Bad Apple and TB Prevention

Tuberculosis (TB) is a chronic infectious disease of Public Health importance caused by bacteria known as Mycobacterium tuberculosis and affects people in most countries of the world. Almost every organ of the body can be affected but Pulmonary Tuberculosis (PTB) accounts for more than 80% involvement. The commonest symptom of PTB is persistent cough lasting two weeks or more, usually accompanied with one or more of weight loss, malaise, drenching night sweat, loss of appetite, low grade fever, chest pain, dyspnea or hemoptysis.

TB is highly preventable and curable. However, patients are placed on medication for as long as 6-8 months (depending on the drug regimen) and poor compliance results in multiple (MDR) or extreme drug resistance (XDR) TB both of which have very poor prognosis.

Global Situation of Tuberculosis

In 2010, there were 8.8 million incident cases of TB, equivalent to 128 cases per 100 000 population and 1.45 million TB-related deaths globally. About 13% of cases occur among people living with HIV (PLHIV) while 290 000 cases of MDR-TB are estimated to exist.  Most of the estimated number of cases in 2010 occurred in Asia (59%) and Africa (26%); smaller proportions of cases occurred in the Eastern Mediterranean Region (7%), the European Region (5%) and the Region of the Americas (3%). India and China accounted for 40% of the world’s notified cases. 92% of the global TB cases are found in 97 countries most of which are developing countries. 22 countries with 80% of global TB cases were classified as high-TB burden countries (HBC) and have been given priority attention since 2000. In 2009, there were an estimated 9.7 million children who were orphans as a result of parental deaths caused by TB. The disease is also more common among men than women, and affects mostly adults in the economically productive age groups; around two-thirds of cases are estimated to occur among people aged 15–59 years. Treatment success rate among new cases of smear positive pulmonary TB was 87% in 2009.²  

In Nigeria, TB, Malaria and HIV/AIDS are major causes of mortality across all age groups. TB interests me because it’s not just a global disease of public health importance but my country, Nigeria ranks 5^th among the high-TB burden disease countries.²The prevalence of TB is estimated at 199 cases per 100 000, far above the global prevalence.² A Study by GI Pennap et al demonstrated statistically significant relationship between low socioeconomic status and high TB burden in Nasarawa State, Northern Nigeria.³ Lower literacy, higher unemployment, higher poverty index are associated with higher TB incidence. The Fulani (tribe) nomads and communities also drink unpasteurized milk from their cattle accounting for relative high cases of abdominal TB (extra-pulmonary TB).³   The distribution of TB follows similar pattern as HIV/AIDS. In 2006, 30 in every 100 persons living with HIV/AIDS had TB. 4

This poses a monumental task in achieving the Millennium Development Goals (MDGs) of halting and then reversing new TB infections by 2015 relative to 1990 levels.

Etiology of Tuberculosis

Mycobacerium tuberculosis is transmitted from a person with TB disease to another person through inhalation of droplets when such person coughs spits or sneezes. In general, a relatively small proportion of people infected with Mycobacterium tuberculosis will go on to develop TB disease. The risk of exposure depends on presence of a person with untreated PTB or poor ventilation or overcrowded areas; risk of developing TB is much higher among immune-deficient individuals such as People Living with HIV/IDS, systemic illness like diabetes mellitus, patients on cancer chemotherapy, prolonged use of steroids, chronic alcoholism and malnutrition.

As an endemic population, many Nigerians have dormant TB infection which could easily be reactivated. Unhealthy behaviors linked to the high TB burden in Nigeria include but not limited to failure or refusal to immunize children, consumption of unpasteurized milk, indiscriminate abuse of cheap local but unrefined alcoholic drinks, declining of HIV screening by high risk groups, harmful cultural practices like female genital cutting and building of homes without adequate ventilation. The strong presence of some religious faith which campaigns against use of contraceptive devices including condoms and relative weak health system are also contributory.⁵

TB Prevention: 'Bad Apple' vs 'Curve Shifters'

Huge financial resources are being committed annually by TB endemic countries and the global community in diagnosis and treatment of TB disease. Ironically, most of the highly endemic countries are among the world’s poorest countries. Among 97 countries for which trends can be assessed since 2006, funding is expected to reach US$ 4.4 billion in 2012, an increase from  US$3.5 billion in 2006.² All these money are being spent on diagnosis and treatment of cases which is the main focus of the World Health Organization (WHO) Stop TB Strategy. This is a ‘Bad Apple’ approach as such huge amount of money is being utilized to control TB among a population at the tail of the Geoffrey Rose Curve. 

