One of the more singular events of the past week was a trip with the Sivananda Rehabitalition Centre doctors on their twice weekly tour of the associated TB treatment centers that they supervise. Tuberculosis was the major focus of my prior clinical research during a Fogarty fellowship in South Africa, and as such it’s both a disease that I know a bit about and have a strong interest in.
By way of background, TB therapy presently hinges upon the Directly Observed Therapy, Short-course (DOTS) approach that the World Health Organization (WHO) rolled out in the mid-90’s. This program in the US context is largely known for the “directly observed therapy” aspect of its care – less appreciated are the multiple policy aspects that also play key roles as parts of the DOTS strategy, aspects that have been vital for the marked improvements in TB control by National Tuberculosis Programs (NTPs) worldwide:
(the World Tuberculosis Report from the WHO is an excellent review of the present state of TB control worldwide – the tables and data referenced throughout this post are taken from the most recent (2012) report)
The initial goals of NTPs were to have a case detection rate of 70% (ie, finding 70% of the projected patients with smear-positive tuberculosis nationally) and a cure rate of 85% (result of “cure” for 85% of the pulmonary TB patients found – alternative results include defaulted (stopped therapy), moved districts (from the one where originally registered), treatment failure (continues to be smear positive despite taking therapy), and dead (relatively self-explanatory)). On our tour of the SRH locations, we were told that their cachement area (which sounded to be about 500,000 people, with 5 microscopy centres) was close to both of these goals, with a case detection of 75% and a cure rate of 83% (as I recall – any errors are mine!).
They also expounded on their approach to TB diagnosis and therapy – patients with symptoms consistent with TB are sent for screening from outpatient clinics (private and public – they told us this was about 3% of outpatient visits), and of those, about 10-15% will screen positive for TB. All TB screening cases are referred for HIV testing, though this occurs at a separate facility. All cases positive for TB are strongly encouraged to report for HIV testing once more (there is a slot for it on the reporting forms), and all TB patients have to give two phone numbers and have a home visit to confirm where they live. Therapy is given 3 times a week, either at a DOTS center or via a community DOTS provider – below is the picture of the clinic for a private “doctor” (not actually a degree holding physician, as in common in the Indian private sector – see this paper by Das, as well as this super depressing piece about the TB regimens prescribed by non-NTP providers) who was overseeing ~6 cases for SRH. As one can readily appreciate, the frequency and length (6 months to 24 months, depending on resistance) of TB therapy drive the NGO to find a treatment supervisor for patients that is close to their home and readily accessible.
As in South Africa, the Indian NTP has provided a series of forms and ledgers that allow for easy importation of patient information from the individual sheets, to a DOTS centre register, to the district register, and thence to the NTP itself (perhaps via the state TB program first).
I found this experience engaging on a range of levels, but one I’d focus on is the realization of policy. Global health encompasses a huge range of programs that are debated and shaped on international and national fronts, funded by any of sundry different actors, but ultimately boil down to this – a patient, a treatment supervisor, a white box of medications, and months of working together to treat a disease. The mosaic of TB results – decreased mortality of 41% globally since 1990, incidence falling at 2.2% globally of late – is made from these individual tiles, conglomerated sheet by sheet, register by register.
And it will these by these same single cases which will determine where we find TB in 2050, the WHO’s goal time for the elimination of TB as a public health problem:
A lot of our discussions during this trip have turned upon making explicit connections between diseases and the social constructs that impact them – most clearly healthcare, but also economics, public health policy, politics, culture, and the environment. Increasingly, I’m realizing that my own global health education was in many ways spent learning about the intertwined character of health and society, and then about how to try and impact change via multifaceted approaches. I look forward to continued analysis of our trip via that lens!