Thursday, September 19, 2013

The challenges of controlling TB in a mobile population



Reporting from a practicum in southern Africa.

Miriam E. Reda, MD, MPH 2013'
Tuberculosis (TB) disease is as old as history. Throughout time, the disease went from death sentence to, with the discovery of the causing organism by Robert Koch and extensive experiments, vaccinations theories and cures, that by the 20th century it was considered a curable disease en route to elimination. However, the age of optimism was short lived as the HIV epidemic emerged in the late 20th century and TB resurged in more extensive, aggressive and resistant forms. The concomitant burden of TB and HIV has since been top on the health agenda of international organization, medical conferences, donor societies, philanthropists, affected countries and the civil society.
  
Lesotho is one of the countries with very high burden of co-infection currently being supported by ICAP at Columbia University. A small country in southern Africa with the world’s third highest HIV prevalence at 23% and the fifth highest incidence of TB in the world,  Lesotho bears this double challenge.

In addition, with a very limited employment opportunities for men in Lesotho, the South African mining sector represents a prospect for many Basotho men to cross the borders and work on making a better living to support their families. However, this opportunity comes with substantial occupational hazards for acquiring TB.  Miners work in closed poorly ventilated mine shafts with prolonged exposure to silica dust and are exposed to the social consequences of living away from their families for extended period of time. The combination of all these different factors leads to a disproportionately high disease burden among miners with TB incidence in gold mines in South Africa being the highest in the world and in Lesotho 10 % of TB patient and 25% of MDR-TB patients are either current miners or ex-miners.

TB REACH care supporter performing TB screening for a miner and his wife at TEBA Maseru 
This troubling situation was addressed by the South African Development Committee (SADC) in its August 2012 Declaration aiming at the elimination of TB in the Region through improving practices of environmental, health and safety standards of the mining sector in the region.

Less than a year after this declaration, ICAP, in collaboration with the Lesotho Ministry of Health (MOH) and The Employment Bureau if Africa (TEBA), worked extensively on the design and implementation of the TB REACH project which targets 26,000 miners and their families through establishing TB clinics at TEBA sites to provide TB education, counseling, on-site prompt diagnosis and same day treatment initiation with close follow up and contact tracing. The project is innovative in its nature since it is able to catch the highly mobile population of miners through establishing points of care at TEBA where miners report regularly to get their deferred payments, offering services over the weekend and making use of the latest advancement in TB diagnosis with onsite GeneXpert machines.
 
TB REACH laboratory technician running sputum samples on the GeneXpert machine at TEBA Maseru

I had the opportunity to contribute to this project in Lesotho as my practicum for completing my Masters in Public Health graduation requirements. My experience in Lesotho and with TB REACH has been highly interesting and enriching.

Despite the fact that Lesotho is a small country with various challenges, it is full of very friendly people. I was overwhelmed by the kindness I was welcomed with to the country and by the approachable and pleasant way people interacted with. Moreover, Lesotho offers breathtaking sceneries; gorgeous mountains and some parts of Lesotho are a very concrete example of rural villages with rocky roads, basic lifestyle, poor access to transportation and scarce health clinics all of which make the provision of medical services extremely challenging. I had to chance to visit some of the most remote health clinics abundantly mentioned in public health textbooks.

As for setting up the TB REACH project, my experience was vastly educational and fulfilling on various levels. Initially, I was involved in drafting, revising and finalizing the nurses’ and health care workers’ training curricula. It was a challenging task taking the WHO guidelines and trying to contextualize them to suit Lesotho’s National guidelines and regulations however through discussions with several clinical advisors I was able to further understand the process and I learned greatly on the mechanisms of integrating both the medical and public health aspects of one disease.

Then, I was heavily involved in delivering the actual training which was a very exciting experience as I was able to interact with the nurses, understand their perspective about patients’ management, explore their creativity in resource limited settings and touch the difference in their knowledge by the end of the training. After this training I realized that capacity building is a fascinating area in public health that I plan on developing further as it is a process of mutual exchange of information, knowledge and skills.

TB REACH launching with Dr. Wafaa El-Sadr and ICAP staff is Lesotho, TEBA Country Representative Mr. Kikini Kikini and WHO Country Representative Prof. Mufunda

Moreover, I was involved helping establish Monitoring and Evaluation tools and indicators, procurement of medical supplies for clinics, supervision and mentorship of clinic’s staff and creation of educational material that would convey comprehensive yet simple, understandable messages to miners. Despite learning extensively about all these aspects of a project throughout my courses at school, the actual realities of adequately implementing the theory on the ground with heavy stakeholder involvement are worth hundreds of hours of classroom experience. A few hours spent with the people and the communities addressed can prove to be the best way to learn how to design and implement a successful intervention.

The TB Reach project was launched by the Lesotho Minister of Health and Dr. Wafaa El-Sadr in late July and is currently running in three districts in Lesotho. Moreover this project represents the first step towards a more holistic approach of the TB/HIV co-infection among miners and in Lesotho in general as ICAP will continue working on expanding services to integrate the inseparable TB and HIV services in accordance with its overall goals and mission.


Top picture: Dr. Wafaa El-Sadr with the Lesotho Minister of Health Dr. Pinkie Manamolela



Bottom right: Ribbon cutting during TB REACH launching by Dr. Wafaa El-Sadr, Dr. Pinkie Manamolela (Minister of Health) and Mr. Kikini Kikini



Bottom left: ICAP Lesotho Country Director Ms. Blanche Pitt (right), ICAP global director Dr. Wafaa El-Sadr (middle) and ICAP Lesotho Technical Director Dr. Koen Frederix (left)

Mariam E. Reda, MD
MPH Candidate, Mailman School of Public Health