The Rose Curve is a graphical representation of a group or population distribution of a health behavior of interest. It is a quadratic curve with the level of health-related behavior on the horizontal axis and the percentage population with that behavior on the vertical axis. It depicts that a small percentage of the population are at both extremes of a health-related behavior while most people are near the average point. This curve can be plotted for various health-related behaviors such as salt consumption, drinking habit, sexual behavior, exercising, personal hygiene, smoking habit, vaccination against infectious diseases, etc. According to Tom Farley & Deborah Cohen - two public health experts, disease control strategies using diagnosis and treatment have over the years proven not very effective as they target the small high risk population while more deaths are recorded among the majority apparently not-at-risk population. Individual health-related behaviors may fall on any side of the curve while that of the group is represented by the entire curve.¹ The “curve shifters” refer to four key features that affect the environment and influence the daily behavior and norms of a population and can be used to achieve a healthy behavioral change in a whole population. 

WHO admitted in her 2011 report that MDG target for TB cannot be attained in 2015 especially in the African Region. Rather than spending so much on a less successful curative approach, I strongly feel a better result would be achieved should Nigeria and other countries with similar health system create a better environment and promote healthy behavioral pattern using the Farley & Cohen "curve shifters" as described below;  

Accessibility: The Nigerian government has a policy of free vaccination of all children less than 5 years against preventable endemic diseases including TB.  However, the vaccines are only free in government-owned health facilities. The rural population most of who live below one dollar per day cannot afford to pay for vaccination. Accessibility to BCG vaccine can be increased if the government builds more health centers and/or partner(s) with the private local health centers closer to underserved population to provide free vaccination services. Malnutrition is one of the commonest causes of Under-5 mortality in Nigeria and a significant portion die from TB infection. Many rural dwellers are subsistence farmers but their farm produce perish due to lack of proper preservation. Food can be made more available and accessible if modern preservation methods are provided. Pasteurized milk should be subsidized and accessibility increased by states of the Fulani tribes.   Free condoms should be made more accessible by installing Condom dispensers in clinics, tertiary institutions and public places like hotels, supermarkets and motor parks. This would reduce risk directly of HIV and opportunistic TB infection indirectly.

On the other hand, accessibility to alcohol and tobacco use should be restricted.

Physical Structures: A Study to determine the factors responsible for the high incidence of TB among children who received BCG vaccination in Okposi, South East Nigeria, found that the vaccines lost potency because the cold chain was not maintained by the local health facility.⁶ As a country with irregular supply of electricity, solar powered refrigerators should be provided to all health facilities while government intensifies efforts to stabilize power supply by building more power stations. Some people complain they don’t enjoy sex with the use of condoms. Making condoms thinner and more sensitive can increase its utilization.  Building of physical infrastructure like good roads, potable water supply and electricity in most communities would accelerate development, promote economic activities and reduce unemployment and poverty. More housing should be provided to prevent overcrowding in highly populated cities.

Social Structure: With increased accessibility to BCG vaccine, a law or policy that would make refusal or failure to vaccinate children a punishable offense and can be helpful. Promotion of community participation in health promotion by strengthening the link between the local community associations to the public health institutions through relevant policies can improve compliance with existing policies that promote healthy behavioral change.

Imposition of heavy tax on the cheap local alcoholic spirits which are mostly abused will reduce its consumption. Indoor, outdoor or workplace smoking bans can be implemented by states and local health authorities. Policies that provide minimum acceptable house standard allowing proper ventilation in buildings should be enacted and enforced especially in the rural areas.

Media: A major challenge in acceptance of immunization was a misinformation that led to the rejection of vaccines by some families. Community and religious leaders and their followers can be more educated through a combination of direct engagement and use of local ‘town-criers’, print and electronic media to promote vaccination and other healthy behaviors in the community. Pornography in prints and electronic media should be reduced to the barest minimum to check indiscriminate sex and HIV transmission. 

