PRESENTATION

TB CONTROL IN DEPRIVED COMMUNITIES CAPE TOWN

INTRODUCTION

Namaste and greeting - My name is Ria Grant.

I am from Cape Town in South Africa and it is a great honour for me to have been given the opportunity to discuss TB Control in Deprived Communities.

South Africa's TB epidemic, like yours, is one of the worst in the world. The incidence is 700 new cases per 100 000 per annum and is approximately 50 times higher than a country like the USA.

Asia has the highest number of TB patients but in the Western Cape we have the highest incidence.

The AIDS epidemic is magnifying the TB scourge. In 1995 about one in every four people who developed TB did so because they were HIV+. At least half of all new cases are contagious and will spread the disease to an average of ten other people every year.

Without effective management the number of TB cases in South Africa is expected to quadruple over the next ten years.

Of all the cases of TB treated in South Africa 31% occur in the Western Cape Province. In the deprived communities of the Western Cape, those areas with the poorest housing, education and lowest level of income: it has been shown that 1 in 3 houses has had a case of TB in the last 10 years.

The reason for the rise in TB notifications in the Western Cape over the last 10 years is uncertain but could be related to:

  1. a unique urbanisation process over the past two generations which has seen 700000 persons move from what were termed the native homelands (rural areas) to Cape Town;  
  2. poor health infrastructures in the rural areas which force seriously ill patients to seek medical assistance in the City;
  3. the result of an infrastructure which encourages the reporting of TB.

Policies to control tuberculosis in South Africa have been in operation ever since Act 36 of the Public Health Act was promulgated in 1919.

SUGGESTED TB CONTROL MECHANISMS FOR DEPRIVED COMMUNITIES

I would like now to put forward some proposals for the control of TB in deprived communities and to relate these to my own experiences in combatting TB in Cape Town over the past 30 years.

There are TWO fundamental control strategies:

[I] PRIMARY CONTROL ie the PREVENTION strategies and
[ii SECONDARY CONTROL ie the CURE and CURE SUPPORT strategies.

[i] PRIMARY CONTROL

The long term control strategy in any deprived community must be toward

a] a raising of basic standards of living;
b] nutrition education; and
c] general health education.

Until the socio economic status of the deprived classes of Cape Town and any other place in the world is improved, particularly in respect of housing and nutrition, concerned health officials must continue to strive to secure such relief in these three areas.

d] Immunisation

Specific protection of up to 80% of previously unexposed persons can be obtained by means of immunization with BCG vaccine. In Cape Town this is routinely given at birth.

Financial and manpower resources are clearly cardinal in the effective primary control of TB.

[ii] SECONDARY CONTROL

I propose the following key strategies in secondary control of TB ie in the cure and cure support phase:

a] Early Diagnosis
b] Effective treatment (DOTS) - which in itself can be categorised into hospital and clinic treatment and community based treatment .
c] Social support which comprises

i. Counselling of patients
ii. Development of the Individual
iii. Patient Incentive Schemes
iv. Financial support of patients

d] An integrated National TB Control Programme.

DIAGNOSIS

Efforts to diagnose cases of tuberculosis as early as possible are directed mainly at those groups in the community most likely to be affected, namely those who have been in contact with known cases and those who have suspicious symptoms.

In Cape Town suspects are referred to the City Health Department by many different health services, private and public.

Contacts - comprise the second most important high risk group.

Routine annual mass X-ray screening, a key strategy of former years, is no longer encouraged in Cape Town. The emphasis is now placed on pre-employment screening and focussed checks on high risk groups.

The case finding yield per hundred thousand X-rays is relatively small and in the year ended June 1995 only 7 cases of active pulmonary tuberculosis were discovered out of 3926 examinations.

TREATMENT

Hospital and clinic treatment.

Hospital and clinic treatment still provides the cornerstone of TB treatment though this is changing.

In Cape Town the majority of patients receive a 6 month course (5 days per week) of chemotherapy, administered under supervision on an out­patient basis.

Every possible step to retain the patient as a functioning member of society needs to be taken throughout the treatment period.

Hospitals

The Provincial Hospital Services play a role in the diagnosis, hospitalisation, treatment of patients and in the training of health personnel. Staff at these hospitals and related institutions often provide support and consultation for those in the field and in the management of difficult cases.

There are TWO TB hospitals in Cape Town:

1. The Brooklyn Chest Hospital [a Government hospital] caters for patients who are too ill to be treated as out-patients and serves the whole region.

