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Hidden heroes in
straining health systems
HDN Key Correspondent
[Note: Following the Stop TB Partners Forum, HDN Key Correspondents
visited a DOTS clinic in centre of New Delhi. Below is the story of that
visit]
Stopping tuberculosis is a daunting task and it takes more than just the
DOTS strategy to succeed. It also takes the hidden heroes - the men and
women who work in TB centers every day, oftentimes underpaid, overworked
and unrecognized.
The moment we entered the New Delhi-based DOTS clinic, it was immediately
clear that the centre is run by a well-trained staff that care deeply
about the men, women and children that are treated for TB there. The
clinic is spotless and despite limited resources, is well organized and
well cared for. It is also very busy. A display board shows the number of
clients visiting the centre each month, and the catchment area served by
the centre, 2 million residents in the densely populated city of Delhi.
Behind the well-trained staff and the well-kept clinic, is the doctor in
charge, who has been working in TB control for over 30 years. Initially,
he was reluctant to speak with our group of five having just identified
ourselves as participants of the Stop TB Partners Forum. He was unaware
there was a Stop TB Forum happening. In fact, he was unaware that there
was a Stop TB campaign at all. But he was aware that 30% of all TB cases
are found in India and he was aware of the programmatic deficits and
resource shortages that are preventing the clinic from operating at an
optimum level. His frustration was palpable. He lamented that he has been
working in TB control in the capital city of Delhi for three decades yet
no one bothered to inform him or the hundreds of health workers who are
working with DOTS in TB clinics.
As his anger subsided, he relaxed a bit and began to talk- not as a
doctor, not as a manager, but as a hidden hero working in the fight
against TB. He told us about the thirty-five DOTS clinics he manages and
proudly showed us the notice board displaying statistical details of the
clinics’ performance during the past few years. The cure rate of 82% in
2003 achieved by his facility is impressive and should be recognized. He
also explained why he is frustrated and at times feels helpless. The gap
between those working on the ground and those making policy decisions is
ever widening and the power imbalance is sharpening. These people who are
fighting against TB are the best people to talk about the challenges they
face on daily basis and how to improve the DOTS programme to function at
an optimum level.
These are just a few of the problems he described. “My area of operations
should have at least seven Medical Officers but I have been provided with
just one. Even the number of senior treatment supervisors and senior
laboratory supervisors is far from adequate. How do I do the monitoring
and supervision without these people?” He also stated that while the
doctors are well paid, his staff is not. Living on just 6,000 rupees a
months (roughly 4USD a day), the health workers are barely getting by. And
despite the reality that working in a TB clinic is an occupational hazard,
the government tacks on a measly 100 rupees a month (2 USD) to compensate.
Most difficult he says, is the geographic area, plus the population of 2
million his TB clinics cover with meager resources, one vehicle and an
inadequate staff.
“I have been involved with tuberculosis for the last three decades, first
with the National TB Program and now with the revised national
tuberculosis control programme [the DOTS strategy for India]. We have
built up this program brick by brick, person by person. We have put the
systems in place, reached out to people in slums to the high society
societies. But no one even sends out an announcement about an
international TB meeting to inform the people who are the closest in the
fight against TB.”
Touring the facility, we found that systems are very much in place. The
laboratory is simple, only a handful of equipment but lab technicians are
well versed in their work. They keep up-to-date and detailed records of
their work with simple hand-drawn bar graphs drawn to scale (one inch
equals 100 patients) depicting the monthly incidence of new TB cases and
smear positive patients being treated in their centre.
The nursing staff at the TB ward was caring, compassionate and appeared to
take excellent care of the patients and their needs. Some patients in the
ward had been there for months, for many reasons. Some were very sick and
needed to have around the clock care and nutritious meals. Some lived far
away, in areas that DOTS does not reach and were unable to make the
daily/weekly trips, and therefore had to remain on site to be treated.
