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The tuberculosis pandemic: implications for health in the tropics
TRANSACTIONSOFTHEROYALSOCIETYOFTROPICALMEDICINEANDHYGIENE(1999)93,678-679
r-~
Correspondence
The tuberculosis pandemic: implications for health in the tropics I enjoyed reading the excellent and succinct article about tuberculosis (TB) and its control in the developing world bv ZUMLA et al. (1999: Transactions. 93, 113). However, I would like to take issue with the authors over a number of points. First, theystate that HIV-infection is associated with a higher nrouortion of extrauulmonarv disease (EPTB) su;h asmihary TB, lymphadenopathy, bone and skin disease. Clinical studies in a variety of African countries have shown that bone and joint TB is not a common findina in HIV-nositive uatients WADHAWAN & HIRA, 1989:-Medical journal of Zambia, 24, 16; Kelly et al.; et al., 1992: 1990: Transactions, 84, 725; MIGLIORI Tubercle and Lung Disease, 73, 285; NUNN et al., 1992: Tubercle and Lung Disease. 73. 45). Our own clinical studies in Malaw: have con&ned‘these findings, and have shown that bone and joint TB is more common in HIV-negative patients than in those who are HIV-positive (HARRIES et al.. 1997: Annals of Troaical Medicine and Parasitology, 91,‘771). Similarly;skinAdisease is not highly prevalent (HARRIES et al., 1997: International Journal of Tuberculosis and Lung Disease, 1, 346), and in fact one would not expect lupus vulgaris or papular necrotic tuberculides to be associated with profound immunosuppression. The authors also make no mention of the most common type of EPTB found in HIVpositive patients in sub-Saharan Africa, namely pleural effusion. Second, they state that some developing countries, for economic reasons, use an anti-TB treatment regimen consisting of a 2-month initial phase of quadruple therapy followed by isoniazid and ethambutol (EH) for 6 months rather than isoniazid and rifampicin (RH) for 4 months. Prices of all anti-TB drugs- have declined dramaticallv in the nast few vears. The 1996 UNICEF price list showed that 1000 iablets of EH cost US$22, very similar to the cost of 1000 tablets of RH at US$24. The decision to use 6 months of EH is currently based not so much on economic reasons, but rather on the fact that EH is administered unsupervised while RH should be given by direct observation. Direct observation of RH to patients for longer than 2 months would place an intolerable burden on TB staff and on TB patients in most resource-poor countries. Third, the authors state that slavish adherence to the WHO control strategy is not the answer to TB control in the short or medium term, and that we need urgent creative innovation in service delivery to TB patients. This is an unjustified swipe at WHO. The WHO control strategy, with its excellent ‘j-point policy package, is based on the late Karyl Styblo’s model of TB control which was developed while he was scientific director of the International Union against TB and Lung Disease (IUATLD). Those of us involved in the field in the fight against TB in sub-Saharan Africa know that the model and this strategy are our only practical hope to control TB in the short or medium term. We also know, and are supported in these efforts by both WHO and the IUATLD, that in the face of HIV-infection we need to make modifications to this model if TB is not to overwhelm our health care services. WHO is currently supporting operational research in 8 countries in subSaharan Africa to test out different ways of making service delivery more acceptable to patients and the community (MAHER et al., 1997: InternationalJournal of Tuberculosis and Lung Disease, 1, 276). Creative innovation is already underway and being widely tested. Finally, Zumla and colleagues (Zoc.cit.) believe that the eradication of TB will occur onlv with the creation of a caring global society and the ending of gross inequity in
the sharing of global resources. Ifwe wait for the creation of this ‘utopian global village’, we will wait forever! In the 16 years since I first came to work in government and university-based health institutions in sub-Saharan Africa, I have seen nothing to convince me that we are bridging the gap between rich and poor. This gap gets binner vear bv vear. and with the Western World’s seemingly uns*toipable desire and drive for more and more advanced technology, most people in sub-Saharan Africa will be left way behind in future years to come. But that does not mean that ‘Africa is lost’ or that there is no hope. Far from it. In TB control programmes, there are many talented, hard-working and motivated people on this continent who are tryingto work out local solutions to the many problems and difficulties with which they are faced. It is important that health care providers in Africa make the most ofwhat resources they have. For example, for most HIV-positive TB patients in Africa the use of HAART (highly active anti-retroviral therapy) will never be more than a far-away dream, but the use of cotrimoxazole prophylaxis which can reduce mortality rates by 50% (WIKTOR