[FoRK] (no subject)
Rohit at ICS.uci.edu
Mon Sep 20 14:36:52 PDT 2004
There are few more cost-effective ways to reduce human suffering than
clean water. Even "old" drugs are up there, too... sigh. Rohit
September 19, 2004
By TINA ROSENBERG
No one dies of AIDS. This is not denialism. The truth is that the AIDS
virus does not kill you -- it simply degrades your immune system so
that something else does. Quite often that something is tuberculosis.
TB is the leading AIDS-related killer, perhaps responsible for half of
all AIDS-related deaths. In some parts of Africa, 75 percent of people
with H.I.V. also have TB.
Tuberculosis is a wasting disease, usually of the lungs, and until the
discovery of antibiotics, it affected millions of people even in
wealthy nations. Today, more people die of it than ever -- about two
million per year -- and in sub-Saharan Africa, cases are rising by 6
percent a year. The reason for the TB explosion is the spread of AIDS:
having H.I.V. makes an individual vastly more susceptible to
tuberculosis. In turn, TB has brought an especially early death to many
AIDS victims. An H.I.V.-positive patient who contracts TB and does not
receive treatment has a 90 to 95 percent chance of dying within a few
TB has played a part in making AIDS the plague it is today. But the
horrifying collision of these two diseases also offers a double
opportunity to save lives. The obstacle is that TB is still regarded as
a relic. Granting tuberculosis the respect it deserves offers a
crucial, and unheralded, way of delivering hope to AIDS sufferers.
In the long term, antiretroviral therapy must be made available to all
who need it. But millions in the third world will die waiting. For
many, curing their TB with a regimen of inexpensive pills or injections
could allow them to live years longer. The very universality of TB
makes it ripe for intervention. Fully one-third of the world's
population is infected with TB. In the vast majority of people, the
infection is latent. But when an individual becomes H.I.V.-positive,
his or her immune system is less able to ward off the onset of active
TB. So millions will suffer from TB early in the course of AIDS --
sometimes years before they would have been stricken by another deadly
infection. Curing this early TB can buy people years of health while
they wait for antiretrovirals.
How many years? One answer comes from Cange, a village in central
Haiti, where the Boston-based group Partners in Health runs a medical
complex. In 2001, doctors from the organization published a paper about
a group of TB patients they treated in 1994. They found that nearly all
of the TB patients who also had H.I.V. were still alive in 2001 and
that only 5 of the 27 they could track down needed to start
Imagine a cancer drug that could bring patients seven more years of
caring for their children, of working -- of living. It would be
considered a huge success. A drug that performed this feat for $11, in
AIDS patients, without antiretrovirals, would be called a miracle.
In contrast to antiretrovirals, TB pills have the enormous advantage
of being cheap: even though TB patients must take medicine for six to
eight months, the complete course costs about $11. And the course is
effective. Even the poorest countries can cure more than 90 percent of
the TB cases they treat -- if they employ a relatively new strategy.
That strategy is known as DOTS (Directly-Observed Treatment,
Short-Course), and it is one of the world's most cost-effective health
interventions. Malawi and other African countries pioneered the program
in the 1980's, and in 1995 the World Health Organization introduced it
globally. It is used far too little -- in Africa, two-thirds of those
with both H.I.V. and TB live in places where DOTS still hasn't arrived.
But where it is used, it works. Peru and Vietnam cure more than 90
percent of their cases. Half of China uses it, and rates of cure there
approach 96 percent for new cases.
A successful DOTS program requires a political commitment to sustained
TB control. To prevent more lethal strains of the disease from
spreading, a country must ensure an uninterrupted supply of drugs.
Clinics must have a simple, cheap method of diagnosis and must track
and report patients' progress. They must also find ways to ensure that
patients take their medicine every day for at least the first two
months. In many countries, the patient chooses a family member for this
job. In Haiti, Partners in Health trains and pays largely illiterate
community members as accompagnateurs. They visit three or four families
a day, watch patients swallow pills and provide moral support.
Now suppose you are an African AIDS official struggling with questions
like: How can I identify the sick and persuade them to come for
treatment? How can I get them a steady supply of pills? How can I help
them to take their medicine, day after day after day? If your country
has DOTS, you already know the answers. You have a system that reliably
gets drugs to patients, teaches them to take pills regularly and tracks
their progress. And in many places, the patients with TB are
essentially the same people who have H.I.V. Doctors Without Borders has
a pilot clinic in Khayelitsha, a slum outside Cape Town, South Africa,
that combines TB and AIDS services. It started as separate next-door
clinics, says Eric Goemaere, who runs the program, but doctors decided
to merge the clinics when they noticed that patients were going out one
door and in the other.
The fact that tuberculosis clinics are filled with H.I.V. sufferers
should offer a way to solve one of the most vexing problems in both the
prevention and treatment of AIDS -- finding the sick and getting them
testing and counseling. Yet less than 1 percent of TB patients
worldwide get AIDS testing.
Why aren't more places adopting DOTS, testing TB patients and using
their TB programs as models for treating AIDS? In large part, it's
because TB is still invisible. The Global Fund to Fight AIDS,
Tuberculosis and Malaria devoted only about 10 percent of its last
round of grants to fighting TB. Research is so neglected that there
have been no new drugs developed specifically for TB in the last 30
At July's international AIDS conference in Bangkok, Nelson Mandela
talked about the tuberculosis he suffered from in prison and the
world's desperate need to fight the disease. ''TB remains ignored,''
Mandela said. One reason is that he is practically the world's only
famous TB patient since the Bronte sisters. It's a disease of the
slums, of the poor and of prisoners. AIDS, by contrast, affects the
rich as well. The sons of African presidents get AIDS. But they don't
And Mandela merely used to have TB. No one used to have AIDS, which is
treatable but incurable. AIDS activists -- without whom there would be
no affordable AIDS treatment anywhere -- are largely people who
identify themselves as living with AIDS. TB has no citizen-activists --
''People go quiet as soon as they are cured,'' says Alasdair Reid, who
works on both diseases at the W.H.O. There are doctors who care
passionately about TB, but they have been working in a ghetto. The
world needs to join their battle -- both to stop a tuberculosis
explosion and to save lives in the fight against AIDS.
Tina Rosenberg writes editorials for The New York Times. Her last
article for the magazine was about DDT.
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