Tuberculosis and the Creative Spirit

Last Wednesday I visited Abu Anga Hospital in Omdurman, which is the only specialist centre for managing ‘Multi Drug-Resistant’ tuberculosis (MDR-TB) in Sudan.

I travelled by bus, which can get rather painfully hot when stuck in the morning traffic. But buses do give you a chance to see many examples of everyday Sudanese ingenuity at work. Today for instance, as I got to my seat, I stepped over a large hole in the floor resourcefully covered with wooden planks and several dozen nails, so that you could barely even see the road below anymore. Another little example – as the conductor started to collect fares, he ran out of pockets and hands and so started to put coins in his ears. Every inch of space on buses is used. An extra row of seats on hinges fold up and down to fill the aisle, so that passengers are packed in like sardines.

You can get on and off the bus at any point. To get the driver to pull over, you just click your fingers and make a “kssss kssss kssss” sound – as if he were a huge cat (maybe if I try to tickle him I can get a journey for free?). Indeed, for some reason that I haven’t yet discovered, many bus drivers seem to wear furry, leopard-print slippers. There are hundreds of these vehicles on Khartoum’s roads, bus-sized tins of sardines driven by huge furry cats.

Further inspired opportunism isn’t hard to find. Driving past one street corner in central Khartoum, you can see what is very clearly a hearse (i.e. a car with a large glass compartment for displaying a coffin on the way to a funeral). It now rests there on the pavement for evermore, and has been plastered bizarrely with blue and yellow advertisements, plus full colour photos, for a male baldness therapy. But my favourite example of this creative spirit, though unrelated to buses or roads, is the pot of strawberry jam in my room. The maverick designers have created a very colourful illustration on the label, which shows not a single strawberry, but does include figs, bananas, mangos, and (my new favourite fruit) carrots.

Whilst this kind of innovative approach to life can be very handy, when it comes to tackling tuberculosis then good intentions and creativity can create problems rather than solutions. 

The bit about Tuberculosis                                                                                             

Tuberculosis is common in Sudan, out of a population of 44 million people there are around 25 000 new cases every year and a total of about 82 000 cases at any one time (WHO 1). In the UK, for comparison, out of a population of 62 million people, there are just over 7 000 new cases a year, with a total of around 9 600 cases at any one time (WHO 2).

Clinics at both Soba Hospital and the Omdurman Hospital for Tropical Diseases have been full of patients with tuberculosis. The bug – mycobacterium tuberculosis (M. TB) – may infect many different parts of the body, and so patients can present to doctors with symptoms involving anything from the head, neck and spine, to the chest, abdomen and skin.

TB care is co-ordinated by the National TB Programme, based in Khartoum. Treatment for patients should be completely or partially subsidised, and there are very clear World Health Organisation (WHO) guidelines for the use of anti-tuberculous drugs.

(Any readers with a slightly shaky interest in TB management close your eyes now for a couple of paragraphs…)

Patients who fall into ‘Category One’ (i.e. patients newly presenting with tuberculosis) receive first-line treatment (two months of HRZE and then four months of HRE – see below for abbreviations).  If all goes well, patients can be completely cured and symptom-free after six months.

However problems arise when patients present with tuberculosis for a second time, after having started a course of treatment at some point in the past. There are generally three reasons for this:

1) Default – The patient did not complete the full course of medication (i.e. they stopped too early) – for example because they start feeling better, or cannot meet the costs of treatment, or supplies of drugs run out.

2) Relapse – the patient completed the treatment course and was cured, but has been re-infected.

3) Failure – the treatment failed to kill the TB bugs

In re-presenting patients with these backgrounds, the M. TB are more likely to have developed resistance to some of the first-line drugs. They then fall into one of two treatment pathways. Patients who (1) default or (2) have relapsed are deemed to be ‘Category 2’ and are prescribed an adapted regimen including streptomycin (see WHO 2010b).  

However if (3) first-line treatment has failed, then there is a strong possibility that the patient is infected with Multi Drug-Resistant Tuberculosis (defined as proven resistance to H+R). This can be investigated with Drug Susceptibility Testing (DST) of the TB bugs, though this is expensive and can be time-consuming. Where DST is not available (like in Sudan, where it is normally used only for research purposes), such patients are assumed to have MDR-TB, and begin treatment with second-line drugs (see note below for more detail on these).

This second line regimen is far more expensive, lasts for longer, and has more potential for causing serious side-effects in the patient. Financial help is available from a WHO subsidiary called the Green Light Committee (GLC), subject to some fairly stringent criteria to do with the use and monitoring of these second-line drugs. Considering the difficulties that many countries face in applying international standards even for first-line drugs, it can be a huge challenge to satisfy conditions for GLC funding. In such countries, the spectre of an MDR-TB epidemic is alarming.

In Sudan, data from 2009 shows that a quarter of previously-treated patients were confirmed as having MDR-TB, much higher than rates in neighbouring Ethiopia (12%) or Uganda (13%) (Eldin et al 2011).  This is where we come back to the beginning and the ‘creative spirit’.

(…and open your eyes again)

TB drugs are not like buses, you cannot get on and off when you want, you must stay on for the full ride (around 8 months for first line drugs). If part of the drug regimen is missing, it cannot just be tacked over and forgotten about. Each drug acts in a slightly different way, and if one of them is missing, then the M.TB may survive and develop resistance to the first line drugs.

Unlike my strawberry jam label, patients need to be very clearly informed about what they are about to consume. TB drugs can have a range of nasty side-effects. Doctors need to educate their patients, to steel them against coming difficulties, and advise them to continue taking their medications and report any side-effects.

