Barriers, obstacles or problems to Access Tuberculosis Diagnosis and receive TB treatment in Afghanistan: Comparison of female and male patients.
The Islamic Republic of Afghanistan, located in the center of Asia, is in most cases geographically recognized in association with central Asia, South Asia, and the Middle East. It is bordered by Pakistan in the south and east, with Iran to the west. It has an estimated area of 251,772 sq mi, with 0% of that represented in waterways. The 2007 population estimate was 31,889,923; the GDP estimate of 2007 was $20.099 billion which is notoriously tied to the opium trade, organized crime and terrorist factions like the Taliban.
The Taliban are Sunni Islamist and Pashtun nationalist that ruled over the majority of Afghanistan from 1996 until 2001. When their officials were removed from power by collaborative military efforts between the Northern Alliance and NATO countries, they flocked to the frontier tribal areas of Pakistan. It was in these regions that they were able to regroup and engage in guerrilla warfare against the current government of Afghanistan. NATO while participating in Operation Enduring Freedom was able to lead International Security Assistance Force (ISAF) and the effort to expand operations and influence in Pakistan to counter this insurgence.
Headed by Mullah Mohammed Omar, the Taliban was a mix of small military unit commanders and Madrasah teachers. The majority of those contributing to the Taliban movement were ethnic Pashtuns from southern Afghanistan and western Pakistan along with a smaller number of volunteers that came from North Africa, the Middle East and the Soviet Union. The Taliban received the bulk of their training, supplies and arms from the Pakistani government, the Inter-Services Intelligence unit (ISI). Despite the fact that the Taliban maintained control of the capital of Afghanistan, Kabul, for over five years, and most of the country, the regime identified as the “Islamic Emirate of Afghanistan” has only received diplomatic recognition from three states, Pakistan, Saudi Arabia, and the United Arab Emirates. The Taliban is most notorious for their strict interpretation of Sharia Law and their cruelness towards women.
Sharia, a body of Islamic religious law, it means ‘path’ or’ way to the water source.’ Sharia is seen more as a system of how law should serve humanity. Similarities between Islamic law and the common law of the United States have also been noted, particularly in regards to Constitutional law. Sameer S. Vohra states that the United States Constitution is similar to the Qur’an based on the fact that Constitution like the Qur’an is the supreme law of the land. They are both similar in the fact that it is the basis from which laws of the legislature originate. Asifa Quraishi states that the methods used in the judicial interpretation of the Constitution are the same as those of the Qur’an. He says this specifically referring to the methods of “plain meaning literalism, historical understanding “originalism,” and reference to underlying purpose and spirit. Vohra further notes that the legislature is similar to the Sunnah in that the “legislature takes the framework of the Constitution and makes directives that involve the specific day-to-day situations of its citizens. He notes that the judicial decision-making process is similar to the qiyas and ijma methods, pointing out how judicial decision-making is a means to apply law to individual disputes “, that “words of the Constitution or of statutes do not specifically address all the possible situations to which they may apply” and that “at times, it requires the judiciary to either use the consensus of previous decisions or reason by analogy to find the correct principle to resolve the dispute.” The inability of the Afghan judicial and legislative system to produce effective health policies has more to do with the way terrorism and organized crime have blended and become virtually indistinguishable from one another or the Afghan’s Democratic process.
One key contrast between organize crime and terrorist regimes that can immediately be distinguished is their difference in historical origin. Most terrorist factions stem from stern religious and political ideological views. Specifically, with the war in Iraq between the Muslims and the Israelites to find the starting point of the conflict, one would have to trace their history as far back as the first crusade. This rich history of civil, religious, and political war, as well as the corrupt factions incorporated in the Democracy to which they have given rise, accounts for Afghanistan’s socioeconomic climate and the can be credited as the core reason why the battle against the Tuberculosis (TB) epidemic receives virtually no financial support from the Afghan government.
1.2 Health System in Afghanistan
Beginning in 1979, military conflict destroyed Afghanistan’s health system. Most medical professionals left the country in the 1980s and 1990s, and all medical training programs ceased. In 2003 Afghanistan had 11 physicians and 18 nurses per 100,000 population, and the per capita health expenditure was US$28. In 2004 Afghanistan had one medical facility for every 27,000 people, and some centers were responsible for as many as 300,000 people. In 2007 international organizations provided a large share of medical care. An estimated one-quarter of the population has no access to health care. Neonatal care is especially poor, and infant and child mortality rates are among the highest in the world. In 2005 the number of infant deaths within the first month after birth, 60 per 1,000 live births, was the second-highest rate in the world, and in rural areas, one in five children dies before reaching age five. The maternal death rate, 1,900 per 100,000 live births, also is one of the world’s highest.
While there has been much progress in developing health services, the shortcoming of the Afghan health system as far as funding or lack of education for qualified professionals can be directly connected to terrorism and organized crime in the region. The effect of war on the Afghan water supply and sanitation technology, as well as the deprecating effect the war has on the socioeconomic state of the middle class Afghan household is a major contributor to the frailty of the health system as well as a large number of the population, mostly women that are left vulnerable to contracting and transmitting Tuberculosis. It is this reason why the end of war in Afghanistan is a significant necessity for any future possibility of ending the TB epidemic.
