By Ryan Ahern
It is always startling to reach the southern border of the relatively developed province of Kwa-Zulu Natal on the N2 national highway and enter the desolate Eastern Cape. I leave the first world behind and cross a muddy river into the third. By the time I reach the Numlaco, where the Boston-based NGO Sibusiso works, the humidity precipitates tiny droplets on my skin. Looking out over the rolling hills dotted with settlements, grazing cows and horses, I see in the distance the dark blue clouds that promise a break from the heat. As the storm approaches, the lightning increases in frequency and the thunder shakes the unsteady houses and shacks. This, without a doubt, will be yet another storm bringing heavy rains and gusting winds. But beyond rain and mist; humidity and lightning, there are bigger storms sweeping through this country.
At the 2006 Harvard International HIV/AIDS Workshop in Durban, titled The Realities of Antiretroviral Rollout: Overcoming Challenges to Successful Programmatic Implementation, Charles Wells, MD, of the United States Center for Disease Control and Prevention, portrayed the Perfect Storm: the onslaught of Multi-Drug Resistant Tuberculosis (MDR-TB) in matrimony with HIV/AIDS. Though TB has been endemic in South Africa for decades, it has found a renewed gusto within the country’s increased number of immuno-compromised individuals. The rise of drug-resistant TB, which develops when treatment is interrupted in a patient, is not at all uncommon in resource-poor settings, and only further complicates the situation. Drug-sensitive TB can be treated with a six month course of moderately accessible oral antibiotic combination therapy. However, given a number of socio-economic realities, patients often miss their doses. If and when a dose is missed, the TB bacilli have the potential to mutate and become resistant to the first line drugs. As the prevalence of this drug resistance rises, MDR-TB makes its way into the population spreading from person to person with dreadful effects. What is worse is that epidemiologists are just now starting to uncover an even more drug resistant strain here in South Africa, appropriately titled Extensively Drug-Resistant Tuberculosis (XDR-TB).
In 2003, when the anti-retroviral therapy (ART) program was first rolled out in South Africa, the already struggling healthcare system was further fragmented. The task of navigating the referral process between the provincial TB facilities and the ART sites is daunting even for healthcare professionals, not to mention a sick patient. Here in Numlaco, patients walk six kilometers east to obtain their TB medication and 15 kilometers in the opposite direction to fetch their HIV therapy, if they are among the lucky few on ART. These logistical challenges are especially burdensome considering the increased susceptibility with which an HIV+ individual will develop TB. Even at the world-renowned Massachusetts General Hospital, the convergence of HIV and drug-resistant TB presents complicated treatment challenges. It is easy to understand why Dr. Wells portrayed such a gloomy forecast for South African health, not to mention the related socio-economic ramifications.
Back in Numlaco, people scatter about preparing for the impending storm. They gather food, water and clothes that have been drying on fences fashioned with barbed wire. Bracing myself for the clap of yet another lightning bolt, I am surprised to hear a different kind of noise. It begins as a singular banging, like someone is standing somewhere in the distance, banging a metal pole. But its singular nature quickly spreads. Within minutes, the beating of pots and metal barrels abounds from all directions. Noticing my puzzlement, one of the women I live with, Yolisa, explains to me that in Xhosa tradition the beating is the sound of people uniting to re-direct the storm or at least dampen it so that it does not destroy their dwellings.
But the storm came, and though it did bring high winds, keeping us and our neighbors inside for days, it will also bring something needed and refreshing-water. Community barrels sitting at the corner of the most modern homes collect run-off water from the gutters. This water will relieve the people of having to walk down the valley to a small, muddy stream shared with cattle and other livestock. As they walk back up valley, they pass the local water treatment plant that pumps clean water right past their homes into the town of Bizana. With heavy buckets skillfully balanced on their heads, they may take notice and ponder the injustice. Or perhaps they focus elsewhere, all too accustomed to such inequality. Either way, the passing storm provides a break from this arduous task, even if just for a few days. And the people are thankful.
I wish I could point to some comparable positive outcome from the storm of HIV and TB that Dr. Wells forecasted. But the fact is that there is nothing good that will come of this; only more sickness and hunger and death in a country that so desperately deserves a day in the sun after 40 years of apartheid and hundreds more of oppressive colonial rule. Despite this, there are so many brave South Africans, like HIV/AIDS activist Zinhle Thabethe of Kwa-Zulu Natal and nursing professor Sarah Mahlungulu, PhD, of the Eastern Cape, who stand in the face of the impending infectious storm beating their proverbial pots and barrels, begging the storm to change its course, trying to push back the thunder and lightning. However, it will take more than this. Entire communities must form a grass-roots movement demanding integrated prevention and care for HIV and TB from a national department of health that, thus far, has turned a deaf ear to their cries.
I hope that the beating of pots and barrels will spread from a brave few to the greater South African community in order to form a sound even more unifying than the one that rose this afternoon above the darks clouds approaching. I hope that members of the global community will stand in solidarity, utilizing their expertise and resources to add to the racket. But most of all, I hope that those who do beat against the “Perfect Storm” of HIV and drug-resistant TB will have better luck than the people of Numlaco at re-directing or at best dampening the storm shaking the walls of our house as I write this. For its rain will pound and destroy, not settling for roofs and windows. It will transcend houses and enter homes, and will further assault an already battered society.
Ryan Ahern is a medical student in the University of Washington Medical School and has done traveled extensively through South Africa. He can be contacted for questions or comments at ahernr@gmail.com.
Further information:
For information on Sibusiso Inc.’s work in the village of Numlaco and elsewhere in South Africa, please visit http://www.sibusiso.org
To learn more on the challenges of caring for HIV and TB in South Africa, please visit: http://aids.med.harvard.edu/news/symposia/southafricaworkshop.htm which compiles the presentations and discussions at the 2006 Harvard International HIV/AIDS Workshop.
Journal of Infectious Disease article by Dr. Charles Wells based off his presentation at the 2006 Harvard International HIV/AIDS Workshop. HIV infection and multidrug-resistant tuberculosis: the perfect storm. J Infect Dis. 2007 Aug 15:196 Suppl 1:S86-107
For a supplemental edition by the Journal of Infectious of Diseases based on topics discussed at the 2006 Harvard International HIV/AIDS Workshop, please visit http://www.journals.uchicago.edu/toc/jid/196/s3