Urgent need to scale-up community TB services

On the 28th October last year, WHO announced that TB had overtaken HIV as the leading global killer by infectious disease. How could that happen? It's tempting to blame it on MDR-TB. But many people with TB are simply never diagnosed and just don't find their way to clinical services in time. 

I was in Bangkok, technically assisting the HIV Foundation Asia, in the week the WHO announcement was made. The foundation runs community-based outreach for documented and undocumented migrants. I was asked to go to a slum to help a guy with TB, but by the time we got to him it was too late. His lungs were full of fluid and the hospital couldn't save him.

The thing about slums is they're crammed with people. You can't burp in a slum without everyone knowing and gossiping about it. But none of this guy's neighbors took action to help him when he got sick; nor did they appear to have the community mechanisms available to help them do so. Most were frightened or misinformed and those with children were, understandably, hostile.

The WHO ENGAGE-TB project publishes resources to empower and engage communities in TB activities. As they say, "although (TB is) diagnosed in clinics and hospitals, TB thrives in the community. Action in the community is therefore essential." So here are some new community technologies and practices that can professionalize community services and empower communities to save lives:

•  Out of the clinic and into the city. Most of the work I do is in Asian cities. Over the past year I've helped the HIV Foundation Asia incorporate Google Maps into their outreach practice for TB and HIV. Their service model involves heading into the slums of Bangkok and Yangon to be a resource for health. Using Google Maps they can now notify each other 'in real-time' at the moment they identify a newly diagnosed person with TB: by simply using their Smartphones to add information to their online team map while in the field. At the end of each week - in outreach meetings - they refer to their Google map to identify the places with highest undiagnosed TB and HIV - they prioritize outreach to those places in the following weeks. 
• Getting people to the hospital on time. Community-based case management can get people to the hospital, help them and their families with a discharge plan and visit them at home. Caseworkers can support long-term treatment adherence by developing plans that help people through TB treatment and its side effects. Setting up cell phone reminders for treatment adherence or to remember hospital visits is a basic part of the plan. Caseworkers, in conjunction with families, can manage multiple problems as they arise before-during-after the treatment period.
• A plug for Expert Patient TB Programs. Employing people in outreach and case management who have survived TB themselves is incredibly powerful. They know what it's like and they know what to say. They carry an authority about TB; their experience can be deeply comforting to the person who has active TB and their families. Think of the power of these words: "I had TB too. It's ok, you can get through this. If I did then you can too. Let me tell you what happened to me. Some of what I've been through might be what you can expect."

Some Useful Resources

• An explanation of urban mapping for outreach and community case management for HIV can be found here.
• Community engagement for TB in Myanmar is funded by the USAID  CAP-TB Project and supported by the Myanmar National Tuberculosis Program- read about it here.
• PATH and the International HIV/AIDS Alliance's Community-based TB and HIV Integration Good Practice Guide  is a useful resource for the field so far - read it here.
• And last but not least, the Stop TB Partnership is the best resource for keeping up with the latest global happenings on TB - get there from here.