Miracles do happen when patients and their communities take charge of their own illness. The Omaheke Health and Education Programme bears testimony to that. By Catherine Sasman GOBABIS It is not uncommon these days to see people on the side of a national road waving their yellow or green medical cards at cars as they try to hitchhike a ride in the Omaheke Region. These people are usually tuberculosis sufferers on their way to a clinic. Because many of these patients are desperately poor – and more so because of the disease – they often struggle to get to the nearest clinic for a check-up and fill-up on their prescription drugs. But they do try because of a heightened awareness on the prevention and management of the disease in the region. Patients and community members across the region have joined hands with health services in the battle against tuberculosis and HIV/AIDS since the introduction of a groundbreaking participatory health and education programme in September 1999. “Through participation in the treatment and monitoring of the disease, people have begun to understand their own illness,” says Executive Director of the Advanced Community Healthcare Services (CoHeNa), Dr Cordelia Zvavamwe. The organisation is a newly established non-governmental organisation where it is involved in the prevention of TB and HIV/AIDS through the Omaheke Health and Education Programme (OHEP). The region has since experienced a dramatic decline in TB cases, with the 2006 sentinel survey results showing a decline of 7.9 percent last year from 13 percent in 2004 on the HIV/AIDS prevalence in the region. A baseline study in 1999 revealed a mere three percent detection rate of TB cases. Since the introduction of the programme, this has gone up to 71 percent, “beating the World Health Organisation Standard”, according to CoHeNa Programme Coordinator, Eustasia Makhulumo. Since the introduction of the programme, the cure rate in the region went up from 28percent in 1999 to above 85percent and at one point reached a high of 91percent. Currently the default rate on the protracted treatment period of about six months is zero percent, as opposed to a 51.4percent default rate in 1999. Before, patients just simply did not complete their treatment. Because of the close link between HIV/AIDS and TB, the programme jointly addresses these diseases. HIV/AIDS is tackled with more community-based outlets available and more sensitization of the disease. The baseline study provided a barometer that enabled measurement of the programme achievement, and where the study did not reach, programme staff did a situation analysis to establish the data, says Makhulumo. “Before our programme,” she adds, “TB and HIV/AIDS were low profile diseases. No-one wanted to be associated with it or anyone with the disease. But things have dramatically changed, and we can proudly say that our work has contributed immensely to this change.” Adds Dr Zvavamwe: “The programme was introduced in Omaheke not because the region experienced the highest TB prevalence, but because there was a problem in the management of the disease.” The HIV/AIDS rate among TB sufferers is high. According to Alfons Badi, Programme Officer at the TB National Office of the Ministry of Health and Social Services, 60 percent to 70 percent of the 30 percent TB patients tested for HIV/AIDS test positive. The HIV/AIDS prevalence rate currently stands at 21percent. What makes matters worse is that TB is an endemic disease in the country. The current case notification rate of TB is 15 771 (2006), which translates into about 765 cases per 100 000 people. This means that Namibia has the second highest TB case notification rate in the world after Swaziland. What is TB ? TB patients, says Dr Zvavamwe, suffer as much stigma as HIV/AIDS patients – although this picture has radically changed in Omaheke. “This is probably the case because of the relative relation between TB and poverty. There was also the belief that people with TB automatically suffer from HIV/AIDS.” TB patients, she says, have often lost their jobs, and family members turned their backs on them because of fear of contagion. “Before we started with our work, many TB patients were left to sleep outside or in a small corner of a house,” says an elderly volunteer support giver, Lena Kavee. TB is a disease that usually affects the lungs, but can also affect any other part of the body. It is caused by the Mycobacterium tuberculosis, which can affect anyone of any age, and it is contagious. TB infection can come about as a result of a prolonged close contact with someone with the disease. It is often associated with overcrowded places with poor ventilation, poverty, poor nutrition, alcohol and smoking. It is also associated with immune depleting diseases such as HIV/AIDS, diabetes, cancer and other chronic diseases. It is usually observed when a patient has been coughing for three or more weeks, experiences a loss of appetite and subsequently weight, has difficulty breathing and has chest pains. A patient may also cough up blood and experience night sweat and fever. It is not, says Dr Zvavamwe, incurable or deadly if treated. “People must know that this disease is curable, even if you are HIV/AIDS positive. But it is imperative to go for treatment as soon as possible.” Why Omaheke Is So Successful. With the region’s success in curbing TB and observing a zero default on treatment, the Ministry of Health has baptized it as a model for other regions to emulate. The OHEP programme, according to