Interview: Dr Alphonse Okwera on Why He Keeps Fighting TB Despite the Risks

Dr Alphonse Okwera (Photo by: Mike Segawa)

Dr Alphonse Okwera is a passionate physician who has devoted his life to fighting Tuberculosis.

This year, this web he makes 34 years at the frontline of preventing, check treating and curing the disease as a physician, researcher and lecturer.

He is also the head of the Tuberculosis Unit at Uganda’s Mulago National Referral Hospital and one of the doctors taking part in the new research project, Tuberculosis: Working to Empower Nations’ Diagnostic Effort (TWENDE) incorporating East African countries of Uganda, Kenya, and Tanzania.

In an interview, Dr. Okwera speaks about his 34 year journey and his recent findings from the research conducted about Tuberculosis.

He warns about complacency in the control and management of TB which has surged according to a recent survey citing over 100,000 cases each year from 50,000 on official records.

What keeps you going, given the risks this particular disease exposes to the practitioners?

That is an interesting question. I don’t have an answer… But I think it is passion. I am passionate about my work. I have loved it. In the beginning it was different, but with time I found out not many people have interest in the area, yet we do a lot to make patients feel better’’.

I find it interesting and exciting to do research working it drove me in deciding what l wanted to do with my future. I have invested a lot into research which I have done and still do. I have helped in training colleagues to develop a critical mass of human resource to handle this disease which is fortunately treatable and curable. I am inspired by seeing people become healthier and productive and it is our responsibility to ensure a healthy population.

TB is an infectious disease but we have appropriate control tools and guidelines to follow. If you follow them very well the risk of getting TB is really minimal; (Mulago Hospital) being a national referral hospital, we have put that in place. We have state of the art effective control measures to prevent transmission of TB from patient to patient, or from patient to healthcare workers, both in the laboratory and in the wards.

What is the status of TB in Uganda like?

Tuberculosis is a communicable disease; in fact, it is an infectious disease that is spread through the air when one comes into contact with an infectious case especially of the lungs or the throat. And also if one has a problem with their immune system like diabetes, cancer of the blood stream and other types of cancer that reduce one’s immune system and suppression due to HIV.

Alcoholics that take a lot of alcohol, malnutrition, and many other conditions, expose one to the disease. TB can infect anyone; young, old, women, men, children, are all at risk. We are all at risk.
Now the situation of TB in Uganda is like that in most developing countries. It is very challenging. We have many cases of the disease in our communities.

TB in Uganda is being managed by the National TB program which is under the Ministry of Health. The informational data on all diagnostics in the country is with them. The reports we have received in the last five years are recorded and analysed by the TB and Leprosy program showing we have up to over 50,000 TB cases every year, which includes new cases of tuberculosis, and recurrent TB arising from drug resistance.

So, we believe that the diagnostic management strategy by the government is not adequate as indicated by the recently concluded preliminary findings of the national survey, which shows we expect more than 100,000 TB cases every year. The situation of TB in Uganda is therefore a huge challenge.

Which are the areas in Uganda that are most vulnerable to TB?

I cannot commit myself on that. The scientific survey is done by random though according to the reports of the program show urban areas have more cases of TB than rural areas. Women cases versus men are also getting to 1:1. It used to be many in men in the past because of their social behaviour, but now women have more access to other social services and that has come with the disease. TB is also more prominent in East and Central.

In terms of research done in Uganda, what are your biggest concerns about TB?

The first important research that we have done in this country which also made positive impact on policy implementation to control TB started way back in 1989 when we wanted to know the risk factors associated with TB. We found out that HIV was the driving factor behind the huge proportion of TB of the time. New cases of TB in 1989/90 were 67% HIV infected. Thank God, with the Aids control program and awareness in communities, the percentages has come down to 50%. We follow the control program in place.

We did research as the drugs used to treat TB were not working and took a long time to complete the dosages. They took 16 months, including injections to complete the dosage. We did studies to reduce the duration of treatment and improve on compliance of TB treatment. The duration has now come from 16 to six months in case of new cases. It is a huge milestone. This research was done here in Uganda.