Some were homeless, migrant workers who had nowhere else to turn. But all
were well cared for - not just because of the effective drug treatment but
also because of the emotional support given by fellow patients and staff.
During the Stop TB Partners Forum the lack of community to advocate for
better treatment and medications at the global level was a recurring theme
- but here in Delhi, just a few kilometers from the Sheraton Maurya,
TB-infected patients were supporting each other in the daily struggle.
There is no doubt the critical role the Stop TB Global Partnership has in
the fight against TB. Since the creation of the Partnership, governments,
donor agencies, NGOs and others have organized to streamline a more
concerted, strategic effort towards achieving the objectives of the Global
Plan to Stop Tuberculosis. To truly keep the pledge the unavoidable
conclusion from this site visit is that the “hidden heroes” who have
dedicated their lives to improving those of people infected/affected by
TB, be brought on board and given a more meaningful role in the
partnership.
Source:
http://eforums.healthdev.org/read/messages?id=409
In Haryana,
shoemaker leads war against TB
By Toufiq Rashid, Express News Service, dated 29th March
2004
It’s an unlikely battleground in India’s fight against TB; a disease that
former Prime Minister Atal Bihari Vajpayee believes poses a serious threat
to the country’s progress and well being. Bansi Lal is an unlikely
warrior.
But try telling him that. A shoemaker who lost his father to the disease
and saw his brother struggle against it has turned a small room in his
run-down double-storey house in Karnal’s (a city in north Indian state of
Haryana) Sadar Bazaar area into a TB clinic for nearly 110 patients. After
having joined as a community volunteer in the tuberculosis control
programme of the Government a year ago, he has put 50 patients on the path
to recovery.
Lal decided to join the war against TB, for which he takes no
remuneration, after his younger brother contracted and survived the
disease. ‘‘My father died of it and my brother also got it. When it
happens in the family, you realize how fatal it is,’’ he says.
Everyday TB patients from nearby houses line up outside Lal’s house to
take their daily dose of medicine. If the queue gets too long, his teenage
daughter Madhu and his younger brother Mohan Lal pitch in.
Lal is one of the hundreds of volunteers registered as DOTS provider under
RNTCP in India. The programme advocates taking help from the community to
implement DOTS, wherein a patient is administered medicines under the
supervision of a trained person—a doctor or a paramedic.
Explaining the importance of volunteers like Lal, TB in-charge of the
district Dr N. Saini says: ‘‘To have each and every TB patient monitored
by a doctor is not possible in India as the patient load is very high and
the number of doctors very less. So these community volunteers are a great
help.’’
Read the full story at:
http://www.indianexpress.com/full_story.php?content_id=43966
A local initiative in
rural Andhra shows the way to community participation in TB control
Contributed by Jyothirmayee Kidambi, E-mail JKPerfect@yahoo.com
The South Indian state of Andhra Pradesh (AP) continues to grapple with a
rising number of tuberculosis patients. The rural belt of the state has a
less than optimal primary health care system. Thus the achievement of
targets set up by Revised National Tuberculosis Control Program (RNTCP)
under the DOTS strategy is proving to be a formidable task for AP. However
an innovative community participation project being implemented by a
community based organization in thirty villages of Bommalaramaram
sub-division of Nalgonda District of the state is making an effort to
provide a working solution to achieve effective tuberculosis control in
such a disadvantaged situation.
Every year more than five thousand new sputum positive tuberculosis (TB)
patients are detected in the state. The number of TB patients has risen to
1, 08,180 at the end of March 2003 from 69,622 in March 1997. Various
constraints faced by RNTCP in AP include low motivation levels and
inadequate training of health workers, little community participation made
worse by illiteracy, ignorance and superstitions, technocracy marred by
top down decision making and lack of monitoring and evaluation of
programme delivery.
The DOTS services were launched in the Nalgonda District in November 2003.