The key issue U.K. and U.S. military face with subduing the TB outbreaks in Afghanistan has to do with finding cases early through DOT testing and enlisting patients into the treatment process. . The U.S. military allied with the U.K. forces, since the 9/11 attacks, have devoted their efforts to developing capabilities for collecting, analyzing, and acting quickly on intelligence pertaining attack on health facilities and units that provide care for Afghan citizens. In Afghanistan specifically allied forces are finding that advanced technologies are very helpful in identifying insurgents or collecting information to counter their actions. Insurgents have been frequently able to adapt tactics, techniques, and their procedures to avoid these advanced methods. The difficulty to collect intelligence in Afghanistan stems from a lack trust shared between the community and allied forces, which is why U.S. and U.K. troops are trained to invest time in gaining the trust of indigenous locals.
The use of analytical methodology is also used to measure the impact that advancements in the use of have on the local population. This analysis can be tricky as Progress cannot be measured by the advancements of medical facilities across a map; focusing only on the infrastructure of the medical system misses much of the broader support network; a complicated array of political, economic, social, and military factors can fuel the health service initiatives in Afghanistan, and there are rarely ideal predefined qualitative or quantitative target metrics. (Jones 2001, p122)Ultimately the U.S. and U.K. government, and international medical contributors are competing with the insurgence for the trust of the locals, while registered cases of TB increase . Sense one of the key meeting locations for communication and interaction in areas like Afghanistan are place of worship, the mosques must be monitored as well. There are 107 mosques in the city of Kandahar out of which 11 are preaching anti-government themes. Our approach is to have all the pro-government mosques incorporated with the process and work on the eleven anti-government ones to change their attitude or else stop their propaganda and leave the area. (Jones 2001, p22)Here it becomes apparent that U.K. and U.S. troops alike must adopt the attitude of becoming community organizers. Their interactions with Afghani people is a core part of the democratization process, and collecting information to find insurance, criminals and potential terrorist factions.
The American and U.K troops are the first impression and immediate representation of their countries. So, in the case of the U.K. and their alleged mistreatment of the Afghani people and having over 150 cases of sever misconduct, this does not assist allied western forces in resolving conflicts in the Middle East, much less does it help in collecting intelligence on underground terrorist activity. In fact, it does the opposite. The main flaw that can be found in the foreign policy shared by both the U.K. and the U.S. revolves around the lack of training the troops are given to interact with foreign parties. If the troops are the first impression of America they must behave well enough to earn and deserve the trust of all Asian citizens. Secondly America and the U.K. both need to adopt foreign policies that safeguard nations from having their trade resources exploited by multinational corporations outsourcing out of either the U.S. or the U.K. Not only do these corporations create a bad impression of democratic nations with their slave wages, and inhumane business practices, but their capitalistic ideologies cripple the economies and corrupt the judicial systems of foreign nations. In the case of Afghanistan, corrupt business pracitces carried out by deployed US and Eurpean influence combined with a large amount of revenue from the GDP devoted to funding terrorist factions, has resulted in a Health service system entirely reliant on donor support. This happens because outside businesses have separate agendas from the governments of the countries they set up shop in, and especially different priorities than those of the governments they from which they outsource.
Currently, the health system in Afghanistan is overseen by The Ministry of Public Health (MOPH). Its Basic Package of Health Services (BPHS) has been the mandatory benchmark for health providers since 2003. The most notable improvement the BPHS has made in the Afghan health system can been seen in the way over 77% of the population now has access to the services. Every form of primary health care (PHC) as of 2003 was mandated to provide BPHS services.
Robert Rotberg touches on the dramatic influence that the BPHS has made on the afghan medical industry. He first poses a valid question when he asks, “How could Somalia, a nation-state of about 9 million people with a strongly cohesive cultural tradition, a common language, a common religion, and a shared history of nationalism have a medical system that would fail, and collapse? (Rotberg 2008, p427)” He goes on to suggest that the areas in Africa and Asia first elected their democratic officials more as an experiment in democracy than as an act of establishing a substantial government (2008, p427). Rotberg refers to these experiments in democracy as weak nation-states and he recognizes that a country’s decent from being a weak nation to a failed nation is not guaranteed but a product of neglect and weak willed officials in power. Ultimately this type of governmental behavior leads to financially inadequate nations. In the case of Afghanistan medical funding must come from donations, specifically in the fight to counter TB outbreaks. can be the discovery of abundant natural resources. He says, “nation-states are blessed or cursed by the discovery or absences of natural resources, like oil or diamonds, within received borders. But it is not the accidental quality of their borders that is the original flaw; it is what has been made of the challenge and opportunities of a given outline that determines whether a state remains weak, becomes stronger, or slides toward failure and collapse (Rotberg 2008, p432).” The conflict of nations with half fast run democracies and key resources exploited by outside interest groups stems from initiatives set in U.K. and U.S. foreign policy dating as far back as the close of World War II. Currently, without organizations like
1.2.1 Health situation
The physical and psychological effects of war have substantially increased the need for medical care in Afghanistan. Thanks to poor sanitation and insufficient potable water supply, infectious and parasitic diseases such as malaria and diarrhoea are very common. Malnutrition and poor nutrition also represent a major trend among Afghan citizens, especially women. The drought of 1999–2002 enhanced these conditions, left an estimated 800,000 Afghans disabled. Health authorities consider Afghanistan a high-risk country for human immunodeficiency virus (HIV) because of the high incidence of intravenous drug use, unsafe blood transfusion procedures, large numbers of refugees, poor health facilities, and illiteracy. The comparative impact of those factors is unknown. WHO initiated implementation of DOTS strategy (WHO recommended TB control strategy) in Republic of Afghanistan in 1998.The Strategic Programme to fight TB for 2004-2008 was approved by the Cabinet of Ministers’. GDF approved the first line TB drugs supply for 5 oblasts for three years in 2003.The GFATM proposal for USD 13.8 million grant was approved. Green Light Committee (GLC) has approved the second line TB drugs supply for 60 patients of Tashkent city’s DOTS plus pilot (Management of MDR TB patients).
