Ethiopia’s New Campaign to Stop Treating TB, posted by Daniel

One of the most frustrating things I’ve encountered while working here is the government’s multitudinous and varied ways of undermining efforts to treat the patients most in need of care.  I certainly expected challenges when trying to practice medicine in rural Ethiopia, but amongst the obstacles I imagined, government ineptitude was well below poverty, hunger, illiteracy and lack of clean water on the list. The prime example of this incompetence and betrayal (although there are so many examples) is the Federal Ministry of Health’s inability to provide enough anti-TB medication to its infected citizenry.  One third of the world’s population is infected with the bacteria that causes TB and this bacteria causes 25% of avoidable adult deaths in the developing world.^[1]  This is despite the fact that the bacteria that causes TB was identified in 1882, that in 1993 the WHO declared TB an international emergency and that in 2000 the Global Partnership to Stop TB was established.  The impact of the Stop TB campaign is difficult to discern as there are over 9 million new cases per year and 1.7 million deaths per year, mostly in the developing world  This is more than a bit bothersome as TB is thoroughly understood and entirely treatable. And when I say treatable, I mean that the curative medications are provided for free to the countries in need, countries like Ethiopia.  Somewhere, the supply chain breaks, and that is where the trouble begins.

            First, a little background on how we treat TB.  The TB treatment program at our clinic follows the WHO’s Directly Observed Treatment, Short Course (DOTS) program.  It is an internationally implemented program that is intended to identify people with TB, to treat them effectively, to prevent spread to the community and to prevent drug resistant TB.  A few times a week we diagnose patients in our clinic with TB, inform them of the results and enroll them in the 8 month DOTS program.  For the first two months of treatment, the “Intensive Phase,” each patient comes to the clinic every morning to take the daily dose of anti-TB medications.  In order to come to the clinic daily, patients who live outside of our village leave their homes and families to move the 6 or so hours to live in a rented room or relative’s house in Chiri.

            To ease the financial burden associated with moving near our clinic and giving up 2 months of income from farming or working at home, our clinic often fully subsidizes food and housing for Intensive Phase patients.  Not only is this the humane thing to do, it is also a pragmatic necessity if one is serious about reducing death from TB, transmission of TB and avoiding drug resistance to TB.  If patients cannot take anti-TB medications consistently and uninterrupted they will not only die of an entirely treatable disease.  While they are slowly consumed by TB they will also share the disease with their families and neighbors.  Worse yet, if they had the good fortune to start treatment but could not continue, the TB they spread will likely be drug resistant, fating their surviving friends and families to suffering and death from a mutant form of TB that is far more difficult to treat.

            Fortunately, nearly all of our patients complete the full course of treatment and make remarkable recoveries. Over the first two months of treatment, the Intensive Phase, we get to know many of the 30 or 40 patients who come to the clinic each morning for their Directly Observed Therapy.  Once they finish the Intensive Phase and return to their communities, it is a real source of satisfaction to see these formerly ill, bed-ridden and cachectic patients come back to the clinic once a month for a free check up and medications for the next month. Because we serve a large, rural area with a population of around 150,000 people, many of these patients hike over six hours to report to the clinic and get the next month’s prescription.  Rather than exhausted and complaining, they arrive smiling and proud of their diminishing coughs and skyrocketing weights. You might imagine, then, the great disgust that accompanies my increasingly frequent need to tell patients that the multimillion dollar supply chain has not provided sufficient medication to treat them for another month.

            In Ethiopia, anti-TB medications are provided for free to the Ministry of Health from the Global Fund to Stop TB, distributed by the central government to regional pharmaceutical supply centers, then from the regional centers to the zones and from the zones to the woredas (woredas are similar to greater metropolitan areas).  For reasons that appall and confound me, our clinic has faced a severe shortage of these essential medications for the past two months.  We keep meticulous records and duly file the required reports with the government.  We have a file for each patient and a government provided TB Register.  My predecessor as Medical Director even designed a robust, yet elegant Excel file to track our TB patients - from the day a patient starts taking anti-TB medications, we can tell you how many pills they will need for the entire eight months and the exact dates on which they will come to the clinic to collect these pills. Despite the precision and ease with which this information is available, the medications arrive haphazardly, if at all.  Just last week we started rationing - providing only one week of medications instead of a month to each patient, hoping to spread our limited supply until a new shipment arrives. 

            USAID and the Ethiopian Federal Ministry of Health collectively spend tens of millions of U.S. dollars a year to control TB in Ethiopia. In fact, last week USAID’s Supply Chain Management System donated another 1.7 million USD worth of trucks, motorcycles and other equipment to Ethiopia’s Pharmaceutical Fund and Supply Agency.  So the race to the clinic is on - modern trucks in a broken supply chain versus rural patients with an age-old disease.  I’m betting on the barefoot Ethiopians. Just like in the Olympics. But when they cross the finish line here they don’t get a Gold Medal, just a little bit closer to a Multi-Drug Resistant TB epidemic.

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^[1] Gill GV and Beeching NJ, Lecture Notes: Tropical Medicine, 6th edition. 2009; 85-100.