et al., 1999: Lancet, 353, 1469) is certainly a very real, cheap and practical option. We need to grasp these opportunities, set our own targets and goals for what we believe we can achieve, and then be proud when we have achieved them. This course of action has much more appeal (to me at least) than waiting forlornly for all of mankind to be on an equal footing. Anthony D. Harries Technical Adviser to National TB Control Programme c/o British High Commission l? 0. Box 30042 Lilongwe 3 Malawi lOJune 1999 Fax +265 782 6.57 The tuberculosis pandemic: implications for health in the tropics: a reply We are delighted to receive vigorous feedback from Anthony Harries on our article on tuberculosis and its control in the developing world (ZUMLA et al., 1999: Transactions, 93, 113) and we thank him for his kind remarks concerning the quality of our article. We do, however, take very seriously his implication that we are taking a ‘swipe’ at the WHO and denigrating the excellent pioneering work of Karel Styblo. Both were very far from our intention and, indeed, we quite categorically stated that ‘The principles of the WHO (DOTS) strategy are not contentious’. We would certainlynot criticize the need for government commitment, a dependable supply of good-quality drugs, facilities for microscopical diagnosis and systems for monitoring the performance of the control programme. We do, however, see problems with the 5th element of the WHO strategy-direct observation of therapy-and with the details of how the other elements should be put into practice. RANGAN and UPLEKAR (1999: in: Tuberculosis-an Interdisciplinary Perspective, Porter, J. D. H. & Grange, J. M. (editors). London: Imperial College Press, p. 265) have skilfully summarized the many ethnic, cultural and psychological variables that need to be considered in ensuring that patients receive their drugs, as well as the many other aspects of care essential for a full recovery. In this context, tuberculosis does not just affect the lungs and other organs, it affects many aspects of the patient’s life-social, psychological, economic and others-so that successful healing involves much more than the destruction of tubercle bacilli in the lesions. Merely advocating direct supervision of therapy by a trained person without attention to the many other health-related issues, including the rights of the patients, may even have a negative effe:t on tuberculosis control (HURTIG et al., 1999: ZnternationalJournal of Tuberculosis and Lung Disease, 3, 553). Indeed, in his statement that ‘ in the face of HIV-infection we need to make modifications to the WHO model if TB is not to over-
r-~
Correspondence
The tuberculosis pandemic: implications for health in the tropics I enjoyed reading the excellent and succinct article about tuberculosis (TB) and its control in the developing world bv ZUMLA et al. (1999: Transactions. 93, 113). However, I would like to take issue with the authors over a number of points. First, theystate that HIV-infection is associated with a higher nrouortion of extrauulmonarv disease (EPTB) su;h asmihary TB, lymphadenopathy, bone and skin disease. Clinical studies in a variety of African countries have shown that bone and joint TB is not a common findina in HIV-nositive uatients WADHAWAN & HIRA, 1989:-Medical journal of Zambia, 24, 16; Kelly et al.; et al., 1992: 1990: Transactions, 84, 725; MIGLIORI Tubercle and Lung Disease, 73, 285; NUNN et al., 1992: Tubercle and Lung Disease. 73. 45). Our own clinical studies in Malaw: have con&ned‘these findings, and have shown that bone and joint TB is more common in HIV-negative patients than in those who are HIV-positive (HARRIES et al.. 1997: Annals of Troaical Medicine and Parasitology, 91,‘771). Similarly;skinAdisease is not highly prevalent (HARRIES et al., 1997: International Journal of Tuberculosis and Lung Disease, 1, 346), and in fact one would not expect lupus vulgaris or papular necrotic tuberculides to be associated with profound immunosuppression. The authors also make no mention of the most common type of EPTB found in HIVpositive patients in sub-Saharan Africa, namely pleural effusion. Second, they state that some developing countries, for economic reasons, use an anti-TB treatment regimen consisting of a 2-month initial phase of quadruple therapy followed by isoniazid and ethambutol (EH) for 6 months rather than isoniazid and rifampicin (RH) for 4 months. Prices of all anti-TB drugs- have declined dramaticallv in the nast few vears. The 1996 UNICEF price list showed that 1000 iablets of EH cost US$22, very similar to the cost of 1000 tablets of RH at US$24. The decision to use 6 months of EH is currently based not so much on economic reasons, but rather on the fact that EH is administered unsupervised while RH should be given by direct observation. Direct observation of RH to patients for longer than 2 months would place an intolerable burden on TB staff and on TB patients in most resource-poor countries. Third, the authors state that slavish adherence to the WHO control strategy is not the answer to TB control in the short