In 2008 the Ministry of Health reported 435 cases nationwide, but it estimated that a total of 2,000 to 2,500 citizens were currently infected. In 2005 an estimated 1 million people were using narcotics, 200,000 of whom used opium. Despite large-scale international assistance, in 2004 the World Health Organization did not expect Afghanistan’s health indicators to improve substantially for at least a decade.
Currently, WHO officials estimate that Afghanistan deaths due to TB have declined by 50% as of January 7, 2008, which they argue has resulted in about 10,000 prevented deaths from the disease. The IRIN News reports about 20,000 people in Afghanistan used to die from TB each year (2007). These improvements can be credited to substantial advancements in the Afghan health system between 2005 and 2007, according to studies done at the Johns Hopkins Bloomberg School of Public Health and the Indian Institute of Health Management Research.
1.2.2 The health service system
Currently the basic health service package provided in Afghanistan involves TB diagnosis and treatment and reaches more than 80% of countrymen and women. In 2001 there were only 36 reported TB diagnostic treatment centers, whereas the current total has been estimated at 991 by the WHO. The organization also points out that between 2001 an 2006, 103,000 TB cases were diagnosed and treated wh9ich is estimated to have prevented more than 67,900 deaths and reduced chances of infection for more than 500,000 people. Afghanistan represents one of 22 countries with the highest TB burden globally, according to IRIN News. WHO estimates that every year there are about 50,000 new cases of TB recorded, 67% of which occur among women due to their vulnerable nutrition, multiple pregnancies and lack of education about TB. IRIN reports show that despite the progress Afghanistan has had to fund health services over the past decade, it is becoming increasingly more difficult to sustain the financial support. This is largely due to the fact that donors supply the majority of the funding. If Afghanistan does manage to sustain its donor support, the Kaiser Family Foundation estimates TB in the region can be completely eliminated by 2050.
1.2.3 Health expenditure
Total population: 26,088,000; Life expectancy at birth m/f (years): 42/43; Healthy life expectancy at birth m/f (years, 2003): 35/36; Probability of dying under five (per 1 000 live births): 257; Probability of dying between 15 and 60 years m/f (per 1 000 population): 500/443; Total expenditure on health per capita (Intl $, 2005): 26; Total expenditure on health as % of GDP (2005): 5.2
Following 9/11 and Operation Enduring Freedom in 2001 to liberate Afghanistan and install a democratic government, heroin opium and production persist and are still a problem for the central Afghan government. Securing the country under democratic rule means the Government of Afghanistan must be able to assert the rule of law, including its ban on opium production.
The security threat posed by both narcotics and the insurgency in southern Afghanistan is considered as being both narco-traffickers and the Taliban. Because they both profit from a symbiotic relationship. Narco-traffickers establish trade within Taliban-controlled areas, as well as supply the Taliban with intelligence, weapons, ammunition, money and transport. The Democratic corrupt involvement is a major source of lossed income for medical services, and the key reason why health service funding is largely contributed from outside of the region. The Taliban impose local levies on opium production and sales, but alsol as heroin laboratory production. They profit from the production of narcotics and their sale in drug bazaars throughout the region. .
This is a convenient marriage reciprocated between the Taliban, which provides security for narcotics exported across the Pakistan and Iranian borders. It also meets the overarching goal for both parties of maintaining instability in the south and thwarting the rule of Afghanistan’s elected government under President Karzai. Drug profiteering in Afghanistan has global links to organized-crime networks, including Canada. It is worth considering that a kilogram of the highest quality heroin at 90-per-cent purity in a drug bazaar sells in Kandahar for $3,000 US. When this same kilogram is transported and sold by Middle Eastern traffickers, its value increases to $30,000–$40,000 US. When it reaches the streets of Vancouver, Toronto and Montreal, after purity has been cut to 60 per cent, the kilogram that originated in the fields of Afghanistan sells for approximately $120,000 CA ($100,000 US). Organized crime groups profit substantially from feeding addiction, while narcotics production in Afghanistan feeds operations against Coalition and Afghan Forces.
