Zambian Activist Spreads TB Message in Ann Arbor
World TB Day got a pre-season boost from Carol Nawina Nyirenda when she visited Ann Arbor in early March and engaged in a whirlwind of presentations in the community and at the University of Michigan. These ranged from an intimate gathering in an activist’s home to auditorium lectures for medical students. At every stop, people were interested in her experiences organizing her community and stepping onto the world stage. Her diffident smile and easygoing accessibility charmed all who encountered her.
What moved me most was her personal story as a person living with HIV and a TB survivor, which she told in full only at the intimate gathering. When Carol related her family’s initial rejection of her, I felt her pain and, for me, stigma moved from a concept to an experience. Her family originally believed she would soon die but embraced her when she got treatment and recovered. However, it did little to ease the hurt.
Medical and public health students at the University of Michigan have been educating themselves for years on issues related to HIV/AIDS and embraced this opportunity to learn more about interrupting the synergistic effects of the HIV/AIDS and tuberculosis co-infection. They were especially interested in dual screening procedures and the mechanics of avoiding spreading TB to HIV patients sent to a TB clinic for screening.
Vernard Green, a senior public health advisor with Centers for Disease Control and Prevention and the Detroit City TB program and operations manager, joined Carol at the public health and medical school presentations. It was interesting to note how the city of Detroit and the country of Zambia set up similar cross screening at about the same time. Detroit emphasizes also doing preventative treatment of all people who were exposed to active TB. Carol has been advocating in Zambia for such a prophylactic treatment of HIV-positive people with latent TB.
Another intersting difference was the length of time during which patients are observed taking their TB medication (DOTS). In Detroit, patients with simple TB are observed for nine months and those with multidrug-resistant (MDR) TB are typically observed for 18 months, but in Zambia patients are observed for only two months, though they are given four more months worth of additional medication. I learned that the Zambian model is probably sufficient but that in the United States the threat of a TB outbreak is considered so harmful to the public good that the extra months of treatment are done as a precautionary measure.
According to Carol, the biggest obstacle to treatment in Zambia is the lack of good testing, especially for non-pulmonary and MDR-TB. Part of the problem is a shortage of sophisticated labs, but a bigger problem is that most clinics are only able to do testing of sputum. Some patients can not produce adequate sputum for testing and sputum testing only reveals TB in the lungs. We learned from Carol that many HIV positive patients develop TB in other parts of their bodies.
The biggest obstacle to treatment in Detroit is the number of man hours required to adequately treat people living in crisis — especially the homeless and mentally ill. So many logistical problems need solving so treatment can proceed without interruption, and adequate nutrition and shelter are prerequisites for conquering tuberculosis. Case workers, who must help clients manage their lives and observe them take their medication daily, can handle only about eight cases each.
Carol’s final presentation was cosponsored by the University of Michigan chapter of ONE. Students interested in advocacy, Africa, and HIV/AIDS attended. Carol spoke about HIV/AIDS and TB co-infection and about how HIV-positive women started finding each other and organizing once the clinics had treatment options. Her presentation was followed by the movie “Where the Water Meets the Sky,” which focuses on a project in which Zambian women from rural areas make a documentary about HIV and their lives. Carol validated some of the points made in the movie, such as the vulnerability of women and orphans who see prostitution as their only viable option for survival, how all their property reverts to the family of their husband upon his death, and the plight of women who stay faithful to their spouse but are infected because the men often stray. On other points, like the initial reticence of the women to speak out, she observed that while that might be common in the villages, it was no longer the case in the cities.
After Carol’s visit, the Michigan Daily ran a great front page story, and the Ann Arbor News obtained background material to use in a story for World TB Day. Nineteen new people signed up to advocate for legislation and policies that promote tuberculosis control, and eight medical students indicated a desire to be actively involved with RESULTS. All of us who attended presentations had our understanding of the issues deepen, and we now feel a personal connection that adds to the urgency of assuring adequate treatment worldwide.