TB in Liberia: ‘I thought it was African sun – meaning you’re cursed’

For six months, Augustine has scrutinised Beatrice from his isolation ward window. Ensconced on the same wooden bench every day, she cradles their newborn, while pining for her husband just metres away.

Augustine (26) has multi-drug-resistant tuberculosis (MDR TB), a growing problem as the world’s deadliest infectious disease morphs into increasingly resistant strains

"Do not be afraid, do not be discouraged," is written in scripted lettering on a wooden door he can't exit, five metres from his bed. He'll stay in this ward in Harper, southeastern Liberia, for eight months in total, a gap in employment that has left his family homeless even as Augustine yearns for them.

TB remains one of the top 10 killers in the world. About 1.6 million people died from it in 2017 alone, according to the World Health Organisation – about 4,000 a day. In 2016, almost half a million people were diagnosed with MDR TB. Yet health workers say public awareness campaigns have failed to catch on in the same way as those around HIV/Aids, meaning there's less concrete action to tackle the disease. Politicians aren't as interested, some suggest, because TB disproportionately affects the poor.

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Next week, the United Nations will hold its first-ever high-level meeting aimed at ending tuberculosis, bringing together health ministers and heads of state from around the world.

"While TB has climbed up the list to become the world's deadliest infectious disease, it's been stuck at the bottom of the list of political priorities," said Aaron Oxley, the executive director of Results UK, a London-based organisation which campaigns around TB awareness, calling its prevalence as much a political failure as a scientific failure.

“The UN high-level meeting on TB is a once-in-a-generation opportunity to change this.”

“TB is much more political than other diseases because it’s airborne,” said Joia Mukherjee, the chief medical officer for international medical charity Partners in Health. “There hasn’t been that awareness that this is a totally treatable disease.”

In countries already struggling, TB can quickly fall behind other priorities.

Damaged healthcare system

Liberia is one of those countries. The west African state is recovering from two civil wars and the Ebola crisis, which killed almost 5,000 people between 2014 and 2015. Ebola decimated the healthcare system, though both Liberians and the international community rallied to respond to it, eventually wiping it out.

While the Ebola response resulted in increased community outreach and more accessible services, an ongoing lack of funding and general inefficiency means Liberia’s counties can still be left without doctors, doctors left without pay, clinics left without medicine, and victims left without hope.

During an interview in Monrovia, Liberia's new minister of health, Dr Wilhemina Jallah, said she is calling for the country's diaspora to begin sponsoring hospitals to help the funding crisis. "Even you could sponsor one," she told a group of visiting journalists.

About TB specifically, Jallah added: “TB is not only a Liberian problem, it’s a worldwide problem. Most of the African countries are having that problem. One of the big causes of TB is poverty.”

Liberian TB victims told stories of having to walk alone for two days to access healthcare, trudging through mud or rain along undrivable roads from remote villages. This adds to other reasons for a late diagnosis. Some Liberians who become infected are also highly superstitious, believing there’s another prognosis entirely.

“I thought it was African sun – meaning you’re cursed,” said Bento Williams (23) about the day she began vomiting blood. “It was grinding in my chest. Pain and grinding.”

Particularly affected are people living in overcrowded areas: slums and prisons included.

Prison fatalities

Monrovia’s Central Prison was built for 375 inmates, but currently there are 1,102. Men catcall from packed cells, many eyes peering out of each small, barred window. One hissed and pulled a threatening finger across his throat.

It’s a place where TB spreads quickly. A week before I visited, a 27-year-old prisoner died from the disease – no one came to collect his body and there was no funeral. The same week, one staff member was infected after using a substandard mask for protection.

In 2017, two prisoners with MDR TB escaped after being sent to an isolation unit. They’re still on the run, though a healthcare worker from an international organisation privately admitted he had tracked them down and was treating them. “They’re not criminals to me,” he said. “They’re people in need.”

The prison’s main sick bay is inside the grounds, just across a dusty yard from the main block of cells. Behind a heavy, metal gate, 12 TB patients share mattresses in cells, with little special treatment. They’re fed just twice a day.

Varaney Luke, the gruff superintendent in charge of the prison, says more needs to be done to prevent overcrowding. “How do you expect us to work? You want us to manage things we can’t manage. It is very appalling.”

In the TB Annex, Liberia’s main tuberculosis hospital, doctors say they’re paid less than $200 a month and have no insurance. Sometimes their pay comes weeks late without explanation.

Nurse Esther Saah (32), a sweet, smiling woman who laughed with patients during her rounds, said she is struggling through her work. “This is where I grew up, this is my passion,” she said. “We find TB in poor people who cannot afford help. As a clinician you have to fill in.”

Body disposal

Staff here didn't anticipate everything their jobs would involve. Sometimes they chase patients who escape, to convince them to continue treatment. One nurse, Lydia Minaue, is in charge of disposing of the bodies of patients who die. Between January and May, 14 were abandoned – their families either too frightened or too poor to pick them up – so she ended up co-ordinating the burials herself.

It's clear the point of infection can't always be traced, and its timing can be especially tragic. Rose Robert spent decades as a refugee in Ghana, after fleeing brutal war. Last year, she finally decided to come back home and find her family. When she reached their neighbourhood, she discovered her relatives' house had been burned down to stop the spread of Ebola.

Robert continued to try and trace them, but before long she started getting sick. “I was sweating, coughing, not eating, losing weight.” After presenting at a hospital, she was diagnosed with TB.

Robert has seven children, and – when she can muster the strength – she does odd jobs inside the TB Annex to earn money for them, mainly washing other patients’ clothes. Today, she regrets ever coming home. “We used to talk about how beautiful it is, how good Liberians are. [But] I didn’t find my people. I got stranded. I got sick. If I knew this would happen I wouldn’t have come to Liberia.”