1.2.4 Equity in Utilization of Health Service
While controlling disease outbreaks and reducing mortality must be the immediate focus in many post-conflict states, all current information shows that despite political instability in Afghanistan, and limited resources, the NTP of the region has managed to provide top quality TB treatment. This is thought to be due to increased funding that has progressively grown over the past decade.
It is also crucial for these regions to plan for the longer-term development of the health systems, and to help restore civil rights and the legitimacy of the government by providing basic health services. This often involves developing the health system so that it can provide basic services to many overlooked members of the society. In the case of Afghanistan, for example, less than 10% of the population had access to basic health services in 2003. After the fall of the Taliban in 2001, Afghanistan had some of the worst health indicators ever recorded in the world. This was specifically true for pregnant women seeing as how in 2002 the maternal mortality rate exceeded 1600 per 100 000 live births, reaching 2200 per 100 000 in some parts of the country. The infant mortality rate was estimated to be 165 per 1000 live births, and 257 children per 1000, a little over 1 in 4 died before the age of 5 years.
Health facilities had been damaged or destroyed during the years of fighting and, in many rural areas, neither facilities nor trained health workers were available. To improve the health situation rapidly, the Ministry of Public Health (MOPH) of Afghanistan developed the Basic Package of Health Services (BPHS) to deal with those areas in which the country faced its most pressing health-related problems: maternal and neonatal health, child health and immunization, nutrition, communicable diseases, mental health, disabilities and the regular supply of essential medicines. The package reflected priorities for promoting health and rebuilding the health system. A central principle of the BPHS was equity, meaning that the BPHS would be extended to as many people as possible throughout the country.
Because of high maternal, infant and child mortality rates and lack of access to basic services, the MOPH and major donors in the health sector – the United States Agency for International Development (USAID), the European Commission and The World Bank – were most interested in helping to extend access to primary health care, especially for women and children. The BPHS was viewed as the best way to achieve this in a planned and coordinated manner that would address the major health problems faced by Afghanistan. At the MOPH’s direction, the donors took responsibility for funding health services and development activities in different provinces, thereby covering the entire country. The MOPH remained the steward and overseer of the health system and directed efforts to improve it.
1.3 Epidemiology of TB in Afghanistan
Tuberculosis is a significant and major global health threat. There are more than 8.8 million people diagnosed yearly with TB; and within this group, more men than women are noted in having it. This has often sparked interest about gender and its relation to the disease.
2.Problem Statement, objectives and methodology
2.1 Problem statement
With women representing 70% of the registered TB case group, there is a drastic need for advancements in the health system pertaining to female care and services.
2.1.1 Female rights in Afghanistan
According to the 2007 Afghanistan Human Development Report, there is still an enormous gender gap prevalent in the country despite tremendous strides in civil rights. Only 12.6% of adult females are reported as literate limiting their economic opportunities leaving them vulnerable to discrimination and violence. The infant mortality rate has fallen from 165/1000 in 2001 to 135/1000 (2007), which accounts for more than 40,000 successful births each year. Low literacy, lack of access secure food, drinking water, and sanitation is a significant contribution to why the mortality rate is still high. In Zarghoona Salehi’s study on the increase of Turberculosis in Afghan women, he found that bad economic conditions resulting in most families desinating women to using wood while cooking, doing jobs such as weaving carpet and baking bread make them more vulnerabl candidates for tuberculosis. The Ministry of Public Health in 2007 reported that 40,000 women had TB and 8,500 of them died, and that 70% of the people with the disease were women.
Gender issues, pertaining to TB in the health sector of Afghanistan has been a major concern for WHO Afghanistan. The organization has been supporting an integrated health program with an emphasis on vulnerable and disadvantaged groups like women and children. The main goal of the program has been to increase equity and access to health resources, by all segemtns of the population. WHO has devoted its efforts to increasing health facilities for women by physically taking health services to women through outreach mechanisms. This is very similar to the „child to Child“ strategy dealing with the readication of polio campaign previously carried out in Afghanistan by EPI in 2001 in collaboration with UNICEF. WHO has also incorpprated into their strategy the training of nurses in basic health centers as vaccinators. This is thought to better equip medical units to deal with female issues. Femlae volunteers are ecouraged to contribute to the process as well. These female enumerators tend to be recrutited when surveys are being conducted for EPI coverage, or during house-to-house registrations conducted for EPI. WHO is also working to improve the role women play in Afghan health services in collaboration with the U.N. agencies. This can be seen in how the WHO helped re-open the Kandahar nursing school where over half of the students out 105 students and 160 students were female. The WHO primarily supports centers with medical supplies and training where 70% of the TB cases treated are females.
