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! CLASH OF CULTURES
© 2007 Nature Publishing Group http://www.nature.com/naturemedicine

()6 AND TUBERCULOSIS ARE A DEADLY COMBINATION RAVAGING

POPULATIONS IN !FRICA AND !SIA "UT THE TWO DISEASE CAMPS
ARE TOO BUSY FIGHTING EACH OTHER TO HEED THE CRISIS SAYS
*EAN ,OUIS "ELLURGET !POORVA -ANDAVILLI

7HEN THE WALL CAME DOWN EVERYTHING CHANGED 4" SUFFERERS IN +HAYELITSHA ARE ()6 POSITIVE #ROSS REACTIONS
0EOPLE WHO HAD RARELY AGREED ON ANYTHING MET AND 4" IS THE LEADING CAUSE OF DEATH IN PEOPLE /NE IN EVERY THREE PEOPLE IS THOUGHT TO BE
HALFWAY AND TOGETHER SET A NEW PARADIGM FOR WITH ()6 INFECTED WITH THE BACTERIUM THAT CAUSES 4"
FIGHTING TWO OF THE MOST DEVASTATING SCOURGES /NE DAY IN  THE -3& STAFF DECIDED ON BUT FEW GO ON TO EVER SHOW SYMPTOMS )N
THE WORLD HAS EVER SEEN IMPULSE TO TEAR DOWN THE WALL AND WITH IT THE MOST PARTS OF THE WORLD 4" IS AN OLD DISEASE
/N THE DAY THEY DECIDED TO BREAK THE WALL ARBITRARY SEPARATION BETWEEN THE TWO DISEASES DATING BACK TO THE S AND IT WIPED OUT THE
THOUGH FEW REALIZED ITS SIGNIFICANCE h)F WE HAD ASKED PERMISSION FIRST IT CERTAINLY MOST SUSCEPTIBLE PEOPLE LONG BEFORE MEDICINES
4HE WALL HAD SEPARATED A TUBERCULOSIS 4" WOULDNT HAVE BEEN GRANTEDvSAYS %RIC 'OEMAERE BECAME AVAILABLE
CLINIC AND AN !)$3 CLINIC IN +HAYELITSHA A POOR HEAD OF -3&S 3OUTH !FRICA MISSION "UT IN !FRICA 4" HAS BEEN PRESENT FOR
TOWNSHIP ON THE OUTSKIRTS OF #APE 4OWN 3OUTH h)T SEEMED SO OBVIOUS THAT WE DID IT WITHOUT LITTLE MORE THAN  YEARS h9OU JUST HAVE LESS
!FRICA +HAYELITSHA IS HOME TO ABOUT A MILLION THINKING ABOUT ITv 'OEMAERE RECALLS h)TS ONLY RESISTANCE TO INFECTION AND DISEASE IN !FRICAvSAYS
PEOPLE )T ALSO HAS ONE OF THE HIGHEST BURDENS OF AFTERWARD WHEN ) SAW HOW MUCH RESISTANCE THERE #HAISSONh9OU ADD ON THE ()6 EPIDEMIC WHICH
()6 AND 4" IN THE WORLD WAS TO DOING IT THAT ) REALIZED HOW SYMBOLIC IT OBLITERATES RESISTANCE TO THE DISEASE AND YOU HAVE
%VERY THIRD PREGNANT WOMAN IN THE TOWNSHIP HAD BEENv AN EPIDEMICv
IS ()6 POSITIVEAND THE RATE OF NEW 4" INFECTIONS 4HAT SAME YEAR -3& TOOK THEIR SOLUTION ONE )N 3OUTH !FRICA :IMBABWE ,ESOTHO AND
IS  FOR EVERY  PEOPLE EACH YEAR STEP FURTHER OPENING AN INTEGRATED CLINIC WHERE "OTSWANA THE INCIDENCE OF 4" HAS INCREASED
NEARLY  TIMES THE GLOBAL RATE THOSE WHO PRESENT WITH 4" ARE TESTED AND TREATED SEVERAL FOLD IN THE PAST DECADE
&OR YEARS -£DECINS 3ANS &RONTIÞRES -3& OR FOR ()6 AND VICE VERSA 7HEN ()6 AND 4" ARE PRESENT TOGETHER
$OCTORS 7ITHOUT "ORDERS STAFF WHO HELP RUN /UTSIDE +HAYELITSHA HOWEVER RELATIONS ITS IMPORTANT THAT THEY ARE MANAGED TOGETHER
!)$3 SERVICES IN THE TOWNSHIPHAD SEEN THE SAME BETWEEN THE ()6 AND 4" COMMUNITIES REMAIN BECAUSE AT THE SIMPLEST LEVEL THERE ARE DRUG
PEOPLE LINING UP ONE DAY TO RECEIVE 4" DRUGS THE LESS THAN CORDIAL UNDERMINING THE FIGHT AGAINST INTERACTIONS TO WATCH FOR &OR EXAMPLE THE
NEXT FOR !)$3 MEDICINES WITH SEPARATE FOLDERS THE CRISIS IN !FRICA AND ELSEWHERE 4" DRUG RIFAMPIN INTERFERES WITH SOME NON
AND MEDICAL FILES IN EACH CLINIC 4HE 4" CLINIC h()6 PEOPLE THINK 4" PEOPLE ARE DULL OUT NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
HAD ALWAYS BEEN MANAGED BY THE CITY AND THE OF DATE AND THEY DONT READ PUBLISHED LITERATURE AND PROTEASE INHIBITORS BUT NOT WITH THE MORE
NEWER !)$3 SERVICES BY THE PROVINCE 4" PEOPLE THINK ()6 PEOPLE CANT SEE BEYOND EXPENSIVE OPTIONS
/VER THE YEARS HOWEVER IT HAS BECOME INDIVIDUALS TO THE COMMUNITYv SAYS 2ICHARD )N ()6 INFECTED INDIVIDUALS 4" ALSO
INCREASINGLY OBVIOUS THAT THE TWO DISEASES #HAISSON DIRECTOR OF THE #ENTER FOR 4" 2ESEARCH PROGRESSES MORE QUICKLY "Y THE TIME THEY
ARE INSEPARABLE AND THAT THEIR TREATMENT TOO AT *OHNS (OPKINS 5NIVERSITYh) WORK IN BOTH AND TURN UP AT THE CLINIC MOST ARE IN DIRE NEED OF
SHOULD BE MANAGED TOGETHER !BOUT  OF ) FIND IT VERY FRUSTRATINGv MEDICINES 4HE GENERAL PRACTICE IS TO START THEM

