Cindy Gibb is a nurse from New Zealand working in MSF’s groundbreaking treatment programme for children with drug-resistant tuberculosis in Tajikistan, Central Asia
It is 8 am in Dushanbe, the capital of Tajikistan, and already it’s hot in the summer sun. I like to start my working day before the others come to the office. Today I need to find time to work on the sputum induction protocol. It’s difficult to diagnose tuberculosis in children bacteriologically, because most kids, especially the younger ones, can’t produce enough sputum for the tests. Paediatric TB is a neglected disease, and there isn’t enough research and development, or any clear-cut advice, on how to treat it in children. Our project is significant – both for MSF and globally – because we are developing guidelines that simply haven’t existed before.
My time is divided between the office, the children’s TB hospital in Dushanbe, and the TB hospital in Machiton – 17 km east of Dushanbe – where MSF has just opened a specialised ward for treating children with drug-resistant TB (DR-TB). I also do home visits. Currently, we have 10 patients receiving outpatient care, and the geography of my regular trips ranges from a 20-minute drive to visit 13-year- old Marhabo, whose family lives within the old city walls, to a four-hour drive to Shaatuz and Hamadoni, in the southern Khatlon province. We have two families to visit in the area, where the prevalence of DR-TB is among the highest in the country, but health provision remains unreliable.
At 9.30 am I am in the children’s TB hospital with our doctor. Commonly children are admitted here from as far away as Khatlon province (in the south) and Sogd (in the north), some for six to eight months of treatment. There are about 30 children with drug-sensitive TB, and five children with drug-resistant TB. My role is to oversee the treatment and how the hospital staff are dealing with the side effects of the TB drugs.
We’ve been busy recently, with three patients in our programme discharged within one week. They will receive the rest of their treatment at home. Yesterday I visited a mother with multidrug-resistant TB (MDR-TB) and her two little boys, who are also sick with TB. Nadira and her family live in a hard-to-reach village north of Dushanbe. It’s just 40 km away, but around two hours’ drive each way due to the poor condition of the road. We always climb the last 20 minutes on foot – a steep uphill struggle, best suited to the donkeys who overtake us on the way. But the scenery is amazing; we are surrounded by the almost unbearable beauty of the summer river valley. We know that the earth road will barely be passable from autumn until springtime, and in the winter the villagers will be cut off from the highway by snowfalls.
When a child is discharged from the TB hospital, I have to prepare everything for their smooth passage: I make sure that the drugs are available, that the nurse at the local health post is trained and motivated to work on the case, and that there is transport available in case the family needs to travel to the nearest clinic. Usually, it’s the local community nurse who observes the daily intake of drugs and gives the injections, but in the case of Nadira’s family, it’s a volunteer who we have trained who is also a distant relative of theirs. She has no formal health training but neither does anyone else in their village. We provide ‘enablers’ – such as transport and mobile phone credit – to the families and care providers performing home visits. Patients also get weekly food parcels containing basic products, such as tinned meat, fish, milk and vegetables.
Next week I’m going to visit the family of Nadira’s sister, Gulnara, another part of the heartbreaking mosaic of ‘family TB’. Both Gulnara and her two children, Hassan and Dilnoza, are sick with MDR-TB. Identifying close family contacts is an important part of the project, given the strong family ties and the tradition of extended families living together in one household.
Lunch in the office is the time when all the team comes together and discusses work and non-work related issues. I also have my regular hour of Tajik language lessons. I discovered pretty soon after I arrived that knowing how to say even basic things in Tajik opens up many doors – and hearts – in my professional and personal relationships.
The doctor and I, along with our translators and a driver, are going to drive for three hours along the picturesque – if bumpy – mountainous road before dark falls, then will stay overnight in Shaartuz. The following day we will see our patient and family and check on the local health post and medical staff.
In the car, I eventually have some time to work on the policy on sputum induction in children with TB. The rest of the trip we practice our Tajik. My work requires a lot of travel, but I feel privileged to do this job and to see all the little corners of Tajikistan. The project is growing, we will have more and more patients receiving outpatient care, and I am looking forward to finding a Tajik staff nurse to help me.