With the failure of the South African National AIDS Committee (SANAC)’s 1.1-billion Rand (round 8) application to the Global Fund to Fight AIDS, TB and Malaria (GFATM) and the ongoing political uncertainty with a “caretaker” government until the 2009 elections, South African delegates attending the World Lung Health conference in Paris last week expressed fears that many long awaited activities to scale-up TB and TB/HIV services will be placed on hold for some time to come.
Some South African activists and doctors even went around the conference with hat in hand hoping to find alternative funding sources for stalled community education campaigns, DOTS expansion and the like.
“We need about $5000 to print training materials for a nationwide treatment literacy campaign on TB/HIV and I’m not sure where we will get it,” one activist told aidsmap.com.
“The emergency response to TB that is so desperately needed in South Africa continues to be delayed,” another South African delegate told aidsmap.com.
The divide between civil society and government
According to most, the failure of the GFATM proposal is yet another consequence of the long-standing rift between civil society and the government on health issues.
Notably, the divide was very evident at the first national South African TB Conference, held in Durban just three months ago, which, ironically, had tried to pull both sides together, with the theme of “working as one.”
In the last couple of years, South Africa has indeed begun mobilising to fight TB. In 2007, South Africa launched a Tuberculosis Strategic Plan; it has marshalled considerable resources for its implementation — and many clinical teams and non-governmental organisations are performing exciting work on the ground. But according to Dr Refiloe Matji, the regional director of the University Research Co (URC), and the conference chairperson, these efforts are often happening in isolation.
“It is time to make the concept of ‘working as one’ a reality to have a nationwide impact against all aspects of the disease,” Dr Refiloe Matji said during her opening welcome at the South African TB conference. In particular, she stressed the importance of meaningfully engaging civil society and people with TB and/or HIV (who are at very high risk of TB) as equal partners combating the disease.
“Making people with TB part of the team is key to achieving our goals of a TB-free South Africa,” she said.
The flashpoint: facility-based treatment of people with drug resistant TB
Dramatic evidence that this isn’t truly happening yet was reported by the local newspapers just days before the conference, when people with drug resistant TB (DR-TB), complaining of intolerable living conditions, went on a rampage and broke out of isolation at a TB hospital in the Eastern Cape — for the third time in over a year.
How best to manage the care and treatment of people with drug resistant TB (DR-TB) — while respecting their human rights — would be a divisive and hotly debated issue throughout the course of the four-day meeting (and to this day).
South Africa hasn’t released formal guidance on how manage such patients (draft guidelines are now being reviewed), but the de facto policy is to hospitalise all DR-TB patients once beds in a TB isolation ward become available, including by forced isolation if a patient withholds consent. However, recognition of drug resistance usually comes months after the subject develops active infection and most provinces have long-waiting lists for beds. Isolation, generally in close quarters with other DR-TB patients who are possibly infected with other drug-resistant strains may last anywhere from six months to two years.
Early during the conference, representatives from the Department of Health conceded that there was a problem.
“The outbreak caught us unawares and the facilities that have been provided to accommodate MDR patients have certainly not been geared for this type of condition — patients who are likely to be hospitalised for a long duration of time - in some cases in excess of two years,” said Mr David Mametja. “But those facilities where these people live have not been structured in a way that responds to a long stay in hospital.”
But the fact that several TB hospitals in South Africa are surrounded by barbed wire and have posted guards, as well as the use of police to forcibly isolate some patients, have led some to characterise the policy as one of incarceration.
And incarceration is a loaded term in South Africa.
“When one talks about detention without a trial in a South African context, there’s a whole history that comes with that and therefore there’s an absolute need to be a lot more cautious when you’re engaging in that process,” Professor Karthy Govender, a member of the South African Human Rights Commission, said during a skills-building session at the conference.
So despite the organiser’s valiant efforts, by the end of South Africa’s first TB conference, representatives of civil society and the health department were shouting at each other.
What direction will the new Minister of Health take?
We had planned to release a more complete report on the South African TB Conference in tangent with our coverage of the recent changes in South Africa’s government leaves many things up in the air.
While appointment of new Minister of Health, Barbara Hogan has been widely hailed by activists, it is unclear what she will be able to accomplish before the next election, which will probably be held in April 2009. At present, she presides over a fractured department, with some elements loyal to the previous administration — and party unity may come before major policy changes.
Furthermore, the minister, who has no professional medical background, will likely be guided by the TB experts in the ministry. It is important to recognise that there can be a clash of cultures between the conservative TB treating community — which often cleaves to time-tested if somewhat paternalistic medical approaches — and the HIV activist community, which is fostering the growing TB activist movement, and which takes a human rights (and often more innovative) approach to the delivery of health care services.
Already, there are indications that TB policy will not change all that much. According to comments from the Treatment Action Campaign (TAC), AIDS Law Project (ALP) and the AIDS Right Alliance for Southern Africa (ARASA) on the new Draft Policy Guidelines for the Management of Drug-Resistant Tuberculosis, the Department of Health continues to follow a policy of hospitalising DR patients, but “are silent regarding specific guidance to health care workers on how to enforce the policies contained in the guidelines, such as isolation and treatment of patients without consent, particularly on when forced isolation is justified.”
And time is tight to work with SANAC to apply for the Round 9 call for Global Fund proposals, due January 21, 2009. Given the virtual shut-down that typically occurs in South Africa’s government during December and January, it may take an emergency response just to get the funding application in.