Tuesday, November 25, 2008

XDR-TB @ home

The term XDR-TB is unfamiliar to most outside the field of public health and to those unable to have closely followed the events in South Africa over recent years. Extensively Drug Resistant Tuberculosis (XDR-TB), in addition to the less viral but just as deadly, Multi-Drug Resistant tuberculosis (MDR-TB), is, as the name suggests, a mutation of the respiratory virus deemed unresponsive to usual medication and treatment.

Though in existence for years, XDR-TB was brought to the mainstream media when a story published in the New York Times (March 25, 2008) disclosed the quarantine and isolation practices taking place within hospitals. Former patients revealed that the “inhumane quarantines” whereby they were restricted to live with other severely ill patients, amounted to psychological torment.

In South Africa today, XDR-TB has found a different mode of treatment: home-based care (HBC). Despite being long in place as a viable choice of treatment for people living with HIV/AIDS, hospital beds are now simply unavailable due to increased demand resulting from the countywide impact of both AIDS and TB. The topic of HBCs will be discussed in a later entry, but what is particularly useful to mention here is that in the province of KwaZulu-Natal, one community has successfully managed to reduce the number of MDR and XDR-TB cases to a much lower percentage than the national average. What is also worthy of note is that home based care forms part of a strategy which places housing squarely at the center of treatment. Whereas informal settlements are often bear a high prevalence of overcrowding and closely-sited dwellings, people in the aforementioned community reside in small family groups and their custom-designed houses are set at great distances from each other. In this community, a combination of HBCs and the proper site planning of housing appears to be more effective than the alternative quarantine facilities.

And yet, ‘the Eastern Cape province of South Africa seems to have placed public health ahead of individual freedom', concluded one BBC reporter covering this story. Patients are required to remain in facilities which restrict their movement and interaction with the outside world is beyond the boundary of the facility.

Therein lies one of the major paradoxes of the present quarantine strategy: patients tested positive for XDR and MDR-TB are forced to remain in close and confined facilities in forced coexistence with several other patients, bearing witness to a slow but nonetheless extremely high mortality rate in these compounds.

As architects, designers and planners, we are challenged to prioritize the development and design of alternative spaces, facilities and strategies to confront the expected global increase in XDR and MDR-TB. Whilst it remains clear that governments, multi-laterals and civil society must deliver a partnered action in their care of this increasing constituency, the argument made here is that Design and Planning professionals can be central actors in the process, participating in forging solutions by intelligently using the role that housing can play in dealing with global dilemmas. An increase in the number of health facilities, clinics, and hospitals cannot alone provide a sustainable solution to the problem. As the number of infected persons increases globally, HBCs, especially in developing countries and the informal settlements where in many instances the epidemic has become rife, may become the most sustainable approach to delivering care to those most in need.

Until new drugs are developed, XDR and MDR-TB will continue to kill thousands upon thousands of victims. If drugs to combat XDR are not found and developed, then the implications may be even direr in light of the present statistics that over 100,000 children around the world die each year from the epidemic, even though treatment does exist.

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