How important is nutritional support to TB patients and their families?

Hara Mihalea, CNS Correspondent, Thailand
There is a debate whether providing food packages to TB patients motivates them to stay and successfully complete their treatment and so far there is no evidence to fully support this theory. However, people like me who for years have worked at the patient level, can say with confidence that when families do not know when their next meal will come from, they will not seek care when they are sick because they neither want to lose their daily income nor spend the little money they have at the health centre or hospital. 

Their priority is to provide whatever little they can for the family and so they continue to work until they are very seriously sick and unable to work. It is only then that they finally seek care at the cost of the family often going without meals.

In the case of TB we understand that one of the main symptoms of TB is weight loss. So one can imagine what happens to a person with TB who is already rapidly losing weight with no food to eat. Imagine if that TB patient is a child—undernourished and taking TB drugs. And what if he/she is also co-infected with HIV?  Malnutrition is inevitable and adhering to treatment is extremely difficult.  Recently a mother told me, “My daughter has been on anti-TB drugs for six months now but she is not gaining any weight. I want her to gain her weight back and be healthy again but there is not much food I can give her.” She said that when she takes her daughter to the health centre the staff there scolds her because they say that unless she feeds her daughter well she will not recover fully. “This makes me sad and angry at the same time but there is not much I can do, I am poor and have no education,” laments the mother.

And what if an elderly TB patient is also suffering from diabetes? Over and over again we hear a person telling us how difficult it is for them to take the anti-TB drugs because of the side effects and taking them without or with very little food makes it even worse. 

San Savy, Som Bopha, Cheal Sophal, and Pick Ann are some of the community volunteers who have supported TB patients and their families for many years in Cambodia. All of them said that food for the TB patient and the TB affected families is essential to accessing care, and starting and completing treatment. San Savy told me that she has tried to help her community in Russey Sros Village for more than 10 years.  She has met many people with TB and she has referred them to the health centres.  She has supported them with their treatment but most importantly she told me that the biggest support they need is food and transportation. So San uses her motorbike to take patients back and forth to the health centre and gives them as much food as she can. “This is my merit,” she says.  “If they do not have food they will not be cured and they and their families will suffer.”

Away from the Cambodian communes in Ulaanbaatar, Mongolia Mrs. Enkhtsetseg is one of the many volunteers of the Mongolia Anti-Tuberculosis Association  dedicated to supporting TB and MDR-TB patients. She along with  300 other volunteers are very actively implementing the Lunch DOTS programme and the Homebase programme in 8 districts in Ulaanbaatar.  The Lunch DOTS programme is designated to provide free lunch for people on TB treatment who are at risk of opting out of treatment, to encourage them to continue taking their anti-TB medications and complete their treatment.  D. Enkhtsetseg and her colleagues come everyday to the Lunch DOTS programme to give patients their anti-TB medications.  During my visit to one such Lunch DOTS programme I met with one young couple and 3 older gentlemen, all TB patients at different stages of TB treatment.  They told me how grateful they were to the volunteers and how much the lunch they were given daily helped them with adhering to  their treatment. “We come here everyday to have lunch and take our medicines from the volunteers.  The volunteers are very kind and without their help I do not know if I could continue to take these medications”, said one of them. Another was happy that after coming to this lunch programme he had gained weight and got back his strength.  Gaining weight can also occur because the patient is on anti TB drugs and getting better so his/her weight tends to increase, but for these people the food they are getting through these programmes is what is keeps them going and they are determined to complete their treatment.

Mrs. Enkhtsetseg said that, “Unless we go to the patients the patients cannot come to us. Some are just very sick and weak; some have no  money for transportation. The inclement weather is also a big factor--when is very cold outside people cannot come out of their homes. Having a warm plate of food and a nice hot drink is so very important to these people as it helps them stay motivated, encouraged and on treatment. Most of the patients that come to the Lunch DOTS programme are either very poor, or homeless and/or alcoholics. We must  expand  these programmes to other areas and districts as well.” 

Even if there is no hard evidence to prove this, we know from experience at the ground level that provision of free nutrition packages to TB patients act as enablers and incentives to accessing and adhering to TB treatment. The World Food Programme strategy to provide food packages to TB patients has been very successful in countries where it was implemented and followed within the programme guidelines.  And the simple logic is that when people are sick and poor and unable to work they need to have food to get stronger and get cured. Recently WHO released the nutritional care and support guidelines for Patients with Tuberculosis. Another tool that countries can have is to access the nutritional status and needs of TB patients.  Assessing  and making sure that every patient gets the daily nutrition they need is a task that needs good programming, collaboration, integration, and replication of successful programmess like the Home base and Lunch DOTS programme in Mongolia. 

Hara Mihalea, Citizen News Service - CNS
March 2014
(The author is a global TB activist and international public health and TB consultant based in Chonburi, Thailand)