Many reasons, within and outside the health system may have contributed to this situation. Within the health system, diagnosis of tuberculosis is mostly done through passive screening of patients who present to health facilities. TB is a disease of the poor. Though we know the disease is common among persons with poor living conditions and nutritional status such as estate workers and urban slum dwellers, there is no established system to actively screen these vulnerable groups for the disease.
Microscopic examination of sputum for acid fast bacilli, which is the gold standard of diagnosis, is only available from base hospital and above. However, many patients seek care from primary level curative health institutions from which patients have to be refereed to specialized units for diagnosis and treatment. Getting this test done in the private sector is costly, which may limit its use among the private sector users. The net result is undiagnosed tuberculosis patients spreading the disease for years in the community.
Though most of the stigma for this disease has been removed, it has not totally disappeared from the community which prevents patients from seeking treatment and continuing their treatment.
The treatment of tuberculosis has been simplified over the years, however, there is a risk of poor compliance given the long duration of treatment. The the patients who usually get tuberculosis are most likely to be less complaint, due to their difficult socioeconomic background. This has the added risk of creating multi drug resistant tuberculosis (MDR-TB) and extremely drug resistant tuberculosis (XDR-TB) which have massive economic burdens to the health system.
With the epidemic of diabetes mellitus sweeping through the country, there is a risk of shooting up of tuberculosis. Similar trend was seen with HIV/AIDS in Africa. Though Sri Lanka has low prevalence of HIV/AIDS, the risk of an HIV/AIDs epidemic in Sri Lanka too cannot be excluded with the close socio-cultural and economical ties with India.
Sri Lanka is on fast tract to development, with the motto of being the “Wonder of Asia”. Urbanization is an inevitable byproduct of this process. Crowded and poorly ventilated houses in the urban setting as well as in estates create ideal spreading grounds for the disease. Colombo municipality and estates reporting large number of Tuberculosis cases is an evidence for this challenge.
Social determinants of health are operating in a very strong manner when it comes to tuberculosis. In other words, poor people, those who live in poor living conditions, those who abuse alcohol and substances and those who are malnourished are more prone to the disease. It is evident that the health sector has little control over these social determinants. Thus, until they are controlled, the disease will continue to be a challenge for mankind.
Despite these myriad of reasons, control of this deadly disease is not an option but a must. The good news is that there simple diagnosis and treatment methods are available to control this disease.
Active screening programmes should be conducted in a routine and sustainable manner to diagnose and offer treatment for tuberculosis patients among vulnerable communities such as urban slum dwellers and estate populations. The lessons learn from the Malaria control could be use for this.
The primary level curative health personnel need to be provided with in-service training on improving their diagnostic and therapeutic skills for tuberculosis. Microscopic diagnosis should be made available at primary level curative health care institutions. Existing health staff could be trained to diagnose tubercle bacilli with provision of cost effective simple equipment and training. Similarly, The medical clinics which are catering for diabetes mellitus patients should be geared to diagnose and treat patients with tuberculosis.
Community awareness programmes need to be continued focusing especially on the curability of the disease in order to reduce stigma. Newer methods to ensure the drug compliance could be used. For example, since mobile phones are used so commonly in the country, they could be used to remind patients to take their daily drug dose. DOTS providers could be identified within the work places so that the accessibility and compliance could be improved.
The politicians and policy makers should be encouraged to incorporate measures to improve the living conditions of the urban and estate populations. Targeted interventions need to be carried out to improve their income, nutrition and lifestyle.
Control of tuberculosis is a must if the country is to be the Wonder of Asia. Reasons that we are aware of prevents the control of this disease. Thus, strategies aimed at the health system and broader social determinants of health is needed to control tuberculosis in Sri Lanka.
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