Fully aware of the impediments being faced by RNTCP in other areas of AP,
Rural Organization for Social Education (ROSE) aided by a Spanish
Foundation, ANESVAD decided to launch a project to provide services
through Community owned and managed trained health workers, working hand
in hand with the existing Government infrastructure and Staff stationed by
RNTCP.
As a part of the project ROSE has trained 90 Community Health Workers (CHWs)
- 3 villagers from each of the 30 villages in the entire sub-division. The
training programme covered various aspects of TB - physical, economical,
social and psychological; Health communication, DOTS and Disease
Surveillance.
These CHWs have been provided skills to identify suspected TB cases. They
motivate such patients to access the services provided by RNTCP for
detection and treatment of TB. These workers also take care that the
patients adhere to the treatment regimens and other DOTS protocols. In
fact these workers act as a 'mediator' between patients and DOTS
providers. They also conduct regular awareness programmes to educate the
villagers about TB and DOTS services.
The involvement of Community Health Workers, who have taken upon
themselves the responsibility of their own villages, has helped TB
patients in the villages to begin treatment without delay, and adhere to
the regimen as well. Within six months of implementation of the project,
ROSE with its trained staff has identified seventy-nine cases of Sputum
Smear Positive TB cases in just eight villages of the project.
Thirty-seven of these patients have been cured and remaining forty-two are
under treatment.
Thus ROSE with its trained CHWs has become a reliable entry as well as
enquiry point for the villagers to avail of DOTS services. The CHWs have
become a visible local link between RNTCP and their community.
Corner Groceries and Tea
Stalls Double as TB Clinics in India
Rama Lakshmi, Special to The Washington Post, September 12, 2004
For a long time, customers have come to shop at Prem Neelkanth's corner
grocery store in a sprawling Bombay [Mumbai] slum, buying eggs, bread, tea
and sugar. But in the last two years, sickly men and women, some coughing
painfully, have also lined up to obtain their tuberculosis medicine.
Neelkanth, 36, is a volunteer in the government's effort to supervise
tuberculosis patients as they take their medication. He is one of an army
of health workers and neighborhood participants in a federal program known
as DOTS, Directly Observed Treatment -- Short Course, funded by a $142
million World Bank loan.
He hands tuberculosis medicine to a patient at his grocery store in New
Bombay. Neelkanth keeps a neat row of medicine boxes marked with patient
names and visits the homes of those who fail to show up. His grocery
stands near a row of overcrowded shacks, with narrow alleys of open sewers
and piles of putrid garbage -- a veritable breeding ground for the
infectious, airborne disease.
The TB patients he sees are daily laborers who live nearby and do not have
time to make three trips a week to the hospital for six months to receive
their required dosages. So on their way to work, they just make a quick
stop at the grocer's.
"My grocery shop is now like a TB clinic," said Neelkanth, pointing to a
neat row of medicine boxes marked with patient names, given to him by the
city's health officers.
"I know everyone in this neighborhood. So if someone does not turn up for
their dosage, I go and knock on their door in the night with the
medicines. It is my duty to ensure they don't miss a single dose," he
said, watching a 50-year-old cart-puller gulp six pills.
Read the full story at:
http://www.washingtonpost.com/wp-dyn/articles/A14636-2004Sep11.html
Pimpri Chinchwad
Municipal Corporation Shows the Way in TB Control
Contributed by Dr. Vikas Inamdar, Pune
Pimpri is an Industrial town near Pune in Maharashtra with a population of
over one million. A 'City Tuberculosis Control Society' (CTCS) was set up
in 1998 to implement the Revised National TB Control Programme (RNTCP).
The first task that faced CTCS was to provide training to doctors and
Para-medical workers. Till date, 35 doctors; 16 Laboratory Technicians; 25
Multi-purpose Health Workers & 16 other health workers have been trained
as per RNTCP guidelines. The CTCS set up nine Microscopy Centers and 21
Corporation run Dispensaries and Hospitals as treatment observation
points. A unique feature of the programme is that DOTS centers have also
been set up in clinics of 30 Private Practitioners. In a period of three
years from 1999 to 2001 the program has registered and treated 3769
patients and achieved a cure rate of 90%.
