On World TB Day, Go Home and Be Well

Anne Boyle
March 23, 2018 | 2 Minute Read
Health | Health Systems | Tuberculosis
Does treatment for tuberculosis (TB) have to mean a long and lonely stay in an isolated hospital? Expert Anne Boyle explores an alternative.

In the weeks after the bombing of Pearl Harbor, and like many young Americans at the time, my granddad enlisted in the armed services. He traveled from his home in Scranton to Philadelphia and began to prepare himself for what war might bring. But he never made it to the front lines. Instead, he was diagnosed with tuberculosis (TB) during his medical screening. This was 1942 and, in those days, the best-case scenario was a year-long stay in a TB sanatorium and painful treatments that included repeatedly collapsing his lungs. The treatment was almost never fully curative but it was the only path available and, if the disease was mild enough, patients would often recover. So, my granddad spent the next year in the Pocono Mountains, away from his family and the woman he loved. He was 24 and his life was put on hold. But most thought he was lucky, and he was. He eventually recovered, completed medical school, and had a family.

In the years after my grandfather’s recovery, a miracle happened: the discovery of antibiotics. Streptomycin became the disease’s first reliable cure, and patients could now be treated in their community hospitals instead of isolated facilities and return to their families to pick up their lives in a matter of weeks, not months.

For decades, TB seemed to fall off the world’s radar. Almost overnight it had gone from one of the world’s leading killers to a curable and preventable disease. But as other diseases that weaken the body’s immune system, such as HIV, began to emerge in the 1980s, TB incidence rates in many parts of the world began to climb. These days, as the disease becomes harder to treat because of growing antibiotic resistance, many high-burden countries feel the pressure to continue long hospitalization periods to ensure that patients are taking their medication regularly and their side effects are being monitored.

For decades, TB seemed to fall off the world’s radar.

Sometimes outdated clinical preferences are responsible for this. Many high-burden countries that used to be part of the Soviet Union have inherited vertical treatment systems that separated the treatment of TB from all other diseases. Patients were referred to specific TB hospitals for diagnosis and treatment rather than being able to go to a community-based clinic. Still revered in many parts of the region, this Semashko System has persisted as the model for TB care across the former Soviet Union. And with average ages of TB specialists in their 60s and 70s across the region, this is the system that most clinicians trained under.

There are also structural incentives to keep patients after the initial intensive treatment phase, which in many countries, especially post-Soviet countries, is the typical cut-off for hospitalization: health systems are often funded based on the number of beds, rather than the total number of patients seeking care. TB hospitals, therefore, have an incentive to perpetuate inpatient infrastructure over outpatient options. And it is only relatively recently that we are beginning to realize the importance of home and family when it comes to curing TB. Long periods of hospitalization can lead to social isolation and depression, which in turn can lead patients to stop taking their medicine. Additionally, the emergence of multi-drug resistance adds a new variable. It puts patients at risk for complicating their disease if exposed to fellow patients with different drug resistance profiles.

This trend is changing, however. In Ukraine, for instance, the Ministry of Health changed the country’s national guidelines for treating TB in 2013 and began to pursue patient-centered approaches that now include decentralized health system funding that gives localities greater control over health-care budgets. Around that time, Ukraine also began to move away from the vertical Semashko System and develop primary care approaches for treating TB. In the industrial city of Kryvyi Rih, for instance, the local government participated in a study by the USAID Strengthening Tuberculosis Control in Ukraine project that compared the treatment outcomes and cost for both inpatient and outpatient care in a cohort of TB patients. Kryvyi Rih is a city of 650,000 and has nearly 600 inpatient beds in three large TB hospitals that serve the city and five smaller communities nearby. The city also has seven new primary care clinics that began treating TB in 2013 which made a study like this possible. For the first time, patients could choose to receive their treatment at home or in the hospital. Significantly, the study found that treatment adherence was 24 percent higher and up to 15 times less expensive in the outpatient model.

Treatment adherence was 24 percent higher and up to 15 times less expensive in the outpatient model.

My granddad had no choice but to endure the isolation and loneliness of his treatment, but patients around the world are now able to continue treatment courses at home. This is possible partly because of technological advances: more sensitive diagnostics make it easier for doctors to tailor appropriate treatment and to determine when a patient is no longer contagious. It is also possible because medical authorities are studying the effects of outpatient treatment when it comes to treatment adherence, patient outcomes, and health system cost. They are also pursuing patient-centered change, like primary health-care settings and evidence-based decision-making. TB is an old disease, but it has adapted over time and so must its treatment.

About Anne Boyle

Anne Boyle is a director in Chemonics’ Global Health Division.