Makhulumo, was the first initiative to bring home-based care to communities. With that came more education about the disease and tools to manage it. The standard treatment of the disease is six months, hence the high default rate. And herein lies the rub. Patients ought to take daily doses of tablets as part of their treatment. But, as with any other medication, the default rate is unacceptably high. “We now make use of home-based directly observed treatment [DOT],” says Makhulumo. What this entails is that patients can ascribe someone to supervise them when they take their medication, and to make sure that they have sufficient supplies of the necessary tablets. “It goes so far that these supervisors make sure that the person has swallowed the tablet, that there is nothing hidden under the tongue and that the throat moves. We do not cut corners,” she says, adding, “We have realized that this supervisory strategy works. It ensures observance of the entire treatment period.” The patient and supervisor then jointly document the adherence to the treatment regime. “There are as many DOT supervisors as there are patients,” continues Makhulumo. “Once a person is diagnosed positive, we get in touch with that person’s closest contacts at home or work, and scan them for the disease.” The programme has established community-based structures, and community clinic health committees – often consisting of former patients – that form a link between health services and the community. They all get training regarding the control and management of TB and HIV/AIDS. “These structures are very powerful and we have regular peer reviews,” says Makhulumo. “Our village committees often start from water point groups, to the literacy teacher that becomes a communicator of TB and HIV/AIDS prevention. We are really proud of what we have achieved in this region. It is something we can write home about.” Lena Kavee, the volunteer supporter of the Epako TB and HIV/AIDS group, was co-opted for the programme from church. A total of 75 volunteers signed up, but eventually most fell out. “But I remained in the programme because today it can be your house that is infected, but who knows what will happen tomorrow? Then it can be my turn,” says Kavee. “Every morning I go from my house into the community. With the help of the coordinators we move the community.” With the help of their field promoters, the volunteers would collect sputum samples, and counsel people before and after their diagnoses. They also counsel people on how to take their medication correctly and how to improve their nutritional intake. Willem Araeb, who is HIV/AIDS positive and formerly suffered from TB, is currently supervising the treatment of his sick wife and small grandson, who contracted TB. When New Era visited his home in Epako, his wife was lying weakly outside on a spread of blankets. “Many people are now coming forward and want to be tested for TB or HIV/AIDS,” says field promoter Maria Modise. “In the beginning we had to run after people.” “We are much better now,” said Araeb, after he joined the programme. Today he feels strong and empowered. Before, he was bedridden and felt dying of AIDS. He lost his job three years ago because of the disease and is solely responsible for the payments on his house. “I also supervise another patient that has recently been cured of TB although he is HIV/AIDS positive. I would go with him to the clinic to collect his tablets, and to go for a general check-up.” One problem, said Araeb, is hunger. Oxfam Canada initiated the Omaheke project, and has through its work identified the need for supplementary nutrition to the many patients. It has thus provided small stipends of maize meal. But since it has wrapped up its activities, the food supplies have come to a halt. But structures have been put in place to enable patients and volunteers set up gardening and chicken projects to provide some extra food to the sick. The Epako support group has started a chicken laying farm inside Gobabis with the initial assistance of Oxfam Canada. After that, the USA Embassy provided the farm with new chickens. Jakobus Kibigotsi, chairperson of the Epako support group, says that each of the 228 patients the group takes care of gets seven eggs per week “for extra strength”. The rest of the eggs produced at the farm are being sold to private businesses in the town to sustain the project. The volunteers rotate their work between the house-to-house visits and duties at the chicken farm. They visit nearby villages such as Kromberg, Vergenoeg, and Drimiopsis that do not have clinics in pairs. They received the piece of land from the Gobabis town council for free, but says Kibigotsi, they are now pressured with water and electricity bills. Other gardening projects are in Leonarville, Tasmanas, Otjinene and Epukiro. “We did not panic when Oxfam Canada pulled out,” says Dr Zvavamwe, emphasizing that the fight against the two diseases also requires a multi-pronged poverty alleviation strategy. “What is important for people to know,” stresses Dr Zvavamwe, “is that people should know that TB is curable and that it is not a punishment from God. The most important thing is for people to come forward the minute they detect the disease.” Adds Kavee: “Our sick people are no longer treated as cockroaches. We are getting on track. Even the bedridden speak out more freely. We teach the families of the patients how to wash and take care of them. In that way, the families feel more empowered and more willing to accept the ill.”