Third world countries are currently struggling with many dangerous diseases, one of
Tuberculosis cases and mortalities, the United States Agency for International Development
(USAID) has created the Care II Project designed to give patients more comfortable, efficient
treatment.1 Currently less than half of the patients effected by Tuberculosis in Bangladesh are
being diagnosed.1 This leads to the rapid and widespread of the Tuberculosis bacteria.2
Bangladesh is considered an optimal host for this bacteria to thrive because it presents an
abundance of risk factors, including but not limited to, massive poverty, extensive overcrowding
combined with a transient population, malnutrition, and religious constraint.2,3 For these reasons,
Bangladesh has become one of the few nations that Tuberculosis provenance has actually
increased whereas everywhere else they are learning to manage the spread of this dangerous
bacteria. Unless Bangladesh takes action now to increase knowledge and create a better system
The current action Bangladesh is taking to decrease the prevalence of tuberculosis is the
bare minimum required by the Center for Disease Control (CDC) and World Health
Organization (WHO). In May of 2014 WHO, in conjunction with several other national health
organizations, put out their recommendation and goal as to how the global community, are going
to eliminate Tuberculosis.4 The agreed upon hope in that by 2035 Tuberculosis will be
eliminated from all communities, and this elimination should be of top priority.4 The pillars of
how the global nation will make this happen are as follows: to provide patient-centered care, to
provide strong political support, and to increase research efforts.4 While all three of these broad
steps are a necessary start, they must be taken to the next level and put into action around the
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world. There are significant barriers to this approach. There are no specifics as to how each step
should be accomplished and each requires funding and nationwide participation in order to
achieve real success. While these efforts have currently been implemented in Bangladesh, they
are not successful because of the cultural barriers that are in place.
communicable disease that is hard to diagnose and treat.2 Tuberculosis is an airborne bacterial
infection that effects the patients lungs, leading to coughing, fatigue, fever, night sweats and
more.2 A large number of the Tuberculosis cases include patients with latent Tuberculosis. Latent
tuberculosis is when an individual does not show symptoms of the disease however, they still
carry the pathogen and can transmit it to others.2 Latent Tuberculosis is particularly scary
because while it does not affect the patient directly it is very hard to diagnose, meanwhile the
patient is still able to transmit the disease to those close to them. The current treatment for
Tuberculosis is six months of taking INH or RIF pills, that can be quite harmful to the patient.2, 5
For this reason, many people in the past have prematurely stopped treatment once the symptoms
subside. One of the major reasons for the increased prevalence of this disease is that it has such a
long treatment period, which becomes a burden to families. This has caused the disease to mutate
Tuberculosis that has become resistant to the drugs that are usually used to treat Tuberculosis.6
This has become especially tricky because the treatment time with this strain is four times longer
than the regular Tuberculosis and the medications used cause several dangerous side effects.2 To
this day there is not a safe way to treat patients diagnosed with MDR tuberculosis.
Bangladesh is currently working off the CARE II plan presented by the USIAD which
has led to the implementation of several preventative measures.1 Bangladesh recently put in
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place the directly overserved treatment (DOT) program.7, 2 This dictates that high risk patients
are observed taking the tuberculosis treatment, which helps to ensure that patients actually
completely their treatment plan. Bangladesh has also been in the process of building
Tuberculosis treatment centers across the nation to provide easier access to treatment.5 These
centers are designed to have the technology to accurately diagnose Tuberculosis at all stages.
