Homa Bay lies on the banks of Lake Victoria in Kenya. Fishermen set sail onto the lake from the small harbour, women wash their clothes on the shores, the town is small and pretty and all would seem - to the untrained eye - peaceful and well here.
To those in the know, however, Homa Bay has another face. It boasts HIV rates of 35% among young women alone and 60% of those have tuberculosis - the biggest AIDS-related killer. Many women come to the harbour to sell sex for food, many fishermen have the clichéd 'woman in every port'. HIV spreads like wildfire in this environment, as does the tuberculosis which goes along with it.
But unlike HIV, the tuberculosis at least is curable. Homa Bay Hospital's Ward 7 is the TB ward. It contains 34 beds which, compared with TB rates, seems woefully inadequate - but there is at least a TB ward. With more than one patient per bed, the hospital is struggling with the admission-rate but these patients are getting the help they need.
MSF is helping out in the TB ward: Olivier V. and Arno J. are both young, French doctors who specialise in HIV/AIDS and TB. They - and the nurses of Ward 7 - seem motivated, skilled and above all passionate. Especially when they start speaking about default (drop-out) rates, the dangers of multi-drug resistance combined with such high HIV rates and the shocking lack of research into a new treatment.
Because while the current treatment for tuberculosis, DOTS (Direct Observed Therapy), is effective, it is also labour-intensive, takes eight months to complete and is often too expensive for Kenyans. It was developed over 30 years ago, and there has been next to no research into a more 'user-friendly' treatment. The vaccine, meanwhile, was developed at the beginning of the twentieth century and can no longer guarantee complete protection from latter-day TB - for people like Olivier and Arno, who got their injections and boosters when they were small just like anyone else in France, walking into Ward 7 of Homa Bay Hospital carries a risk. Let alone working there day in day out.
While Olivier explains DOTS treatment, a patient behind him starts coughing, her paroxysms shuddering her body and leaving her weak for several minutes afterwards.
"Don't worry, all the patients here are taught to cough into their handkerchiefs," says Olivier once he can make himself heard again. The patient is painfully thin, sharing a bed with another, younger, woman, and lies on her back apparently exhausted. The women in the female part of the ward range in age from late teens to late sixties, with the men lying at the other side of the curtain which separates the ward in two. Above each bed on the wall is written the bed number in chalk. The nurse, Susan Ayugi, jokes and laughs with the patients while dispensing the medicines.
'The medicines' is actually a litany of long and convoluted names: Rifater, Rifampicin, Isoniazid, Pyrazinamide, Ethambutol, Rimactazide. "Yes," says Olivier, "the treatment for TB is quite complicated." He points at the pots and jars and ampoules crowding the trolley - all this for one disease. He continues: "The treatment takes in total eight months: two months for the first, intensive phase during which three to five medicines have to be taken every day, depending on if the patient has defaulted or not. Then six months for the secondary phase during which two medicines have to be taken daily."
Complicated, especially when you consider most patients have to walk for miles to clinics every day to get their medicines and they have to be seen to take them - hence the Direct Observed Therapy. If they are not watched, they may default and would have to start all over again. Complicated for the patient, labour-intensive for the staff.
Francis O. is one patient who relapsed. He's young and very thin, coughing occasionally while he speaks to us.
"I forgot to take my medicines because of the pressures of work," he says quietly. Most of these patients speak softly - not because they are particularly reticent, but because it's all their lungs can manage. He said had to work round the clock to earn enough money for his family, so he literally had no time to go to the clinic to take his medicines. He is now in Ward 7 taking his intensive phase medicines and not working at all while he is here - which is a higher price to pay.
George Ombora lies in the bed next to Francis. He has been treated before. In 1997 he took the medication for six months but defaulted because the staff at the clinic which supplied him with medicines went on strike. So here he is again, now in Ward 7 as an in-patient. Kenya is such that the slightest mishap can interrupt the eight-month course of medication - and the patients' financial status usually compounds the fragile process.
Elston O. is 17, looks well-fed and smiles a lot. But he has had tuberculosis for a long time now. It first developed when he lived in Nairobi in 1997, and he diligently took his medication every day at Kenyatta Hospital.
