• A lingering threat fuelled by stigma

Tuberculosis (TB), a bacterial infection that primarily affects the lungs (but can involve any body part except hair and nails), has been a global health concern for centuries. Despite the significant progress made in the treatment and control of TB, Sri Lanka is still grappling with a growing risk of TB infection, largely due to the persistent stigma and discrimination associated with the disease.

In Sri Lanka, as in many parts of the world, the availability of testing and treatment for TB is not the issue, with health procedures having made substantial strides in this regard, with accessible testing centres, free treatment, and an adequate supply of medication. However, the real challenge lies in persuading individuals to approach these healthcare facilities and adhere to the prescribed treatment regimen.

As per reports published by the Epidemiology Unit Ministry of Health, Nutrition, and Indigenous Medicine, by the end of 2020, the estimated number of TB deaths was 3.8 per 100,000 of the population. The Epidemiology Unit, in its reports, notes that in order to reduce the TB caseload, what is most important is breaking the chain of transmission – that is, to identify and treat the index case to prevent transmission of infectious droplets to a healthy person either at the community or institutional level. 

However, testing and identifying patients remains a major concern. Stigma and discrimination have, unfortunately, cast a dark shadow over the fight against TB in Sri Lanka, with many people, even when symptomatic, hesitating to seek medical help. The fear of being labelled, isolated, or rejected by their community due to the nature of the illness remains a significant barrier to early diagnosis and timely treatment.

Stigma and obstacles against testing 

Speaking to Brunch, Ratnapura District Public Health Inspector (PHI) Kushan Induranga shared that a major obstacle when it came to effective TB treatment was that individuals affected were reluctant to come in for testing.  

“TB as an illness has certain negative connotations attached to it. Often in the more rural areas, villagers feel that if their TB-positive status is revealed to their community, they would then be ostracised and that subsequently due to the infectious nature of TB, their families too would then be ostracised,” he said. 

He shared that district-wise, there were dedicated clinics which provided for TB care needs covering all 26 districts – the District Chest Clinics (DCCs): “The area PHI will ensure that persons who display symptoms attend the clinic and get tested. However, while convincing individuals to get tested itself is a difficult task, oftentimes they do not continue with treatment as they do not want their community to know that they are visiting the clinic for treatment.” 

He further noted that there was a relief package available for persons suffering from TB offered by the Social Services Department in each district, where a maximum amount of Rs. 5,000 was allocated to each patient. However, the stigma attached to TB is such that there are many who refuse to claim this compensation for fear of being ousted as a TB patient. 

“Many of those who suffer from TB are from low-income families and the concession provided by the department is a significant support to their livelihoods. However, in order to claim the amount, they must first register with the District Chest Clinic, acquire a certificate confirming their TB status, and complete a form. Then they must submit both documents to the Grama Niladhari, who will confirm their income status to be eligible for the allocated amount. The amount may vary depending on their district and income status. However, many refuse to do this for fear of being labelled as a TB patient,” Induranga revealed. 

In addition, Induranga shared that the nature of testing posed an issue as well, given that the test for TB (sputum test) required the patient to visit the clinic on at least two occasions, and those residing in areas situated in rural parts of the district may face major challenges when having to travel a significant distance for two days.

“The test requires the person to submit a phlegm sample upon arrival, as well as one collected early morning by themselves, which they must then bring to the clinic, and provide another sample at the clinic. Only then will they get their test results. Understandably, this can be challenging for those who have to travel far to reach the clinic, many of whom must forgo a day of work for this,” he said. 

The concern of nutrition 

With World Food Day being celebrated on 16 October, understanding that nutrition plays a direct role in both the risk of contracting TB and the success of its treatment is a critical aspect of the fight against this disease. Malnutrition weakens the immune system, making individuals more susceptible to TB infection. Additionally, adequate nutrition is essential to support the body’s ability to combat the infection and adhere to the medication regimen.

National Programme for Tuberculosis Control and Chest Diseases (NPTCCD) Consultant Community Physician Dr. Hemali Jayasekera shared that given the direct link that had been identified with nutrition and TB, there were five key guiding principles that should be considered. 

She noted that these principles were intended to inform and assist those providing TB care, TB treatment services, and/or maternal and child health services in countries affected by TB, in formulating national or subnational nutritional recommendations.

She shared the five following principles for clarity:

• First, that all people with active TB should receive TB diagnosis, treatment, and care according to WHO guidelines and international standards of care. 
• Second, an adequate diet containing all essential macro- and micro-nutrients is necessary for the well-being and health of all people, including those with TB infection or TB disease. 
• Third, given the link between undernutrition and active TB, there should be nutrition screening, assessment, and management that are integral components of TB treatment and care. 
• Fourth is the identification of poverty and food insecurity as two causes and consequences of TB, and those involved in TB care therefore play an important role in recognising and addressing these wider socio-economic issues.
• Fifth, that TB is commonly accompanied by comorbidities such as HIV, diabetes mellitus, smoking, and alcohol or substance misuse, which have their own nutritional implications, and these should be fully considered during nutrition screening, assessment, and counselling. 

Sri Lanka must confront the double-edged sword of TB and stigma, tackling both with equal determination. Public awareness campaigns, community education, and de-stigmatisation efforts are vital in this battle. When people feel safe and supported in seeking testing and treatment, Sri Lanka can truly make strides in reducing the incidence and impact of TB.

In conclusion, while Sri Lanka has made significant advancements in healthcare, the risk of TB infection persists due to the deep-rooted stigma and discrimination surrounding the disease. In honour of World Food Day, we must also recognise the critical role that proper nutrition plays in preventing and treating TB. It is essential that the nation unites in its efforts to combat not only the disease itself, but also the social barriers that hinder progress in the fight against TB.