There have been initiatives implemented that are designed to help better train health care
for people working in the health care system, are also open to community members who are
looking to support the cause.1 Through the use of some social media, in conjunction with word of
mouth, there has been as attempt to distribute accurate information about Tuberculosis to the
peoples across Bandladesh.8 As accurate knowledge is spread to a wide range of people, it allows
for a better understanding of each persons individual risk factors. Patients are also more likely to
seek out treatment for themselves, or their family, if they are better informed about the dangers
of this disease. The spread of accurate knowledge is a primary factor in the ability to diagnose
Bangladesh has made some great initial steps in combating Tuberculosis however, more
must be done to make a bigger impact if there is ever hope to make Bangladesh a safe place to
live. There are currently a lot of challenges that must be overcome before a highly noticeable
difference in Bangladesh can be made. A lot of these challenges stem from the culture in
Bangladesh as well as the environment in which they live in. Bangladesh has been plagued with
overcrowding.9,10,11 In the 1970s the primary religion in Bangladesh was Islam, which
encouraged procreation, producing large family sizes.10 While fewer people practice this faith,
the result of high birth rates is still effecting the country today. The average family size has
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decreased from 5 children to about 2.5.10 Even though the family size has decreased the
overcrowding is still a factor and makes Bangladesh an ideal environment for the spread of
Tuberculosis. Since this is an airborne bacterium, the closer quarters people are forced to reside,
the easier it is for entire families to become infected. The overcrowding allows for several people
to become infected at once. While there is no easy way to eliminate this problem, encouraging
people to closely watch their family members and to implement some form of isolation once one
member is effected may be able to help decrease the likelihood that an entire family would
Poverty is another factor that has allowed the Tuberculosis bacteria to thrive in
less than a dollar a day, meaning that they are well below the poverty line.13 It is common for
people to live in a slum environment and for all family members to be constantly working.11, 3
Since the treatment for Tuberculosis is so long, 6 months, and patients are required to
consistently visit a clinic to be monitored and to pick up their medication. This becomes a burden
on the family.7 Due to the primary socio-economic status being so low, it is crucial that even
individuals diagnosed with Tuberculosis are back at home as soon as possible so that they can
work. Clinics are not available in every single village, which means that travel to receive a
diagnosis or treatment can be a lofty trip.7 Outside of time wasted from going to and from the
clinics, the treatment and medication itself is expensive, especially if any form of hospitalization
is required.7 Some clinics are able to perform the diagnostic testing and give medication at a cost
only to the government itself, however these clinics may be even further away from the patients
primary location.7, 11 The primary cost to patients comes from a loss of work for the patient, as
well as their care provider. This only encourages patients to stop treatment early so they can
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return to work, or to not seek treatment at all until the bacteria has already mutated and is unable
to avoid. This is a huge contention because unless people are willing to come to clinics at the
first sign of the disease, they will only spread the bacteria to others causing the epidemic to
spread quickly. It is currently financially unwise for patients to seek treatment; this is a problem
that needs to change. Some ideas are to find a way to shorten treatment length, give individuals a
financial incentive to seek treatment, and reduce travel time for everyone, specifically targeting
rural areas.
Another challenge for this area is the significant transiency of the population.9 This leads
to a plethora of road blocks including an inability to track patients and their treatment, a
difficultly spreading accurate knowledge that will reach everyone, and that transiency is an
effective way for the Tuberculosis bacteria to travel from one community to the next swiftly.
Since patients are constantly moving, it is nearly impossible for clinics to manage the individuals
living in their community as they are ever changing. Even if clinics were to attempt to test
everyone there is no way of monitoring when families move or arrive.8 This causes a lot of
incomplete data collection, which creates an incomplete and inaccurate picture of how
detrimental Tuberculosis is on this nation.4 One way that Bangladesh is attempting to combat
Tuberculosis is ensuring that everyone how accurate information. In the study done by the
Journal of Health, Population, and Nutrition, it shows that current citizens of Bangladesh have
an insufficient knowledge of how to identify Tuberculosis, seek treatment, and what the risk
factors are.12 This lack of knowledge is caused by the transient mentality. People are moving all
other the country making it difficult to spread knowledge, without it getting construed through
misunderstanding. Lastly this transient nature allows the bacterium to spread far and wide. If one
location is infected and someone moves from that area to another, they are most likely carrying
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the bacteria with them and will infect this new population. As people move around they are
giving the Tuberculosis bacteria an ideal way to affect the masses easily. These challenges are
hard to overcome and it would require a behavioral change that is extremely hard to achieve. In
the meantime, however, if the government began using country wide forms of communication to
spread information it would decrease these misconceptions and allow for the same information to
spread everywhere.
Bangladesh is a country that has high levels of malnutrition, primarily due to the large
decrease in the bodys immune system.13 It is very common for Tuberculosis to begin in the
latent stage, but the weakening of the immune system from malnutrition can cause it to turn
active. As more and more children are living in these slum locations, unable to get adequate
food, their risk obtaining Tuberculosis greatly increases. While it may seem contradictory, in the
last few years there has been an increase in agricultural distribution, increasing the economy in
Bangladesh, the malnutrition status did not change.13 This increase of wealth in Bangladesh has
exaggerated the problem by creating an even larger wealth gap across the nation.13 When
individuals are unable to receive adequate nutrition their bodies must distribute the limited
energy they have into performing necessary function, greatly decreasing the amount of energy
left for the immune system. This decrease in immunity does not only contribute to the advancing
cases of Tuberculosis but every chronic disease, including HIV. Which has been recently
connected to the advancement of the Tuberculosis endemic.2 When an individual has HIV it
requires the full use of the immune system to fight this nasty disease. This leads to an opening
for Tuberculosis to join in attacking the body. The combination of these two diseases working
together is becoming more popular across the nation, and is increasing mortality rates.2 When
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HIV and Tuberculosis are co-infecting a patient it also makes the Tuberculosis treatment more
dangerous as the side effects are magnified.2 Treatment must therefore be modified creating a
greater risk for a relapse, usually causing the development of MDR Tuberculosis.2
When attempting to tackle the problem of Tuberculosis in Bangladesh there are many
cultural challenges that must be worked around. This can be an overwhelming endeavor,
particularly when it may seem that there are more pressing matters that must be eradicated first.
