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Presents the author's experiences as a doctor treating tuberculosis and other diseases in South Africa. Author's first trip to South Africa as a boy; Trip in 1974; Tuberculosis at Jane Furse hospital, Northern Transvaal; The hospital under apartheid in 1989; The author's return to South Africa in retirement; Problems of neglect, apathy, shortage of doctors, and traditional healers like witch doctors; How to control tuberculosis in South Africa.

Background: People in sub-Saharan Africa frequently consult traditional healers before reaching the government health services (GHS). This can lead to delays in starting effective anti-tuberculosis chemotherapy. To our knowledge, no studies have shown a direct relationship between visiting traditional healers, increased morbidity and death from TB., Methods: All patients starting on anti-tuberculosis chemotherapy at a rural hospital in South Africa in 2003 were included in the study. TB nurses interviewed the patients and established how long they had had symptoms before treatment was started, whether they had visited traditional healers before coming to the hospital, their performance status and, later, whether they had died., Results: Of 133 patients, those who attended a traditional healer took longer to access anti-tuberculosis chemotherapy (median 90 days, range 0-210) than those who went directly to the GHS (median 21, range 0-120). Patients who visited a traditional healer had worse performance status (P < 0.001), and were more likely to die (24/77 [31%] vs. 4/33 [12%], P = 0.04)., Conclusion: Treatment delay due to visiting traditional healers can have dire consequences for patients with TB. Efforts are required to engage with health care practitioners outside the government sector to improve the prospects for patients with TB.

Objective: To illustrate successes and difficulties for the South African National Tuberculosis Programme in a rural area., Design: Prospective cohort study., Setting: Sekhukhuneland, Provincial Health Service Southern Region, Northern Province, South Africa., Subjects: All patients diagnosed with tuberculosis (TB) in the catchment area of four rural hospitals between January 1997 and June 1999., Main Outcome Measures: Standard outcomes for TB treatment as defined by the World Health Organisation. Treatment failure, treatment interruption and death were grouped as poor outcomes., Results: One thousand four hundred and seventy-six people were diagnosed with TB. The majority (76%) had smear-positive pulmonary disease. Treatment was given by directly observed therapy (DOT) throughout in all but 15 instances. Excluding 10 subjects with known multidrug-resistant TB (MDRTB), 723 (66%) were cured, 68 (6%) completed treatment, 73 (7%) interrupted treatment, 37 (3%) failed treatment, 66 (6%) transferred out, and 134 (12%) died. Of the 920 initially smear-positive patients who survived the first 2 months to receive DOT in the community, 693 (75%) were supervised by unpaid community volunteers. Poor outcomes were no more common among patients supervised by these volunteers than among patients supervised by professional health care workers. Male gender (odds ratio 1.38, 95% confidence interval 1.02, 1.87) was significantly associated with a poor outcome., Conclusion: Although there were difficulties, the national programme was successfully applied with no additional funds or facilities. Explanations for the high death rate and poor outcomes for men need to be found. Great efforts will be required to preserve the quality of the TB programme if it is devolved to primary care level.

Setting: Tuberculosis programmes that rely on district hospitals for diagnosis and initiation of treatment may disadvantage those living furthest away. We present an analysis of such a programme in rural South Africa to see whether those living furthest from the hospital were at greatest risk of dying from tuberculosis., Methods: All patients diagnosed and treated for tuberculosis in three health districts in 1997 and 1998 were included. An estimate of the distance each patient travelled to get to the hospital was obtained. The distances the patients travelled were categorised into four groups. The furthest distance patients could reasonably be expected to travel to get to their nearest hospital was estimated as 60 km. Outcomes of treatment were recorded using standard definitions. The mortality of patients in each of the four groups was compared., Results: Of 1187 patients started on treatment for tuberculosis in the hospitals, 877 (74%) were known to be alive at the end of treatment, whereas 158 (13%) had died. Distance travelled was a risk factor for death, but only amongst those travelling more than 60 km to get to the hospital (0-20 km: n = 313, odds ratio [OR] 1; >20-40 km: n = 436, OR 1.09, 95% confidence interval [CI] 0.71-1.67; >40-60 km: n = 205, OR 0.97, 95%CI 0.57-1.65; >60 km: n = 79, OR 2.87, 95%CI 1.59-5.17)., Conclusion: The mortality from tuberculosis was high, even amongst those living closest to the hospital, and did not rise significantly within 60 km. The situation may be different for the relatively small number of patients who come from further away. The distance travelled to hospital for initial diagnosis does not account for the relatively high mortality amongst tuberculosis patients in this area.