But it’s difficult. Poverty and a lack of education are powerful stimulants to ‘creativity’. If you get some side effects, like hepatitis, or losing your colour vision, then without free and easy access to a doctor and some treatment it’s rather tempting to stop taking your TB pills – particularly if your cough has cleared up.

If they have run out of a particular TB drug at your local clinic or district hospital, or it is only available upon payment (as opposed to being free), then both patients and doctors may try to ‘adapt’ drug regimens to make the best of what they have. This has been a problem in Sudan, with patients being hurt by inadequate private sector regulation (Maalaoui 2008).


So what to conclude? I guess many of the things I’ve discussed here affect people all over the world, not just in Sudan – so maybe this should end with some kind of rallying call for global health. Tuberculosis is not like buses or strawberry jam, and health is not just about pills and doctors. It also involves access to healthcare, income levels, education, private sector behaviour, government regulation, international organisations, guidelines and financial programmes – and that’s all before you get down to the individual, creative level. So it’s not all that simple. It involves structures and processes which can appear very difficult to change, and presents some fairly testing challenges. But with a bit of creative thinking in the right places, surely its possible to get it right?



First line drugs: H = Isoniazid; R = Rifampicin; Z = Pyrazinamide; E = Ethambutol; +/- S = Streptomycin

Second line drugs: These include a parenteral drugs such as amikamycin; fluoroquinolones, such as moxifloxacin and levofloxacin; oral bacteriostatic agents such as ethionamide or cycloserine; and ‘group 5’ drugs such as clofazamine and imipenem (see WHO 2011, especially p19, and WHO 2010b p84-7).

DST – Drug Susceptibility Testing

GLC – Green Light Committee

M.TB – Mycobacterium Tuberculosis

MDR-TB – Multi drug-resistant tuberculosis

WHO – World Health Organisation



Eldin et al (2011) Tuberculosis in Sudan: a study of Mycobacterium tuberculosis strain genotype and susceptibility to anti-tuberculosis drugs. BMC Infectious Diseases. 11: 219   –

Maalaoui, N. (2008) Strengthening TB Drug Management in the Sudanese National TB Control Program: In-Depth Review of TB Drug Management –
WHO (2011) Guidelines for the programmatic management of drug-resistant tuberculosis (2011 Update) –
WHO (2010a) The human face of tuberculosis in
WHO (2010b) Treatment of Tuberculosis: guidelines for national programmes. 4th edition
Green Light Committee (WHO subsidiary for tackling MDR-TB and XDR-TB) –
Sudan: Stop TB website – Eastern Mediterrean Regional Office – (Information about the National TB Programme).

(WHO1) WHO Tuberculosis statistics for Sudan:

(WHO2) WHO Tuberculosis statistics for Great Britain and Northern Ireland:


2 thoughts on “Tuberculosis and the Creative Spirit

  1. Very interesting Pete.

    I really like the pragmatic categorisation approach taken to patients who represent – it seems to be a logical way of making decisions in a resource limited setting. Can I ask what format for the diagnosis of a primary presentation of TB seems to take? From what I’ve seen over the past couple of months over here, the approach to all TB cases seems to be very much based on getting the vital sputum/aspirate/biopsy/stool/urine/etc/etc sample off to the lab for microscopy, culture and DNA testing (catching any likely MDR TB cases straight away). Some of these samples are easy to get, but some require all manner of CT/USS-guided biopsies, and even CT PETs. Still, there is occasionally a dissonance between the lab results and the clinical picture, and usually the final decision seems to be based much more on the clinical impression! I wonder how much they strive for a laboratory diagnosis in Sudan, and how much they rely purely on clinical acumen? It seems to be a big decision to put someone on 6 months of TB treatment, and I wonder if there is any difference in diagnostic accuracy between countries, and what impact that might have.

    • Hey Joel,
      Great comment! Its reassuring to know that the clinical guideline stuff I’ve put into some of the posts isn’t just boring people!
      I can only give you an answer from what I saw, and from what Sudanese doctors discussed with me. But I think that pretty much the WHO guidelines are adhered to fairly closely for diagnosis. That said, the WHO guidelines give recommendations for a range of contexts (i.e. for both ‘resource-rich’ and poor countries). So which category does Sudan fall into here?

      In theory, TB diagnosis (and treatment and follow-up and all) should be paid for by international bodies such as the WHO. But I believe that in reality, these good intentions get swallowed up somewhere along the line, and lots of patients end up having to pay for something at some point of the whole medical process. In addition, hospitals in the UK enjoy access to some top-end diagnostic facilities. I think Sudan falls into the majority of countries who don’t share in such opportunities. For example drug susceptibility testing is really only used for research purposes. There is neither the money nor capacity to extend it further right now.
      So overall clinicians in Sudan will follow the WHO guidelines for more ‘resource-poor’ contexts. This gives heavy weighting to clinical impressions. Investigations such as X-ray, culture of sputum or aspiration (from a lymph node for example) were commonly used in the centres I visited – although I would imagine that even access to these is far more limited outside of Khartoum and the major towns.

      I think also that clinicians in Sudan are readier to start treatment on the basis of their clinical feeling (despite negative or inconclusive investigation results). I guess may be there are several reasons for this. Firstly that TB is so common; this means that doctors will see a lot of it, and know how it presents, and also that TB is legitimately high-up on a differential diagnosis.
      Secondly, I think that because treatment is free, the question of cost for the patient is removed, which makes a trial of TB treatment an easy option. I’ve seen patients come in after an unsuccessful trial of TB medications (i.e. they report no symptom improvement at their one-month follow-up) who have turned out to have Hodgkin’s Lymphoma. They were started on TB meds on the off chance that it might have been TB, which is much cheaper to treat than cancer!

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s