Combating TB, poverty and HIV at the Blue House

Blue House, a clinic run by Médecins Sans Frontières (MSF) in Mathare, one of the most populous slums in the Kenyan capital, Nairobi, means salvation to thousands of people infected with tuberculosis and HIV. In the yard of the large, windowless building, where high walls and a thick iron gate keep the surrounding bars, shops and homes at bay, several dozen patients, many of them mothers with babies, sit on benches in the open air, but conversations are scarce. "We opened Blue House [in 2001] because at our existing dispensary in Mathare we were detecting lots of TB and HIV cases, and it was difficult to refer patients to the [state-run] Kenyatta National Hospital because proper care for TB and HIV did not exist there at the time," said Christine Genevier, MSF head of mission in Kenya. Mathare is home to an estimated 250,000 Kenyans and refugees who have fled strife in neighbouring countries. Families are crammed into single rooms in tightly packed shacks and market stalls line the congested dirt alleys, creating an ideal environment for spreading highly contagious TB. The Ministry of Health has noted a sharp rise in cases and estimates that TB linked to poverty, malnutrition and HIV, which weakens resistance to infection, claims the lives of 200 Kenyans daily. "Most people in Mathare, before they can think about treatment or anything else, must think about finding something to eat every day - we have so many destitute people there," Genevier said. Because TB so often occurs with HIV, Blue House is dedicated to the treatment of both diseases. Genevier thought around 70 percent of TB patients in Mathare were also HIV positive, part of an AIDS pandemic that caused the death of 70,000 people in 2005. "Once diagnosed, the patient is administered generic drugs, approved by the [UN] World Health Organization, made in India and bought by us," she said. The medication must be taken at regular, designated intervals for a period of up to eight months. Consistency is crucial; not only does interrupting the treatment - even briefly - cancel its effectiveness, it can cause the disease to become resistant to the drugs. "Mathare has the problem of social instability, where patients are mobile - their stay in the area depends on their income, and they often move up-country from the slums, where we cannot reach them," said Genevier. "We have a large structure of social workers and community assistants in Mathare tracking the patients for follow-up." Each patient is allocated a box containing their medication, which stays in Blue House, where they have to come to take it. Keeping the medicine in the clinic ensures that it is not sold to provide for other needs, and that patients make regular trips to the clinic, allowing medical workers to monitor their status. Blue House treated 3,500 TB patients in 2005. The stigma associated with both TB and HIV prevents many people from seeking treatment for fear of being seen visiting the centre. "Most patients come to us as discreetly as possible - some even get here before dawn, when it's still dark, so that neighbours don't recognise them," said a nurse at Blue House, who preferred anonymity. MSF has started education programmes encouraging people to come for treatment and adhere to their medication. In Mathare the organisation has moved away from the traditional Directly Observed Treatment System (DOTS) for treating TB, where patients report to the clinic daily for their pills, to a 'light DOTS', in which the patients fetch their TB medication weekly or monthly and get their antiretroviral drugs for combating AIDS at the same time. According to Genevier, "In order to ensure compliance with the drugs, we try to have a very strong education system, and ensure tight and heavy follow-up of the patients."