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4" INCIDENCE PER 

ON 4" THERAPY WHICH THEY USUALLY NEED MORE TAKING ()6 DRUGS 3TART TOO EARLY AND THEY
)NDIA 
URGENTLY AND THEN GIVE THEM ANTIRETROVIRAL MIGHT DEVELOP THIS BIZARRE SYNDROME 3TART TOO
#HINA 
DRUGS WHICH ARE INCREASINGLY AVAILABLE IN LATE AND THEY MIGHT DIE
!FRICA h)F YOU WERE TO ASK FIVE DOCTORS WHAT THEY 3OUTH !FRICA 

)N THEORY BECAUSE !)$3 DRUGS IMPROVE THE WOULD DO YOUD GET FIVE DIFFERENT ANSWERSv 2USSIAN &ED 
CELLULAR IMMUNE RESPONSE YOU WOULD EXPECT SAYS 3ALIM +ARIM DIRECTOR OF #APRISA A 3OUTH "RAZIL 
TO SEE THESE PEOPLE FIGHT 4" BETTER AND BECOME !FRICAN CONSORTIUM OF !)$3 RESEARCHERS h4HIS :IMBABWE 
HEALTHIER !ND THATS TRUE IN ABOUT  OF QUESTION IS BEING ANSWERED IN THE DEVELOPING )NDONESIA 
CASES WORLDv
4HE REMAINING  PARADOXICALLY GET MUCH 3CIENTISTS ARE JUST BEGINNING TO GRAPPLE WITH ()6 PREVALENCE IN 4"
© 2007 Nature Publishing Group http://www.nature.com/naturemedicine