However, as steps are taken to eliminate this Tuberculosis it will require the country as a whole
to make large changes that will in turn decrease the prevalence of other chronic diseases.
Bangladesh has already taken several promising step to attempt to decrease the cases of
Tuberculosis by following all recommended pans given by the USAID, WHO, and the CDC.
While this is a start, the fact that Bangladesh is still one of the few nations that there is an
increasing number of Tuberculosis cases, it is essential that they need to take these programs a
step further. Since Tuberculosis is highly contagious the first step is going to be to create a better
system for identifying every case at its initial onset. The next step will be to increase the
knowledge the population has for this disease in order to help people avoid future risk factors.
Step three will be to decrease the economic burden Tuberculosis has on families in order to
create greater incentives to receive treatment. The last step will be to increase research and
continue prevention measures, even when the disease burden has decreased.
There has been a significant amount of research in Canada about the screening Refugees
for Tuberculosis when they enter the country.5 Canada has been dealing with a large number of
refugees coming to their counties from high risk locations. In response they created a system in
which all legal immigrants are required to receive all recommended vaccines and be tested for
Tuberculosis before they are approved to live in Canada. This project has been successful in
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allowing people to take refuge as well as keeping the current citizens safe from disease. A
essential that everyone is teste to ensure there is accurate data. Since there is currently no way for
clinics to regulate who does or does not get tested, it is up to each subgroup community to hold
each other accountable. There are many women in Bangladesh that are looking for work who
could be trained to identify tuberculosis. Once clinics were created to teach at least one women
in every two-mile radius, they could go out and test each individual in their home. These women
would be trained as nurses, with the knowledge necessary to give patients accurate information
on how to receive treatment for Tuberculosis. Once these women were in place it would then
become a community effort to keep their neighborhood safe from future outbreaks. The small
challenge of the transient population would also be fixed, because similarly to the refugees, once
a family enters a new community they can be immediately tested.5 This style of immediate
testing has been successful in Canada by almost eliminating all cases of Tuberculosis. It could
conjunction with testing for Tuberculosis.5 Another benefit of this type of community
involvement is that these women would be able to send the data they collected, as to the number
of individuals effected, to the closest clinic allowing more accurate knowledge as to the size and
distribution of the disease. The size of Bangladesh and the unwillingness of people to go out and
get tested themselves is a challenge that is solved using this approach. This program will increase
the number of available jobs for women, increasing their familys income and therefore
decreasing the number of families below the poverty line. This would therefore benefit the
countries overall economy. People do not have to leave their homes to ensure their family is safe,
and this is a great way to empower women, giving them a clear purpose within the community.
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The next step to eradication would be to increase the publics knowledge about this
disease. There was a study done by African Health Sciences which indicated that the citizens of
knowing the risk factors of the disease.11,12 This is a problem because families need to be able to
avoid risk factors and identify when a family member is infected, so that entire families do not
develop and spread the disease.11,12 Once community nurses are hired it would be essential that
they are responsible for going home to home, ensuring that every family has at least one member
that is highly knowledgeable on the subject. This would create a community surveillance
system.10 If each person could identify when a neighbor is infected by Tuberculosis and insist
they reach out for treatment, it would promote a positive, healthy environment. Each clinic does
not have the capacity to watch every individual within their community. Promoting community
involvement through increased knowledge and self-surveillance will encourage people to seek
and complete treatment.10 The overcrowding issue would become an advantage because it would
be harder for people could hide from receiving treatment. Another underused platform is that of
television and radio.3 If the government was able to create countrywide ads that played
nationwide twice a day, both on the television and radio, accurate information would get out to
the public rapidly.3 This method would also ensure that all citizen would have the same
knowledge about this disease as well as which risk factors to avoid. This would alleviate the
problem of transient families, because it would be a country wide distribution. It would no longer
matter what community you were in or moving to, everyone would have the same accurate
information.
