Tuberculosis medication shortage

As I continue to learn more details, I am realizing that I should have written this post a while ago and have to no reason to delay it further. For the past few weeks, there has been a shortage of anti-tuberculosis medications in Uganda. As I learn more stories, I am getting a better sense of the impact of this shortage. Of note, the shortage is not making headlines, for which reasons I have no clue, though \”corruption,\” the common response to most problems, is being uttered on the lips of health professionals.

Right now, patients who come to the National Tuberculosis & Leprosy Programme (hospital ward across from my office) with tuberculosis have to pay 80,000 Ugandan shillings (~$41 USD) to a private pharmacy to receive a month\’s worth of treatment including isoniazid, rifampin, and pyrazinamide – 3 of the 4 necessary medications in a tuberculosis treatment cocktail. That is, if even the private pharmacies have it. The NTLP only has ethambutol, the fourth medication, in stock. In order to receive it, the pharmacist needs to see the purchase of a month\’s supply of the other three drugs before he gives out ethambutol to a patient to complete the tetrad.

Previously, the patients would receive all drugs at no charge through the international funding of the NTLP. Now, the poorest people (the ones who experience active Tb more often) cannot afford or obtain the medication given that it is likely much more than their monthly salary.

There are the obvious risks of death, especially in HIV+ co-infected persons, increased transmission to others, and people who in some way will get incomplete treatment regimens. This in turn, may lead to increasing drug-resistant strains of Tb, the last thing needed to be exacerbated here.

Forebodingly, Nicholas Kristoff in a recent NY Times article (07 December 2008) talks about the global concern needed and the action we must take with the continued growth of multi-drug (MDR) and extrememly-drug resistant forms (XDR) of Tb: http://www.nytimes.com/2008/12/07/opinion/07kristof.html. He relays this grossly underreported health issue that continues to accelerate, an issue global powers need to address with the fervor HIV/AIDS has received.

One of the doctors working in the NTLP told me patients have cried when they realize they cannot receive their medications. This doctor also told me that even 80,000 USh would be costly for him, to put price in context. At $41 per month for 8 months of treatment, it is easily seen how families making less than $300 USD/year equivalent would have a hard time paying for such medication for one person.

If that were not enough, a similar shortage is occurring with anti-malarial drugs right now. This is especially problematic because we remain in the rainy season when malaria infection is higher. Here is the latest I have found on this topic: http://www.monitor.co.ug/artman/publish/regional-special/Govt_hospitals_running_short_of_malaria_drugs_75510.shtml. I need to speak with a few more doctors on the current situation since I do not interact with malaria studies or clinics much. And recently, there was a shortage of anti-retrovial medication for HIV, though I have heard by word-of-mouth that this one has been improving.

You will note in the conclusion of the malaria news article that Global Fund money has not been forthcoming. I do not know the exact reason why but I have heard it has to do with the mismanagement of funds previously. Perhaps this article lends credence to this possibility: http://www.monitor.co.ug/artman/publish/news/We_are_using_Global_Fund_money_better-_PS_65626.shtml. Are funds being used better since three years ago? I am not sure, but for some reason, the needed dispersements have not been provided.

Research project participants in our collaboration continue to receive anti-Tb medications. Those that receive referrals to the NTLP through a research project are part of contigency plans to the best of my knowledge, including the study on which I spend the bulk of my time where patients were previously simply referred to the NTLP.

I am going to try and spend time in the NTLP on Friday and next week to gather individual stories and learn how doctors convey shortages to patients. It will make for a sobering prelude to Christmas, but for many here, it will be an even more difficult and possibly life-threatening Christmas for them.

It is particularly frustrating because Uganda, at least in this region is modern, growing, promising. (Some Ugandans would agree or disagree with this.) Maybe this could be \”expected\” (though unjustly so) in a less developed country, but because Uganda appears at face value to be one of the more modern African regions, I believe events such as  these should be all the less tolerable. I will amend this post as I receive updates and change the data/time of the post to make it appear \”new.\” Stay tuned…