Afghanistan: People with tuberculosis face multiple barriers to accessing treatment

(DR-TB) Patient Diagnose and Treatment | Bibi Shahisto Story

Afghanistan 2022 © Lynzy Billing

Jawahira was referred to the Doctors Without Borders/Médecins Sans Frontières (MSF) tuberculosis (TB) hospital in Kandahar earlier this year from a clinic in Daikundi, central Afghanistan. “I used to visit private clinics, but instead of giving me TB medication, they usually just prescribed painkillers,” she said.  

MSF’s 24-bed TB hospital in Kandahar is the only medical facility providing advanced TB care in southern Afghanistan. Many of the patients come from the nearby provinces of Helmand, Uruzgan, Nimroz and Zabul, but others travel from more than 200 miles away, from Farah, Dikondi, Badghis, Ghazni, and Paktika provinces.  

“Our catchment area is so big, it is impossible to know exactly how many people are in it,” said MSF medical advisor Allieu Tommy. “Many travel from afar, and we support them by paying for transport costs, housing expenses, and food to alleviate some of the economic burden.” Without such incentives, most patients could not afford to come for treatment.  

(DR-TB) Patient Diagnose and Treatment | Sputum Sample
MSF nurse Aziza Khushal waits to collect a sputum sample from a new patient on the women’s side of the MSF drug-resistant tuberculosis hospital in Kandahar. Afghanistan 2022 © Lynzy Billing

The cost of searching for treatment also took its toll on Jawahira. “My home is far away in Uruzgan, so when we went to see a doctor, I had to spend 6,000 Afghani ($67) for the car fare and then 13,000 ($146) for the drugs they gave me.”  

The amount Jawahira spent on each visit to the doctor is about one-third of the average monthly income in Afghanistan. According to the World Bank, an estimated 60 percent of the country’s population is out of work and has no income at all, exacerbated by sanctions and other financial measures against the government of the Islamic Emirate of Afghanistan (IEA). People often struggle to afford even basic food items, let alone travel expenses and medical fees for hospital visits. Meanwhile, the public health care system is under-resourced, under-staffed, and under-funded

Jawahira’s story is just one of many told by MSF patients that show how, all too often, Afghanistan’s broken economy and dysfunctional health care system leave people who need advanced medical treatment without any reasonable options.  

MSF teams spread awareness about TB 

Another barrier to TB treatment in Afghanistan is the widespread lack of knowledge about the disease. 

“Our daughter Bibi is nine years old and has been sick since childhood, but we did not know of her illness—we had never heard the name TB before,” said her father Hamdullah.  

(DR-TB) Patient Diagnose and Treatment | Bibi Fazlia Story
Nine-year-old Bibi Fazlia makes jewelry in the women’s inpatient ward of the MSF drug-resistant tuberculosis (DR-TB) hospital in Kandahar. She has been receiving treatment here for 18 months.  Afghanistan 2022 © Lynzy Billing

MSF teams carry out regular health promotion activities in local communities in Kandahar to spread awareness about TB. They also provide information to patients and caretakers at the hospital in Kandahar.  

“When a person arrives for the first time and learns that they have TB, we talk to them about what it is, how it’s transmitted, how to be careful around family members, and how long the treatment will take,” explained MSF nurse Taiba Azizi.  

(DR-TB) Patient Diagnose and Treatment | Bibi Fazlia Story
Nine-year-old Bibi Fazlia and her father Hamdullah sit outside at the female inpatient ward at the MSF drug-resistant tuberculosis (DR-TB) hospital in Kandahar.
Afghanistan 2022 © Lynzy Billing

Providing this information is simple but effective. “Now I understand the symptoms and people back home know it is a dangerous disease,” said Hamdullah. “If somebody had seen her [Bibi] earlier, they would have said she would not recover. But now, we know she can get past this. She has already started to eat and walk. We hope she is getting better.” 

MSF also tests a patient’s family for TB, as the disease is highly transmissible, particularly when people live close together.  

(DR-TB) Patient Diagnose and Treatment | Gull Sima Story
MSF nurse Aziza Khushal talks to a patient’s caretaker about her medication on the women’s side of the MSF drug-resistant tuberculosis (DR-TB) hospital in Kandahar city.
Afghanistan 2022 © Lynzy Billing

At-home treatment 

Some patients have a form of the disease that is resistant to conventional TB drugs and requires treatment that lasts nine to 12 months. This can be especially difficult to cope with during a hospital stay, far from friends and relatives. As a result, many patients stop their treatment early. In 2023, a six-month short course regimen will be rolled out that should make it easier for people to finish their treatment. 

MSF has already set up a DR-TB program that combines specialist inpatient care with supervised home-based treatment to help patients better cope with the regimens.  

(DR-TB) Patient Diagnose and Treatment | Bibi Amina Story
Bibi Amina and her nine-year-old granddaughter Sayeeda wait see a doctor on the women's side of the MSF drug-resistant tuberculosis (DR-TB) hospital in Kandahar city.
Afghanistan 2022 © Lynzy Billing/MSF

“What we offer is a system whereby a person spends the first 30 days in our facility under careful observation and, if they do not experience major adverse side effects from the drugs taken, they are discharged for homecare,” said Azizi.  

“Our staff then do weekly follow-ups over the phone, so patients only need to come back to the hospital once a month to renew their medications and have an in-person consultation.”   

Women and children are most vulnerable to TB 

Over 70 percent of patients in MSF’s Kandahar TB hospital are women and children. “Women and children stay at home in dusty, poorly ventilated rooms for longer periods of time than men,” said Tommy.  

(DR-TB) Patient Diagnose and Treatment | Bibi Amina Story
An MSF nurse talks to patients in the women's waiting area of the MSF drug-resistant tuberculosis (DR-TB) hospital in Kandahar city.
Afghanistan 2022 © Lynzy Billing

“If a woman gets infected, the children are likely to catch the disease as well. Other cultural factors play a role too. Women whisper or speak in very low tones to one another, especially if men are in the room. Respiratory tract infections are then easily transmissible due to their proximity.” 

An additional challenge for female patients is that they are generally required to be accompanied by a male family member to the hospital, and this coupled with the economic barriers can significantly reduce their access to health care.    

(DR-TB) Patient Diagnose and Treatment | Gull Sima Story
Two-year-old Gull Sima is weighed by MSF nurse Aziza Khushal at the Médecins Sans Frontières (MSF) drug-resistant tuberculosis (DR-TB) hospital in Kandahar city.
Afghanistan 2022 © Lynzy Billing

It is estimated that TB and its resistant forms kill more than 13,000 people in Afghanistan every year. Access to proper care remains a major challenge for patients in the southern part of the country, mainly due to insufficient medical infrastructure, length of treatment, and financial obstacles. While MSF’s TB hospital in Kandahar provides free quality treatment for many, the people of Afghanistan need a more robust and sustainable health care system to meet their many urgent needs. 

MSF’s Kandahar TB hospital aims to provide patients with free and effective treatment. The hospital has a laboratory, an outpatient clinic, and 24 beds for patients with DR-TB and commorbidities, and for those who develop severe side effects after taking DR-TB medication. MSF teams have provided more than 13,000 consultations for patients with drug-sensitive and drug-resistant TB so far this year and admitted more than 70 patients for inpatient treatment.  

MSF also provides patients with mental health support, carries out health promotion activities, and delivers technical and financial support to provincial laboratories that offer TB testing.