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Holley's corridors are long and dark, with fluorescent tubes throwing harsh white light on drab walls. One room is filled with hulking machines once used to collapse lungs, sometimes by inserting ping pong balls. Antique cabinets hold metal tools for spreading and removing ribs -- all from a time when TB was rampant and the hospital's 500 beds were filled.
Only 50 beds are funded today, but those are mostly full. More than half the patients are court-ordered into treatment after refusing to take their meds on the outside.
Juarez came voluntarily. In the beginning, he was isolated and forced to wear a mask when he left his room. He could touch his Peruvian family only in pictures taped to the wall. He missed his dad, his siblings, his dog, his parrot, and especially his mother.
"I was very depressed," he said. "I had all this stuff in my mind."
He spent countless hours alone inside the sterile corner room reserved for patients on extended stays -- dubbed "the penthouse" because it is bigger and lined by a wall of windows.
His moods ran hot and cold. He punched holes in the walls out of frustration, played loud reggaeton music with a thumping beat and got into fights with other patients. He covered his door's small window with a drawing of an evil clown to keep nurses from peering inside. He made friends with new patients, but was forced to stay long after many of them came, got cured, and left.
Early on, Juarez's treatment was similar to chemotherapy. Drugs were pumped into his bloodstream intravenously three times a day, and he choked down another 30 pills, including some that turned his skin a dark shade of brown. He swallowed them with spoonfuls of applesauce, yogurt, sherbet and chocolate pudding, but once they hit his stomach, waves of nausea sometimes sent him heaving. He would then have to force them all down again.
"When he first came in we really had to throw everything and the kitchen sink at him," said Ashkin, the hospital's medical director, who experimented on Juarez with high doses of drugs, some not typically used for TB. "It was definitely cutting edge and definitely somewhat risky because it's not like I can go to the textbooks or ... journal articles to find out how to do this."
After 17 years of handling complex cases -- including TB in the brain and spine -- Ashkin had never seen a case so resistant. He believed he would have to remove part of Juarez's lung.
Ashkin dialed Peru to talk to the young man's father.
It's a rare disease, said Ashkin, hard to define. Your son is one of two people in the world known to have had this strain, he said.
"What happened to the other person?" his father asked.
Juarez's adventure in the U.S. had turned into a medical nightmare.
About 60 million people visit the U.S. every year, and most are not screened for TB before arrival. Only refugees and those coming as immigrants are checked. The top category of multidrug-resistant patients in the U.S. -- 82 percent of the cases identified in 2007 -- was foreign-born patients, according to the CDC.
The results are startling among those tested, said Dr. Angel Contreras, who screens Dominicans seeking to enter the U.S. on immigrant visas. The high rate of MDR-TB in the Dominican Republic coupled with high HIV rates in neighboring Haiti are a health crisis in the making, he said.
"They're perfect ingredients for a disaster," he said.
Juarez's homeland, Peru, is also a hotspot for multidrug-resistant TB. DNA fingerprinting linked his disease to similar strains found there and in China, but none with the same level of resistance.
"So the question is: Is this a strain that's evolving? That's mutating? That's becoming more and more resistant?" asked Ashkin. "I think the answer is yes."
Doctors grappling with these new strains inadvertently give the wrong medicines, and so the TB mutates to become more aggressive and resistant.
Poor countries also do not have the resources to determine whether a patient's TB is drug-resistant. That requires sputum culturing and drug-susceptibility testing -- timely, expensive processes that must be performed in capable labs. WHO is working to make these methods more available in high-risk countries as well as negotiating cheaper prices for second-line drugs.
"There's a lot of MDR and XDR-TB that hasn't been diagnosed in places like South Africa and Peru, Russia, Estonia, Latvia," said Dr. Megan Murray, a tuberculosis expert at Harvard. "We think it's a big public health threat."
Experts argue if wealthy countries do not help the worst-hit places develop comprehensive TB programs, it puts everyone at risk.
"You're really looking at a global issue,'" said Dr. Lee Reichman, a TB expert at the New Jersey Medical School Global Tuberculosis Institute. "It's not a foreign problem, you can't keep these TB patients out. It's time people realize that."
Juarez spent a year and a half living alone in a room plastered with bikini-clad blondes, baseball caps and a poster of Mount Everest for inspiration. There were days when he simply shut down and refused his meds until his family convinced him to keep fighting.
"I was thinking that maybe if I need to die, then that's what I need to do," he said, perched on his bed in baggy jeans. "I felt like: 'I'm never going to get better. I'm never going to get out of here.'"
When put side by side, his CAT scans from before and after treatment are hard to believe. The dark hole is gone, and only a small white scar tattoos his lung.
"They told me the TB is gone, but I know that TB, it doesn't have a cure. It only has a treatment like HIV," he said, his English now fluent and his body weight up 32 pounds from when he first arrived. "The TB can come back. I saw people who came back to the hospital twice and some of them died. So, it's very scary."
His treatment cost Florida taxpayers an estimated $500,000, a price tag medical director Ashkin says seems like an astronomical amount to spend on someone who's not an American citizen. But he questions how the world can afford not to treat Juarez and others sick with similar lethal strains.
"This is an airborne spread disease ... so when we treat that individual, we're actually treating and protecting all of us," he said. "This is true homeland security."
In July, at age 21 -- 19 months after checking in -- Juarez swallowed his last pills, packed a few small suitcases and wheeled them down the hospital's long corridor.
The last time doctors saw him, he was walking out of the sanitarium into south Florida's soupy heat.
Copyright 2009 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
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