In conclusion, the WHO Stop TB Strategy would record more success if Nigeria and other high-TB countries if more money is voted into providing physical and social environments that would improve the socio-economic status and consequently promote healthy behavior of the people using the "curve shifters" as discussed above. Efforts on treatment of diagnosed cases and prevention of HIV  and other chronic diseases should be sustained as they are not mutually exclusive. 

References

11. Tom Farley and Deborah A. Cohen, Prescription for a Healthy Nation. Beacon Press, Boston, MA. ©2005

22. World Health Organization; WHO Report 2011, Global Tuberculosis Control

33. G. I. Pennap, S. Makpa & S. Ogbu – Prevalence of HIV/AIDS among Tuberculosis Patients in a rural community in Northern Nigeria. Trakia Journal of Sciences, Vol. 9, No2, pp 40-44, 2011, Copyright © 2011 Trakia University

44. Nigerian Federal Ministry of Health, National TB & Leprosy Control Program; 2006 National TB Sentinel Survey

55. Family Health International; Community TB Care in Nigeria: a project review, ©2009 fhi

66. Ndukwe, S.O, et al; Factors responsible for the Incidence of TB among Children who received BCG Vaccination in Okposi, South East Nigeria; National Postgraduate Medical Journal (Public Health Edition) 2004

How Beneficial is Tobacco Smoking?

"They are very fond of smoking and they inhale the smoke, which intoxicates them and makes them ill, but they keep on doing it" - Gabriel Franchere

Tobacco is a very important leaf, just as so many people love it, much more people appear to hate it. It commands so much interest from both sides of the divide. Those who chose to love it can't stop enjoying the euphoric feeling they get from puffing. Lovers of the leaf cut across socioeconomic strata, age, race, religion, profession and any societal grouping you may think of. It's a wonderful leaf. A friend once described it as "a gift from above". Others who dislike have spent so much money in conducting research on and preaching to people on how tobacco is one of the greatest killers of mankind. It's a product used by the most productive age group (for consumption), medical scientists (for research), businessmen (for maximum profits), just name it.
I don't know which side of the divide you are, but let's kindly review some indisputable facts together;

Tobacco leaf contains the almighty NICOTINE, the substance that causes smokers to continue to smoke. More so, smoke from tobacco products like CIGARETTE has been found to contain over 4000 chemicals including carbon monoxide (same gas produced by automobile exhaust pipes), hydrogen cyanide, carbon dioxide, DDT (used as rat poison), chloroform, formaldehyde, benzene, etc. These chemical contents not only have toxic effects but over 60 of them have been demonstrated to have mutagenic and carcinogenic effects.

Why is Cigarette addictive?
When someone smokes, nicotine gets absorbed into the lungs and reaches the brain within only ten seconds. The nicotine component causes a release of dopamine, neurotransmitters that carry information across synaptic clefts of the brain neurones, acts on the mesolimbic-dopamine circuit (the brain's pleasure center). This center also seems to reward activities that increase the likelihood of survival, such as sex and eating. Activation of this pleasure/reward circuit also causes a cascade of biochemical changes in the brain cells, creating memory of the event and the motivation to do it again, hence the setup for addiction.


What other effects does smoking have on the body
The tar gets deposited in the lung tissue causing the darkening; carbon monoxide competitively displaces oxygen from binding with haemoglobin (blood), this means that less oxygen gets to the body tissues for use; hydrogen cyanide causes the dis-functioning of the lung cilia - tiny hairs that help clean the lungs by moving foreign substances out. It raises the blood pressure and heart rate, causes narrowing of the tiny blood vessels and reduction of blood flow to the heart, kidneys and other vital organs of the body. It weakens the immune system and predisposes people in TB-endemic countries to develop tuberculosis disease.