The Ramakrishna Mission
TB Sanatorium: Tackling TB in remote areas
The Ramakrishna Mission in India has been at the forefront of
philanthropic and charitable activities especially in remote, inaccessible
areas of the less developed parts of the country. The medical services
provided by the mission are illustrative of providing the best with the
minimal of resources and at the doorsteps of people who actually need
them. The Ramakrishna Mission TB Sanatorium has been in existence since
1948 and is providing medical care of patients with Tuberculosis.
The tribal areas of Jharkhand, earlier part of Bihar, are some of the most
backward, undeveloped areas, not only of the state but also of the
country. Many of the villages are inside forest areas with footpaths and
beaten tracks connecting them. There are no bridges over the rivers, and
in the rainy season when the rivers are swollen, one has to wait for the
water to recede to a reasonable level before crossing. The houses are
mud-walled huts with a single door and no windows, and thus have no
provision for ventilation. Often animals – cattle and sheep – are also
kept inside the house at night. Potable water is a severe problem. People
use open wells for drinking water and ponds for other purposes and have to
go to open fields for their excretion. This kind of environment causes
many common ailments – malaria, diarrhoea, dysentery, anaemia,
tuberculosis, epilepsy, leprosy etc.
Considering these prevailing circumstances and conditions, it was felt we
could do something to alleviate the suffering of these people by providing
medical relief and health care, and by having a mobile medical Unit, which
could visit the villages. Our objectives are to provide relief for common
ailments and to identify and treat diseases like Tuberculosis. This would
help prevent further spread of the disease, as one TB patient can infect
15 to 20 persons. We would also spread awareness of nutrition,
cleanliness, personal hygiene, community hygiene, safe use of water,
protection against water-borne diseases, malaria etc.
With these objectives in view, a Mobile Medical Unit was started in
September 1993 with two centres – one at Gutigara and another at Bandua,
45 kms and 23 kms respectively from our Sanatorium.
The Mobile Medical Unit functions like an OPD (Out-patients Department).
The doctors of the Unit examine the patients, prescribe medicines, and
explain the dos and don’ts. The dispensing section supplies the medicines,
explaining when and how to take it.
In cases where patients complain of cough for more than 3 weeks after a
chest examination and TB is suspected, they are asked to submit 3 samples
of sputum in containers supplied by the Unit. After laboratory tests,
patients who test positive for TB bacilli are further examined – chest
X-rays are taken, blood and urine are checked, etc. Then they are put on
ATT (Anti-Tuberculosis Treatment). Initially, weekly medicines are given,
and when the drugs are well tolerated, fortnightly drugs are supplied.
Wherever necessary, the patients are admitted in our Sanatorium and
treated free of cost. In the case of patients who test sputum negative,
they are put on antibiotics, and if they fail to improve, then X-rays are
taken and they are treated accordingly.
One important factor, in the treatment of all ailments, but particularly
in TB cases – apart from free supply of drugs etc. – is the human factor.
A kind and sympathetic attitude is found to be very essential. A person
suffering from TB, or any other acute disorder, is invariably depressed
and very much low in morale. A few gentle, kind and affectionate words go
a long way in boosting the patient’s spirits and help the patient take a
genuine interest in his own cure. This motivates the patients to follow
the advice, take the medicines properly and collect the medicines
regularly. When the patient does this, the medicines become effective, the
patient improves and his confidence and faith in the treatment increase
and complete the course successfully. Not only this, he or she motivates
others also.
Source:
http://www.rkmtbs.org/main.htm
Useful links
Stop TB:
http://www.stoptb.org/worldtbday05announcement.asp
CDC:
http://www.cdc.gov/nchstp/tb/WorldTBDay/2005/resources.htm
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