There were some medicines that were dangerous for people with HIV, and Uganda again came up with findings that were adopted by the World Health Organization which changed the policy of treating TB in the whole world.

What else was in the research finding?

We also knew that human beings were the biological reservoirs for TB, particularly those that were HIV infected, so they were vulnerable. We did studies to see whether we can give anti-TB drugs to prevent breakdown of people infected with HIV and active TB. This was done in 1992/97 and was found to be very effective. The drug is called Isoniazid which is taken in just six months. It is a tablet taken when one has HIV to prevent TB infection. It was also adopted by WHO. You can see what we have done here.

The current studies we have done involve the diagnostic areas, such as modifying the new technology of diagnosing TB using the molecular method which is done in less than three weeks and results come out.

Currently we have a lot of research work in getting better methods of treating TB by avoiding giving injections, and two, we want to reduce the duration of treatment from six month to below in drug sensitive type of bacteria and from 24 months for drug resistant TB to less than eight months. We are also conducting those studies currently here, to see if we can develop cheaper, effective, curable, and to ensure there is minimal side effects when it comes to treatment of the current HIV/TB.

The studies also combine areas where we can diagnose TB whether it is sensitive or resistant; to the anti-biotic we use to treat TB. We have technologies to address how quietly we can diagnose TB as soon as possible to reduce transmission in communities, improve or enhance cure, and also to improve on the quality of life of the people with TB.

Drawing from your experiences practicing in the TB sector, share with us your medical story.

I am a physician by profession. I have a lot of training background in public health. You know TB is a community health problem. At the same time, we don’t just look at patients, so we do a lot of training.

Our work environment here is a national referral centre for the entire country. We carry on other works such as training medical students, undergraduate and post graduate.

We also do a lot of work in respect to research in the area of looking for new drug compounds that work better in terms of combinations, duration of therapy, and in compliance with good human protection for people that participate in the study, we also do a lot activities to reach out to regional referral hospitals in this country to make sure they give quality care to TB patients who are in their jurisdictions. So, this is the work that we do here.

What can ordinary Ugandans and East African do in the prevention of TB?

It is by going there and telling people to be vigilant in their communities. Let them watch out for symptoms and report to the healthcare workers as soon as possible. Signs to watch are persistent coughs which do not respond to medication, fevers, loss of appetite, weight loss, are key signs. One should seek testing for TB at a medical facility.  We also recommend BCG vaccination for children.

What message do you have for policy makers as far as TB management in concerned?

Here in Uganda, we have got tools for treating and managing TB. However, this disease has been with us for a very long time. You can say since mankind inhabited this planet. It became an endemic. It was rampant in Europe but the good news is, we know a lot about it; how it spreads, how to prevent, treat and cure it.

Unfortunately, we lack resources to do this work as we wish we could. We need as a country to invest in areas that would develop a critical mass of health care worker to help in this work countrywide. We also need facilities to ensure that we research on the disease as well as its management.

We need to carry out procurement of lab and TB drugs in time as the long procedures constrain the process. Government should also improve monitoring of control programs as well as be able to facilitate the transportation of monitors across the country. Our mission is to ensure we respond to TB in time and for patients to complete their medications to avoid recurrent TB which makes it more difficult to manage.

As a country, we should realize that we are vulnerable and therefore, we must endeavour to make research and mobilize resources relentlessly.
This should happen as we train human resources to implement the science that helps in managing the disease.

What don’t most people know about TB?

There is a lot of miss information about TB. People don’t know how the disease is acquired. However, people should know that TB is preventable, treatable and curable. That is key. We should improve on sensitization and awareness in our people about the disease, and empower them with knowledge that would help them prevent getting infected especially in areas such as slums.

We should therefore create a strong arm of TB awareness so that no one is complacent about the disease.
We also have funding gaps. Policy makers should know that TB patients are less productive, and we need to take TB awareness and management to the level we took HIV/AIDS.


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