Drug resistant tuberculosis (DR-TB) is on the rise in Southern Africa, fueled on the one hand by high HIV prevalence, and on the other by its highly contagious nature. The disease reaches deep into rural Zimbabwe where MSF runs a DR-TB project. Steps need to be taken urgently to curb transmission before it has spread too widely to be contained.
Before tuberculosis treatments were invented, rich Europeans suffering from "consumption" (as the disease was then known) sought refuge in luxury sanatoria in Switzerland where the brisk Alpine air was considered their best chance for a cure. Those locations were not so dissimilar from Lorraine ZEMBA's Takawira village in rural Zimbabwe – well, except for the "luxurious" part of it, as her round thatched hut can scarcely compare to a high-end Swiss chalet. But in the early days of winter, where a chilly breeze runs through the immensity of gentle hills – not a house in sight, just a few trees breaking up the yellowing savannah – her modest house feels very, very far away from the places usually associated with the TB epidemic: Prisons. Overcrowded slums. Narrow winding streets trapping the bacteria that, without a cleansing gush of wind, can stay in suspension in the air for hours. But it took us close to an hour's driving from the main road through the bumps and holes of a dirt trail to reach Lorraine's home, so remote that the range of rocky hills rising behind it feels like the end of the world. So, how did she get infected by DR-TB, the drug resistant strain of the bacteria?
DR-TB used to be blamed on patients who did not take their tuberculosis treatment correctly and therefore built up resistance to first-line antibiotics. But that was not the case with Lorraine, who had finished her treatment and been cured from a previous tuberculosis episode four years earlier. Moreover, almost half of MSF's patients in Buhera have never contracted tuberculosis before suffering from the drug-resistant strain; they were just unlucky enough to get into contact with the resistant bacteria coughed up by someone infected with it. Another factor explains the surge of DR-TB in Southern Africa: Lorraine, like one in six adults in Zimbabwe, is HIV-positive. As it weakens people's immune system, the HIV virus opens the door to opportunistic infections like TB which would not necessarily make a healthy person fall ill. The combination of the two infections is very dangerous. "DR-TB is a brand new epidemic that requires a new strategy, new tools, new drugs, and new public health approaches," insists Dr Eric Goemaere, HIV and TB expert for MSF.
Lorraine and her husband Isaac are subsistence farmers growing sweet potatoes, some vegetables, and a patch of maize bordering their home. When Lorraine fell ill with DR-TB, life at the Zembas held on by a tenuous thread. She had to hide away from their two-year-old son – the tender whispers from mom’s sick breath could have meant death for him.
"When the MSF doctor explained what DR-TB was, I thought there was no hope and that Lorraine was going to die", Isaac remembers. "She couldn't eat because she had sores in her mouth and she was so thin it was as if her body had disappeared. As I had to take care of our toddler, I could barely do any work to feed the family. Some friends were telling me to get another wife, but then we got counselling from MSF, and Lorraine's family also came in to help us, so I didn't do it".
DR-TB treatment is an all-consuming, two-year-long process. In Zimbabwe, as in most parts of the world, only medical professionals are allowed to dispense drugs, especially the daily injections that are part of the DR-TB treatment regimen for the first six months. Lorraine was supposed to go every day to the nearest clinic, located seven kilometres away from her house if she cuts straight through the bush. So, every day, Lorraine – coughing her lungs out, weak from the disease – was supposed to walk for two hours, guided only by the stars and moon, so as to make it in time for her 7am appointment. "But then MSF said that I could receive the treatment at home, and that was a huge relief," she says. Lorraine is now officially cured, and her home treatment was an indispensable component for her to get there.
When she was diagnosed in 2012, one MSF car was doing the rounds of DR-TB patients: 8am to 4pm, about 350 kilometres of dirt trail to reach this little hut here and this small brick house there. Get out of the car. Don a surgical mask to avoid getting infected. Get the pills out, the injection ready. Stab an arm or a leg, observe the patient swallow his or her pill. Hop in the car, go. Next! "Yeah, it was tough, but now we have two cars doing the rounds so it's getting easier", laughs Simbarashe KAMBA, the MSF nurse who has been on the job since the beginning.
DR-TB used to be rare in Buhera; some years none were diagnosed, sometimes one, rarely two. Then, by mid-2011, it jumped to one new case every month, sometimes more. The difference? A new diagnostic machine that can easily spot DR-TB, GeneXpert, was introduced by MSF in Buhera. National protocol now recommends that every HIV patient with a suspected cough is screened for TB using GeneXpert. Statistically, with 38 cases diagnosed within three years, Buhera stands out with DR-TB patients on treatment in rural Zimbabwe; neighboring districts have very few cases, while some haven't recorded any. But they also don't have GeneXpert either. "The big difference is that now we are actively looking for DR-TB. And when you look, you find," summarizes Dr Ye Htun Naing, MSF doctor in Buhera. The current burden of DR-TB in Zimbabwe is not known; a prevalence study is ongoing to have a better idea on the real number of DR-TB cases in the country. Meanwhile, without diagnostics or treatment, patients continue to spread it when they cough.
Decentralized DR-TB care requires a lot of resources: cars and drivers to roam the countryside, two full-time nurses dedicated to visiting a handful of patients scattered around. And if that is possible to do for an international organisation like MSF, it will put a strain on the local health department's limited resources once it is handed over MSF's operations next year. The alternative is even more expensive: locking patients away in hospitals like the old consumption patients in 19th century sanatoria. But it is not really a matter of choice. "DR-TB is an emergency that needs to be addressed now, while it can still be curtailed," says Dr Sandra SIMONS, MSF's medical coordinator in Harare. If nothing is done, the disease spreads unchecked by itself; already five out of the 39 patients in Buhera – more than 10% – got infected by a close relative: husband and wife, mother and child.