The dilemma of a deadly disease: patients may be forcibly detained
Pastor Dale Morgan
The dilemma of a deadly disease: patients may be forcibly detained*
Doctors fear TB strain could cause a global pandemic if it is not controlled
Chris McGreal in Johannesburg and Sarah Boseley, health editor
Tuesday January 23, 2007
The Guardian
South Africa is considering forcibly detaining people who carry a deadly
strain of tuberculosis that has already claimed hundreds of lives. The
strain threatens to cause a global pandemic, but the planned move pits
public protection against human rights.
The country's health department says it has discussed with the World
Health Organisation and South Africa's leading medical organisations the
possibility of placing carriers of extreme drug resistant TB or XDR-TB
under guard in isolation wards until they die, but has yet to reach a
decision.
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Pressure to take action has been growing since a woman diagnosed with
the disease discharged herself from a hospital last September and
probably spread the infection before she was finally coaxed back when
she was threatened with a court order.
More than 300 cases of the highly infectious disease, which is spread by
airborne droplets and kills 98% of those infected within about two
weeks, have been identified in South Africa.
But doctors believe there have been hundreds, possibly thousands, more
and the numbers are growing among the millions of people with HIV, who
are particularly vulnerable to the disease. Their fear is that patients
with XDR-TB, told that there is little that can be done for them, will
leave the isolation wards and go home to die. But while they are still
walking around they risk spreading the infection.
Now a group of doctors has warned in a medical journal that if enforced
isolation is not introduced XDR-TB could swamp South Africa and spread
far beyond its borders. Regular TB is already the single largest killer
of people with Aids in South Africa.
Pandemic
Jerome Amir Singh of the Centre for Aids Programme of Research in South
Africa and two colleagues wrote in the peer-reviewed journal Public
Library of Science Medicine that the government must overcome its
understandable qualms over human rights in the interests of the
majority. Without exceptional control measures, including enforced
isolation, XDR-TB "could become a lethal global pandemic", they say.
"The containment of infectious patients with XDR-TB may arguably take
precedence over any other patients not infected with highly infectious
and deadly airborne diseases, including those with full-blown Aids. This
is an issue requiring urgent attention from the global community," they
wrote.
"The South African government's initial lethargic response to the crisis
and uncertainty amongst South African health professionals concerning
the ethical, social and human rights implications of effectively
tackling this outbreak highlight the urgent need to address these issues
lest doubt and inaction spawn a full-blown XDR-TB epidemic in South
Africa and beyond."
Mary Edginton of the Witwatersrand university's medical school endorses
enforced quarantining.
"You can look at it from two points of view. From the patient's point of
view, you are expected to stay in some awful place, you can't work and
you can't see your family. You will probably die there. From the
community's point of view such a person is infectious. If they go to the
shops or wander around their friends they can spread it, potentially to
a large group of people," she said.
Karin Weyer of the Medical Research Council has called for enforced
hospitalisation of high-risk TB patients on the grounds that the risks
to society outweigh individual rights. But she opposes forcible
treatment because of the dangers associated with the drugs.
Professor Edginton said that medical authorities in the US and other
countries can obtain a court order to detain a person with infectious TB
or someone who is non-infectious but has failed to adhere to treatment.
"The Americans are much better at enforcing their laws on this," she said.
South African law also permits enforced isolation but some lawyers say
it comes into conflict with the constitutional guarantees on individual
rights. However, the constitution also guarantees communal rights,
including protection from infection and the right to a safe environment.
South Africa's health department yesterday said it has discussed the
possibility of enforced isolation with the country's Medical Research
Council and the World Health Organisation but has not reached a conclusion.
Poor housing
Ronnie Green-Thompson, a special adviser to the health department, said
the issue at stake is the human rights of the individual weighed against
the rights of the wider public. "The issue of holding the patient
against their will is not ideal but may have to be considered in the
interest of the public. Legal opinion and comment as well as sourcing
the opinion of human rights groups is important," he said.
"Also of importance is preventing those factors that lead to infectious
TB and these are poverty, poor housing, overcrowding and poor nutrition
and any other factors that weakens patients' resistance to acquiring
infections."
Umesh Lalloo, of Durban's Nelson Mandela School of Medicine and head of
the research team into the first XDR-TB outbreak, said he is not
persuaded that detention is necessary.
"It's a very difficult call. Given our recent past with human rights
violations we need to be careful. I'm not dismissing such a move but
it's a very radical step. What we should be pushing for is a
reinforcement of the TB control programme which would contain the
spread," he said. Professor Lalloo said one consideration is that almost
all infections appear to have spread to patients in hospital.
The doctors and co-authors said that it is essential that patients were
detained in "humane and decent living conditions" and they urged the
government to change the rules so that those in hospital with TB
continue to receive welfare payments which are cut off if they are
treated at the state's expense.
Although cases of XDR-TB were discovered in South Africa a decade ago,
the disease started claiming dozens of lives at the small Tugela Ferry
hospital in rural KwaZulu-Natal two years ago. XDR-TB's origins are
uncertain but the WHO says the misuse of anti-tuberculosis drugs is the
most likely cause.