By Michael Gwarisa
The heat wave is blazing hot in Shurugwi, a small town in the Midlands province, and Brighton Mangwiro (30), is preparing to go to the gold mine shaft where he temporarily works. Due to the El Nino weather patterns, the heavens have not been so generous in the just-ended 2023-2024 cropping season, and many farmers in Shurugwi are already counting their losses. This has pushed more young men, and women in the area into artisanal gold mining in a bid to fend for themselves and loved ones.
Artisanal gold mining is a major household economic driver for Shurugwi residents. Brighton, a young man with a young family has not been spared by the economic demands that have been presented by the El Nino-induced drought, and has to work just like anyone to feed his small family.
However, his story is different. Brighton is still recovering from a recent positive Tuberculosis (TB) diagnosis, and is in his last month of treatment. Even though evidence suggests that once a person is diagnosed with pulmonary TB, they will not be contagious after two to three weeks into their course of treatment, health experts encourage survivors to continue taking basic precautions during the treatment period to stop TB from spreading to family and friends.
Brighton however cannot afford this luxury as he is not formally employed, and artisanal gold mining is the only available option for him.
I have to work my brother,” says Brighton as he collects some equipment he uses for mining. “I got diagnosed with TB on 12 September 2023, and I was initiated into treatment which lasts for six months, and I am about to finish my course.”
Even though his treatment course is ending soon, Brighton recounts how he almost quit taking medication due to the food insecurity situation at home.
“You can’t take TB medication on an empty stomach. Somehow, you feel like you want to vomit and it weakens the body. I was tempted to quit at some point but I managed to get this job at a Mine and whenever I get money, I prioritise buying food even though the money is not enough.”
According to a study, artisanal miners like Brighton are 18 times more susceptible to TB infection in Zimbabwe owing to a myriad of factors which range from prolonged exposure to silica dust due to lack of protective gear, working in poor ventilated environments among other reasons.
Food security and nutrition play an important role in HIV and TB care and treatment, including improving treatment outcomes, adherence and uptake of HIV and TB care. Poverty, food insecurity and poor nutrition in the population are important contributors to the burden of TB.
Brighton’s wife, Pamela Muyangi (27), a TB survivor herself, is happy that her husband is about to complete his medication course in a few days but cannot stop worrying about their food security situation.
“I tested positive for TB on October 20, 2022, and I completed my six months course. However, the TB relapsed and this time it was Drug Resistant TB (DRTB) up to January 16, 2024. This year there is a drought, and as someone who experienced TB, I worry for TB patients, especially about their nutrition. Even though my husband now has a little income, you find that it is not enough to sustain his nutrition needs during these times when he needs to have a balanced diet. I think the government should assist TB patients financially and also support them through health workers to visit them regularly,” said Pamela.
Food is a major catastrophic health expenditure for TB patients and this is associated with adverse TB outcomes. This often leads to a worsening of food insecurity for patients and their families during the disease. Catastrophic cost is defined as a financial burden above 20 percent of the household income due to the condition. The El-nino drought is likely to amplify the risk of discontinuation of TB medication by TB patients in Zimbabwe.
Speaking in an interview with HealthTimes, Dr Ronald Ncube, the Union Zimbabwe Trust
(UZT) Executive Director said addressing the impact of El-nino induced shocks to
TB treatment should be prioritised.
“Predictably, El Nino-induced drought is likely to lead to potential food shortages and/or food insecurity, resulting in lack of access to nutritious food options for TB patients, who are likely to have underlying malnutrition from the disease itself. It has been found that malnourished TB patients have delayed recovery and have a higher risk of dying than well-nourished TB patients. The impact of an El-nino induced drought could potentially have a knock-on negative impact to overall treatment outcomes of TB patients,” said Dr Ncube.
He added that it was highly likely that in circumstances where food security is a marked concern, the vulnerable TB patient is likely to be more pre-occupied by “hunting” for their next meal, relegating adherence to their TB medicines as a secondary priority, escalating the risk of treatment failure.
“El Nino induced shocks can cause mitigatory migration of affected communities, and for TB patients, disrupting their established TB treatment routine, likely to compromise treatment adherence. Psycho-socially stress and anxiety associated with such movements may equally impact their individual ability to adhere to their treatment plan.”
He further noted that malnutrition has been noted to increase the risk of getting TB in the first place, while having TB can lead to malnutrition. Malnutrition can lead to secondary immunodeficiency that increases the risk of one developing TB. Inversely, patients with TB have reduced appetite, absorption of important nutrients, and altered metabolism that leads to wasting.
“As most TB patients are diagnosed with diminished nutrition, effective TB treatment should be coupled with a nutritious diet to help normalize the nutritional status. Raising the nutritional status of a population should be part of a cocktail of measures particularly in underdeveloped communities, to effectively reduce the burden of TB disease.”
