A Day in the Life: Lal Bibi
21 Jun 2010
Lal Bibi first caught tuberculosis (TB) about 40 years ago. “The first time I got it, when I had my first daughter, I probably hadn’t even hit 20 years old,” she figures. Although she’s not sure what year it was, the treatment—“every third day an injection …I had eight pills in the morning, eight at night”—is burned into her memory. She recovered, but this would be only the beginning of Lal Bibi’s tuberculosis ordeal.
Years later, her brother came down with TB and she caught it again. The drugs worked for her, but not for her brother, who died from the disease. Several years later, Lal Bibi’s sister also succumbed to TB, and afterward Lal Bibi came down with her third case of it. “After my sister passed away, I got it again, due to all the depression and pain, and the stress of having to take care of my young kids.”
Each time she came down with TB, Lal Bibi endured months of powerful antibiotics to clear the bacteria from her body. She might have been catching TB anew each time, but these drugs can sometimes push the TB bacterium, Mycobacterium tuberculosis, into hiding. It can stay dormant for years before resurfacing. Either way, being stressed, depressed and/or malnourished boosted her chances of coming down with TB again.
Those stressors are all too common for people in Lal Bibi’s neighborhood, Baldia Town, an especially poor neighborhood in Pakistan’s biggest city, Karachi. More than a million people are crowded into a 38-square-kilometer area—about the same density as in Manhattan. Instead of high rises, most people live in cramped, spare cinderblock houses, like the one Lal Bibi and her family rent. Her husband passed away long ago from a stroke, and she gets help from some of her kids, but she mostly works odd jobs—embroidering, cleaning, or peeling shrimp coming off the nearby docks.
When Lal Bibi started coughing again, over a year ago, her daughter told her about the newly opened Indus Hospital, which was treating TB patients for free. She went in and got a sputum test, coughing up a bit of phlegm that the doctors could test for TB. At around 60 years old, Lal Bibi came up positive for TB for the fourth time. But this time it was multi-drug resistant TB (MDR TB).
Sometimes when TB patients get treated, a few remaining bacteria prove resistant to the antibiotics that were used to fight the infection. These mutant bacteria can accumulate more and more resistance genes while growing in one person, or as the bacteria pass from person to person. MDR TB strains can fend off the two “front-line” drugs—rifampin and isoniazid—usually used to fight the disease, forcing doctors to resort to “second-line” drugs—which are weaker, and carry worse side effects.
In Pakistan, treatment with these more expensive drugs costs about 10,000-12,000 rupees (USD $120-140) per month, more than the income of most families in Lal Bibi’s neighborhood. For her and many other MDR TB patients across the developing world, their only hope is to get the drugs through a free hospital or government program. Otherwise, they’ll almost certainly die from the disease.
Now she’s again taking a handful of pills each morning and each night. “The doctor was great. I got more strength,” she says, pushing her shawl aside and flexing her sinewy biceps. Lal Bibi will most likely remain on the drugs for at least two years. If sputum tests come up clean three months in a row, she’ll be declared cured and can quit the treatment.
Fourteen months into her treatment Lal Bibi says that the side effects—loss of appetite and nausea—have subsided a bit, but they’re still bad. “It feels as if my innards are burning up, like there’s a fire inside,” she says. She’s recently been experiencing heart palpitations.
In some ways Lal Bibi’s been lucky. Some patients on these drugs suffer permanent deafness, or psychosis. “It hurts my heart and makes me uneasy,” she says, “But I have to have it, so I take it.”
To help MDR TB patients stay properly fed, and to motivate them to stay on the grueling regimen despite the side effects, the hospital gives the patients a 40-kilogram sack of food each month, filled with flour, lentils, and cooking oil. The doctors, nurses and other staff try to help patients finish their treatments—also in part to slow the spread of TB that’s resistant to the existing drugs.
Lal Bibi is committed to her treatment, but she’s worried about what will happen once she gets better. “The treatment only lasts for two years, and after that the food [deliveries] will stop,” she says. “Then I will only have God to turn to.”