Furthermore, cigarette smoking has been found to cause erectile dysfunction, irregular menstrual cycle and other fertility problems. Even innocent children are not spared, as the smoke they inhale from the environment predisposes them to having Sudden Infant Death Syndrome (SIDS). It is also the ultimate risk factor for various types of cancer especially cancer of the lungs, esophagus, stomach, blood, etc

Fig. 1 - the internal organs of a chronic cigarette smoker during an autopsy

Smoking leads to many other disease conditions including emphysema, chronic obstructive pulmonary disease, coronary heart disease, gastric ulcer, and a poor post-operative prognostic factor.

Does smoking affect the society?
Behaviourally, tobacco smoking promotes unhealthy acts such as drunkenness, unsafe sex, rape, violence which inadvertently leads to increase in the incidence of HIV/AIDS, delirium, suicide, homicide, road traffic injuries or related deaths (from drunk-driving), etc. Anyone in the society is affected directly or indirectly. When a "high" driver hits the road, his life, those of the passengers and other road-users are also at risk. These have both health and economic consequences.

Benefits of tobacco
What smokers consider as benefits are just the transient mood-altering effects of the drug. The producers of this killer drug can give a thousand and one economic benefits and the employment opportunities it creates. I hope one can sponsor a holistic and minimally biased comparative analysis of the economic and demerits of tobacco across the globe.

Why do people smoke?

Fig. 2 - compare the lungs of a non-smoker to that of a smoker

Many people start smoking from teen age and usually results from peer influence. Young people start smoking to feel that the "belong" to the group "wey dey run things" or as a way of developing their "swags". Most smokers are aware of the dangers the habit constitutes to their health, perhaps they don't know that it also constitutes danger to the health of their loved ones around them who don't smoke. For instance, studies in America shows that smoking kills over 440,000 Americans annually and about 50,000 non-smokers die every year from lung cancer and heart disease caused by 'side-stream smoke' (indirect smoking).

Even in developing countries, there has been rising cases of death from cancer. Though not all those cases of cancer were linked to cigarette smoking, they may not be unconnected with the unchecked pollution of the environment from tobacco smoke and industrial pollutants. While efforts to curb smoking was being intensified (mainly by Public Health practitioners) in the United States, Nigeria offered license to British American Tobacco to build one of her largest factories in Ibadan. With increased availability of the products and non-existent or poorly implemented regulatory measures; awareness of the dangers of smoking alone cannot stop people from engaging in the habit.

Nigerian government's effort so far to control smoking

The most successfully implemented anti-smoking policy in Nigeria is the ban on advertisement of tobacco products. Ironically, the policy came a few years after same government granted license to British American Tobacco to establish a factory. BAT had long completed building a very big factory in Ibadan, Oyo State. Their arrival into the market was very noticeable as they bought over the front pages of all national dailies to advertise their products and tobacco jingles were played on radio and television stations almost at 5 minutes intervals.
The government has also enforced the inscription on every cigarette pack "The Federal Ministry of Health warns that smokers are liable to die young" on the packet of every tobacco product. Although no known study has been reported on how many persons this message has persuaded from engaging in or quitting smoking, I am convinced that at best, any  positive effect would be infinitesimally small and insignificant.
More so, the ban on smoking in Public Places in Abuja, the federal capital territory only ends on the media as it is not being enforced anywhere. People still smoke on the roads, gardens and parks, and even in offices.

What we can do
A combination of the various psychological approaches to influence behavioural changes may appear ideal but studies have shown that its impact is negligible even in the United States society where such has been implemented. Rather than concentrate so much futile efforts on convincing chronic smokers to quit, or using much of our scarce resources to institute smoking-withdrawal programs, it would be more beneficial to stop the things that make people to engage in smoking and channel other resources to strengthening our health system so that people can stop dying from curable ailments.

I strongly recommend that the Nigerian government has to make policies and implement programs and activities based on Geoffery Rose's curve shifters by;
* Reduction in the Accessibility of tobacco products
This could be done by increased taxation on tobacco products, restriction of sales to young people lower than 18 years of age as well as stoppage of sales by 'mallams' who serve as gates-men in our neighborhoods.
*Provision of Anti-Smoking Physical structures
British American Tobacco should be made to reduce the amount of nicotine each stick of cigarette contains. Relaxation centers should designate a place for smoking so that non-smokers would not be put at risk by the pollution from the smoke.
*Provision of Anti-Smoking Social structures
The ban on smoking in public places should be enforced in FCT and states governments should make similar policies in the various states.
*Media Campaigns against smoking
Although the ban on advertisement of tobacco products remains in force, government should fund anti-smoking campaigns in the media. Popular Nollywood artistes and musicians can be used for the adverts. More so, script writers and producers in Nollywood should be encouraged to do movies that would discourage smoking.

