Send to a friend
Jerome Singh argues that we need to isolate patients with extensively drug-resistant tuberculosis to prevent a global epidemic.
In September 2006, the World Health Organization announced that Tugela Ferry — a small town in KwaZulu-Natal, South Africa — was host to the largest outbreak of extensively drug-resistant tuberculosis (XDR-TB) ever recorded. 53 people were diagnosed with the disease and their median survival time from sputum collection was just 16 days.
Since then, as national surveillance of XDR-TB has increased, more than 400 people have been diagnosed with the disease, and the number is growing.
Yet despite this growing crisis, South African officials have been reluctant to consider mandatory isolation of infected individuals, believing such a measure could lead to stigma and the disease being driven underground.
Such an approach, while politically correct, is unwise and could thwart efforts to prevent the outbreak from becoming a regional — or even global — epidemic.
A question of resources?
But mandatory isolation of patients carries with it an inevitable logistical and financial burden that many developing countries could struggle to cope with.
South Africa’s health system — like that of many other countries in sub-Saharan Africa — is already overwhelmed with patients suffering from HIV/AIDS and related opportunistic infections.
There are simply insufficient resources to cater for everyone infected with XDR-TB. This means that potentially dozens of XDR-TB patients are being treated as outpatients, or at general hospitals where they share wards with people infected with other strains of TB, putting potentially curable patients at risk of acquiring a possibly incurable disease.
Other countries in sub-Saharan Africa, such as Lesotho or Malawi, are even worse off, with little or no resources for XDR-TB diagnosis, surveillance, tracing or treatment.
Given the critical lack of hospital beds, home-based care has been mooted as one option for treating XDR-TB patients. But the disease’s airborne nature and its lethality to those with immune systems compromised by HIV/AIDS make this a less than optimal solution.
It would be better to have dedicated community-based isolation units, where XDR-TB patients can be treated without putting other members of the local community at risk. Of course, establishing and maintaining such units will have profound financial and logistic implications and may not be feasible or sustainable in poor countries unless — or even if — they are backed by investment from the international community.
In addition, isolated patients and their families deserve financial and social support to cope with the prospect of possible isolation until death. Indeed, such support may incentivise infected people to comply with isolation measures.
The ethical dimension
But, even if community-based isolation measures can be financed and logistically provided for, they could still lead to stigma and discrimination. Such strategies then must be accompanied by proper educational and protective mechanisms such as outreach and social support programmes, teaching clinics, and the provision of and training in the proper use of universal precautions such as masks and respirators to guard against XDR-TB infection.
Restricting the mobility rights of people infected with XDR-TB also has ethical and human rights implications. Ethically, patients are entitled to self-determination. Legally too, patients are given a host of human rights by virtue of domestic and international laws, such as the International Covenant on Civil and Political Rights (ICCPR).
Still, these rights are not absolute. The ICCPR, for example, holds that public health may be invoked as grounds for limiting certain rights so that states can take measures to deal with a serious threat to the population’s health.
Seen in this context, isolating XDR-TB patients — involuntarily if needs be — is a reasonable and justifiable measure to protect the health interests of the wider population. Governments in the developing and developed world alike should not be reluctant to act on human rights grounds alone.
The need to act promptly
But they must act quickly and resolutely.
On May 30, 2007, US officials announced that a citizen diagnosed with XDR-TB had undertaken trans-Atlantic flights and, in so doing, may have put dozens of people at risk of infection. If, as the passenger alleges, authorities knew of his travel plans in advance, their failure to prevent him undertaking the journey and his subsequent easy re-entry into the country constitutes gross negligence, notwithstanding his allegedly low state of infectiousness.
Although the infected individual has since been isolated — under the first such federal order issued in the United States since 1963 — the incident serves to highlight how XDR-TB could potentially spread beyond individual regions very quickly. It also underlines how prompt and restrictive isolation measures could have prevented the incident.
XDR-TB is a global problem that already affects people across the world, including those in affluent countries. Governments must act decisively and responsibly to implement isolation measures in a sensitive and humane way to manage XDR-TB before it becomes an unmanageable pandemic. Prevention is better than cure.
Jerome Amir Singh is head of Ethics and Health Law at the Centre for the AIDS Programme of Research in South Africa.