2.1.2 TB epidemiology among female to male
The physical response to tuberculosis is moderatley gender specific between men and women showing some differeing symptoms but for the most part sharing many parallels, but it is the economic state of the country that leaves women more vulnerable. Both men and women with TB experience continuous coughing, weight loss, going unconscious, a decrease in appetite, fever and sweating at night. Both parties are equally contageous, as the bacteria that causes TB is highly infectious and can be transmitted through breathing. Dr. Mohammad Hashim Wahaj, head of hospital and Wahaj Diagnosis Clinic in Kabul informed PAN that the obsessivley conservative traditions of the Afghan culture prevent women from going to healthcare centers and is seen as the core cause of the increase of the disease among women. Another major cause of this increase is the lack of food for women in many Afghan households, as in the typical home the women rely on their husband’s leftovers and rarely prepare food for themselves. Wahaj credits this as the cause for a country wide trend of Afghanan women who have weaker immune systems than their male counterparts. Dually, it is customary for women to do all of the housework and tend to the sick in the family, which opens them up to even more chances of contracting the illness.
Biologically, research shows that men and women are actually not all that different, bothwhen psychologically coping with disease, and in their physical response.
Pertaining to cognition, Afghan men are reportedly more suited for mental rotation, navigation using geometry and recognizing objects within visual backgrounds. Women show better memory for locating objects and navigating through the use of landmarks (Allen, Goldscheider, & Ciambrone, 1999; Baider et al., 1995; Ben-Tov, 1992; Ptacek et al., 1994). As far as motor skills, from age 3-5 years old onward, men show an exceptional accuracy at aiming projectiles, while women show the ability for exceptional speech rate and small amplitude coordination. Pertaining to math skills, men are best suited for solving abstract reasoning problems, while women tend to be statistically best at computation and calculation problem solving. As far as verbal abilities go, women show earlier development of virtually every aspect of verbal ability, verbal memory, spelling grammar and fluency (Oren & Sherer, 2001). When emotions come into play, men and women use different areas of their brains to control sexuality, but most of the chemical systems overlap and most of the social bonding is somehow connected to the sexual process. Men and women have different forms of aggression. In most mammals, men tend to be the aggressor; many forms of aggression are controlled through different neural pathways (Oren & Sherer, 2001). BNST manages ‘affective attack’; this region is sensitized by testosterone and desensitized by estrogen. AVP stimulation increases aggressive behavior and drives persistence; circuits for this neuron are also more prevalent in males than in Females (Allen, Goldscheider, & Ciambrone, 1999; Baider et al., 1995; Ben-Tov, 1992; Ptacek et al., 1994). The mild biological differences that exist between men and women can only be significantly contrast their methods of responding to stress when the stressor in some way capitalizes on either sex’s chemical weakness. For example, men are psychologically more prone to substance abuse; a man under the influence of a substance that inhibits or enhances the circulation of AVP would affect the testosterone levels in the male’s bosy, thus making him more or less aggressive. This shift in behavior would entirely be dependent on whether the male abuses substances as a coping strategy for stress. This would have the same effect for a woman, but men are more prone to this dysfunctional behavior. Oddly enough, maternal stress can lead to a drop testosterone development desynchronizing or preventing masculinization. Stress can also effect the human body’s ability to heal itself when sick or influence the method of coping with disease.
To measure the social adjustment of those enduring psychological distress experienced by fighting with TB Neta Peleg-Oren & Moshe Sherer conducted a study. In it a total of 87 participated along with their spouses participated. The patients underwent active treatment; three questionnaires were used to assess information, a personal information sheet, a Brief Symptom Inventory (BSI) list to identify stressors, and the PAIS-SR to examine psychosocial adjustment to physical illness. Surprisingly, it was found that the spouses reported encountering the same level of psychological distress as those actually coping with the disease. Women and men both reported having difficulty with their social adjustment. The key finding of this report was that men reported having a higher level of anxiety and paranoia (Oren & Sherer, 2001).
The authors found that in a study of 100 TB patients, all undergoing therapy, men were more likely to use denial as a coping strategy or a defense mechanism when facing their disease (Oren & Sherer, 2001), this assumed to be due to a feeling of obligation to maintain the male sexual identity and the traditional male role. Women were found to be more likely to develop distress and pychopathology as a reaction to negative life events. Men were much less susceptible to this trait. This was due to the fact that in Almeida and Kessler’s studies, women reported having a higher prevalence of high-distress days than men (1998). There researchers supposed that this was based on the argument that the socialization of women prevented them from being psychologically developed enough to endure stress induced pressures. Spouses of the TB patients were found to have just as much stress as their loved ones dealing with the disease, but the patients reported having more difficulty than their spouses dealing with sexual relations and extended family relationships. This was an important finding because it was a result that maintained regardless of gender. Both male and female patients showed equal discomfort enduring sexual or family relations. The result of this finding was that TB is equally stressful for patience and spouses whether they are male or female, which puts spouses in a position where they can not automatically be treated as support system for patients, but as potential patients themselves undergoing a crisis who may need psychological attention (Allen, Goldscheider, & Ciambrone, 1999; Baider et al., 1995; Ben-Tov, 1992; Ptacek et al., 1994).
