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FROM afghanistan Helen Meville is a nurse from Wagga Wagga. She has been working with Médecins Sans Frontières on a TB program in Afghanistan since January 2003. This is her third mission with the agency, following previous postings in Uzbekistan on a TB program and Congo-Brazzaville during an Ebola outbreak. Médecins Sans Frontières has worked in Afghanistan since 1980. TB: the plague makes a comeback :: I could write to you about a country that has suffered 23 years of war, about being awakened by machine gun fire, about seeing illnesses unheard of in our society: vitamin A deficiency, scurvy, polio, severe malnourishment. But instead I want to issue a warning about a disease once thought to be under control – tuberculosis. For centuries a true terror, the “white plague” which killed a billion people between 1850 and 1950, TB was thought to have been contained in the last 50 years. But here in Afghanistan, and in other poor countries, it is making a comeback. At least two million people die from it around the world each year, eight million suffer from active TB and on average each infected person will spread the disease to up to 10 to 15 people annually. And yet TB patients are still treated with drugs developed 40 years ago and little research into new drugs has occurred since the 1960s. I am working in a TB program set up by Médecins Sans Frontières in two separate refugee camps on the outskirts of Herat, a city in northern Afghanistan. The people have fled here to escape fighting and a four-year drought. The camps are poor and overcrowded – they are perfect breeding ground for tuberculosis. Treatment is complex, and arduous for the patient – a full course of TB treatment lasts at least six months and must include a combination of at least four different anti-tuberculosis drugs. TB medicines which take far less time to treat and fixed dose combinations (combining drugs into one tablet) are desperately needed. However, as a disease affecting mainly poor people, international efforts to address these problems are limited. Despite this, a well-run tuberculosis program has truly rewarding benefits for the patients and communities. Patients so close to death that they have only a matter of days to live can make remarkable recoveries. I have watched one elderly woman, who was once so breathless that she was unable to walk any further than the doorway of her house. Two months into the treatment, I saw her run the length of the camp to ensure she wouldn’t miss her food ration. I saw a teenage girl who had to be carried in each day by wheelbarrow, she was so weak. Now, three months on, she walks into the clinic, and I’ve seen her blossom into a beautiful young woman. A lucky few patients are currently receiving treatment in our TB program. In December, just before I got here, 10 people from the Shayidee camp started on anti-tuberculosis treatment. They attended the clinic daily for their first two months, then every second day for the next four months and, now, have only one month of treatment remaining; no-one has defaulted. In Mazhlak, the second refugee camp, on the opposite side of Herat city, treatment commenced for 45 patients in February. Every patient has shown improvement in his or her condition, and there is an 80% conversion rate in smear positive to smear negative (which means they are no longer contagious). Sadly we have one defaulter: a three-year-old girl with spinal tuberculosis whose family come from a region plagued by fighting. For the present the tuberculosis program here goes well, but there is still upwards of four months to go – and if they default on their medications now, their condition will again deteriorate to become life-threatening. Even worse, intermittent or incomplete treatment can result in the TB bacteria becoming resistant to existing medicines, and multi-drug resistant tuberculosis (MDR-TB) can result. Treatment for MDR-TB is expensive, the side effects can be severe and success is not guaranteed. Such treatment is rarely available in many developing countries and left without treatment, MDR-TB is almost always fatal. Laurie Garret, author of The Coming Plague, has described MDR-TB as “Ebola with wings”. While Médecins Sans Frontières has not seen many MDR-TB cases
in its programs in Afghanistan, ad hoc purchases of TB drugs in the unregulated
market here means that the emergence of such a form of TB is always a risk. Other
developing countries, such as the neighbouring states of the former Soviet Union,
are already experiencing high rates of MDR-TB. June 2003
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