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Tackling TB in the Field

July-August 2008

Lesotho is a country of breathtaking beauty and heartbreaking poverty. The twin epidemics of HIV and drug-resistant tuberculosis may also make it the site of the most devastating pandemic of the twenty-first century.

I am in the capital, Maseru, wearing a face ventilator and standing with Partners in Health (PIH) director Jim Yong Kim—professor of social medicine at Harvard Medical School and François-Xavier Bagnoud professor of health and human rights at the Harvard School of Public Health—outside a new 24-bed hospital devoted to the most serious and infectious of Lesotho’s extensively (XDR) and multidrug-resistant (MDR) TB patients. It is Kim’s first visit in more than a year, and the PIH hospital, four months old and the first in the country with state-of-the-art infection control, bears witness to the devastation of the disease.

Take Molahlehi (not his real name), a patient on the wards who used to work in the South African mines. HIV-positive and now, after intermittent and incompetent treatment for tuberculosis, resistant to all of the most important drugs, he is a classic XDR TB case. The stigma associated with his condition is such that his village won’t have him back, nor would his children when he tried to return home over Christmas. He called PIH to pick him up again when he realized the extent of his isolation. While PIH is caring for his family members (his wife left him) and educating his village about his condition, PIH’s MDR-TB program director, physician Hinda Satti, is praying that he will respond to treatment. The outlook is grim; a cure rate of 50 percent is deemed the highest success.

 

“These are, hands down, the most complicated patients I’ve treated in my life,” says Jen Furin, PIH’s country director in Lesotho and a physician at Harvard-affiliated Brigham and Women’s Hospital in Boston. Furin has worked on MDR cases at PIH sites from Haiti to Peru. But in Lesotho, where the incidence of HIV and TB co-infection is among the highest on earth, the patients are far sicker—and far more likely to stay that way.

The challenges extend far beyond clinical treatment of the condition. As patients move from the hospital wards to PIH-run halfway homes, and, finally, back to their villages, community health workers trained and employed by PIH help them navigate their twice-daily drug cocktails—more than 20 pills a day for many, for a minimum of two years—and educate community and family members.

The success thus far has been astonishing. Of the 94 patients who have made their way through the wards since November, Satti says, not one has defaulted on therapy. The hospital is already attracting international attention: a contingent of doctors from the South African province of KwaZulu Natal—doctors who, given their own country’s wealth, medical infrastructure, and history with XDR TB, should be training Basotho (as citizens of Lesotho are called)—were learning from the hospital staff the day I arrived. And Kim, after visiting the newly renovated TB and microbiology lab (which eliminates sending specimens to South Africa for testing), was as excited by its capacity to help Lesotho as by the precedent set for other countries: “I was talking to the director of the TB department at the World Health Organization about your work here,” he raved to lab head Mathabo Mareka, “and he is so excited about it.”

In Lesotho, Partners in Health (PIH) has set up a modern laboratory and treatment center for the care of patients with drug-resistant TB. Many are also infected with HIV.

Photographs by Justin Ide/ Harvard News Office

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A recovering TB patient lives in a home near the hospital where doctors monitor her care.

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At a rural clinic, PIHs Jen Furin admits a patient with AIDS, TB, and meningitis.

image of Kim in the field

Kim in the new PIH-affiliated hospital pharmacy in the capital, Maseru.

image of Kim in the field

PIH leader Jim Kim (right), with Furin (center), meets Moses Phakis, a local clinic administrator, in Bobete.

As important as these TB projects are to PIH’s healthcare-delivery and capacity-building efforts in Lesotho, they are far from the whole story. Unlike organizations that pursue narrower aims or are restricted in their use of funds, PIH owes some of its success to its commitment to comprehensive care: not just to the most serious XDR cases, but to any patient in need.

I encounter a vivid example on a visit to a patient with Furin. We are idling in our car along a rain-washed road, lost in the sea of shacks and shanties outside Maseru, looking for a six-year-old boy, Molise, whom we saw earlier in the week. HIV-positive and rail-thin, he hasn’t been able to walk since dislocating his knee last year. His hands are swollen and elongated from shuffling around, crab-like, on the ground; his leg, permanently skewed to the side, is unusable. If PIH had a mandate, that leg would likely fall outside it. But Furin has a plan to fix not just the leg, but the leg and everything else.

An hour passes before Molise, wearing shorts and a shirt provided on our last visit, crawls excitedly toward us. As Furin examines the boy on her knee, for a moment the hospital wards, the dying Basotho isolated in the mountains, the pandemic quietly sweeping southern Africa—all fade into the humanity of the child’s grin. “This [leg],” she says, the lines of exhaustion on her face fading briefly into a smile, “this is actually something, something that’s savable.”

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