Another key finding was that spouses tended to feel isolated in society, and the effects of this proved to be more dramatic for men than for women due to a more communal and social network base common of females. This was also found to be an issue in that male spouses find themselves more intensely isolated from both society and their marriage due to a lack of ability to properly care for the patient. As, Oregen and Sherer note, “For many reasons, embracing the roles of care and support giver for an ill female spouse can be problematic for the healthy male spouse. Typically, males view their primary role in the instrumental areas of relationships and trust their female spouses in the emotional ones, which are those that closely approximate the care-giving role (2001). With all of these very narrow differences in coping reactions, it suggests that the discrepant failure the Afghan health system has had in controling and treat the transmission of TB in women over the past decade is more due to socioeconomic differences than biological ones.
In her masters thesis Gender and the Cultural Epidemology of Tuberculosis Among Patients, Ellen Stamhuis assesses the gender and its relation to Tuberculosis in Afghanistan. In the study 79 TB patients were interviewed in a public sector of central Afghanistan through the use of semi structured EMIC interviews. Through the use of quantitative and qualitative analysis, patterns of distress (PD), percieved causes (PC), stigma and help seeking (HS) for TB were studied for gender. The key finidng of the research showed that there were gender specific features of TB, and the psycho social burden of the disease was found to be very among both men and women, ptainet delay was longer men than found for women, but diagnostic and treatment delays were longer for women; and for both parties, dust was percieved as the most common cause of TB. The core implication of the research was the finding that to better advance TB control, health staff need to better equipped to respond to gender differences in those experiencing the illness.
2.1.3 Diagnostic delay on TB (‘cause of cultural status of females)
During a one-year study period, 316 new smear-positive adult PTB patients were recruited, of which 61.1 % were males and 38.9% females. The mean age was 44.2 years, range 15-70 years with a median age of 45 years. In terms of the distance between respondents’ homes and the nearest health facility, kilometers or time taken was used, depending on whether the two points were connected by proper roads or not. For the 210 respondents who judged the distance by kilometer, 37.4% claimed they lived 10 km away from a health facility. Of the other 106 respondents, 25.4% said their house was more than 30 min away from any health facility. With regards to occupation, 22.8% were farmers, 18.7% housewives, 9.9% civil servants, 26.2% employed by private firms, 5.4% self-employed and 15.8% unemployed. For household income, 38.3% of respondents claimed a household income of less than ringgit Malaysian (RM) 300 per month, which was classified as indicative of poor families in Sarawak; 29.7% households had an income between RM301 and 600 (below the poverty line); and the remaining 32% of households lived above the poverty line. While 243 respondents (76.9%) had no history of an index case for TB, there was a positive history in 73 respondents (23.1%). The index case in this study included household contacts, workplace contacts and village contacts.
The median patient interval was 30 days. Of the 224 patients who volunteered the information, 48.4% claimed that they did nothing for their TB symptoms before seeking a medical consultation, 15.5% treated themselves with over-the-counter drugs, while 7% sought treatment from traditional healers. The remaining respondents claimed that they treated themselves as well as using traditional healers. The final decision to seek medical advice was most influenced by the severity of the symptoms (81%), while spouses, relatives and friends were other motivators (17%). Based on cumulative distribution, 42.7% of the respondents consulted a medical worker more than 30 days from the onset of TB symptoms. The longest delay was reported to be one year.
Patient delay was analysed by patient characteristics. Significantly fewer male respondents (36%) had a patient delay, compared with female respondents (57%) (χ2 = 7.64 on 1 df, p = 0.006). There was also a statistically significant difference in patient delay by race (χ2 = 9.68 on 4df, p = 0.046), with the Bidayuh ethnic group having the highest (64%) patient delay. Using logistic regression analysis, (Table 1), only being female was associated with increased patient delay. The Hosmer and Lemeshow test provided a χ2 of 5.342 and was not significant (p = 0.142) showing an acceptable fit of the model. Over all 62.3% of cases were predicted correctly as to whether or not they had a patient delay. There was no significant interaction between independent variables.
Diagnostic delay in tuberculosis has can lead to an increased infected period that one spends in the community. According to the Center for Disease Control and Prevention, the May 2008 reports, 3.2 million girls between the age of fourteen and nineteen have been infected by at least one of the four: HPV, chlmyadia, herpes simplex virus, and trichomassis, most common STDs. According to the data in the 2003-2004 National Health and Nutrition Examination Survey, the two most common overall STDs were HPV leading with 18 percent, and clhamydia, with 4 percent. The human papillomarvirus (HPV) is a group of viruses that has over 100 different strains. Of the hundred strains, over thirty of these are sexually transmitted. HPV infection causes abnormal Pap tests in women, which can show to cancer of the cervix, vulva, and vagina.
2.2 Study question: What obstacles need to be overcome to ensure the successful use
of DOTS in female afghan TB cases? What methods must be taken to ensure the WHO meets the 2050 deadline for TB control?
2.3.1. General objective:
The National Strategic Plan for TB Control, 2006-2010, organized a roadmap for TB control and goals to achieve over the next few years. These goals focus on working to eliminate TB as a public health problem in Afghanistan by 2050, and they consist of three parts:
· A structured situation analysis of the general health system;
· An objective review of the NTP’s progress with DOTS Strategy since implementation began;
· A new strategic direction for 2006-2010 based on the current situation with adaptation of new approaches for accelerating DOTS expansion toward the 2015 global targets for TB control laid out in the Millennium Development Goals (MDGs).