WORSE DEVELOPING HUGE ABSCESSES IN THE STOMACH THIS SYNDROME WHICH THEYVE DUBBED )2)3 )NDIA 
AND ELSEWHERE SWOLLEN LYMPH NODES AND LESIONS FOR IMMUNE RECONSTITUTION INFLAMMATORY #HINA 
IN THE BRAIN -ANY SUFFER HORRIBLY SHUTTLING IN SYNDROME BUT SAY IT IS DEVASTATING BOTH TO THOSE
3OUTH !FRICA 
AND OUT OF HOSPITALS FOR MONTHS !BOUT ONE IN IT AFFLICTS AND TO THE HEALTHCARE WORKERS WHO TREAT
2USSIAN &ED 
SEVEN DIES THEM
"RAZIL 
h4HIS IS BECOMING VERY VERY COMMON ALL 3OME AT THE 7ORLD (EALTH /RGANIZATION
OVER !FRICA ITS BEING REPORTED ALL OVER THE PLACE 7(/  HOWEVER ARE DISMISSIVEh4HIS IS WHAT :IMBABWE 

7(/
AND IN VERY SIGNIFICANT NUMBERSv SAYS 2OBERT YOU FIND WHEN YOU TALK TO ACADEMIC RESEARCHERS )NDONESIA 
7ILKINSON PROFESSOR OF INFECTIOUS DISEASES AT THE WHOSE JOB IT IS TO GO AND LOOK FOR PROBLEMSv
$EADLY DUO 4HE 4" EPIDEMIC IS AT ITS WORST
5NIVERSITY OF #APE 4OWNh.OBODY KNOWS HOW SAYS 0AUL .UNN COORDINATOR OF 4" ()6 AT THE WHEREVER ()6 IS THE MOST PREVALENT
TO DEAL WITH ITv 7ORLD (EALTH /RGANIZATIONS 3TOP 4" PROGRAM
!T A GLOBAL SCALE .UNN SAYS )2)3 HAS NOT
!LL IN THE TIMING HAD A BIG IMPACT AND HAS YET TO BE PROPERLY DEEP RIFT BETWEEN BASIC RESEARCHERS AND THE
!T A PRACTICAL LEVEL THE DEBATE HAS BOILED DOWN DEFINED PUBLIC HEALTH WORLD 7(/ OFFICIALS RARELY GO TO
TO TIMING WHEN SHOULD THOSE WITH 4" START .UNNS COMMENTS ARE INDICATIVE OF THE MEETINGS WHERE SCIENTISTS PRESENT THEIR FINDINGS

