BONELA is extremely disturbed by the unacceptable degree of the tuberculosis (TB) epidemic in Botswana, and the inadequate national response to this crisis. According to 2005 World Health Organization estimates, Botswana has the fifth highest rate of new cases of tuberculosis in the world. TB is linked to, and driven by, the HIV/AIDS pandemic. People living with HIV are at a much higher risk of developing and dying from active TB disease, which remains the leading cause of AIDS-related deaths – despite TB being an entirely curable disease.
In response to these concerns, BONELA organized a TB stakeholders meeting at the end of April which brought together Ministry of Health officials, public sector clinicians and treatment literacy trainers to discuss this crisis. The aim of the meeting was to assess the current state of the TB response in Botswana, identify the main challenges that we face in eliminating tuberculosis, and develop a set of corresponding recommendations that need to be acted on urgently by government, health care workers and civil society.
Several critical areas were identified as being in need of urgent intervention, one of the most concerning being the extremely poor infection control that is practiced in our hospitals, clinics and communities. TB is an airborne disease that is transmitted through droplets released when people who have not been treated for active disease sneeze, cough or spit. There are simple measures that can be taken – both in institutions and homes – to reduce the airborne spread of TB: improving ventilation, covering one’s mouth when sneezing or coughing, and reducing exposure to people during the infectious period are a few such measures. However, very little has been done to educate communities about these measures, and they are not being widely practiced in health care facilities. Even more disturbingly, many hospitals and clinics function as breeding grounds for the spread of TB, due to their failure to separate TB patients from the general population: allowing for rapid cross-infection to take place in wards and waiting rooms.
This is especially concerning given the high prevalence of HIV in Botswana, which is the most significant risk factor for TB. TB and HIV are often referred to as ‘married’ or ‘twin’ epidemics. Botswana has made significant progress in its efforts to administer Isoniazid Preventive Therapy (IPT) to people living with HIV, in order to reduce the risk of them acquiring active TB infection. Nonetheless, much more work is needed to improve the collaboration between TB and HIV programmes, particularly on integrating the provision of care and treatment services to co-infected people (people living with HIV as well as TB).
Another worrying trend is the increasing number of drug-resistant TB cases, which are much more difficult to treat, are concentrated among HIV positive populations, and are associated with extremely high mortality rates. Over 100 cases of Multiple Drug Resistant (MDR –TB) have been identified in Botswana in the past year, as well as at least 2 cases of the rarer Extremely Drug Resistance (XDR - TB). Urgent action is needed to stem the spread of these even more dangerous sub-epidemics before they explode in our communities. Such action would include improving diagnostics and increasing access to treatment, which are two other critical action areas that were identified at this meeting.
The sad truth is that these figures – frightening as they are – probably do not reflect the full extent of the crisis. Lack of diagnostic capacity and inadequate monitoring make it likely that many TB cases are not captured by the health system, meaning that the reality of the TB situation in Botswana is much worse than the official statistics indicate.
Too many governments and communities around the world waited for HIV/AIDS to devastate populations before they took serious action on it. We need to learn from our mistakes – this cannot happen again. TB is curable – it can be stopped, and it should be stopped now. Now is the time for decisive, swift and radical action, from all of us. Although the government has plans and strategies to deal with the tuberculosis epidemic, we are concerned that the national response and allocation of resources to TB does not reflect the alarming urgency of the situation. We are running out of time, and urgently call upon our leaders and communities to take responsibility to Stop TB before it is too late.