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Doctors' Participation in TB Battle Crucial for DOTS Intervention in Bangladesh

By Pamela Philipose, Womens Feature Service

The shadow of tuberculosis (TB) has long lingered over Bangladesh. Today, it ranks sixth among the 22 high TB burden countries of the world. According to WHO's Global TB Report 2010, in 2009 Bangladesh had 360 cases of TB in all forms per 100,000 population, with 225 cases per 100,000 surfacing each year.

"Bangladesh certainly cannot afford to neglect TB control," remarks Dr. Mosaddeque Ahmed, Line Director, National TB Control & Leprosy (NTP) Elimination Programme, "Our challenge is to reach out to the affected community, so that no one afflicted by TB is left behind. In fact, our big achievement is in ensuring almost universal access to TB diagnostic and treatment services."

In 1993, the NTP adopted the Directly Observed Treatment Short course (DOTS) as one of its strategies to combat the disease. By 1998, DOTS was available in every upazila (sub-district). In 2002, to strengthen the programme the Global Fund To Fight AIDS, Tuberculosis and Malaria (GFATM) began its financial support and is the largest contributor to the NTP today.

But ensuring better management of DOTS and involving medical institutions and professionals in the process, was a concern. Observes Dr. Erwin Cooreman, Medical Officer, Tuberculosis and Leprosy, WHO, Bangladesh, "DOTS had dramatically changed the approach to treatment and could potentially bring down TB levels drastically. But since the traditional medical approach to TB was very different, there was a need for the greater involvement of hospitals and colleges. They needed to take ownership of DOTS. There is scope to increase this sense of ownership."

A step in this direction was made when 13 public and 26 private medical college hospitals in the country, after engaging with participating NGOs, agreed to set up DOTS Corners within their premises. They were to be run by NGOs and serve as delivery points for free treatment. They were to coordinate with the patients and also facilitate their transfer to other facilities after discharge.

Since the idea is to involve the entire medical fraternity more closely in the DOTS intervention, there are organisations like the Society for Empowerment, Education and Development (SEED) which are working to involve private practitioners in the programme. As Dr. Shamim Sultana, NTP Deputy Programme Manager, puts it, "We welcome such initiatives. We want these doctors to refer patients to DOTS Centres, supervise their treatment and provide documentation. In return, we include them in our workshops so that they remain current on TB management."

In Dhaka alone some, 700 general practitioners have received training in DOTS and are part of the programme, according to Dr. Md. Ashaque Husain, Programme Manager, NTP. There is a plan now to train 19,000 village level para-medics in DOTS because they can deliver continuous treatment being based locally.

While the process of involving more doctors and hospitals is carrying on apace, impacting medical education has proved more difficult. Says Dr. Cooreman, "Bringing medical schools into the Stop TB initiative is definitely on our agenda. What is generally taught is as per the older curriculum, so we need to include professors and students in the process." Today, most elements of the Stop TB strategy have become a part of the general medical college curriculum, but some professors prefer to recommend the traditional approach to treatment.

"But we are on the right track," adds Dr. Cooreman, "Considerable progress has been made compared to a decade ago. The programme has had to adapt to the medical education system, and the professors have had to be more accommodative to new approaches." Incidentally, WHO Bangladesh has a work plan to evolve a general curriculum for medical education.

In 2008, the government, with Global Fund support, began a pilot DOTS Plus project at the National Institute of Diseases of the Chest and Hospital (NIDCH), Dhaka, to detect and treat MDR-TB patients. The coordinator of the country's DOTS Plus project is Dr. Md. Wahiduzzaman Akhanda. Since the project began, doctors at NIDCH have been able to identify 465 MDR-TB patients, among whom 112 have been admitted in the hospital. They being currently treated, while 51 cases have been declared as cured. There is a default rate of about 14 per cent.

Students have been brought into this process. Says Dr. Akhanda, "Study tours for students from different undergraduate and post-graduate institutions are held here and we also conduct post-graduate diploma and doctoral courses in tuberculosis and chest diseases. The attempt is to build up a good future cadre of medical personnel familiar with the latest treatment."

Change is in the air and it bodes well for Bangladesh in its battle against TB and MDR-TB. In NIDCH's large wards are patients with their lives on hold, wearing masks over their mouth. Many have not met their families in months. Some have been deserted by their spouses, or seen hard-earned earnings dwindle to nothing.

But where there's life, there's hope. The patients here dreams of going home.

Womens Feature Service covers developmental, political, social and economic issues in India and around the globe. To get these articles for your publication, contact WFS at the www.wfsnews.org website.