It is an incontrovertible fact that tobacco smoking is not beneficial to the body. It is a killer and must be avoided. And various governments in Africa must begin now to stem the tide as it has continued worsening our health indices, in addition to the infectious diseases. Meanwhile, opposing views are welcome with factual arguments. Let's make our air clean enough for the use of our body.

Nigeria's 51st Independence Anniversary: any cause for celebration?

I wanted to write on the above subject, then I remembered my write up exactly 4 years ago, 4 months into Late President Yar'Adua's administration. I lamented the failures of the past and expressed optimism for the future.

I have examined the present state of the nation, there are many things to lament about and few to celebrate. Let me heed to President Jonathan's counsel that we should lament no more. Should I remain optimistic? Yes, I should. The hopes I expressed in the article below were later dashed but I will never be a pessimist.
I see a better Nigeria. I remain committed to contributing my own quota to national development and I recommend that every Nigerian should do same.

You may kindly read through the article below written in October 2007 and published in The Nation newspaper, share what you feel about Nigeria and your expectations for the future.

Together we can! In unity we shall build a new Nigeria. God Bless Nigeria!

Wazobia: any cure for this sick patient at 47?

Nigeria, our beloved country recently celebrated her 47^th independence anniversary. I was in Abuja then and I had expected to witness the usual week-long programme as it used to be during the immediate past administration. That was not to be, rather, it was marked in a low-key manner.

On that morning, my eyes were glued to the television to listen to Mr. President’s address. I was quite pleased with the short but precise speech devoid of self praise and the so called political statements. I must state unequivocally that President Yar’Adua’s style of governance so far has triggered a restoration of my hope and belief in the Nigerian project; which was dwindled by the pseudo-tyrannical approach of the last administration.

Moreover, I would liken the story of Nigeria to that of Mr. Wazobia, a 47 year old chronically ill patient. This patient was delivered normally. He was growing normally, well nourished and catered for until about 6^th year of life when he sustained an injury with a secondary bacterial infection. While the infection was still on but tolerable, he suffered a ghastly road traffic accident that incapacitated him for 3 years. The wounds sustained were yet to heal when Wazobia got infected with a deadly virus. The virus caused severe damages in his system. Working synergistically with the bacteria and other micro organisms, they caused severe starvation, vomiting and diarrhea.

Luckily, the chronic bacterial infection got cured when he was 19 years but recurred 4 years later and lasted for another 16 years. The bacteria finally gave way when a strong combination therapy was used for it, at this time, Wazobia was 39 years old. The viral treatment commenced thereafter. Due to improper use of the drugs, the virus has developed some resistance thereby making the disease very difficult to manage. All these explain the short stature of Wazobia, the scars on his body and other noticeable abnormalities.

In fact, it is sad to know that Nigeria has not been able to address any of the major problems that militate against the socioeconomic development namely: power, water, good transport network and corruption. Nigerians suffer flood disasters but do not have portable water to drink. The poor state of railways and road network are incontrovertibly obvious.  All these work synergistically with corruption to cause a persistent high level of poverty and disease.

The consolation, however, is that the new president seems to be truly committed to taking the country back to the path of progress. The concept of servant leadership, total respect for the rule of law and electoral reforms should be pursued holistically. Mr. President has done well by not wasting the tax payers’ money on elaborate jamboree and fun fare for the elites in the name of independence anniversary celebration. Its better we just mark the day and channel the huge sums to projects that would positively affect the lives of the masses.

Let’s hope the new physician; Dr Y would be able to cure Wazobia of the chronic viral infection (corruption). Meanwhile, Dr Y would require supportive services from other health workers (other leaders) and the prayers and good conduct of the patient’s children (all Nigerians).