(EALTH AGENCY PULLS BACK ON @PATRONIZING APPROACH TO 4" TREATMENT

&OR MORE THAN A DECADE THE 7ORLD (EALTH /RGANIZATION 7(/ HAS RELIED ON $IRECT /BSERVED 4HERAPY 3HORT COURSE OR $/43 TO FIGHT
TUBERCULOSIS 4" ˆAND FOR NEARLY AS LONG THE STRATEGY HAS BEEN CONTROVERSIAL
4HE IDEA BEHIND $/43 IS THAT A HEALTHCARE WORKER SHOULD DIRECTLY OBSERVE THOSE INFECTED SWALLOW THE 4" DRUGS AT LEAST FOR THE FIRST TWO
MONTHS OF THE SIX MONTH THERAPY !S THE 7(/ LIKES TO POINT OUT THE APPROACH HAS SUCCESSFULLY TREATED MORE THAN  MILLION INDIVIDUALS
WORLDWIDE h)N COUNTRIES WHERE THEY HAVE DONE $/43 WELL YOU DONT SEE A HIGH RATE OF DRUG RESISTANCEv SAYS #HRIS $YE COORDINATOR OF 4"
MONITORING AND EVALUATION FOR THE 7(/S 3TOP 4" PROGRAM
)MPLEMENTING $/43 WELL HOWEVER IS NO EASY TASK
!CTIVISTS AND MANY ON THE GROUND HAVE LONG ARGUED THAT THE $/43 APPROACH IS PATRONIZING AND IMPRACTICAL AND THAT IT DOESNT TAKE
INDIVIDUAL CIRCUMSTANCES INTO ACCOUNT "UT IN THE PAST FEW YEARS ITS BECOME APPARENT TO EVEN THE STAUNCHEST $/43 ADVOCATES THAT AT LEAST
IN !FRICA THE APPROACH NEEDS TO BE REVISED h$/43 AS A STRATEGY HAS ITS LIMITATIONSv SAYS $YE
&OR EXAMPLE ONE 4" CLINIC IN $URBAN 3OUTH !FRICA SAW  INFECTED INDIVIDUALS LAST YEAR NEARLY DOUBLE COMPARED WITH FOUR YEARS
EARLIER 4HE ()6 EPIDEMIC HAS ALSO
COMPLICATED MATTERS PARTLY BECAUSE ()6
POSITIVE INDIVIDUALS ARE AT GREATER RISK
OF 4" INFECTION AND BECAUSE THE $/43
RECOMMENDED DIAGNOSTIC METHOD FOR 4"
THE SMEAR TEST DETECTS FEWER THAN  OF
4" INFECTIONS IN ()6 INFECTED INDIVIDUALS
h$/43 WILL MEET ITS GOALS EVERYWHERE
BUT IN !FRICAv SAYS 2ICHARD #HAISSON
DIRECTOR OF THE *OHNS (OPKINS #ENTER FOR
4" 2ESEARCH h)F ACTIVITIES IN !FRICA ARE
RAMPED UP SUBSTANTIALLY IT MIGHT NOT BUT
BASED ON CURRENT PROJECTIONS IT WILL FAILv
4HE 7(/S NEW GLOBAL PLAN TO STOP
4" LAUNCHED LAST YEAR IS SEEN BY MANY
AS A LONG OVERDUE CONCESSION TO THE
REALITY ON THE GROUND ACKNOWLEDGING THAT
hADDRESSING 4"()6 MULTIDRUG RESISTANT
4" AND OTHER CHALLENGES REQUIRES MUCH
GREATER ACTION AND INPUT THAN $/43
IMPLEMENTATIONv
!POORVA -ANDAVILLI .EW 9ORK
7(/

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 .%73

CASE DEFINITION TO ADMISSION THAT $/43 THE CORNERSTONE OF ITS

THERAPEUTIC GUIDELINES 4" PROGRAMS MUST TAKE ()6 INTO ACCOUNT SEE
TO STANDARD OPERATING BOX PAGE  
PROCEDURES ITS ALL 4HE 7(/ NOW RECOMMENDS ()6 TESTING FOR
WRITTEN IN STONE AND THOSE INFECTED WITH 4" PREVENTIVE 4" DRUGS FOR
CASTv SAYS 'OEMAERE ()6 POSITIVE PEOPLE AND INTEGRATION OF 4" AND
h)VE NEVER SEEN SO ()6 PROGRAMS
MANY GUIDELINES )TS )N 2WANDA AND +ENYA  OF 4" SUFFERERS
ALMOST 3TALINIANv ARE BEING TESTED FOR ()6 NOTES .UNN h4HATS
4HE ()6 COMMUNITY UP FROM NOTHING ABOUT A YEAR AND A HALF AGO
© 2007 Nature Publishing Group http://www.nature.com/naturemedicine

