Thursday April 5 2007
Shorter version at: Friday April 6 2007
An Army of Housewives Battles TB in Bangladesh
Photo: Zahida Khatun Jharna looking over medicines she has for sale at her home in Betgari, Bangladesh. Ms. Jharna is one of nearly 70,000 women across the country who work for a private group that fights tuberculosis (Tomas Munita for The New York Times)
By SOMINI SENGUPTA
BETGARI, Bangladesh In the golden haze of dawn, Mohammed Salim Sheikh walked slowly through the paddies, so frail and thin that the lungi wrapped around his waist looked like a clown’s oversize trousers.
Carrying a treatment chart in one hand and a stainless steel water glass in the other, he crossed the threshold of a house. The housewife inside, Zahida Khatun Jharna, rose from her cooking fire, fetched his medication and filled his water glass. Then she ticked off his chart for the day and sent him home.
The routine plays out in countless villages across this country every morning, and it represents a remarkably simple but apparently effective effort to tackle a stubborn and deadly epidemic: tuberculosis, a scourge that kills 1.6 million people worldwide each year.
In a country plagued by years of corrupt and sluggish governance, Bangladesh has come up with a novel innovation to curb the disease. Private groups have stepped in to take charge of the national tuberculosis treatment program.
The largest effort, run by the Bangladesh Rural Advancement Committee, or BRAC, deploys an army of unsung housewives like Ms. Jharna, one of nearly 70,000 women across the country.
They conduct daily household surveys in their neighborhoods, hunt for patients like Mr. Sheikh who have been coughing for more than three weeks a standard measure of detecting potential patients coax them to get tested and, most important, administer a long and rigorous treatment.
The enterprise has steadily borne fruit. The detection rate in Bangladesh inched up to more than 70 percent in 2006, according to the World Health Organization, and the cure rate to 89 percent. Among the 22 countries that are considered to be heavily burdened by tuberculosis, few have reached those levels, the health organization says.
“They are a doorstep away from whoever supervised the treatment,” said Marijke Becx, until recently the tuberculosis adviser for the W.H.O. in Bangladesh. “They don’t need to walk for hours or spend money for buses or rickshaws in order to get their supervised treatment, and I am convinced that this largely contributes to the high cure rate.”
A survey by her office found that 80 percent of tuberculosis patients in Bangladesh now received treatment from community-based approaches like this one.
Much of that success depends on keeping patients in treatment for six months. Patients the world over stop their medication too early once they start feeling better, which usually takes no more than a couple of months. The danger is that the disease lingers in the body and can become drug-resistant and a far more dangerous blight.
To help ensure that patients stay in treatment, the health workers collect a deposit. Ms. Jharna holds the equivalent of about $3 cash from Mr. Sheikh, a tidy sum here. At the end of six months of treatment, she will have to make sure Mr. Sheikh is tested one last time. If his lungs are clean, she will return the deposit.
“They’re very happy when they get the money back,” Ms. Jharna said. All told, she said, she has cared for 27 tuberculosis patients in the last 12 years as the health volunteer in this village. For each one cured, she earns a stipend of about $2.50 and, as she described it, her community’s abiding respect.
Whether the Bangladeshi model can be replicated elsewhere is open to debate. The country has not yet felt the burden of AIDS, which has vexed tuberculosis treatment elsewhere, in large numbers. Nor has it been affected in a big way by drug-resistant forms of the disease, which have been the bane of other countries, particularly in Eastern Europe.
With a population of 140 million, Bangladesh is among the poorest and most crowded countries in the world, which makes it fertile ground for tuberculosis: Like the common cold, tuberculosis is contagious, airborne and spread by close contact, when an infected person coughs or spits.
According to the World Health Organization, there are 300,000 new tuberculosis cases and 70,000 tuberculosis-related deaths each year in Bangladesh.
The Bangladesh program’s army of housewives acts as the eyes and ears of the public health system, and a sort of mobile pharmacy as well. Its reach is an apt metaphor for how the nonprofit sector rather than the government has filled a gap in delivering the most basic public services in this country. For instance, it also runs a university, a bank and a network of informal schools that educate more than a million children nationwide.
On a recent Tuesday morning in Majira Dakkhinpura, a nearby village, Monowara Begum went along the narrow alleys with a small drugstore stuffed in her shoulder bag and a journal in her arms to document the health of the village. She pushed in creaky gates. “Can we come in?” she hollered at each door.
Monowara Begum showing medicines to families in Majira, another village in the program. The village caregivers sell simple medicines and hygiene products, as well as identify the sick and monitor treatment. (Tomas Munita for The New York Times)
The women of the household gathered around her, and she took notes. Have the children received polio drops? Has anyone been coughing for three weeks? Does the household have a proper toilet?
Then, she started a mild sales pitch. Her bag was full of medicines for ordinary ailments “tuki taki” is what she calls it in Bengali this small thing, that small thing, which included acetaminophen for aches and pains, oral rehydration salts for people suffering from diarrhea, sanitary napkins, lotions to soothe skin rash, deworming pills, birth control pills, condoms.
Stopping off at 17 households that day, Ms. Monowara sold a few sachets of rehydration salts, two bottles of vitamins, some skin lotion and a strip of 10 painkillers.
On average, the health workers say the sale of medicines, offered at wholesale prices, brings in about $5 a month. It is an incentive, BRAC officials say, for the women to go out and scour their villages for suspected tuberculosis patients.
Mr. Sheikh, of Betgari, is a typically tough case. He was a bus driver’s assistant until tuberculosis weakened him too much to work. He has been sitting at home for several months, penniless, sick and sleeping most of the day, and increasingly seen by family members as a freeloader.
He says he now feels pressed to return to work, a prospect that Ms. Jharna dreads because she fears that he will be unable to come each morning for his treatment. She has gone to see his sister and urged her to feed him for another couple of months, at least, until he gains some strength. She said she hoped the family would understand.
Ms. Jharna, for her part, says she has steadily gained credibility in her community.
When she started doing the rounds 12 years ago, some of the village leaders, all men, waved sticks and shouted insults. They accused her of being a Christian. They said it was unbecoming of a Muslim woman to go door to door through the village.
Now, she said, one of her most strident former critics salutes her when she crosses his path. She thinks it is because she sold some cough syrup for one of the children in his family and it made the child feel better.
Her own financial health has improved as well. She makes her own money, modest though it is, from the sale of medicines. No longer, she said, must she cup her hands before her husband, who works as a rickshaw driver. The village knows her.