· And an estimated budget designed in order to meet the needs laid out in this strategic plan.
These objectives form the criteria for ideal TB control. While they represent a broad range of Afghan citizens with TB, it must be remembered that women make up 70% of the control group specified.
2.4. Methodology:
Through the use of Directly Observed Therapy Short-Course (DOTS), NGOs in Afghanistan have been very successful in mildly controlling the expansion of TB. The DOTS rely on an accurate diagnosis of a large number of cases as well as an adequate regular supply of useful drugs to be successful. Regular monitoring and periodic evaluation is irrefutably a key part of this process. Trained laboratory technicians are also a major contributor to the success of this program. DOTS involves diagnosis through monitoring TB and the constant self-evaluation of the programme’s effectiveness. The core attribute of a DOTS intervention in a TB case is that anti-tuberculosis drugs be taken under the supervision of someone aside from the patient. If enough data are extractable of these sources to make a Piot model this would be awesome, maybe from a field study made by an health organisation (e.g. Red Cross, doctors without borders, Medair).
3. Problem Analysis
The TB situation in Afghanistan is critical. The country is one of the 16 in the WHO European Region countries with a resurgence of the disease and a dramatic increase in notification rates in the last 10 years.
3.1.1. The PIOT model
3.1.2. General information about the study
An institution based cross-sectional study was conducted in 10 TB clinics in randomly selected divisions in Sarawak from June 2003 to May 2004. Delay was analyzed from two perspectives: (1) period between the onset of TB symptoms to any first medical consultation (patients’ delay); and (2) period between the first medical consultation to the diagnosis of TB (diagnosis delay). Patients were interviewed on diagnosis or within the admission period using a semi-structured questionnaire. This study was approved by the ethics committee of both the funding organization and the Malaysian Ministry of Health, and conformed to ethical procedures for research in Malaysia. Informed consent was also obtained from each respondent.
An institution-based cross-sectional study was conducted from June 2003 to May 2004. Three divisions were randomly selected from the nine divisions in Sarawak. All the 10 TB clinics located in these divisions were included in the study. Two of these TB clinics provided services to a combination of urban and rural populations, while the other eight provided services to a rural population only. Patients were interviewed directly after their diagnosis of TB or while in hospital until the intended sample size was achieved. Patients above 15 years of age with smear-positive PTB who were mentally well were included in the study. Smear negatives and cases with a diagnosis based on X-ray, and relapsed cases were excluded.
We aimed for a sample of 320, because a sample of this size would allow us to include up to eight parameters in a regression model, using the rule of thumb that 20 observations with the event of interest (in our case ‘delay’) are required for each parameter in the model. Each study site was then assigned to recruit a sample size almost equivalent to 10% of new PTB cases registered in 2002.
A pre-tested semi-structured questionnaire was used to collect the study data. Medical assistants who manned the TB clinics were trained to perform the interviews. The questionnaire assessed socio-demographic details, major presenting symptoms of PTB, duration of major presenting symptoms, and the date of first health-care visit. The major symptoms asked about were the presence of a cough, production of sputum and haemoptysis. The interval between first medical consultation and the date of diagnosis was obtained through respondents’ out-patient card and interview. The patients’ TB registration card and TB registers were cross-checked to assure the quality of collected data.
Recommended standard procedures applied to the diagnosis of PTB in Malaysia are to collect and examine three sputum specimens from patients with suspected TB, one on-the-spot and another two early-morning specimens on two consecutive days. Examination of sputum by direct microscopy for the presence of acid-fast bacilli (AFB) is performed at the laboratory nearest to the TB clinic. Pulmonary TB is confirmed when there are at least two AFB-positive smear results. As a quality assurance standard, every month 10% of the negative smears and all the positive smears are sent to the laboratory of the State TB Control Unit for further analysis.
3.2 Findings
A total of 316 new smear-positive PTB patients participated in the study. The median patient interval was 30 days. Gender was found to be significantly associated with patient delay. The median diagnosis interval was 22 days. Respondents’ incomes, health-care professional first consulted and actions taken by the health-care providers during the first consultation were significantly associated with diagnosis delay. The medium treatment interval was 0 days.
TB cases in males. The cases of Tuberculosis in the Afghan prison demonstrates both the effectiveness of control systems have established over the past decade. The findings also stand as prevailent proof that increases in the In 2003, there were around 49,000 prisoners held in pre-trial detention centers (SIZO), prisons and settlement colonies. In 2000, Afghanistan had the third highest rate of prisoners (590per 100,000 population) after the USA and Russia. Due to penal reform and amnesties, the number of prisoners has declined to less than 50,000 and Kazakhstan has dropped to the 17th place on the ranking list. MoH, MoJ and MoI collaborate in tuberculosis diagnosis, treatment and surveillance. However, in 2004 the TB notification rate was over 1,500 per 100,000 and the reported mortality rate as high as 80 per 100,000.