IN CONTRAST DRIVEN THATS PROGRESS ON AN ENORMOUS SCALEv HE SAYS

IN PART BY ACTIVISTS IS h7E HAVE ILLUSTRATED THAT IT CAN BE DONEv 4HE
FOCUSED ON EMPOWERING 7(/ IS MEETING IN -ARCH TO EXPAND THE PILOT
THE INDIVIDUAL WITH SCHEME TO MORE COUNTRIES
A HEAVY EMPHASIS ON )N 3OUTH !FRICA TOO THE INTEGRATED CLINIC IN
APPLYING THE LATEST +HAYELITSHA IS A RESOUNDING SUCCESS OVERFLOWING
RESEARCH WITH THOSE WHO ARE HAPPY TO GET ALL THEIR
4HE ()6 4" CRISIS MEDICINES IN ONE PLACE 4HE INTEGRATED PROGRAMS
HAS RESULTED IN A POWER MAY ALSO HELP ANSWER SOME FUNDAMENTAL
!POORVA -ANDAVILLI

STRUGGLE BETWEEN QUESTIONS ABOUT 4" PATHOGENESIS

THESE TWO CULTURES 2ESEARCHERS FROM THE 5NIVERSITY OF #APE
LEADING UP ALL THE WAY 4OWN ARE COLLECTING SAMPLES FROM THOSE WHO
TO THE 7(/S OWN 4" COME TO THE CLINICS STUDYING ()6S EFFECT ON 4"
*OINING FORCES 4HE -£DICINS 3ANS &RONTIÞRES CLINIC IN +HAYELITSHA 3OUTH !FRICA
AND ()6 PROGRAMS PROGRESSION AND PERHAPS BY EXTENSION WHAT
IS A RARE EXAMPLE OF COLLABORATION BETWEEN THE 4" AND ()6 COMMUNITIES
TREATING INDIVIDUALS LIKE 0AMELA ABOVE FOR BOTH DISEASES AT THE SAME TIME
h%VERYONE WONDERS PROTECTS PEOPLE FROM 4" SAYS 7ILKINSONh4HIS
WHOS GOING TO SWALLOW IS ONE OF THE GREATEST EXPERIMENTS IN PUBLIC
EVEN THOUGH THOSE RESULTS OFTEN INFORM POLICY THE OTHERv SAYS 'OEMAERE HEALTH EVER INVENTEDv
DECISIONS "UT THERE ARE SMALL SIGNS THAT THINGS !POORVA -ANDAVILLI IS .ATURE -EDICINES
! DECADE AGOhTHE PUBLIC HEALTH COMMUNITY ARE CHANGING BEGINNING WITH THE 7(/S SENIOR NEWS EDITOR
WAS ACCUSED OF BEING PHILISTINE OR NARROW
MINDED AT BEST AND ALIENATED FROM THE BASIC
SCIENCE COMMUNITYv SAYS #HRISTOPHER $YE
.UNNS COLLEAGUE AT THE 3TOP 4" PROGRAM
3POTLIGHT ON -ARK (ARRINGTON
h4HERE WAS SOME SENSE THAT WE WERE ENEMIES &OR A LIBERAL ARTS GRADUATE WITH NO FORMAL SCIENCE BACKGROUND -ARK (ARRINGTON HAS A LOT OF
OF EACH OTHER AND ALL THIS KIND OF NONSENSEˆ INFLUENCE ON RESEARCH FOR !)$3 AND TUBERCULOSIS 4" 
NOT ANYMOREv $YE SAYSh)TS WAY BETTER THAN IT 4HE HEAD OF THE .EW 9ORKnBASED ACTIVIST ORGANIZATION 4REATMENT !CTION 'ROUP 4!' 
WAS ABOUT TEN YEARS AGOv (ARRINGTON COMMANDS RESPECT FROM EVEN THE MOST SENIOR !)$3 AND 4" RESEARCHERS ,AST YEAR
