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Cure or perish

April 13, 2018

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A SHORT skit and a poster exhibition by children of the Behbud School on World TB Day came as a stark reminder that the scourge of tuberculosis continues to menace our society.

I wondered how many of those young artists and performers had had a personal encounter with the disease. This was likely because the incidence of TB in Pakistan continues to be pretty high, with 518,000 new cases being diagnosed every year, making it the fifth largest TB-infected country in the world. There is no way of knowing how many cases are not even detected.

We are reminded of this routinely every year. One suspects that not enough is being done to eliminate the disease which is no longer incurable. The Minister for National Health Services spoke of a ‘huge shortfall’ of funds even though 28 per cent of the TB budget was being provided by the Geneva-based Global Fund to Fight Tuberculosis.

There is no way of knowing how many cases of TB go undetected.

The minister is to be believed, given the government’s criminal neglect of the health sector. It is time to point out that the privileged can buy the most expensive healthcare but their wealth cannot protect them from TB. They are also vulnerable as they are also infected by this stigmatised disease. After all, viruses and bacteria know no barriers!

It is heartening to meet doctors who are dedicating their lives to what was dubbed as the poor man’s disease. The Behbud Association runs two clinics a week for tuberculosis patients under the care of Dr Farhat Ajmal, who has been working there on a voluntary basis since 1998 after she retired from government service. These clinics have the conventional outpatient department approach with patients who come in for diagnosis and treatment.

Even this can be tricky. Many patients do not complete the full course of their treatment once they feel better. That is dangerous as a relapse results in multidrug resistant MDR TB. In Pakistan, some 27,000 new cases of MDR TB are recorded annually.

In 2014, the World Health Organisation (WHO) declared the TB day theme as ‘reach the three million’ (those ‘missed’ by the health system and who received no treatment). This got the Behbud doctor thinking. She knew that many of those ‘missed’ were women and children who are not mobile enough to reach a health facility when they fall ill. That is how the idea of a mobile clinic — in a van — occurred to her.

It took Behbud a lot of fund-raising skills to get someone to donate a van and finance the project for two years. Surveys had to be conducted to decide the locality where this experiment was to be carried out.

But the most important exercise had yet to follow. It involved engaging with community elders, mosque peshimams and the union councillors to win their confidence and cooperation. Awareness-raising was undertaken in a big way.

Sultanabad (population 100,000) which is mainly inhabited by Pakhtun migrants was selected. After the preliminary mobilisation had been done the van stationed itself at a central spot and people started to come in. Of the 1,000 households visited, 2,900 individuals (66pc female) responded and were screened in the first year. Thirty-five (75pc female) were diagnosed as positive.

With a staff of three — a doctor and two social mobilisers (the male couples as the driver) the van has proved to be a highly effective strategy. Initially, security was a major concern but the union council has taken care of that by providing police protection.

Then came the main challenge ie to ensure that no one discontinued the treatment that was started. That entails keeping an attendance record and if even a single patient is absent on the scheduled day, the social worker actually traces her/him and administers the drugs. So far 25 patients have completed their course and have been declared TB-free. Nine are on track while one defaulted. This means some 680 lives were saved from the jaws of death — as one patient infects an estimated 20 people. This shows 97pc compliance, a remarkable achievement. This is DOTS (Directly Observed Treatment Short-course) that WHO devised when it was noticed that patients were not completing the six-month course and creating a more serious problem ie MDR TB.

Behbud’s tuberculosis programme is working as a public-private partnership and the mobile clinic has proved that this can be a cost-effective strategy if funds are made available. The van was designed to be a two-year pilot project that is nearing completion. Now more funds are needed — at least Rs2.5 million per annum — for its running expenses. The van is underutilised. Behbud feels it need more money if it is to expand its operations to the optimum capacity.

It certainly needs to be expanded. The Behbud team has proved that this strategy can work in Pakistan.

www.zubeidamustafa.com

Published in Dawn, April 13th, 2018

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