TB Heroes of the Hinterlands

Ramadhan Milanzi darted out of the door like one possessed or, as his assistant said, because he was possessed. Presently, he was not the calm man who had welcomed us into his clinic – a two-room house, which was fenced in by a mosaic of tin sheets and pieces of clothing. He was in a trance. He stomped, he gasped, he yelled, muttering incomprehensible sounds, which his assistant rushed to interpret. This went on for about 10 minutes, before he shuddered and collapsed in a heap on the floor. Then, suddenly, he metamorphosed, gathering himself calmly to attend to his clients, who had come to him with diverse physical, spiritual and social ailments.

Every morning, Milanzi reports to duty here in Dar es Salaam’s Kingugi kwa Mnyani slum, where he offers prompt solutions for problems ranging from failing marriages, faltering businesses, asthma and anything in-between.

However, there is one exception – he knows well not to mess with TB.

“I have been trained to recognize the signs of TB, and to appreciate that I cannot cure it,” he said after recovering from the trance-like state. “If someone comes with signs of the disease, we connect him with community health workers and send him off to hospital for screening and treatment.”

The ailing in the community come to see him long before they can visit health facilities, says Milanzi.

Milanzi and his colleague, Hassan Juma Tingi, are among 50 traditional healers trained by MUKIKUTE – a community-based organization made up of TB survivors – to find missing cases of TB in Tanzania. Tanzania health partners know that people will keep going to traditional healers like Tingi and Milanzi, and so have engaged them as champions for the effort to find more missing cases of TB. They have educated the healers on how to keep their places of work – traditionally dark and often smoky – open and well ventilated to reduce risk of transmitting the disease.

On a recent visit to his home, we found Tingi attending to Nasri Omar, a young man suspected of having TB. Omar had been coughing incessantly for two weeks and had come to Tingi for healing. After listening to him, Tingi suspected TB and got a sputum sample, before connecting with a health worker who would deliver the sputum to a lab for testing. When patients return a positive test result, Tingi supports them through the long-drawn treatment – usually more than six months. He sees them through the treatment process, ticking the patient’s medical card after every dose of medication.

Years ago, Tingi himself had suffered from TB. The disease affected him severely, but his traditional medicine could not cure the disease. He went to a health facility for treatment and later joined MUKIKUTE to fight the disease alongside other TB survivors.

In its first national TB prevalence survey published in 2013, Tanzania learnt that it registers over 100,000 missing cases of TB every year – people that go undiagnosed, untreated and unreported. Beatrice Mutayoba, Manager of the National Tuberculosis and Leprosy Program, says more than 30,000 of people missed by health systems die every year.

“We are determined to reverse these trends,” says Mutayoba. “We are investing in fighting TB in the health facilities and expanding beyond health facilities with a view to finding 70 percent of missing cases of TB and 80 percent of missing cases of multidrug-resistant TB by 2020.”

Global health partners can learn from Tanzania’s efforts to broaden outreach to marginalized groups, as they confront one of the most urgent challenges facing TB programs in the world today. According to the Global Tuberculosis Report 2016, 40 percent of the 10.4 million cases of TB, and 80 percent of the 580,000 cases of drug-resistant TB, are missed by health systems every year across the world.

Those missing millions are concentrated in India, Indonesia, Nigeria, Pakistan, South Africa, Bangladesh, Democratic Republic of Congo, Mozambique, Myanmar, Ethiopia, Thailand, Philippines, Uganda, and yes – Tanzania. These 14 countries account for more than 80 percent of missing cases of TB. To end the global TB epidemic by 2035, the target set in WHO’s End TB Strategy, the world has to find, treat and cure more cases of the disease. Despite progress made against TB, the current response to the disease still falls short, leaving behind large numbers of people unable to access treatment, says a new progress report by Stop TB Partnership on the Global Plan to End TB 2016-2020.

A community health worker

Another foot soldier in Tanzania’s effort to reach people left behind in the fight against TB is Rashidi Gora, a community health worker tracking missing cases of TB in Dodoma, central Tanzania.

For Gora, finding the next TB patient is a life mission. On a recent morning, Gora bid his wife goodbye, grabbed his bag and hopped on his motorbike, heading to the remotest villages of Kondoa District in the country’s interior, where rugged roads disappear into endless fields of millet and corn.

In the last year, Gora has screened hundreds of people for TB in areas far removed from mainstream health systems. It is not a glamorous job. Gora collects samples, smears the sputum on a slide for ease of transportation and delivers them to hospital labs for analysis. When the results are ready, he rides back to the distant villages – often for more than an hour – to read out the outcomes to his patients. In case of a positive result, he links patients to clinics and supports them through the long treatment process. In a calm voice, he also takes time to educate the people on how to avoid infection, or infecting others.

“When I got the training, I fell in love with community health work, and I dedicated myself to saving my community from this disaster,” says Gora. “The Global Fund and MDH gave me the training, now is my turn to contribute.”

MDH (Management and Development for Health) is a local nongovernmental organization that is part of a national effort to find TB cases led by Global Fund and the nonprofit Save the Children. MDH has trained and deployed more than 2,000 community health workers across Tanzania to bring TB screening and treatment to the people.

In order to find more than 100,000 missing cases of TB spread across Tanzania – a vast country almost the size of Germany and France combined – the government is working with the Global Fund to train staff in health facilities to test for TB among all patients, and connecting community health workers like Gora and traditional healers like Milanzi with formal health systems. The partnership is investing in prompt and accurate diagnosis of TB in health facilities with the goal of identifying all TB cases that arrive at the hospital. The partnership has made TB screening routine during all medical visits, which has more than doubled the number of TB cases detected in the last year.

Dr. Sode Matiku, a public health specialist in Tanzania, says making TB screening a central pillar of ending TB in the country means taking four main approaches:

• Increasing access to TB services, TB screening and diagnosis to all patients attending health facilities
• Improving organization and management of active TB case finding at regional, district and health facility levels
• Improving access to TB diagnosis to make sure that no TB cases are missed
• Involving the community in strengthening active TB case detection at community level

Whether community health workers, traditional healers or mainstream health workers, people from all segments of society have a vital role to play in the effort to find missing cases of TB. Systematic TB screening of all patients in health facilities and engaging diversity of people and interventions in finding missing cases of TB in Tanzania will be the game changer for the country, says Matiku.