Providing high-quality care in this remote hospital is a real test. Because patients sometimes live far from Akuem, the teams could not require them to follow the World Health Organization's Directly-Observed Treatment-Short course protocol, or DOTS.

Patient numbers vary from from dry to rainy season - rains being so heavy people cannot travel. Some of the patients who arrive for treatment in Akuem, a small village in the center of southern Sudan's Bahr El Ghazal region, have walked up to four days to get there.

Devastated by 20 years of war, the region is sorely lacking in health care facilities. MSF's health care center offers medical visits, hospitalization, obstetrical care and nutritional services. It is one of the few facilities in the entire region to offer TB treatment.

Since MSF's TB program began in 2002, 991 patients have received treatment, which hardly reflects the prevalence of the illness within the population. Although no reliable data exists regarding the extent of TB, in East Aweil, the county where Akuem is located, anti-TB vaccination coverage among children under 5 years of age is extremely low.

According to UNICEF, only 6,000 children under 5 - fewer than 8 percent - received the BCG anti-TB vaccination in 2004. BCG vaccination has been shown to give 70?0% protection against TB.

Providing high-quality care in this remote hospital is a real test. Because patients sometimes live far from Akuem, the teams could not require them to follow the World Health Organization's Directly-Observed Treatment-Short course protocol, or DOTS.

"After the first intensive hospitalization phase at the MSF facility, we couldn't possibly ask patients to stay in Akuem for the total six-month treatment period to take their medicine every day," explains Dr. Brigitte Vasset, one of the doctors in charge of TB programs for the MSF medical department.

"So beginning in November 2004, we made changes to the treatment regimen. After the intensive phase, patients come for medical visits just once a month and pick up their medicines for the next month. The six-month treatment protocol is based on fixed-dose drug combinations (two to four drugs in a single pill), which are easier to take."

Thirty patients per month are seen in the program. The number has been voluntarily limited because of the lack of space, but in early 2006, three years after the program was launched, the limitation on admissions during the dry season, when patients can travel easily, was lifted. A new hospital was built on a site near the old one to improve treatment for all patients. It has been operational since mid-2005.

"During the rainy season, though, the rivers are so high that people cannot travel," Dr. Vasset said. "The admissions level will then return to 30 new patients per month."

Staff at the hospital's laboratory performs sputum microscopy. The team is composed of an international nurse and doctor and five Sudanese nurses. One of the Sudanese nurses spends all of her time explaining the illness and treatment to patients and family members in an effort to improve treatment compliance. An X-ray machine will also be installed to improve diagnosis.

Last year, 77 percent of patients were treated successfully. Fewer than 10 percent of all patients abandoned treatment and 6 percent died. "In Akuem's difficult context, these are encouraging results," Dr. Vasset says. The failure rate for first line treatment, though, is up to a disturbing 7 percent.

"We saw the number of admissions for second treatment rise, and failures are also up," Vasset says. "So two months after the initial treatment phase, we looked at sputum under the microscope. In 2005, 50 percent of the new pulmonary TB cases were treatment failures. After the fourth month of treatment, 22 patients were still positive. Those 22 had to be hospitalized again, and this time for eight months."

It is possible that humidity caused the medicines to deteriorate, even when they were stored properly at 15 - 25Ã?° C (59 - 77Ã?° F). It is extremely hot and humid in this part of Bahr el Ghazal, where temperatures can reach 50Ã?° C (122Ã?° F). Although considerable efforts have been made to transport and store medicines properly, the process remains a major challenge for the teams. In addition, the MSF laboratory in Akuem cannot perform tests that would analyze treatment failures. Samples must be sent to Anvers, Belgium, where more sophisticated labs can carry out the necessary tests.

Some children and adult patients are severely malnourished. In the last few months, two young children and three adults with TB also had to be treated for severe malnutrition. A young girl died. "They get here too late, so they were very sick" Dr. Vasset explains. "As in our TB treatment programs in Ghazni, Afghanistan, patients treated in Akeum are among the most seriously ill that I have seen."