It can accommodate 90 females, 157 males and 56 children.
Patients are hospitalised for a minimum of 2 months.
Many of the children have TB Meningitis.

2. The DP Marais SANTA Centre [managed by SANTA and subsidised by the Government] caters for ambulant patients whose home conditions would not be conducive to their treatment -[homeless people], retreatment defaulters who are not compliant often alcohol and drug abusers and multi-drug resistant cases.

Patients are hospitalised for 6 to 8 months.
They have 178 male beds and 60 female beds.
They do not accommodate children.

The Local Authority Health Services

The executive function of rendering comprehensive health care services is in the process of being delegated to the Local Authority. The head of the Local Authority Health Service has a wide area of responsibilities of which the control of communicable diseases and especially tuberculosis is one of the most important. This person is responsible for the organisation of the services and is accountable not only to the public via the respective council, but also to the Director General of National Health.

Community Health Centres

1. Local Authority Community Health Centres number 54.

These facilities support a total of approximately ................ patients.

Community Based Treatment

Many of the people in the deprived communities do piece work. This entails having to leave their homes very early in the mornings to stand by the road side where contractors pick them up for the day, if they are lucky. They return late in the afternoon after the clinics have closed. This results in poor treatment compliance.

A TB caseholding project initiated by CHASA (Community Health Association of Southern Africa) aimed at improving the compliance rate of patients has been implemented in our region.

The project is a departure from the traditional medical model of TB treatment and involves the community, NGO's and the health providers as equal partners. The collaboration of all these different players has led to the formation of the "TB Alliance".

It is a DOTS project. Patients are given the opportunity of receiving their treatment in the community, workplace, school, creche or at the clinic. This means that patients can negotiate to receive their treatment at a time and place convenient to them.

In order that patients receive treatment in the community, lay volunteers are selected and trained to administer TB treatment. These 'treatment supervisors' receive incentives based on the number of patients they supervise. They are allocated up to 10 patients each.

This project was implemented in 1994. It has proved to be a valuable control to the TB Control programme and the benefits to the community are numerous:

The sunflower, a symbol of life and vitality, illustrates the togetherness, upliftment and hope that the TB Alliance provides. The intertwined flowers represent the joint efforts of the three major players; non-government organisations, health providers and the community. For TB patients it is the promise of a healthier future.

Social support - Non Governmental organisations

Non governmental Organisations [NGO's] tend to complement and extend the functions of health services organised and funded as a result of legislation.

They play an important role in:

  1. increasing public awareness of the problem of tuberculosis, in health education;
  2. in mobilising support for tuberculosis patients and their families;
  3. in supervising TB treatment. SANTA administers residential centres (about 5000 beds) for tuberculosis patients;
  4. providing useful models for working more closely with communities.

TUBERCULOSIS CARE COMMITTEE

Social Work Intervention: Counselling & Casework - Patient centred approach

Groupwork and Community Work

Patient Incentive Schemes

The incentive to patients to complete their programme of treatment is a key control strategy. In Cape Town we have the following patient schemes:

FUNDING

The acquisition of funds is obviously a key issue for any organisation involved in the Control of TB in Deprived communities.

The TB Care Committee expended R1 035 161 on TB Control for the year ended March 1996. Our main source of funding is as follows:

The Health Departments are refunded in part by the Central Government for costs incurred in TB control.

Social Assistance

The degree and extent of state assistance to TB patients will be a major factor in determining strategies for TB Control in deprived communities. In South Africa a very unfair system of social assistance prevailed in the pre-election era.

Members of the "White" and "Coloured" race groups were entitled to government disability grants while they were undergoing treatment. To qualify for this assistance they had to be deemed unable to work for 6 months.

The Black community on the other hand did not qualify as the criteria differed and they had to be declared unfit for 1 year. TB is supposed to be cured in 6 months therefore this category of patient did not qualify for social relief.

Married women did not qualify at all, regardless of their breadwinning status.

Unfortunately after years of crisis management the groups which qualified for social assistance have become so dependent on hand-outs of Government grants that they are not interested in helping themselves.

Developing TB has for some become an art. For many families the amount of money they receive from social assistance is more than they would be capable of earning. There is no advantage in being cured. This is not conducive to treatment compliance.

The discrepancies based on race and gender have now been rectified but the financial drain on the country's financial resources would be astronomical if every adult TB patient were given a monthly pension and every dependant was catered for.

To this end the Government and NGO's are working at development projects which would improve patients' skill bases and earning capacities in an endeavour to eradicate the dependency on social assistance.

