Nepali Times
TB or not TB


Every year, on World Tuberculosis Day, attention of Nepal's biggest killer disease peaks. On 24 March seminars are held, ministers give speeches and the next morning's papers are full of reports.

But, as is usual with this sort of flash flood coverage, the interest soon dies down and the disease slips off the radar screens. Half of all Nepalis are infected with the TB bacillus and of these nearly 100,000 have active TB. There are 40,000 new cases every year and up to 7,000 people die annually from the disease. And 15 percent of all TB cases are in children, the infections spread rapidly because of malnutrition.

Still, a lot more Nepalis would be dying from TB every day if it had not been for the national tuberculosis program managed by the state-run National Tuberculosis Centre (NTC) with technical and financial assistance from a consortium of international health agencies. Indeed, Nepal's efforts with TB control is regarded as a model for other developing countries. Treatment success rates in Nepal have more than doubled from 40 percent in 1994 to over 88 percent now.

"Today, we are able to save the lives of 80,000 people, that's the number of people with active TB," says Christian Gunnberg of the UN's World Health Organisation (WHO), one of the government's main partners in the TB program.

The anti-TB drive in Nepal has been heading in the right direction especially with the Directly Observed Treatment Short (DOTS) course. Introduced in 1996, DOTS is now been implemented in all districts and 75 percent of the population has access to treatment.

"I lost my grandfather when he was 50 because he did not know where to go for treatment," says 18-year-old Sabita Nakarmi. Fifteen years after her grandfather died, Sabita was also infected with the same disease but eight-month of DOTS cured her completely. "I'm lucky to be alive, I only wish that such treatment had been available for my grandfather," says Nakarmi.

Even with the conflict situation, the DOTS strategy has faced minimum difficulty. It is available in more than 2,500 treatment centres and sub-centres throughout the kingdom. "TB is the disease of the poor, there should never be any obstacle in its treatment," says Nem Mitra Shrestha of German Nepal Tuberculosis Project (GENETUP), which runs one of the most effective DOTS centres in the country.

The treatment is available in rural areas but there are serious concerns about whether TB patients can reach these health centres for the antibiotics. For the first two months, patients have to take their medicines daily in front of trained heath workers. The medication will not be effective if they miss even a single day. Constant Maoist road blockades have interrupted the treatment for many TB patients.

"Access to DOTS like all health care is a fundamental right for all citizens, the provision of services and people's access to them should be protected, respected and promoted by all concerned in this conflict," says Susan Clapham of the British aid group, DfID. But Clapham adds that the conflict has not really impacted the TB program. DfID supports the national TB program by providing $7 million worth of anti-TB drugs through WHO annually.

Despite transportation challenges, NTP has sufficient drugs stored in all centres so patients have enough medicines and because communities have learnt to value the NTP's service, patients continue to show up for treatment despite hardships. Many health professionals involved in helping TB patients agree that even those families displaced due to the conflict continue DOTS as the treatment is available anywhere in the country and the drugs are free.

An improved program, DOTS-Plus, is being added this month to treat patients with multi drug resistant-TB, one of the leading causes of death among patients. Others who die of TB have multiple complications like AIDS, leukaemia, cancer, lung and heart diseases. "TB program works when it is well thought out and designed and treatment centres and diagnostic services are placed close to patients," says Keshab Bhakta Shrestha, director of NTP.

Experts have found that the best way to improve the efficacy of DOTS is by raising awareness and educating patients. Nepal's success in this has attracted a large number of aid agencies especially since the government categorised the TB program as a high development priority. Over 14 key agencies from Germany, UK, Japan, Netherlands, Norway and France have been actively participating in the national program.

Explains DfID's Clapham: "Nepal's TB program has adopted a commendable public health approach, it has decentralised care provision right down to sub-health posts. In addition to the fact that frontline health workers provide care, so do trained community volunteers."

This 'de-medicalisation' is said to be a key learning point not just for TB but for other diseases in other developing countries.

(11 JAN 2013 - 17 JAN 2013)