MSF: Discussing Alex – dilemmas in tuberculosis treatment

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Guest post from Rebecca Welfare, who is a TB specialist nurse with Médecins Sans Frontières (MSF)

The weekly multidisciplinary committee on drug-resistant tuberculosis (DR-TB) had assembled to discuss the case of Alex, a 25 year-old man who had commenced treatment for multidrug-resistant tuberculosis (MDR-TB) 12 months previously [editors note: the patients name was changed to protect identity, and this patient is representative of many such cases worldwide].
During his first year of a 2-year treatment regimen, Alex needed to take a cocktail of drugs 6 days a week, including an injection for the first 6 months, under the direct observation of a healthcare worker. He also had underlying co-morbidities, which complicated his treatment further, and he was finding it increasingly difficult to take his daily medication due to side effects. Although his condition initially improved on treatment, the past 6 months had seen a period of slow and continuous clinical deterioration. With all options for a cure having been exhausted, the Committee was faced with an ethical dilemma: should Alex’s TB treatment be stopped? If so, how and where were they going to provide end-of-life care? Stopping treatment is a fairly new concept in TB programmes, which has been highlighted by the emergence of multidrug-resistant and extensively drug-resistant TB. These resistant forms of the disease are associated not only with a longer duration of treatment but also greater morbidity and mortality than drug-sensitive TB. Although there has been increasing acknowledgement of the need to provide palliative care for TB patients, such measures continue to be sporadic in many countries and are often predominately focused on cancer and HIV/AIDS.

On March 24, 2011, World TB Day completes its final year of a 2 year-campaign ‘On the move against TB’. This encourages us all to think outside the box to develop new ways of tackling this global public health emergency. Strategies to address the needs of individuals like Alex, for whom treatment is deemed to have failed, is a challenge currently faced by national tuberculosis programmes and public health authorities, who also have to carefully balance the rights of the individuals with that of society. Despite treatment, Alex died one week after the discussions held by the DR-TB committee. His death leaves no doubt that we urgently need new tools, new drugs, and new approaches to TB prevention and control, now and in the future. In the meantime, we need to ensure that the continuum of care in TB programmes also includes palliative care services for people like Alex, for whom all treatment options have been exhausted and for whom a cure from MDR-TB is unfortunately unlikely with the current resources at hand.

Rebecca Welfare is a TB specialist nurse. She has worked with TB programmes in the UK, East Timor, and India. Since joining Médecins Sans Frontières in 2008, she has supported the implementation of DR-TB components of TB programmes in Uzbekistan, Georgia, and Zimbabwe.

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