Essay on tuberculosis

Dr. Tauseefullah Akhund M.B.B.S, MPH (Sydney), (Australia)

The impact of disease and availability of newer technologies and treatment required to make a policy which would cover a widespread population with a very high cure rates. WHO implemented a TB control policy in early 1990s aimed to detect maximum number of cases and curing the patients (Maher et al, 1997). The main aims were to detect 70% of smear-positive TB cases and to treat 85% of smear-positive new cases successfully. This Directly Observed Treatment Strategy (DOTS) used sputum smear microscopy for diagnosis and short course chemotherapy (SCC) for the treatment of TB. This tool used combination of several drugs in SCC to be more sensitive and short duration to improve the compliance. Under DOTS, the treatment to each person would be given by the health professional directly on daily or on alternate day bases. Either health worker would go to the patient to supply him his drugs or patient would come to the health worker to take his dose daily (Maher et al, 1997). Governments of most countries including Pakistan have implemented this policy in their countries and have succeeded to control TB to a large extent.

DOTS has become an important part of National TB Programs in Pakistan. The main framework of DOTS in Pakistan is to reach at every part of Pakistan, rural and urban, in terms of diagnosis and treatment; accountability and supervision of health care workers; and evaluation of new and relapsed cases (Maher et al, 1997). Under DOTS, categories have been made according to new cases, relapsed cases, treatment failure cases, site and severity of TB, chronic cases, interruption of treatment and so on. The treatment is based and differs according to the categories. The DOTS policy, which looks very effective on paper, hasn’t worked up to the mark in Pakistan because of several reasons. WHO’s TB control policy is too general and does not consider local and cultural factors into account.

The leaping rise in Pakistan’s population along with increasing density and less housing management have raised the threat of TB. Although the percentage of poor people is reducing, the total number of poor has increased substantially over past decades.  It is not easy for DOTS to reach all people. The rural population is increasing, not being able to access DOTS. People in the slums of urban areas are the worst affected. In the absence of any registry of such people, their continuous movement from one place to another and increasing homeless people are worries for one hundred percent coverage of all people under DOTS. Participating in NTP is one of the least important things for such people no matter how severe the impact of disease may be in their lives. The most important reason of such frequent moving people is their poor financial conditions. For the successful registering of such people and their coverage it is important to offer them monetary incentive to stick to the DOTS program. It can also be advised that some of these specific areas with slums and poor housing conditions should be segregated and converted into target health sectors so that special attention can be given and the health services can be re-oriented according to the need of specific health sectors.

Another factor, socio-cultural, is also a hindrance in the success of DOTS. Lack of education and religious preponderance has led to several misperceptions regarding TB. A study carried out by Liefooghe et al (1995) in a hospital of Sialkot district of Pakistan suggested that people consider TB as a lethal and incurable disease. Some of them also linked TB with ‘sins’. These misbelieves cause social isolation of the persons having TB and sometimes their families. Young people can’t find proper match for their marriage; engagements are often broken and divorces are reported. The study reveals that the condition of women is even worse. Women are completely dependent on their husbands and family-in-laws and need their support. There is also some fear that pregnancy leads to the relapse of TB. These misperceptions and social stigma have led to denial of diagnosis and rejection of treatment. The times have come when DOTS address such issues. There is no doubt that education and awareness for such misperceptions is inevitable, but this education should not be anti-religion. Rather, the religious leaders should be encouraged to motivate people to take active part in the TB campaign. Although, DOTS involves health workers at several levels, it should also involve these religious leaders. Their role in removing these social taboos is vital to overcome socio-cultural obstacles.