Guyana Chronicle
Georgetown, Guyana
April 25, 2004

Delivering treatment directly: A DOTS worker challenges TB

A GPHC feature

`It is joy to my soul to experience my own patients recovering full health after my daily visitations and observations.’ DOTS mobile worker, Noel Holder ASTRIDE his still new Zongshen motorcycle, a young male DOTS worker visits an outpatient at home, to administer a combination of tablets and capsules guaranteed to cure and conquer another case of tuberculosis.

Meet Noel Holder, not yet 25, but mature and responsible beyond his years years and giving substance and meaning to the expression, `Professional and Caring’.

Following in the footsteps of his father, Noel Snr., the Chief Medex with the Ministry of Health, the young Holder willingly completed a Community Health Workers Course offered at the Region One Moruka District Hospital.

The Georgetown-born young health worker was exposed to such primary health care areas as immunisation and maternity techniques, amongst many other subjects. Hands-on, intern-like experience was afforded at the Moruka Hospital but the Tuberculosis (TB) component of the course concentrated only on the transmission of the disease.

Young Holder, therefore, returned to the capital in 2002 to benefit from in-depth training in the nature, history, management and treatment of Tuberculosis. This was offered by the Ministry of Health’s Tuberculosis Control Programme coordinated by Dr. Shamdeo Persaud, the Ministry’s Principal TB Officer.

Naturally, when the TC Control Programme’s DOTS project was launched in September of 2002, Noel Holder was one of the first trainees in the programme.

But what is Tuberculosis? And what is the DOTS programme?

Tuberculosis is one of the world’s earliest scourges that is even mentioned in Biblical texts. The infectious pandemic once threatened human existence before drugs were developed to effectively combat the disease. TB is caused by the mycobacterium tuberculosis germ. It is spread in the air when infected persons sneeze, cough, talk, sing or spit, and others with little immune capabilities inhale the germs released in the air. The TB germ attacks and damages any part of the body it may become lodged in. However, the lung is the most frequent and significant site of attack.

Tuberculosis was generally under control in the late 1970’s early 80’s in Guyana. However, it re-emerged in dramatic fashion in the early 90’s, attacking a much younger age group than its earlier manifestations. By 1993, the World Health Organisation was forced to recognise the disease as a target for drastic worldwide action once again. And it was easy to realise that TB was a primary `beneficiary’ of the latter-day pandemic, HIV/AIDS.

However, notwithstanding Guyana’s earlier and relatively crude identification and isolation approach; notwithstanding the stigma still attached to TB victims who cough continuously and suffer significant weight-loss, it is now known that tuberculosis itself is curable. Those who succumb to TB in later life, despite the country’s Infant Immunisation Programme against the disease, can now access effective treatment. Thanks to the Health Ministry’s Tuberculosis Programme through its Chest Clinics.

And that is where DOTS worker Noel Holder and his nine colleagues come in.

Because Dr Shamdeo’s Clinic was discovering that TB patients receiving treatment were not complying with the strict regime of medication being prescribed, it was decided that some other strategy had to be employed. Enter the DOTS Initiative in September 2002. Community Health Workers, under the aegis of the National Plan on TB in Guyana, were trained in the treatment of TB, but with the additional role of DOTS.

The actual meaning of DOTS is “Directly Observed Treatment, Short-Course”. As described, it is Direct Observation Therapy and Strategy which sees Noel Holder and his workmates actually visiting TB patients in their homes to administer the nine tablets and capsules that make up the `cocktail’ or medication that must be taken on the five mornings of the week that the DOTS workers deliver to them. And once TB patients comply with the regime, their discipline, supervised by the mobile young DOTS brigade, results in the good news: there is a 95 per cent success cure rate amongst those afflicted and receiving TB treatment under the DOTS programme.

The drugs used include Isoniazid(INA) Pifazinamide (PZA), Ethanbutol and sometimes, Streptomycin – the latter being an injectable drug. One set of statistics reveals that last year, 78 persons died from Tuberculosis and TB-related illnesses, 595 new cases were diagnosed and some 200 Guyanese families were affected. But now, with the DOTS initiative being ably assisted by the WHO/PAHO and Canada’s CSIH (Canadian Society for International Health), and spreading countrywide, TB is being counter-attacked in Guyana.

Vital to the programme’s success is patient-compliance with their medication. As TB searches for persons with weak immune systems – sufferers with with HIV, diabetes, some forms of cancer and other chronic diseases – the Chest Clinic, Noel Holder and his fellow workers stand ready to counter.

But it is all up to the TB sufferers ultimately.

Noel, under the immediate supervision of Nurse Neibert Tucker, is one of 10 DOTS workers visiting 18 patients in Central Georgetown through rain or storm five mornings a week. He admonishes his stubborn patient-friends who sometimes hide when the motor bike engine is heard; when they absent themselves when he is scheduled to administer medication and to observe – or when they complain about the “bitter-bitter-bitter Ethanbutol”.

Noel Holder’s satisfaction is seeing his compliant patients recovering completely: coughing goes, weight regained and Dr Shamdeo’s investigative X-rays and sputum tests reveal that the lung fields are clear – another TB patient cleared and cured.

“It is joy to my soul to experience my own patients recovering full health after my daily visitations and observations”. And there is no reason why all of his patients – ages 16 – 54 – cannot hope for, or experience full recovery after his six months of dogged, consistent and noble toil, supplemented by their full cooperation.

With the National Tuberculosis Control Programme, the DOTS Initiative, and Noel and his colleagues, Guyana is once again poised to defeat Tuberculosis.