or medium term, and that we need urgent creative innovation in service delivery to TB patients. This is an unjustified swipe at WHO. The WHO control strategy, with its excellent ‘j-point policy package, is based on the late Karyl Styblo’s model of TB control which was developed while he was scientific director of the International Union against TB and Lung Disease (IUATLD). Those of us involved in the field in the fight against TB in sub-Saharan Africa know that the model and this strategy are our only practical hope to control TB in the short or medium term. We also know, and are supported in these efforts by both WHO and the IUATLD, that in the face of HIV-infection we need to make modifications to this model if TB is not to overwhelm our health care services. WHO is currently supporting operational research in 8 countries in subSaharan Africa to test out different ways of making service delivery more acceptable to patients and the community (MAHER et al., 1997: InternationalJournal of Tuberculosis and Lung Disease, 1, 276). Creative innovation is already underway and being widely tested. Finally, Zumla and colleagues (Zoc.cit.) believe that the eradication of TB will occur onlv with the creation of a caring global society and the ending of gross inequity in
the sharing of global resources. Ifwe wait for the creation of this ‘utopian global village’, we will wait forever! In the 16 years since I first came to work in government and university-based health institutions in sub-Saharan Africa, I have seen nothing to convince me that we are bridging the gap between rich and poor. This gap gets binner vear bv vear. and with the Western World’s seemingly uns*toipable desire and drive for more and more advanced technology, most people in sub-Saharan Africa will be left way behind in future years to come. But that does not mean that ‘Africa is lost’ or that there is no hope. Far from it. In TB control programmes, there are many talented, hard-working and motivated people on this continent who are tryingto work out local solutions to the many problems and difficulties with which they are faced. It is important that health care providers in Africa make the most ofwhat resources they have. For example, for most HIV-positive TB patients in Africa the use of HAART (highly active anti-retroviral therapy) will never be more than a far-away dream, but the use of cotrimoxazole prophylaxis which can reduce mortality rates by 50% (WIKTOR et al., 1999: Lancet, 353, 1469) is certainly a very real, cheap and practical option. We need to grasp these opportunities, set our own targets and goals for what we believe we can achieve, and then be proud when we have achieved them. This course of action has much more appeal (to me at least) than waiting forlornly for all of mankind to be on an equal footing. Anthony D. Harries Technical Adviser to National TB Control Programme c/o British High Commission l? 0. Box 30042 Lilongwe 3 Malawi lOJune 1999 Fax +265 782 6.57 The tuberculosis pandemic: implications for health in the tropics: a reply We are delighted to receive vigorous feedback from Anthony Harries on our article on tuberculosis and its control in the developing world (ZUMLA et al., 1999: Transactions, 93, 113) and we thank him for his kind remarks concerning the quality of our article. We do, however, take very seriously his implication that we are taking a ‘swipe’ at the WHO and denigrating the excellent pioneering work of Karel Styblo. Both were very far from our intention and, indeed, we quite categorically stated that ‘The principles of the WHO (DOTS) strategy are not contentious’. We would certainlynot criticize the need for government commitment, a dependable supply of good-quality drugs, facilities for microscopical diagnosis and systems for monitoring the performance of the control programme. We do, however, see problems with the 5th element of the WHO strategy-direct observation of therapy-and with the details of how the other elements should be put into practice. RANGAN and UPLEKAR (1999: in: Tuberculosis-an Interdisciplinary Perspective, Porter, J. D. H. & Grange, J. M. (editors). London: Imperial College Press, p. 265) have skilfully summarized the many ethnic, cultural and psychological variables that need to be considered in ensuring that patients receive their drugs, as well as the many other aspects of care essential for a full recovery. In this context, tuberculosis does not just affect the lungs and other organs, it affects many aspects of the patient’s life-social, psychological, economic and others-so that successful healing involves much more than the destruction of tubercle bacilli in the lesions. Merely advocating direct supervision of therapy by a trained person without attention to the many other health-related issues, including the rights of the patients, may even have a negative effe:t on tuberculosis control (HURTIG et al., 1999: ZnternationalJournal of Tuberculosis and Lung Disease, 3, 553). Indeed, in his statement that ‘ in the face of HIV-infection we need to make modifications to the WHO model if TB is not to over-