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The Phony-Drug War
Fake drugs are increasing drug-resistant tuberculosis.

Waiting for TB treatment Cape Town

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Cape Town, South Africa — Alice Ndlovu has tuberculosis but, relatively speaking, she is one of the lucky ones. Hers is a strain that responds to the best medicines available, which also happen to be the cheapest. At 28, this single mom knows that without treatment she would likely die, leaving her child to face the orphanage in a country that already has a million orphans. “I still have six weeks’ treatment to go, but hopefully that will be the end, and I’ll be home. I will see my son grow up,” she told me at her home in a poor suburb of Cape Town.

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At least a quarter of the world’s population — overwhelmingly concentrated in poorer regions of the world — is infected with TB, which generally lies dormant until the carrier’s immunity is impaired by another disease. (Often, this is HIV.) Without treatment, about half of the patients with active TB will die. According to the World Health Organization, TB claimed 1.7 million lives in 2009, most of them in Africa.

The standard treatment for TB is long and complicated: It requires that patients take antibiotic combinations, at least 15 pills per day, over a six-month period. The side effects of treatment are unpleasant, including fever, vomiting, jaundice, and blurred vision. If treatment is stopped too soon or skipped, the bacteria that are still alive can become resistant, leading to a form of TB that is much more dangerous and difficult to treat. And in malnourished or weak patients, drug-resistant strains of TB can quickly become fatal. 

Resistance-driven drug failure is largely due to patient noncompliance with the regimen prescribed. When patients start to feel better, they often stop taking the medicine before the TB is completely overwhelmed by the drug. As a result, the still-living strain develops resistance. This problem is not unique to the developing world. In fact, the same process is the primary reason that Western health-care systems are plagued by “superbugs.” But in Africa, inconsistent drug availability and inferior drugs that fail even when the patient completes the course of treatment compound widespread patient negligence.

Over the past few years, my research team has sampled the critical first-line TB medicines, Rifampicin and Isoniazid, from a dozen African and Asian cities. In the worst locations, such as the Congo, up to 30 percent of all TB drugs are substandard, with an average of about 8 percent across poorer markets. The drugs were underdosed in some way — some were falsified products, being passed off as something they were not, others were degraded due to poor storage. But the largest problem is sloppily made drugs, made by legal manufacturers in Africa, China, and (to a lesser extent) India. These underdosed drugs are harming patients and building drug resistance.

Aside from the health burden, the financial cost of treating TB is astounding. The total drug cost for the cheapest treatment is about $60, which is reasonable even for the poor in many countries. But treatment for resistant cases consists of a bigger range of less-effective drugs with more severe side effects for a period of two years, most of it spent in the hospital. This treatment costs no less than $15,000.



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