"But then my father died," he says, "so I had to go from Nairobi back home for the funeral which cost a lot of money. I stopped the medication for one month, also because my family had no more money to give me to reach the clinic. When I did finally get to the clinic, they sent me away saying I was stupid to have stopped taking the medicines - but they gave me no advice about where to get more medicines." He smiles apologetically, as if it really were his own fault. "Then," he adds, "I was playing football with my friends when I noticed it was hard for me to breathe. I knew I still had tuberculosis. My friends told me to go to Homa Bay where I would get help."
Susan A. is one of the nurses working at the hospital. She is holding a pile of medical charts which are of out-patients who did not turn up today for their medicines. She seems irritated more than anything, knowing that these patients may default and exacerbate the TB rates in Homa Bay.
"Well, they're walking around with TB aren't they? It's very contagious," she says. "Many feel better after a little while of taking medication, so they don't see the point of taking medicines any more," she explains. "Also, for some it's too expensive to travel here, or to pay for the syringes they need to have the injections with one of the intensive-phase medicines." The hospital does not supply the syringes, it transpires. She bustles off again pushing the noisy medication trolley in front of her.
Olivier explains that MSF also provides supervision of health centres around Homa Bay: Marindi, Pala and God Kojowe - the latter has a laboratory for diagnostics. "People walk far," he says. "We've just started supplying Pala with intensive-phase medicines, because it's too far away from the hospital. Until now, the hospital here in Homa Bay was the only place where patients could take the intensive phase medication. And we're developing a new project in which Community Health Workers - who are volunteers - distribute medicines to patients at home every day. It's very labour-intensive, but at least the patients are reached and treated."
But what's really needed for the long run? Arno J. is involved in MSF's Access to Essential Medicines Campaign and voices his concerns passionately. "Well, indeed, what will happen in the future? The Dutch government, who supply Kenya with all TB drugs, are pulling their funding at the end of this year. What do you think will happen?" he says angrily and glares at the patients around him. "Catastrophe of course, an explosion of TB, an explosion of death." He says this with such urgency that the melodrama of his words does not seem out of place.
He continues: "We need to find other donors who can fill the vaccuum left by the Dutch. Or we're looking at similar TB epidemics as Europe had at the end of the nineteenth century. Actually, it'll be worse: here there is also the danger of multi-drug resistance which is still low, but on the increase. Can you imagine that? HIV is raging across Africa, AIDS-related TB is the biggest killer and we may not be able to treat it in the near future. In Eastern Europe, they have one doctor for only twelve patients because the TB there is drug-resistant and is extremely difficult to treat. Here we just don't have the resources to do that.
"And meanwhile most research is going into multi-drug resistant TB because that's hitting the richer countries much more than here. The only vaccine we have was developed in 1923 - it's shocking that there hasn't been research into a newer, more effective vaccine. Meanwhile DOTS treats and cures, yes, but it takes too long, it's too laborious, and was developed over 30 years ago. We need something that's easy to take, easy to administer - we need research into this or millions of innocent people will die," he adds, sounding angry, desperate and compassionate all at once.
Understandably so. Every year two million people die from TB world-wide and there are eight million new cases, almost all in the developing world. Multi-drug resistant TB, currently costing between $US 5,000 and 8,000 per patient, will be a death sentence for the vast majority of those who live in poor countries. And research is insufficient: in today's market, essential life-saving medicines are treated like any other commercial product, and TB in Africa is not a 'viable market'. Small wonder that Arno, who has to face the patients every day, is so angry.
Elston meanwhile is not aware of this bigger picture. It doesn't occur to him to hope for a more efficient treatment than DOTS. When asked about what he thinks of DOTS and its lengthy duration, he merely smiles and says: "I'm determined to finish the course. Whatever it takes." If he does, he will have completed the course before the Dutch government withdraws its funding in December for the drugs he is currently taking.
Ironically, if no other donor is found before December, if research into tuberculosis continues to be so scant, and if he doesn't relapse, Elston will in fact prove to have been a very lucky young man indeed.