The dilemma of a deadly disease: patients may be forcibly detained

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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

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.

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.