Some of the patients I’ve met stand out in my mind for various reasons. A couple of weeks ago, a trembling young man came into the clinic accompanied by another person who, it turns out, was accompanying him from the drug rehab program in which the patient is enrolled. He needed to have a TB test and had already completed an HIV test; grimly pulling the lab report from his pocket, he told us that he was HIV-positive. Perhaps it was the drug withdrawal or perhaps it was some other sickness(es), but he was in such bad shape that I saw not a hint of shame when he admitted this. He seemed to have acknowledged in what dire straits he had found himself, if only because his poor physical condition made it impossible to ignore or deny any longer, and was too agitated to pay much attention to the reaction of the nurse and community health worker on hand (who assured him that Jesus would take care of everything). What floored me is that the young man was 22 – my age. Suddenly the world did not seem quite so large anymore.
Another young patient (21 years old) came in today with his girlfriend and the positive results of a TB x-ray test (some people who have TB come up with negative sputum smears, but the diagnosis can be confirmed with a pulmonary x-ray). He seemed upbeat and otherwise healthy, and his girlfriend was clearly supportive, but I could tell that he was a little shocked at the intensity of the treatment he was in for – 4 pills every day for the next two months, taken in person at the clinic, and medication three times a week for four months thereafter (assuming he doesn’t abandon the initial regimen or turn out to have multiple drug-resistant TB – MDR-TB – in which cases the treatment will be longer and harsher). Although he could receive his medication at a hospital closer to his school, he opted to attend the clinic where I’m working – a staff member told me later that it was because he didn’t want to be stigmatized as a TB patient should any of his peers from school find out. Apparently he can escape to the clinic for his daily treatment during breaks between classes.
There’s the MDR-TB patient who has stopped and started his treatment countless times, ended up in the hospital for a month (at one of only two in the country that offer full treatment for MDR-TB patients), and has undergone pills, chemotherapy, and injections to fight the disease. Although the nurse who directs the TB program has told me that he’s just “disobedient,” and often yells at/about him and his noncompliance, he told me once in a low voice, when she was out of the room, that he kept having to stop the medications because chemotherapy is really, really tough. He couldn’t keep down any food as a result of the treatment (and taking the pills on an empty stomach exacerbates the side effects further still) and he felt ugly and miserable with a bald head because of the chemotherapy. He, like several other patients, is still crazy-skinny, but at least he’s been showing up lately for his medications.
And then there’s another, older man, who always seems so beaten down when I see him enter the clinic. The nurse’s impatience with him also doesn’t seem to be helpful, and whenever I ask how he’s doing he usually just shakes his head and shrugs. Yesterday he told me that it’s a 30-minute walk from where he lives to the clinic. Today he said that knee pain has been making the journey even more trying. I hope to talk to him in more depth soon, and I wonder if he has a family, a job (from which he may have already been fired for missing work due to his treatment and/or discrimination against TB patients), or other obligations that make the daily, hour-plus ordeal of getting his medications even more costly.
I was relating some of these stories to a friend the other day, who remarked, “but you’d think they would have found a way to make TB treatment easier by now!” Yes, you would think so, given that TB is one of the oldest known diseases afflicting human beings. The global health care economy, though, like the rest of the global economy, is market-based, and pharmaceutical companies supply what’s in demand, which in turn dictates research priorities. Unfortunately, TB almost exclusively affects people who do not have enough money to demand anything. There is research on TB occurring around the world - but unfortunately it's not the type that can relieve many of the logistical and physical hardships of TB treatment. If poor living conditions and malnutrition were not such critical factors in TB epidemiology, if Mycobacterium tuberculosis, like cancer cells, did not discriminate according to the size of its victims’ bank accounts, perhaps we would have found a way to make treatment easier by now.
"Our society ensures that large numbers of people, in the United States and out of it, will be simultaneously put at risk for disease and denied access to care. In fact, the spectacular successes of biomedicine have in many instances further entrenched medical inequalities. This necessarily happens whenever new and effective therapies - from antituberculosis drugs to protease inhibitors - are not made readily available to those in need. Perhaps it was in anticipation of late-twentieth-century technology that Virchow argued that physicians must be 'the natural attorneys of the poor.'"
- Paul Farmer, Infections and Inequalities
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