In South Africa we have SANTA, a National Tuberculosis Association with branches country-wide. It is a well known NGO which has played a leading roll in the fight against TB through providing hospitals in rural areas, health education and material relief. My colleague will tell you more about their role.

THE NATIONAL TUBERCULOSIS CONTROL PROGRAMME

In 1996 a new TB Control programme was launched by the Department of National Health, based on International (WHO and IUALTD) programmes and adapted to suit local conditions.

This programme enables clinics to manage patient treatment effectively, to evaluate outcome and to assess service impact themselves according to standardised procedures.

DOTS: Directly Observed Treatment, Short-course incorporates the following elements:

  1. Direct observation of patients as they swallow their medication;
  2. Patient-centred care;
  3. Microscopy Services;
  4. Measuring cure rates - TB registers;
  5. Training of health workers.

It cannot be emphasised enough that adequate preventative measures, early aggressive treatment - especially of smear positive cases - and, most importantly, the attainment of patient compliance until cure are paramount in controlling this disease.

The Conventional Biomedical TB Treatment Strategy

The treatment and management of Tuberculosis in the conventional way, whether curative or preventative, has remained largely individualistic, focusing on the patient or person at risk [Andrews, Williams & Kinney, 1988].

The essentially individualistic nature of the treatment is thus maintained through clinic supervision, with little meaningful involvement by the patients themselves. Patients are expected to engage in behaviour adjustments related only to the demands for compliance without proper account of the socio-economic and larger structural issues affecting compliance.

An Expanded Approach for effective Treatment of TB Patients

One must realise first of all that the disease is but one of many concerns for especially poor patients or at risk individuals. While practitioners may often not be able to conceive how people can allegedly not be concerned about their own health and that of their families, poor families will often make provision first for those perceived essential material needs. And if the disease is not perceived as immediately life threatening they will postpone or put off visits to doctors or clinics.

Secondly we must recognise that for the patient compliance is secondary to the person's overall goal to upgrade life. Non-compliance is likely if:

  1. the medical regimen is complicated;
  2. takes a long time;
  3. requires major behaviour change;
  4. the provider agency is inefficient or inconvenient;
  5. the patient-provider relationship is not very close, and if the patient is dissatisfied with the relationship.

Compliance is likely if:

  1. the patient believes the disease to be life threatening;
  2. believes himself/herself to be personally susceptible;
  3. therapy is efficient and painless;
  4. there is involvement of supportive personal networks.

We need to make an assessment of financial, material, social and psychological problems. The sickness problem of the patients cannot be treated in a social, economic and political vacuum. Failing this realisation we will be sending patients back to the very conditions from which they come ie that gave rise to their sickness, non compliance and continued chronic sickness.

It is necessary to establish and strengthen, where existing, the formal and informal support systems for communities excluded from helping networks for so long and to utilize these in our combat strategy.

Many of these tasks have to be performed by other professionals, assistants and community volunteers. The effective incorporation of these into our combat programmes can best be effected through a team work approach.

CONCLUSION

It is to be hoped that the importance of "Patient centred care" will be recognised as one of the key elements in this National Control programme and that the patient and the community is included in all aspects.

To effect cure, compliance is paramount. If one assumes that compliance is less than perfect in some cases, reasons for it would certainly lie at levels other than mere personal ones. People concerned about making life more tolerable amidst such destitution, as is often associated with tuberculosis, may be less concerned about compliance. This often includes socially deviant ways, such as alcohol and substance dependence, vagrancy and others.

Assessment needs to be made of the financial, material, social and psychological situations, as well as the nature of the support systems in such destitute communities.

The battle against tuberculosis has to be a joint effort between those working in health services [both formal and informal], researchers and funders, patients and the communities to which they belong.

The process of building a common vision and purpose among all who have a stake in it, is probably the most important ingredient of any strategy and structure designed to eradicate the epidemic.

This is where the importance of the TB NGO's support could make the difference in this TB Control Programme.

If you invest in a reliable, credible and accountable NGO then you as funders will be investing in a better world for everyone.

In our African tradition we believe in "Ubuntu" - you need a person to be a person.

B I B L I O G R A P H Y

Dr MEE Popkiss - The Annual Report of the Medical Officer of Health of the City of Cape Town

James HP Ellis PhD - The Treatment of Tuberculosis: A Patient Perspective

Department of Health - The South African Tuberculosis Control Programme: Practical Guidelines