Focus on tuberculosis

Like every other Monday and Friday morning, by 07:00 local time at least 100 people were sitting quietly on the hard benches in the tuberculosis (TB) clinic at Temeke District Hospital in the commercial capital, Dar es Salaam. The clinic was not due to open for at least an hour, but the patients were already lined up and ready to take their medicine before getting on with their day. For some - in the early stages of the TB treatment known as Directly Observed Treatment of Tuberculosis (DOTS) recommended by the World Health Organisation (WHO) - queuing for registration and pills is a daily ritual. Others, who had begun treatment months earlier, were just paying their monthly visit to the clinic and would continue to treat themselves at home. Since its inception 25 years ago, DOTS is well established and highly effective in Tanzania, and there are clinics like the one at Temeke across the country. However, despite the well-practised routine of the system, health workers and government officials warn of a massive resurgence of TB and the emergence of stigma attached to the disease, largely because of its perceived automatic link to HIV/AIDS. "I know that many of my fellow Tanzanians are now afraid just to know that they have TB, because they automatically assume that they are HIV/AIDS," Dr Anna Abdallah, Tanzania's minister of health, said. She was speaking just after launching preparations for this year's World TB Day, on Monday, which has as its theme "DOTS cured me, it can cure you!" "TB is curable, and we have proved this here in Tanzania. I want the press to tell people that, while there is a link between HIV/AIDS and TB, people should not be afraid to come forward. It is not true that every TB patient is HIV positive," she said. However, statistics point to a massive increase in the number of cases of TB, mainly due to HIV/AIDS. According to Tanzania's National Tuberculosis and Leprosy Programme, although most TB patients are HIV negative, "sixty percent of the increase in the incidence of TB in Tanzania can be attributed to HIV". The programme's fact sheets also state that TB is the most common opportunistic infection in HIV/AIDS patients, and someone who is HIV positive and infected with TB is "30 times" more likely to become sick than someone who is HIV negative. Since the HIV/AIDS-linked resurgence of TB in the early 1990s, the incidence of TB cases has steadily risen. The health ministry estimates that there were over 60,000 new cases of TB in 2001, and it expects the figure to double in 2003. Moreover, health officials are still concerned over the number of undetected cases of TB in the country. "There is a lot of stigma because of the link to HIV/AIDS, and are many cases slipping through the net," Dr Mohamed Amri, a disease prevention and control officer for the WHO in Tanzania, said. "It is difficult to say exactly how many, but we estimate we might actually only be seeing 60 percent of TB cases." To make matters worse, Amri said, DOTS was only effective if patients completed the course thoroughly with two months of daily visits to TB clinics, followed by six months of self-treatment at home. "This is potentially very hazardous, as stigma is lowering attendance rates for treatment in the clinics. Relapsed cases tend to become resistant in the long run. Resistant TB is a very serious problem and costs 100 times the amount to treat," he said. Rajabu Hamisi, 35, a patient attending the Temeke TB clinic, illustrates Amri's views. "People in the community do gossip when they see us going off to the clinics. They say we are infected with HIV/AIDS," he says. "I don't pay much attention to them, but there are others, lots, that can't handle it." Another patient, Binasa Bakari, said she did not experience the stigma as much, but lamented the lack of real education in her community on TB and HIV/AIDS. "I have understanding friends and family around me, but this is only information we have picked up and passed amongst ourselves. I would like people to be more educated about these diseases," she said. Health workers at the Temeke clinic say they are doing their best to disseminate information, but it takes time and there is an acute lack of funds for these types of activities. "If the community was aware of the differences between the two diseases, they could help by bringing in the patients that are hiding [out] there," Dr Angelina Malewo, the TB coordinator at Temeke District Hospital, noted. "We are training some of the traditional healers and the heads of the villages. but it is at a low level." She said there was not enough money in the budget to hire people who could carry out community-based health-care education so the hospital often came to rely on people volunteering their time and knowledge. But Anna Abdallah said that "the most sustainable advocacy can be done by the people and their organisations, not the government. I call upon people to form organisations that can be the mouthpieces for the fight against TB. Sufferers and non-sufferers alike should form groups that tell people about this treatment and how effective it is."