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Lack of medical workers stifles efforts to combat AIDS and TB
Jim Landers
May 24, 2007

http://www.dallasnews.com/sharedcontent/dws/dn/latestnews/stories/052007dnintafricaone.601ef.html

MABATLANE, South Africa - July Letsebe could not believe the doctor. Tuberculosis! The illness that killed his sister and two aunts, the "Big Cough" that tore his mother's lungs for years.

The young gardener had passed out while playing soccer on the dirt field next to the fetid, smoking dump of the rural township here called Leseding. Now he was in a hospital bed, unable to move.

In southern Africa, where a shortage of nearly 1 million health care workers is killing people like him every day, Mr. Letsebe is alive only because of charity efforts funded in part by the Dallas-based Wilson Foundation.

Though the World Health Organization says TB patients should be watched to ensure they take their medicine, no one could be spared to keep an eye on Mr. Letsebe. As he began feeling better, he put the pills under his pillow, or threw them out the window. He demanded to be released.

"I wasn't coughing, so I did not believe I had TB. I went to Botswana to see a healer," Mr. Letsebe said. "He said I was bewitched. He told me not to take the Western medicine and gave me 2 liters of a mixture that he said would cure me. It didn't work." Doctors, nurses and health educators simply are not available in many parts of southern Africa, particularly in rural communities like Mabatlane. There aren't enough doctors and nurses to diagnose diseases such as TB and AIDS, to educate patients on what causes these infectious illnesses and what medicines work, or to make sure patients take all of their medicines to avoid developing drug resistance.

Severe TB strain

AIDS has long been a grim reaper here. But because of the health worker shortage, another incurable disease - a pernicious form of TB - is rising here and threatening the world.

More than 285,000 South Africans fall ill with TB every year. Almost half of those on TB treatment programs fail to complete the six-month course of medicine to cure the disease. They are prime candidates for drug-resistant strains of TB, for which treatment is far more difficult and expensive.

Late last year, the WHO declared an emergency in southern Africa due to an outbreak of extremely drug-resistant tuberculosis, or XDR-TB. This highly lethal form of the disease does not respond to the medicines now used against TB.

HIV and AIDS are transmitted through sexual contact, contaminated needles and blood transfusions. XDR-TB can spread as easily as a cold. Victims breathe in germs coughed into the air by an infected person, and TB bacteria take up residence in the lungs.

People with immune systems compromised by the human immunodeficiency virus are particularly vulnerable. In South Africa, about 5.5 million people, or
21.5 percent of the adult population, are HIV-positive.

The WHO alarm was raised after 53 cases of XDR-TB were found among patients at a hospital in South Africa's KwaZulu-Natal province. Within 25 days of diagnosis, 52 of the patients were dead.

More than 330 cases have since been reported across South Africa.

"For all we know, it's happening in many places throughout the region. You might not even recognize the problem for years," said Dr. Ndwapi Ndwapi, head of the Botswana Ministry of Health's HIV/AIDS medications program. "We're all tied down. We don't have the manpower to keep up. And this is a time bomb in a big way."

Dr. Jason Kessler, a University of Pennsylvania faculty member doing TB research in Botswana, put it this way:

"XDR-TB could be an HIV disaster all over again, except that there's no hope of treatment this time. This disease poses a huge problem, not only in this region, but worldwide."

Effect on AIDS cases

XDR-TB may be the most combustible consequence of southern Africa's health manpower shortage. But it is not the only one.

Of South Africa's HIV-positive population, as many as a million need anti-retroviral drugs, which are lifesavers for AIDS patients with seriously compromised immune systems. But just a quarter of those people are getting them. The government requires patients to collect their drugs once a month at hospitals. In towns like Mabatlane, that means a long drive, and very few people here have cars.

"The whole generation my age are dying of AIDS," said Dr. Jennifer Johnson,
29, who spent three months at Mabatlane (also known as Vaalwater) as a UT Southwestern Medical Center fellow. "They don't have to die. People my age should not be dying."

Thanks to President Bush's pledge of $15 billion, as well as the Bill and Melinda Gates Foundation, Warren Buffett, the Clinton Foundation and other charities, there is finally enough money and medicine to mount a counterattack against AIDS in Africa. There just aren't enough trained health care workers to carry it out.

"The shortage of workers is the key problem. The funds are pouring in, the drugs, but there's no staff," said Dr. Ezekiel Nukuro, an adviser for human resources development with the WHO. "The severest problems are in Africa."

Texans have been helping to fight these manpower shortages in innovative ways.

Dallas interior design superstar Trisha Wilson's Wilson Foundation has been a prime backer of the Waterberg Welfare Society, a private medical care center serving HIV and TB patients in Mabatlane.

The Waterberg Welfare Society has helped dozens of gravely ill patients, and several - including Mr. Letsebe - have recovered to the point where they are now trained community health care workers. They urge others in the township to seek help and to take their medicines.

"There is still a huge stigma about HIV and AIDS here," said Dr. Peter Farrant, a pediatrician who chairs the Waterberg Welfare Society. "One of our major goals is to obtain acceptance by the community for what we do."

Mr. Letsebe was one of those who ignored the welfare society. As his illness progressed, the morning came when he lacked the strength to leave his tiny home. He stayed there for two years, on weeks when the sun made the corrugated metal walls and low roof too hot to touch, or when the cold seeped beneath his thin blanket, long weeks when his weary wife rose to go out to cook and clean.

When Mary Stephenson, director of the welfare society, came to see Mr. Letsebe in 2005, she found an emaciated, dying 34-year-old man. Mr. Letsebe, who is 5 feet 9 inches tall, weighed 85 pounds. He not only had TB but was HIV-positive and sinking quickly into AIDS.

Reluctant patient Mr. Letsebe said he could not have TB. Ms. Stephenson told him TB can take many forms, and she persuaded him to let her help.

His recovery took a long time. Though he did not develop XDR-TB, X-rays showed his right lung was black. A tube was placed in his side to drain the lung. It is still there and occasionally drains pus from his infected lung.

Mr. Letsebe was put on medications requiring two injections a day, five days a week. There was a discussion about whether he should get a lung transplant, but AIDS had so weakened his immune system that a transplant was out of the question. Doctors started him on anti-retroviral drugs.

When Mr. Letsebe was well enough to walk the dusty streets of Mabatlane again, friends asked him which healer had freed him of his curse.

"What I've learned about the whole process is, because we believe so much in witchcraft, we don't end up taking the medications," he said. "The only reason I'm here is because of the medicine. If I had taken it when I needed to, I would still have my lung."

Earlier this year, the Limpopo provincial government gave Mr. Letsebe an "unsung hero" award for his work with the clinic.

"A lot, lot, lot of people have died here," he said. "What is painful is that I was not even able to go to many of their funerals because I was in bed or in the hospital."

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