March 24th, 2010
Once again it is International TB Day.
Today we make this posting in memory of Frank, the Ugandan we treated in hospital in December in Lyantonde who was dying of HIV-TB co-infection. This week we have heard that he is dead.
It's difficult for us to make complete sense of this, particularly because we have no further information.
Frank as we found him in December
Frank was our first moxa patient in Africa - indeed we believe he was the first patient anywhere in the world with TB-HIV co-infection to have been treated with a moxa treatment protocol for TB resurrected from 1930's Japan. He was thus our number one patient. In Japanese, "number one" is "ichiban" and means not just the first, but also equally the most important. For exactly this reason, when we returned to Uganda earlier this month we had hoped to trace him and develop the treatment more fully with his sister, but we were unable to find any trace of him. The last we'd heard, he was walking in the ward and was eating, and he appeared to have subsequentlty left the hospital but no-one knew where.
Did he continue with the simple moxa treatment? Did it help prolong his life, or merely prolong his suffering?
This stuff is hard to make sense of. We know for sure, though, that despite his condition he clearly responded to the moxa treatment. Richard Mandell, the director of the PAAP was one of those who let us know about Frank's death, and he'd seen what had taken place when we treated him. This is what he wrote: "I do not know for how long his struggle continued, but I will never forget the joy associated with that one treatment.
It's equally hard to make sense of the most recent WHO global report on Drug Resistance in Tuberculosis, published to coincide with the anniversary of the original identification of the tuberculosis bacillus. In relation to Frank and in relation to what we found earlier this month in Kampala it is pretty bewildering. For instance, it merely tentatively identifies TB's possible association with HIV - "If confirmed such a finding could have significant implication for control of the dual epidemics in Sub-Saharan Arica". This seems at least a little of an understatement.
Of course we have no idea actually if Frank was drug resistant. " Contemporary diagnostics for MDR-TB are available in less than half of the MDR-TB high burden countries", and Uganda isn't even considered high-burden. But how could it be? The last survey from Uganda is thirteen years old, and in any case was only done on a local basis. In fact the report actually states that the "estimated numbers [of drug resistant cases] in many African countries are based on mathematical modelling rather than empirical studies".
This means that still no-one really has any real idea as to what's happening in terms of drug resistance on the continent with the highest rates of TB and TB mortality. It means that the resource is still inadequate to control it - in fact the report startlingly discloses that "no low income country anywhere has continuous drug resistance surveillance in place". (South Africa, it can be noted, is not included as a "low income" country). So the very places where this disease thrives most still have the least resource to combat it. Plus ca change, plus c'est la meme chose (perhaps more appropriately translated as "the more this mutates the more it is the same thing"). This lack of appropriate targeted resource is exactly why TB was never driven into submission as it should have been since the 1940's.
In Kampala we found unexpected and almost unbelievable evidence of drug resistance (certainly in the context of the WHO report). Of the first patients enrolled on our programme, over 35% were drug resistant (defined simply by being still sputum positive after six weeks of drug treatment). According to the WHO report it should have been less than a tenth of this - and even more frightening more than half of these were primary infections. This means that a pool of drug resistance is already in existence in Kampala , and it suggests that the same may be the case in any conurbation south of the Sahara.
What we hope we have left in place in Kampala is a seed - with a group of feisty health workers engaged in a struggle to manage the unmanageable who are now trained in the Moxafrica treatment protocols, and who in turn are training the "buddies" of their patients to implement daily treatment. We must wait to see how this develops over the next months - but we hope we will see signs that it may help.
For more information, please look at our "Uganda" page.
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