People power: Mongolia’s battle against tuberculosis

Volunteers take anti-TB medications to around 400 patients each month. Image from shutterstock.com

Chinggis Khaan (or as he is known in many countries, Genghis Khan) is Mongolia’s national hero. The famous 12th and 13th century leader used considerable military and political savvy to build one of the largest empires in history. But while he was building an empire, another invader silently spread from person to person.

This invader, Mycobacterium tuberculosis, favours stealth over force. The disease that it causes, tuberculosis (TB), has endured from ancient times into the 21st century.

It is estimated that one-third of the world’s population is infected with Mycobacterium tuberculosis and around 5% to 10% of these will develop active TB in their lifetime.

Even with effective antibiotics, TB is still a major global health problem, though it is rarely seen in developed countries such as Australia. TB disproportionately affects the world’s vulnerable, with over 95% of active cases and deaths caused by TB occurring in developing countries. Mongolia has a high burden of TB relative to its population.

Chinggis Khaan’s status was re-affirmed in July when the capital, Ulaanbaatar’s main square was renamed Chinggis Square. Image from shutterstock.com

The World Health Organization’s (WHO) most recent Global TB Report estimated that in 2011 there were 8.7 million new TB cases and each day, the disease claims around 4,000 lives. For a disease that is treatable and curable, these statistics are alarming.

This year I’m working with the Mongolian Anti-Tuberculosis Association (MATA). Founded in 1993, MATA is a “home-grown” example of community health workers having a positive impact on TB control. Through a nation-wide network of 300 health volunteers, this organisation coordinates the provision of anti-TB medications, mainly targeting people unable to visit health clinics regularly.

The WHO recommends that anti-TB treatment is given through a scheme known as DOTS (directly observed treatment, short-course), as adherence to medicines over the typical six-month treatment course can be sporadic unless patients are adequately supported. Under DOTS, each dose of anti-TB medication is supervised and signed off by a health worker or volunteer.

MATA volunteers take anti-TB medications to around 400 patients each month through home visits, with volunteers serving patients living in their local city sub-district or town. An additional 280 patients attend contracted cafeterias for a free meal along with their anti-tuberculosis medications.

Volunteers are trained in the basics of TB and can become an important primary source of information, support, early identification of treatment issues and also a vector for encouraging contacts of patients to attend clinics for TB screening.

L-R: S Munkhjargal (MATA volunteer), D Enkhtsetseg (MATA Volunteer Supervisor), T Bayanjargal (TB clinic nurse in Ulaanbaatar) and Y Byambaa (MATA volunteer). These women are part of the team working towards eradicating tuberculosis in Mongolia Cameron Wright.

For their work, volunteers are provided with a small monthly stipend, the Mongolian equivalent of around 30 Australian dollars. They are supervised by MATA staff and work with tuberculosis clinic doctors and nurses who take responsibility for treatment decisions.

The results of this program so far are impressive. This is best demonstrated by looking at treatment outcomes for a specific group of new patients who have returned positive tests, of which approximately 30% of the national total are involved in MATA’s program.

Of 621 patients from this group enrolled with MATA in 2011, 600 (about 97%) successfully finished treatment and almost all of these were cured of the disease. This is compared to an overall treatment success rate for this group of around 88%, reported by the National TB Program.

I spoke to some volunteers based in Bayanzurkh district, an area of Ulaanbaatar (also known as Ulan Bator) with one of the highest prevalence of TB in Mongolia. I asked one volunteer why she was involved in MATA’s program and she replied, through translation,

There is a great feeling of accomplishment for me and the patient when someone finishes their treatment and is cured.

Meeting these volunteers – and witnessing their dedication – makes me think that with time, the TB situation can improve.

Managing a community-based treatment program on a national scale inevitably comes with a set of challenges. The last two decades have seen widespread internal migration, especially during winter, from the countryside into Ulaanbaatar.

Multiple factors have caused this including the transition to a market-based economy following the fall of the Soviet Union, with people increasingly seeking opportunities in the city.

Urban slums are ideal breeding grounds for TB. Image from shutterstock.com

Adding to this, a series of dzuds (particularly harsh winters, commonly associated with a high livestock fatality rate) over recent years has made the continuation of a traditional herder lifestyle untenable for many.

This has led to an expansion of the “ger districts”, urban slums with a multitude of social problems and high rates of TB. The close living quarters during winter, when temperatures can plummet below -40°C, create ideal conditions for TB transmission.

Keeping track of TB patients who have started on treatment is one of the main problems our volunteers face in providing treatment, with many people returning to the countryside during summer. Other issues include reaching patients living in very remote places or those frequently moving around.

Lack of awareness and misconceptions can also be problematic when trying to encourage patients to complete their treatment. A 2012 national survey showed that most people know that TB is curable (84%) and is an air-borne infection (74%).

But many of those surveyed did not know treatment is provided free of charge (49%) or the signs and symptoms of TB (43%) which typically include a chronic cough, night sweats, unexplained weight loss, fever and/or tiredness.

Educating the public about TB can greatly improve case finding and treatment efforts and there is still progress to be made in this area. Providing high-quality training to volunteers is another important aspect of the program and this is complex to manage on a national scale.

Just over half of Mongolians surveyed knew the signs and symptoms of TB. Image from shutterstock.com

Earlier this year I had the chance to participate in the external review of the National Stop TB Strategy 2010-2015, conducted with the support of the WHO. This provided an opportunity for reflection; to praise the many positive achievements of the National TB program and to identify areas where improvements could be made.

My main observation working in the TB area so far is that teamwork is central to reducing the global TB burden. From MATA, to the National TB Program and more broadly the WHO, the Stop TB Partnership and the International Union Against Tuberculosis and Lung Disease (among others), there is a huge network of people working towards a common goal.

Through utilising these partnerships, praising the good and improving the not so good, we can work towards making TB join smallpox as a disease of the past, in spite of the huge challenges that lie between this goal and the present situation.