CAPE TOWN, South Africa - Behind high fences patrolled by guards to prevent escape, a drab building once used for smallpox victims houses patients with a new, virtually uncurable strain of tuberculosis.
Patients sleep or sit listlessly in the 12-bed women's ward, which is equipped with a TV, a fridge and a table with a couple of loaves of bread. It's a similar scenario in the men's ward, home to a minibus taxi driver who reluctantly agreed to be admitted after exposing hundreds of people every day to his potentially lethal germs.
Critics say enforced quarantine is a violation of medical ethics and individual human rights. Health authorities - who earlier this year resorted to the courts to compel four patients to stay at the hospital - say they have no choice.
"We are dealing with very depressed people. They feel like they are in prison, but it's the only way," said senior nurse Joan Blackburn.
Andrew Speaker, an Atlanta lawyer with drug-resistant tuberculosis, was held under a federal isolation order in May after he went on a European wedding trip and refused health officials' directives that he not take any commercial jets back to the U.S.
"At least our patients won't be able to get on a plane and fly around the world," said Simon Moeti, medical superintendent of the Brooklyn Chest Hospital.
South Africa's AIDS epidemic has brought a related upsurge in TB cases, including multi-drug-resistant and extremely drug-resistant strains.
South Africa reported 343,000 TB cases in 2006, of which an estimated 6,000 were multi-drug-resistant. South Africa's first official case of extremely drug-resistant tuberculosis, or XDR-TB, was reported last year. The government says that there have been about 400 cases, but groups like Doctors Without Borders say this is a big underestimate.
Testing methods are hopelessly slow and out of date - and it is particularly difficult to diagnose TB in HIV-positive people. Nearly 60 per cent of South African TB patients have the AIDS virus. Many people with drug-resistant TB die before they are tested and treated - having probably infected other people in the meantime.
"There are challenges without answers," Moeti said. "There are people who are refusing treatment, people who want to abscond," he told journalists visiting the 308-bed clinic on the sidelines of an international TB conference that ends Monday.
Treatments are also woefully outdated and inadequate. The Global Alliance for TB Drug Development told the conference that trials of two possible drugs were promising. One of them, antibiotic moxifloxacin, could shorten treatment time and the other, PA-824, had potential for drug-resistant strains. But even if clinical trials are successful, it may take years for the drugs to reach the market.
"We can't wait that long. We need new drugs now," said Winston Zulu, a Zambian AIDS and TB activist who lost four brothers to TB.
Experts worry that the drug-resistant strains will continue to spread - largely the result of people not sticking to the six-month course of treatment for normal TB.
In the Western Cape province that includes Cape Town, 64 cases of XDR-TB have been identified this year, according to local health officials. Twenty of the patients have died and 39 of the survivors are currently being treated at Brooklyn - 24 in the fenced-off ward and others elsewhere in the hospital.
They will be there for at least six months. If they are declared clear of the disease they will be free to leave. But, with treatment of XDR-TB still in its infancy in South Africa, their longer-term prospects are unclear.
The youngest patient is just a year old. Her mother died last year, before local authorities started testing for XDR-TB, although that was most likely the cause, Moeti said.
"But she's doing OK," he added, picking up the child, who was sitting with other infants. He refused to divulge identities because of confidentiality, and journalists were not allowed to speak to patients in the clinic.
The scattered collection of small buildings was purchased from a farmer in 1872 because of its isolation. It was initially used for smallpox, then for the big influenza epidemic and now for TB. Structurally there have been few changes in the past century. Although the clinic is in dire need of a coat of paint, Moeti says its design allows for good ventilation - TB thrives in closed spaces.
Hospital authorities reluctantly decided to erect the fence around the XDR-TB unit after four patients absconded. Two guards, both wearing protective face masks, stand by the fence. Any patient wanting to go to another part of the hospital has to be accompanied. Family visits are allowed but are strictly controlled.
Patients hate going there - because of the stigma of TB and its association with AIDS. The hospital constantly struggles to get staff. It was bad enough before, but the arrival of XDR-TB has made it even worse, said Moeti.
The minibus taxi driver initially refused to be admitted, saying he couldn't afford the loss in earnings. But he eventually accepted Moeti's arguments that he was endangering the lives of countless passengers.
