Tuberculosis

Many times in this blog we have discussed the disease Tuberculosis (or TB). Usually TB is referenced just briefly when describing a sick patient or a resource scarcity problem. But, in many ways, TB is the most frustrating and tragic disease that we face here. On the eve of admitting the 1000th patient into our TB program (since 2002), we feel it is time to explain why…

Tragedy #1: The Disease
Many of our sickest patients arrive at Chiri Health Center with advanced TB. TB is a disease that’s spread in the air by coughing, sneezing or breathing. Most people who are exposed to TB never develop symptoms—living for years with “latent TB” in their bodies. Latent TB is so widespread (the WHO estimates that 1/3 of the world has it) that we don’t even screen for it. For those who do develop the disease, about 10% of exposed individuals, TB is vicious. Small children coughing up blood. Previously healthy 20-year-olds who are under 80 pounds. Women with every bone visible in their bodies. Boys who are unable to breathe because pus and fluid is filling their chest cavity. A small girl whose abdomen is so full of fluid generated by TB that her stick legs can’t support her bodyweight. TB manifests itself in many ways. All of which are terrible.

Tragedy #2: The Treatment
The good news is that TB is treatable. The bad news is that its one of the more intensive diseases to treat in the world. Up to four medicines must be taken every day for up to eight months. If a patient misses his medicine, or stops taking it early, drug resistant TB can develop. Multiple Drug Resistant (MDR) TB, TB that won’t respond to any of the primary treatment regimens, is increasingly common and we have few options of treating the disease or fighting its spread. It is therefore required that health centers treat TB using directly-observed therapy (DOT) to prevent resistance. A patient must come to the health center and take his medicines while being watched by one of our clinicians or pharmacists for the first two months of treatment. So a patient who lives many hours away from a health center, who has no means of food or income other than his farm, must find a way to pay room and board near the health center for two months in order to receive treatment. He must also stop working on his farm and caring for his family. After completing the first “intensive phase” and going home, he must return to the health center every month for six additional months to pick up more medicine. Our health center recognizes these insurmountable barriers and helps TB patients with food and housing so that they can complete treatment. As far as we know, we are the only health center to do so in our entire zone of over 1 million people.

Tragedy #3 The Resources
Despite the billions of aid dollars flowing into this country, we receive no support for our TB program from the government or larger aid organizations other than free drugs for treatment. In previous posts we have discussed the glaring disparities between investment in HIV and TB services. But this is not only a problem here in rural Ethiopia. It is true across the globe. Drug research and development has almost entirely ignored TB. A new drug has not been developed to specifically treat TB in more than 50 years (drugs developed for other purposes, such as Cipro, have been shown to be effective at fighting TB). Aid that is often funneled through disease-specific channels does not make a dent in the TB problem. Here at Chiri Health Center, we have no staff who are specifically assigned to TB, a limited budget to feed and house TB patients during treatment, and no resources to search for the disease in the community (let alone the capacity to serve the hundreds of patients we would find if we did). But we patch together a program to the best of our ability out of necessity. Because the countless patients who show up at our door with TB can’t be ignored.

Tragedy #4: The Deaths
And so this brings us to the biggest tragedy of all. Despite the fact that TB is treatable. Despite the fact that it has been practically eradicated from most developed countries. Despite the fact that we are trying our best, with limited resources, to mitigate the problem. People in our community are dying. And so this week, as another patient dies of a preventable, treatable, and completely ignored disease, we have no choice but to write this post.

"We know most things about it, but TB still kills more people than any other pathogen, far more than alcoholism, AIDS, malaria, tropical diseases, and Ebola combined, and nobody seems to care...Where is the shame? Where is the outrage?" - Lee Reichman