updated 1/22/2007 9:09:14 PM ET 2007-01-23T02:09:14

Doctors have recommended forcibly detaining people in South Africa who refuse treatment for a drug-resistant form of tuberculosis, an extreme measure meant to keep the infected away from others to curb the spread of the disease, according to a paper published Monday in an international medical journal.

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Since detecting extensively drug-resistant tuberculosis, also known as XDR-TB, in South Africa last year, health officials have called for increased measures to combat the strains, including better surveillance, diagnostics and drugs.

In their paper in the Public Library of Science Medicine journal, physicians Jerome Amir Singh, Ross Upshur and Nesri Padayatchi propose that XDR-TB patients who refuse treatment be involuntarily detained in hospitals or other health care facilities. Singh and Padayatchi are at the Centre for AIDS Programme of Research in South Africa, and Upshur is the director of the Joint Centre for Bioethics at the University of Toronto.

Ronnie Green-Thompson, an adviser to the South African Department of Health, said the idea had been discussed by health experts in South Africa and elsewhere, and was a possibility.

"Holding the patient against their will is not ideal but may have to be considered in the interest of the public," Green-Thompson said in a statement issued by the South African Department of Health. "Legal opinion and comment as well as ... the opinion of human rights groups is important.

In the 1990s, New York City health authorities authorized the forcible detention of people who rejected TB treatment, some for as long as two years, ultimately leading to a significant dip in cases. The detainees were held in Bellevue or Goldwater hospitals.

Last September, the World Health Organization announced there were 53 confirmed XDR-TB cases in South Africa, of which 52 were fatal. Most of the patients were also HIV positive. To date, more than 300 cases have been identified, and at least 30 more are picked up each month.

Though extensively drug-resistant tuberculosis exists worldwide, including in eastern Europe, Russia and the United States, Africa's high number of HIV/AIDS patients makes it particularly worrying. Not only does HIV/AIDS fuel the spread of tuberculosis, but infection with both HIV/AIDS and XDR-TB means an almost certain death. Weak African health systems lack the means to treat XDR-TB patients, for whom the only drugs that might work are much more expensive than regular TB drugs.

There are also social conditions in South Africa to foster the spread of XDR-TB, including a population of migrant laborers and an active tourism industry. In addition, South Africa routinely suspends social benefits to people when they are hospitalized, so many patients avoid treatment.

In their paper, the doctors recommend that XDR-TB patients be paid while being detained.

"This isn't a carte blanche to public health authorities to start locking people up," Upshur said. "If we ask individuals to forgo their rights, they need to be supported."

Some public health experts say South Africa and the international community haven't taken basic outbreak response steps, such as drafting an emergency plan, conducting a proper investigation and reinforcing surveillance. WHO and its partners have held a flurry of international meetings since XDR-TB in South Africa was identified, but little has changed for patients in Africa.

"The government hasn't yet done the most obvious things to shut down transmission," said Mark Harrington, executive director of the Treatment Action Group, a health advocacy group. "Starting to imprison patients is a step very far downstream from where we are now."

Green-Thompson, the South African Health Department adviser, said all measures were being considered and that early diagnosis and treatment were "of paramount importance."

Others worry that involuntarily detaining people would result in "driving patients underground," said Dr. Tido von Schoen-Angerer of Medecins Sans Frontieres, the international medical aid group.

Tuberculosis experts at the World Health Organization believe XDR-TB is as serious a threat to global health as either bird flu or SARS. But Dr. Mario Raviglione, director of WHO's Stop TB department, isn't certain involuntary confinement is warranted yet. Without proper patient data from South Africa, Raviglione says it is not known whether lack of compliance is a significant factor.

Still, he will not rule out the tactic.

"We can't put the public at risk of a disease that is almost incurable," Raviglione said.

Copyright 2007 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.


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