Table 2: TB Notification And Mortality Among The Prison Population
Years 1997 1998 1999 2000 2001 2002 2003 2004
Registered 11,903 12,970 12,628 9,163 8,060 8,242 6,240 6,042
TB Cases
New TB Cases 5,555 5,061 3,434 3,038 2,908 3,011 2,137 1,388
Notification Rate 4,721 4,268 2,995 2,515 2,210 2,316 1,937 1,573
Number of Deaths 1,302 1,218 345 175 174 134 103 74
Mortality Rate 880 820 300 140 130 100 90 80
Source: Ministry of Health 2004
3.2.2 Knowledge and awareness of TB in public, especially in females
According to the 2007 Afghanistan Human Development Report, there is still an enormous gender gap prevalent in the country despite tremendous strides in civil rights. Only 12.6% of adult females are reported as literate limiting their economic opportunities leaving them vulnerable to discrimination and violence. The infant mortality rate has fallen from 165/1000 in 2001 to 135/1000 (2007), which accounts for more than 40,000 successful births each year. Low literacy, lack of access secure food, drinking water, and sanitation is a significant contribution to why the mortality rate is still high. In Zarghoona Salehi’s study on the increase of Turberculosis in Afghan women, he found that bad economic conditions resulting in most families desinating women to using wood while cooking, doing jobs such as weaving carpet and baking bread make them more vulnerabl candidates for tuberculosis. The Ministry of Public Health in 2007 reported that 40,000 women had TB and 8,500 of them died, and that 70% of the people with the disease were women.
Gender issues, pertaining to TB in the health sector of Afghanistan has been a major concern for WHO Afghanistan. The organization has been supporting an integrated health program with an emphasis on vulnerable and disadvantaged groups like women and children. The main goal of the program has been to increase equity and access to health resources, by all segemtns of the population. WHO has devoted its efforts to increasing health facilities for women by physically taking health services to women through outreach mechanisms. This is very similar to the „child to Child“ strategy dealing with the readication of polio campaign previously carried out in Afghanistan by EPI in 2001 in collaboration with UNICEF. WHO has also incorpprated into their strategy the training of nurses in basic health centers as vaccinators. This is thought to better equip medical units to deal with female issues. Femlae volunteers are ecouraged to contribute to the process as well. These female enumerators tend to be recrutited when surveys are being conducted for EPI coverage, or during house-to-house registrations conducted for EPI. WHO is also working to improve the role women play in Afghan health services in collaboration with the U.N. agencies. This can be seen in how the WHO helped re-open the Kandahar nursing school where over half of the students out 105 students and 160 students were female. The WHO primarily supports centers with medical supplies and training where 70% of the TB cases treated are females.
4. Discussion
It is recommended to improve basic Afghan health policy the MoPH, along with advisers, need to develop specific guidelines to govern the system. To insure that all developers of the health program are on the same page, those in charge should convene in a group of all of the major health promoters, specifically MoPH, UN, NGOs, and private practitioners. This way there will be a free flowing exchange of information between health practitioners and all other relevant parties. It is also recommended that the MoPH does not set itself up for failure by over extending itself, or committing to unrealistic obligations. Likewise, the MoPH should at all times remain wary of the Basic Health Service Package priorities, like disability services and mental health obligations, while accounting for the real financial state of the region. Finally the needs of the internally displaced, conflict-and-drought-affected members of the Afghan society represent those particularly susceptible to the TB epidemic, there should be specific priority reserved for them within the policy, especially returnee patients like those with chronic illnesses.
In recommendations for health management NGO’s should
More than two decades of conflict and 3 years of drought have led to widespread human suffering and massive displacement of people in Afghanistan. Resolution 1378 of the UN Security Council provides the opportunity and framework for recovery and reconstruction efforts to buttress the political settlement. Afghans themselves need to manage the process of reconstruction and the international community is committed to help. To this end, a Steering Committee of donor governmentsrequested the Asian Development Bank (ADB), the United Nations Development Programme (UNDP), and the World Bank to conduct an urgent preliminary needs assessment for consideration at a Ministerial Meeting in Tokyo on 21-22 January, 2002. The purpose of the assessment is to help determine the requirement of external assistance to support Afghanistan’s economic and social recovery and reconstruction over the short and medium term. The assessment does not cover humanitarian assistance. It identifies a program of activities that encompass both short-term priorities and options for longer-term development initiatives.
5. Conclusion and Recommendation
In sum, since both patients and health providers played a role in delaying TB diagnosis. Females appeared to have longer delay. Respondents living above the poverty line had diagnosis delay as they made more visits to GPs or different government clinics without proper investigations for TB. A mechanism is needed to increase all health-care providers’ suspicion of TB so that proper investigations can be done during first consultation. It has already been established through the data that there is a severe need for not only response time to diagnostics in TB cases in Afghan women, but in complete systematic treatment. The WHO has mainly demonstrated a successful approach to advancements in TB testing on registered cases, and it would only seem most effective to further their funding, as well as position their department at the forefront of TB strategic planning in the future.
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Annexes
