TB control in times of trouble

Babs Verblackt, CNS Special Correspondent
Photo credit: CNS: citizen-news.org
Challenging enough already, TB control gets even more complicated in times of conflict. Anything from social unrest to civil war can disrupt basic TB services, affecting groups at special risk of the infectious disease. Because of fear and chaos, reaching and engaging communities becomes increasingly difficult in conflict situations--though not impossible.

"TB control is a marathon, not a 100 metres spectacular show," said Dr Mario Raviglione, Director of the Global Tuberculosis Programme at the World Health Organization (WHO). It becomes clear that in times of conflict even this marathon comes with extra hurdles.

Akmal Nasrat, Afghanistan
Photo credit: Babs V/ CNS
Conflict is a double edged sword, affecting both TB affected populations and TB control activities," Akmal Nasrat, Programme Coordinator at ACREOD in Afghanistan said. Over three decades of civil war left much of the country's health infrastructure in ashes and supply of material disrupted. Immigrations, internal displacements, limited access to health services and poverty increased the number and vulnerability of TB affected communities.

As the security situation deteriorates, the quality of TB services is greatly affected, Nasrat explained based on experiences of the Stop TB Partnership TB REACH program. Comparing districts with various degrees of security, those areas with very bad security clearly performed lower than those with very good security. Bad security negatively influenced detection, treatment follow up and quality of care.

Dangerous and difficult
Callixte Minani, AAA
Photo credit: Babs V/ CNS
Stories of other conflict areas painted similar pictures of deserted and destroyed health care facilities and unreachable patients. "With millions of people displaced, Sudan is in a mess. Where there is a bit of peace, we do our job, expanding programmes all over the country," Callixte Minani of the Arkangelo Ali Association (AAA) International told of the TB screening and treatment activities. "But some areas remain chaotic, dangerous and difficult to reach. Logistics are very hard."

Over 10 years of political crisis greatly disrupted TB programmes in Cote d'Ivoire. Against the draw back of the most recent 2011 post-election crisis, a one-year policy of free health interventions was implemented. "In a post-crisis context, removing financial barriers to access TB services should be top priority," Patrick Agbassi of Aconda-VS argued. The abolition of fees had more impact on TB notification than the one year intensive active case-finding that followed as part of the TB REACH initiative. "The project showed that the financing of transport of patients or samples to basic management units further improved access to TB detection."

Reach out to all
Emmanuel Andre, UCL, Belgium
Photo credit: Babs V/ CNS
During conflict it is important to reach out to all vulnerable groups, even if they might be considered the 'bad guys', Emmanuel Andre of Cliniques Universitaires Saint-Luc (UCL) in Brussels emphasized. He presented the case of South-Kivu, Congo, with 10% of the population internally displaced due to conflicts. Intense presence of official army and several armed groups is linked to different forms of violence impacting local communities. "Because of the violence people are afraid to move which affects their access to health care," Andre says. "Yet soldiers themselves are among the poorest in these populations, with bad living conditions and at high risk of TB and HIV."

To overcome these difficulties, military authorities and health services were actively involved in both TB activities targeting the province as well as the identification of health issues among the military population. "This lead to a better understanding and access of the affected communities and improved the quality of health service to the vulnerable military group."

Treatment stopped
Research showed that HIV infection among TB cases was much higher in the military population (60%) than the general population (36%). Over 50% of TB cases in military facilities are lost in follow-up. Treatment adherence is often weak among soldiers, Andre reasoned. "Once a soldier feels better, he will be send back to work and stop taking medication."

A small behavioral study showed that more than half of the soldiers knew someone with TB yet did not know the disease was curable. Furthermore, some soldiers used condoms to light a fire or clean their shoes. "Their fear of getting a sanction for not having clean shoes seems bigger than that of getting HIV," Andre remarked. "Still there is a high risk of HIV transmission to the general public because of sexual violence."

Work before health
Stopping treatment to go back to work proves also common among readymade garment workers in Bangladesh. TB incidence among them is four times higher than in the general population. There is no intensive screening programme for the sector and multidrug-resistant TB (MDR-TB) poses a big concern.
Khurshid-Ekhoda Talukder
Photo credit: Babs V/ CNS

Efforts to improve screening and detection in the factories are challenged by yet another turmoil situation. "There is a lot of conflict over workers' rights with subsequently political unrest," says Khurshid-Ekhoda Talukder of the Centre for Woman and Child Health in Savar. "Accessing factories is often difficult. Nongovernmental organizations are seen to support workers' rights and therefore regarded with suspicion. Factory managers worry that worker unrest can be provoked if access is given to outsiders."

Time is money
Another major concern is time. "Asking a worker about TB symptoms takes 45 seconds, the management was mainly reluctant because it would hamper production," Talukder comments. "We originally planned to involve factory nurses, but none of the factories wanted to release them for training. Now our programme personnel go down the factory line to ask questions."

Stigma further complicates the situation. "Many workers fear losing their job once diagnosed. There is an awareness programme not to sack TB patients but we heard stories of workers being forced to take a holiday. They keep their salary, but without payment for working overtime it is too low to meet living needs."

With various forms of conflict and many challenges in TB care presented, the worldwide case studies underlined that strategies to engage communities should meet the country specific context. Continuation of care is a concern. The best take-home message might have been that in the many faces of conflict one should never forget the most important face in the crowd: that of the patient.

Babs Verblackt, Citizen News Service - CNS
6 November 2014
(The author is reporting for Citizen News Service (CNS) from the 45th Union World Conference on Lung Health in Barcelona, Spain, with support from the Global Alliance of TB Drug Development (TB Alliance). Email: babs@citizen-news.org)