A guard in a surgical mask patrols a wire fence designed to keep dozens of patients with a lethal form of tuberculosis at Cape Town's Brooklyn Chest hospital isolated from the rest of the world.
Inside the ward, sufferers of extreme drug resistant tuberculosis (XDR-TB), a near untreatable strain of the disease, battle boredom, depression and the side-effects of a daily palmful of pills.
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As doctors and government officials scratch their heads over the inherent clash between individual freedom and the public health risk posed by XDR-TB, patients are more concerned about when, if ever, they can return home.
"I feel like I'm in prison," a 25-year-old bookkeeper complained from her hospital bed in the female section of the ward.
"I am bored and I want to get out of here," she told AFP in her seventh month of hospitalisation.
A two-metre-tall (6.5 feet) fence was erected around the XDR-TB ward recently in a bid to dissuade anyone from fleeing the hospital, even as doctors lack the legal tools to forcibly confine patients or compel them to take medication.
"We encourage them not to leave -- by law, you can't force them," said an exasperated Dr Simon Moeti, senior medical superintendent at Brooklyn Chest.
The facility set a national precedent last year by obtaining a court interdict against four of its patients who absconded repeatedly and put their loved ones at risk.
The court ordered the four to return to hospital, to be discharged only once they have tested negative for three consecutive months. One has since died and the other three ran away again.
But health facilities still need to apply for individual court orders which are both costly and time-consuming and therefore essentially rely on the goodwill of patients to remain isolated from the rest of the world.
"The court interdict was really a painful decision," said Dr Krish Vallabhjee, the health department official responsible for TB hospitals in South Africa's Western Cape province, of which Cape Town is the capital.
If they refuse the drugs, they will die here
Some of of the occasional absconders were breadwinners who felt they had left their families in the lurch.
"There are two aspects to it," said Vallabhjee. "One is the public health risk. The other is, having confined them, getting them to comply with treatment.
"If they refuse, they will die here. It is a very awkward situation."
Resistance to TB drugs can develop when patients fail to take their medication as prescribed, and in a minority of cases through direct transmission from person to person.
Multi-drug resistant TB (MDR-TB) fails to react to the two most powerful anti-TB drugs, while XDR-TB is resistant to these and at least two others.
While six months of out-patient treatment for non-drug resistant TB costs about 400 rand (55 dollars, 38 euros), XDR-TB drugs cost around 100,000 rand and patients require up to 24 months in hospital.
At a recent lung health conference, the South African health department said 391 cases of XDR-TB were diagnosed between January and October last year, compared to 74 in 2004.
And it said it was mulling legislative amendments to deal with the issue of mandatory isolation and treatment.
"What you have at the moment in terms of the South African constitution, is that in each case we want to deal with we have to seek legal recourse," said the department's director-general Thami Mseleku.
"It is a process that takes a lot of time and energy. We are looking at whether we can find clauses in our legislation that will allow a general approach to the matter."
About 120 MDR-TB and XDR-TB patients absconded from hospitals in the Eastern Cape province last month alone.
At Brooklyn Chest, 60 XDR-TB patients were admitted since September 2006. Twenty have died, but none have been cured or discharged.
"It is too early in the XDR epidemic to know exactly what the cure rate is," said Vallabhjee. "But it is fair to say the prognosis is not good."
He cautioned against steps that patients could perceive as punitive, saying this would discourage the afflicted from seeking help in a country where stigma and fears of bewitchment already complicated TB treatment.
Instead, institutions like Brooklyn Chest were doing what they could with limited resources to make their facilities as friendly as possible.
The female XDR-TB ward sports a television and a few centrally placed chairs around a rickety table decorated with a plastic cloth and a clutch of flowers that attempts to offset the sterile environment and heavy aura of doom.
But most choose to spend their days in bed and a recreational area with scanty gym equipment, a pool table, dart board and a reading nook goes mostly unused.
"The patients are depressed," nursing sister Johanna Blackburn, 54, tells AFP through her mask.
"The medicine upsets their stomachs, it makes them dizzy. And they feel like they live in a jail."
With hopes for a new drug still years off, people like Blackburn do what they can to balance patients' needs with those of society at large.
"We are chasing our tail, basically, trying to keep up," said Vallabhjee.
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