air. People here live at close quarters in overcrowded shacks that sprawl, like colorful jumbles of debris, as far as the eye can see. They go to work crammed into minibuses. They gather in the evening in the homes of friends who have televisions, or in small saloons.

Almost 6,000 people were found to have TB in just this one community last year. About 200 of those with drug-resistant TB joined the pilot project. Each day for at least two years, participants are required to go to a clinic where a nurse watches them swallow more than a dozen pills. For the first six months, they must get daily, painful injections. Many of them suffer nausea, and some become permanently deaf because of the drugs. Three-quarters of those enrolled are also H.I.V.-positive and many of them must take antiretroviral medicines.

Cheryl McDermid, 59, a Canadian doctor with Doctors Without Borders, manages the project here. She said the early results were hopeful, if sobering.

About a fifth of the patients enrolled last year died, either while waiting weeks for a diagnosis or after treatment began. One in six of those who started treatment dropped out. But most patients have stuck with it and are now no longer infectious. It is still too early to know how many will ultimately be cured, but there is no evidence that they are infecting the people who live with them, Dr. McDermid said.

Health workers in the program know they will have to work hard to coax those who quit back into the fold. One counselor, Thami Ndlovu, recently went searching for Xandile Charlie, 22, a pregnant woman who had missed a week of clinic visits.

Ms. Charlie told Mr. Ndlovu that the drugs were compounding her nausea. She also complained that she had been told she was not sick enough to qualify for a welfare grant, though she is unable to work. That meant she was short of food -- and taking the medicines on an empty stomach is hard.

Mr. Ndlovu listened sympathetically, promising to get someone to help with the grant. But he also warned that if she quit treatment, her tuberculosis could turn into an even deadlier, more resistant form of TB.

"You might die," he told her. "Please, today, go to the clinic."
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