-AYBE SO "UT .UNNS PERSPECTIVE IS STILL FAR THE GROUP PUBLISHED A COMPREHENSIVE ANALYSIS OF FUNDING FOR 4"ˆSHOWING FOR EXAMPLE THAT
REMOVED FROM THE URGENCY WITH WHICH MOST 4" GETS LESS THAN FIVE PERCENT OF THE AMOUNT SPENT ON !)$3ˆTHAT HAS QUICKLY BECOME A MUST
RESEARCHERS ON THE GROUND SPEAK OF )2)3 HAVE RESOURCE IN THE COMMUNITY
h4HE PUBLIC HEALTH PEOPLE WHO IGNORE THE (ARRINGTON HIMSELF SITS ON THE ADVISORY BOARDS OF POWERFUL AGENCIES INCLUDING THE 53
CLINICAL IMPORTANCE OF THINGS THEY UNDERMINE .ATIONAL )NSTITUTES OF (EALTH AND THE 7ORLD (EALTH /RGANIZATION 7ITH A FOUR YEAR
THEIR CREDIBILITY IN THE EYES OF THE PEOPLE WHO  MILLION GRANT FROM THE "ILL  -ELINDA 'ATES &OUNDATION HE IS TRYING TO STRENGTHEN
RUN THE PROGRAMv SAYS #HAISSON h9OU NEED A SUPPORT FOR 4" BY TRAINING !)$3 ACTIVISTS ON THE ISSUES COORDINATING OUTREACH WITH !FRICAN
PUBLIC HEALTH APPROACH BUT YOU NEED TO TAKE ACTIVIST GROUPS EDUCATING ADVOCATES AND POLICY MAKERS IN 7ASHINGTON $# AND PUSHING FOR
CARE OF PATIENTSv MORE FUNDS
h7E NEED TO HAVE STRONG ACTIVISTS IN THE COUNTRIES MOST AFFECTED BY ()6 AND 4" SO THEY CAN
0OWER STRUGGLE RAISE THE AWARENESS OF THE GOVERNMENTSv HE SAYS
(ARRINGTON IS NO STRANGER TO ADVOCACY )N 
4HIS DISCONNECT IS EVEN MORE STARK
DURING THE EARLY DAYS OF THE !)$3 MOVEMENT HE JOINED
IN THE RADICALLY DIFFERENT CULTURES
THE FAMOUS !#4 50 GROUP IN .EW 9ORK (E LAUNCHED
OF THE ()6 AND 4" COMMUNITIES
4!' FOUR YEARS LATER 4HOUGH STILL HEAVILY INVOLVED IN
4" IS AN OLD DISEASE AND ITS !)$3 ACTIVISM (ARRINGTON IN  BEGAN CAMPAIGNING
APPROACH SET PRIMARILY BY THE FOR 4" A NEGLECTED DISEASE WITH FAR FEWER ADVOCATES
7(/ IS FAITHFUL TO THE PRINCIPLES h4" IS A DISEASE OF THE POOR AND THE EXCLUDED AND
OF CLASSIC PUBLIC HEALTH DOING THE THERES NEVER GOING TO BE A WORLDWIDE MOVEMENT OF 4"
BEST FOR THE MOST PEOPLE 7ITH THE ACTIVISTS THE WAY THERE IS WITH ()6v SAYS (ARRINGTON
PERCEPTION THAT 4" WAS CURABLE h7ERE NOT GOING TO GET TO WHERE WE NEED TO BE WITHOUT A
INTEREST IN 4" RESEARCH ALSO DRIED MASSIVE INVESTMENT INTO BASIC SCIENCEv
UP AND THINGS ARE DONE MUCH THE !LISA /PAR .EW 9ORK
SAME WAY THEY WERE DECADES AGO -ARK (ARRINGTON LEFT WITH THE 7(/S (AILEYESUS
h)TS EXTREMELY RIGID FROM 'ETAHUN

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