The Insidious Spread Of A Killer Virus

Doctors have told Saeed Taha that he has only weeks to live. The 48-year-old electrician is sprawled on a Cairo hospital bed with tubes connected, seemingly, to every major vein and artery. A decade ago he was diagnosed with hepatitis C. Overcome with fatigue, the father of three quit his job and spent his life's savings on interferon, one of two drugs approved to fight the virus. But it didn't help. "Don't believe what is said about medicine and doctors," he says. "In this disease nothing makes a difference."

On the next bed lies Abdullah El-Shahhat, 70, who was diagnosed four months ago but already displays the swollen legs and belly characteristic of liver disease. The two are among the 15 to 25 percent of Egyptians infected with hepatitis C--the highest rate of any country in the world. Many contracted it in the same way as Taha: through a government-sponsored campaign begun in 1961 to fight the tropical disease schistosomiasis. Medical workers injected millions of Egyptians with used, unsterilized needles. Sayyeda Hassan Metwally, 54, remembers a nurse injecting her 11 relatives and four neighbors with a single syringe. The campaign ended only when an oral drug came on the market in 1982. Now the government is scrambling to control an epidemic it helped create.

This story would be tragic enough even if Egypt were an isolated case, but it's not. Hepatitis C has become a global epidemic. About 170 million people, 3 percent of the world's population, suffer from the disease--four times more than HIV. Hepatitis C doesn't kill with the virulence of AIDS, but it kills nevertheless. About 15 percent of patients mount a strong-enough immune response to completely throw off the virus. But the remaining 85 percent have the disease for life. Of those, one in five develops cirrhosis, which can lead to cancer or liver failure. What really has health officials worried is what is expected to happen in the next 20 years. Since HCV, the hepatitis C virus, can lie dormant in the bloodstream for decades, millions of people who are already infected but don't know it will start getting sick. That will boost the rate of liver failure around the world, making organs for transplant even scarcer than they are now. The demand for costly drugs to suppress the disease may skyrocket, putting them even further out of reach of poorer countries, like Egypt, whose public-health systems are already stretched.

Health officials can't even begin to estimate what resources they're going to need, because even basic data about hepatitis C are virtually nonexistent. That's partly because scientists identified it only 14 years ago. By the time they developed tests to spot the pathogen, it had been spreading silently for decades. In Europe and North America, public-health officials began screening blood supplies in the early 1990s, at least eliminating the virus's spread. Developing nations, which account for the vast majority of HCV patients, have only begun to follow suit. So far only a minority, including Thailand, South Africa and Brazil, screen blood. In other countries wealthy enough to perform transfusions, such as China and India, contaminated supplies may still be infecting new patients. Carlos Varaldo, a hepatitis C patient advocate in Rio de Janeiro, calls it a "viral time bomb."

In Egypt, it's already exploded. "We wish to give free medication to all of the patients," says Sa'eed Aoun, undersecretary for preventive affairs at Egypt's Ministry of Health. "But this requires billions of dollars every year." Already more than 50 percent of Egypt's health-care spending goes toward treating patients with liver disease, most of whom have hepatitis C. The majority qualify for vouchers that they can redeem for free medicine. But to get the vouchers, hep C patients, already weak from their illness, must stand in line for hours outside the Ministry of Health. And the value of the vouchers is unpredictable--it varies from month to month, based on a patient's persistence, political connections and what the government has in its coffers. That puts pressure on doctors. "It is very difficult to decide what medication to prescribe for a patient when you know he might not be able to get the same [government] allowance each month," says Dr. Mamdooh Diaa of the Munufeyya public hospital, just north of Cairo.

In sub-Saharan Africa, which has one of the highest rates of HCV infection in the world (ranging from 1.3 to 6 percent of the population), most patients simply go undiagnosed. "Doctors aren't looking for hepatitis C," says David Heymann of the World Health Organization (WHO). "They're looking for TB or malaria." And, say many African physicians, there's little motivation to test for a virus they simply cannot afford to treat. The situation is equally dire in Russia, where hepatitis C has increased fourfold in the past decade, due mostly to rampant IV drug use. "We are already considering this an epidemic, and there is very little we can do to stop it," says Sergey Kolesnikov, a deputy in Russia's Duma who is lobbying to start a national program to combat all forms of hepatitis. The government, he says, has imported only a limited amount of medicine, which it distributes to those who can afford it. "We are really only curing the rich," he says. Even Brazil, with one of the best health-care systems in the developing world, is struggling. Up to 5 million people are believed to be infected, but only a small minority have been diagnosed. As more and more patients develop symptoms, the government is concerned it may simply run out of drugs, which it now distributes free.

The spread of HCV is of particular concern for countries with a high rate of HIV. In the United States, it affects as many as one third to one half of all HIV patients. And the presence of one makes the other more deadly. Two recent studies have shown that co-infection with hep C leads to a more rapid progression from HIV to full-blown AIDS. The reverse is also true. As HIV knocks out a patient's immune system, it undermines the body's ability to fight off HCV, making it more likely that a sufferer will progress to end-stage liver disease. Co-infection also complicates treatment. "Hepatitis C appears to increase one's risk of toxicity from the HIV medicines," says Dr. Stuart Ray, an expert on co-infection at the Johns Hopkins University School of Medicine in Baltimore, Maryland.

