A nurse made her rounds at a hospital in Port Elizabeth, South Africa, where patients with drug-resistant tuberculosis are involuntarily confined.

By CELIA W. DUGGER

PORT ELIZABETH, South Africa - The Jose Pearson TB Hospital here is like a prison for the sick. It is encircled by three fences topped with coils of razor wire to keep patients infected with lethal strains of tuberculosis from escaping.
But at Christmastime and again around Easter, dozens of them cut holes in the fences, slipped through electrified wires or pushed through the gates in a desperate bid to spend the holidays with their families. Patients have been tracked down and forced to return; the hospital has quadrupled the number of guards. Many patients fear they will get out of here only in a coffin.
“We’re being held here like prisoners, but we didn’t commit a crime, Siyasanga Lukas, 20, who has been here since 2006, said before escaping recently. “I’ve seen people die and die and die. The only discharge you get from this place is to the mortuary.
Struggling to contain a dangerous epidemic of extensively drug-resistant tuberculosis, known as XDR-TB, the South African government’s policy is to hospitalize those unlucky enough to have the disease until they are no longer infectious.
The public health threat is grave. The disease spreads through the air when patients cough and sneeze. It is resistant to the most effective drugs.
And in South Africa, where these resistant strains of tuberculosis have reached every province and prey on those whose immune systems are weakened by AIDS, it will kill many, if not most, of those who contract it.
As extensively drug-resistant TB rapidly emerges as a global threat to public health - one found in 45 countries - South Africa is grappling with a sticky ethical problem: how to balance the liberty of individual patients against the need to protect society.
Most other countries are now treating drug-resistant TB on a voluntary basis, public health experts say. But health officials here contend that the best way to protect society is to isolate patients in TB hospitals. Infected people cannot be relied on to avoid public places, they say. And treating people in their homes has serious risks: Patients from rural areas often live in windowless shacks where families sleep jammed in a single room - ideal conditions for spreading the disease.
“XDR is like biological warfare,’’ said Dr. Bongani Lujabe, the chief medical officer at Jose Pearson hospital. “If you let it loose, you decimate a population, especially in poor communities with a high prevalence of H.I.V./AIDS.
But other public health experts say overcrowded, poorly ventilated hospitals have themselves been a driving force in spreading the disease in South Africa.
The public would be safer if patients were treated at home, they say, with regular monitoring by health workers and contagion- control measures for the family.
Locking up the sick until death will also discourage those with undiagnosed cases from coming forward, most likely driving the epidemic underground.
“It’s much better to know where the patients are and treat them where they’re happy, said Dr. Tony Moll, chief medical officer at the Church of Scotland Hospital in Tugela Ferry.
Zelda Hansen, 37, the wife of a welder and mother of sons ages 4, 12 and 14, has lived at the hospital for more than a year. She was among the 31 extensively drugresistant patients who escaped from the 350-bed hospital before Christmas.
Soon the media trumpeted news of the infectious runaways. A provincial health department spokesman vowed they would be “hunted down. On December 23, a Sunday morning, Mrs. Hansen said, police officers wearing infection-control masks came to her door. A crowd of neighbors gathered for the spectacle. Mrs. Hansen refused to go. She begged for a few more days - just through Christmas.
Her middle son, Trevino, 12, fearing she had done something wrong, offered his barefoot mother his sneakers, called tekkies here. “ ‘Here, Mommy, take my tekkies, go with the police,’ she said he had pleaded with her. “ ‘Please, Mommy, go.’
Back at the hospital, Mrs. Hansen descended into despair. “I felt like going to the trees and just hanging myself, I was so humiliated, she said.