On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 n.8 Cape Town Aug. 2008
South African ARV roll-out pioneer and now MDR TB community treatment trailblazer, Dr Eric Goemaere, awarded an honorary doctorate of science in medicine by the University of Cape Town this June, says the cloak of HIV stigma that existed 10 years ago today enshrouds extremely drug-resistant and multidrug-resistant tuberculosis (XDR/ MDR TB.)
With 250 notified MDR TB cases in his treatment stamping ground of Khayelitsha, Cape Town, and more than 10 000 combined XDR/MDR TB cases country-wide, community-based education and treatment are the only alternatives to the regressive policy of isolating patients in central facilities, he asserts.
'Locally we have two problems and they are echoed country-wide: our TB hospital (Brooklyn Chest) is full and with the specificity of disease and the time it takes to diagnose, people are infectious long before they can be isolated,' he says. It was an 'illusion' to think patients could be taken out of circulation on the day of diagnosis.
'Slowly and surely' it would sink into national health department thinking that XDR/MDR TB was also the community's responsibility. 'It's like when TB started - people were put in sanatoriums. Now XDR/MDR-infected people are portrayed in the media literally as suicide bombers walking the streets to spit deadly disease in the face of everyone. We've managed to largely overcome HIV/AIDS stigma, certainly in Khayelitsha, with our varied NGO and community partnerships, but now it is the turn of XDR/MDR.'
Goemaere said TB was 'everywhere' so infection control education and training in health care facilities and homes was vital. Natural ventilation, fans and putting the patient in a separate room, were basic requirements.
'We try to make people understand that the disease is not new, it's a concern of everyone and we must fight it together instead of isolating patients.'
His experience with ARV roll-out where the organisation he heads in South Africa and Lesotho, Médecins Sans Frontiêres (MSF) (which had 1 000 people on treatment in Khayelitsha alone by the time government began its programme 4 years later in 2004), proved beyond doubt its feasibility in urban and rural settings (rural being the MSF's Lusikisiki site in the Eastern Cape).
After a shaky start in Alexandra township in August 1999, when his attempts to begin PMTCT there met stolid government resistance, much to his amazement and surprise, he moved to Khayelitsha, where conditions and health politics were more conducive to the work he was trying to do.
He sees his greatest achievement and is most satisfied by the partnerships he has developed with the widely varying groups of MSF staff, NGOs, local authorities and communities in Khayelitsha.
'We've developed a common understanding of what can make everybody's lives better and have reached agreements with the community in spite of all the conspiracy theories and alternative medicines.'
The twin epidemics of HIV and MDR TB have required innovation and resourcefulness, but most of all a raising of awareness in communities through successful home and clinic-based interventions.
Intensive collaborative research by the University of KwaZulu-Natal and Yale University at Tugela Ferry in KwaZulu-Natal, where the index cases of XDR/MDR TB in 2005 numbered 53, predicted, with no new interventions, a rise to 1 300 new cases there by 2012, more than half of them nosocomial.
The team recommended a mix of mask use, reduced hospitalisation time and a shift to outpatient therapy, confidently predicting that these would prevent nearly a third of infections there. Supplementing this with improved ventilation, rapid drug testing, HIV treatment and TB isolation facilities could avert 48% of Tugela Ferry's MDR/XDR TB cases by the end of 2012, they concluded in a paper published in The Lancet (2007; 370: 1500-1507).
Involuntary detention could result in an unexpected rise in incidence owing to restricted isolation capacity at the hospital, a problem reflected at urban and rural hospitals across the country.
Twin epidemics fuel prevalence
According to the late Ivan Toms, Cape Town's former Medical Officer of Health and a struggle-era health care icon who ensured stalwart support for MSF and their local township partners, an untreated HIV-positive person has a 10% annual chance of contracting TB. Toms compared this with a 10% lifetime risk of TB for a HIV-negative person. In effect this means that an untreated HIV-positive person has a 60 times greater chance of contracting TB. Almost all MDR/XDR TB cases in Cape Town are HIV positive, with 1 out of every 2 TB patients HIV positive, and MSF has developed an integrated programme to take account of this.
MDR TB cases in Cape Town have remained relatively constant at 1% of new cases and 4% of re-treatment cases, thanks to an excellent overall TB control programme. The Western Cape also has the lowest HIV transmission rate from mother to child (4.5%) in the country (the national figure is about 18%), again due in no small part to interventions and groundbreaking work by the MSF in collaboration with city and provincial health authorities.
The Belgian born Goemaere, whose wife Katherine, a biochemist, nutritionist and epidemiologist, is seconded to the province to help pilot an HIV treatment surveillance programme, also supervises the MSF ARV roll-out in Lesotho, where 3 000 people now benefit from a sophisticated programme in multiple resource-poor settings.
Government 'ungracious' - UCT orator
The Goemaeres, who have two locally schooled, university-aged children and have been here nearly 10 years, have to register annually with the HPCSA and Foreign Workforce Management to practise as volunteer doctors and are still 'temporary residents' who have to renew their work permits annually.
Goemaere said that if attempts by a new immigration lawyer he recently hired to secure a longer-term exceptional skills work permit and/or permanent residence for his family failed, they would soon have to make some 'clear decision' about their future. 'We can't leave our children without a university diploma. I recently sent my son to Europe to explore and make up his mind and he doesn't want to live there, he sees himself as South African and wants to live here,' he said. Unless the family secured permanent residence, neither child would be able to attend university locally, and this was unacceptable to them, meaning they might leave altogether.
A previous attempt to secure a less tenuous status, bolstered by a letter to Home Affairs from the province's former HIV/AIDS chief, Dr Faried Abdullah, was summarily dismissed. 'Basically the director at Home Affairs asked me what I wanted him to do with such a letter and said he could do nothing with it. We'd have to queue like everyone else,' Goemaere told Izindaba. The same man had some years later, and while working as a consultant to Home Affairs, offered to secure him the necessary documentation for a 'fee', but he refused on principle.
Goemaere's immigration lawyer, Gary Eisenberg, said his information was that Goemaere had never submitted an application for permanent residence but that an exceptional skills-based work permit for up to 3 years would be fully in line with government's policy of encouraging an inflow of skills.
There should also be 'no problem whatsoever with permanent residence based on their extraordinary skills - the only thing is that it has to be lodged and a really speedy resolution could take up to a year'.
Goemaere was general executive director at the MSF headquarters in Brussels from 1994 to 1999, where he was in charge of general policy and development of the largest MSF operational section with 110 permanent staff at head office and 420 field staff in different countries. Notably, at the end of this period, MSF won the Nobel Peace Prize.
In his oration to the honorary degree conferred on Goemaere on 13 June at UCT, Professor Francis Wilson said Goemaere had 'transformed the reality of health care' for HIV/AIDS patients through a well-organised roll-out of ART, with the Khayelitsha programme hailed by the WHO as a best practice programme with limited resources.
'Over the past 10 years Eric Goemaere has played a major role in helping South Africa to begin to heal itself. We are deeply grateful to him and we honour him. We hope too that this recognition may enable our Department of Home Affairs to affirm his work by welcoming him as a permanent resident. It is surely ungracious for our country, to which he has contributed so much, to require that he apply every year for a work permit.'