By Fred Womakuyu and Ben Okiror
PAUL coughs persistently as if he is about to die. For two years, the 40-year-old has been suffering from tuberculosis (TB). He was receiving treatment from Mulago Hospital until January 2009 when the hospital ran out of drugs.
Paul went to Kawolo Hospital in Lugazi, hoping he would get the drugs, but they were also out of stock. Justin List, an American medical student, says: â€œI visited the TB wards at Mulago in January and there hadnâ€™t been any pediatric TB medication since December 2008.â€
List is in Uganda for a year on a US-funded research to learn about the progress of the disease. He says the TB drug, Ethambutol, that was being given to patients at Mulago had expired.
â€œThere was a two-month initial phase treatment for only 12 people as of January 2009. But on March 19, when I visited the TB wards pharmacy, there had been no new medication received even after the stock had been replenished,â€ he adds.
Dr. Sam Zaramba, the director general of health services, confirms the shortage. â€œWe know the problem is there, but there is nobody giving patients expired drugs. I will personally cross-check with Mulago and punish anybody doing this,â€ he says.
Zaramba, however, blames the shortage on unfulfilled promises by the Geneva-based Global Fund. â€œDonors had given us drugs that will last till December 2008.
The Global Fund had been promising to fill the gap, but when we ran short of drugs, there was no response from them,â€ he says.
Ugandaâ€™s problems with the Global Fund started in 2005 when all grants were suspended for three months, following mismanagement by the Programme Management Unit.
But a source in the ministry blamed the ministry for the shortage. â€œWe do not have any money budgeted for tuberculosis-related activities. The ministry depends on donors, yet many of them give empty promises.â€
Following the frustration of the Global Fund, Zaramba discloses that the ministry purchased TB drugs on a loan from Kenya to counter the shortage. TB continues to be a major health problem in Uganda.
According to a 2004 study entitled: Burden of tuberculosis in Kampala, Uganda, Uganda has a high prevalence of Tuberculosis infection at 14% annually.
The study was jointly carried out by Makerere University Institute of Public Health and the US-Ohio based Centre for Global Health and Diseases.
The study, however, cautions that healthcare managers and TB control authorities believe the prevalence of the disease is much higher than the notification figures reveal because of under-reporting and poor access to healthcare.
Mulago sees about 25% of Ugandaâ€™s TB cases and has been receiving 250 TB patients per month.
What does the shortage mean to patients?
A drug shortage creates a dire situation in the country since many patients are suffering from TB. Speaking at the Uganda Health Communication Health Alliance Workshop recently, Dr. Francis Adatu-Engwau, the programme manager of the National TB and Leprosy Programme, said Uganda is ranked 15th among the 22 TB high-burden countries worldwide.
â€œIn 2007, the country reported 41,579 cases, of which 20,364 (49%) were infectious. The proportion of expected cases detected was 50.2%, below the 70% global target. Only 75.5% of the 2006 cohort were successfully treated, below the 85% target,â€ he said.
List says a shortage of TB drugs means a patientâ€™s treatment regime is interrupted, leading to a high risk of TB transmission.
The disease is spread through air droplets which are expelled when someone with infectious TB coughs, sneezes or speaks.
It is common in areas where living conditions are unsatisfactory with overcrowding, poor hygiene and inadequate sanitation.
Such living conditions, coupled with high prevalence of HIV at 6.4% and lack of access to healthcare may lead to a vicious circle of TB interruptions and transmission.
List warns that patients with interruptions in TB treatment are at risk of developing multi-drug resistant strains of TB, which are difficult to treat with first line TB drugs Isoniazid, Rifampin, Pyrazinamide and Ethambutol, currently used in Uganda.
â€œWorldwide, multi-drug resistant TB is more difficult to treat and the drugs are more expensive. It is, therefore, in everyoneâ€™s interest to have uninterrupted treatment,â€ List adds.
To counter the transmission, Zaramba says the Global Fund has finally released money to purchase anti-TB drugs to last a year.
â€œThe manufacturer has been paid and by next week, we shall be receiving the drugs. For the time being, we are still using the drugs purchased from Kenya,â€ he says.