Eliminate poverty and injustice!
An all-embracing approach to controlling TB
Von Christian Auer / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
Modern short-course chemotherapy to treat tuberculosis (TB) is one of the most cost-effective intervention tools that exist against any major disease. Much could be achieved by using this tool more efficiently, but chemotherapy, and other interventions, like improved vaccines, are unlikely to provide a permanent solution to the problem. It must not be forgotten that the dramatic decline of TB in industrialised countries was brought about more by improved socio-economic conditions than by medical interventions. To quote a recent article in the Lancet (1), "The best tuberculosis control strategy is undoubtedly elimination of poverty."
The spread of tuberculosis is influenced by a whole complex of factors. Family-based factors, such as quality of housing and nutrition, and emotional stress, are often a result of local and national factors, such as insufficient resources and allocation by the local and national governments. For many countries, in turn, the resources available by the national government are severely restricted which is co-determined by international factors such as globalisation favouring the well-off countries and a differential value of human life. Poverty and injustice are underlying most of these factors and, therefore, the darker sides of the human nature must be taken into account.
This article considers the problem from the vantage point of the South. A case story from the Philippines may illustrate the devastating effect of TB among the poor and serves as a point of reference for the discussion.
In 1992, Alena, 50 years old and belonging to a very poor family in a slum of Manila, had a persistent cough. She went to a private doctor and TB was diagnosed. Her drug intake was irregular and she did not fully recover.
In late 1992, an NGO worker became her neighbour and realised Alena's need of regular treatment. He gave her anti-TB drugs weekly. Without much success, he talked to her about the importance of daily drug intake. Alena completed six months of irregular treatment.
In mid-1995, Alena's condition deteriorated. She was brought to the 'TB hospital' of Manila. Her husband, also sick with TB, took care of her in the hospital. Only first-line drugs were available. Sometimes, Alena managed to buy Ofloxacin.
By early 1996, Alena was back in her shack. She died some months later.
Why did Alena succumb to tuberculosis? What are the approaches and actions to take to reduce the TB-related morbidity and mortality?
Obstacles and Issues in TB Control
The case presentation reveals the several layers of constraints in TB control. First of all, on the biomedical level, the course of therapy is long and cumbersome, which made it difficult for Alena to complete it. Later on in her illness, she needed an effective and affordable treatment for TB that was resistant to the first-line drugs. Research into novel therapeutic agents is necessary. Secondly, a basic question is: "Why did Alena become ill in the first place?" On the household level, more effort is needed to understand the multiple factors - social, cultural and economic - that determine vulnerability to TB.
It has been shown that the DOTS strategy (Directly Observed Treatment, Short-course) - when well implemented - helps patients to adhere to treatment. Directly observed therapy (DOT) might have been the prompting or support that Alena needed to adhere to treatment. An important question is how DOT can be carried out so that the patients perceive the observation process as supportive rather than punitive (2). Structural or managerial parts of a programme, like the organisation of direct observation, should not divert attention from the importance of the health providers having good relational skills (3),(4).
Five years after WHO declared TB to be a global emergency, DOTS was only being used for about 20% of patients in the world (5). The reason for this has to be sought at the level lack of national and international politics.
How can the understanding that TB is a reflection of underlying societal conditions of inequity and poverty be promoted (6)? Further applied research addressing the fundamental large-scale causes of disease is needed (7). This in turn has to be seen in the context of a possible new ethos of international co-operation (8), against the background of continuing globalisation.
Finally, how can we ensure that the available resources are more justly shared? How can we reduce the tendency to set a different value on human life according to where it is lived? When there is a chance to save the life of a sick person in a high-income country, costs are normally not a limit. But in other places, patients go untreated because the necessary intervention is not "cost-effective". This is brutally expressed in the remark of a prominent member of the WHO: "The best thing that could happen for the millions of TB patients around the world would be for one famous Hollywood actress to catch multi-drug resistant TB." (9)
How to control TB?
The political will to control TB is vital if a world-wide effort is to be made. There are many encouraging signs that show that this will is growing. For example, a global public-private partnership has been established to co-ordinate and strengthen the development of new drugs against TB (Global Alliance for TB Drug Development) (10). Many other initiatives are needed. A disease with so many facets needs a holistic approach to control, requiring a comprehensive understanding of the situation. For instance, the patient and her/his behaviour must not be the only point of attention. Focussing on the patient results in an exaggeration of the importance of the actions of the individual, and quickly leads to the common notion that the main problem is the "non-compliant" patient. It is vital to incorporate an understanding of how an individuals actions are constrained by poverty and inequality (11) as outlined above. Compliance should be seen as a chain of responsibilities, involving not only the patient but (i) the health professional (health provider compliance); (ii) the existing health system; (iii) the decision-makers in the Ministries of Health and of Finance, and other ministries and international agencies and institutions involved in the fight against poverty; and (iv) society as a whole (12),(13). "Health provider compliance" means the use of satisfactory diagnostic procedures and correct prescription practices. Co-ordinated efforts are needed to establish better diagnostic methods and to ensure that diagnostic and case-management guidelines are available and are followed. This asks for close collaboration between the public and the private sector, including the pharmaceutical companies.
On the societal level, the large-scale forces that hinder rapid progress in reducing sickness and death must be exposed and addressed. Different sectors of society should be asked to become partners in the fight against TB. Health professionals are among those whose voices should be heard at all levels - Virchow argued that physicians must be the "natural attorneys of the poor" (11). Health professionals who have an all-embracing understanding of causality and an awareness of the non-medical dimensions of disease are more likely to link their work with that of other sectors of society, like the religious sector. This sector may be a part of providing treatment supervision, offer the emotional and spiritual support so badly needed by patients suffering from a severe and stigma-attached illness (14), and engage in advocacy. For example, in the Philippines, the Catholic Church is now formally seeking ways in which it can strengthen TB control in terms of patient support and advocacy.
A great deal of progress has been made in understanding the pathogen causing TB, in developing tools of control, and in understanding the health systems factors involved. It is in the light of this progress, acknowledging the difficulties of TB control that still remain at many levels, that we also need to remind ourselves that in addition to our scientific research and public health action, we must remember the advice of an ancient Asian king who said: "Speak up for those who cannot speak for themselves, for the rights of all who are destitute. Speak up and judge fairly; defend the rights of the poor and needy."
*Christian Auer, Swiss Tropical Institute. PhD thesis since May 1999: "Tuberculosis control in Manila: Comparison of two treatment approaches and enhancing public private health sector collaboration".
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