When attempting to eliminate chronic disease, the economic burden to the families
infected is often overlooked.7 The number one reason people withhold or stop treatment is
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because of the economic challenges.7 The medication is expensive, the treatment period is long,
and it is far to travel to the closest clinic.7 Since most clinics at this time are giving free or
reduced costs of medication, leading to the next step of solving the problem of travel and loss of
labor costs. In step one, the training of women in each community would be an ideal method to
solve this problem. People could be treated in their home. This would allow families to not loose
working hands, especially for a long treatment of six months. The nurses could ensure that each
patient completed the entire treatment regimen by going to each house and administering
treatment. Ensuring all treatment was completed fully would help reduce the cases of MDR
Tuberculosis, which would be a huge assistance to the safety of the country. Training and paying
community nurses would be a costly endeavor, however a necessary one that would bring back a
return to the government by saving on hospitalization costs. It would also be helpful to switch
from INH to RIF pills. The treatment is the same length, but the RIF pills are cheaper and have
shown reduced side effects.8 While there will always be a burden associated with any disease
diagnosis, these steps will decrease that cost to families and overall ensure the well-being on
every community.
Lastly all changes must continue, even once the prevalence of this disease has decreased.
Since Tuberculosis is highly contagious, any decrease in the education, prevention and diagnosis
could easily cause another outbreak to occur. Continued research in the causes, treatment and
prevention of Tuberculosis is vital to the irradiation of the disease. The treatment is very long
and it is still difficult to detect all cases of tuberculosis, especially the ones that are inactive.8 A
vaccine for tuberculosis would also significantly change the face of this disease and the effect it
has on populations around the world. A vaccine would allow the public health community to be
proactive about eliminating this disease rather than reactive as they are now.
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There are three key limitations for the proposed initiative, personal training and money.
This program requires a lot of women in need of work, would like to pursue a career in nursing
and are willing and able to be trained. If there are not enough women in each community to
commit themselves to ensuring the elimination of tuberculosis within their community, the
initiative will not be successful. If the government made decreasing the prevalence of
Tuberculosis their primary priority it would encourage women to stand up and help. The training
of these women would also be expensive. The government would need to find and pay
knowledgeable staff who could train the woman, who in turn would need to be paid for their
services. Bangladesh, while their economy is growing, they would not alone have enough to
supply all of the necessary funds. While they would be a good candidate for outside funding
from the CDC, WHO, or other outside investors there is no guarantee they would be able to
receive the necessary assistance. The final limitation is facilitating the training of these women.
It is essential that they have up to date knowledge on Tuberculosis. The locations for these
training to occur must be widespread so that every community has easy access, however they
must each teach the same information. Ensuring that these trainings are successful and
convenient is a challenge that can be solved by providing financial incentives to attend these
trainings including covering travel expenses to the training locations. Without the fulfillment of
these three limitations it will be impossible to find success with this proposal.
Bangladesh in one of the few countries where the prevalence rates of tuberculosis are
going up.1 Unless the country as a whole is willing to put their personal agendas behind and
work toward the common goal of treating all tuberculosis cases immediately, the disease will
continue to mutate becoming more deadly, causing more destruction. Taking steps to train and
educate the people of Bangladesh will not come cheap, it almost always leads to a financial
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return and the satisfaction of saving a community. God is not prejudice when it comes to who is
effected by disease.14 It is therefore the global communitys responsibility to assist our neighbors
in their treatment and recovery in any way they can, on a global and local scale.
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References:
4. Uplekar M, Weil D, Lonnroth K, et al. WHO's new End TB Strategy. The Lancet.
2015;385(9979):1799-1801. doi:10.1016/s0140-6736(15)60570-0.
8. Lnnroth K, Castro KG, Chakaya JM, et al. Tuberculosis control and elimination 201050:
cure, care, and social development. The Lancet. 2010;375(9728):1814-1829.
doi:10.1016/s0140-6736(10)60483-7.
10. Levine R. Case Studies in Global Health Millions Saved. Mississauga, Canda: Jones and
Bartlett Learning; 2007.
14. Holy Bible: New Living Translation. Wheaton, IL: Tyndale House Publishers; 1996.
15. Merson MH, Black RE, Mills AJ. Global Health: Diseases, Programs, Systems, and
Policies. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2012.