Encouraging TB patients to adhere to their medication during El-nino induced droughts requires addressing the specific challenges at hand. According to Dr Ncube, these include but not limited to providing health education for TB patients to understand the importance of adhering to their medication, emphasizing the link between treatment adherence and successful outcomes; Maintaining a strong treatment support system through both health care workers and community/family support structures for treatment monitor at household level; use of innovative reminders such as text messages, phone calls or even community-based support groups; ensuring access to nutritional support for TB patients through food assistance programs, community gardens, or initiatives promoting sustainable income generating programs.
Moreso, offering flexible treatment options that include self-administration or getting re-supplies from another facility, should there be a need for the patient to relocate; offering psychosocial support through counselling and stress management throughout their treatment journey; , Strengthening health systems and ensuring consistent availability of TB medicines and Community engagement and participation to ensure communities are at the centre of addressing challenges associated with El-nino induced drought and associated treatment adherence concerns.
Dr Fungai Kavenga, the acting Deputy Director AIDS & TB Programs (TB Control) in the Ministry of Health and Child Care (MoHCC) said there is a need for programs to assist TB patients meet their nutrition requirements during the food insecurity period.
“The El Niño-induced drought can indeed pose challenges to TB drug adherence, particularly if food insecurity becomes a prevalent issue post-harvest season. In such circumstances, it is crucial to adopt proactive measures to support TB patients. Collaborative efforts between healthcare providers, government agencies e.g. Ministry of Public Service, Labour and Social Welfare, and non-governmental organizations can help ensure the availability of food assistance programs specifically targeted towards TB patients,” said Dr Kavenga.
He added that these programs can provide nutritional support, food vouchers, or access to community kitchens to address the food insecurity concerns and enable patients to maintain their adherence to TB medications.
In Zimbabwe, the Global Fund has a facility whereby only people with Multi-Drug Resistant TB receive a monthly substance allowance of US$25.00 and a food hamper US$20.00 to supplement their nutritional needs.
Dr Kavenga added that good nutrition plays a vital role in supporting the effectiveness of TB medications.
“When undergoing TB treatment, the body requires proper nourishment to help fight the infection, minimize side effects, and promote overall healing. A balanced diet rich in proteins, fruits, vegetables, and whole grains can provide the necessary nutrients to boost the immune system and aid in medication absorption. TB patients need to consult healthcare professionals or nutritionists who can guide them on appropriate dietary choices during their treatment journey.”
To prevent patient loss due to defaults, Dr Kavenga said a comprehensive approach is necessary as well as strengthening the healthcare system’s capacity to monitor and track TB patients is vital.
“This includes implementing robust patient follow-up mechanisms, utilizing mobile health technologies for reminders and notifications, and establishing efficient communication channels between healthcare providers and patients. Furthermore, proactive identification of patients at risk of loss to follow-up through community health workers, engaging family members as treatment supporters, and implementing patient-centred strategies that address individual barriers to adherence can significantly reduce rates of patients lost to follow-up. Continuous training and capacity building for healthcare workers on patient-centred care and adherence support are also essential to ensure comprehensive and quality care for TB patients,” said Dr Kavenga.
He also emphasized the need to adopt a holistic approach that addresses the nutritional, social, and healthcare aspects, which is says can minimize loss to follow-up rates and ensure that TB patients receive the necessary support to successfully complete their treatment, even in challenging circumstances like drought-induced food insecurity.
Data from the National TB Program shows that the national TB treatment coverage was 54 percent in 2021, decreasing from 72 percent in 2019 (Global TB Report, 2022). The treatment success for TB in Zimbabwe was 88 percent in 2020, which is still below 90 percent WHO recommendation. An estimated 12,520 cases were missed in 2021. The TB/HIV co-infection rate of 50 percent (Global TB Report, 2022), a drop from 54 percent in 2021.
Meanwhile, with support from the United States Agency for International Development (USAID), the Union Zimbabwe Trust (UZT) in collaboration with three other local partners, namely; Baines Occupational Health Services, Jointed Hands Welfare Organization and Hospice Palliative Care Association of Zimbabwe is implementing various interventions that promote TB treatment adherence across eight priority districts in the country. These include development and distribution of Information, Education and Communication material on TB patient care; health promotion and awareness through mass media; training of health care providers on patient centred care; community engagements through strengthening the oversight role of health centre committees in TB control as well as provision of palliative care services.
With support from the STOP TB Partnership’s TB REACH Wave 9 funding mechanism, UZT trained health care workers across three provinces on TB case finding, treatment adherence support and provide food hampers to patients with drug resistant. Lastly, with support from the United States Centres for Disease Control and Prevention, UZT is supporting a comprehensive evaluation of TB Preventive Therapy in Zimbabwe in the context of assessing treatment adherence, completion and adverse events across three provinces.
