Urban #TB hotspots cannot be on blindspot, if we are to #endTB!
Bobby Ramakant, CNS (Citizen News Service)
Our governments have committed to achieve the 17 Sustainable Development Goals (SDGs) by 2030 but without concerted
action, the promises will barely remain a mirage. For instance, unless social influencers of tuberculosis (TB) get due
attention from all different sectors that have a role to play, we cannot end TB. Also with rapid urbanization, we need
to address TB in the context of urban planning and development, that is rapidly and aggressively taking place globally.
Although burden of TB varies across countries, but one trend is undeniably too common to miss: the alarming manner in
which TB is concentrated in vulnerable populations not just in least developed and developing nations but also in the
developed world.
Ethnic minorities, migrant groups, indigenous peoples, those with poor access to medical care, among others, are at at
higher risk of TB everywhere globally. These populations often end up living in marginal urban neighborhoods with poor
living conditions, overcrowding, economic inequality, social and gender inequities, unemployment and violence.
What adds fuel to the fire is the fragmented and fragile health systems, disjointed health and development programmes,
and the failure to adapt TB care which is tailored to the unique needs of the most disadvantaged populations, such as
ethnic minorities, women, children, migrant workers, injecting drug users, people living with HIV, elderly, among
others.
Hopefully the forthcoming WHO Global Ministerial Conference: Ending TB in the SDG era: A multi-sectoral response, in
Moscow, Russia (16-17 November 2017), will not miss this golden chance of engaging different health and non-health
ministries and sectors, around urban TB, as well. A United Nations High Level Meeting on TB in 2018 could be another
forum to bring world's attention on urban TB.
At the recently concluded 48th Union World Conference on Lung Health in Guadalajara, Mexico, a day-long workshop
focussed on urban TB. It was organized by KNCV with support from Eli Lilly. The 'house full' sign outside the hall in
which it was facilitated, indicated high level of interest among the delegates in urban TB. Hope lessons shared in this
workshop ripple beyond and influence policy making and programming to address urban TB in countries globally.
Dr Netty Kamp, senior advisor in TB control for KNCV, shared with CNS (Citizen News Service) that "Ending TB is not only
dependent upon medical care alone but also has everything to do with social determinants. The way forward to control TB
is to take into account these social determinants and other sectors that can influence these social determinants. This
is about urban TB and is more prominent because rapid urbanization is happening worldwide. In future we will live more
in cities than in rural settings. TB will be more difficult to eradicate if we do not take into account the urban
circumstances and context. That is the reason why we had put together this workshop to highlight the different
components of urban TB control."
Urban TB, and not slum TB
Using a framework which was developed in the Americas with help from the Pan American Health Organization/ World Health
Organization (PAHO/ WHO), the workshop highlighted several issues around addressing urban TB: identifying target groups
in urban settings in local contexts, intersectoral work, health systems, private sector, social protection schemes,
insurance schemes, among others. "When we say social protection we do not only mean incentives for TB but social
protection beyond the health sector so that people are not as vulnerable when they get sick with TB as they are now.
Also it can highly contribute to the reduction of patients' catastrophic costs. Intersectoral work has been proven to
work already" shared Netty Kamp.
Mexico, where this world lung health conference was held, provides an example of making efforts to address TB in urban
settings. This framework is being applied after being adapted to Mexican and local contexts in 30 cities.
Epidemiological mapping has been done, different target groups were identified, a plan was developed to engage specific
sectors and specific groups within those sectors. For example, prioritising working with factories where people are all
together without much ventilation and without free time to go out for seeking healthcare. "There are different contexts
and each cities can be different in each country. There are slums scattered all over the urban area and affects TB
transmission between the slums and the rest of the population. So we cannot say that we are not affected. That is why we
call it urban TB and not slum TB" reflected Dr Netty Kamp.
PUBLIC AND PRIVATE SECTORS NEED TO UNITE TO END URBAN TB
In south India, Chennai case study was shared with participants on how they involved the private sector while having an
interface with the national TB programme in the country (formally called the Revised National TB Control Programme -
RNTCP). Chennai model is based upon private-private collaboration. They are working with an interface with RNTCP but
there is a need to network with a range of different type of private providers. Pharmacy is the most used first point of
care which can refer the patient to the private sector which is engaged in TB control. This model shows it works in
those settings. Private sector engagement was paid attention since the very beginning of the project and their concerns
addressed. For instance, giving them access to proper diagnostic tools, technical updates and feedback and being able to
keep their patients with interface NGO’s treatment support enhanced their collaboration. The project resulted in rapid
increase in number of doctors, specialists and family doctors, engaged as a result of which the private sector
notification of TB cases shot up. Using the right diagnostics and treatment yielded better treatment success rates.
Examples of addressing urban TB in African settings were also part of the workshop. Experiences from Nigeria focussed on
improving quality of care in private sector. The argument that goes against private sector usually is 'the government
national TB programme cannot work with private sector because they do not know their job'. But in several countries it
is the private sector where TB patients first go to for seeking care. So not engaging private sector can be
counter-productive in efforts to end TB! "This Lagos model in Nigeria showed we can do quality improvement in TB care
but again there is a cost associated to it, as we have to get supervisors trained etc. This is replicable once it
finishes in one and half years from now. Chennai model also will be available for replication by end of this year" said
Dr Kamp.
"This was the first time when we could share a Latin American experience with the Urban TB framework of PAHO/ WHO with
the rest of the world" remarked Dr Netty Kamp.
IF THERE IS A WAY TO DO IT BETTER, FIND IT!
These Edison's verses come to mind when we see the mountainous challenge urban TB presents in current context of
urbanization, and the positive results of adapting and implementing this framework. But there is no doubt, best can be
made better! Agrees Dr Netty Kamp: "We have to strengthen the framework as there are some weaknesses. Also with the
experience of other countries like Nepal, Nigeria, Mexico, India, among others, there are lessons to be learnt to make
this framework even more effective in addressing urban TB. Urban TB must be much higher on the agenda at all levels
because that is where TB cases might be aggregating! It does not mean that we should stop working for rest of the
country but we can focus on urban TB and factors that contribute to TB but are beyond the health sector."
SYNCHRONIZE HEALTH AND DEVELOPMENT PROGRAMMES
The way forward for sustainable development is through a united and well-coordinated approach. Different health and
non-health programmes need to find synergies and optimize resources to have the maximal impact. Hope that governments
meeting next month in Moscow for WHO Global Ministerial Conference and UN High Level Meeting on TB next year, will find
newer ways to synchronize different health and development programmes to not only end TB but also to enhance development
outcomes.
Bobby Ramakant, CNS (Citizen News Service)
(Bobby Ramakant is the Policy Director at CNS (Citizen News Service) and a WHO Director General's WNTD Awardee (2008).
Follow him on twitter: @bobbyramakant or visit www.citizen-news.org)
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