Developed countries are equally concerned. Ironically, the virus is more of a priority in wealthier nations, which have a relatively low rate of infection, plenty of resources and fewer competing health concerns. Hepatitis C has recently grabbed headlines in the United States as celebrities ranging from former "Baywatch" star Pamela Anderson to country singer Naomi Judd have announced they're infected. "I can't go to a social event without meeting someone with hepatitis C," says epidemiologist Miriam Alter of the U.S. Centers for Disease Control and Prevention. By the end of the decade, the death toll from hep C is expected to triple in the United States. In the United Kingdom, roughly 5,000 new cases are being diagnosed each year, and the government is racing to keep up. "The epidemic is growing faster than the number we're treating," says Nigel Hughes of the British Liver Trust. That's not because the disease is spreading faster, but because increasing numbers of Britons who were infected as a result of IV drug use in the 1970s--the so-called "flower power generation"--are developing symptoms and being diagnosed. The pattern is similar in the United States, where drug use was rampant during the '60s. Why has the C virus come to light so recently, and traveled the world so fast? Consider its habitat. Unlike the A virus (which spreads via fecal matter) or the B virus (which passes easily between sex partners), the C virus can't spread unless a carrier's blood enters another person's veins. And the opportunities for such commingling exploded during the 1940s and '50s, when reusable syringes caught on and hospitals began using blood as medicine. By the late 1960s, physicians were seeing liver disease in people who didn't have either of the known hepatitis viruses. Lacking a better name for the syndrome, they dubbed it "non-A, non-B" hepatitis.

To this day, there is no reliable cure. The best treatment available is a combination of the protein interferon, which boosts immune response, and the antiviral drug ribavirin, a distant cousin of AZT. Taken together, they clear the virus in 50 to 55 percent of patients after six months to one year. But they cause such severe side effects--including hair loss and heart failure--that, in the United States, one patient in seven abandons the regimen. Bill Schwartz, 65, a retired lieutenant colonel, compares his yearlong treatment to "West Point plebe year and Vietnam combat." And it didn't control his infection.

Few people in developing countries can afford treatment. A full course of interferon costs about $20,000--the price of a small house in Brazil, or about what the president of South Africa earns in one year. For people like Nvansri Toommnon, 72, the wife of a retired Thai Air Force colonel, that's not a problem. She can afford a private room at Bangkok's Bumrungrad Hospital. But even Thai doctors would be hard-pressed to afford the treatment for themselves. "If I had to be treated, it would be almost impossible," says Dr. Sirirung Songsivilai, a professor at Mahidol University's school of medicine. Also, because the medication needs to be taken regularly over a long period of time and comes with serious side effects, a country must have a good public-health system in place to deliver the drugs. For these reasons, the WHO advises developing countries to focus on stemming the spread of new infections, rather than on treating existing ones.

The best hope of fighting hepatitis C in the Third World, says the WHO's Heymann, is to find a vaccine. That's a cause Michael Houghton, vice president of hepatitis C research at Chiron Corp., who led a team of scientists in identifying the virus in the late '80s, is now devoted to. But he says the formula is at least five years away from U.S. government approval. Improved drugs are also in the pipeline. The market for hepatitis C treatment is now exploding, and drugmakers have several new compounds in the works. At least three companies are developing protease inhibitors, which block a key enzyme that allows the virus to replicate. And Schering-Plough, the current leader in hep C treatment, is developing molecules that could be combined with protease inhibitors to create the kind of multidrug cocktail that has proved so effective against HIV. "The parallels between these two [epidemics] are just phenomenal," says Dr. Lawrence Deyton, chief public-health officer for the U.S. Veterans Administration. "We're today in hepatitis C where we were in HIV 10 years ago, where we had only one or two drugs that were very toxic and not very effective. If a patient's liver is not in trouble, it may be perfectly appropriate to watch and wait for something better to come along."

In the meantime, many are turning to herbal remedies. Even in the United States, where most people can afford medical treatment, roughly 30 to 40 percent of HCV patients prefer alternative medicines. Dr. Robert Gish, medical director of the liver-transplant program of the California Pacific Medical Center in San Francisco, tells patients: "I have medicines that can cure you, but will make you sick. Herbalists have medicines that will help with your quality of life, but won't cure you." For the developing world, herbal remedies have the advantage of being affordable. One of the most popular herbs is milk thistle, or silymarin, which has been used to treat liver disease, or "bad bile," for more than 2,000 years. Chinese use the herbs schizandra and licorice root for the same purpose. Scientists have only begun to test many of these remedies. So far there's little evidence that they do much more than perhaps relieve symptoms such as inflammation. That's good enough for Haj Hussein, who goes to the old neighborhood of Bab El Khalk, just outside the old gates of Cairo, every couple of weeks to purchase a $3 bag of herbs. The 62-year-old, with yellow-tinged skin and dark shadows under his eyes, says the herbs work wonders. "When I know that my enzymes are OK, I can work. I can live!" For the vast majority of hepatitis C sufferers around the world, such cheap remedies will have to do until scientists and health officials can offer something better.

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